HomeMy WebLinkAbout04-17-121505610105
REV-1500 EX (oz-ii) (FI)
PA Department of Revenue eons lvania OFFICIAL USE ONLY
P
Y
Bureau of Individual Taxes EO.,.
.,E~ o.aE~..~E
County Code Year File Number
INHERITANCE TAX RETURN
PO Box zso6o> ~~
Harrisburg, PA 1'7128-0601 RESIDENT DECEDENT \ ~
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date
__ of Death MMDDYYYY Date of Birth MMDDYYYY
_ _,_ _,
Decedent's Last Name Suffix Decedent's First Name MI
Swenson Eva M
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Retum 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 U 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 Schedule O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
r
Nathan C. Wolf, Esquire (717) 241-4436n `--' -~,
REGISTER OF ~JS~ ONt~~ <-
First Line of Address
Wolf & Wolf
Second Line of Address
10 West High Street
City or Post Office State ZIP Code
_._
Carlisle PA 17013
T. -_. ~_-.- L.. _ _-.
~ -w..~ :. ~ t
~
i - ..
~ `!"7
,; 7-rr
^ -
'
"
,
T _
~
~ _ ~--.
. . , -r~
c,=
DATE FILED
Correspondent's a-mail address: nathancwolf@embargmail.com
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge an belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSO_ N ~SPONSIBLE FOR FILING RETURN DATE
910 Macoun Drive, Mechanicsburg, PA 17055
SIGN~ATU~~F PREPA~~THER THAN REPRESENTATIVE DATE 1
10 West Higf~et, Carlisle, PA 17013-2922
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610105 1505610105
1505610205
REV-1500 EX (FI)
Decedent's Social Security Number
Deoadanrs Name: Eva Mae Swenson
RECAPITULATION
1. Real Estate (Schedule A) ............................................. 1.
2. Stocks and Bonds (Schedule B) ....................................... 2. 4 3,905.16
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. ''
4. Mortgages and Notes Receivable (Schedule D) ........................... 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5.
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7. '
10, 038.58
7,495.47
64,167.48
8. Total Gross Assets (total Lines 1 through 7) ............................. 8. s 85,606.69
9. Funeral Expenses and Administrative Costs (Schedule H) ............. ...... 9. 19,938.95
10. Debts of Decedent, Mortgage Liabilities and liens (Schedule I) ......... ...... 10. ' 1,585.36
11. Total Deductions (total Lines 9 and 10) ........................... ...... 11. ".`. 20,984.31 ``
12. Net Value of Estate {Line 8 minus Line 11) ........................ ...... 12. ' 64,622.38
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. ' 64,622.38
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. Amount of Line 14 taxable
at lineal rate X .0 45
17. Amount of Line 14 taxable
15.
1s. ~ 2,908.00
at sibling rate X .12 17.
..... ___ - .._ ~ s. _...,.,
18. Amount of Line 14 taxable
at collateral rate X .15 18.
19. TAX DUE .........................................................19. '; 2,8~8.0~
__ __ _ __
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
1505610205 1505610205
REV-1500 EX (FI) Page 3
Decedent's Complete Address:
117.50
DECEDENT'S NAME
Eva Mae Swenson
STREET ADDRESS
920 Macoun Drive
CITY
Mechanicsburg STATE
PA ZIP
17055
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments
B. Discount
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
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.
File Number
(1)
908.00
Total Credits (A + B) (2) 2,467.50
(3)
(4)
(5)
2.74
443.24
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 ........................................................................................................................ ...... ^
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 [72 P.S. §9116(a)(1.2)].
2,350.00
• 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(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-i5o3 EX+ (~-u)
~ Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDI~ILE B
STOCKS & BONDS
ESTATE OF FILE NUMBER
Eva Mae Swenson _ 21-11-0552
eu .,.,,~e'r„ ininr~v ewnpd with right of survivorship must be disclosed on Schedule F.
If more space is needed, insert additional sheets of the same size
REV-1508 EX+ (11-i0)
~ Pennsylvania SCHEDULE E
DEPARTMENT Of REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Eva Mae Swenson 21-11-0552
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. U.S. Savings Bonds held by decedent -see attached index 6,844.58
2 Belco CCU Checking Account 1,084.69
3 Capital Blue Cross - Reimbursement of Premium 290.20
4 United Healthcare Insurance Company -refund of expenses pay during lifetime 1,470.00
5 Entitlement to 1 day of retirement benefits from PSERS 7.83
g Unclaimed property held by Pa Treasury 341.28
TOTAL (Also enter on Line 5, Recapitulation) $ 10,038.58
If more space is needed, use additional sheets of paper of the same size.
REV-1509 EX+ (Di-i0)
~ ~ Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF: FILE NUMBER:
Eva Mae Swenson 21-11-0552
If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A• Darlene G. Swenson 920 Macoun Drive Daughter
Mechanicsburg, PA 17055
B.
C.
JOINTLY OWNED PROPERTY:
fIEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTCRJTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FOR]OINTLY HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET % of
DECEDENT'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
i. A. 07/31/76 Belco CCU Account No. 082900 1,084.59 50 542.35
2 A. 10101173 Belco CCU Acxount No. 070980 3,296.51 50 1,648.26
3 A. 10101f73 Belco CCU Acx:ount No. 070980 10,205.25 50 5,102.63
4 A. 03/02/92 Citizen's Bank Alxount No. 6100716368 404.25 50 202.23
TOTAL (Also enter on Line 6, Recapitulation) I $ 7,495.47
If more space is needed, use additional sheets of paper of the same size.
REV-1510 EX+ (OS-U4}
~ Pennsylvania
DEPARTMENT OF REVENUE
[NHERIfANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
Eva Mae Swenson 21-11-0552
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
INQUDETHENAMEOFIHETRANSFERff,7}1EIRREWTIONSFIIPTODECEDENTANO
THE DATE OF TRANSFER. ATTACH A COPY aF THE DEED FOR REAL ESrATE.
