Loading...
HomeMy WebLinkAbout03-21-12.' 1505610101 REV-1500 EX (oi-io) OFFICIAL USE ONLY PA Department of Revenue ~E~~ County Code Year File Number Bureau of Individual Taxes ~ ~~ INHERITANCE TAX RETURN PO BOX 280601 Harrisburg, PA 1128-0601 1 RESIDENT DECEDENT - ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY -ti Decedent's Last Name Suffix Decedents First Name MI _~. S,T2E~rG . (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI R. - Spouse's Social security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust Q 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) Litigation Proceeds Received O O 9 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 - THtS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Daytime Telephone Number Name v 7 / 7 ~ _ -2-~ I ~ ~ ~- K ~ ~ (l, /< / c ~ C v -r, REGISI' N'gLS U~NLY S~`i C f V Z ~ , First line of address Cf7~ .: ~ ~-. - ~ ~ ~ ~ , t r c_ '~ ro RED FoX ~ ~N~ ~ ~-- ~ ~ ~'_.. _ _ -i ~ Second line of address ~_. ~:~ ~..> i DATE FILED City or Post Office State ZIP Code m~~~~~~~s~u~ ~ ~~ ~7aso Correspondent's a-mail address: C 00/~/~S~o 3 ly' ~1JA"7L~ff5f" N£T - Underpenalties p 'ury, I declare that I have examined this return, including accompanying schedules and staternents, and to the best of my knowledge and belief, it is true, Corr t a complete. Declarati of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATU ERSON R PO E FO FILING RETURN D TE ~ ~~/~~ I ~_ ~ ADD SSU /) SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J 1505610105 , REV 1500 EX Decedent's Name: Decedent's Social Security Number ~ '~ ~ / Z:~l X9,;0: 7. RCVNr11YW11VIV - - - -„ 1. Real Estate (Schedule A) ............................................. 1. ,4..~:~ g .,lea s3~s~.:~_°~:c.- 2. Stocks and Bonds (Schedule B) ....... ................................ 2. 3. Closely Held Corporation, Partnership or Soie-Proprietorship (Schedule C) ..... 3. ' .....~ 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. ' 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. rf ~ ~, ~ (P ~ T 9 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. J 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ~-- - - ~~;;.w,.•~a~nr ~.s~';~s~;~K,~,.~ (Schedule G) p Separate Billing Requested........ 7. ~=' 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ~ '~ ~ !.{ 9 x 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. / w ~ S:O 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. ~ ~"~ .~ ~; (P ~_ ~.b.._.:.~~y .._~;~~ 11. Total Deductions (total Lines 9 and 10) ................................. 1 L .~ 5' 7 )a ' ~ " T 13. an a ectionto ~xovernmentalnBequest /Sec 9113 Trusts for which 12 f ~~, r .,~•~ G~ / ~~/ f r `, has not been made (Schedule J) ........................ 13. ~, 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 02 ~ J ~ '~ ! 4~ TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 .' ,~ , , s ~ , ~ , , . ~, T.. „ ~ (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable ~" ~ - ~ ~°.~-:~.'`' .~~r.~ ~~-,:~x~+~y,r.,:, ,~,;~a.~~,,, at lineal rate X .0 _ ~ 16 `s - ~ 17. Amount of Line 14 taxable . , {~ ~ ' ~' at sibling rate X .12 ~ ~ ~ ~ 17 ~ ' ~ _,~ 18. Amount of Line 14 taxable ~'~ ` ~" ' ~`~~'~~ { at collateral rate X .15 = ~ ~ 3 ~ 3 18. ~ ~ ~ / 19. TAX DUE ......................................................... 19. ° _ . ~ ~ ~ / 3 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610105 1505610105 O REV-1500 EX Page 3 f1~w.~J~..i7~. I~wM MIA~A Addrn~c• File Number rvvvvv... .. ~~...r-~__ - _«_..-- DECEDENTS NAME n /~ e T7'y TAitl ~ J 7~/2 ~~ ~ G ---- STREET ADDRESS ~ ~ ~ Pv,~~~ ~~~~ 20~ ~ CITE //~ m to ~/ J/ 'STATE ~~~ 21P / ,,O // Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditsJPayments A. Prior Payments - B. Discount /Jr'• (4 9 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. c1) ~/3, ~'3 Total Credits (A + B) (2) / ~ ~ (3) (4) (~) '~a 9~ i5~ 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 :..................................................................................... ...... b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ c. retain a reversionary interest; or .................................................................................................................... ...... ^ ^ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........................................................................................................ ...... ^ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ........ ...... ^ 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 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 x[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-i5o8 EX+ (u-io) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEp~1LE E CASH, BANK DEPOSITS 8c MISC. PERSONAL PROPERTY ESTATE OF: ~ ___- - FLLE NUMBER: r elude the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disdosed an Schedule F. ITEM VALUE Af UAI E NUMBER DESCRIPTION. __ OF DEATH 1. ~~~,,, QC~r?~c'~~~ dam G'~ Cdr ~~ ~~~~~/~ ~' J ~ - ~ ~~ ~ /~. / 7c~ // ~ i~, ~~ U ~, .~ ~J O v~2~~r, a,u,~ ~' ~te~~ ~` a~3 /a31v1 ti _ f iv ~ ~i ~~b~~ 3 Cb , c~ s 0 ~` Co, C~~®,~~7 ~I,D~~,~ c.x0 ~ ~"" TOTAL (Also enter on Line 5, Recapitulation) $ I ~ ~ ~~' ~ / If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-d9) Pennsylvania SCHEDULE H oEPAarMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESloaar oECEOENT ESTATE OF ~ ~ v JOE ,Eu ~' FILE NUMBER o?e1~ - 04 d 7a2. Decedent's debts must be reported on Shcedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. 1 ADMINISTRATNE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City Year(s) Commission Paid: 2. Attorney Fees: 3. 'Family Exemption: (If decedent's address is not the same as daimald's, attach explanation.) Claimant Street Address 4. 5. 6. 7. City State _ Relationship of Claimant to Decedent Probate Fees: ~ ~~. fj~ Accountant Fees: Tax Return Preparer Fees: State ZIP ZIP TOTAL (Also enter on Line 9, Recapitulation) I $ 9~• SO If rtwre space is needed, use additronal sheets of paper of the same size. REV-1512 EX+ (12-OS) Pennsylvania DEPARTMENT OP REVENUE INHERITANCE TAX RETURN RESIDENT DECREPIT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES 8i: LIENS ESTATE OF FILE NUMBER Report det+ts hlalrred bIr the decedent prior to death that ra aired unpaid at the dale of death. indudh~p um+elmbursed medipl . 