HomeMy WebLinkAbout07-02-12 (3)15056101171
r
REV-1500 Fxtat_r°'
OFFICIAL USE ONLY
PA UepaRment of Revenue pen'r~sytvania
County Code Year File Number
Bureau of individual Taxes INHERITANCE TAX RETURN p' !r "y `' "°°°'F" ~ f
PO BOX z8D6oi
HarrisburD. PA 17128-o6Di RESIDENT DECEDENT ~'. ~ - _ ~~ ~ ~'
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMODYYYY
,. : 7 °~~°,r 2.0 ~7
Decedent's Last Name Suffix
~. t.
(If Applicable) Enter Surviving Spouse's Information Below
Date of Birth MMDDYYVY
08~1~9~7932 t8 y
Decedent's First Name MI
`' ,., ~.
Vii, r i~ 1, _ d ~ r e.d h. ° ., ., ,~H~..~a x E
Spouse's Last Name Suffix Spouse s Fvst Name MI
=,~ j yam- « - t ..r,w . ~. A ... "^„~' `y4 ~.'°"`
na oY .4
A ~'
1 ) ~ 4 I` '~ ~` ~ p h
,«ta a,f3 C . _i" .. + '.. ...£n . ~; r ~-. ~ v ...: -. e .~ .. ..... m F. 9 ,1 '., ...... Aa n wl ,mwr4
Spouse's Social Secunty Number
- --~ i + ~ # THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
,~_ ,,,, , , s .~ ~ ~ ~~ REGISTER OF WILLS
FII_I IN APPRCIPRIATE OVALS BELOW
r t. Crigiral Return O <. Supplemental Return
O ~...~„~.~d Eata.e. O +a I°uture Interest Compromise (data cf
death after 12-12-82)
O 6. Decedent Died Testate O 7. Decedent Malntalned a Llving Ttuat
(Attach Copy of WiN) (Attach Copy of Treat)
O 9. Lltiga8on Proceeds Reoalvad O 10. Spousal Poverty CredX (date of death
between 12-31-91 and 1-1-95)
O ... mainder Return (date oT death
' prior to 12-13-82)
O ... Federal Eo.ata Tax ,.oh;m Reyul ~..
1 8. Total Number of Safe Deposit Boxes
O 11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL GORRESPONOENGE AND CONFIDENTIAL TAX INFORMATION SHOULD SE OIREGTED i0:
Name Daytime Te one Number rv
m, ^- . ~ m ...: , .
M a"r~ 1 T n R~ ~ ~M~ c.C a 1'e b~ E`s.q .' X7,7 ~7; b 1 7,
. , . , <. r ~,..~ .,. i
REGISTER ~ 1[t!IL~.9' USE bNl
~~ rTl I
First line of address ~ C7',7 -q
2 1 9 Era. s~t° ~M~ari n .. Set pr e.e~t n`;y
Second line of address n .-
r ~ ,.
3 i~' Cfl
i
City or POSt Office StatO ZIP Code DATE FILED
... . .t -. .I. N.
M e c h a n i c's?b ;u}r g P A' 1 7 0"5 5 .a ,
Correspondent's a-mail address:
Under penalties of perjury, I dedare that I have examinetl this return, indutling armmpanying schetlules and statements, and to the 5est of my knowletlgc and ballet,
d is true, correct and complete. Oedaretion of preparer other than the personal representative is based on all inlonnatlon of which pmpamr has any knowledge.
Richard L.
ADDRESS
SIGNATURF_ OF PREPARER OTHER THAN REPRESENTATIVE
nATF
279 East Main Street. Mechanicsburg. PA 1;055
PLEASE USE ORIGINAL FORM ONLY
Side 1 ,
1505610101 1505610101 J
~- }
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~~
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t
1
1505610105
REV-1500 EX
Decedent's Sotial Security Number
oecedent's Name: Mildred Elizabeth Hann ' .<
RECAPITULATION
................. 1 ~., x4_,..~
7. Real Estate fSchedule A) ... ........... .. ......
2. Stocks and Bonds (SChbdule !3) ........ .... ...... ................. 2. , " " ~ '~ Q
@w ,''.f
3. Closely Neld Corporation, Partnership or Sole-Propdalorship (Schedule C) .... 3.
.;:
4. Mortgages and Notes Receivable (Schedule D) ........................... 4.. ) ' i
5. Cash, Bank Deposits antl Miscellaneous Personal Property (Schedule E).... ... 5. {
d;ti
6. Jointly Owned Property (Schedule F} O Separate Billing Requested .... ... 6. ;;
7. Inter-Vivos Transfers & Miscellaneous Noo-Probate Properly `~")'
(Schedule G) O Separate Bllling Requested..... ... Z i
~~
8. Total Gross Assets (total Lines 1 through 7) .......................... ... 8. `?
9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9 ,
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .......... .. 10
11. Total Deductions (total Lines 9 and i0) ........................... .. .. 11.
12. Net Value of Estate (Line 8 minus Line 11) . - ....... ... .. .. 12
13. Charitable and Govemmentaf Bequests/Sec 9113 Trusts for which e'"'~
an election fo tax has not been made (Schedule J) .. ................ ... 13. ,~
14. Net Value Subject to Tax {Line 12 minus Line 13) .. . ................ ..... 14.
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 911P
(a)(1.2) X .0.(L 15.
16. Amount of Line 14 taxable
at lineal rate X .0 ~ 16.
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Anrount d Line 14 taxable
at collateral rate X .15 16.
t9. TAX DUE ......................................................... 19.
