HomeMy WebLinkAbout02-17-12 (2)~. .
~,
OFFICIAL USE ONLY
PA Department of Revenue PennsylvaMa
Bureau of Indtvidual Taxes "'""~""~'" "~""~` Counly Code Year File Number
Po Boxzso(ioi INHERITANCE TAX RETURN 2 1 1 1 0 0 7 6 7
Harrisburg. PA 17128-o6oi RESIDENT DECEDENT
1505610101
REV-1500 °` t°'-'°' d~!'
Social Security Number Date of Death MMDDYYYY Da-te~-of Birth MMDDYYYY
2 0 1 1 6 1 9~ 0 5 1 8 0 1 1 r01~ 616-~
Decedents Last Name Suffix Decedent''s~Fi-rst~N-aim-e MI
S ar ver ® 'Iv ~Inl IT -~
(If Applieabb) Enter Surviving Spouss's Information Below
Spouse's Last Name Suffix ~S'p'ouse's First Name ~~''''(('' MI
r r
® ~Blen t . -...rLl~
Spouse's Social Security Number
T~~~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
1 6 2 2 2 4 3 16~ REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Retum O 2. Supplemental Return O 3. Remainder Return (date of death
pdor to 12-13.82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Retum Required
death efter12-12-82)
r 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 1 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 TO:
Name Daytime Telepho-n
e-Number
M
ar. t i n R
M c
C a 1 e b ~
r
17 1.7_619_1 717~7~0~
REGISTER OF WILLS USE ONLY
na
0
First line of address ~ ~ ran
219 E ast Ma i n St re et ~ ''r~ r;
p0 c,.
Second line of address ~ ~ - r "~ 1
~ o r'~ _;
E LED ~ ~F-• r?
Clty or Post Office State ZIP Code
'~ ~
e c h a n i c s b u r P A 1 7 0 5 ~' ,~ ~~
Correspondent's e-mail address:
Under penalties of perjury, I dedare that I have examined this return, induding accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, coned and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge:
SIG RE OF PE N SPONSIBLE FOR FILING RETURN DATE
ADDRESS Dennis L. Sarver
Side 1
L 1505610101 1505610101 J
s,
219 East Main Street. Mechanicsburg. PA 17055
PLEASE US ORIGINAL FORM ONLY
J
REV-1500 EX
Decedent's Name:
1505610105
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 (Schedu~ D) ........................... 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E). • • • • • • 5.
6. Jointly Owned PropeAy (Schedule F) O Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property
(Schedule G) O Separate BNling Requested. • .. • • • • 7.
8. Total Gross Assets (total Lines 1 through 7) ............................. 8.
9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9.
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10.
11. Total Deductions (total Lines 9 and 10) ................................. 11.
12. Net Value of Estate (Line 8 minus Line 11) .............................. 12.
13. Charitable and Governmental BequestslSec 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.
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 .0~
16. Arhount of Line 14 taxable
at Ilneal rate X .0
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
Decedent's Soaal Secudty Number
15.
16.
17.
18.
19. TAX DUE .........................................................19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REF.U~;~iF,~,i~d1 OVERPAYMENT
Side 2
1505610105 1505610105
O
REV-1500 EJC Page 3 , , ~ ,
Decedent's Complete Address:
Fik Number
CEDENTS NAME
Ivan L. Sarver
STREET ADDRESS
11 Burgners Mill Road
CITY
Plainfield STATE
PA ZIP
17081
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2' ~~~ 2,500.00
A. Prar Payments
B. Discount 131.58
3. Interest
4. If Line 2 is greater than Lkre 1 + Line 3, enter the diflererrce. This is the OVERPAYMENT.
FiN in oust on Page 2, Line 20 m request a rotund.
(t) 3"306.8
Total Credits (A+ 13) (2)
2.631.58
(3) 0.00
(4)
0.00
5. H Line 1 + Lure 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 67 4 . ~Q
Make check payable to: REGISTER aF WILLS, AGENT.
