HomeMy WebLinkAbout01-25-12 (2)1505610143
~ REV-1500 Ex (°'-'°' >;
PA De artment of Revenue ~ OFFICIAL USE ONLY
p Pennsylvania County Coda Year File Number
Bureau of Individual Taxes aEP/,RIMEMOFREVENUE
Po Box.zaosol INHERITANCE TAX RETURN 21 11 0 5 4 7
Harrisburg,. PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
205 09 9272 04 28 2011 06 15 1921
Decedent's Last Name Suffix Decedent's First Name MI
HOUCR AGNES C
(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
REGI STER OF WILLS
FILL IN APPROPRIATE OVAL5 BELOW
® 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death
prior to 12-13-82)
^ 4. Limited Estate ^ 4a. Future Interest compromise ^ 5. Federal Estate Tax Return Required
(date of death after t2-12-82)
Q
® g. Decedent Dletl Testate
(Atlaoh Copy of Wtll) ^ 7. Decedent Maintalnetl a Living Trust
(Atteeh Copy of Trust) 8. Total Number of Safe Deposit Boxes
^ 9. Litigation Proceeds Received ^ t 0. Spousal Poveny creda (date a death t t ,Election to tax under Sec. 9113(A)
~
Detwaen 12-37-91 and t-1-95) (Attach Sch. O)
CORRESPONDENT • THIS SECTION MUST BE COMPLETED. ALL
Name
KEITH D WAGNER
Firet line of address
6 E MAIN STREET
Second line of address
PO BOII: 323
City or Post Offiee
PALMYRA
Correspondent's e-mail address: keith~bwzlaw.COm
AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Daytime Telephone Number r a
717 838.,48 ~ ~
r
State 21P Code
PA 17078
REGISTER OF
DATE FILED
"p
Z
..
O
r~
t'ri r~i
t~
examined this return,
reparer other than the
schedules and statements, and to the best or my knowledge and belief,
is based on all information of which preparer has any knowledge.
Gerald J. Brinaer
6 E. Main Street
P.O. Box 323,~Imyre, PA 17078
~~ZY~i L
DIUIVg1URG t1F Yr}rr~q r{VII'Itr(1/1gIV r(tF'KtJtIVIAIIVt DATE
-~,/~~/ Keith D Wagner ~~ z y~, z
ADDRESS / ~
6 E. Ma Street, Palmyra, PA 17078
Side 1
L 1505610143 1505610143 J
Vv~
.J
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedents Name. HOUCK, AGNES C. 205 09 9272
RECAPITULATION
1. Real Estate (Schedule A) ......................................................................................... . 1.
2. Stocks and Bonds (Schedule B) .............................................................................. . 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... . 3.
4. Mortgages & Notes Receivable (Schedule D) ........................................................ .. 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... . 5. 7 4 , 3 2 6.41
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ............ . 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ^ Separate Billing Requested ............ . 7.
8. Total Gross Assets (total Lines 1-7) ...................................................................... . 8. 7 4, 3 2 6. 4 1
9 6 , 2 4 8 . 0 7
9. Funeral Expenses & Administrative Costs (Schedule H) ........................................ .
.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. .. 10. 1 6 , 9 7 8 . 3 7
11. Total Deductions (total Lines 9 & 10) .................................................................... .. 11. 2 3 , 2 2 6 . 4 4
12. Net Value of Estate (Line 8 minus Line 11) ........................................................... .. 12. 5 1 , 0 9 9 . 9 7
13. Ctraritable and G,~vemmental Bequests/Sec 9113 Trusts for which
' 5 0 8 4 9 . 9 7
election to tames not been made (Schedule J) ........................_.....................
ar; .. 13. ,
14. c„;,
;~:~.,
Nfpt.Value~ ~~to Tax (Line 12 minus Line 13) ...............................................
.. 14.
250.00
TAX C0IAAPU +BEE INSTRUCTIONS FOR APPLICABLE RATES
15. AMOunt o irte l~laxable
atthe spoai5sl.f8x:Xdte, or
trapsfers Und~r$pe: 9116
X16. ArticWnt of Line 1~~13xable
at liAeal rate X .045 16.