~3 1s4
wlf
;2;2'8
k~'a~~t
`~ ]`$
rl#1'.3
"1
3 0>6
~-
=4 ' 2~ 0
~6 t 5~8
~6 5Q8
20. FILL IN THE OVAL IF YOU ARE REQUESTING AREFUND OF AN OVERPAYMENT
Slde 2
15D5610105 1505610105
EV-1500 FJC Page 3
IecedenU's Complete Address:
File Number
_MilArPri Flizaheth Hann -- -
STREETADDRESS
Mechani
9X v~~ipgne~ ?t2ti r'rcriii~'
la% Ilne jt'age L, Line i'J)
C.redf~PaynlBllfS
B. OiscouM
Interest
li tine a is greater Than line i + Line 3, artier the diiierertce. Tnis is the uVER'rwiTir'eNT.
Fi0 in oval on Page 2, Line 20 to request a refund.
ZIP
PA 17055
(tl L.~62.4L
Total Credits (A+ B) (2) 0.00
(3)
0.00
(4) 0.00
H Line 1 + Line 3 is greater than Line 2, en~r the dlHisrence. This is the TAX DUE. (5) 2 , 962.42
-• - - -- -
e~~r,e ,.heck „~„~Cte +e: REGt~Tr=u ns;::NILL~ nr.-.ti t
~. ~~.~ .,, r y~ .,.. , "..,. .., .
PI EASE ANSl4rER TNF FOLLO!rlrlN~ QUESTIONS R1/ PI 4(:INL !~N "J[" t1Y I Nt_ ANt'tt4,IMKlAt t t3LUt:tl~
1. Did decedent make a trarader arid: Yes No
a. retain the use or income of the property transterr~ :.......................................................................................... ^
b. retain the dght fo designate who shah use the property transferred or its inrxtme :............................................ ^
c. retain a reversionary interest: or .......................................................................................................................... ^
d. receNe the promise far kfe of eidler paymerrts, berlahfa or cere? ...................................................................... ^
?_ It ~ th ~~~RO~ 3ger nor_ ~ ~, ~uxZ, nib nP~aaenr [rgnetar Prruwrty anrhin nn[+ year ni rina_ ih I ' _
witl~awuaipi'ru Kj adequate WiWdBiauOn? ............................... J ICI
3. Did decedent own an "in Wst tor" or payable-upondeath bank account or security et his or tier death? .............. ^
r. uw da~.2daili umi au xwrv'fuua rotr,mnarit acccun;, an„~,.r ~, Odtc, ,wu-pv .2 property, t:. t
contains a tlenefictiary desi9natron? ....................................................................................................................... ® ^
IF THc ANS~r'€R TO AiiY OF THE ABOVE KUE3nOtJB ~ Y€S, YOU A1UST COaIPLETE SCHED!!LE G Al:O F;LE ;? AS PART OP THE R.RURH.
br data.; of deaut ut it atu?r July t, 1394, and Before Jan. i,1395, u;a tax rata trnposad an iha rat Ya ue of transfers to or for the use of tine st:n-iYing sp^..u5e iw
percent (/2 P.S. §911s (a) (1.1) (ij].
~tr dates u. ~o°~,~ ~- o, a°8r Jars. i. ~~~°.. ~ia felt rat@ {m^w^52d G,~ i. ! ,"t of tan ..n. v. f.., the a p 1h etm„ ~ p c ! p_„
h ..~..~ ..mot..,,. ~ e ~ ~n souse t_ terra ..
r2 ?S. §3116 (a) (i. i) ~ri11. i he 6fat'u'ui uiRrS nin'" exempt a transfer to a survirruJ apousa ..o.., taX, a~rd 1~a pw~y ,~D'tremenw'or disclwure of assets and
ling a tax retiarr are still appNcable even if tire surviving spouse is tire oMy benetiaary.
'ar dates of death on w after July 1,2000:
The tax rate imposed on fire net vaiue wvansfers hen a dec~sed citiid 21 years of aye u yourryer ai deaut to or cur ~re use of a nat;Hai parz,~t, an
adoptive parent or a steppanant of the chid ~ o percent (?2 as. §sfts(a>(t2>l.
The tax rd[B On Iie flat Value of Transfers t0 Or fur the U58 Of Iha det~danYS {meal barraPwiaries i5 4.v peiccid, except w n('iiod iri
7z es. §siis(i.z (7z Ps. §siis(a)(ig.
Ttw Tn. i.3,r-l~u.n.-,eu ,nc :ie ire, value of ua„n,es .u ur tv~ u,e .is~ vi .h,'le dawdc,., ,»u{S,.CS :,, ':~ a..,C..+ i {~~ Re Coll R/a !i 7}i 9 ht.,,' _ dutined, Undel
c v. ate,. . n
ve~iitir 3 i a2, as an irwTv""idiiai who ,iaS at Aa'at Oita parent ii. x,~.,wn Y'9µ µo d~dent, t•Jheµer by .hf'Y.7'.. Or adop.on.
REV-1502 EX ~(ti 97)
1
SCHEDULE A
REAL ESTATE
Mildred Elizabeth Hann SS~~ 10/01/2011 21-11-1133
All real property owned solety or as a tenant in common must be reported at fair market value. Fair market value is defined as the price
at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable
knowledge of the relevant facts. Real orooertv which is jointly-owned wkh right of survivorship must be disclosed on Schedule F.
