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HomeMy WebLinkAbout11-30-111505610101 REV-1500 Ext01_1°' ' OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes ~""A,ME~. p`VE"°` County Code Year File Number PO BOX 28o6oi ~ INHERITANCE TAX RETURN Harrisburg, PA 1'7128-0601 RESIDENT DECEDENT o~ ~ ~ ~ C~ ~ _~ (,; ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY f ~ .~ ~ 7 Z ~ ti '7 U 3 ~ ~ ,.Z ~~ t ~ o ,`~ ~ Ca t Q i `7 Decedent's Last Name Suffix Decedent's First Name MI RE ~ ~ .T`~~ NAt~ 2Y ~, (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 OVALS BELOW ® 1. Original Return O 2. Supplemental Return Q 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 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 T0: Name Daytime Telephone Number First line of address !o I o VN a u t`t T Second line of address City or Post Office L. ~ w i S ;13 L~ /2 2 ~/` ~ ! 2 `( 2 ~ State P A ZIP Code t 7 3 3~ g i L y REGISTER OF WILLS USE,ONLY C~ '~"1 !'] '_ _ , n ~ ,. ? '~ - ~ i ', ; ~, -, i i DA'# FILED ' ni ;, Correspondent's a-mail address: 1/a r/p j /.~~QfjF F -Yy11~/'L Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PE~SON RESPONSIBLE FOI~FILING RETURN DATE _ ADDRESS ~ I © N~~T y4 f R~~ i2n. ~ ECu l5 ~ 22 ~r ~7A ~ ~ 9 .. q / SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J 1, I 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: RECAPITULATION + ~ r ~ J ~ ~. ~ f 7 ' 1. Real Estate (Schedule A) ........... .. . ............................ ... 1. • 2. Stocks and Bonds (Schedule B) ........ ............................ ... 2. • 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. • 4. Mortgages and Notes Receivable (Schedule D) .. ...................... ... 4. • 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).... ... 5. 6. Jointly Owned Property (Schedule F) p Separate Billing Requested .... ... 6 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property . ~ (Schedule G) p Separate Billing Requested..... ... 7. 8. Total Gross Assets (total Lines 1 through 7) .. ............. . .......... ... s. ~ ~i ~l (• Z 1 9. Funeral Expenses and Administrative Costs (Schedule H) ..... . ........... . s . . ~ S 3 3 ~ o 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........... 10 . .. . 1 C3 O ' Cn . C7 i`i' 11. Total Deductions (total Lines 9 and 10} ......................... 11 " ...... .. . zS 39.8 12. Net Value of Estate (Line 8 minus Line 11) .. 13. ........ ................. Charitable and Governmental Bequests/Sec 9113 Trusts for which _ ... 12. 7 `f a ( • 5 3 an election to tax has not been made (Schedule J) ..................... ... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........... .......... _ ...14. 