1TEM VALUE AT DATE ~~uu~cn TIFCfRiD1TI1N OF DEATH ~ . 6= e /d Sri ~~ vi r~ Sr- ~,P/~'I ~'f~ ~ .c ~, 2 e,~ ~~nk Cap ~C. ~~ ~s~~F~. ~Q~ ~ C~ ~ L~~Lrn Qi~ /~ ~ S_ ~ ~ ~a. Girls n C~f~ /, /3~.~0 ~; ~~~, ~s ~, 4~ ~ o-~ i, ~~• ~ ~ ~~ ~ ~ ~ 1e3~~ 'I o1; t~ 7 ~. ~~ TOTAL (Also enter on line 10, Recapitulation), $ i'~ ~'~lP ~~ If more space is needed, insert additlonal sheets of the same size. REV-1513 EX+ (11-08) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE BENEFICIARIES ESTATE OF FILE NUMBER 074/ - d D07~ RELATIONSHIP'f0 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 distributions and transfers under Sec. 2116 (a) (1.2).] 1. ~Q~ cki e ~C~Ct.~1 ~oo /< ~aC, ~6,ee2T ~ eoo~ /v /fed Fox ~~n-e- ~e (~,,~ ~ c ~6c~b, ~~ l 7 0 5~ - a ,/~ ~e~/e ~ Gv~ s.~ ~-l ~ e c.e. ~~ a ~ ~~ d ~~ ~d~~- ~~~ /~~, P~ i 7 o i ~ X3/3. ~.3 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, insert additional sheets of the same size. J~~T WILL AND TESTAMENT OF BETTY JANE STREBIG I, BETTY ]ANE STREBIG, a resident of the olo~' 11 wells andsodicils alany time Last Will and Testament, g publish and declare this to be my heretofore made by me. . FIRST: I direct that the expenses of my last illness and funeral, the expenses of the istration of my estate, and all estate, inheritance and similar taxe'n eyreas for malt ems thereon shall adman included in my estate, whether or not passing under this will, and any 'd out of my residuary estate, without apportionment and with no right ~of reimbursement from any be pai _ recipient of any such property. Nav Bell Clock to my friend ROBERT D. COOK. I give all of SECOND: I give my Y friend RICKIE J. COOK. I n-y Oriental hand carved e ~ ~ ~ d o myi~end's son,1DAV ID LONG. my g-ve my antique s-de tab All other tangible personal property is given as hereafter provided with respect to my residuary estate. I ve all the rest, residue and remainder of my property and estate, both real THIRD: gt manner and personal, of whatever kind and whereverf ~ated, that I own or to which I shall be in any ed to as my "residuary estate"), as follows: entitled at the time of my death (collect-vely re estate (the FIItST SHARE) as follows: A. I give 75 percent of my residuary (a) If my friend ROBERT D. COOK and mgERT D. COOKJandCmy friend RICKIE J. shall survive me, to those of my friend RO COOK who survive me in equal shares. friend ROBERT D. COOK and my friend RICKIE J. COOK shall not survive (b) If my residua estate to the otl-er beneficiaries of my me, I give the aforesaid 75 percent of my t7' residuary estate, in proportion to their interests under this Article 'THIRD and subject to the provisions of this will. (c) If none of the aforesaid beneficiaries shall survive me, I give the aforesaid 75 percent rest nephew KURT A. WAGNE;R and my great niece of my residuary estate to my g 'rARYN M. WAC,NER, or either of them who shall survive me, in equals arcs. /~eel~ ~~~G~ B. I give 25 percent of my residuary estate (the SECOND SHARE) as follows: (a) If my niece DANIELLE D. WISE and my nephew in law JAMES L. WISE or either of them shall survive me, to those of my niece DANIELLE D. WISE and my nephew in law JAMES L. WISE who survive me in equal shares. (b) If my niece DANIELLE D. WISE and my nephew in law JAMES L. WISE shall not survive me, I give the aforesaid 25 percent of my residuary estate to the other beneficiaries of my residuary estate, in proportion to their interests under this Article THIRD and subject to the provisions of this will. (c) If none of the aforesaid beneficiaries shall survive me, I give the aforesaid 25 percent of my residuary estate to my great nephew KURT A. WAGNER and my great niece TARYN M. WAGNER, or either of them who shall survive me, in equal shares. FOURTH: If any property of my estate vests in absolute ownership in a minor or incompetent, my Executor, at any time and without court authorization, may: distribute the whole or any part of such property to the beneficiary; or use the whole or any part for the health, education, maintenance and support of the beneficiary; or distribute the whole or any part to a guardian, committee or other legal representative of the beneficiary, or to a custodian for the beneficiary under any gifts to minors or transfers to minors act, or to the person or persons with whom the beneficiary resides. Evidence of any such distribution or the receipt therefor executed by the person to whom the distribution is made shall be a full discharge of my Executor from any liability with respect thereto, even though my Executor may be such person. If such beneficiary is a minor, my Executor may defer the distribution of the whole or any part of such property until the beneficiary attains the age of eighteen (18) years, and may hold the same as a separate fund for the beneficiary with all of the powers described in Article SIXTH hereof. If the beneficiary dies before attaining said age, any balance shall be.paid and distributed to the estate of the beneficiary. FIFTH: I appoint my friend RICK]E J. COOK to be my Executor. If my friend RICKIE J. COOK shall fail to qualify for any reason as my Executor, or having qualified~shall die, resign or cease to act for any reason as my Executor, I appoint my niece DANIELLE D. WISE as my Executor. I direct that no Executor shall be required to file or furnish any bond, surety or other ;security in any jurisdiction. SIXTH: I grant to my Executor all powers conferred on executors under the Pennsylvania Probate, Estates and Fiduciaries Code, as amended, or any successor thereto, and all powers conferred upon executors wherever my Executor may act. I also grant to my Executor power to retain, sell at public or private sale, exchange, grant options on, invest and reinvest, and otherwise deal with any kind of property, real or personal, for cash or on credit; to borrow money and encumber or pledge any property to secure loans; to exercise all powers of an absolute owner of property; to compromise and release claims with or without consideration; and to employ attorneys, accountants and other persons for services or advice. The term "Executor" wherever used herein shall mean the executors, executor, executrix or administrator in office from time to time. SEVENTH: I direct that for purposes of this will a beneficiary shall be deemed to predecease me unless such beneficiary survives me by more than thirty days. This document was prepared under the authority of 10 U.S..C. §1044 and implementing military regulations and instructions, by Captain Joseph Krill, United Staters Army, who is licensed to practice law in the State of Pennsylvania. ~ /~, refs IN WITNESS WHEREOF, I, BETTY JANE STREBIG, sign my name and publish and declare this instrument as my last wilt and testament this2~ day. of !JN'D~-9~A/ , 2006. BETT BIG The foregoing instrument was signed, published and declared by BETTY JANE STREBIG, the above-named Testatrix, to be her last will and testament in our presence, all being present at the same time, and we, at her request and in her presence and in the presence of each other, have subscribed our names as witnesses on the date above written. ~~~, ~w having an address at "~Di3 having an addre~ses'at C~~ ds-~ , t ?via 3 Y ~ ACKNOWLEDGMENT AND AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA, COUNTY OF CUMBERLAND, ss. We, the Testatrix and the witnesses, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix, BETTY JANE STREBIG, signed and executed said instrument as her last will and testament in the presence and hearing of the witnesses, and that she had signed willingly, and that she executed it as her free and voluntary act and deed for the purposes therein expressed, and that each of the witnesses at the request of the Testatrix, in the presence and hearing of the Testatrix and each other, signed the will as witness, and that to the best of his or her knowledge the Testatrix was at the tame at least eighteen years of age or emancipated, of sound mind and under no constraint, duress, fraud or undue influence. ~ ' BE J BIG Testatn~~x,, print: ILo ~t~ L • 1 ~~ ~hS Witness ~~ ' print: CSi~ ~ ' Witness Subscribed, sworn to and acknowledged before me by the said BETTY JANE STREBIG, Testatrix) and subscribed and sworn to before me by the above-named witnesses, this ~ day of ~ld~P 7J/IC/~ , 2006. - - Notary Public My comnussion expires on COMMONWEALTH OF PENNSYLVANIA Notarial Seal BOSa A. Ortiz, Notary Put~lic Carlisle Bono, Cumberland County ~' Commissi~ Expires Nov. 8, 2Q09 Member, Pennsylvania Association of Notaries COMMONWEALTH OF PENNSYLVA""^ COUNTY OF CUMBERLAND SHORT CERTIFICATE I , GLENDA EARNER STRASBAUGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 19th day of January, Two Thousand and Twelve, Letters TESTAMENTARY in common form were granteci by the Register of said County, on the estate of BETTY JANE STREBIG 1 a to of EAST PF_NNSBORO TOWNSHIP !Post, Middle, Last1 in said county, deceased, to RICKIEJ COOK !First, Middle, Last! and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hasid and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this I!~th day of January Two Thousand and Twelve. File No. PA File No. Date of Death S.S. # 2012- 00072 21- 12- 0072 12/28/2011 187-12-1907 eglster l :~. 1 NOT VALID WITHOUfI' ORIGINAL SIGNATURE AND IMPRESSED SEAL BETTY J STREBIG R1CKlE D COOK ATTY -FF B818nCe8 35 + 37 >~ # 164/169966 rrt i3aiar+oe _111 ge Dsiiy t381ance ~ Interest ` ' _ i 0 07 Annual PgeYreki-Famed ; 0.0196 Paid this Period ~~ ~~ Pew S 0.07 Paid Last Y~r ; ~•~ Paid'Year--To-Date - 'The interest earned and the krterest paid may differ 1:0.18. - ;: depending on when interest is carrdited to your acxount. Checks Posted Ctreck 8 Date Paid Amount Reference Check # D~a Paid Amormt Reference 34400 2 973847510'- 11 i 12128 11483:34 994516275 101 109 4 170 12116 375000 977377045 3 Check(s) Posted = 32.277.34 An asterisk (7 indicates a skip in sequential ctreClr numbers. An (E) indicates check was converted to an electronic item. Account Activity ~Wditiw~s Subtractions BMance bate l~scription 35,054.54 i2-CS Beginning t3alance 344.00, 55,010151 . i2-01 CHECK ; 1Q8 - _ ~....., ec r-n~ ~ 12-30 !Nl ERES ~ c;rttu~ r ---- 12-31 Ending Balance 310,630.57 16411699th page 2 of 3 BETTY ~ sTREelc Account # 2339 DANIELLE D WISE ~_ Balances Beginning Balance $60.13 Current Balance $3,637.60 Deposits/Credits + $3 577.47 Average Daly Balance $2,296.04.. Interest Paid this Period " $ 0.02 Annual Percentage Yield Famed 0.01 °~ Famed this Period $ 0.02 Paid Last Year $0.28 Paid Year-To-Date S 0.02 `The interest earned and the interest paid may d'rffer depending on when interest is credited to your account. $erVIC@ Fees - It@1771Zed Date # Transactions Fee Total .MONTHLY MAINTENANCE-.FEE 01/20/12.. 1 1000 $10.00 FEES WAIVED 01/20/12 1 -10.00 - $10.00 Total $0.00 Account Activity Date Description Additions Subtractions Balance $60.13 12-22 Beginning Balance 01-03' US TRFASURY 3i2 XXCIV SERV 01G312 ` 52,122.95' $2;483.08 F 2533792 W-CS~ -- _ 01-03 US TREASURY 312 XXCIV SERV 010312 $746.50 -~ ~ $2,929.58 A 3044848 0 CSA ~ - -" 01-03 US TREASURY 303 XX OC SEC 010312 $708.00 ~- $3,637.58 A SSA .. 01-20 INTEREST CREDIT $0.02 $3,637.60 $3,637.60 01-22 Ending Balance paRe2 of3 233l03h195 eEm ~ SrREerc Account # 2331036195 DANIELLE D W15E Balances Beginning Balance $3,637.80 Current Balance $60.17 Deposits7Credits + $p.02 Average Daily Balance $1,852.62 ..,:.~...e...~~ert~,~ -53.577.45 Interest Paid this Period ' $ 0.02 Annual Percentage Yield Earned 0,01 % Earned this Period $ 0.02 Paid Last Year $0.26 Paid Year-To-Date $ 0•~ 'The interest earned and the interest paid may differ depending on when interest is credited to yowr account. Service Fees -Itemized Date # Transactions Fee Total MONTHLY MAINTENANCE FEE 02721/12 1 1000 $10.00 FEES WAIVED ~ 02/21/12 1 -10.00 - $10.00 Total $0.00 Account Activity Date Description Additions Subtractions Balance $3,637.60 01-23 Beginning Balance $708.00 $2;929:60 01-26 RETD US TREAS 303 SOC SEC 010312 RECLAIM 02-10 RETD US TREAS 312 CIV SERV 010312. $2,122.95 $806.65 RECLAIM 02-10 RETD US TREAS 312 CIV SERV 010312 $746.50 $60:75 RECLAIM 02-21 INTEREST CREDIT $0.0:2 $60.17 02-21 Ending Balance $60.17 puRe2 of3 233/036195 9800 F-edericksbu~g Road San Mtonio, Texas 78288 U5~® 05308.HFQO.JSS343305753.01.01.2274 EST OF BETTY J 10 RED FO% LN MECHANICSBURG STREBIG PA 17050-1627 Subscriber's Account Annual Statement for 2011 February 27, 2012 As a member-owned association, our mission is to serve our members. And we're proud that in today's economy, military families can depend on us. You can rest assured your association is strong, growing and well-positioned for the future. The Subscribers' Accounts are a benefit of membership in our association, and they assist in maintauvng the association's financial strength and in meeting the needs of its members. Below you will see your allocation and distribution.