DATE OF DEATH
VALUE OF ASSET
% OF DECD'S
INTEREST
EXCLUSION
pF APPUCABIE)
TAXABLE
VALUE
I• Proceeds of sale of 4033 Cherokee Avenue sold on Sept 24, 2010, previously '
was owned jointly with Darlene G. Swenson since Nov 24, 1997 134,334.95 50 3,000.00 64,167.4!
prior deed was recorded in the Office of the Recorder of Deeds for
Cumberland County at Deed Book 168, Page 318
See attached HUD-1 from sale occuring on September 24, 2010
TOTAL (Also enter on Line 7, Recapitulation) ~ I 64,167.48
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (10-09)
r Pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERCfANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Eva Mae Swenson 21-11-0552
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
I' Neill Funeral Home 8,822.15
2 Meal of condolence costs 200.00
3 Burial Expenses -Rolling Green Cemetery Company 1,395.00
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
2.
3.
4.
5.
6.
~.
s
9
~o
~~
City ____
Year(s) Commission Paid:
State _ - ZIP
Attorney Fees:
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
claimant Darlene G. Swenson 5,000.00
3,000.00
Street Address 920 Macoun Drive
city Mechanicsburg _..._ state _ PA zIP _17055 _
Relationship of Claimant to Decedent Daughter ____
Probate Fees: 128.50
Accountant Fees:
Tax Return Preparer Fees:
Cumberland Law Journal -Legal Advertising 75.00
The Sentinel -Legal Advertising 168.30
Additional probate costs for appointment of Administratrix D.B.N. 40.00
Reserve for outstanding expenses 500.00
__
TOTAL (Also enter on Line 9, Recapitulation} ; 19,938.95
If more space is needed, use additional sheets of paper of the same size.
REV-1512 EX+ (12-08)
~ Pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Eva Mae Swenson 21-11-0552
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
If more space is needed, insert additional sheets of the same size.
LAST WILL AND TESTAMENT OF
EVA MAE SWENSON
I, Eva Mae Swenson, of Lower Allen Township, Cumberland
County, Pennsylvania, declare this to be my Last Will and
Testament and revoke all Wills and Codicils previously made by
me.
ITEM I: I direct that my legally enforceable debts and
funeral expenses, together with the expenses of the
administration of my estate shall be paid from my residuary
estate as soon as practicable after my decease, as a part of the
expense of the administration of my estate.
ITEM II: I devise and bequeath all of my estate of every
nature and wherever situate unto my daughter, Darlene G. Swenson,
provided she shall survive me. Should my said daughter fail to
survive me, I devise and bequeath all of my estate of every
nature and wherever situate unto my niece, Joanna Acker. Should
both my daughter, Darlene G. Swenson, and my niece, Joanna Acker,
both predecease me all of my estate of every nature and wherever
situate shall be distributed to the estate of Joanna Acker and
shall be distributed as a part thereof.
ITEM III: All Federal, State and other death taxes payable
because of my death, with respect to the property forming my
gross Estate for tax purposes, whether passing under this Will or
otherwise, including any interest or penalty imposed in
connection with such taxes, such be considered a part of the
expense of the administration of my Estate and shall be paid out
of the principal of my Residuary Estate without apportionment or
right of reimbursement.
ITEM IV: I appoint my daughter, Darlene G. Swenson,
Executrix of this my last Will and Testament. Should my said
daughter fail to qualify or cease to act as Executor, I appoint
my niece, Joanna Acker, Executor of this my last will and
Testament.
ITEM V: I direct that my personal representative, as well
as her successors, shall not be required to give bond for the
faithful performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal,
this f }~-~ day of November, 2007.
~ ~•-~ ^Z'171,~--L ,,,~.c.rl--€•'N-a-~`Vt`.- [SEAL]
Eva Mae Swenson
The preceding instrument, consisting of this and one (1)
other typewritten pages, each identified by the signature of the
Testatrix; was on the date thereof, signed, published and
declared by Eva Mae Swenson, the Testatrix therein named, as and
for her last Will, in the presence of us, who, at her request, iii
her presence and in the presence of each other, have subscribed
our names as witnesses hereto.
n
~~ /f ~ ~
_ 3
-2- _
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
We, Eva Mae Swenson, Dale F. Shughart, Jr., and Darlene G.
Swenson, the Testatrix and the witnesses, respectively, whose
names are signed to the foregoing instrument, being first duly
sworn, do hereby declare to the undersigned authority that the
Testatrix signed and executed the instrument as her last Will and
that she had signed willingly, and that she executed it as her
free and voluntary act for the purposes therein expressed, and
that each of the witnesses, in the presence and hearing of the
Testatrix, signed the Will as witness and that to the best of
his/her knowledge the Testatrix was at that time eighteen years
of age or older, of sound mind and under no constraint or undue
influence.
~~~ ~
Testatrix
,y .-QC~2~'e~~,
Witness
~~ ~
~ ;~
1 j° f
Witness
ry~~~
Subscribed, sworn to and acknowledged before me by
Eva Mae Swenson, the Testatrix, and subscribed and sworn
to before me by Dale F. Shughart, Jr., and Darlene G. Swenson,
i1
witnesses, this "" day of November, 2007.
._.._ _ N___~.~.~.~..,..~,,,,~.,,
BONNIE L. COYLE, NOTARY PUBLIC
BORO OF CARLISLE, CUMBERUWp CO. PA
MY COMMISSION EXPIRES OCTOBER 17, 2010
__,
-- ;
Notary.Pu~lic
J
-3-
Calculated Value of Your Paper Savings Bond(s)
Calculator Results for Redemption Date 05/2011
Total Price Totat Value Total Interest YTD Interest
$787 50 $6,844 58 $6,057.08 $0.00
Bonds: 1-21 of 21
Seria! # Series Denom Issue
Date Next Eina!
