The URL can be used to link to this page

Home My WebLink About03-01-12i '' ~ 15D5610140 REV-1500 ~` (°'-'°' PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes INHERITANCE TAX RETURN ~~ Code Year File Number Po Box 2ao6o1 2 1 1 1 0 1 3 2 8 Harrisburg PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of bath NIMDDYYW Date of Birth MbIDDYYYY 2 D 1 1 8 6 D 2 5 1 2 0 1 2 D 1 1 0 9 0 6 1 9 2 3 Decedent's Last Name Suffix Decedent's First Name MI M c G O W A N V I R G I N I A L (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Soaal Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 1. Original Return ~ 2. Supplemental Retum ~ 3. Remainder Retum (date of death pnorto 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Retum Required death after 12-12-82) Q 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Wiil) (Attach Copy of Trust) 9. Likigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 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 CONFIDENTUL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number R O G E R B I R W I N E S Q U I R E 7 1 7 2 4 9 2 3 5 3 First line of address I R W I N I~ Second line of address 6 0 W E S T City or Post Office C A R L I S L E M c K N I G H T P C P OM F R E T S T R E E T State ZIP Code REGISTER OF tMLLS USE ONLY /-~ raa t J r:. `J ~~ sa ~~ - -~' ~_ n- .r y 1~-1 ! ~ ~C~;`~ ~ D - f~il~o-r P A 1 7 0 1 3 =:~', r •J ~:`' Correspondent's e-mail address: ~,~ ,-~ c^~ _~ :~ r._~ - C.:.' _~- ~ 3 .. -a . ; .._5 "- ' '=i c. ~ ~- -=ro Under penaltles of perjury, I declare that I have examined this return, induding accompanying schedules and statert~ents, and to the best of my knowledge and belief, it is true, correct and complete. Dedaretfon of preparer other than the personal representative is based an all information of which preparer has any knowledge. SIGNA RE OF PE O RESPONSI E,~OR FILING RN D TE , ~, ~ /t ADDRESS 1903 GEORGE AVENUE CARLISLE PA 17013 SIGNATURE OF PREPAJiER OTHER THAN REIjfjESENTATNE BATE , L 60 WEST POMFJ~ET STR 1505610140 T CARLISL PLEASE USE ORIGINAL FORM ONLY Side 1 15D5610140 J 1505610240 REV-1500 EX Decedent's Social Security Number DecedenYsName: VIRGINIA L• McGOWAN 2 0 1 1 8 6 0 2 5 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 Receivable (Schedule D) .......................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 2 9 0 1 1. 5 8 6. Joint) Owned Pro Schedule F g q Y party ( ) ^ Separate Billin Re nested ....... 6. 9 D 9 9. 2 5 7. Inter-Vivos Transfers & Miscellaneous Probate Property (Schedule G) ~ 8 6 5 1 0 2 5 Separate Billing Requested ....... 7. . 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 1 2 4 6 2 1. 0 8 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9. 1 0 2 1 4 . ? 5 10. Debts of Decedent, Mor~age Liabilities, and Liens (Schedule 1) ............. 10. 3 D 7 3 . 1 8 11. Total Deductions (total Lines 9 and 10) ............................... 11. 1 3 2 8 7. 9 3 12. Net Value of Estate (Line 8 minus Line 11) ............................ 12. 1 1 1 3 3 3 . 1 5 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) .. ............. ..... .. 14. 1 1 1 3 3 3. 1 5 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2)x.o _ D. 0 D 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate x .045 1 1 1 3 3 3. 1 5 1 s, 5 0 0 9. 9 9 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17. 0. 0 0 18. Amount of Line 14 taxable at collateral rate X .15 D. 0 0 1 g, 0. 0 0 19. TAX DUE ...................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 5 0 0 9. 9 9 Side 2 1505610240 1505610240 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 11 01328 DECEDENTS NAME VIRGINIA L. McGOWAN STREET ADDRESS 87 SCHIMMEL WAY CITY CARLISLE STATE PA ZIP 17015 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 250.50 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 m request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) 5,009.99 Total Credits (A + B) (2) 250.50 (3) (4) 0.00 (5) 4,759.49 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 : ...................................................................... ^ Q b. retain the right to designate who shall use the property transferred or its income; ............................... ^ c. retain a reversionary interest or ................................................................................................ ^ Q d. receive the promise for I'rfe 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 adequate consideration? ....................................................................................... ^ 0 3. Did decedent own an 'intrust for" or payable-upon~eath 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)]. 