- . ,, Subscriber's Account Annual Statement for 2011 Prior Balance 1,323.79 2011 Allocation +$ 72.95 ---------------"S 2011 Year-End Balance $ ~"1,396.74 7'R4~ ~is .~tst a RThat is a Subscriber's Account? All companies hold a certain amount of capital. Since USAA is a reciprocal (member-owned) company, it cannot issue stock to raise capital and must raise capital through other means -primarily strong earnings and continuous oversight of capital needs. One of the ways USAA manages its capital is through the Subscriber's Account program. USAA holds a portion of its capital in each member's name in a Subscriber's Account. Subscribers' Accounts play an important role in USAA's financial structure by providing capital to satisfy legal and regulatory requirements, support current and future operations and pay large unexpected losses such as member claims from catastrophes. How_does the_Subscriber'a~ Account. balancx increase? _ _ ___ This is not a bank account where a member can make deposits. Rather, based on the amount of income earned during the year, the USAA Boazd of Directors may allocate funds to Subscribers' Accounts the following February. The amount of allocation to an individual Subscriber's Account depends on the member's existing Subscriber's Account balance and the amount of premiums that the member paid the prior year for his/her auto and property insurance. The amount allocated to your Subscriber's Account is shown in the box above. 04481-0112 00645 99 87 HSFALS Page 1 of 2 RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date: 1/19 2012 Cumberland County - Register Of Wills Receipt Time: 08: 5:53 One Courthouse Square Receipt No.: 1068448 Carlisle, PA 17613 STREBIG BETTY JANE Estate File No.: 2012-00072 IWKIE J COOK Paid By Remarks: R ~ Receipt ------------------------ Distrib ution ------ ------- -------' --- Fee/Tax Description Payment Amount Payee-Name PETITION LTRS TEST 45.00 00 15 CUMBERLAND CUMBERLAND COUNTY COUNTY GENERAL GENERAL FUN FUN WILL SHORT CERTIFICATE . 8.00 50 23 CUMBERLAND COUNTY GENERAL BUREAU OF' RECEIPTS & CNTR FUN M.D JCS FEE AUTOMATION FEE --------- . 5.00 ------- CUMBERLAND COUNTY GENERAL FUN Check# 5908 $ 96.50 Total Received......... $ 96.50 DESCRIPTION OF CHARGE QUANTITI( UNIT PRICE AMOUNT STRETCHER VAN -1 Way Transport T2005 1.0 108.75 108-75 Transport Van Mileage S0209 0.5 3.74 1.87 ~~ Total Cha 110.62 DESCRIPTION OF PAYMENT REC©PT PAYMENT DATE AMOUNT _ __ _._ __ -- Total Credits 0.00 PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT --a- ;110.6Z tiC t lJt'ftrCY vncvn rcc -.pv..w 'ATIENT NAME: STREBIG, BETTY ~ ~• NUMSER: 224839iN AMOUr~Ir PAID: /I o. !off o~rosrzolz IMPORTANT MESSAGES: wig ACCOUNT IS PAST DUE! Send your payment snow or aoi>tact our office tD make payment arrarigmnents. WEST SHORE EM8 -BLS ZOS GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011-1708 GOLDEN LIVING CENTER PO Box 644407 Pittsburgh, PA f5284 ITEMIZED RESIDENT STATEMENT RESIDENT NAME Be Strebi RESIDENT NO. 44082 AGILITY NAME West Shore FACILITY NO. STATEMENT TYPE INTERIM x DISCHARGE 3/16/2012 DATEIPERIOD COVERED DESCRIPTION DAYS CHARGES CREDITS 12/13-27!11 Room & Board 15 $3,985.16 12113-27/11 Ancil{a char es $83.47 12/27/11 Pa ment $3,784.15 BALANCE FORWARD CHARGES CREDITS AMOUNT DUE x0.00 54,068.63 x3,784.15 x284.48 i,~ ~, ~'' , GOLDEN LMNG CENTER ~ PO Banc 644407 ' P1tEabuigfy PA !5264 r ~ ITEMIZED RESIDENT STATEMENT ~ Be ~a~mr wwE est Shore I~sioe~rr rlo. 44082 Fnalm No. 285 STATEMENT TYPE INTERIM x ~~~ a- oov~ nESCRI~noN ou- 1/11 cHat~s /2012 cltEOlrs 08h17/11 - 08134!11 Barber and Bea 3 ~ ~• 09107J11 -0927/11 Barber and Beau 4 `r ~. i, 101101/11 -101'04H 1 Room and Board 4 x1,062.71 10104/11 -14125/11 Barber and Bea 3 ~ •~ ~ 11/11/11 -11/30!11 Room and Board ~ 20 S5 229. ' 11I08N 1 -11129111 Barber and Bea \ 4 ;64. / 12/01M1 -12102111 Room and Board 2 5`~'• 12/13!11 -1228111 Room and Board 15 (3,985 12/13/11 -1228/11 Medical S ies 26 5232.67 / 1on7n1 Pe nt 58 472. 12127/11 Pa ment S1 ~' B C CHARC3ES CREDITS N ;0,00 511,291.54 58,955.34 57,336.20 V"~ r ®~ Flexible Eamirgs Card GIN Flmturle Eariyrigs Ptaurrixn MasterCard Account Accatait Ntni!»v 5522 3400 911 B 1306 BETTY J STREBIG Page 1 d 2 From November f3 2011 to Decetr~er 7, X11 U1urlirKari Payment Due Payment Due Date 6575.00 darxsay,, 2012 a BaNri~ P i 64,413.70 otr rse =o.~ dil G s - 60.00 B ra ier O PluctraseslDebds + 636.00 Balance Transfers + 60.00 Cash Advances + 60.00 Past Due Amount 644®.00 Fees Changed + ~~ New Relents ~•~'~ Credo Umu ~'~ Credit AvaBable ~'~ Cash Litnill' 60.00 Cash Available 50.00 S'tabwrietrt Cbsirig Date December 7,-2011 Days ~ Bum C!~ 31 tCash l.irriR is a portion of Totat CredB l.itrlR. 0 a e N fairestioris? 24-Holm Alrlorrisbed Atxoirrd IMOrrraNion 1~00~-9107 1-800.3889107 toot or Stden Cad 1-800-421243 Outside USA Caned 1 7570 TDD/Hesrig lmpdred 1-800~8~-8020 Lie Payrrinrt Ylfarr~ig : H we do not receive your nlilirxan ~ dam listed above, you may have to pay a late fee of up to 636.00 and yoim APRs may be itxxe~ed b the Penalty APR of 30.9996. Mmaralm Payment WatNng:lf you make aih- the rriirirrauri payment ~ Period, you wul pay more in itderest and it wiw toe you bnger to PeY ~Y~ balance. For exetnpie: H you make do addDor>af You wi pay off tfie And you wul end up paying chargesearip Ws cad.. 6a~ite shown an an esHrriated.tol~ of..._ and each month you tlii8 statement hi may,., about... Orly the minimum 15 Years 67.706 6148 3 Years 65.373 (Savblgs =52,335 1 1f you world iloe information about cradle sesvices tau 1-8tu3,5t~-?27T. Paytrierit Addre~ HSBC Card Services. PO Boot 37281, eaitkriore, MD 21297281 9 bigdrie~ Customer Cerlbar, P.O. Boot 8001)2, Sates. CA 938'12-0082 Manage You alx~lait onihie at www,gmflexcardcan IF YOU ARE UNABLE TO SEND YOUR PAYMENT TODAY PLEASE CALL 800•Z85S700 TO DISCUSS A REPAYMENT ARRANGEMENT. I As a , yar ~- PaY Yom' reedit cad b~ online or through our sutornated phone system Tor no tae. ~. ~ - _ _~ ~ ~_ of Transadiori or Credit Piudrase Type Niar~ AmourK Trans Date Post Date Dascripffon ~ _ Amount Trans Date Post Date Description ofi Pees Reference NuMar s 12101/11 12A1/11 u-TECHARGEASSESSINENT 10000002061Z019~866~0 63`'.