17. Amount of Line 14 taxable
17
at sibling rate X .12 .
18. Amount of Line 14 taxable
0 0
2 5 0
18.
3 7. 5 0
.
at collateral rate X .15
19. Tax Due ................................................................................................................... .. 19. 3 7 5 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505610243 1505610243 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21 - 11 - 0547
Houck, Agnes C.
STREET ADDRESS
Messiah Village
641 OakAva
CITY
Mechanicsburg STATE
PA ZIP
77055
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments
B. Discount
3. Interest
4. If line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check boz 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)
(1) 37.50
(2) 0.00
(3) 0.00
(4)
(s) 37.50
Make Check Payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred :.................................................................................. x
b. retain the right to designate who shall use the properly transferred or its income :.................................... x
c. retain a reversionary interest; or .................................................................................................................. x
d. receive the promise for Iffe of either payments, benefds or care? .............................................................. x
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ....................................................................................................................... ^
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... ^ ^x
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ...................................................................................................................... ^
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)j.
For dates of death on or after January 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. §9118 (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 rettum 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 irensfers from a deceased child 21 ears 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 p2 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) . A
sibling is defined under Section 9102, as an individual who has at least one parent in common wdh the decedent, whether by bloo~ or adoption.
SCHEDULE E
CASH, BANK DEPOSITS, ~ MISC.
CCNMONWEALTN OF PENNSYLVANIA PERSONAL PROPERTY
INNERRANCE TA% RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF HOUCk, Agnes C. 21 - 11 - 0547
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 DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 PNC Bank -Certificate of Deposit #31400315787 10,334.07
(Includes accrued interest of $42.33)
2 PNC Bank- Certificate of Deposit #31500314938 5,149.03
(Includes accrued interest of $3.16)
3 PNC Bank -Certificate of Deposit #31900316200 10,298.06
(Includes accrued interest of $6.32)
4 PNC Bank -Checking Account #50-0488-2971 10,435.58
(Includes accrued interest of $0.21)
5 PNC Bank -Money Market Account #50-0488-4627 1,748.92
(Includes accrued interest of $0.19)
6 Miscellaneous Personalty -Sale Proceeds 280.00
7 (2) Leather Chairs -Retained 250.00
8 Verizon -Refund 16.15
9 Mutual of Omaha -Medical Reimbursements 6,100.00
10 Messiah Village -Refund on Apartment 28,102.00
11 Cash on Hand 286.49
12 Miscellaneous Jewelry -Sale Proceeds 330.00
13 Final Annuity Payment 996.11
TOTAL (Also enter on Line 5, Recapltulatlon) ~ 74,326.41
COAMONWEALTN OF PENNSVLVANfA
MNERRANCE TAX RETURN
RE61DENi DECEDENT
SCFf.DI~E H
~F~UyI~~~iA~LpD~ S 8r
I"IId1~~~71 rW~
FILE NUMBER
ESTATE OF Houck, Agnes C. 21 - 11 - 0547
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT
A. 1 Hetrick-Bitner Funeral Home 41.75
2 Messiah Village -Funeral Luncheon 100.00
3 Jane Long -Pianist 75.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Gerald J. Brinser
street Address 6 E. Main Street, P.O. Box 323
city Palmyra state PA zip 17078
Year(s) Commission paid 2011/2012
2. Attorney's Fees Brinser, Wagner ~ Zimmerman -- Keith D. Wagner
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills (Ctrs. Pd. $90.00 = $25,001 - $50,000)
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1 Register of Wills -Additional Cost of Letters
3, 750.00
1, 800.00
145.50
45.00
TOTAL (Also enter on line 9, Recapltulatlon) g,24$,p~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Schedule H