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. REV-1508 EX+ (11-10) • Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: VIRGINIA L. McGOWAN 21 11 01328 Indude the rooeeds of litigation and the date the proceeds were received by the estate. All properly ~Oirrtly owned with right of survhronthip must be discbsed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. PERSONAL PROPERTY -SETTLEMENT STATEMENT ATTACHED 2,767.50 2. MEMBERS 1ST FEDERAL CREDIT UNION -SAVINGS ACCOUNT #17893-00 3. MEMBERS 1ST FEDERAL CREDIT UNION -LIFE SAVINGS ACCOUNT #17893-04 4. MEMBERS 1ST FEDERAL CREDIT UNION -INVESTMENT SAVINGS ACCOUNT #17893-05 5. MEMBERS 1ST FEDERAL CREDIT UNION -CERTIFICATE OF DEPOSIT #17893-40 6. ~ M&T BANK -CHECKING ACCOUNT #427616 TOTAL (Also enter on Line 5, Recapitulation) 13 If more space is needed, insert additional sheets of paper of the same size 459.63 4, 000.00 1,177.91 6, 921.08 13,685.46 4 REV-1509 EX+ (01-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: VIRGINIA L. McGOWAN 21 11 01328 ff an asset was made jointly owned within one year of the decedents date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. SHERRY L. DARR 174 MEADOW LANE DAUGHTER ABBOTSTOWN, PA 17301 E;. JUDITH A. BOND 4 BUCHANON DRIVE #315 CARLISLE, PA 17013 DAUGHTER c. DONALD W. iCAUFFMAN JOINTLY-OWNED PROPERTY: 1903 GEORGE AVENUE CARLISLE, PA 17013 SON ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENTS INTERESI 1. A. 09/2007 MEMBERS 1ST FEDERAL CREDIT UNION 45,496.24 20. 9,099.25 CERTIFICATE OF DEPOSIT #17893-43 TOTAL (Also enter on Line 6, Recapitulation) I S 9 099 25 If more space is needed, use additional sheets of paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent .VIRGINIA L. McGOWAN 21 11 01328 Decedent's Name Page 1 File Number Schedule F-1 -Jointly Owned Property SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT D~ JEFFREY P. KAUFFMAN 13 MAPLE AVENUE SON WALNUT BOTTOM, PA 17266 REV-1510 EX+ (08-09) = Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER VIRGINIA L. McGOWAN 21 11 01328 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDETHENAMEDFTHETRANSFEREE,THEIRRELA7IDNSHIPTODECEDENTAND THE DATE of rRnNSFER. aTTacN A air aF THE DEED Fat REU EsrATE. DATE OF DEATH VALUE OF ASSET %OFDECD'S INTEREST EXCLUSION nF,wPUC~ TAXABLE VALUE 1. ALLSTATE -ANNUITY CONTRACT #GA19672308 86,510.25 100.00 86,510.25 BENEFICIARIES: JUDITH A. BOND SHERRY L. DARR DONALD W. KAUFFMAN JEFFREY P. KAUFFMAN 2. TOTAL (Also enter on Line 7, Recapitulation) S 86 510 25 If more space is needed, use additional sheets of paper of the same size. h REV-1511 EX+ (10-09) • pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER VIRGINIA L. McGOWAN 21 11 01328 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HETRICK-BITNER FUNERAL HOME, INC. 2,023.08 2. WESTMINSTER CEMETERY LLC -INSCRIPTION 210.00 3. WESTMINSTER CEMETERY LLC -VAULT/URN/MEMORIAL 275.50 3. GEORGE'S FLOWERS -FLOWERS 189.74 4. MICHAELS -FLOWER ARRANGEMENT 27,49 5. ORGANIST 100.00 6. FIRST PRESBYTERIAN -FUNERAL LUNCHEON 180.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2, AtromeyFees: IRWIN & McKNIGHT, P.C. 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 5 Acx:ountant Fees: 6. Tax Retum PreparerFees: PATRICIA A. ROSENDALE, CPA 7. REGISTER OF WILLS -FILING FEE 8. CUMBERLAND LAW JOURNAL -ESTATE NOTICE 9. THE SENTINEL -ESTATE NOTICE 10. JUDITH BOND -TRAVEL EXPENSES ($345.14 ONE WAY) TOTAL $690.28 11. ROWE'S AUCTION SERVICE -PUBLIC SALE COMMISSION 12. SHERRY DARR -TRAVEL EXPENSES 3,250.00 93.50 375.00 30.00 75.00 189.54 690.28 1,088.62 1,417.00 TOTAL (Also enter on Line 9, Recapitulation) I S 10.214.75 If more space is needed, use addiiti~onal sheets of paper of the same size. a REV-1512 EX+ (12-OB) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8 LIENS ESTATE OF FILE NUMBER VIRGINIA L. McGOWAN 21 11 01328 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. M&T BANK -REIMBURSEMENT OF SOCIAL SECURITY INCOME 288.00 2. MASLAND ASSOCIATES -MEDICAL 61.26 3. FAMILY HOME MEDICAL -MEDICAL 92.80 4. CENTURYLINK -TELEPHONE 95.51 5. IUGI -UTILITY 6. CARLISLE REGIONAL MEDICAL CENTER -MEDICAL 7. MED-ED -ELECTRIC 8. 9. 10. CRESSCARE MEDICAL -MEDICAL CUMBERLAND CROSSINGS -NURSING BANK OFAMERICA -CREDIT CARD TOTAL (Also enter on Line 10, Recapitulation) I S If more space is needed, insert additional sheets of the same size. 154.88 164.97 433.09 28.67 1, 544.00 210.00 18 REV-1513 EX+ (01-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: FILE NUMBER: VIRGINIA L_ McGOWAN 71 11 n1~7R RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributlons and transfers under Sec. 9116 (a) (1.2).] 1, JUDITH A. BOND Lineal 27,833.29 2100 KINGS HIGHWAY LOT 109 1/4TH REMAINDER PORT CHARLOTTE, FL 33980 2. SHERRY L. DARR Lineal 27,833.29 174 MEADOW LANE 1/4TH REMAINDER ABBOTSTOWN, PA 17301 3. DONALD W. KAUFFMAN Lineal 27,833.29 1903 GEORGE AVENUE 114TH REMAINDER CARLISLE, PA 17013 4. JEFFREY P. KAUFFMAN Lineal 27,833.28 13 MAPLE AVENUE 1/4TH REMAINDER WALNUT BOTTOM PA 17266 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ it more space is neeaeD, use aaalaonal sneers or paper of the same size. ..-, ~, /^-~ .. ' T Ll -' - -~ ~, .. I i ..:...~ ~,~~ t..~ ~ ._ .. f"' __ _ ,-' ~7 f ._ LAST WILL AND TESTAMENT,`" ~=_; _~ I, VIRGINIA L. McGOWAN, of the Borough of Caisle,:Coun't~ .r_- of Cumberland, Commonwealth of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void all former wills and codicils by me at anytime heretofore made. FIRST. I order and direct that all my just debts and funeral expenses be paid by my personal representative or representatives, hereinafter named, as soon as conveniently may ~~ be done after my decease. I further authorize my personal representative to expend funds from my Estate in such amounts as my personal representative shall consider appropriate, for the disposition and memorial of my remains. SECOND. I authorize my personal representative or representatives herei:~after named to distribute, in accordance with his or her