~ 635 ~ Total Fees For Tlds Period Arriowrt Description oT Charge INTEREST CHARGE ON CASH ADVANCES ~'~ INTEREST CHARGE ON PURCHASES ~'~ = INTEREST CHARGE ON BALANCE ~'~ _ TRANSFERS _ Toff aiterest For This Period 545.E rlaEarh and rases bosom poAion ~ your parm/~. 11107814E 0a 0090000108 S7M1>?3 Q 8 818 QFE1 Ea! teVMSe side 1bf iwpsftalk ieroflsslioe 0?J1V12 58.558.1, J ~ 4.00 ~:~,~ CHASTE,. Aooount number: 4147 2Q20 2893 7286 1 ~/ n,7 ~, tinetre year dreek payable to: C. f2rassCardServioes. ~ ~ ~J~a~ /, 7/3- 4 PMaae write amowrt enolosad. Ntew amdre.s or o•man Print on beck. 41472020284372650008790000655617rD00000000000005 BETTY d 87'f~it3 .1 1, I ,^ ^^^ ^ 1111 ..I.i 1 I. 1. 1 1 1.11 1 ~~Z~aMO 1 1111 III II 111 11111 i l 11 111111 11111 770 POPLAR CFiVRCH RD ` CA1AR FMLL PA 17n11 2902 CARDER SERVICE '~ PO BOX 15163 IfY1Lfi8NQTON (~ 19886.5153 ~n,~~ ~u,~~~ uun~~ n,~~u~,~u~~r ~~ nu^ ~,~~u^~~~un~~n~ ~: 5000 ~ 60 28~: 3 5 9 20 28 ti 3? 2 6 5 2~' CHASE O . WxaYeyouraaaorarsontiaac awtaarw9+wke Addltlorraleantact • 1-lOO~W6-2DOp informMon ar book C', ACCOUNT SI~AARY A~ooollltt Ntwtbsr: 4147 2000 2d{3 72{S Previous Bslerroe~ yg.ggS,gg ~' Cterits 50.00 Purdrases SD.00 Csetf;Advarwes 50.00 Belanoe Transfers 50.00 Fees Ctwged +SS5.00 irrteoest c~argea ~.1s ^~""'~ 56,656x1 OpenlrlglCkwing Data 12/15/11 - 01/1N12 credit Aooess Lure s2oaoo AvaMeble Credit 513,443 Cash?Aocess Line 54,000 Avadpble for Cash f Sp PAYMENT MIFORMATION Mew Bder~e 56,666.11 ~ ~ 02/1 f/12 MinYntrrn Payment Clue 5156.00 Past Due Amours 5724.00 Tat~d IlAtriratrn Payment Oue Late Payment Warning: if we do not receive your mirrirrxn payment by the data Meted above, you may nave to pay a late fee of up to 596.00 and your APR's w+3 be subject b irrcreese to a maximum Penalty APR of 29.8996. ~ym.nt wartliin~ H you make only tt,e rrdNrtwm PaYrr1enl each period. you wM pay more in inlarod arxl it wit take you longer to pay off your balsrroe. For example: If you would ilea irriormslion about credit oorsreeirg services. oat 1-8®0-797-2885. H you make rro You w8 pay off the And you wB end up orrsl drarges beisnoe shown on paying an estimated ueirrg tlris osrd and this slalenrertt in total of... each nrorNFr you about.. pay__. ~- ~ ~- x11.112 l>ay~t 5212 3 years 57.619 lsawinge~s,48s) YOUR At~OIN~T AQES This aooount b Cbesd and no Iwgsr avsilsbls for ues. ff you have a balarroe rerrieMtirrg on 8rs aooourrt, please oorainue to make monthly payrnertta by the due data. Thank you. CHASE FREEDOM REWARDS r Eam up b ~ addYorrd 10% cxefr book when PreWpus MorrW's 8alarrce 50.00 you shop aNne www.drsseoaNrearardepk,re. Add authorized users, and sign up b have your mon8rly bie charged b your card -why not Dam Dash beds for ar those pwcMess bo? ~~ Citizens Bank ESTATE OF BETTY J STREBIG 10 RED FOX LANE MECHANICSBURG PA 17050 osoeoooe~a March 6, 2012 Re: Acct# ending in 4718 Dear ESTATE OF BETTY J STREBIG: This letter is to confirm your telephone authorization on March 6, 2012 giving us permission to initiate a single ACH debit to deduct funds from your checking account and apply them as payment to your credit card account. Below please find a summary of your telephone payment uest: Am Payment Date: March 6, 2012 Confirmation Number: 64-27378-12 If we are unable to obtain funds from your bank for any reason (insufficient funds, invalid account number, etc.), we will reverse your credit card payment. In the event that a minimum payment is not received on time, your credit card account may be subject to late fees and/or interest charges. If you have any questions concerning your payment, please contact 1-800-684-2222. Sincerely, Customer Service Your Credit Card is issued by RBS Citizens, N.A. JRUSQRT///CTZ001/CTZ001/0~/~092 • Bridgeport, CT 06601-7092 • 1-800-684-2222 CITZ-1009 PO BOX 18204 BRIDGEPORT, CT 06601-3204 rR: f 1-800-684-2222 ~ \~ ~ i h( 1 . h nJlld 11 h. Il ndu 1 . d n.i II a ~\ u 1 it ill 11 t 1 I 1111 it nlnl I I I ~ ~ ~ u~ , 9~ CITIZENS BANK CARD SERVICES PO BOX 42010 Paymerrt IrMor tion PROVIDENCE, RI 02940-2010 AODO~ Wixn6er 0562 4718 New Betanoe 58.4,57.04 34922 3 AB -360 03-080928-6053-6L35-D38-T=083 IYinimumMwwtOue 51,2p1,gg 1..1 11. .. idll i :I h IIG.I . h .d 1 ~`` ~"~ •'' '~'''"` ~ ~ ``=~~'~ I 16 Ihu I u 1 II dlu 11111 1 i 1 I Iill Pam oae o0~ ,; ~; zo12 BETTYJSTREBIG s:POO~a922 Tam ,.----.~..--..---...--..:.. 770 POPLAR CHURCH RD ~ ~ "'~""""'"' CAMP HILL, PA 1 701 1-2302 Encbsed ~ '• paescic ror eiwg. daa~sa. Compbb nsMraddren on ~. DS6D005624718 D00120185 DOD8457D4 oeaa~nem.gr~ur. ---•-----------••----------------_..__...----- ............... Patlogand.Y~P~.~~tanouw ne ineM,aoa ~ fhe ~.::~-.~~::~:::::--._.,.-•-•---.._.------ :I~hunber:; 6?4p_3lpq p5lp~ ~ZiB .:-' Summary afACCpurrt Activkyr - Prarfous Balance ._ . g,yg: - a aed~ . - - . _ ~ oao . T~adp~ < + OAp , Bafai~oeTiansfers + pbp. aoo? - ~. "ka"'ea~„ce s.~s.os: TdaF C3arR ppp. AYaii6le LattBt Q00: Cash L~lk Linn . OA9 /baie6le Ceah - D~p- Slelement.t8os6g.de~e _ .. 011OOi12 f~-rMter 4f days i~ 6H4g ~ycis - 31 .... :: oe~.~oe~wnbeF~o;:w1a =:~,ua~iaB; 2012 - Iw.wwwa-~ ~-t-~_a:__ Hwtt Ts Read [US - - - - (j, .. ~ - TAIL-FREE. i iN1LINE_ ^ PAYII~NTS: S CQR,RESPQI CUSTOMERSERiHa'~ :x%~EtVS3ANKCGM~ZEi7+TCARD . 1-FiOelc~6-?'"=c..2 ~~ZFlfSBANK GhFit? ~RYK~S CI't17~{S $At~{K Ge~.Rfj S'Ef~'t~IC£S NOSOX~40 PO!a3?C7042 LOST QR STOLE.Y CARD: ~ PRLN!lp~~C,., Rl Q24A0•~"3t0 $RfCkePORT. CT tl8trf? 1 •C~G•443-v'f dE 1:4 !?OEie'ZS) ~~- - - -~ - - ~ ~ - - ~--- ~ ~ -- ~--.. t~:.~"~-cam DISCOVER s ;8 ~Ce -- Minimum Payment Due Account Number ending in 4853 $712.00 - Enter Amount Enclosed Bebw Payment Due Date January 12, 2012 ~I~[[1[~L,Ihml~~~[„I,~~[I[[I[II,[~ullh[[ull[,nrl~h~[II 00025029 01 AV 0.337 T2 17 SDSt RA02 147 BETTY STREBI6 770 POPLAR CHUR CAMP H 17011-2302 ~ ~ ~ 9 39.3/ Address, o-mail or Go to www.Dncovercom or print change in space above. Please make check payable to Discover Card. Minimum payment due tnckides a past due amou of 5563.00. Phone and Internet payments must k made by S:OOpm ET For same day posfing. Working to achieve a bri ter finarxiol future$ We can p. Visit our secure website at hops://www.CardmemberAssistance.com ' PO BOX 71084 CHARLOTTE NC 28272-1084 iH[nl[,I1.