Funeral F.~er»es 8~
1+1.7
ESTATE OF Houck, Agnes C. FILE NUMBER
21 - 11 - 0547
2 ~ The Sentinel -Legal Advertising
3 ~ Cumberland Law Journal -Legal Advertising
4 ~ Register of Wills -Filing Fees (REV-1500 and Inventory)
5 I Venzon -Phone
125.82
75.00
30.00
60.00
Page 2 of Schedule H
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
D~eR` µ E~A%RETURN~w LIABILITIES, ~ LIENS
RESIDENT DECEDENT
ESTATE OF HOUCK
Agnes C. FILE NUMBER
, 21 - 11 - 0547
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
1 Alert Pharmacy 32.36
2 Center for Neurological Health 470.71
3 Hospice 100.00
4 Verizon -Phone 29.84
5 Celtic Healthcare, Inc. 46.00
6 P P & L -Electric 51.55
7 Capital Area Health Association 146.00
8 Messiah Village -Final Bill 16,101.91
TOTAL (Also enter on Line 10, Recapitulation) ~ 16,878.37
REV-t S7 3 EX+ (17-08)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDEM
SCHEDULE J
BENEFICIARIES
ESTATE OF Houck, Agnes C. I FILE NUMBER
21 -11 - 0547
NUMBER NAME AND ADDRESS OF PERSONS
()
RECEIVING PROPERTY RELATIONSHIP TO
DECEDENT
Do Not List Trustee(s) SHARE OF ESTATE
(Words) AMOUNT OF ESTATE
($$a)
I, TAXABLE DISTRIBUTIONS[include outright spousal
dlstnbuhons, and transfers
under Sec. 911 B (a) (1.2)]
1 Joanne Taylor None Personalty - 250.01
Messiah village (2) Leather Chairs
100 Mt. Allen Drive
Mechanicsburg, PA 17055
Eller dollar amounts for distributions shown above on lines 15 t hrough 18 on Rev 1500 cover she et, as appropriate.
II NON-TAXABLE DISTRIBUTIONS:
. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1 Messiah Vllage, 100 Mt. Allen Drive Residue of Estate 50,849.97
Mechanicsburg, PA 17055
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI 50,849.97
c~
~' , ,,
,,^,
., , ~ ,
-
~~ :~
, '
WILL ~T~-,
: `:,
_ , ,~;
_~:-~ ,.- -
AGNES C. HOUCK :n-~ ~~= c~
--;
,
I, AGNES C. HOUCK, currently of Upper Allen Township, Cumberland
County, Pennsylvania, declare this to be my Last Will and Testament, hereby revoking
any and all prior Wills and Codicils made by me.
I. I direct that all my just debts and funeral expenses be paid from the assets of my
estate as soon as practicable afier my demise.
II. I direct that all estate and inheritance taxes that may be assessed in consequence
of my death, shall be paid out of the principal of my general estate to the same effect as if
said taxes were expenses of administration and all property includable in my taxable
estate whether or not passing under this Will shall be free and clear thereof.
III. I bequeath unto my friend, Joanne Taylor, my two (2) red leather chairs. If she
predeceases me this bequest shall lapse and pass as part of my residuary estate belaw.
IV. All the rest, residue and remainder of my estate I devise and bequeath unto
Messiah Village, Mechanicsburg, Pennsylvania, to be used in its Endowment Fund.
V. I appoint Gerald J. Brinser Executor of this my Will. In the event that he fails to
qualify or ceases to act as Executor, I appoint Keith D. Wagner Executor of this my Will.
VI. I direct that no bond be required of my fiduciaries for the faithful performance of
their duties in any jurisdiction.
IN WITNESS WHEREOF, I, AGNES C. HOUCK, herewith set my hand to this
my Last Will, typewritten on two (2) sheets of pa er including the attestation clause and
signatures of witnesses, this I(o~' day of ~~~ , 2008.
~~ ~~ SEAL)
A S C. HOUCK
..
Signed by AGNES C. HOUCK, by her declared to be her Will in our presence,
who h ve hereunto subscribed our names as witnesses in her presence and at her request,
this /~ day of ~QA, , 2008. ~/^/~
~~.Q, ~ residing at
~ residing at
-2-
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF LEBANON
WE, AGNES C. HOUCK, GERALD J. BRINSER and Gw~yk..k ~- ~ ~-s ,
the testatrix and the witnesses, respectively, whose names are signed to the attached or
foregoing instrument, being first duly affirmed, do hereby declare to the undersigned
authority that the testatrix signed and executed the instrument as her Last Will and that
she signed willingly (or willingly directed another to sign for her), and that she executed
it as her free and voluntary act for the purposes therein expressed, 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 our knowledge the testatrix was at that time eighteen years of age or
older, of sound mind and under no constraint or undue influence.