7 ~ ~ ~ TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 3 1 ~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0._ 16. Amount of Line 14 taxable 15. '' at lineal rate X .0~~ '7 ~ p i J-3 16 17. Amount of Line 14 taxable . -3 .j J ~= 7 at sibling rate X .12 , 17 18. Amount of Line 14 taxable ` at collateral rate X .15 18 19. TAX DUE .........................................................19. ' 333• 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610105 O 1505610105 J REV-?500 EX rage 3 Decedent's Complete Address: DECEDENT'S NAME File Number ~ ~12t2~~/ 7, ~EE ~-~2 STREET ADDRESS ___ Rio thou„:T ~t2~'l~cD CITY - --- _- 1, E ~t.S3 Et22 y Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments - ~ - - ------- B. Discount _ ~ - - _ -. .-- - I STATE -_ ---- - __- -- ZIP Via, i `73s'h'- ~l7~v (1> 333• ~~ 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. Total Credits (A + B) (2) _ v - (3) - e: - (4) (5) =33.3: 0 7 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Ditl 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; or .......................................................................................................................... ^ 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? .............................................................................................................. U [~ 3. Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death? .............. ^ [~" 4. Ditl 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 tS 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 disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. RE'/-1508 EX ~ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER ~-{flf2.2~1 '~ . ~21EEG ~~, Cn~~ 2 I -t t ~vy Z Cn Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ~W~ ~'T 13fl~K ~ er ~c~~'T .~. • ~ 7o74~io4 (2Et1- l M~Ct2tNC~ q.Z I~,7~ 2. ~,t 87l3 ~ H K /g eCo c.:_ ~v T" ~ of c~ 3 ~'3 `l' © i ~S ~ Rf P ~A~yIE,E, I ~ 3; L Z :3• ~..u'WI bE2c.. qnc A couu~~ ~<1. ru tI ~ 3 i~ l - V ~ ~. REfL ~ f-2 r;3 ~~f2~ toe ~ ~' c~QSe/~t(~Tto:`c- Z~~u~A 12h.Z1 i. S V ~ l3~YL, t ~ L ~K ~~ rlSi£ TOTAL (Also enter on line 5, Recapitulation) I $ c{ 9 y L ~ Z (If more space Is needed, Insert addltlonal sheets of the same sizel j ~ i `~ ~_ /. ~ ~f ~~~ ORIGINATING ~ 'COST / -. / CENTER {~ EMPLOYEE NUMBER EBI 1. WIP T ~ CTION /+ f I I~ 7 ` { GF-269 (8/0~ . ~ 4/ T A~ORIZATION ~ -/.+!~-~-a o DATE : S~ = S°// `` SUB PRODUCT A COUNT # f ~ ~ CUSTOMER NAME (PRINT) ~ j DESCRIPTION ~ ~ ~_ - - "' ~ I ~.-: f .. x ~ f .. Original -Processing Wow rk`~' °~` "~ Copy -Branch ~. ~ /1.~.r ,L. ~ CUSTOMER SI ATURE G/L NO. POSTING COST CTR. JULIAN DATE ORSTICENITER SEQ. NO. s h AMOUNT ~ Z Z ~ ~ _ ~;.::M:.~ ~ - -z `; - .:~. r pl s - . ~>`, ,: .t `~ .~ EMPLOYEE1NUMBER 4 ORIGINATING DEBIT: WIP ~' kN ACTION ~ ~ C r GF-zss(e/o~ TER AUTHORIZATION DATE ~-.S~/1 SUB QRODUCT AC OUN4T # ~ ~"` CU OMER NAME (PRINT) ~~Z ~C/ DESCRIPTION .' __/ «J n t G ,~ ~ ~ f Original -Processing Work CvP-y -Branch • ~~~~~ ,_' ,~~ ~ C - -`~ ~ ' I ~,;,~; ` T ~,CUS OMER SIGNATURE ~ _., ~ ~, ORIGINATING G/L NO. POSTING COST CTR. JULIAN DATE COST CENTER 2 1 9 0 7 8 7 ® 7 SEQ. NO. -.. ~~ - _ ~.,,.,;~"'~.