[[[III[I~~[[III[I[I[[~~Il~l[~~[~III[[[[[IIII[I[~lll~ 0951219864523323060330718263000000000?1200 _ Opening Date: November 18, 2011 - Cbsing Date: December 17, 2011 Discover More Card Account Summary Cardmember since 2009 Account number ending in 4853 Previous Balance $7,054.33 Payments And Credits - 0.00 Purchases + 0.00 ~^ Balance Transfers + 0.00 Cash Advances + 0.00 fees Charged + 35.00 ~. Interest Charged + 93.30 New Balance ---- -- 7,182.63 See Interest Charge Cokuk~tion section hollowing transactions for detailed APR information Credit line 57,200.00 page 1 of 2 Payment Information New Balance $7,182.63 Minimum Payment Due* $712.00 Payment Due Date January 12, 2012 *Includes port due amount of 2563.00 late Paymrstrt Warning: If we do not receive your minimum payment by the date listed above, you may have to pay a late Fee of up to $35.00 and your purchase and balance transFer APRs for new transactions may be increased up to the Penalty APR of 20.99% variable. Minimum Payment Wanng: If you make only the minimum payment each period, you will pay more in ir~erest and it will take you bnger to pay off your balance. For example: Cash Advance Credit Line 51,800.00 ~tttgittrs~r'd and tFus atotement to eshmf't,~tlt~$pt C ' Cash Advance Credit line Available 217.00 Fr Cpordfa you pay ;. ab+3Vi... ~~ You may be able to ovoid Interest Charges, see Additional Ctnly the minimum 20 years S 17,085 Importar~ Information for details. payment Vasnoacx nvnus- Anniversary Month August Opening Cashback Bonus Balance S 0.00 New Cashback Bonus This Period + 0.00 CoshbodcsonusBafance $ 0.00 To loam more, log in at www.D'tsa~rercom 3 Easy Ways to Contact Us 1. Access your account securely at www.D'escovereom ' 2. Call 1-800-DISCOVER (1-800-347-2683) Please have your Discoverecord available. If you would (like information about credit counseling services, toll 1-800.3117-1121. Manage Your Account Online at www.Discover.com • Access free online tools like Paydown Planner to create o plan to day dawn your balance, securely access statements, pay bil s online and easily track all transactions Checking Account Summary ~ Page 1 of 1 Online Banking Home I Customer Service I Contact Us I Log Out Find an ATMIBranch Account ~ Transfer Funds ~ Blll Pay & e-Bills ( Stop Payments ~ Change Login Preferences ~ Reorder Checks • Account Summary 3 Cfiecking Account » Printable Version Account Number: 1641170298 Current Date: 03/09/2012 Summary Information Available Balance $3,227.29 Ledger Balance 53,227.29 Today's Deposits $0.00 Ledger Balance as of 03/08/2012 Today's Witfidrawals $0.00 Last Deposit $10,630.57 Interest Acerued This Statement $0.04 Last Deposit on 01/19/2012 Interest Paid YTD $0.08 Balance Last Statement $8,780.29 Interest Paid Last Year $0.00 Last Statement Date 02/17/2012 Next Statement Date 03/19/2012 Posted Activity ss A v n Search I >s Download History DaEe Activity Descri on Deposits Withdrawals Ledger Balance 03/08/2012 CHECK 105 - ~ ~SQ-O V ~~ $9:39.31- $3,227.29 03/08/2D12 CHECK 106 ~,\tR.o.e-' $1,7:L3.69- RBS CITIZENS NA Lli ,~~-~'Z'Qrt S 00- $1 9D0 88D.29 $5 03/D7/2012 PAYMENT 120306 . , , 011500126601047 02/27/Z012 CHECK 9999 ~ ~ S~5 ~ '~ ~ $1,000.00- $7,780.29 02/17/2012 INTEREST CREDIT ~/~' $0.08 $8,780.29 02/14/2012 PHARMERICA WEB PAY ~3 $307.04- $8,780.21 120213 57024849550 01/26/2012 CHECK 102 $110.62- $9,087.25 01/26/2012 CHECK 103 $1,336.20- 01l23/2012 CHECK 101 $96.50- $10,534.07 01/19/2012 DEPOSIT $10,630.57 $10,630.57 » Printable Version Quick Search For All Available Activity - Submd® ' ShortWt Select adage - Copyright 2010 Sovereign eardc. AU rights reserved- ~ Equel Housing Lender -Member FDIC https://www.site-secure.com/cgi-bin/cgiga7.exe/sovbank/SrF5yhy5/,688480001399,AcctInfo 3/9/2012 PharMer~ca 1900 S. SUNSET UNIT 1-A • LONGiiAONT, CO 80501-6599 800-984-8363 • www.pharmerica.com/mybill Pa~~mgnt can be made rniin°. BETTY STREBIG 10 RID FOX LANE MECHANICSBURG, PA 17050-1627 BETTY STREBIG olnvl2 GLrWEST SHORE 5702-48-49550 ~ ~ r 636.31 Balance Forward: ADDITIONAL IhFFORMATION RECEIVED -SICCED TO INSpRANCE ! ~ -3.i5 iz/iz1i1 7 AMLODIPINE BESYLATE 5 MG r' ~ -16.36 12/12/ii 7i: AZITHROMYCIN 500 MG TABLE ~ -13.50 12/12/ii, 5; CEFTRIAXONE 1 GM VIAL ~ ~ -3.86 ! iznz/il 20 LIDOCAINE HCL 1~ VIAL ~ i -3.32 12/12/ii' 7 SIMVASTATIN 20 MG TABLET ~ ~ -38.07 12/iz/ii 71 VESICARE 10 MG TABLET ~ ~D ! f -161.71 12/12/iil 14, OLANZAPINE 5 MG TAB ; ~2/iz/i1' 21; METRONIDAZOLE 500 MG TABL ~ g ~ ~ ~ ~ ~ -14.83 iz/lz/ii 15' ATROPINE 1~ EYE DROPS I i -42 ' 89 i2/i2/u~ 30! LORAZEPAM 0.5 MG TABLET /~~~ ~f i / -3.86 12/12/il' 30j LORAZEPAM 1 MG TABLET `' V" ~~~,~.-~'f ~ ~ ~tj' i -3.99 i2/is/ii', 30 MORPHINE SULF 100 MG/5 ML ~Y i 9 ~~ ~ I -16.58 12/ls/ii, 44 LORAZEPAM 2 MG/ML VIAL ~Ip ; l ~3° COPAY FOR DEDUCTIBLE PER MEMBER'S INSORANCE ~ ! 3.41 ~! 12/12/ii 7!: AMLODIPINE BESYLATE 5 MG 6.63 ~ 5.00 iz/12/ii! 7 AZITHROMYCIN 500 MG TABLE i --- -- __- --- __ ~: N ~ w ~ _;_ s .'r~~tPr'lr=~,i.~l:,l'c~31,a - .. it i=~E•~ti.~iAr~l..~:; , .; --- - _ ------------- - -- -266.01 -331.49 370.30 FOR YOIIR CONVENIENCE, PA~Cl~NTS CAN BE MADE ONLINS AT liiflfii.'f?BARMERICA. COM/MYB~ LL PL~::.tiE RE:TU~N E_C'iV'JE'n2 ~GRTlON lR~l'S"s-!'••r?4..'F' pl`tti~[~`' '•,t•^~,^"••,••~, _, _. i. r~,' t ~ NSA ! , PharMerica 1900 S. SUNSET UNIT 1-A • LONCi~AON'T, CO 80501-6599 !_ _ _---- ------ .;.. ~ - - 31111-90AA MK: ALLPILES ~ ~ ,~. ilr,7e- ~- -~-~ ~,', Tiir.axrsrG;JiYr .F' r r RETURN SERVICE REQUESTED UPON RECEIPT { $370 30 5702-48 49550 r '----------------~---------..------_i-------_- ----_---- -, i ._ _ . ,r~ - . _ ., ~ f-, .~r_~~, n{ ..,~~ ~, " r r CUSTOMER NAME: BETTY STREBIG NII J ~I1111161hI~~~11 11 111'1'111'11111"IIII'lllllllll'1111'11'1"IIIIIIIIIII"""Iii1 'I'I'I~1111~11111111iI II II I I I I I I I III II oz~~z ozoz PHARMERIC:A BETTY STREBIG 10 RED FOX LANE PO BOX 644458 MECHANICSBURG, PA 17050-1627 PITTSBURGH, PA 15264-4458 5702480409050500000370307 PAGE: I of 2 ou. eiu~n•~a ___ 11111~[f~~~-~17e79 -_ 3_.:--'~ ---_ -.. --. - PharMer~ca 1900 S. SUNSET UNIT 1 A • LONGMONT, CO 80601 800-984-8383 • www.pharmerica.comlmybill ~: ~rn..