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HomeMy WebLinkAbout03-07-12REV•sne Ex (tz~a> INI'1EHI-TANGS TAX JOINT BANK ACCOUNT COUNTY FILE NUMBER ai- ~~- a~ ApYANCE PAYMENT WORKSHEET INHERITANCE TAX RECEIPT NUMBER DECEDENT'S NAME (LAST) (FIRST) e~ 1 YYxar~ c, ~a V I ~'~ll-Z (MIDDLE INITIAL) DECEDENT DECEDENTS SOCIAL 8ECURITY NUMBER ~~ Z ^' ~ ~ ~ ~ ~~" DATE OF DEATH 1 - ~y ~' ~ ~ INFORMATION ~ ADOR~ OFJ;E EU (,J$ /q~ X~ RC) ~ ~ ~~ ~ T w / I ~ C 1 ( G l'-'C i -( ` =1J ~ NAME OF FI NANO Al INSTIT~'T ON _ ~ ,, ~ Q / ~ ,,~ ~ Q~ ~Yl 1 ~ m CiYV~ ~~s r l(S•~' ~`~''" °' `'t ~n FINANCIAL .. INSTITUTION ADDRESS nn - CITY ,An ST~A~E,,,,s SCX~ ~y1S2. ~ ~ ~ y~ ~V D,p7( ~a !" IPC~n I C`"'~YO ~~ ~/~• ~7 INFORMATION TELEPHONE TYPE OF ACCOU ^ SAYINGS CHECKING ^ TRUST ^ CERTIFICATE OF DEPOSIT ^ OTHER ACCOUNT INFORMATION ACC NT BALANCE (INCLUDE INTEREST TO DATE OF DEATH) ACCOUNT NUMBER ,~ ~ 3 , `~ -~ ~ a ~~ g~' •- D O f ! ACCOUNT TITLE AS A RS SIGNATURE CAR O CD ORIGINAL DATE ESTABLISHED NAME (feet) (First) (Midd~tlal) ~ t 4'J b I~ ~ ~ d . , r rl,~ .c, GL SURVIVING ADORES{S ~~~ 1 S~ ~ I..ti~ ~ E JOINT OWNER INFORMATION cITY STATE ZIP CODE ~ ~ 1 S~2- I ~ ('~ (~ RELATIONSHIP TO DE ENT TELEPHONE NUMBER - ~ ~ ~ ~ 3~ ~ V ~ ~ - TAX RATE -r ~ t 7 av NAME (Last) (First) (Middle Initlel) Q fV ~ ~~ a SURVIVING ADDRESS TAx I E ~ JOINT OWNER "' ~ ~`~ o CITY STATE ZIP CODE C'7 ~ ~ ; <~ %"5 ' ~' INFORMATION ~ ' z _ .~-~. RELATIONSHIP TO DECEDENT TELEPHONE NUMBER - AihRATE .. F. `~ NAME (Lest) (First) (Middle IMtlaQ .. SURVIVING ADDRESS PERCENTTAXARI.! JOINT OWNER Cl.n, STATE ZIP CODE INFORMATION RELATIONSHIP TO DECEDENT TELEPHONE NUMBER AX RATE LIST DEBTS 8 DEDUCTIOtJS BELOW Date Paiq t'a ee Descri Iffon Amount Pald C.~/1'~ n Note: Please attach to receipt Total $ ~•~ REV-548 EX (12.03) IIVI'1C1'i11A1V(,:t IA1~ JVINT BANK ACCOUNT C.OUNTrFILENUMBER ApYANCE PAYMENT WORKSHEET INHERITANCE TAX RECEIPT NUMBER OECED NT'3 NAME (LAST) ' St ~~ (FIRST) (MIpDLE INITIAL) L~l Vl +`~ , DECEDENT DECEDENT 80CIAL SECUpITY NUMBER Q ~ ~ A ~ ~ r I Z ~ L"f DATE OF DEATH , - ~ / INFORMATION ~ - ADDRESS DEC ENT ~~ CITY j~~jATE 21P / ~+-~^ ~ ~ ~ .~ ~ I r"t >i ~ Q/V NAM,E~/OAF FINANCIAL INSTITUTION ~,,_}... ~ ~/~ ,,~ ~ ~,~o ~, ( ~ '~ I'/~ ~O ~ S ~~ " R.~' " h ~ aY7 F~ '" ~" ` !' -~° FINANCIAL ' V ~ ' . . ~".r~'v INSTITUTION ADDRESS t Y' SpGp c ,iJt SQ.