C. ~~
HOUCK
._-_
WI SS
Subscribed, sworn or affirmed and acknowledged before me by AGNES C.
HOUCK the testa nx, GERALD J. BRINSER and C'1^ ~y f~~ w ~ µ s ,witnesses,
this r~D~~day of ~~a~.f~1v, 2008.
AL)
otary Public
eOMMQNWLrALTM OF PENNSYLVANIA
NOTARIAL SEAL
bVENDY L. CRAWFORD, Notary Public
Palmyra Boro.. Lebanon County
M Commission Ex fires Se temper 10, 2009
-3-
Jan, 20. 2012 2:30PM PNC BANK
No, 0210 P. 1/2
~~`
~ow6tkEw~tr
January 20, 2012
Brinser Wagner & Zimmerman
6 East Main St Second Floor
P O Box 323
Palmyra, PA' 17078
1tE: Namc: Agnes C Houck
SSN: 205-09-9272
DOD: 04-28-2011
Dear Sir/Madam:
In responsc to your request for Date of Death (DOD) balances for the customer noted above, our
records show the following:
Certificate of Deposit
Account # 31400315787 Established: 07-10-2007
AGNES C HOUCK
DOD balance: $10,291.74 + 42.33 accrued interest
Account# 31500314938 Established: 07-10-2007
AGNES C HOUCK
DOD balance: $ 5,145,87 + 3.16 accrued interest
Account # 31900316200 Established: 07-10-2007
.. AGNES C HOUCK
DOD balance: $ 10,291.74 + 6.32 accrued interest
Checking Account
Account# 5004882971 Established: 02-13-2006
AGNES C HOUCK
DOD balance: $ 10,435.37 + 0.21 accrued interest
Savings Account
Account # 5004884627 Established: 02-21-2008
AGNES C HOUCK
DOD balance: $ 1,748.78 + 0.07 accrued interest
Page 1 of 2
___ _ _ _
Jan, 24, 2C?~2 1,19PM PNC BANK ~No, 0182 P, 2/2 ~
i
I
1
I
Please notc that this office provides date of death balances for deposit accounts (IRAs, CDs, Checking and
Savings). We do not process any Snancial transactions or provide statement. !f you need assistance with
any of these items, please call 1-888-PNC-BANK (i-888-762-2265) or stop by your local PNC Bank branch
o#~ice.
Sincerely,
National Financial Services Center
PNC Bank, N.A.
Member FDIC
This message is intended far the use of the individual or entity to which it is addressed and may
contain informs#on that isprtvilegec~ confidential and exempt from disclosure under applicable law.
If the reader of this message is not the intended recipient or the employee or agent responsible for
delivering this message to the Intended recipient, you are hereby notified that any dissemination,
distribution or copying of this communications is strictly prohibited. If you have received this
communication in error, please notes me immediately by reply or by telephone at 800-762-1775 and
immediately destroy this faxed document.
Page 2 of 2
R
~ ~ ~ . ~ ~ g>
Account Number Due Date Amount Due
:" °~ 717 790-2271 45653Y $.00
•
ver~on
Don't Move Without Verizonl
Call 1-888-416-9691 before you move. We'll help
set up your Internet, TV & Ptwne for your new address.