Accrual Maturiity Issue
Price Interest
Interest Rate
Value .Note
L324358545E E :
$50 12/1956 „ ,..., ..._. ~, 12/199.6 ~ _$37.50 ; $361 62 _ _ __ . _,,.$399.12 ~. MA
~L451582070E E .
___
$50: 12/1957 ~ 12/1997.,.
.._.. ,,_$37 50:p $324 44 _,5361_.94 _ MA
L780707454E E $50 12/197
1 _ 12/2001. „$,37.50,,... $215 82 _ _ _.$253.32,_ MA
.............
L783366597E
E
$50 ..
2/1972
1
_ ;_12/2002
$37 50;
$219.16:._ _ , _
__$256.66,
MA
L1025292071E E $50 ,
12/1973 . _. _. :..12/2003 _ $37 50 $219 46a ,_ _.,,$256,_96 _ MA _
11048804567E E ~ __
$50: 12/1974 : _ 12%2004.. ,...,$37.50;,. $225.68; __ $263.18 MA_
L1078415387E E $50, 12/1975 _ _,12/2005 $37.50'. $232.00'. __ _ $269.50: MA
L470951677E E $50: 12/1958 , _
12/1998° $37.50 $341.18! $378.68° MA
L491465974E E $50' 12/1959 q 12/1999 $37,50,'„ ,,,$339.50'.., _. _$377OO, ,MA
L539738982E .....E $50 12/1960
, . _12/2000._ _...$37.50!„ $356.86. „_ $394.36 MA_
_.
_.
L569021860E E $50 ; .
,_
12/1961 ..,__.
12/200.1 $37.50 ~ $376.00 $413.50 MA
_.
L590029908E
E
__
$50
12/1962
:.12/2002 `
$37.50
$392.94;
$430.44
MA
L618977837E E $50 .12/1963 _ _ _„ °,12/2003 _ $37 50 ` $411 60 $449 10 . MA
~L640111054E E $50 12%1964
` _. , ,,..12/2004 _ $37„50 $430 72. _ _.._$468 22 _ MA_
L665316748E E _
$50 ,
a 12/ 1965 , _ ; .12/ 1995. _ ,.., $37.50 $218.74 j _ _ $256.24: MA
L684691013E E $50 .12/1966 __ ;_.12/1996 $37 50 $2.14 20; _ $251.70 MA
__ __.
L719560512E
E
$50
;,12/1967
_ __ 12/1997
.., $37.50,;.
$225 06
_ $262.56.
MA
_.__
L749720057E
E _
$50
:12/1968
: _ 12/1998:.
_ $37 50Q
$237 06':
$274 56,
,MA..
L759650493E E _
$50 12/196
9
; ,,.,. 12/19,99_.
,_ $37 50~ $233.94', ._ .,_.,$271.44;_ MA
L800288538E ! E _
$50 .
_
!,12/1970 .,
. 12/2000
__ .,,, $37.50,,, $242.52 _ _ _ $280.02 MA
_. _
L2023299698E E _
$50 12/1976
: __ ,,,12/2006 ._,$37.50':~ $238.58.:, _ __ ° ___.$276.08 MA_
__ ..
Totals for 21 Bonds'.
$787.50;
$6,057.08' '
$6,844.58:
Notes
NI 'Not Issued
NE .Not eligible for payment
P5 .Includes 3 month interest penalty
MA 'Matured and not earnin interest
o~TJ,1MEarCkh`~ OMB Approval No. 2502-0265
A. Settlement Statement (HUD-1)
`o ~eafn Qt`~
~eRx oeJE~n
D T..nn wr 1 n
1. ~ FHA 2. Q RHS 3. ~X Conv. Unins.
4. ~ VA 5. ~ Conv. Ins. 6. File Number:
201000661 7. Loan Number:
000002801 8. Mortgage Insurance Case Number.
C. Note: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown.
Items marked "(p.o.c.)" arere paid outside the closing; they are shown here /or informational purposes and are not included in the totals.
D. Name and Address of eonower:
Robert D. Wevodau
12 Ridgeway Drive
Mechanicsburg, PA 17050 E. Name and Address of Seller:
Eva Mae Swenson
Darlene Gale Swenson
4033 Cherokee Ave.
Camp Hill, PA 17011 F. Name and Address of Lender:
Orrstown Bank
77 East King Street
Shippensburg, PA 17257
G. Property Location:
4033 Cherokee Ave.
Camp Hill, PA 17011
Cumberland County, Pennsylvania H. Settlement Agent: 25-1849506
Bankers Settlement Services-Capital Region, LLC
4400 Deer Path Road ,Suite 207
Hanisburg, PA 17110 Ph. (T17~71-4556 I. Settlement Date:
September 24, 2010
Place of Settlement:
1224 Holly Pike
Carlisle, PA 17013
J. Summary of Borrower's transaction K. Summary of Seller's transaction
100. Gross Amount Due from Borrower: 400. Gross Amount Due to Seller:
101. Contract sales rice 145,000.00 401. Contract sales rice I 145,000.00
102. Personal ro 402. Personal ro
103. Settlement Cha es to Borrower Line 1400 5,449.53 403.
104. 404.
105. 405.
Ad ustments for Items aid b Seller In advance Ad ustments for Items old b Seller in advance
106. Coun 1Tw Taxes 09124!10 to 01!01/11 173.24 406. Coun /Tw Taxes 09/24/10 to 01/01111 173.24
107. School Taxes 09124!10 l0 07!01!11 920.67 407. School Taxes 09/24/10 to 07101!11 920.67
108. Sewer/Tresh 09!24!10 to 10!01/10 6.04 408. SewerlTresh 09124/10 to 10/01!10 6.04
109. 409.
110. 410.
111, 411.
112. 412.