- ~ r ~ ~ P~ g o x ~ ~(c~Ct-,tnccsk~r~ ~ ~ 7~ INFORMATION TELEPHONE NU E ~-- ~ - ~ ~a 2-83 --- 2 3 z~ ~~ 7i 7 b 97 - ~3r :z,,. TYPE OF ACCOUNT SAVINGS ^ CHECKING ^ TRUST ^ CERTIFICATE OF DEPOSIT ^ OTHER ACCOUNT A OUNT BALANCE (INCLUDE INTEREST . ~ ~ TO DATE OF DEATH) ACCOU NUM b D Q - ~ INFORMATION 7 ~ ]~ 7 a , b ~ ~~ ~ ?COUNT TITLE AS A EARS ON SIQNATURE CARP OR C a ~S ~ M~iJ~ne Y~ ORIGINAL DATE ESTABLISHED - l >7 2 S - U v ~ n q cx ~ f NAME (Lest) (First) Mtlle inHleq SURVIVING ADDRESS }_.~, ~~ ~ 1J~ ' ' 7 ~ 'I ~a~~ BLE JOINT OWNER INFORMATION CITY ~ I'~ i ~. STA ZIP CODE +~ ~ i '] D ~ S RELATION3F~p~ DECEpE ~n(` I TELEPHONE NUMBER _ ~ ^ ~ ~ ~ 7 y ' rI r f f TA RATE ` ,r ~ i C ~ NAME (Last) ~~le Initlsl) (Ff ~ t) SURVIVING AODRE33 PER NTTA7(ABIE JOINT OWNER ~In, STATE ZIP CODE INFORMATION RELATIONSHIP TO DECEDENT TELEPHONE NUMBER TAX RAT NAME (Lest) (Flrat) (Middle InlOel) SURVIVING ADDRESS PERC TAXABLE JOINT OWNER clrY STATE ZIP CODE INFORMATION RELATIONSHIP TO DECEDENT TELEPHONE NUMBER TAX RATE LIST DEBTS & DEDUCTIONS BELOVS/ Date Patti Pa Descri tion Alrwunt Paid ~-e-c~ a:.~-e-~. I rst--c Note: Pl~ae attach to receipt Total ~ p,0p DEBTS AND DEDUCTIONS ESTATE OF DAVINA DESIMONE Date Paid Payee Description Amount Pd 1. 12/08/11 Ewing Brothers Funeral Home Grave opening,. $722.24 630 S. Hanover St, Carlisle fees for St. Pat's 2. 12/2/11 Rock of Ages/Eby Granite Works Engraving 116.00 P. O. Box 187, Newville, PA 3. 11/26/11 George's Flowers Family spray 322.24 101-199 G St, Carlisle, PA 4. 11/29/11 Luigi's Italian Restarant Funeral Dinner 1537.00 204 N. Hanover St, Carlisle, PA 5. 11/26/11 PLCB Wine for Funeral 187.43 Wine 8~ Spirits Store 2110 Stonehedge Shopping Center Carlisle, PA 6. 12/2/11 Kohl's credit card payment 88.53 7. 12/12/11 Guardian Long Term Care Pharmacy Rx payment 1.54 TOTAL $2974.98 INHERITANCE TAX CALCULATION '/Z checking account + %z savings account ='/z (2463.73 + 6972.75)= $4718.24 Minus total debts of decedent 2974.98 Taxable Value of Decedent's Interest in Bank Accounts 1743.46 Multiplied by lineal descendant rate (4.5%) X .045 Tax Due $78.45 1~ P= s 1 ~ M ti 3 z W W "' ~ n.1 rv .~ r ~ r .. Fj O ~\ O ~! r ((~~,, r o„ '~1 W ~ ~.. 