You can be up & running in no time! DON'T WAIT! And
be sure to ask ii FiOS is available in your area. Service
i ~
VERIZON CRG
I ~~ 185 FRANKLIN ST
n
Acxount Information
Statement Date: B/14/11
AGNES NDUCK
Phone: 717-790-2271
Account Summary
Previous Balance $60.00
Payments Received -$fi0.00
Adjustmerds and Credits
__ _ $76.15
- __
Balance Forward tA0
New Charges
VERIZON PA
FLOOR 6 BOSTON, MA 02110.1511
0005663277'
Number
717/790-2271 CREDIT BALANCE REFUND
DATE TELEPHONE NUMBER TOTAL REFUND
06/15/11 7177902271 $16.15
I ~
I
SJ 1
I
~S I I~
~' ~ 1
I
FOR ANY QUESTIONS, PLEASE CALL 800/483-3000 16.15 I
i • a ~ • •~ a ~• ~ •
I I
to Processed 04-25-11 Patient AGNES C HOUCK Certificate Number: 021129768
:~~rR~ er.NFC c Noucl< Draft Numberoo22141z Claim Number=-5s,341o142tooR oio
Less Charges Less Benefit
Provider Name Date of Service Nature bmitted
S Not Covered Deductible Remaining Remaining
PolicylPlan Number From To Service u
Charges Amount o° Amount Charges % Amount Amount
~SIAH VILLAGE 30111 040111 NRS CARE 9375.00 6275.00 1 3100.00 1 3100.00
1598-98M
DAYS 100.00/DY ____-~"~
'. ACCT !r: U
~,
`I
I ~ ~
3
~~
TOTAL 9375.00 3100.00
PAYMENT SUMMARY
Benefits Paid To:
C/0 WILLIAM HOUCK
Amount 3 ~ , ~
3100.00
NOTES:
1 THE DAILY RODM AND BOARD CHARGE EXCEEDS THE DAILY ROOM LIMIT.
PLEASE RETAIN FOR YOUR RECORDS - ADDRIONAL
DATE PROCESSED: OCT 27 2011 PATIENT:
INSURED: AGNES C HOUCK PLAN NUMBER: 864598-98M
021129768
CLAIM NUMBER: 583410142100 014
~n,
~~ ~ ~~)
Hetrick-Bitner Funeral Home, Inc.
3125 Walnut Street
Harrisburg PA 17109
Phone # 717-545-3774
Invoice
Date Invoice #
5/ 11 /2011 2749
Bill To
Gerald Brinser
6 East Main St.
Palmyra, PA 17078
Terms Due Date Client
COD 5/II/2011
Qsanttty Description Rate Amount
Memorial Folders 50.00 50.00
Obituary in Patriot News 83.36 83.36
9t`a ~ a pleaouxe ura u~~~~ Total $133.36
~~ A,
" Payments/Credits $-91.61
~
~.'
K .s'
Balance Due
541.75
~~s ~h~
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH Receipt Date: 5/05/2011
Cumberland County - Register Of Wills Receipt Time: 14:15:54
One Courthouse Sqquare Receipt No.: 1065501
Carlisle, PA 17Q13
tl ~
HOUCK ES--C
Estate File No.: 2011- 00547
Paid By Remarks: GERALD BRINSER
DB
------------------------ Receipt Distrib ution ------ ------- ------- ----
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 90.00 CUMBERLAND COUNTY GENERAL FUN
WILL 15.00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 12.00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN
Cash ----------------
$145.50
Total Received......... $145.50
'f! a Sentinel
ww~wj.cumberlink.com
~y~G
c.~e,"~;e'~:-a-r=a~riseuee~c ~aa~ cairrv
ZIMMERMAN BRINSER, WAGNER 8:
6 E. MAIN STREET, 2ND FL.
P.O. BOX 323
PALMYRA, PA 17078
717$38348
AD NUMBER PAGE NO.
398242 1 of 1
BILL DATE SALESPERSON
06/22N1 wolfs
START DATE STOP DATE
06/08/11 06/22/11
398242 NOTICE NOTICE IS HEREBY GIVEN THAT 1 10 PUBLIC NOTICES 122 ' 2 cols I
Publication Insertions Rate Net Amount Gross Amount
3 THE SENTINEL -LEGAL 3 LGL $116.82
TOTAL AD CHARGE $116.62
3 MOBILE SITE M082 $2.00
3 PROOF OF PUBLICATION 01PRF $7.00
Purchete Girder Est.Agnes Houck PAY THIS AMOUNT $125.82 $150.98*
•AFTER 07!17/11
THE SENTINEL
Thank you for advertising with The Sentinel! Deadline for Go LEE NEWSPAPERS
in-column legal ads is 4:00 p.m. two business days prior to PO BOX 540
date of insertion. For questions, call (717) 240-7130. WATERLOO IA 50704-0540
~GG~y~
Notary Public
My commission expires:
NOTARIAL SEAL
BAM81 ANN HECKENDORN
Notary Public
CARLISLE BOROUGH, CUMBERLAND CNTY
My Commission Expires Jan 27, 2014
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, PA 17013
Tele: (717) 249-3166 Fax: (717) 249-2883
July 1, 2011
Cumberland Law Journal is published every Friday by the Cumberland County
Bar Association and is designated by the Court of Common Pleas as the official legal
publication for Cumberland County and the legal newspaper for publication of legal
notices.