ITEM DESCRIPTION VALUE AT DATE
NUMBER OF DEATH
1 House and lot, - known and numbered as 9 East Simpson Street, 49,000.00
Mechanicsburg, PA; acquired by Decedent by deed of Horace M. Han
and wife, dated 08/21/1976, recorded in Cumberland County Deed
Book "T", Voltvne 26, Page 473; value based on appraisal. by Brett
Lechthaler, Pa.C.G.A..
TOTAL (Also enter on line 1, F
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPbystems, Inc.
000.00
Form REV-2502 EX (Rev. t-s77
REV-1503 E%a(1 -$'n
SCHEDULE B
STOCKS & BONDS
FILE
Mildred Elizabeth Hann SS~~ 10/01/2011 21-11-1133
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE
OF DEATH
1 Frontier Communications, Inc., - 28 shares, common @ 168.70
$6.025 (9/30/11: high=6.25; low=6.10; 10/3/11:
high=6.09; low=5.66).
2 Verizon Communications, Inc., - 120 shares, common @ 4,425.30
$36.8775 (9/30/11: high=37.34; low=36.78; 10/3/11:
high=37.15; low=36.24).
TOTAL (Also enter on line 2, Recapitulation) 4,594.00
to more space is needed, insert additional sheets of the same sizej
Copyright (c) 1996 form software only CPSystems, Inc. form REV-7503 EX (Rev. 1-97)
REV-1508 E% ~ (1 -~.7)
SCHEDULE E
CASH, BANK DEPOSITS, 8r MISC.
PERSONAL PROPERTY
Mildred Elizabeth Hann SS~~ 10/01/2011 21-11-1133
Include the Proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Citizens Bank, - Checking Account No. 6100705676, principal 18,551.81
balance as of date of death (no accrued interest).
2 Household goods, contents, furniture and furnishings. 520.00
3 United American Insurance Co., - refund of nursing home insuranc 363.84
premium.
4 United American Insurance Co., - insurance reimbursement paid to 12,000.00
Estate for nursing home expenses incurred before D.O.D.
(05/04/2011 - 09/30/2011)(150 days @ $80.00).
TOTAL (Also enter on line
(If mare space is needed, insert additional sheets of the same s
Copyright (c) 1996 form software only CPSystems, Inc.
31
Form REV-7508 EX (Rev. 1-97)
REV-15 ;OE%~(,~~> SCHEDULE G
INTER-VIVOS TRANSFERS &
COM MONW EALTH OF PENNSYLVANIA
INHERITANCE TA%RETURN MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
Mildred Elizabeth Hann SS~~ 10/01/2011 21-11-1133
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
RELATIONSHIP TO DECEDENT AND THE PATE O~TRANSFER.
ATTACH ACOPY OF THE DEED FOR REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET % OF
DECD'S
INTEREST
EXCLUSION
QF APPLICABLE)
TAXABLE VALUE
1 Protective Life Insurance 22,848.49 100% 22,848.49
Co., - Annuity Contract No.
U000725205, payable to
Decedent's son, Richard L.
Hann, as designated
beneficiary upon Decedent's
death.
TOTAI
(If more space is needed, insert additional sheets of the same
Copyright (c)1996 form software only CPSystems, Inc.
Form REV-1570 EX (Rev. ,-s7)
REV-1511 EX all ~9~
SCHEDULE H
FUNERAL EXPENSES 8
ADMINISTRATIVE COSTS
Mildred Elizabeth Hann SS,+p 10/01/2011 21-11-1133
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1 Myers-Buhrig Funeral Home, - funeral services. 5,025.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s) / EIN Number of Personal Representative(s)
Street Address
Ciry State Zip
Year(s) Commission Paid:
2. Anorney'sFees Law Offices-Marlin R. McCaleb 5,000.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Stree[ Address
City State Zip _
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills 308.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1 Brett Lechthaler, PA Cert. Appr., - appraisal of real estate. 300.00
2 Chuck Bricker, - appraisal of household contents. 75.00
3 Citizens Bank, - service charge. 8.25
4 Citizens Bank, - service charge. 2.00
5 Citizens Bank, - service charge. 2.00
6 Citizens Bank, - service charge. 2,00
Total of Continuation Schedule(s) 633.24
TOTAL(Also enter on line 9, Recapitulation) E 11 , 355.99
(If more space is needed, insert additional sheets of the same size)
Copyright (c)1996 form software only CPSystems, Inc. Form REV-1517 EX (Rev. 1-e])
Estate of: Mildred Elizabeth Hann
Soc Sec ~~:
Date of Death: 10/01/2011
Continuation of Schedule H-B7
(Other Administrative Costs)
Item Description Amount
~~
7 Citizens Bank, - service charge. 2.00
8 Citizens Bank, - stop payment charge. 35.00
9 Citizens Bank, - service charge. 2.00
10 Citizens Bank, - service charge. 2.00
11 Cumberland Law Journal, - advertising Letters. 75.00
12 Register of Wills, - filing Inventory and Appraisement. 30.00
13 Register of Wills, - reserve for filing Account, Releases. etc. 350.00
14 The Patriot News, - advertising Letters. 137.24
--------------
633.24
REV-161 IX a (1 -j37)
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, AND LIENS
Mildred Elizabeth Hann SS~k 10/01/2011 21-11-1133
Include unreimbursed medical expenses
ITEM
NUMBER
DESCRIPTION
AMOUNT
1 Barry L. Heckard, Tax Collector, - account payable, 2011-12 1,490.21
School District Real Estate Tax.