120. Gross Amount Due from Borrower 151,549.48 420. Gross Amount Due to Seller 146,099.95
200. Amounts Pald b or in Behalf of Borrower 500. Reductions In Amount Due. Seller:
201. De sR or earnest moos 2,000.00 501. Excess de sit see instructions
202. Princi al artwunt of new loans 115,000.00 502. Settlement cha as to Seller Line 1400 10,555.00
203. Existi bans taken sub'ect to 503. ExisOn loans taken sub'ecl to
204. 504. Payoff First Mortgage
205. 505. Pa ff Second Mort a e
206. 506.
207. 507. De it disb. as roceeds
208. Sellers Assistance 500.00 508. Sellers Assistance 500.00
209. Transfer Tax aid b seller 509. Transfer Tax aid b seller
Ad ustments for Items un old b Seller Ad ustments for Items un aid b Seller
210. Coun /Tw Taxes to 510. Coun /Tw Taxes to
211. School Taxes to 511. School Taxes to
212. Sewerlf-rash to 512. Sewer/Trash to I
213. leaseback-securi de sit 500.00 513. leaseback-securl de osft 500.00
214. leaseback-Rent 9124-10/1 210.00 514. leaseback-Rent 9124-1011 210.00
215. 515.
216. 516.
217. 517.
21 B. 518.
219. 519.
220. Total Pald b /for Borrower 118,210.00 520. Total Reduction Amount Due Seller 11,765.00
300. Cash at Settlement fromfto Borrower 600. Cash at settlement tolirom Seller
301. Gross amount due from Borrower line 120 151,549.48 601. Gross amount due to Seller line 420 146,099.95
302. Less amount aid b/for Borrower line 220) ( 118,210.00 602. Less reductions due Seller Ilse 520) ( 11,765.00
303. Cash a From ~ To Borrower 33,339.48 603. Cash ^X To ~ From Seller 134,334.95
The undersigned hereby acknowledge receipt of a completed copy of pages 1, 2 8 3 of this statement & any attachments referred to herein.
Borrower ~ ~ wt.l~, Seller ~`~r~-~~~~,.2c~'c~
Robert D. Wevodau Eva Mae Swenson
-l
~a ens Gale Swenson
Tha Pubfic Raportinp Burtlen 1« tNS cwedlon of Infortnatlon la estimated al 35 mMUtea per response f« odlectlnp, rwbwing, antl reportM the date. TMs egenuy may not coreq Ihla Mformation, antl you are rwt required to
complete this Porn, unbaa tl dlaplaM a currently vatld OMB control number. No mnfitlentleldy la eawred; thin dledowre is mandatory. TNa ie deelpned to provide the partles to a RESPA mvered transactlon with iMOrmalion
dudng tM aetllement Process.
Page 1 of 3 HUD-1
(201000661.PFDI201000661l13)
L. Settlement Char es
700. Total Real Estate Broker Faes $ 8,670.00 PaW From peW Fmm
Divisior of commissron (line 700J as follows: aorrmrers savers
701. 4 335.00 to Homestead Grou
Funds et
FLAWS at
702. 4 335.00 to Real Estate Excel settlement sauement
703. Commission aid at settlement 8 670.00
704. Broker Fee to Real Estate Excel 250.00
705. Broker Fee to Homestead Group 200.00
800. Items Pa able In Connection with Loan
801. Our o ' ination cha a Includes O ' ination Point % or $ 1,175.00 from GFE #1
802. Your creditor charge (points) for the specific interest rate chosen $ (from GFE #2)
803. Your adjusted origination charges to Orrstown Bank from GFE #A 1,175.00
804. A raise! fee to Ausherman Bros. Real Estate from GFE #3 350.00
805. Credit Re rt to CBC Innovis from GFE #3 18.80
806. Tax service to Orrstown Bank (from GFE #3) 75.00
607. Flood certification to CBC Innovis (from GFE #3) 10.00
808. (from GFE #3)
809. (from GFE #3)
810. (from GFE #3)
811. (from GFE #3)
900. Items Re ufred b Lender to Be Paid in Advance
901. Daiiy interest charges from 09124!10 to 10!01!10 7 Q $13.580000 !day (from GFE #10) 95.06
902. Mort a e insurance remium for months to from GFE #3
903. Homeowner's insurance for 1.0 ears to Erie Insurance from GFE #11 POC:390.0
g04, from GFE #11
905. (from GFE #11)
1000. Reserves De osited with Lender
1001. Initial de sit for r escrow account from GFE #9 559.92
1002. Homeowner's insurance 4.000 months Q $ 32.50 per month $ 130.00
1003. Mort a e insurance months $ r month
1004. Property taxes $
CitylTown Taxes months Q $ per month
County Taxes months ® $ per month
Assessments months Q $ per month
1005. months Q $ per month $
1006. County Taxes 10.000 months (~ $ 53.77 per month $ 537.70
1007. School Taxes 6.000 months Q $ 100.37 per month $ 602.22
1008.
1009. Aggregate Adjustment $ -710.00
1100. Title'Cha es
1101. Title services and lender's title insurance (from GFE #4) 1,158.75 10.00
1102. Settlement or closin fee $
1103. Owner's UUe insurance to BSS-CR from GFE #5 150.00
1104. Lender's title insurance tc BSS-CR 1,158.75
1105. Lender's title li limit $ 115,000.00
1106. Owner's title li limit $ 145,000.00
1107. A ant's rtion of the total title insurance remium to BSS-CR $ 1 048.69 End: $0.00
1108. Underwriter's portion of the total title insurance premium to ITIC $ 260.06 End: $0.00
1109. Attorney fees to Wolf & Wolf, Attorneys at Law 225.00
1110.
1111.
1112.
1113.
1200. Government Recording and Transfer Charges
1201. Government recordin cha es to Recorder's Office from GFE #7 157.00
1202. Deed $ 62.50 Mortgage $ 94.50 Releases $ Other $
1203. Transfer taxes to Recorder of Deeds (from GFE #8) 1,450.00
1204. CirylCounrytax/stamps $ 1,450.00 $
1205. State taxlstam s $ $
1206. Transfer Tax to Recorder's Office 1,450.00
1207.