discretion, items of tangible personal property from my Estate in accordance with any of my wishes expressed in ~riting. Such tangible personal property shall be restricted to common personal possessions and shall not include cash, bank books, stock certificates, bonds or the like unless otherwise expressly stated in my said written wishes. In the event of any conflict between my said written wishes and this my Last Will and Testament, this shall control. In the event of any cash bequests in my said wishes expressed in writing, I hereby authorize my WAYNE F. SxADE Attorney at I.aw 53 West Pomfret Street Culisla, Pennsylvania 17013 f personal representative or representatives hereinafter named to distribute the bequests to any minor legatees directly to any parent or legal guardian of the minor legatee. In the event of my failure to leave a list, I order and direct that all of my said tangible personal property, other than as specifically bequeathed herein, be liquidated and distributed as part of my residuary Estate. In the event of the failure of any of the legatees designated in any of my said wishes expressed in writing to survive me, I order and direct that his or her bequests be liquidated and distributed as part of my residuary Estate. In the event of the failure of one of the legatees to survive me, nothing herein shall be interpreted to prevent my personal representative or representatives hereinafter named from selling any of the items which would have passed to that legatee to my other legatees at fair market value. In the event of a dispute as to any aspects of the list, I order and direct that any such disputed tangible personal property be liquidated and distributed s part of my residuary Estate. THIRD. For the purposes of this my Last Will and Testament, ~a person shall not be deemed to have survived me unless he or she r Q ~(.~~_\ shall have survived me by more than nine ~`~ FOURTH. I order and direct that my ~~ Glendale Street, Carlisle, Pennsylvania, c~, `\ ,\~ including all draperies and other window Drum and that none of the contents of my ty (90) days. residence at 250 be listed for sale treatments with Gwen residence be removed until the house is under agreement of sale with all contingencies WAYNE F. SHADE Attorney at Law under the a reement removed . 53 West Pomfret Street g Carlisle, Pemsylvsaia 17013 ~, give, devise and bequeath unto my children, JUDITH A. BOND, SHERRY L. DARK, DONALD W. KAUFFMAN and JEFFREY P. KAUFFMAN, in equal shares. If any of them should fail to survive me, I give, devise and bequeath his or her share unto his or her issue, if any, in equal shares by representation and not per capita. If any of them should fail to survive me and fail to leave issue to survive me, I give, devise and bequeath his or her share unto such of my issue who shall survive me, in equal shares by ~~~~~representation and not per capita. SEVENTH. I order and direct that any estate, inheritance or FIFTH. I give, devise and bequeath my residence at 2100 King's Highway #109, Port Charlotte, Florida, and all of the ~~ ~ contents with the exception of any automobiles which I may have ~~ °~ ~,,~ there unto ANN E. McGOWAN, KATHLEEN BARNETT and JOHN L. McGOWAN, ~4 the grandchildren of my late husband, JOHN W. McGOWAN, as joint tenants with right of survivorship. SIXTH. All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, I WAYNE F. SHADE Attorney at Law 53 West Pomfret Street Carlisle, PeonayWania 17013 , imilar tax due as a result of my death with respect to any property passing as a result of my death, shall be paid from the residue of my Estate before its division into shares and prior to distribution as an expense of administration and that no part of the taxes should be prorated or apportioned among the persons or beneficiaries receiving the taxable property. It is my express intention that all inheritance taxes imposed as a result of my death be paid from the residue of my Estate whether or not the property passes under my Last Will and Testament. My personal n .Z. representative shall have full power and authority to pay, compromise or settle any such taxes at anytime whether with respect to present or future interests. EIGHTH. I order and direct that any liens against any personal property which passes to a designated person either under this my Last Will and Testament or otherwise shall be paid from the residue of my Estate prior to distribution as an expense of administration and that such specific bequests of personal property not pass subject to any liens thereon. NINTH. Any and all decisions, determinations or actions made or taken by a personal representative or Trustee hereunder, ~ `Ilif made in good faith, shall be final and conclusive on all persons who are or may become interested in my Estate. No fiduciary acting under this my Last Will and Testament shall be liable for any error in judgment or for any depreciation or reduction in value of any Estate or Trust assets at anytime, in the absence of willful default. TENTH. I order and direct that, upon my death, my body be ted in lieu of burial and that disposition of my ashes be at the discretion of my personal representative. LASTLY. I nominate, constitute and appoint my son, DONALD WAYNE F. SHADE Attorney at Law 53 West Pomfret Street Carlisle, Pemsylvsaia 17013 ~W. KAUFFMAN, to be the Executor of this my Last Will and Testament, but if, for any reason, he should fail to qualify as such Executor or decline or cease so to serve, I nominate, constitute and appoint my children, JUDITH A. BOND, SHERRY L. ~DARR and JEFFREY P. KAUFFMAN, as successive alternate personal representatives, all to serve without bond. My designation of -^ - f Donald as my primary personal representative is not intended to reflect any lack of faith or love and affection with respect to my other children. It is simply a matter of convenience in that he would be most likely to have the most time available to perform the responsibilities of Executor. IN WITNESS WHEREOF, I, VIRGINIA L. McGOWAN, have hereunto set my hand and seal to this my Last Will and Testament which consists of seven (7) typewritten pages to each of which I have affixed my signature, this 21st day of October , A.D. One Thousand Nine Hundred Ninety-Six (1996). l~ ~ ~J c AL ) Vir nia L. McGowan The preceding instrument, consisting of this and six (6) WAYNE F. SHADE Attorney at Law 53 West Pomfret Stred Culisle, Pennsylvania 17013 other typewritten pages, each identified by the signature of the Testatrix, was on the date thereof signed, sealed, published and declared by VIRGINIA L. McGOWAN, the Testatrix therein named, as her Last Will and Testament, in the presence of us, who, at her request, in her presence, and in the presence of each other, have subscribed our names as witnesses hereto. i~~ r~s _c_ f Acknowledgment COMMONWEALTH OF PENNSYLVANIA ) SS: COUNTY OF CUMBERLAND ) I, VIRGINIA L. McGOWAN, the person whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by VIRGINIA L. McGOWAN, this 21st day of October , 1996. ~/ ~ Go Vir nia L. McGowan Notary Pu is Notarial Seal Connie J. Tritt, Notary Public Carlisle, Cumberland County My Commission Expires Oct. 5, 2000 Affidavit COMMONWEALTH OF PENNSYLVANIA ) SS: COUNTY OF CUMBERLAND ) We, Wayne F. Shade and Susan O'Hara the witnesses whose names are signed hereto, being duly qualified according to law, do depose and say that we were present and saw the Testatrix sign and execute the instrument as her Last Will and Testament; that the Testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testatrix signed the Will as a witness; and that, to the best of our knowledge, the Testatrix was at that time eighteen or more years of age, bf sound mind and under no constraint or undue influence. WAYNE F. SHADE Attorney at Lw 53 West Pomfret Street Carlisle, Pemsylvanis 17013 Sworn to or affirmed and subscribed to before me by Wayne F. Shade and Susan O'Hara witnesses, this st day of Octo er , 1996. Cam, ~,~,~" Notary Pub is Notarial Seal Connie J. Tritt, Notary Public _ Carlisle, Cumberland County My Commission Expires Oct. 5, 2000 ~~ WAYNE F. SHADE Attorney at I.aw 53 Went Pomfret Street Carlisle, Peoosylvania 17013 MEMBERS 1'~ FI~BRALCRBDIT UNION SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner LIFE SAVINGS ACCOUNT: 17893-00 12/04/1975 $459.63 $.00 $459.63 None Account Number/Suffix 17893-04 Date Account Established 02/01/2001" Principal Balance at Date of Death $4,000.00 Accrued Interest to Date of Death $.00 Total Principal and Accrued Interest $4,000.00 Name of Joint Owner None *Opened by transfer of funds from 17893-00. INVESTMENT SAVINGS ACCOUNT: Account Number/Suffix 17893-05 Date Account Established 05/02/1995 Principal Balance at Date of Death $1,177.91 Accrued Interest to Date of Death $.00 Total Principal and Accrued Interest $1,177.91 Name of Joint Owner None CERTIFICATES OF DEPOSIT: EEI~E~ ~~, ~JA~ 0 6 2012 IHWIN & NIcKNIGH~' l.AW OFFlCES Account Number/Suffix 17893-40 17893-43 Date Account Established 07/20/2011" 09/2412007"" Principal Balance at Date of Death $6,921.08 $45,496.24 Accrued Interest to Date of Death $.00 $.00 Total Principal and Accrued Interest $6,921.08 $45,496.24 Name of Joint Owner Sherry Darr Sherry Darr/Judith Bond Donald Kauffman/Jeffrey Kauffman Date Joint Ownership Established 07/20/2011 09/24/2007 _ ~::`. *Rollover from certificate 17893-42, originally established 06/25/2007. "`Rollover from certificate 17893-45, originally established 09/23/2005. E ERS 1~sT~F~ED~EQRAL RED ION Danielle A. Kline Lending Insurance Support Specialist January 4, 2012 Estate of: VIRGINIA L. MCGOWAN Date of Death: 12/01/2011 Social Security Number: 201-18-6025 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 wwwmemberslstorg p ~rs~nx 499 Mitchell Road, Millsboro, DE 19966 Adjustment Services Irving and McKnight PC 60 West Prolmfret Street Carlisle, PA 17013-3222 Re: Estate of Virginia L McGowan Social Security: 201-18-6025 Date of Death: December 1 2011 Phone 888-502-4349 Fax (302) 934-2955 January 13, 2012 JAS ~<'~ 202 iR~!IN.i~:lwcKIV1GHr, i:AIN!OFElCE Dear Sir or Madam: Per your inquiry on December 23, 2011, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type of Account Checking Account Accoura Number 427616 Ownership (Names o, fl Virginia L McGowan Opening Date 09/01/67 Balance on Date of Death $13,685.39 Accrued Interest $ .07 Total ----------------------------------------------- $13,685.46 For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds, please ~ the High Street Carllsie OlSia at#717-240536. We were unable to locate any safe deposit box for the above-mentioned decedent This letter does not include any accounts in which the deceased may have been listed as Power of Attorney, C~Stodian of Uidform Transfers, Representative Payee, or Trustee under a written Agreement Sincerely, ~l/ Tammy Spencer Adjustment Services ~~ --®ROWE'S AUCTION SERVICE- HRH 79L) 2505 Ritner Highway • Carlisle, PA 17015 Bill Rowe (AU 153.8L) 249-1978 215-1044 574-1008 Dave Rowe (AU 2295L) Auction Is Action Ca-lIl "Rowe" For Satisfaction SELLERS NAME _~(~.