TO: Keith D. Wagner, Esquire.
RE: Agnes C. Houck Estate
Legal advertisements must be received by Friday Noon. All legal advertising
must be paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on the following dates:
June 17, June 24, and Juty 1, 2011
Advertising Cost $ 75.00
Proof of Publication $ 0.00
Second Proof Request $ 0.00
Payment received $ 0 .00
Total Amount Due $ 75.00
Payment received by
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16, 1929), P. L.1784
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
ss.
Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and
State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law
Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid,
was established January 2, 1952, and designated by the local courts as the official legal
periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly
issued weekly in the said County, and that the printed notice or publication attached hereto is
exactly the same as was printed in the regular editions and issues of the said Cumberland Law
Journal on the following dates,
viz:
June 17, June 24, and July 1, 2011
Affiant filrtller deposes that he is authorized to verify this statement by the Cumberland
Law Journal, a legal periodical of general circulation, and that he is not interested in the subject
matter of the aforesaid notice or advertisement, and that all allegations in the foregoing
statements as to time, place and character of publication are true.
isa Marie Coyne Editor
SWORN TO AND SUBSCRIBED before me this
1 of July, 2011
Houck, ~a C., deed.
Late of Upper Allen Township.
Executor: Gerald J. Hrinaer, En-
quire, 6 East Main Street, P.O.
Box 323, Palmyra, PA 17078.
Attorney: Keith D. Wagner, Es-
quire.
Notary
NOTARIAL SEAL
DEBORAH A COLLINS
Notary Public
CARLISLE BOROUGH, CUMBERLAND COUNTY
My Commission Expires Apr 28, 2014
__
U ~ UUUUU
V~ Ql ri V~ O N to O N
• errw~ouiooa~
N rl N rl O r7 M O N
N ri r-I
N
~ O
~ o O o O O O O O O
7D O O O O O O O O
O
r
r-I
a
m
ui
c~
'-r
z ~
H lf5
a o
a
m
a
~+ ~
a
~ 'cN 01 rl W O N 4fl O N
x wrm~ovloow
• N N ~"~ N rl O rl Y~1 O N
N
W
a
a
x
o
~..~ ~ O O 0 0 0 0 0 0
F
Q
mooo~.1 ~~7 ~ ~'
• (x7 N O Ch N O ~7
~
° ~
W H
~i N
O
V' ~
•
p~
O
°~ ~~OHa°QO
Q
w
a ~ O
~
~
~
~°'Oo
W
°
H a~
o
~
a ~
~~u~~~~~
w
~ ~
u pa w 1n~
O N N rl ri ri N N r-I ~
. x
N fJ1 O 1D r C1 N O
u (~' 0 0 l0 r tll IL1. b~
W 0 N O ri r'1 r-I ri r-I 111
w N 711 Q7 7q 01 01 01 r
00 W DD W tD tD W ID
~ ,
}+rr rrrrrr
E
E
-1
ri ri r-I ri rl rl r~l rl rl
U r+1 ri N ~ ~ ut N to O1
O rl ri e-1 e-l e-1 c-f rl c-1
• sr V~ V~ d~ d~ d~ d7 eN sN
* o 0 0 0 0 0 0 0 0
W
O
H ~
M
O N
M
a
~~~
~W~ ao
ax N
~~ ~ N ~
~:
~ r-r
l
(~
~;
;a~~~
`~
w
II
J
o "~~
o
&'
~ ~
<a
~ n
M ~t1
N
M Ilf
#~ , ~
W
N O
Center of r Neurobehavioral Health
PO Box 526
Manheim, PA 17545-0526
(866)665-7983
Agnes C Houck
c/o Gerald J Brinser
7 E Main Street
Palmyra, PA 17078
BILLING STATEMENT
Cynthia Socha Gelgot, PhD
Robert Stein, PhD
Account #: 2088
Date: 05/04/11
Acct Balance: $ 470.71
Date CPT Description Charges Credits Open