1'1.1 '~' ~ (:.,~ X1.1 i ( i r r t ~ ~R ru ~ I `~, i ~' '* J~ ~ ~. i ~. i i~ ~N~~ r0~~ cn C ~ ro~~~ a -~ ~v ~' c ~ w ~` {' ~ 'v ~~ 1 ~n ~~ W ~Es `~ o0 ~~ N St vIEMBERS 16t EDERALCREDIT UNION Send lnqulres lo: 6000 Loulse Drlve PO Box 40 Mechsnksburg,PA 17065 www.mambsrslst,org Main 6tivltchtwartl: (800) 283.2328 EZ Call: (777) 697-4372 ar (800) 283.4372 TDD: (777} 697.5372 or (800) 263-2328 exl. 5312 TeleBranch: (800)237.7288 Statement of Accounts Dee 25, 2011 thru Jan 24, 2012 `._.._..,__... _..._ti, Account Number: ~. 124888 I Balances at a Glance Checking: 3, 096.53 Savings: 3,975.48 -"' Certificates: 0.00 -- I_oans: 0.00 "'- 1031 1 AV 0.350 1031-1031 ~_ Irnlllrirlllrr,irrllrlrlJrlri~l,rllrl„I~~Iirrrll~lilJlrr,l = DAVINA DESIMONE ~ MADELINE R WEBS ~ C/O MADELINE WEBB a 15 COUNTRY ROAD CARLISLE PA 17015 Money Management: 0.00 Swipe 5 YTD Reward : 0.00 Page: 1 of Your aggregate balance as of January 1st is $7,072.01. An aggregate balance of $2,500 and having 3 products will place you in the Silver MLR level. Want to earn some extra cash? Take advantage of our CASH4U referral program. Ask an associate for details. C~ JECISILUCz,A000U NTS - ..QQ11 - CHECKING_ 1 D~_ Transacibn DescriDNon Additions Subtractions _ Balance Dec 25 8a/ance Forward 3,098.25 Dec 31 Deposit Dividend 0.100% 0.28 .-1 ~ 3,098.53 Annual Percentage Yield Famed 0. fOtl16 from 12/01/2011 through 12/31/2011 ` t / Based on Alrerage Quay Ba~nce of 3,258.57 ~-T 4~ Jan 24 Endk~g Bence ~ ~ 3 ,096.53 2011 D~inilenals Pakf 3.95 SAVIN ~ A~~TS -` ~ 0000 --REGULAR SAVINGS~~ ~. - -- ',~7~.75 QQ,te _ _ ,?r~nsag>~gLi. Q~%r~?q~n -------------------- Additions - Subtr2r:tions ._ 88lznce Oec 15 Balance Fonva~d 3,974.60 Dec 31 Deposit Dividend 0.25096 0.88 3.975.48 Annual Peit7entage Yre/d Famed 0.250A6 hnm 12/01/201 f d~rotrgh 12/31/2011 Jan 24 End/ng Balance 3,975.48 2011 Diuidevids Paxf 25.14 YTD SUMMARIES TOTAL DIVIDENDS PAID 0000 REGULAR SAVINGS 0.00 0011 CHECKING p.OD Total Year To Date Dividends Paid 0.00 NOTE; Total includes closed shares Total 2011 Dividends Paid 29.09 ' Ewing Brothers Funeral Home, Inc. ~"-' 630 South Hanover Street Carlisle, PA 17013- (717)243-2421 November 30, 2011 Madeline R. Webb 15 Country Rd. Carlisle, PA 17015 The Funeral Service for Davina M. (Patino) DeSimone We sincerely appreciate the confidence you have placed in us and will contin ue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. I. PROFESSIONAL SERVICES Services of Funeral Director/Staff , _ 51865.00 Embalming. 