~~~'J~IU DATE ~02 l~ ADDRESS a ~~3 (~C~~'~/!___ Q2 _~~/~,rk('ar' S~ i~~ / 7/) PHON~ ~ ~~l 5 - `l~~ a? ~,~ OTHER AUCTION DATE/LOCATION AUCTIONEER % ~_ CLERK % ~~ -~~ DESCRIPTION OF MERCHANDISE c~~-- t ~ ~ ~ 5 ~ ~0- C..~..IA~ ~..estan..- S ~ ~' Z" ~ L -~- er.,~-~~,~ d~ ~l~"' ~ ~ ~'~ i ~- L 1" ~{ !L`h ~ f _ ~~3 ~/`1 ~. 1 ll.~?' 1 -C-1r I Commission the Auctioneers to sell the merchandise to the highest bidder by Public Auction. Merchandise to be sold as is & grouped as necessary to obtain bids. I certify that I am the owner or authorized represen- tative of the merchandise, goods and or property and have good title and the right to sell and that they are free from all incumbrances. I agree to accept all responsibility for providing merchantable titleyand for delivery of title to the purchaser. ee to hold harmless the Auctioneers against claims of the nature ref ed: to in this a ment. /~ ~~ AUCTION~SI NATURE ~ LLERS SI R .'~ Total-Sales (Clerking Tickets Attachedl $ _~~a ~~ ~~ ,~~~ Less Sale Expi;,:,;. r :,,~,, ..,~'x`> % CommY~`s;on Auctioneer $ ~ ~,:~,.,_ % Commission'~lerks $ ~~ "`~--~' :. ~: y.. I' .. OTHER: "°~C,~_~Yr~A4~ ~ ~ c TOTAL SALE EXPENSE DEDUCTED $ ~ ®~ ~ ~~ SELLERS NET $ ~ ~~' ~ ~ Allstate Life Insurance Company Telephone: 1-800-755-5275 ~"; PO BOx 660191 Fax: 1-866-628-1006 Dallas, TX 75266-0191 DONALD KAUFFMAN 1903 GEORGE AVE CARLISLE PA 17013-1127 January 5, 2012 Yiaur Fiep696dnta~iVB CRAIG A NISSLEY INVEST FINANCIAL .CORPORATION 1166 WALNUT BOTTOM RD CARLISLE PA 17015-9160 (717)249-0795 RE: Original Allstate® Preferred Performance #GA19672308 Your New Allstate® Preferred Performance #AC1097848B Dear Donald Kauffman: Your claim has been processed. A check has been sent to you under separate cover and should arrive within the next seven to ten business days. The first table represents the entire benefit value under the original contract as of the date of settlement, as well as any transactions that may have occurred on that date. cam. ~~I~'A~ ~:~~~ r~ ~RI~i1N,f~L; ~liy~'rr.a~ras Transaction Transaction Investment Units for this Transaction Transaction Date Type Alternative Transaction Unit Value Amount 01/05/12 Total Claim 1 Year Guarantee Period N/A N/A $-86,510.25 The second table confirms the investment alternatives to which your portion of the benefit value has been allocated. Please review the information below. If you have any questions concerning these allocations, please contact us at 1-800-755-5275. D HETRICK-BTTNER FUNERAL HOME, INC. 3125 Walnut Street, Harrisburg, PA 17109 ~ (717)545-3774 Fax (717)545-2325 Nathan A. Himeti Supervisor Graham S. Hetrick, Funeral Director ^ RONALD C. L. SMITH FUNERAL HOME ^ JESSE H. GEIGLE FUNERAL HOME, INC. A branch of HeMck-Bunn Funeral Home, Inc. 2100 Linglestown Road Harrisburg, PA 17110 325 North Hi Street, Duncannon, PA 17020 (717) 652-7701 Fax (717) 652-2405 (717) 15 Fax (717) 634-9287 Vaughn Miller, Supervisor Timothy A. Hobbs, Supervisor Ronald C. L. Smith, Funeral Director Funeral Expense Agreement This is an explanation of charges as well as a sales agreement presented in acwrdance with the regulations of the PA State Board of Funeral Directors. -STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Charges are only for those items that you Selected fn' are required. If we are required by law or by a cemetery or crematory fo use any items, we will explain the reasons in writing below. If you selected a funeral which may require embalming, such'as a funeral with a vieuring, you may have to pay for embalming: You do not have to pay for embalming you did not approve, if you selected arrangements such as direct cremation or immediate burial. If we charge for embalming we will explain why beloru. Legal, cemetery, crematory or other requirements compelling the purchase of any items listed below: Reason for Embalming: Funeral Services for yl ~~'~ ll. Gf ` , ~ (; Q,.J(H Date of Death /` ~ ~ ! Date of Service GOODS AND SERVICES SELECTED TYPE OF SERVICE AUTHORIZED TO BE PROVIDED ^ Traditional Full Service ^ Viewing day of Service ^ Graveside service only ^ No Viewing ^ Cremation ^ IrtrRr~iate DlsposltiOn ^ Public Viewing ^ Anatomical Gift ^ Private Family Viewing ^ Memorial Service ^ Evening Viewing ^ Shipping Service ^ Receiving Service A. Package Arrangement B. Charge for Services Selected: 1. PROFESSIONAL SERVICES .. Basic Services Fee ..................... $ -f ~- Embalming ........................... $ Cremation ............................ $ r ~ . Other Prepazation of Body Transfer of Remains to Funeral Home ... $ Sub-Total of Professional Services (Bl) ..... $~~ 2. ADDITIONAL SERVICES AND FACILITIES Visitation ............................. $ Funeral Service ........................ $ Memorial Service ...................... $ ~~ Graveside Service ..................... $ Sub-Total of Additional Services and Facilities (B2) ................. $ 3. AUTOMOTIVE EQUIPMENT ~ Funeral Coach ........................ $ G Lead/Clergy Caz ...................... $ I D fl Flower Caz ............................ $ Family Caz ............................ $ Other than local 20 mile Transportation .. $ Sub-Total of Automotive Equipment (B3)... $ Sb' Total of Professional Services, Additional Services n ~/ and Facilities, and Automotive Equipment (B) .. $ 1 C. CHARGE FOR MERCHANDISE SELECTED Casket Description $ Other Receptacle Description $ Outer Burial Container Description $ Urn Description ~ ~~t`''i '~/ ~I A l l d f t~ ~ l $ $ c mow e gemen ~ rt . fry . G Memorial Folders . W-.... ~.:T~f.~......... P ~' ~ $ Register Book ..... - C .. R ............ $ 3s~ J ~~ Prayer Cards .............................. $ Crutafix .................................. $ Temporary Grave Mazker .................. $ Memorial Board Rental .................... $ Casket Rental ............................. $ Clothing .................................. $ Flag Case ................................. $ Other $ _ Total of Merchandise Selected (C) .............. $TJ D. Special Charges Forwazding Remains to Receiving Remains from hnmediate Burial .......................... $ Equipment Rental ......................... $ Direct Cremation .......................... $ Total of Special Charges (D) ................... $ E. Cash Advances Opening of Grave ......................... $1 ~ ~ Cemetery Equipment ...................... $ Clergy/Mays Flowers ....:~ ..................... $ ~ ~ $ i~ Hairdresser ..................... $ Certified Copies of Death Certificate 1.A~..... $ Newspaper Notice .. ~1:X~.~............ $ Cemetery Lot and Deed .................... $ Pallbearers ................................ $ Airfare ................................... $ Vault Service Chazge ....................... $ Honor Guard ............................. $ Organist ......... .. ..................... $ Ckher Cllrrli/ ~r,jC. $ ?~~ For your cmtvenierux, we will advance the mst of the f items; howeveti any error made by any supplier of servioea shall be the sole ~ility of that supplier and our [uneral home is relieved of lisbiliry therefore by acting as your agent Hetridc- Bitner Funeral Home, Inc., Ronald C.L. Smith Furusal Home, and Jesse H. Gei~1e F l H t i t d k d d h unera ome, nc. are ene t e to ta e an retain any iscoun purdtase of a cash advance item ts offered on t e Total of Cash Advances (E) .................... $2~ A. PACKAGE ARRANGEMENTS ............. B. ADDITIONAL SERVICES /FACILITIES .... $ ~,~ $ _+ _L ,L C. MERCHANDISE .......................... $ /7 S D. SPECLAL CHARGES ...................... $ Total of Funeral Home Charges ............ $ E. CASH ADVANCES ........................ $ Total of Funeral Home Charges and Cash Advances .... ... $ x/07 CASH ADVANCES MUST BE REBNBIJRSED PRIOR TO SERVICE DAY ~ ~~ . AGREEMENT: I agree that I have inspected the goods and services selected above and found them ro be a to and according ro g~em to I have selected. I acknowledge receipt pf a. copy. of this Statement of Goods and Services Selected. It is understood that the tots) rlurgea a y be eatima ~ and~reflect~only that agreed upon at the time of this agreement Any additional items of service or merchandix ordered or requited after the time of this g~rall Ix considered part of ttds agreement and the cost wW be ceaect- ed on your Final Statement which we provide. TERMS: 11ris is a msh transaction due in full N 30 days, and in all events becomes past due and delinquent e. A penalty of 15% per annum (1.25% monthly) will be . duuged for. unantrapated Tate payment effective on the 31st day. WARRANTff5: The only wamnty of the mercharutise sold ro mnnectlon with this agreement le the exp my if any), provided by the manufacturer. The funeral direc- tor makes ~no warranty (expressed or implied) with respect ro any funeral mP,Mf..o.i;.. AUTHORIZATION: I or We authorize and ratify prior consort ro the[uneral director ro take possession of the body, give care ro and carry out the arrangements hereto spedfied and agreed ro. I or 1Ve represent ourselves as the person(s) having the krgal right ro arrange for the rural dispositlon of the above named decedent and do hereby grant authority ro the funeral director ro supply the services and merchandise as lured above. I or lVe guarantee the payment of this contract according to thg above terms, and also agree ro paY arty attorney Eee or legal judgement imposed upon the mRection of the cost of this cecvice amt. r( f.'/7 OnlPemtission ro Embalm the above named decedent O Was granted C~7'Was refused by ~~~Lr~//' G~U~~~f1L'^ S/lam Name V on 1 / at approx. (am) (pm) ^ by phone O in person. Reletionstsp FIIVAL ACCEPTANCE: I or We accept and approve the above selections and terms, and acknowledge that the general price list effective / / ,casket price Hst PKPfHVP / / .and Muter burial price list effective / 1 were made available prior to selection of services. Hetrick-Bitner Funeral Home, .Inc. 3125 Walnut Street Harrisburg PA 17109 Phone # 717-545-3774 Invoice Date frnoice # 1/2/20.12 3055 Bill To Donald Kauffman 1903 George Ave. Carlisle, PA 17013 Terns Due Dote Client COD 11212012 Virginia McGowan Quantity Descriptaan ltai'e Amfl~' Obituary in Carlisle Sentinel 116.08 116 OS C" I - OIV, 1 r~ .?ts Sri a pleaauxe ~ ~$ ~ ~ Total s116.os ., . Payments/Credits $0.00 Balance Due $i t6.og lii~i4Ei: ~ tii.1 ~~':CSi?A-. Ht]r+; 2:5 ' '~ ~ ~ ~~ ~~ ° -- ~ ~ ~ g~° ~ ~ - _ a a. a U ~ c ~ d a. .a ~l ~ bs `'~ fem.' p U ~ ~ v a ~ b ~ cL oo ~'. ~p a ~.a '~ Q o ch ~ t t ~ f ~ a ss s9 s9 a ~ °~ y> i U a=N ~ a,y' U I a W U : d Vin, ~rv .o U p ~ ~" : a a a .8 ~ ~ . '1~1 N ~. a ~ i.7 .l' I w ~ ? i-. N O1 a '~ a a ~ a C a Q O ~ ~ tY b .