~~, AMOUNT ,. i . MF,w.. r ~:~. ACCOUNT N0. ACCOUNT TYPE 9853110956 M8T SELECT 00 0 06117M NM I17 3796 ESTATE OF NARRY D REEL RICHARD A REEL, EXEC 610 MT AIRY RD LEWISBERRY PA 17339 INTEREST EARNED FOR STATEMENT PERIOD 0.00 wnnn~~-~T STATEMENT PERIOD PAGE APR.05-MAY.05,2011 1 OF 2 MECHANICSBURG BEGINNING DEPOSITS 8 -0THER CURRENT ENDING BALANCE OTHER ADDITIONS CHECKS PAID SUBTRACTIONS INTEREST PD BALANCE N0. AMOUNT N0. AMOUNT N0. AMOUNT 0.00 2 9,513.00 3 898.26 0 0.00 0.00 8,614.74 ~rrn~~uT wr~TT..rT.. POSTING DATE DEPOSITS,INTEREST CHECKS 8 OTHER DAILY TRANSACTION DESCRIPTION 8 OTHER ADDITIONS SUBTRACTIONS gpLp~E 04-05-11 BEGINNING BALANCE 50.00 04-05-11 DEPOSIT 9,413 00 05-02-11 DEPOSIT . 9,413.00 100.00 9,513.00 05-04-11 CHECK NUMBER 0107 105.50 9,407.50 05-05-11 CHECK NUMBER 0105 784.10 OS-05-11 CHECK NUMBER 0102 8.66 8,614.74 ENDING BALANCE 58,614.74 CHECKS PAID SUMMARY 102 05-05-11 8.66 105* 05-05-11 784.10 107* 05-04-11 105.50 OWN A SMALL BUSINESS? M8T•S BANKING BUILT FOR BUSINESS SOLUTION BUNDLES SOME OF OUR BEST BUSINESS BANKING PRODUCTS AND SERVICES INTO ONE CONVENIENT, CUSTOMIZABLE PACKAGE. YOU'LL ENJOY EXCLUSIVE BENEFITS AND PREMIUM PERKS THAT ADD UP TO SIGNIFICANT SAVINGS. WE CAN HELP YOU WORK SMARTER, SAVE MORE AND PAY LESS. TALK TO US TODAY ABOUT BANKING BUILT FOR BUSINESS. CALL 1-866-281-9441, VISIT YOUR LOCAL M8T BRANCH, OR VISIT US ONLINE AT MTBFORBUSINESS.COM. ~- 1 ~ ~ -- Z. Customer Service Golf Digest PO Box 37065 Boone,lA 50037 Name: HARRY REEL Account #: 1200733929 Control#: MGLF/ 1 The attached check is the refund that you requested. Date: 06/23/11 Amount: $128.21 Check #: 010823 y---- ------- --- R~nnt~ve aocun,lEr'v~r A~oiv~ rHrs I~~Rr=oRA~rION • ~,~ ~-2i2i a 06/23/11 s~ s2322a3 01.0823 $128:21 PAY TO THE HARRY REEL ORDER OF ONE HUNDRED TWENTY-EIGHT AND 21/100 DOLLARS JPMorganChase~j NewYork,:NY 13202 VOID AFTER 90 DAYS / _f l ~~'0 L08 2 3~~' I:0 2 L0000 2 ~I: 800-727-4653 glfcustserv@cdsfulfillment.com www.golf.com 6~3232283~~' ~~ ~~:1Ck~ !a3 Lt.t aY cl ~ 2v i I Law Officsrs of Saidis, Sullivan & Rogers A PROFESSIONAL CORPORATION 635 NORTH 12TH STREET, SUITE 400 CARLISLE OFFICE LEMOYNE, PA 17043 26 WEST HIGH STREET TELEPHONE: (717) 612-5800 -FACSIMILE: (717) 612-5805 CARLISLE, PA 17013 EMAIL: attorneyC~ssr-attorneys.com TELEPHONE: (717) 243-6222 wwwssr-attorneys.com FACSIbtItE: (717) 243-6486 REPLY T LEM YNE April 4, 2011 Richard A. Reel 610 Mt. Airy Road Lewisberry, PA 17339 Our file# 11351 Invoice# 2304 112132 EIN: 27-2700453 RE: Estate of Harry D. Reel, Jr. Payments received since last invoice Accounts receivable balance carried forward $0.00 $0.00 PROFESSIONAL SERVICES 03/11/2011 Telephone call with Richard Reel re opening of estate 03/15/2011 Conference with Richard Reel re opening of estate 03/16/2011 Preparation of letters to heirs re estate procedures etc.; Telephone call with R. Reel 03/17/2011 Conference with R. Reel re filing; Telephone call to D. Reel 03/18/2011 Docketed estate deadlines .. ~,.. TOTAL FEES $551.00 N - z- C)<.-- L.K lea .