1300. Additional Settlement Cha as
1301. Re ufred services that ou can sho for from GFE #6
1302. Whole House Ins coon to BIS Home Ins action Services POC:350.0
1303. Home Warren to AHS Home Warren POC:435.0
1304.
1305.
1400. Total Settlement Cha es enter on Ilnes 103, Section J and 502, Section K 5449.53 10 555.00
ey slpning page 1 or ibis statement, Vw sipnet°ries acknordetlpe receipt d a completed copy d papa 2 d this Mo pepNnt~emen~ jl~
Bankel`rs Se me Services-Capital Region, LLC, Settlement Agent
'POC (B) represents POC Borrower and POC (S) represents POC Seller
Page 2 of 3 HUD-1
(201000661.PFD/201000661/13)
Comparison of Good Faith Estimate (GFE) and HUD-1 Charges Good Faith Estimate HUD-1
Charges That Cannot Increase HUD-1 Line Number
Our origination charge # 801 1,175.00 1,175.00
Your credit or charge (points) for the specific interest rate chosen # 802
Your adjusted origination charges # 803 1,175.00 1,175.00
Transfer taxes #1203 1,450.00 1,450.00
Charges That in Total Cannot Increase More than 10% Good Faith Estimate HUD-1
Government recording charges #1201 170.00 157.00
Appraisal fee # 804 400.00 350.00
Credit report # 805 26.66 18.80
Tax service # 806 75.00 75.00
Flood certification # 807 10.00 10.00
Title services and lender's title insurance #1101 1,478.75 1,158.75
Owners title insurance to BSS-CR #1103 150.00 150.00
Tote I 2, 312.41 1, 919.55
Increase between GFE and HUD-1 Charges $ -392.86 or -16.99°/
Charges That Can Change Good Faith Estimate HUD-1
Initial deposit for your escrow account #1001 565.03 559.92
Daily interest charges # 901 $ 13.580000/day 95.06 95.06
Homeowners insurance # 903 400.00 390.00
Loan Terms
Your initial loan amount is $ 115,000.00
Your loan term is 25 years
Your Initial Interest rate is 4.2500
Your initial monthly amount owed for principal, interest and $ 623.00 includes
any mortgage Insurance Is ^X Principal
a Interest
^ Mortgage Insurance
Can your interest rate rise? ^X No ^ Yes, it can rise to a maximum of %. The first
change will be on and can change again every _ months after
. Every change date, your interest rate can increase or decrease
by %. Over the life of the loan, your interest rate is guaranteed
to never be lower than % or higher than %.
Even if you make payments on time, can your loan balance rise? ^X No ^ Yes, it cen rise to a maximum of $
Even if you make payments on time, can your monthly ^X No ^ Yes, the first increase can be on and the monthly
amount owed for principal, Interest, and mortgage Insurance rise? amount owed can rise to $
The maximum it can ever rise to is $
Does your loan have a prepayment penalty? 0 No ^ Yes, your maximum prepayment penalty is $ _
Does your loan have a balloon payment? Q No ^ Yes, you have a balloon payment of $
due in _ years on
Total monthly amount owed Including escrow account payments ^ You do not have a monthly escrow payment for items, such as property
taxes and homeowner's insurance. You must pay these items directly
yourself.
^X You have an additional monthly escrow payment of $186.64 that results
in a total initial monthly amount owed of $809.64. This incudes
principal, interest, any mortgage insurance and any items checked below:
^X Property taxes ^X Homeowners insurance
^ Flood insurance ^
^ ^
Note: If you have any questions about the Settlement Charges and Loan Tenns listed on this form, please contact your lender.
Page 3 of 3 HU0.1
(201000661.PFD/201000661/13)
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of Wills
One Courthouse S uare
Carlisle, PA 1713
SWENSON EVA MAE
Estate File No.: 2011-00552
Paid By Remarks: WOLF & WOLF
HMW
-------------------
Fee/Tax Description
PETITION LTRS TEST
WILL
SHORT CERTIFICATE
JCS FEE
AUTOMATION FEE
Check# 3162
Total Received.........
Receipt Date: 5/06/2011
Receipt Time: 12:49:38
Receipt No.: 1065519
Receipt Distribution ----- -------- -------- ---
Payment Amount Payee Name
45.00 CUMBERLAND COUNTY GENERAL FUN
15.00 CUMBERLAND COUNTY GENERAL FUN
40.00 CUMBERLAND COUNTY GENERAL FUN
23.50 BUREAU OF RECEIPTS & CNTR M.D
5.00
------------- CUMBERLAND COUNTY GENERAL FUN
---
$128.50
$128.50
Neill Funeral Home, Inc.