PLEASE ANSWER THE FOLLOIMNG 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 trdnsfemed :........................................................................................ .. ^
b. retain the right to designate who shall use the property transferred or its inr:orrre : .......................................... .. ^
c. retain a reversanary interest; or ........................................................................................................................ .. ^
d. receire the promise for life of eiiher payments, benefits or care? .................................................................... .. ^
2. If death occurred. after Dec. 12, t9t32, did decedent transfer property within one year of death
without receiving adequate consideration? ............................................................................................................ .. ^
3. Did decedent own an "in trust far" or payable-upon-death bank account or security at his or her death? ............ .. ^
4. Did decedent own an irxtividual retirement account, annuity or other rron-probate property, which
......................................................................................
oartairls a beneficiary designation? ................................ ^
..
lF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COIMPLETE SCHEDULE G AND f ILE R 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 rtet value of transfers to or for the use of the surviving spouse is
3 pert~at [72RS. §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 survving spocee is O perrxrrtt
]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 evearf the surviving spouse is the only t>evtefitrary.
For dates of death on or after Juty 1, 2000:
• The tax mate imposed on the net vaNie 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 pent or a stepparent of the child is 0 percent 172 P.S. §9116(aK1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal benefiaaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §911fi(a)(1)].
• The tax rate imposed on the net value of trarrefers to or for the use of the decedents sibl'mgs is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under
Section 8102, as an individuaV who has at least are parent in c~rrlmon with the decedent, whether by Mood or adoptan:
REV-1508 EX +(1-97)
SCHEDULE E
CASH, BANK DEPOSITS, 8 MISC.
PERSONAL PROPERTY
Ivan L. Sarver SS~~ 201-16-1947 05/18/2011 21 2011 007_67
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. Citizens Bank, - Checking Account ~~6231189094, opened by Deceden 15,882.12
08/10/2010; principal balance as of D.O.D.: $15,882.08; interest
accrued to D.O.D.: $ 0.04.
2 Citizens Bank, - Performance Money Market Account ~p6231189787, 12,042.10
opened by Decedent 09/29/2010;. principal balance as of D.O.D.:
$12,041.90; interest accrued to D.O.D.: $ 0.20.
3 Citizens Bank, - Certificate of Deposit Account ~~6244375497, 48,348.84
opened by Decedent 08/16/2004; principal balance as of D.O.D.:
$48,347.25; interest accrued to D.O.D.: $ 1.59.
4 Members 1st Federal Credit Onion, - Savings Account ~~9680-00, 170.60
opened by Decedent 10/01/1974; principal balance as of D.O.D.: $
170.58; interest accrued to D.O.D.: $ 0.02.
5 Members 1st Federal Credit Union, - Life Savings Account 4,000.47
~~9680-04, opened by Decedent 02/01/2001; principal balance as of
D.O.D.: $ 4,000.00; interest accrued to D.O.D.: $ 0.47.
6 1998 Buick LeSabre Custom automobile, - (needs several regairs). 1,400.00
7 1990 Buick LeSabre automobile. 300.00
8 A.G.A.I., Inc., - refund of cancer insurance premium. 28.75
9 Myers-Buhrig Funeral Home and Crematory, Ltd., - pre-need funeral 7,954.00
contract.
TOTAL lAlso enter on line 5, F
(If more space is needed, insert additional sheets of the same size)
Copyright (0)1996 form software only CPSystems, lrK.
90,126.88
Form REV-1508 EX (Rev. 1.97)
REV-,5„ EX ~ (,-9'n SCHEbULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES $
INHERITANCETA%RETURN
RESIDENT DECEDENT A~M~N~$TRAT~VE CiOSTS
ca i w r c yr ~ flLE NUMBER
Ivan L. Sarver 5S~~ 201-16-1947 05/18/2011 21-2011 00767
Debts of decedent must be reported on Schedule 1.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1 Myers-Buhrig Funeral F3ome and Crematory, Ltd., - funeral expense. 9,990.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s) / EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney's Fees Law Offices-Marlin R. McCaleb 5,600.00
3. Famiry Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
CiA' State Zip
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills 277.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1 Citizens Bank, - service charge for Estate checking account. 2.00
2 Citizens Bank, - service charge. 2.00
3 Citizens Bank, - charge for printing checks. 13.06
4 Citizens Bank, - service charge. 2 00
5 Citizens Bank, - service charge. 2.00
6 Citizens Sank, - service charge. 2.00
Total of Continuation Schedule(s) 676.28
TOTAL (Also enter on line 9, Recapitulation) S 16 , 566.84
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 farm software ony CPSystems, Inc. Form REV-1511 EX (Rev. ,-97)
Estate of: Ivan L. Sarver
Soc Sec ~~: 201-16-1947
Date of Death: 05/18/2011
Continuation of Schedule H-B7
(Other Administrative Costs)