~ 'p .~? °p a ~ D ~ O ~ V a~~y ~ .~~,: .a •~ .y; ~ ~..~~~„~WL..y^~„~~,'~~U„~~y~a~O ~ +~ ~~raH~v p~.~c°ia o w ~ ~ ' ~ ~ nv y ~ ~ aH ~,' - ~ o ~ o, ,~ ~a a~C G y ~ `a' Q '~ ~a' Lam' ~c0 O ~ ~ ti N o ~c3a pa a ~ h ~ ~ ar ^ ~ ~ ~ ~ a~,' y q_~ ~ ~ p ~ ~ ro . a V) 'L7 ,u v ~ C~ C1 0 ~ ~ a A„ ry Q ~' ~ a _ pti,~,y, ~L'~ .~ 'Li p7 a ~ ~ y C ~ ~ '~ ~ a ~o a .~ ~~ ~~ ~ ~ o a ti~t3 U ~..r° ~ ~ u "' o~ m ~' 5~ ~y~•y ~ ~ fy ~ ~ ~ ~~ ~°Q+~ ~ ~ IY~$Q ~~ ~ y~ 'CCU •fi •~ 1e~~7+ '~ ~ ~ L0. ti G, v 8 M ~ ~ ~ ~ W ~ (,~. Q g~ ~ Oi1Wi „~ 'a >c N° C..) x °^`J0.~~' ~ '~ 4~ a ry Q ~ O °' a ~ v ~~ A ~ y t~ ~ ~ a .q N ~: U ~ ~ N `'~ ~ I ~pU ~ ~~'_ ~ ~ ~~ ~ ~ .. ~ h O ~+ N ~ y GQ ~ O ~ W U "' ,.,~ a w ~a ~ _ - Ir 4 a Retail Installment Contract and Security Agreement Cumberland Valley Memorial Gardens ^ Riverview Memorial Gardens ^ Tri-County Memorial Gardens G~Westminster Cemetery 1921 Rimer Highway 3776 Peters Mountain Rd. 740 Wyndamere Road 1159 Newville Road - Carlisle, PA 17013 Halifax, PA 17032 Lewisberry, PA 17339 Carlisle, PA 17013 717-243-3541 717-896-3272 717-938-3435 717-249-2029 Contract # THIS AGREEMF,,N1', made by and between Seller and ~ _ ` ! ~ . • - ~ '. " +(' ~ -• . '' -.' (hereinafter called the "Putcltase~7 WITNFSSETH THAT Purdtaser. agrees to buy and Sallee agrees to sell to Pnrchasa o t~iis designated benef~iary in acootdattce with the tenors hertrof, the following items to be provided or ttsod at the above clteci:ed location (ltaeinafter called "Cemetety'~. Tn consideration for Seller binding itself to provide the items with- out regud tothe equal cost and. price of said items prevailtttg at the time of perforntacee lateuttder, Purchaser ages that this Ageement shall be imevacable. 1.DESCRIPTION OF BURIAL RIGHfS. The Burial •Rights covered by the Ageemwtt ate shown by .the map. of such gudatlbuilding on file in the office .of the CEMETERY, and ate mae particularly destxibed below The puechase price o[ Btu'ital Rights does not hulude Ioml~ Fees.(opt~ing and dosing t:osfs). Burial Rights in Grave Space(s) *Mausoletrm: ^ Chapel ^ Garden ^ Tandem ^ Side-by-Side ^ Single Lava Crypt: ^ Double Depth ^ Side-by-Side ^ Developed ^ Preconstruction ^ Single ^ Developed ^ Preconstruction Niche: ^ Chapel ^ Garden ^ Single ^ Companion ^ Developed D Preconsttuction #Maximum casket dimmsionr an: length 85"; width 29", height 26" 1st Choice ~ ~~ 2nd Choice 1st Choice Zad Choice Garden Section Lot S l7 1~(s) 2. MERCHANDISE O - ^ Check hero if merchandise is being~purchased for use at another ceatetery. Cemetery's Name: A. VAULT(S) #l. Description #2. Description B. URN(S): #1. Description #2. Description C. MEMORIAL INFORMATION: Memorial Design: Bronze Siu X Granite Siu X Location (Section, etc.) D. MONUMENT INFORMATION: Type: Color: Size: x x P Die: x x P Base• x x P E. CASKET(S): 1. Model: Type: Model # 2. Model: Type: Model # Buildin g Section - No.(s) Level 3. ITEMIZATION OF CHARGES (A) Burial Rights (as described in Pan. t above) $ (B) Perpetual Care $ (C) Less Certificate Discount $ - (D)Second Right of Interment $ (E) Vault(s) $ (~ Um(s) -- $ (G) Mattsolenm T.euering/Crypt Plate $ - (In Memorial/Monument .. $ m Granite Base(s) $ (J) Installation Charge $ (K) Caskets _ $ (L) IntermenUEntombment/Inttmment Fees _ _ $ (M)Permanent Records & Processing Fee $ - 95:1)0 (M Other 'P = - $ (O) Sales Tax $ av rtu. Senn r>du~:su lP- itucu ul a (1) Total Cash Price $ ... •' (2) A. Cash Down Payment $ B. Trade In: $ Old Agreement No. C. Total Down Payment (2A + 2B) $ . (3) Unpaid Balance of Cash Price (1 - 2C) $ (4) Finance Charge $ (5) Total Unpaid Balance (3 + 4) $ 5. PAYMENT: The Purchaser shall pay SELLER for such rights in accordance with the following disclosure statement: FIN~NCi C11AR1iiB Al10UNT FlNANCED TOTAL OF P111(MEMTS T07AL SALE.PfIICE The cost d your txetRt The tblar amount die txedit will The arnottnt of txedit provided The amount you wiN have paid The ~lal cost of es a y~dy rob. cost yet. m you an your own bettelf. after you ~ made al payments ~ ~ as ached y of YOUR PAYMENT SCHEDULE WILL BE: Number of Payments Amount of Payments First Payment Due Date Thereafter, Payments Are Due $ ^ Monthly on the SECWRPI'Y: You are giving a security interest in the goods or property being purchased or in part.of the funds paid under this Agreement held in a Merchandise Trust Fund. PREPAYMENT If yon pay off early, you will not have to pay a penalty and you may be entitled to a refund of part of the Finance Charge. NOTICE:. See the remainder of this Agreement (including General Provisions on the roverse side hereof) for additional information about nonpayment, default, security interests, any. required payment in full beforo the scF-eduled date. and prepayment refunds and penalties. Vase: Y / N Tf you do .not met your contract obl'.igations, you may lose the funds, paid under this Agreement held in the Mercltaudise Trust Fuud. THIS AGREEMENT ARISES OUT OF A CONSUMER CREDIT SALE AND IS SUBJECT TO THE ADDITIONAL GENERAL PROVISIONS CONTAINED ON THE REVERSE SIDE OF THIS AGREEMENT, WHICH ARE A PART OF THI5 AGREEMENT. CPiirr rPCPNPC it7P ti ottt to rnfiteP to ~nnnnr rt.:r A,.wn..