2 Barry L. Heckard, Tax Collector, - account payable, 2011 County 617.12
and Borough Real Estate Tax.
3 Barry L. Heckard, Tax Collector, - account payable, 2011 Per 11.00
Capita Tax.
4 Borough of Mechanicsburg, - sewer and refuse charges (1st, 2nd, 520.60
3rd & 4th Qtrs, 2011)
5 Locust Grove Retirement Village, - nursing home serv ices rendere 26,579.44
to Decedent before D.O.D. (04-28- 11 - 09/30/11).
6 OmniCare of Williamsport, - presc ription medications provided to 1,472.28
Decedent before D.O.D. (07/23/11 - 09/30/11).
TOTAL (Also enter on line 10, F
(If more space is needed, insert additional sheets of the same size I
Capyrig ht (c) 1996 form software only CPSystems, Inc.
30,690.65
Form REV-1512 EX (Rev. 1-97)
REV-1513 E%~~9-00)
i
SCHEDULE)
BENEFICIARIES
ESTATE OF FILE NUMBER
Mildred Elizabeth Hann SS~b 10/01/2011 21-1T _1194
RELATIONS IP TO DECD T AMOU 0 SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS[Inclutle outrlghtspousai dlstributlons,and
transfers under See. 911fi(a)(1.2)]
1 Richard L. Hann Son Entire Estate
1495 Willow Run Road
Honey Grove, PA 17035
ENTEfl DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON R EV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET S 0.00
to more space is neeaeo, insert aotlitional sheets of the same size)
Copyright (c) 2000 form software only Tha Lackner Group, Inc. Form REV-7573 EX (Rev. 9-00)
APPRAISAL OF REAL PROPERTY
LOCATED AT:
9 E Sknpem St
Deee Book 28T Pe9B 473
Machenkahurg, PA 17055
FOR:
The Estate of RftlreE E Henn
r/o MerBn R MoCSlab, 279 E Main St, 6leonaMCabuB, PA 77055
AS OF:
toroln9n
BY:
sea Lechtheler, PA State Carl Gan Appr
Appraisal Sohabrs
78 San Juan Drrae
MarJierdrabrrrg, PA 77055
Schedule A.1
Farm G176-"AfinTOtAL' appraisal software M a le moss, inp.-1-506A1M%l0E
November O5, 2011
Appraisal Solutions
16 San Juan Drive
Mechanicsburg, PA 17055
717-697-1828/Phone
717-697-0220/Fax
Dear Sirs:
The accompanying Summary Appraisal Report is based on a site inspection of
improvements, investigation of the subject neighborhood area of influence, and
review of sales, wst, and income data for similar properties.
This appraisal has been made with particular attention paid to applicable
value-influencing economic conditions and has been processed in accordance with
nationally recognized appraisal guidelines.
The value conclusions stated herein are as of the effective date as stated in the
body of the appraisal, and contingent upon the certification and limiting conditions
attached.
Please do not hesitate to contact me if I can be of additional service to you.
Respectfully,
Brett Lechthaler,
PA State Certified General Appraiser
Farm OCVq - WinTOTP1' appmiael sottiuam by a V moAe, ix.-1-8W-NlAM00E
q. ~
~ 1
SUMMARY OF SALIENT FEATURES
sw~ adaxae
Legal DasaiPtlm
Ctll'
Cwdy
Scb
~ Code
Census Tract
Mao 9eMerce
sac Pace
DacdSab
9prgap/Caad
Lmtler
sine dam Feed
Pnce Da Square FoN
LocaSm
Ape
COMitloa
Tool puma
Betlrema
Bade
Appgser
Dab atAppreced Vabe
FAad FabnBe of Veha
9 E Sinoeon St
Daetl Book 257 Page 473
aaerhanmsMag
Cumbatlaaq
PA
77055
odta.oo
McW28G5/G-7
E NA
NA
NA
The Estate of Nitlretl E Hann
1.552
S
Average
711 Years
Fet
6
3
2
BraO Lepolaaler, PA Stets (`.art Gan Appr
10/OdM2011
E 49,000
Fpm SSD-'WnTOTAL' appacb sollwere bya b mods, im. -1-BU0.gtpA1~E
Mixatsa soemas n,nss~-,a2s
Fqm 7004-'Nm7017LL• apprelsa software 6Y a V mmk, irc.- i-BOPAUmOpE
ramie mae Farm 1004 march 2005
- -- - ranrae Mae Porn 7004 MarCli 2005
Fam 1004- WmTOTAL• appraisal sa0aara by a h ma4e, ux;.-1-B06ALAIAOOE
Ai
" ' -" Fannie Mae fronn 1 W4 March 2005
farm 7004- WinTOTAL• aapi&sal software by a q mOaR am, - t-ADap~M1WE
A. ~
This report form is tlasigned to report an appraisal of a one-unit property or a one-un(t property wtth an accessory untt;
including a untt In a plannetl untt tlevebpment (PUU). This report form is not tlesignetl to report an appraisal of a
manufactured home or a untt in a condominium ar cooperatlve pro)ect
statemartPt oof assumptlonsubanAtlimitlng coontlitlmis cantl ertHic~atlonsnMOdiflcatlons naddMons, orfl eeangonos tmaatlie irvitManded
use, intentled user, tlefinition of market value, or assumptlons and Ilmitlng condPoOns are not pertnttteO. Tha appraiser may
expand the stops of work tp inclutle any atlditlonal research or analysis necessary Dosed on the compleztty of tltls appraisal
assignment. Motlbications or tlaletlons to the cartbicaUans are also not permitted. However, addPoOnal cerUflcations that do
not constihAe material atteratlons to tiffs appraisal report, such as those required by law or those relaretl to the appraiser's
corttlnuing educaUpn or membership In an appraisal organizatlon, are permtttetl.