~~z~t ~ Co t1 Law Offices of Saidis, Sullivan & Rogers A PROFESSIONAL CORPORATION 635 NORTH 12TH STREET, SUITE 400 CARLISLE OFFICE LEMOYNE, PA 17043 26 WEST HIGH STREET TELEPHONE: (717) 612-5800 -FACSIMILE: (717) 612-5805 CARLISLE, PA 17013 EMAIL: attorneyC~ssr-attorneys.com TELEPHONE: (717) 243-6222 wwwssr-attorneys.com FACSIMILE: (71.7) 243-6486 REPLY TO LEMOYNE May 2, 2011 Richard A. Reel 610 Mt. Airy Road Lewisberry, PA 17339 Our file# 11351 Invoice# 2464 112132 EIN: 27-2700453 RE: Estate of Harry D. Reel, Jr. Balance forward as of invoice dated Apri14, 2011 Payments received since last invoice Accounts receivable balance carried forward PROFESSIONAL SERVICES $551.00 $0.00 $551.00 04/05/2011 Telephone call with R. Reel re Estate procedures to be performed 04/06/2011 Discussion with J. Slike; Telephone call to/from R. Reel; Email to J. Slike 04/08/2011 Telephone call with R. Reel; Notices to heirs TOTAL FEES $123.50 f-I - z 112132 Reel, Estate of Harry D. Invoice# 2464 Billins Summ Total professional services ~ 23.50 J Total of new charges for this invoice $123.50 Plus net balance forward 51.00 Total balance now due $6'74.50 * * Trust account remaining balance is $0.00 Page 2 PRIVACY POLICY: During this firms representation of you, we may receive nonpublic, personal information from you or from sources about you. It is our policy and practice that our attorneys and staff do not at any time reveal information relating to our representation of you unless you consent after consultation, except for disclosures that are impliedly authorized to carry out the representation, and except for disclosures required or authorized by the Pennsylvania Rules of Professional Conduct. Interest at 1 1/2% per month on unpaid balance after 30 days. - Z. RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 REEL HARRY D JR Estate File No.: 2011-00426 Paid By Remarks: RICHARD A REEL WZ ------------------- Fee/Tax Description PETITION LTRS TEST WILL SHORT CERTIFICATE RENUNCIATION JCS FEE AUTOMATION FEE Cash Total Received......... Receipt Date: Receipt Time: Receipt No.: Receipt Distribution ----- Payment Amount Payee Name ~ Xa ~~ IY/ ~i`/ c v ~ ~ (`~ ~ ( ~ `7 7U ,^~ C 1'= 4/01/2011 15:43:46 1065030 45.00 CUMBERLAND COUNTY GENERAL FUN 15.00 CUMBERLAND COUNTY GENERAL FUN 12.00 CUMBERLAND COUNTY GENERAL FUN 5.00 CUMBERLAND COUNTY GENERAL FUN 23.50 BUREAU OF RECEIPTS & CNTR M D 5.00 ---------------- CUMBERLAND COUNTY GENERAL . FUN $105.50 $105.50 r~ W C m r N S7 a) v ~ v ~ o ~ a a m ~~~ N c Q , L L ~~~~f) ~ O U ~ ~~ T X 6> y ~ ~ W J ~~~ N ti ~ ~ N 3 o y a Q ~ _ ~ y O N ~ .... V ~ ` ~v~ ~ = ~ ~ } ~ ~ W ,y O N r N ~ 7 Q ~~ Cf~ ~~ .n ~ .J ,. _ O m~ d N ~ N y y 7 O ~ h ~ v J r i b C _ W (~ y d ep .a ^ p .y as O ~~~~ r O y ~ > p U ~ r~ of 01 ~ i i ~ S ~ y C O _ 'n X J ~ ~ L O ~ ~ ~~~, ~ ~ L , u i °- ~ _ p mX _ a ~ `° Q ~~ 3Y ~'~cn J ~ ~ Q L "' ~ y - - X ~ u :n ~ Z - o u Z ~o ~ d~ ~ 0 m In In H ;o ~- m Q m U - a~ o `O .J r ~ ~ m 0 m ti ;. m co ~. 0 0 0 y .~ ~ y -- ----_ j o m v C v y J ~~ , v X . '-' 3 a i~~ `~ ~ o v ~ Q ~„ ~~„~.~ c~ - >. n ~n „ o `n N - v 'n ~ ~ '~'~~ `~ - - ~.rf ~ ~'' = ~ --~-.- - ~ '1> N n _ ~ as m a~ - ~ .n y N Z ~° ~ ~ _ O ~ ' ('(f y L. b ~1.] ~ C _ ,.., y y L O V _ r~~ p Y • N 0 .= ~ ~ y V ~ ~ fO v !i a 0 X J x ,y - O C O- O _ n - y ~ .: ~_ y x X ~ Q ~ y y L a v i J 9 U~ ll ' i~~ ~_ .T ~~~ i o _ ~ -~ ~ S c 0 X ~ d t7 Q ~ y r ~~~ ~ S ,.. ~ (~ J ~ x ? d Q ~~.. ~ V ~ Q -- -__ J aJ v = y Q ~ U = y ~ 7 o C7 n ~° n H . _ `A ~ s .