3401 Market Street
Camp Hill, PA 170114428
(717) 737-8726
Supervisor :Kevin J. Shillabeer
The following is a detailed bill for the professional services and/or merchandise arranged for
Eva M Swenson
Date of Service :May 04, 2011
Darlene G Swenson Statement Date May 06, 2011
920 Macoun Dr Contract Number 741 1 01 000252
Mechanicsburg, PA 17055-7037 Arranger Name Kevin J Shillabeer
Initial Selection Final Selection Difference
Funeral Director and Staff Services
Basic Professional Service Fee $2,680.00 $2,680.00 ---
Total Funeral Director and Staff Services $2,680.00 $2,680.00 --
Care and Preparation of Remains
Embalming $795.00 $795.00 ---
Dressing and Casketing of Deceased $395.00 $395.00 ---
Total Care and Preparation of Remains $1,190.00 $1,190.00 --
Use of Faalities and Related Services
Religious Facility Funeral Ceremony $395.00 $395.00 ---
Total Use of Facilities and Related Services $395.00 $395.00 --
Transportation
Transferring Remains to Funeral Home $495.00 $495.00 ---
Service Vehicle $395.00 $395.00 ---
Funeral Vehicle/Hearse $395.00 $395.00 ---
Total Transportation $1,285.00 $1,285.00 --
Other Goods and Services
Memorial Package $175.00 $175.00 ---
Flowers $241.68 $241.68 ---
Total Other Goods and Services $416.68 $416.68 --
Merchandise
146839 Meridian Wood Hardwood Crepe $2,195.00 $2,195.00 ---
Total Merchandise $2,195.00 $2,195.00 ---
Initial Selection Final Selection Difference
Cash Advance
Clergy !Religious Facility $300.00
Certified Copies $120.00
Musicians or Singers $125.00
Newspaper Notice $115.47
Total Cash Advance $660.47
Total Services, Merchandise and Cash Advance $8,822.15
Total Charges (Total Services +/-Allowances + Taxes) $8,822.15
Less Cash Received
Unpaid Balance Due
$300.00
$120.00
$125.00
$i 15.47
$660.47
$8,822.15
$8,822.15
$0.00
$8,822.15
NAME S f 60-15038
ACCOUNT NO. Iii - ~j 2 ~~~ 313
DATE
~ PAY TO THE
ORDER OF Ll ){
c1_/t,L~ ~ ovDOLLARS 8 a.
' ~ ~lGY1Z71•t~lJSA.~rt7 Gl4dtf~V,ttl~7e~~JJ ~/t -1Lto ,ca
s
o O~sTpwrlBANR
AT}¢ditionofExullenca ~'%~~~ ./~/ NP
~ 7~t110j OOO~..SZ -_-.--- -
MEMO
~:03L3L5036~:
Page 2012
PRENEED COUNSELOR SALES RECEIPT
ROLLING GREEN CEMETERY COMPANY 624 Na.0008359
1811 CARLISLE RD
CAMP HILL, PA 17011
717-761-4055
DATE
RECEIVED FROM `\~Q~p ~~,~~~
Name of Purchaser
THE AMOUNT OF t ~1 -~ C?~~C~a~L~~3~x~c~r ~~~-wts~~ ~ ~ ~=~" -DOLLARS ($ ~ ~~~. (~ )
AS: DOWN PAYMENT ^ REGULAR PAYMENT ^ CREDIT CARD CHARGE ^
CASH L~/ CHECK ^ CARDTYPE ^
FOR THE PURCHASE OF INTERMENT RIGHTS AND/OR MERCHANDISE AND SERVICES FROM THE ABOVE NAMED CEMETERY.
RECEIVED BY CEMETERY SALES COUNSELOR
DATE BY NAME _
GEN 8002 (6/02)
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of Wills
One Courthouse S uare
Carlisle, PA 1713
SWENSON EVA MAE
Estate File No.: 2011-00552
Paid By Remarks: WOLF & WOLF
DB
-------------------
Fee/Tax Description
PETITION LTRS ADM
SHORT CERTIFICATE
Check# 3233
Total Received.........
Receipt Date: 9/02/2011
Receipt Time: 13:16:16
Receipt No.: 1066870
Receipt Distribution ------------------------
Payment Amount Payee Name
20.00 CUMBERLAND COUNTY GENERAL FUN
20.00 CUMBERLAND COUNTY GENERAL FUN
----------------
40.00
40.00
~~ -~
fl- p N
~ C ~
~ 7 O
- ~
~ O
~; ~ N
oaa
3 ~ m
~~'~
O ~ y,
co
m~ ~
~3
O S
~ ~ ~
cn ~
O
v v- ~
N,
v y fD
o~ ~
~ v
v cn p.
w ~° ~.
OQ'fD
,~
o
~ C'f ~
y0o`=
m
~por
~XmZ
O~o~z
a ~~
o a
V ~
m
A N
O
A
0
W W ~ (w~
~ ~ O D m ~
~
~ r ii
m gZ °»
O
cn ~
n -i ;
o
~
~ m v z
=
z W ~ ~
r
~ D m m
C
~ ~
m O
C Z
N
lD
7
O
7
.~
~r1
~~
/~
N
ID
a
o
~ ~
"~ W
D
~ ~
~
C ~ ~
N T ~
Z
-1
z
~~
~ N ~ ~, ~, v
h
° ° ~ ~
~
o
O wo Wo
o c
D ~
~ o
m y
~
V ~
~ a
~ c
m
rn
w v
c
~ ~
o m
D
0
O
'0
C
W
r
n
z
O
-~
n
m
w
O
» r
N Z
m
O y
NI
n ~
~ ~
N
~~
~~
~~
~ F ~~
n
~ ~ „~
0
~ a~
V -1
n
a
V
~~r
N
~~~T
A m =
Owi~=~
T
~~D
wmp
m~
~z
m
W D
v
~ ~
~ v
A ~ ~
rn Z
C
00 D v h
m , ~
rn o o
o
m
m D
~ v ~, m ~, m
Z
~
-+ y
-I C1 ~
CA s O
m z
NAM E ~~a ~p pp~~~,~~
ACCOUNT NO. IO~OOBIW
60-15038
S ~~ 313
DATE I
i
OLLARS 8 ~ °ma,~
~ ~ U
3
ORRSTOWNBANR
MEMO ---------- ------------------
W
PAY TO THE ~j) „~~/
ORDER OF ~ lam{' V
~ I ~
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, PA 17013
Tele: (717) 249-3166 Fax: (717) 249-2663
July 8, 2011
Cumberland Law Journal is published every Friday by the Cumberland County
Bar Association and is designated by the Court of Common Pleas as the official legal
publication for Cumberland County and the legal newspaper for publication of legal
notices.