-ail., r ~~ r~ ice, onlii:_.. BETTY STREBIG ~ BETTY STRffiIG 10 RED FOX LANE ~ ' ~ - O7J21/12 MECHANICSBURG, PA 17050-1627 Balance Forward: o2/i9/ir: ~ PAYMENT - T13ANR YOU DENIEDi BY C(JS~TODiER' 3 INSIIRADiCB D?'O~t IICTJSBENTCE 1QOT COVERED 12/12/li 51 CEFTRIAXONE 1 GM VIAL ` ,a FOR Y017R CONVENIENCE , NE~'J 1kRC~F;~ 13.50 ClirN BE PAGE: 1 of 1 GL-WEST SHORE 5702-48-49550 ~ 370.30 \ f f-307.04 - i ~ 13.50 i f I 1 i F ~ - 1; '../ ~ t ,~ L i F J `; - SC tf j I _ __ -307.04 76.76 i ODiILINE !-T 1ii1M. PSARD~RICA. CODs/D[YSILL F ---- - - -- _ _ _ _ _~ - ----- - _ --- _~ _ ~ !4 PA ~ 'G t3v MA TERCARCT OiSG "~1 ~!?, V~ A i'J~ A^5LR1C 1 EX°~~SS, f!I C. +:11iT BFt.£1Ytl. .. 151 ~ ~ ! PharMerica --_. -________ __ - , E~~,~l, ,90o s. suNSEr uNrr,-n • LoNGMONr, co eo6o,.~ 1 -,- ----__ ____ _ _ __ ! Mc: atlxES I- --- c~~~~ r^aa ~ ~-~~~• r~i~ ~a~~~~rra~r ~ n~e-r. ; RETURN SERVICE REQUESTED f ~ !ut _ i~~rr r.. r1C, u~ i . a ~. oooas~ 0101 ~~~'I1~'1~~11~I~'1111'111111~I11~I~'lll~"1"1'~'1~~~I"111'1" BETTY STREBIG 10 RED FOX LANE MECHANICSBURG, PA 17050-1627 UPON RECEIPT ! $76.76 ~ 5702-48-49550 ! CUSTOMER NAME: BETTY STREBIG ~I~~dyilldl~~ll~l~lllll~~~t~~~11~111111611~11~u~11~1~1~i11~' PHARMERNCA PO BOX 644458 PITTSBURGH, PA 15264-4458 5702480409050500000076769 FN:90MB712 31111-BOM'TFTOMKFDD001~09 ~~•g Checking Account Summary Checking Account Summary Account Number: 2331036195 Summary Information Available Balance Today's Deposits Today's WiLfidrawals Interest Accrued This Statement Interest Paid YTD Interest PaW Last Year Posted Activity Date ActrvrtY Description RETD US TREAS 312 02/10/2012 CN SERV 010312 RECLAIM RETD US TREAS 312 02/10/2012 CN SERV 010312 RECLAIM RETD US TREAS 303 01/26/2012 SOC SEC 010312 RECLAIM 01/20/2012 INTEREST CREDIT US TREASURY 303 01/03/2012 XXSOC SEC 010312 187121907A SSA US TREASURY 312 OI/03/2012 XXCN SERV 010312 A 3044848 0 CSA US TREASURY 312 01/03/2012 XXCN SERV 010312 F 2533792 W CSF 12/21/2011 INTEREST CREDIT RETL INTERNET TFR TO 12/15/2011 CKG #1641169966 RETL INTERNET TFR TO 12/15/2011 CKG # 1641169966 $60.15 $0.00 $0.00 $0.02 $0.02 $0.28 » Close Window ~ » Print Window Current Date: 02/20/2012 Ledger Balance Ledger Balance as of Last Deposit Last Deposit on Balance last Stateme~ Last Statement Date Next Stateme~ Date Deposits $0.02 $708.00 $746.5 $2,122.95 $0.04 2/20/12 5:12 PM Withdrawals $746.50- $2,122.95- $708.00- $150.00- $7,600.00- $60.15 02/17/2012 $708.00 01/03/2012 $3,637.60 01/20/2012 02/21/2012 Ledger Balance $60.15 $2,929.60 $3,637.60 $3,637.58 $60.13 $60.09 https://www.site-secure.rnm/cgi-btn/cgiga6.exeJsovbank/hro5NR50/.897677001416,PrintQuickHist Page 1 of 1 Sovereign January 27, 2012 Estate of Betty J Strebig C/O Executor 10 Red Fox Lane Mechanicsburg PA 17050-1627 Subject: U.S. Treasury Reclamation Sovereign Bank received a notice of reclamation on January 25, 2012 from the U.S. Treasury to return federal payments deposited to the account of Betty J Strebig. The Treasury has advised us that Betty J Strebig date of death was 12/28/ 11 and that all payments made after that date must be returned. Please be advised that the account listed below was debited and the payments were :returned on the date shown. Date of debit: 01/26/12 Account debited: ******6195 Amount debited: $708.00 If you have any questions regarding this reclamation or need additional information, please call our customer service center toll free at 1-877-768-2265. Thankyouu, --- - _ - --__ _ - --- _ _ _ _----- Sincerely, Karen I Baer ACH Department Enclosure For Paperwork Reduction Act Statement and Burden Estimate Statement See Reverse Side'Notice to Account Owner" Copy. ELECTRONIC FUNDS TRANSFER FEDERAL RECURRING PAYMENTS NOTICE~~'O''F RECLAMATION 0562004253* RECIPIENT ANDJOR BENEFICIARY NAME BETTY J STREBIG AGENCY 7RNCE PDAA PAYMENT NU~ER 01-03-12 RSI SSA 03173601 0929976 FROM U.S. DEPARTMENT OF THE TREASURY FINANCIAL MANAGEMENT SERVICE PHILADELPHIA FINANCIAL CENTER POST OFFICE BOX 603 BENSALEM, PA 19020-9921 215-516-8154 DATE 01123/12 23725294 CLAIM NUMBER DATE OF 187-12-1907 A 12-28-11 ticot°Fit~n• acco°NUMt~t C 2331036195 OUTSTANDING TOTAL NOTICE TO ACCOUNT OWNERS FROM THE GOVERNMENT AMOUNT 708.00 708.00 The Government has received information that person named on this notice is deceased. The purpose of this notice is to inform you that by law entitlement to Government benefits for this person ended at death. Therefore, the Government must recover all payments made after the date of death. If there has been an error and this person is not deceased, or if the date of death is wrong, this notice explains how to correct the mistake. If you do not understand this notice, please get help either your financial institution or the Government agency that was making payments. PAYMENTS TO THIS PERSON HAVE BEEN STOPPED Your financial institution has been asked to return the payments shown on this notice to the Government because they were issued-in e~o~'hhe Gwe~nmenT- as s e your manciaT tns~tu ion fo sendthis notice to you, the account owner_ Your financial institution must notify you if it has taken action to recover these funds from the account. Contact your financial institution immediately if you do not understand its actions. If the Government is unable to collect from the financial institution the full amount of the payments made after death, you may be contacted by the agency which made the payments IF THE PERSON IS NOT DECEASED - If the person is not deceased, immediately contact both your financial institution and the agency that made the payments to correct the error. The Government regrets any inconvenience this error may cause. Yaur financial institu- tion can correct the collection action if it is given satisfactory proof that the person is alive. NOTE: YOU MUST CONTACT THE AGENCY THAT MADE THE PAYMENTS BECAUSE THIS ERROR HAS STOPPED FURTHER PAYMENTS. ONLY THE AGENCY CAN RESTART THE PAYMENTS. NOTICE TO ACCOUNT OWNERS os of os 000191 28045300 OMB NO.. 1510-0043 Expiretion Date:0a/3®/l®03 ,r ~~ . •, t ii ~ •- Sovereign February 13, 2012 Estate of Betty Strebig C/O Executor 10 Red Fox Lane Mechanicsburg PA 17050-1627 Subject: U.S. Treasury Reclamation Sovereign Bank received a notice of reclamation on February 08, 2012 from the U.S. Treasury