SCOPE OF WORK: The scope of work for this appraisal is defined by the complexity of this apprelsal assignment antl the
repoNng requirements of this appraisal report forth, Inclutling Ute following tleflnitlon M market value, statement of
assumptlons antl IlmPong cpntltllats, antl certlficMfons. The apprelsar must, at a miMmum: (t) partarm a canplele visual
inspection of the Interior antl exterior areas N the subject property, (2) Inspect the nelghborhooq (3) InspeM each of ma
comparabe sales Dom at least the slreM, (q) research, verify, and analyze data from reliable public anya private sources,
and (5) report his or her analysis, opinions, antl conclusions in this appraisal report.
INTENDED USE: The intentletl use of this appraisal report Is for the lender/cieM to evaluate Dre property prat is the
subject of this appraisal for a mortgage finance transaction.
INTENDED USER: The IMendetl user of this appraisal report is the lender/client.
market uncle ~aflflcpndgbns grequlshe me a fair Sa~e~tlree buyer and sellerpro achya~~uld bring In a competlDva antl open
the price is not affectetl by undue stimulus. Implictt In ibis deflnWon b the consummation otl fna gaffe ~ rNgaaspeary ~ a ~ aln0
me Passing M title Dom seller to buyer antler corMlUOns whereby: (i) buyer antl seller are typically motiva[etl; (2) both
partial ant was irdormatl pr wall advisetl, antl each actlrrg in what he or she considers his or her own pest IMeresD (3) a
reasonable Ume is allowed for exposure in the open markek (q) payment is made In terms M cash in U. S. Dollars or in terms
of financial artanpartrents comparable tlreretp; and (5) bra price rePrasents me nomtal consitleretlon for the Property sold
unaflectetl by special a creative financing or sales concessions` prerrted by anyone assoclaratl with the sale.
`AtllusimeMS to the comparebles must be made for special or creatve financing or sales concessions. No adJushneMS are
necessary for brow costa which are normalty paid by sellers as a result of Daditbn or law in a matlcet area; these costs are
readiy iderptiiable since the seller pays these costs in virtualty all sales iransactlons. Special or creatve financing
adJusmiertis can be matle re the cortgrarable Property by comparisons to flnancinp terms offered by a tltlro Parry InsUtutlonal
lentler that is no[ already involved in tits property ar iransactlon. Arty atlJusbnent should nM ba ralculatetl on a mechanical
dollar for tlobar cost of the financing or concession but the tlogar amount M any adjushnent shoultl approximate the market's
reactlon to the financing or concessions based on the appraiser's JudgmerR
STATEMENT OFASSUMPTIONS AND LIMITING CONORIONS: The appraiser's cerdfication in tins report Is
subJeM to the following assumptions antl limiting conditians:
7. The appraiser will rtM be responsible for matters of a legal nature that affeM eUher the property being appraised or by tltle
to IS except far infomration that he or she became aware of during the researoh involved in performing this appreisal. Tha
appreiser assumes that the title is good and marketable and will nM rentler any opinions about Ure title.
2. The appraiser has provided a sketch In tins appraisal report to show me approximate Gmensions of the improvements.
The sketch is inclutled only to assist the readar in visualizing tin; property and understanding Ure appraiser's tleterminatlon
M Its size.
3. The appraiser has examined the avallabk flootl maps brat are provitletl by the Federal Emerpertcy Management Agency
i(tlantl~tj SdaW sources) and has opted in Ihis appraisal report whether any poNOn of the subject ske is loca[etl in an
pacial Rootl Hazard Area. Because the appraiser Is not a surveyor, Iv or she makes no guarentees, express or
implied. regaroing this tlMertnlnation.
4. The appraiser will no[ give testimony a appear In court because he or she matle an appraisal of the property In questlon,
unless specfbc arrangements to tlo so have been made baforehan4 or as otlterwise required Dy law.
5. The appraiser has noted b this appraisal report any atlverse condftlons (such as neetled repairs, tle[erioraUOn, the
presence of hazaroous wastes, tmdc substances, etc.) observed tluring the inspecUan M Ne suDject property or tltat ha pr
she became aware of dudnp Ute research invoNetl in perorminp the appreisal. Unless otherwise stated In this appraisal
report the appraiser has no knowledge M any hidtlen or unapparent physical deflciencfes or atlverse condPopns ar tire
property (such as, but not smtted tp, needed repars, tleteriareaon, the preserve of hazardous wastes, todc substances,
atlverse environmental candPoOns, etc.) Utar would make tits property less valuable, antl has assumetl that tirere are no such
conditlons and makes no puararrtees or wartarNes, express or implied. The appraiser will not be responsible for any such
contlitlons mar do exist or for any engineetlrtg or testlng mar might be required to tliscover whether such conditlons exist
Because rite appraiser is nM an expert in Ure flab M environrtreMal hazards, brie appraisal report must not be considered as
an environmerrtal assessment of the Property.
6. The appraiser has basetl his or her appraisal report antl valuation conclusion for an appraisal that is subjeM to satisfactory
completion, repairs, or aberetlpns on the assumption that the completion, repairs, or atteretlons of the subject property will
be pertomtetl in a professional manner.