^ ~ ~ ~ cn et r v ~ ~' o y ~ _ ~~ o y .v . J ~ ~~ X -- v ~ ~+ <v x - 3 i ~ ~~_ -- _ N 7 y f n y O lV y _. • + ~ . ~Y ~V } N ~ ~ ~ ~~~". _ ._ C _ N ~ ~ W ~[ ~ Y ~ y ? a ~ ~~ ~ a ~ o ~ V ~ c y _ ~ ~ ^ t. r.. v ~~. ._ _ Q _ n d C y a o us - v~ 7 W t0 4 rtJ __.__ - _ y ~ m y _~ i_ i N '~ W Q7 ~ ~ = i ~ __ J~ y (n ~ C r+ X i ~ ~ ~_ ~ _ ~ _~ ~~~~ M ~- y a °' i U N ~ ~"~ o y a ~ x .- X C p ~ ~ v- U _ Q ~ O ~ ~~ `T c 7 1 = 3 m X c~ a a q Q y~ v s ~' ~ ~~'cn _ u- -~ v X° i N p '~ ~ o ~ Y ~ ~ _- # X y 5 _v ~ Q ~ _ 2 is ~ y ~ m ~ cn N ' - ~ ~ - e _ ~ '- m Q of V - v V ~ O T y - -• i C J y \~ The aPS Store - #3763 275 Cumberland Parkway hlect-,anicsbt.;rg, PA 17055-5677 (717; 195-x818 05/24/11 11;30 .4M 6Ve are the one step for all your shipping, postal and business needs, i~+e offer ai I tiie services yeu need ro keep yo~.,r business going, ~~:~~01 500012 (003) T1 $ 0.90 8.5X11 CENTER COPY QTY 6 Reg Unit Price $ 0.15 SubTotal $ 0,90 SALES (Tlj $ 0,06 Total $ ~`~_'96"~ Cash $ 1,00 Change $ 0,04- Receipt Iu 829!1933005096888835 006 Items CCH: KI~~BERL'r' Tran: 9438 Reg; 002 Thank you for visiting our store. Please come back again soon, i'?~~:atever yoar i~us mess anal personal needs, we are here to serve yu~,. ENTER rOR A CHANCE TO bJIN $1000 file value your feedback To enter please complete the customer satisfaction survey located at: wt,~w.theupsstore,com/survey ~cr official roles and Terms and ~~~~mditions go to www,theupsstore,com end dick on the Customer Experience Survey link l~-~ C._ ~ r that was easy: Low prices. Every item. Every day. Store N o:843 5850 Carlisle Pike Mechanicsbury, PA 17055 (717)785.7580 251525 XX 025 485;15 Receipt #: 48535 VISA #: XXXXXXXXXXXX8084 11118!11 14:58 City Descnptiun Aniaunt 12 E3W SS P~5S LtrlLyl•832551 ~ py SubTotal 1 U8 STANDARD TAX 0.06 Total ~ 1 i4 The Cardholder agrees to pay the Issuer of the charge card in accordance with the ayreernent between the Issuer and the Cardholder. Compare and Save with Staples•brand products. THANK YOU FOR SHOPPING AT STAPLES' A'I!NIA'llp~'IPI~IM1il~~'Ip'p~N!IVN~~I ~~''lUll +~ttwrr,rrm ritrk rr,r+~txr,ti-rr *Y*+~kt. The total charge on your card will include multiple transactions reflected on this receipt. ..+.Wyk,YtH.,Yt+....~.y-.,,f...,..tt„ NOTE: (1) File Inheritance Tax Returns in the Register of Wills Office (2) Must be filed in Duplicate (3) $15 Filing Fee (4) A link to these forms may be found at www.ccpa.net/row (can be completed on-line and printed for filing) PAS TO THP. URDPR OF_ ESTATE OF HARRY D. REEL RICHARD A. REEL, EXECUTOR PH. 717-432-4947 610 MT. AIRY RD. LEWISBERRY, PA 17339 6 313 56117 „ATE h~U 2e)( .its.. ~ w ~~ v I .r~"'~ /~M&T Banlc aaaa~ - Me haniaburq Offca 6-~. d~ ~~ t ~ 109 C ,,qq DOLLARS IJIJ{~~~~....,,~.., 1VJOLLV~.~..~.ITM }~ r 1 ~' I \1 E.11 U ~ ~~i ---- ------ -- h,T, ~:03L302955~: 9853LL095611'OL09 ~' Darryl K. Guistwite, D.O., lnc. ('`~' ~ K `` t ~ t 56 Ashton Street ~ ' - ~ ' ..r_ Carlisle, PA 17015-6914 Darryl K. Guistwite, o.o., inc. (717) 609-2639 56 Ashton Street Carlisle, PA 17015-6914 HARRY D. REEL C/O RICHARD REEL 610 MT. ALRY ROAD LEWISBERRY PA 17339 04/16/11 ~. 