TO: Nathan C. Wolf Esquire
RE: Eva Mae Swenson Estate
Legal advertisements must be received by Friday Noon. All legal advertising
must be paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on the following dates:
June 24, July 1, and July 8, 2011
Advertising Cost $ 75.00
Proof of Publication $ 0.00
~~ Second Proof Request $ 0.00
~~ Payment received $ 0 .00
Total Amount Due $ 75.00
Payment received by
CUMBERLAND LAW JOURNAI
32 SOUTH BEDFORD STREET.
CARLISLE, PA 17013
Tele: (717) 249-3166 Fax: (717) 249-2663
July 8, 2011
Cumberland Law Journal is published every Friday by t~
Bar Association and is designated by the Court of Common PIS
publication for Cumberland County and the legal newspaper fo,
notices.
TO: Nathan C. Wolf Esquire
RE: Eva Mae Swenson Estate
Legal advertisements must be received by Friday Noon. ',
must be paid in advance. Make all checks payable to: Cumberll
Advertisement inserted on the following dates:
June 24, July 1, and July 8, 2011
00EWXE W~~~ET OR OURIC~TE SAFE
r ^ ~
(~
\~
O Q "',
~ ~ I m
I~
Advertising Cost $ 75.00
Proof of Publication $ 0.00
~~ Second Proof Request $ 0.00
~ Payment received $ 0 .00
Total Amount Due $ 75.00
^ ^ R1
O Q
W
r y
W
r
tri ~~
O ~~
Q'' a
:. ,~
O ~1~
C
Z
-~
Z
0
0
a
d
o
r ~
r ,
a ~
;
~ ~ I
"
~~ ~
~
€I
Payment received by
~~ ~~«°'
0~ ~
~~~~
PATIENT NAME: EVA SWENSON
CALL NUMBER: 216693W
WEST SHORE EMS -BLS DISCOVER
205 GRANDVIEW AVE SUITE 211 ~
CAMP HILL, PA 17011 ON REVERSE SIDE
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
EVA SWENSON
920 MACOUN DR
MECHANICSBURG, PA 17055
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE
Stretcher One Way Trans Member T2005 1.0 96.06
OXYGEN ADMINSTRATION A0422 1.0 65.01
Transport Van Mileage S0209 8.3 3.74
NAME
ACCOUNT NO. 11DOIAlD1CiD
~ PAY TO THE j~ rJlZ- ST~~ ~ 3
ORDER OF /I VV-S~o- - f } j,, ~~
t9
ORRSTOWNBANR
ATradtt)ion ofEsallsri/u~ )
MEMO Z / ~ ~n~!~l,/
I:03L3L50361:
INSURANCE: MEDICARE B WCS
CAPITAL BLUE CROSS NONE
DATE OF CALL: 04/18/2011
HARRISBURG HOSPITAL
FROM:
TO: ACUTE REHAB HOSPITAL
ACCOUNT SUMMARY
192.11
TOTAL CHARGES:
0.00
PAYMENTS/ADJUSTMENTS:
192.11
PLEASE PAY THIS AMOUNT:
so-~~o38
313
DATE
I$~~.11
DOLLARS 8 ~ ..~
AMOUNT
96.06
85.01
31.04
total Charges 192.11
AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT --
RETURNED CHECK FEE - $31.00
PATIENT NAME: SWENSON, EVA M CALL NUMBER: 216693W AMOUNT PAID: ~'
05/09/201
IMPORTANT MESSAGES: THIS SERVICE IS NOT COVERED BY MEDICARE OR MEDICAL
ASSISTANCE.
DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT
WEST SHORE EMS -BLS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011
Community Life Team EMS
1119 South Cameron St
Harrisburg, PA 17104
(717) 236-5947
Federal Tax ID: 23-1890444
Patient Name: EVA Swenson
Insurance: HIGHMARK MEDICARE SE 204037398D
CAPITAL BLUECROSS YWM80032413400
EVA Swenson
920 Macoun Drive
Mechanicsburg, PA 17055
DESCRIPTION OF CHARGES
Stretcher van trnsprt w/ 02
Stretcher Van Loaded Miles
NAME 4~4~~
ACCOUNT NO. rr ``oo ~n
l~~ ~"r~
PAY TO THE
~ ~~ BANK
A TiadiNon ofF.xa(/sncc
MEMO ~'
,:.i:03L3L5036~:
s
Patient Number: 50511
Call Number: 1106179
Date Of Call: 04/28/2011
Call Time:
Caller: Hospital Staff
From Location: Harrisburg Hospital
To Location: 1701 Linglestown Rd
Reason(s) CONGESTIVE HEART FAILURE, i
For SHORTNESS OF BREATH
Transport ATRIAL FLUTTER
Atrial Fibrillation
HCPC QUANTITY UNIT PRICE AMOUNT
T2005 i .0 - - )0 95.00
T"~ •" ~0 10.00
so-1~3 g
l J 313
DATE
~~ w
Total Credits
TOTAL CHARGES=>
105.00
0.00
$105.00
Non-Emergency routines are not covered by your insurance or subscriptions. Please pay
promptly.
"DETACH ALONG ABOVE LINE AND RETURN STUB WITH YOUR PAYMENT"
WE ACCEPT VISA 8~ MASTERCARD FOR PAYMENT
_ VISA _MASTERCARD Card
Amount $
Name on Card
Signature of Cardholder
Exp Date
Patient Name: Swenson, EVA M Call Number: 1106179 Amount Due: $105.00
Patient Number: 50511 Current Date: 05/09/2011 Amount Enclosed $
Community Life Team EMS 1119 South Cameron St Harrisburg, PA 17104
Hospice of Central Pennsylvania
1320 Linglestown Road
Harrisburg, PA 17110
Voice: 717.732-1000
FaX: 717-234-0375
Resident:
Eva Swenson
C/O Darlene Swenson
920 Macoun Dr
Mechanicsburg, PA 17055
ROSldent ID: SwensonE
~~
41i' r: &\"1'Mt ~ G ['~:~t1C~1' Lti'a'ti1C f ,~
~1,~
Invoice
Invoice Number:
4589
Invoice Date:
4/30/11
Page:
1
Payment Terms Due Date
Net 15 Days 5/15/11
Description Amount
Residential Care - April 28 - May 1, 2011 (prorated to 43.25/day
I !~'~~ 60-15038
(/~'_ 313
DATE ,,,/ Q~ /`~ /~
,L j~.AI~AA ~ ~ t L ~ v"
DOLLARS L~J ~°~,~
- -
173.00
Please note our new office address -- 1320 Linglestown Road,
Harrisburg PA 17110
Total Invoice Amount 173.0 0
Check/Credit Memo No: Payment/Credit Applied
TOTAL 173 . oa
Thank you for choosing Hospice of Central Pennsylvania.