5895.00 Casketing, Cosmo ctc. _ 5295.00 2. FACILITIES AND SERVICES Viewing (Visitation/Wake) , _ 5495.00 Funeral Ceremony, 5495.00 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Home, $275.00 Hearse (Casket Coach) $275.00 Limousine , 5225.00 Safety/Lead car/Clergy 5125.00 Utility Vehicle for DC retrieval/Filing, 5125.00 FUNERAL HOME SERVICE CHARGES $5070.00 SELECTED MERCHANDISE: 18G Pieta Casket . 52650.00 American Chief OBC, _ _ 51595.00 Acknowledgementcards, _ $10.00 Register Book(s) , _ $40.00 Memorial folders , 585.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED _ $9450.00 Cash Advances Opening Grave, S1720.00 Clergy/Mass Offering, 5150.00 Certified Copies of the Death Certificate , _ $18.00 The Sentinel no photo _ _ $134.34 Organist. $150.00 Cantor $75.00 3 Attar Servers, _ _ _ $60.00 TOTAL CASH ADVANCES AND SPECIAL CHARGES . 52307.34 Total Total Cost , $11757.34 G v eil~ PLraa.~- SU$-TOTAL 511757.34 RVITIAL PAYMENT /DISCOUNT (CREb[TS 0.00 TOTAL AMOUNT DUE SI I?S7 34 The uapaid balance over 30 days is subjccted toe 1.50 % service charge per month - 18.0000 % per annum. 9 ! ~ / 1 ~ I ~''~`'~~ ~~~~ S~ ~ ~ALfl»c.~~vr ,~e.lat,+.j .~'%C'q+~S ~a T ~o--t~-/-~,.r©/ C~~c /Vo~"~'i~!~c.Q~ c 'ove~.~a/ t.[ ,tfp~~r /TJi•,~r/~.pe~~ e S C/t! ! 2 7 a ~~0, ~ ~r ~_ ,/~LJ~~ ~,°~ ~~,s ~'~ ~f~',uT ~-- = Q~,,Fr~•sr- f/C'A~ C i°r~ ~ 7'i GlA7co . ~~~ ~z ~~ ~'~. ~U ~~ ~~,. p, yam' ~~ 6'88,79 ~~- (~u ~~ 6Uifk4 r .~~ jj '~~~ ~~~~ti~ I ~1 ~ ~3 d'~~~ ~~ Z2. ~' 1~ ~- ? ,a ''~` p ~~ ~~' ~~ ~,~~ G ~~ ~~ Eby Granite Works 'Z (lf L /r ~C^~ ...C._ ~!~r~~ .fk1 ,~'1~~.~~.- .mac ~ ~~-~~.- ~ , ,~ ,~ `~l`-~/ ~~~` r `' t9ebra a. Zmn F•O. Box 187 Newviue, PA 17241 Manager 717-776-5118 GEORGES' FLOMERS 101-199 0 ST. CARLISLE, PA 17013 gate: 11/26/2011 ia~e: 11:46:09 AM Order Nun~er: 179393 sty Description Price FAMILY SPRAY S 300.00 Sub Total: Y 300.00 Delivery Charges: t 4.00 Sales Tax Z 18.24 Total A~,nt Due: s x:2+4= Charge to House: S 322.24 Change Due: S 0.00 Thank You For Your 9usir~ess! Tint Date: 03(05/2012 'tint lime: 10:42:49 AM REPRINT , A a N C d ~ ~~ i-+ d a!I ~ ~ ..~ _ ~ o ~ ~ < C y ~ l 7 { , y , W +'a "" ~ y ~ ' _ ` CV ¢ Q N rr ~ d r r~ ;/? Cn Z /~'' ' ~ ~~ J ~" QW~ OQf~ N ~ O ~O! O C7 ~ ~ `v ~ SO OS O N j If! N X N ~~ .