88.0 (1) .Date Description Charge Credit HARRY D. REEL ( 88.0} O1/10/11 NURSING HOME EST. PATIENT 75.00 02/10/11 Ins Pmt-MEDICARE 40.50 $13.54 was applied to your de uctible 02/10/11 Adjustment 10.84 04/13/11 $23.66 was applied to your de uctible 01/27/11 NURSING HOME EST. PATIENT 105.00 02/23/11 Ins Pmt-MEDICARE 67.44 02/23/11 Adjustment 20.70 04/13/11 $16.86 was applied to your de uctible 01/31/11 NURSING HOME EST. PATIENT 75.00 03/02/11 Ins Pmt-MEDICARE 51.33 03/02/11 Adjustment 10.84 04/13/11 $12.83 was applied to your de uctible T TAL FOR RY D. REEL ~- ( Total Due Current 31 - 60 Days 61 - 90 Days 91 -120 Days Over 120 Days 53.35 53.35 0.00 0.00 0.0 0.00 04/16/11 ;! 88.0 Detach this stub and return with payment Balance Date 88.0) 23.66 01/10/11 16.86 01/27/11 12.83 53.35 01/31/11 . ~ Please pay this amount! Detail Statement of Services For Your Records ~~u ''~ "'f` r " Account: Reel Jr, Harry D (188672) Due Date: April 20, 201 1 <'K~ Program: Consult-Older Adult Statement Date: April 5, 201 1 Admit Date: 11/12/2007 Previous Statement Balance: $0.00 Discharge Date: Payments Received Since Last Statement: $0.00 Total New Charges: $8.66 Amount You Now Owe: $8.66 Primary Insurance: Medicare (A & B) (02/01/1982) Secondary Insurance: Aefia (02/16/20091 Payments Received Since Your Last Statement: .~ T ~;~'°srr~~ri:^f ,-~p~-'~_~. , 7'15 r "~~~, _ ~ - h~'~ "F~ a SX_ _ ilj' -} ~l c ~.~\ `! may? S Jc. ', ,f 3 2 t 'Fa~m'~nl•~)r r ~~ ~ ~ ~~ +,~ ~ n _ , , lwf'estriptk • '=,.- ~ i". ~~ - -, - - Total New Charges or Services Since Your Last Statement: u~t_iaf.~tia'~. 3 ~1L~~i~St1~iv~` F ~~~ik~~T~' ~ ~'+"~ 2/07/2011 arlisle y,99862 Med Management Nursing Home $85.0 $g,6 --- - edicare (A & B) - 03/08/2011 $45.501 $28.1 -_ -- _- ---- -- ---- - I1 -_ -__ Aetna 03/21/2011 $2.72~~ $0.0 - f Total New Charges: $8.b f - _ _ _ - Balance Fornard: $O.C __. - - - Total Payment Due: $8.b 4427-194 (188672) Page 1 of 1 Detail fs r PO Box 550 Mt Gretna, PA 17064 ;Phone (888) 302-4710 Ext. 2413 or (717) 270-2413 zlh~~e Business Office Hours: Monday through Friday 8:00 am - 4:30 pm Pruno+l»S Ibp~ haoAn;md wholrnrss Please remit the balance in full within fifteen (15) days using the enclosed reply envelope. Our office accepts checks and credit cards. If you are unable to pay your balance in full or need assistance in understanding your statement, please contact our office at (717) 270-2413 or toll free at 1-800-932-0359, ext 2413 Monday -Friday 8:OOAM - 4:30PM. Someone will be glad to assist you. 'Thank you for choosing Philhaven for your healthcare services. 0-59 ~ ..-~ _ Z ilhavE ~t ~',. PO Box 550 Mt Gretna, PA 17064 ;Phone (888) 302-4710 Ext. 2413 or (717) 270-2413 Business Otlice Hours: Monday through Friday 8:00 am - 4:30 pm f'roma ink Mpti h~n6nt and w ~'.1 1'~ !