FredWe Mac Forth 70 March 2005
Page 4 of 6 Fannie Mae Form 1(104 March 200$
tam 1004-'yM70TP1• apprasa soaware by a D motle, ax.- l-appgtgMppE
a
APPRAISER'S CERTIFICATION: The Appraiser cemfies antl agrees mat
1. I have, at a minimum, developed antl repmmtl This appraisal in accordance with Me scope of work requirements stated in
mis appraisal report.
2. I pedortned a complete Wsual inspection of the In[erbr antl extedar areas of me subject property. I regaled me contlPoOn
of the improvemems in factual, specific terms. t itlentlNetl antl reported me physical tleflclenclas mat coultl affect ma
Ilrabtllty, soundness, or structural Imegrlty of me property.
3. I pertomted mis appraisal in accordance wtth me requlremems of me Unfform Stantlards of Professional Appraisal
Prectlce that were atlopted and promulgated by me Appraisal Standartls Board of The Appraisal Foundatlon and mat were In
place at lire Nme mis appraisal report was preparetl.
4. I developed rtry opinion of me market value of me real property char is me subject of mis report based on tlra sales
compadson approach m value. I have atlequate comparable market tlata m tlevelop a tellable sales compadsen approach
for mis appraisal assignmem. I furtlrer certlty mat I considered me cost and income approaches m value but tlid not tlevelop
mem, unless otherwise Indicatetl in m(s report
5. I msearohed, verified, analyzed, antl reported on any current agreanent for sale far me subject property, any affedng for
sale of me subject property in me twelve rrromhs prior W tlea effective date of Ws appraisal, antl Nre Pnar sales of me subject
property for a minimum of mree years pdw to me effectlve date a mis appraisal, unless otherwise Intllcated In mis report
M the aa~ m sale ~ the ompearabledsale, u~nle sn atlrerv s«e inG cate0 n mport. sales for a minimum of one year pdor
7. i selecfetl and used comparable sales chat are bcatlonally, physically, and func0onally mB most slmtlar m me subject property.
8. I have not used comparable sales mat wee me result of combining a (antl sale with me corrNaa purchase pdce N a hams that
has bean butlt or will be built on Nte lantl.
9. I have reported adlustrnems m me comparable sales mat reflect me markets reactlon m me differences between me subject
property and me comparebla sales.
70. I verified, hom a dlskaerestetl source, all INOrmatlon in mis report mat was provitled by partles who have a Nnanclal Irderest in
the sale or financing a me subject property.
11. I have knowMdpe and expertence In appraising mis type of property in mis market area.
servkes, taz assessment recartlse public land recsoMs antl o~tl7pero uch tlara sources for mee areamrowhichume ~ muNfOk7 Ilsung
13. I obtained me imormaNan, estimates, and opinions tumishetl b omer p oPertY 4s I°cated.
reliable sources mat I believe m be true antl correct. Y partles antl expressed In mis appraisal report hum
14. I have taken imo consideration me facmrs mat have an impact on value with respect ro me subject neiphbahoeQ subject
PrePerb', antl the praamlty of me subject property to adverse Influences In me developmeN of my oplNon of rrradret value. 1
have noted in this appraisal report arty adverse contlttlons (such as, but not limttetl m, needed repairs, detertOretlon, me
presence of hazardous wastes, toxic substances, atlverse environmental contlltlons, etc.) observed tlunng the Inspectlon a ma
subject property or that I became aware of during me researoh Invalvetl in performing mis appraisal. I have considered these
adverse centlitlons In my analysis of ma property value, antl have reported on me effect of the condttlats on me value and
rnadcerebNiry of the sublet[ property.
15. I have not knovrinpty wttlmeld arty signfflcaN imormation from mis aDPraisal report antl, m me best of my knowledge, all
statements and irrforrtaNon in mis appraisal report are true and cortecG
16. I stated In mis appraisal repot my own personal, unbiased, and professional analysis, opinions, antl conclusions, which
are subjea only m the assumptlans antl Ihnltlng condMons fn Nos appraisal report
17. I have no presem ar prospective inmrest in me property mat Is me subject of mis report, and I have no presets or
prospective personal imeres[ or bias with respect m the partlcipaNS in me Iransacgon. I dltl not base, etlher partlally or
completely, my analysis antl/or opinon of market value In mis appraisal report on the rece, color, religion, sex, ape, martial
p~ m Ownerspor occlu I staWS, or national odpln of etlher the prospectlve owners ar accupares of me subject Property ar of the
gams of me Properties in me Wcinity a me subject property or on any other basis prohibtted try law.
18. My employmem ariNor compensadon Tor parfortnfng mis appraisal or any future or aNicipatetl appraisals was not
condltlaretl on any agreemem or understanding, wdNen ar omerwlse, mat I would report (a presem analysis suppafln a
pmdetemdned specific value, a pmtleterminetl minimum value, a range or Oirealon In value, a value that favors Nre cause Of
arty Party, or ttm atrelnment of a spectflc result or occurrence of a specffic subsequeN evem (such as approval a a gentling
mortgage loan appltcatlon).
79. I personally preparetl all conGUSions antl opinions about me real estate mat were sat forth In mis appraisal report. N 1
relletl on Signfficam mat property appraisal assistance from arty IndiWtlual or Indivitluals In me performance of mis appaisat
ar me preparation a mis appraisal report, 1 have nartretl such InOiWtluN(s) antl disclasetl me specmc tasks pertormed in mis
appraisal report I certlty mat arty Intlwitlual so named is quallNetl to perform me tasks. I have no[ aumodzetl anyone m make
a change to any ffem to mis appraisal report; merefore, any change made m mis appraisal is unaumorizetl and I will fake no
responslDitlty fw it
20. I Identlfiad me lender/cliem in mis appraisal mport who is me indHitlual, organfza0on, or agem for me organizaNm mat
omeretl and will receive mis appraisal mport.