09/10/10 90801 PSYC DX INTERVIEW XM 250.00 250.00
10/01/10 90816 IPI-OB-M/S I/P 20-30 MIN 75.00 75.00
10!15/10 90816 IPI-OB-M/S I/P 20-30 MIN 75.00 75.00
11/19/10 90816 IPI-OB-MIS I/P 20-30 MIN 75.00 70.71
12/26/10 Insurance 4.29
~~~~ ~I~
~~ T
Balance Due From Insurance: .00
Balance Due From Patient: 470.71
Keep Top Portion For Your Records
DETACH AND RETURN WITH PAYMENT Statement Date: 04/06/11
Agnes C Houck Amount Due Now: 470.71
c/o Gerald J Brinser
Palmyra, PA 17078 Amount Enclosed
Acct # 2088
Center for Neurobehavioral Health Questions: Please call (866) 665-7983
PO Box 526 Tuesday through Thursday 9:00 AM - 2:00 PM
Manheim, PA 17545-0526
CELTIC HEALTHCARE, INC
150 SCHARBERRY LANE
MARS PA 16046
Phone:724-625-4280
Date: 04/22/2011
Send remittances to the address shown above:
HOUCK, AGNES
100 MT. ALLEN DRIVE
MECHANICSBURG PA 17055
Services For:
HOUCK, AGNES
100 MT. ALLEN DRIVE
MECHANICSBURG PA 17055
CAR HM AETNA
DESCRIPTION
Total Amount Billed to Insurance Company , $ .175.00 _
'Less: Insuranca Company"Contractual'A11ow~nce? " '" -83.00
Net Amount Approved By Insurance Company 92.00
Less: Amount Paid, By Insurance Company,. -71,~g
Amount Not Paid By Insurance Company 20,72
Amount Due 20.72
~'~
~~" ~
p
TOTAL AMOUNT DUE $ 20 72
CELTIC HEALTHCARE, INC
150 SCHARBERRY LANE
MARS PA 16046
Phone: 72425-4280
Date: 04/20/2011
Send remittances to the address shown above:
HOUCK, AGNES
100 MT. ALLEN DRIVE
MECHANICSBURG PA 17055
Services For:
HOUCK, AGNES
100 MT. ALLEN DRIVE
MECHANICSBURG PA 17055
CAR HM AETNA
~ INVOICE FOR HOME HEALTH ;SNFgVICES~04/~i1201-`~ THRC3UGH 04/06/~0'f 1
DESCRIPTION
Total Amount Billed to Insurance Company..,,. „ $ ..175.00
Less: Insurance Company ContFactual Allowance -83.00
Net Amount Approved By Insurance Company 92.00 ~i
Less: Amount Paid By Insurance,Company ,
~ -66.72
~ ~~
Amount Not Paid By Insurance Company
~ 25.28
Amount Due 25.28.
~ TOTAL AMOUNT DUE $ ~ , 25.28
PPL Electric
Utilities
Electric
Service
For:
AGNES C HOUCK
sal oaK ovAr.
MECHAHICSBURG PA 17055
Qaestions about
this bill? Please
contact us Jun 3
at 1-500-34 -5775
(1-500-DIAL-PPL)
.. or write to•
Customer Service
827 Hausman Rs.
Allemown, PA
18104-9392
www.pplelectric.com
Electric
Use
This graph shows
your electric use
over the last 13
months.
Types of
Meter Readings:
Actual -
Adjusted
Estimates
Customer Q
3 i t
N 8 ¢ '
~.,s~,; ~~' Page 1
pp~ ~ ~ :.. ..:.::::..:..;~
§" ~ 12900-75027
Summary Page
Balance as of May 13, 2011
Char es:
Total~PL Electric Utilities Charges
Total Charges
Account Balance
KWH -Average Per Day
12
10
8
6
4
2
0
MJJASONDJFMAM
zolo Months zo11
$24.93
$26.62
$51.55
$51
010//__/~
~, TGP
Meter Reading Information
Meter #84532649
May 13 Actual 28591
Apr 13 Achlal 28451
30 Da s KWH Billed 140
Average -May 2010 2011
573 58
K Day 5
Yearly Use: Total
Use Aver^g
Monthly
Jun 2009 -May 2010 2811 234
Jun 2010 -May 2011 1859 155
Other important information on back ~
Bi111Vlatrlx will charge your credit and ATM card a service fee for making
this payment.