~~ ~~ ~ 'Z v ( c ~ k ~t i ~ ~4 CONTINUING CARE RX ?8 S SECOND 5T NEWPORT PA 17074 ## S T A T E f'1 E N T## Statement Date: 3/31/11 Page: 1 Account #: 100042494 HARRY REEL RICHARD REEL 610 MT. AIRY ROAD LEWTSBERRY, PA 17339 Date Description Clty Amount Previous C3alance 134.70 3103/11 RX# 0270342 ATROPINE 1'/. EYE DROPS 5ML i f0. 00 COPAY 3/10/11 RX# 3284793 ATROPINE 1'/. EYE DROPS 5ML 1 10.00 COPAY 3/10/11 RX# 9204762 LTDOCAINE f% 20ML VTAL 20 5.27 Ending balance - Pay this amount ---------~ 159.97 Past Due Past Due Past Due Current 31-b0 days 61-90 days 90+ days 25. 27 134. 70 . 00 . 00 QUESTIONS PLEASE CALL i-B00-675-2279 EXT:1304 Plea se cut here and remit this portion with payment Remit to: CONTINUING CARE RX 5775 ALLENTOWN BLVD SUITE 141 HARRISQURG, PA 17112 Name: HARRY REEL RICHARD REEL 610 MT. AIRY ROAD LEWI5IiERR'Y, PA 17339 ~-3 . Statement date: 3/31/11 Account #: 100042494 COG Ending balance: 159.97 Amount enclosed: RESIDENT STATEMENT FROM CHURCH OF GOD HOME, INC 801 N HANOVER STREET CARLISLE, PA 17013 717-249-5322 Statement Date Due Date ACCOUNT NUMBER 03/31/2011 Upon Receipt 802776 10 AMOUNT PAID $ Please make check payable to CHURCH OF GOD HOME, INC HARRY D REEL JR c/o RICHARD.. REEL: 610 MT. AIRY ROAD LEWISBERRY, PA 17339: Remit To• CHURCH OF GOD HOME, ING 801 N HANOVER STREET CARLISLE, PA 17013 Please detach and return this portion with your remittance to the address above. Comments ~`'( y ~~ zc'« Please contact Michele Shughart at Ext. 3095 with any billing questions you may have. Thank you. ___ C' K ~ JaS' $0.00 ~ $(66.29) ~ $850.39 $0.00 ;I $0.00 $784.10 _- Date;. _ - Description ^ - ` ! Daysl Rate Chargesf TPayments ~f Bafance ~ Units... (Crect~t} - ',, __ __ _; Balance Forvvard $7,822.39 $7,822.39 02/15/11 - 02/15/11 Copies pg 1-20 (20) $1.28 $(25.60) $7,796.79 02/15/11 - 02/15/11 Copies pg 21-60 (40) $0.95 $(38.00) $7,758.79 02/15/11 - 02/15/11 Copies pg 61 & up (22) $0.32 $(7.04) $7,751.75 02/28/11 - 02/28111 rt Check # rt $(6,225.00) $13,976.75 02/28/11 - 02/28/11 rt Check # rt $6,225.00 $7,751.75 03/04/11 - 03/04/11 Laundry 1 $4.35 $4.35 $7,756.10 03/04/11 - 03/31/11 Room & Board (28) $(249.00) $(6,972.00) $784.10 TOTAL BALANCE DUE:. $784.10 ~J~ FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CHURCH OF GOD HOME, INC HARRY D REEL JR 802776 REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA CERTIFICATE OF GRANT OF LETTERS No . 20 1 1- 00426 PA No . 21- 1 1- 0426 Estate Of : HARRY D REEL JR /First, Midd/e, Lastl a/k/a : HARRY D REEL Late Of : NORTH MIDDLETON TOWNSH/P CUMBERLAND COUNTY Deceased Social Security No: 195-07-2017 WHEREAS, on the 1st day of April 2011 an instrument dated April 20th 1988 was admitted to probate as the last will of HARRY D REEL JR (First, Middle, Lastl a/k/a HARRY D REEL late of NORTHM/DDLETON TOWNSH/P, CUMBERLAND County, who died on the 4th day of March 2011 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: RICHARD A REEL who has duly qualified as EXECUTOR(R/Xl and has agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 1st day of April 2011. .~-- **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) ~~` ~FC:)`?~.:;;~%~ ~_~r SCE OF . ~~~~J~,~ ~'.. ,t~q~C ?