to return federal payments deposited to the account of Betty Strebig. The- Treasury has advised us that Betty Strebig date of death was 12/28/11 and that all payments made after that date must be returned. Please be advised that the account listed below was debited and the payments were returned on the date shown. Date of debit: Account debited: Amount debited: 02/10/12 ******6195 $2122.95 If you have any questions regarding this reclamation or need additional information, please call our customer service center toll free at 1-877-768-2265. Thank you. ~„ ~,~ - '~ ~- Sincerely, Karen I Baer ACH Department Enclosure For Paperv+rork Reduction Act Statement 24000002 OMB NO.. 1510-0043 and Burden Estimate Statement See Reverse Expiration Date: ®4/30/lAe3 Side "Notice to Account Gwner• Copy r ~ I=RON S. DEPARTMENT OF THE TREASURY U ELECTRONIC FUNDS TRANSFER . FINANCIAL MANAGEMENT SERVICE FEDERAL RECURRING PAYMENTS SF REGIONAL FINANCIAL CENTER PO BOX 24760 OAKLAND, CA 94623 NOTICE OF RECLAMATION 510-59471x3 ~~:~IIII~ I~ ~~ 23875073 ~ ~ DATE 02/07/12 ;4 OF DEATH DATE RECIPIENT AND/OR BENEFICIARY NAME . CLAIM NUMBER 12_28.11 BETTY STREBIG 253.37-92WF D A~ A ~ nc~cou it acco~i~tr AneouNr P A T PAYMENT 01-03-12 OPM 12173615 2705239 C 2331036195 2122.95 OUTSTANDING TOTAL 2122,95 NOTICE TO ACCOUNT OWNERS FROM THE GOVERNMENT The Govemment has received information that person named on this notice is deceased. The purpose of this notice is to inform you that by law entitlement to Govemment benefits for this person ended at death. Therefore, the Government must recover all payments made after the date of death. If there has been an error and this person is not deceased, or if the date of death is wrong, this notice explains how to correct the mistake. If you do not understand this notice, please get help either your financial institution or the Govemment agency that was making payments. PAYMENTS TO THIS PERSON HAVE BEEN STOPPED Yvur financial institution has been asked to return the payments shown on this notice to the Government because tt~ey~ere issued-in-ear. The Govemment-has asked~ur-financial-inst~#ution-to-send-this notice-te-you-, -the-aeceunt-- - owner_ Your financial institution must notify you if it has taken action to recover these funds from the account. Contact your financial institution immediately if you do not understand its actions. If the Govemment is unable to collect from the financial institution the full amount of the payments made after death, you may be contacted by the agency which made the payments IF THE PERSON IS MOT DECEASED If the person is not deceased, immediately contact both your financial institution and the agency that made the payments to correct the error. The Government regrets any inconvenience this error may cause. Your financial institu- tion can correct the collection action if it is given satisfactory proof that the person is alive. NOTE: YOU MUST CONTACT THE AGENCY THAT MADE THE PAYMENTS BECAUSE THIS ERROR HAS STOPPED FURTHER PAYMENTS. ONLY THE AGENCY CAN RESTART THE PAYMENTS. _ NOTICE TO ACCOUNT OWNERS, os of os oooos~ . yr E~,~._ Sovereign • February 13, 2012 Estate of Betty J Strebig C/O Executor 10 Red Fox Lane Mechanicsburg PA 17050-1627 Subject: U.S. Treasury Reclamation Sovereign Bank received a notice of reclamation on February 08, 2012 from the U.S. Treasury to return federal payments deposited to the account of Betty J Strebig. The Treasury has advised us that Betty J Strebig date of death was 12/28/11 and that all payments made after that date must be returned. Please be advised that the account listed below was debited and the payments were returned on the date shown. Date of debit: 02/10/12 Account debited: ******6195 Amount debited: $746.50 If you have any questions regarding this reclamation or need additional information, please call our customer service center toll free at 1-877-768-2265. Thank you. Sincerely, Kann I Baez ACH Department Enclosure For Paperwork Reduction Act Statement 24000002 OMB NO_: 1510-Od43 and Burden Estimate Statement See Reverse Expiration Date: A4/3e/2003 Side'Notice to Account Owner' Copy ELECTRONIC FUNDS TRANSFER FEDERAL RECURRING PAYMENTS NOTICE OF RECLAMATION I~=40~III~~ RECIPIENT ANDJOR BENEFIt:1 BETTY J STREBIG AGENCY PAYMENT 01-03-12 OPM t M~BER 12173615 2699572 FROM U.S. DEPARTMENT OF THE TREASURY SF REGIONAL FINANC A CENTERE PO BOX 24760 OAKLAND, CA 94623 510-594-7183 DATE 02/07/i 2 CLAIM NUMBER 304-48-480A TM ot~iT Acc°o~u ~ONU+R~-R C 2331 C136195 23875263 DATE OF DEAT 12-28-11 aMOUNr 746.50 OUTSTANDING TOTAL NOTICE TO ACCOUNT OWNERS FROM THE GOVERNMENT 746.50 The Govemment has received information that person named on this notice is deceased. The purpose of this notice is to inform you that by law entitlement to Govemment dategaf death! Ifthere has beentan error and t s pehson is not Government must recover all payments made after the deceased, or if the date of death is wrong, this notice explains how to correct the mistake. If you do not understand this notice, please get help either your financial institution or the Govemment agency that was making payments. PAYMENTS TO THIS PERSON HAVE BEEN STOPPED Your financial institution has been asked to return the payments shown on this notice ~o the Government because --they were-issuetf in error. The Government has asked-your financial institution to send-this-notice-to-you,-the-accotmt- -- owner. Your financial institution must notify you if it has taken action to recover these funds from the account. Contact your financial institution immediately if you do not understand its actions. If the Govemment is unable to collect from the financial institution the full amount of the payments made after death, you may be contacted by the agency which made the payments IF THE PERSON IS NOT DECEASED If the person is not deceased, immediatey contact both your financial institution and the agency that made the payments to correct the error. The Government regrets any inconvenience this error may cause. Your financial institu- tion can correct the collection action if it is given sMENTSoBECAUSE THIS ERROR HAS STOPTPED FURTHER CONTACT THE AGENCY THAT MADE THE PAY PAYMENTS. ONLY THE AGENCY CAN RESTART THE PAYMENTS. ..~~- -. NOTICE TO ACCOUNT OWNERS, os of os oooo6r