+e.+~ ...:rr,:...,... Lt A\ .t....- .c a__ ~_._ L___ _c+__. ,•r .+ .. .. - .. - - GEORGES' FLOiIERS o gate.: 12/07/2011 ~ Terminal: 2 ime: 10:51:49 A Session: 2013 ;3 " ~ ~ ~~s ~a PAYMENT ~ccaunt Number: 0582666 Account Name: SHERRY MCSHERRY " Balance Due (12/7/2011): $ 0.00 Payment Amount: $ 189.74 New Balance Due (12/7/2011): $ -189.74 Amount Tendered: $ 0.00 Change Due: $ 0.00 Thank You For Your Business! rint Date: 12/07/2011 ~int Time: 10:51:49 AM Where Creativity Happens` MICHAELS STORE #6710 (717)245-2944 MICHRELS STORE X6710 230 WESTMINSTER DR CARLISE,PA 17013 ** Return Harcode ~ 8-9911 -9b66~86~1Er~a'ii62~3111-11$1-1523-111 T 1569 SALE 8000 6710 040 12/07/11 11;52 CUT RIBBON 400000008776 2. 1 @ 2.00 RBN CMAS WHT DMSK 4001008790~i 4.99 1 @ 4.99 ~1 SPRAY-.17" - P 657957137454 1.99 1 @ 1.99 S SPRAY 17" ANG13 P 657457137959 1.99 1 @ 1.99 S PDB-36X48 RED 1 P 79946006643 4.99 1 @ 4.99 FOAMBOARD 20X30 799%129922 5.99 1 @ 5.99 PUSH PINS 50CT RN 400100724156 1.99 1 @ 1.99 PUSH PINS 100CT C 400100725009 1.99 1 @ 1,99 SUBTOTAL 25.93 S(1w.ES TpK 6% 1.56 TOT( 2T.i9 ACCOUNT NUMBER +~~**~~1479 VTS'A/lf1ST6ipRIID 2T . 49 APPROVAL. 015142 SWIPED ONLINE SHERRY L MCSHERRY ~,9941-9fi66-,~16~5111-1181-1523-111 0014-9994-0964-4301-3881-2561-3521-117 ~Igll~l I ~ I I~II~II ~NM I Iiil~ ~ ~ Judith Bond 198 Westponit Dr Carlisle , PA -17013 UNITED STATES FO~10 BEST' WESTERN PLUS Room # Arrival Date Departure Date 112 12.02.2011 12.03.2011 Date Quantity Charge Descriiution 12.02.11 1 AAA Rate (3A) 12.02.11 1 Santee Occupancy Tax 12.02.11 1 SC Room Sales Tax 12.02.11 Payment ~Visa> Cathy Snipes - Golf Director BEST WESTERN PLUS . T Santee Inn PLUS I-95 Exit 98E P.O. Box 188 Santee, SC 29142 (803) 854-3089 Fax (803) 854-3093 41050~hotel.bestwestem.com For Reservations Call 1-800-987-5423 Santee Inn folio Numbr'r Printed Page: 105643 12.03.2011 1/1 73.99 73.99 73.99 2.22 2.22 76.21 5.92 5.92 82.13 • -82.13 0.00 Total Due: 0.00 .i J. Men~er '~ Richard _ . I , Host & General Managgr LeeS~J11IONFEDREN1C e CENTER HOTEL & .~ I ~ 726 East M~ girnatr20176 I~ S Leesburg. Fax 1703) 777-5537 J (703) 777-9400 ~stsinc•car' Email: r.menster®9 www.bystwesternleesburg.com Best Western Santee Inn T-95 Exit 98 • Santee, SC 2911 • (803) 854-3089 fax:(803) $54-3093 Each Best Western® branded hotel is independently owned and operated. • i i r !8B Naycreek Dr Exxon Dealer 26538 Kingsland 6a 31548' I-95 & RT-54 884-798-8885 ~ a';~{u. ~ as u a ~`ti" •=,"a SHELL 57545827887 188 NA4CREEK DR. KINCSLAND , 6A ASHLAND EKRBN , 4761557 31548 816 England St, ASHLAND , UA , 12/82/2811 81:12;31 PN 415617831 12/83/2811 83;56;15 P11 287225688 KKKK KKXK 1DQ0i 9848 VISA INVOICE 724481 VISA KKKKI{XK9848 VISA AUTR 831833 .BOND/JUDITR A INVOICE Y8R1763 PUNPB 16 AUTH 855332 REGULAR 7 9346 PRICE/GAL 3,239 PUNPB 7 Regular g~4A4C FUEL TOTAL S 25.78 PRICE/GAL 3.199 _ FUEL TOTAL ~ 26 88 Subtotal = t 25.78 - iax = s 8.88 Subtotal = f 26,88 Total = 5 25,7A Tax = S A.88 Total = ~ 26.88 CREDIT t 25.78 CREDIT Please Came Back io See Us Credit 4 26.88 Thank You and Drive Safely ' `~ -~__ , LINOAU MOBIL ELLENTON30L 941-723-700 Sale #VISA XXXXXXX9040 Auth. # 07 637 Inv. # ODA 683 9742586 Date 12/02 11 07:58 LINDAU MAR ELLENTON FL Pump # 2 Regular Gall. Price%Gal~~~ 3;099 Fuel Sale .,~ 19.32 CHOOSINGUMOBIL ~' ~~~ Weloome To LovosAB371 1911 HWy 34 Wast I4 i l l on gC 12r83ii,1 88:34 ~P1~8' Gallons Prioe 9.868 # 2.999 Produot Unleaded #8~7u74 B848Ni1881iA1g818Ni8N 848 Card; VISq iAPProval: 88 48 ~T i oket : 482818 Entero~ ward ~ Press ~ F0R.~4SING 24133. ~ , ' ~~' S PORT (~q ~ 337 I I I _~ I'' TEL# 941 784 pipe Store# 11831 KS# 14 Da .O1 11 (Thu) 16:14 ~ S~ 1 KVS Order 30 QTY ITEM 1 LRG DIET CAKE TOTAL 1 MCDOUBLE 1.80 Subtotal 1.00 Tax Take-Out Total 2 ~ 0.20 Cash tendered 3.00 Change 20.00 17,00 i MCDONALp 'S 11837 ~ i r ~A P.O. Box 4650 L~ ACH/EDI Services .-Buffalo, NY 14240-9975 *** This is an Advice *** (800) 724-2240 Date: Friday, December 09, 2011 VIRGINIA L MCGOWAN 87 SCHIlViMEL WAY CUMBERLAND CROSSINGS CARLISLE PA 17015 Subject: Notification of Death /Reclamation Case Number: 38671 Funds Deposited to Account: ******7616 Funds Deducted from Account(s): ******7516 $288.00 This is to advise you that on 12/9/2011 we deducted from the accounts} shown above the amount of $288, for the.Social Security Income of 12/2/2011. Due'tb the fact-that VIRGINIA L MCGOWAN has passed away prior to the issuance of the credit, the Treasury of the United States is requesting reimbursement. In accordance with Federal Regulations, direct deposits may not be retained by the beneficiary unless the beneficiary lived through the entire month prior to the date of issuance. If the number of the 'account deducted from' is different from the account into which the funds were originally deposited, the deduction is authorized under the bank's rules for right of offset because one or more of the owners on both accounts aze the same. Should you have any further questions about this charge, please call and refer to the case number abave. This advice is provided to facilitate the reconcilement of your monthly account statement. Respectfully, ACH/EDI Services M&T ~; ~ C?~