Item Description
~~
7 Citizens Bank, - service fee.
8 Citizens Bank, - service fee.
9 Citizens Bank, - service charge.
10 Citizens Bank, - service charge.
11 Citizens Bank, - service charge.
12 Citizens Bank, - service fee.
13 Cumberland Law Journal, - advertising Letters.
14 Register of Wills, - filing Inventory and Appraisement.
15 Register of Wills, - reserve for filing Account, Releases, etc.
16 The Patriot-News, - advertising Letters.
Amount
2.00
2.00
2.00
2.00
2.00
2.00
75.00
30.00
300.00
259.28
676.28
REV-1573 EX i (9-pp)
SCHEDULE)
BENEFICIApIES
ESTATE OF FILE NUMBER
Tvan T._ Sarver SS~6 701.-] h-1 9[x7 05118/2011 2T -2011 -007b7
LA 10 IP 0 C A O 0 R
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS[Inciudeoutrightspousaldlstrlbutions,and
transfers under Sec. 9716(a)(1.2)j
1 Dennis L. Sarver Son 37,919.77
270 Xoungs Church Road
Shermans Dale, PA 17090
2 Cheryl A. Nickel Daughter 35,548.78
11 Burgners Mill Road
Plainfield, PA 17081
ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON R EV 1500 COVER SHEET
11. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET S 0.00
Ut more space Is neeaea, Insert aGCttlonal sheets of the same size)
Copyright (e) 2000 Form software only The Lackner Group, Ine. Form REV-t513 EX (Rev. 9-00)
-~ .
LAST WILL AND TESTAMENT
I, IVAN L. SARVER, of the Borough of Mechanicsburg, County of
Cumberland and 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 any time heretofore made.
FIRST. I order and direct that all my just debts and funeral expenses be
paid by my Executor or my Executrix, as the case may be, hereinafter named, as
soon as conveniently may be done after my decease.
SECOND. I give, devise and bequeath all the rest, residue and remainder
of my estate, real, personal and mixed, whatsoever and wheresoever situate, in
I
'equal shares unto my children, namely: DENNIS L. SARVER, of Shermans Dale,
Pennsylvania, and CHERYL ANN NICKEL, of Plainfield, Pennsylvania, share and
share alike, absolutely and in fee simple.
LASTLY. I nominate, constitute and appoint my son, DENNIS L. SARVER,
Executor of this, my Last Will and Testament, but if for any reason he shall fail to
qualify as such Executor or cease so to serve, then I nominate, constitute and
appoint my daughter, CHERYL ANN NICKEL, to serve in his place and stead, each
to serve without bond in this or any other jurisdiction.
IN WITNESS WHEREOF, I, IVAN L. SARVER, have hereunto set my hand
UW OFFICES
LIIJ R. McCALE6
and seal to this, my Last Will and Testament which consists of two (2) typewritten
pages to each of which I have affixed my signature this ^~'L day of
A.D., Two Thousand Ten (2010).
G~~ ~` ~ (SEAL)
The preceding instrument, consisting of this and one (1) other typewritten
page, each identified by the signature of the Testator, was on the date thereof
signed, sealed, published and declared by IVAN L. SARVER, the Testator therein
named, as and for his Last Will and Testament, in the presence of us, who, at his
request, in his presence, and in the presence of each other, have subscribed our
names as witnesses hereto.
1
-_~.