~1 ! APR - l PFi 3~ 40 CLERK OF LAST WILL AND TESTAME.N'P ORPHANS COURT of Ct1M8ERLAI~D CO., PA HARRY D. REEL, JR. also known as HARRY D. REEL I, HARRY D. REEL, JR., also known as HARRY D. REEL, of the Borough of Camp Hill, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament, hereby revoking any will previously made by me. I - I direct the payment of all my just debts and funeral expenses out of my estate as soon as may be practical after my death. II - I devise and bequeath all of my estate of whatever nature and wherever situate unto my wife, Ruth L. Reel, providing she survives me by sixty (60) days. III - Should my said wife fail to be living on the sixty-first (61st) day following my death, then I devise and bequeath all of my estate of whatever nature and wherever situate unto my sons, Richard A. Reel and David D. Reel. Should Richard A. Reel predecease me, then his share shall be paid to my son, David D. Reel, or his issue per stirpes. Should David D. Reel predecease me, his share shall be paid to his issue per stirpes. II __. ~ ~ / ..~ ~ AR?~O1,D & SLIKE, ;.rTnk~~EVS,~i-i.:~~ t~n~i ~~t~~k~;r.r sTUF.r_r. ~.~~iP rni.i.. i,_•, ~-oi ~: Page 1 ~ IV - I appoint my wife, Ruth L. Reel, Executrix of this, my Last Will and Testament. Should my said wife fail to qualify or cease to act as such, then I appoint my sons, Richard A. Reel and David D. Reel, to act in this capacity. None of my personal representatives shall be required to post bond in this or any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal on this the G'-~'j day of ~r'r/ 1988. ~' ~ ( SEAL ) Harry D. eel, r. Also known as: °~`~ (SEAL) Harry D. eel Signed, sealed, published and declared by HARRY D. REEL, JR., also known as HARRY D. REEL, Testator therein named, on this and one (1) other sheet of paper as and for his Last Will and Testament, in our presence, who, in his presence, at his request, and in the presence of each other, have hereunto subscribed our names as attesting witnesses. / Name ~~~ Name ~ i ~~ , Address ress \RNOLD & SL.IKE. ~~n~~rt~~tivs~nr~i_,~~~~.zuw,~i;~xr:e.i srsE.[:r <.,~n~t~riu.t- v,~ i,~~:~~ Page 2 COMMONWEALTH OF PENNSYLVANIA) SS. COUNTY OF CUMBERLAND) WE, the undersigned, the testator and the witnesses, respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testator signed and executed the instrument as his Last Will and Testament and that he signed willingly (or willingly directed another to sign for him), and that he executed it as his free will and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testator signed the will as witnesses and that to the best of their knowledge the testator was at that time eighteen-years of age or older, of sound mind, and under no constraint or undue influence. Subscribed, sworn to and acknowledged before me by the testato~, and subscrib and sworn to be re me by both witnesses, this -~_ day of 198 ~ . ~ ~~~~ Notary Public II JHELMA S. McCAUSI..!N, NOTARY PUBUC~ My Commission Expires July 3, 1588 temp Hifl, PA Cumberland County ARNOLD & SLIKE, ATTORNEYS-AT•LAW, 2109 MA0.KET STRf.ET. CAMP HILL, PA 17011 \~~~~ ~ . est r