Fredtlle Mat Fam 70 March 2005 Pape 5 of 6
Farmie Mae Form 7009 March 2005
Fdm 1001-'aMTOTAI' appN581 sonwme by a W moae, ax.-1-800.g1Ak%IpF
~ ! r
21. The lender/clleM may disclose or tlistrlbute this appraisal report to: the borrower, anoher lentler at the request of the
bortower, the mortgagee or Its successors and assigns; mortgage Insurers; gwemmem sponsored emegtdsas; other
secondary market partlcipams; tlata ctlkecfbn or reportlrtg services; Professional appraisal erganbatlons; any department,
agency, or instrumentality of the United States; antl arty state, the Dlshict of Columbia, or other judatlictlons; wNgrrt having to
obtain me appraiser's or supervisory apprsiser's m applicable) consem. Such consem must be obwnetl before mis appraisal
report may be disclosetl or distributed to arty other party (including, but not Nmttetl to, the public tlrrouph adveNSirrp, pubic
relations, news, sales, or oNar media).
22. I am aware that any tlisclosure or dlshibtNon of this appraisal report by me or the lender/cliem may oe sub)ect to certain
laws and regulations. Wrthar, I am also suhjact to the provisions of Ne Uniform Standards of Professional gpprsisal PreCtlce
that pertain to tlisclosure or tlLSMbutlon by me.
23. The bortower, another lender at the request of the borrower, the mortgagee or Its successors antl assigns, mortgage
Insurers, gwemment sponsoretl enterpdses, and other secondary market partlcipants may rely on this appraisal report as part
of any mortgage flnance transactlon that iwolves any one a mare of these partles.
24. tt mis appraisal report was iransmitled as an `electronic ecom' containing my electronic sipnaWre,• as those terms are
tleflnetl in applicable federal and/or state laws (excluding audio antl vltleo recortlings), or a facsimile transmission of this
appraisal report comaining a Copy ar rspresematlon of my slgnaWre, the appraisal report shall De as effective, enforceable antl
va00 as ff a paper version of this appraisal report were deliveetl comainin0 my original hantl writlen signaNre.
criminaly perwlgesMincludin~pl~ but nm rlimtled Wtlflrie or mpidsonmem o~bo~tl7suntleP the proWreslo s td cT eli 81 Unalte0 States
Cotle, Secflen 1001, et seq., or similar state laws.
SUPERVISORY APPRAISER'SCERTlFICATION: The Supervisory Appraiser certdles and a0rees that:
1. I directly supervised the appraiser for this appraisal assignment, have read the appraisal report, antl agree with the appaiser's
analysis, opinions, statements, conclusions, and the apprsiseYS certlficafbn.
2. I accept full responslWlity for the comems of this appraisal report including, bm not Iimttetl to, the appraiser's analysis, opinions,
statemems, conclusions, and me appraiser's certlficatlon.
aPPreisal firma), is Iqual~ffNxf to pertor~rrpi tlifsM report Is effher asub-contractor or an employee of the supervisory appraiser (or the
appraisal, and rs acceptable to pertortn [his appraisal under the applicable state law.
4. This appraisal report complies wiN the Uniorm Standards of Professional Appraisal Practlce that were atlapted antl
promulgatetl 6y the Appaisal S[antlaNs BoaN of The Appraisal Fountlatran antl that were in place at the time this appraisal
report was Prepared.
5. ff tlils appraisal report was transmtttetl as an "electronic record" coma(ninp my "electronic signature,' as mdse terms are
tl~rre0 in applicade fetleral and/or state laws (excluding audio antl video recoNings), a a facsimile transmission of this
a~pprefsal report comainNg a copy or represerrtatlon of my signature, the appraisal report shall be as ettectrve, aMOrceable antl
paper version of this appraisal report were delivered comairdng my ortginal hantl written signature,
SlgnaW
APPRAISER
Name I3reT Leddr,ele~XX~stele~rem Aoe~ --
Company Name Apprei681 Sohabons
Comparry Address to Se Juan Drive Med®rYc~ A 171155
Telephone Number 717-eB7-ta26
Emaa AtltlreSe 6letldheler®comcasLnet
Date of SlpnaWre and RePOrt t 7Y15/2017
Effective Date of Appaisal 10fOtno7t
Stele Certlficaflon # GA003594
or State License #
a Other (tlescrtbe) State#
BhdtB PA
Expiraflan Date of Certificatlon or License o6/3N2013
ADDRESS OF PROPERTY APPRAISED
Medlaraceburo PA 17055
APPRAISED VALUE OF SUBJECT PROPERTY $ 49.OOD
LENDER/CLIENT
Name
Company Name The Estate M Mldratl E Rahn
Compamy AtldreSS r/o Medin R McCabb 219 E Meat St
Metlrerumbuo PA 77055
Email Atltlress
Retltlh Mac Form 70 March 2005
SUPERVISORY APPRAISER (ONLY IF REQUIRED
signature
Name
Company Name
Company gtltlress
Telephone Number _
Email Adtlress
Date of Signature -_
State CetUflcatlon # _
or State License #
State
Expiretlon Date of Certfflcatlon or license
SUBJECT PROPERTY
^ Did not Inspect subject property
^ Ditl inspect extertor of subject property from street
Date of Inspectlon
^ Ditl inspect lmedor antl extertor of subject property
Date of Inspecflon
COMPARABLE SALES
^ Did net inspect eMertor of campareble sales from street
^ Ditl inspem eMertar of comparade sales from street
Date of Inspectlan
Page fi at 6
Torm 7004-'tYInTOTAL' areRisd sollware by a b nwde, bc. - 7-a00.NAM0oE
Fannie Mae Form 7004 March 2185
~. 1
Pomt 100/.(AO)-~nTOiAL' app nasal soM1aare by a h maEe, ha:.-1-90M1A1AN00E
Famtle Mae Foan 1009 Match 2005
1 \ . I
, ~ a
Su elemental Addendum Sle Na.lt-Ham
9DRDY/C feral NA
Adtlrtss 9 E Sbn son St
~ ~~aQp ~ ~~ SYaU PA L Coda 11055
lends TM Estate M Mdtlretl E Ham
SPECIAL LIMITING CONDITIONS
This appraisal is rand ~ t,,,.,,e ;..~....,.a:.... __~ .~_ _
~rN, a,~~~ ~> inn acuny as a Home
inspector when preparing the report. When performing the inspection of this property, the
appraiser visually observed areas that were readily accessible. The appraiser is not
required to disturb or move anything that obstructs access or visibility. The inspection is
not technically exhaustive. The inspection does not offer warranties or guarantees of any
kind.