Before diggingg.. azound your home or property, you should always call the
state's One CaIl notification system to locate any underground utility lines.
You can do this by simpl dialing 811, which will connect you to the One
Call system. Be safe andyca1181I before you dig.
With pa~perless billing, you can receive and pay your PPL Electric Utilities
bills onfine. The process 1s free, quick, convenient and secure. To learn
more or sign up, v1s1t www.pplelectric.com.
Save postage and late charges -sign up for Automated Bill Payment.
New refrigerators use about half the energy as models made before 1979.
If you buy a new refrigerator, get rid of the old one. It's costly to keep two
units running.
~-
CAPITAL AREA HEALTH ASSOCIATES
100 MOUNT ALLEN DRIVE
MECHANICSBURG, PA 17055-6100
06/17/11 ~ 115
Continued
40469
GERALD J BRINSER
22 NORTH RAILROAD STREET
PALMYRA PA 17078-1752
MESSAGES EXPLAINED ~ BELOW
CAPITAL AREA HEALTH ASSOCIATES
100 MOUNT ALLEN DRIVE
MECHANICSBURG, PA 170556100
RETURN TOP PORTION • RETAIN LOWER
03/22/11
04/07/11 1 2 Accept Assign Ad.1'.
OFFICE VISIT EST LEVEL 3 99213 183.0 63
00 -20.00 58.00*
05/31/11
05/31/11 .
AETNA MEDICA Payment
A
t
i 48.00
04/14/11 1 2 ccep
Ass
gn Ad
OFFICE VISIT EST LEVEL 4 99214 183.0 87
00 -5.00 10.00*
05/31/11
04/19/11 1 2 .
AETNA MEDICA Payment
OFFICE VISIT EST LEVEL 4 99214 780.99 87
00 77.00 10.00*
05/31/11 .
AETNA MEDICA Payment 77.00 10.00*
~~
~~' ~o~
~c~~`
1
.~-This bi ll applied against your deductible. You are responsible to pay us.
DATE LAST PAID AMOUNT • ~ • ~ • • ~ • - ~ - ,
.
10/15/10 10.00 30.00 0.00 116.00 0.00 0.00 0.00 0.0 . 00
CAPITAL AREA HEALTH ASSOCIATES
•AKE .
:HECK
100 MOUNT ALLEN DRIVE ~
•AVABLEro: MECHANICSBURG, PA 17055-6100 146.00*
Ph: (71 - 0-8232
PAT~~ 1-AGNES C HOUCK PRV~/ 1-NOORBAKSH, SARAH Y, M.D. Acct: 115
PRV~~ 2-WEBER, JENNIFER E, D.O. Date: 06/17/11
Page 3 of 3
100 MOUNT ALLEN DRIVE, MECHANICSBURG, PA 17055
GERALD J BRINSER
6 E. MAIN P.O. BOX 323
PALMYRA, PA 17078
Form PB-O7
RESIDENT # UNIT STMT. DATE
50108 841 06/30/2011
RESIDENT S
Mrs. AGNES C. HOUCK
TOTAL AMOUNT DUE $0.00
DATE DUE 07/31/2011
DATE DESCRIPTION RATE- Days/
Units CHARGES CREDITS BALANCE
06/24/2011 Balance Forward
PAYMENT RECEIVED -THANK YOU!!!
16,101.91 16,101.91
0.00
RESIDENT #
50108 CURRENT
0.00 OVER 30
0.00 OVER 60
0.00 OVER 90
0.00 OVER 120
0.00 TOTAL AMOUNT DUE
$0.00
RESIDENT NAME Mrs. AGNES C. HOUCK Fam PB-01
WA
Please make check payable to Messiah Village.
A 1 % finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you!
If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You!
~' ~
~~~
~ .\~ 0~
~~ ~ ~
~a ~ ~~~
~~