LAW OFFICES
2LIN R. McCALE6 _2_
~~ ~
One Citizens Drive
ROP112
Riverside, RI 02915
July 20, 2011
Law Offices Of Marlin R. McCaleb
Frankberger Place
PO Box 230
219 East Main Street
Mechanicsburg PA 17055
Estate of NAN L SARVER
Date of Death: May 18, 2011
SSN: 201-16-1947
Dear Sir/Madam:
In accordance with your request, the attached information sheet has been provided in the above decedent's.
name as of his/her date of death.
For Instalhr:;nt Loans or Line of Credit accounts, contact our Loan Department at 1-800-708 ,.58p, For
all other inquiries, please call 1-877-579-2667
Sincerely, _
'sten L. Petrucci
Decedent Account Processing
REF#: 497039
"schedule E.1, E.2 and E.3"
~~~ ~~-
Account Number 6231189094
Account Title NAN L SARVER
Date erred 8!4/2010
Account T e Checkin
Princi al Balance as of DOD $15882.08
Interest from Last Postin to DOD $ .04
Account Balance as of DOD $15882.12
YTD Interest to DOD $4.08
°Schedule E.1, E.2 and E.3"
t~ ~-
Account Number 6231189787
Account Title NAN L SARVER
Date erred 9!29/2010
Account T e Checkin
Princi alBalance as of DOD $12041.90
Interest from Last Postin to DOD $ .20
Account Balance as of DOD $12042.10
YTD Interest to DOD $21,03
`Schedule E.1, E.2 and E.3`
C~tiz~ts B~tl~-
Account Number 6244375497
Account Title IVAN L SARVER
Date erred 8/16/2004
Account T e Time De osits
Princi al Balance as of DOD $48347.25
Interest from Last Postin to DOD $1.59
Account Balance as of DOD $48348.84
YTD Interest to DOD $68.53
"Schedule E.1, E.2 and E.3"
.. ~
MEMBERS 1"~
P®4R Ai.CRBDrf UNION
PRIMARY OWNER: Ivan L. Sarver
SAVINGS ACCOUNT:
Account Number/Suffix 9060-00
Date Account Established 10(01!1974
Prindpal Balance at Date of Death $170.58
Accrued Interest to Date of Death $.02
Total Prindpal ahd Accrued Interest $170.60
Name of Joint Owner None
UFE SAVINGS ACCOUNT:
Account Number/Suffix
Date Account Established
Prindpal Balance at Date of Death
Accrued Interest to Date of Death
Total Prindpal and Accrued Interest
Name of Joint Owner
9880-04•
02f01l2001
$4,000.00
$.47
$4,000.47
None
Opened by a transfer of funds from the Savings Account 9680-00, originally established on 10/01/1974
PRIMARY OWNER: Dennis L. Sarver
SAVINGS ACCOUNT:
Account Number/Suffix
Date Account Established
Prindpal Balance at Date of Deafh
Accrued Interest to Date of Death
Total Prindpal and Accrued Interest
Name of Joint Owner
Date Joint Ownership Established
CHECKING ACCOU
Account Number/Suffix
Date Account Established
Prindpal Balance at Date of Death
Accrued Intereat to Date of Death
Total Prindpal and Accrued interest
Name of Joint Owner
Date Joint Ownership Established
24554-00
06/25!1980
$2,018.25
$.22
$2,018.47
Ivan L. Sarver
06/25/1980
24554-11
03/22/1986
$2,723.39
$0.00
$2,723.39
Ivan L. Sarver
0 312 2/1 98 6
MEMBERS 1S7C/~FI/E//D/~ER~AL G~RE~D~~ITy,U~N~IO~N,
Leig~Stallings '`r"'._ -~6
Lending Insurence SuppoR Specialist
July 19, 2011
Estate of: Ivan L. Sarver
Date of Death: 05/18/2011
Social Security Number: 201-i8-1947
5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 wwwmemberslst.org
"Schedule E.4 and E.5"
Graham
Motor Company, Ins -
~~-C , o~ o~.~ X95'8 .~_~•C.~ r~C c°
~ucx
~~
~~.
_..
,~~®
- ~~
Graham Motor Company, Inc.