-. ~ i/~- ~ _ 8 8 ~ 4~ ~ ~ ,., 8 _ o~ a +~ 9 1C .. m ~ ~,, !l' 8 a. 1 } y v ~ ~ ~ N i ~ ~! ''' v N .N.. ~ J C H er t- y • v C/7 W ~ v W = a ~ W ~ a 8 «t ,c,~ J l:~`,, M .~ .?A C _ ,~ /, ~ ~ ~ un a ~ ~ W ~~ ~ ~ T PA Wine i lplrks Stops ~~ PLCB WINE 8 SPIRITS STORE 2110 STONEHEDGE SgURRE SHP CTR CARLISLE 717-293-1611 11/2fi/11 10:12 AM Trans.: 0952 Store; 02110 Res. 0p1- Till: JBM Cashier ID: 00619011 i~mii YAGO SRNT'GRIR 61.96 T 000007934 4 @ 12.99 Sutter Howe Red 48.93 T 000008189 7 @ 6.99 BERINGER WH 2IN UI 39.95 T 000005236 5 @ 7.99 Sutter Home Red - 7:99 T 000008172 1 @ 7.99 SPA111024 BERINGER WH ZINFDL 27.98 T 000005876. 2 @ 13.99 Subtotal 176.81 Total Sales Tax ( 6 .0X tax rate ) 10.62 Total 187.93. Cash 200,00 Total Tender 200.00 Chance Due (12.57) Total Nuwber of Unit(s) Sold 19 Custower Copy ---------------------------------------- Shop and learn online: FineWineAndGoodSPirits.cow Twitter: @PAWineSNirits Facebaok~ Fine Wine & Good Spirits Please Call 1-800-272-PLCB with questions, concerns or cawwents Name or Address Change? Account Number 029-2439-668 Would you like to receive a-mail sales notification? Due Date Dec 8, 2011 II''~t~~llllli~'~II~ New Balance 588.53 I~ I' Minimum Due 625.00 Kohl's Payment Center -ulaiithisp°'d°nwithyourpayment. PO BOX 2983 4 6 8 MILWAUKEE WI 53201-2983 (IIIIIIIIII'Illllllllllll~lhylilhhlnllnlili11I1'Illlll'IIII Amount Paid $ ~ 8 ~s''3 Il~h~llllll"I'IIIi1'IIIIIII'111"II111111111'IIi11'1111111'1'~I NOTE: oonamWcrhorpmoaeds. 000058506 1 AV 0.340 106481334083151 P Pis ~e ~ aafnDb eo KpML M us oouss DAVlNA DESIMONE 15 COUNTRY RD CARLISLE PA 17015-9498 0000000 029243966852 00025D0 0008853 4 ~KOHLS Carltsle Carlisle, PA 17013 f717) 243-4595 12-02-i1 10;59A 0188/25/5942/6 1859XXX Payment on XXXXXXXX6899 „g;3 BANX CHKED 066530 APPROVED OOOOU~X8887 88.53 THAN( YOU FOR SHOPPING AT KOFL.'S Help Kohl's give $500,000 to Charity) You could win $2,600 in Kohl's Gift Cards Get involved at facebook.com/kohls LOPE TO GIVE HAPPY TO SAVE2 Guardian•LongTermCare Pharmacy 123 BRUBAKER RD BROCKWAY, PA 15824 (814)503-7400 .Invoice Number ` Ievoioe Dato 'Irwoioa Amouat Page IN000001989 11/30/2011 $1.59 1 DATE DE9CRtPTION AD®Di7NT Patient:DESIMONE,DAVINA 09/22/2011 Rx 12901 RX - FUROSEMIDE TAB 20MG Qty 5 Copay: 1.54 Total Legend .. Invoice Total ~/Iw54 ,> ~a,.~E~,C 1z - /z -1/ ,~ _ ~~d /~ ; ~ ~~~~~~ ~z.~i ~~~~~z