o. ~ ~ ~ e
® Customer Service:
HTT 866-362-3880
8AM-SPM, M-F
HOSPITAL TELEPHONE AND TELCOM, LTD.
P.O. Box 39127 Cleveland, OH 44139
EVA SWENSON
920 MACOUN DR
MECHANICSBURG , PA 17055
Invoice #: PH11 05-51926
Date: 5/11/2011
Balance Due: $32.00
INVOICE
Patient Name: EVA SWENSON
Admission Date Discharge Date Service Days Description of Service Balance Due:
4 / 20 / 2011 4 / 28 / 2011 8 TV/PHONE $32.00
These charges are for the convenience of having use of telephone and / or
television services during your hospital stay at Pinnacle. These services are not
covered by any insurance plan.
Please contact us with any questions at our toll free number, 1-866-362-3880,
between the hours of 8:00 AM and 5:00 PM, Monday through Friday. Thank you.
Pay Online at paypatientbill.com
-------------------------------------------
PLEASE PAY ONLINE AT PAYPATIENTBILL.COM OR DETACH THIS SECTION AND RETURN WITH YOUR PAYMENT
Invoice #: PH11 05-51926
Remittance Address:
Hospital Telephone & Telcom Service, Ltd.
P.O. Box 39127
Cleveland, OH 44139
EVA SWENSON
920 MACOUN DR
MECHANICSBURG , PA 17055
Date: 5/11/2011
Please Pay This Amount: $32.00
Make Checks Payable to: HT & T or
Pay by Credit Card:
^ MC ^ VISA ^ DISCOVER
Card #
Expiration Date: Security Code:
Signature:
~. +,~ ~
;,:,
HTT
HOSPITAL TELEPHONE AND TELCOM, LTD.
P.O. Box 39127 Cleveland, OH 44139
EVA SWENSON
920 MACOUN DR
MECHANICSBURG , PA 17055
INVOICE
Patient Name: EVA SWENSON
Invoice #: PH11 05-51924
Date: 5/11/2011
Balance Due: $40.00
Admission Date Discharge Date Service Days Description of Service Balance Due:
3 / 24 / 2011 4 / 3 / 2011 10 TV/PHONE $40.00
These charges are for the convenience of having use of telephone and / or
television services during your hospital stay at Pinnacle. These services are not
covered by any insurance plan.
Please contact us with any questions at our toll free number, 1-866-362-3880,
between the hours of 8:00 AM and 5:00 PM, Monday through Friday. Thank you.
Pay Online at paypatientbill.com
PLEASE PAY ONLINE AT PAYPATIENTBILL.COM OR DETACH THIS SECTION AND RETURN WITH VOUR PAYMENT
Invoice #: PH11 05-51924
Remittance Address:
Hospital Telephone & Telcom Service, Ltd.
P.O. Box 39127
Cleveland, OH 44139
EVA SWENSON
920 MACOUN DR
MECHANICSBURG , PA 17055
Date: 5/11/2011
Customer Service:
866-362-3880
8AM-SPM, M-F
Please Pay This Amount: $40.00
Make Checks Payable to: HT & T or
Pay by Credit Card:
^ MC ^ VISA ^ DISCOVER
Card #
Expiration Date: Security Code:
Signature:
~' a .-.
HTT
HOSP[TAL TELEPHONE AND TELCOM, LTD.
P.O. Box 39127 Cleveland, OH 44139
EVA SWENSON
920 MACOUN DR
MECHANICSBURG , PA 17055
INVOICE
Patient Name: EVA SWENSON
Invoice #: PH11 05-51925
Date: 5/11/2011
Balance Due: $12.00
Admission Date Discharge Date Service Days Description of Service Balance Due:
4 / 15 / 2011 4 / 18 / 2011 3 TV/PHONE $12.00
These charges are for the convenience of having use of telephone and / or
television services during your hospital stay at Pinnacle. These services are not
covered by any insurance plan.
Please contact us with any questions at our toll free number, 1-866-362-3880,
between the hours of 8:00 AM and 5:00 PM, Monday through Friday. Thank you.
Pay Online at paypatientbill.com
-------------------------------------------
PLEASE PAY ONLINE AT PAVPATIENTBILL.COM OR DETACH THIS SECTION AND RETURN WITH YOUR PAYMENT
Invoice #: PHil 05-51925
Remittance Address:
Hospital Telephone & Telcom Service, Ltd.
P.O. Box 39127
Cleveland, OH 44139
EVA SWENSON
920 MACOUN DR
MECHANICSBURG , PA 17055
Date: 5/11/2011
Please Pay This Amount: $12.00
Make Checks Payable to: HT & T or
Customer Service:
866 362-3880
8AM-SPM, M-F
Pay by Credit Card:
^ MC ^ VISA ^ DISCOVER
Card #
Expiration Date: Security Code:
Signature:
0 oE~,..~
•O o
W
r ~
w
~ ~~
O gnu
..
~~ ~I
o '' D G
D
no n ~
a~ O
~~ O
~'
~.
I
0
~.
~d
~ bCJ
~ -~
N ~,
~ y'~
w~
~~ ~