1402 Rally Pike, Carlisle, PA 170!3
,'
~ Jrck Conley
Sales Manager Phom: (7/7J 143-3066
I Fax: 717-149-7998
I K'~'~+:Srahammotors.rnm
1402 Holly Fake, Carlisle, Pennsylvania 17013 • Telephone 717-243-3066 • FAX 717-2~9-7998 -
"Schedule E.6 and F_7~~
Y
- ,~~fi,~z
u _ ,_ -. .
,: _. ..
' ~ i
t~ieryl Ann Nickel
1 i Burgaers M(II_Road.
PO Box 31
Planfield, PA 17081
IN~I~lCE
lnvace. Num. ber: 1(1040
Invoice pate: May 21, 2011
Page: 1
FSE Faciities Staff arld Egtapment $1,192.00
V Vehicles $1,080.00
M Men;harxiise $1,445.00
C:A~emete Crash Advance - C:~netery $ 1,335.00
CA-Newspi 'Crash Advance -Newspapers $385.00
CA-Clergy OastrAdvance -Clergy $ 100.00
CA-Death C Cash. Advance - [>aath Certificates $ 48.00
CA-Flower< Crash Advance -Flowers $ 200.00
CA-Honor ( Cash Advance -Honor Guard $ 100.00
M Merohandise -Flag Case, Beveled Glass $ 85.00
Subtolal $ 9,990.00
Shipping $ 0.00
Sales Tax $ 4.00
Total Irrvoice Amount $ 9,990.00
PaymentlCredit Details: C10012 Paymentr~Ctgd{t ied $ 7,954.00
Past due ao~o~mts are subJect to fete diarges of l.5%perm.m~th.
Thank you for allowing us to serve. you and your family.
Robert L. Buhrlg, Jr., FD, CFSP, Supervisor - Melissa A Etter,. FD - (717) 766-3421 -fax: {717) 795-7291
DirecRa~Myers-Buhrig.com - 37 East Main Street -Mechanicsburg -Pennsylvania - 17055
"Schedule E.9"
PRIMARY OWNER: Ivan L. Sarver
SAVING3 ACCOUNT•
Account NumbedSuffix 9880-00
Date Account Established 10!01!1974
Prindpal Balance at Date of Death $170.58
Accrued Intermit to Date of Death $.02
Total Prindpal and Accrued Interest $170.80
Name of Joint Owner None
~ IFE SAVINGS ACCOUNT
Account NumbedSuffix
Date Axount Established
Prindpai Balance at Date of Death
Accrued Interest to Date of Death
Total Prindpal and Axrued Interest
Name of Joint Owner
9680-04"
02/01!2001
$4,000.00
$.47
$4,000.47
None
' Opened by a transfer of funds from Oie Savings Account9680-00, originally established on 10/01/1974
PRIMARY OWNER: Dennis L. Sarver
SAVINGS ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Prindpal and Accrued Interest
Name of Joint Owner
Date Joint Ownership Established
CHECKMG ACCOUNT:
Account NumbedSuffix
Date Account Established
Prindpal Balance at Date of Death
Accrued Interest to Date of Death
Total Prindpal and Accrued Interest
Name of Joint Owner
Date Joint Ownership Established
24554.00
06!25!1980
$2,018.25
$.22
$2,018.47
Ivan L. Sarver
0 612 5/1 9 8 0
2455411
03/22H 988
$2,723.39
$O.DO
$2,723.39
Ivan L. Sarver
03/22/1986
MEMBERS 1sT FEDERAL CcR?EDIT UNION
Leigheigh`^~Stallm" 9S __ '~""" ~t
Lending Insurance Support Spedalist
July 19, 2011
Estate of: Ivan L. Sarver
Date of Death: 018/2011
Social Security Number: 201-16-1947
5000 Ionise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 wwwmemberslstorg
" Schedule F.1 and F.2"
T
Comments
05/10!11 - 05/17/11 Room & Board 8 $302.00 $2,416.00 $2,416.00
TOTAL BALANCE DUE:
~ 1u~~1'~1
c~i~~o4
$2,416.00
v : ~d . K . n W j. n _ Y.. 5..,
t , ~,
1 4 P
FACILITY NAME RESIDENT NAME ACCOUNT NUMBER
CHURCH OF GOD HOME, INC IVAN L SARVER 803054
"Schedule I-1"