SUPPLEMENTAL CERTIFICATIONS:
I certify that:
- This appraisal was prepared by Brett Lechthaler for the exclusive use of The
Estate of Mildred E Hann, client, to estimate market value in terms of cash or financing
similar to cash for estate evaluation purposes. The information and opinions contained in
this appraisal set forth the appraiser's best judgement in light of the information available
at the time of the preparation of this report. Any use of this appraisal by any other person
or entity or any reliance or decisions based on this appraisal are the sole responsibility
and at the sole risk of the third party. Mr. Lechthaler accepts no responsibility for
damages suffered by any third party, as a result of reliance on or decisions made or
actions taken based on this report.
- In my opinion the reasonable exposure time linked to the value opinion is up to
150 days.
- In my opinion the reasonable market time linked to the value opinion is up to 180
days.
I further certify that, to the best of my knowledge and belief:
- The statements of fact contained in this report are true and correct.
- The reported analyses, opinion, and contusions are limited only by the reported
assumptions and limiting conditions, and are my personal, impartial, and unbiased
professional analyses, opinions, and conclusions.
- I have no present or prospective interest in the property that is the subject of this
report, and no personal interest with respect to the parties involved.
- I have no bias with respect to the property that is the subject of this report or to
the parties involved with this assignment.
- My engagement in this assignment was not contingent upon developing or
reporting predetermined results.
- My compensation for completing this assignment is not contingent upon the
development or reporting of a predetermined value or direction in value that favors the
cause of the client, the amount of the value opinion, the attainment of a stipulated result,
or the occurrence of a subsequent event directly related to the intended use of this
appraisal
- My analyses, opinions, and conclusions were developed, and this report has been
prepared, in conformity with the Uniform Standards of Professional Appraisal Practice.
- No one provided significant professional assistance to the persons signing this
report.
-Brett Lechthaler personally inspected the property and prepared this report.
Brett Lechthaler,
PA State Certified General Appraiser
ram TADD-'WinTOTAL' apDn6al soMiare by a le mode, inc- t-804ALAMDDE
.'
r
LACatlon Nan
Fina MAP1pC - Y41nTCiAL'apprbsal aMlwaa by ala moAe, ia;.-1-800~AlAMppE
/ '
-r,~
Deed
. w
WOI-Ai-W~enpp D 1, ahoet Fpem, Ap,. pl 1Y04-Amon{ (q PIgIq.RmMlny
BaN BJI. Iw, Lipy Pr
DfADE THE 2 SST day of f~46u ST
of our Lord one thvue¢nd nine huxdred in tha year
and seventy-six (1996)
BETWEEN HDRACE M. HANN and ELIZABETH M. HANN, his wife, of the
Borough of Mechanicsburg, County of Cumberland and State of Penn-
sylvania, parties o£ the first part,
axd
Grantors ,
MILDRED E. HANN, of the Borough of Mechanicsburg, County
of Cumberland and State of Pennsylvania, party of the second part,
WITNESSET$ Lh¢t in eoxaideration o Gramtee
f the sum of
in haald paid, the rece' t whereo "`'''rOne ( $1.00) Dotlara,
W f ie hereby ackxowtedyed, the said pr¢tttor s da hereby grant
and convey tD the eai~ grantee ,her heirs and assigns, all their right,
title and interest whatsoever, in and to
ALL THAT CERTAIN House numbered 9 East Simpson Street, being
the west half of a double house, and lot of ground situate in the
Second Ward of the Borough of Mechanicsburg, County of Cumberland
and State of Pennsylvania, bounded and described as follows, to
wit:
BEGINNING at a post on the street line on the North side of
Simpson Street,- one hundred seven and £ive -tenths (10,5) feet in an
Eastwardly direction from the street line of South Market Street;
thence by other land of Elizabeth A. Went ze 1, in a Northwardly
direction, seventy-seven and nine-tenths (']'], 9) feet to as iron
pipe; thence by land of Mrs. Alva Menear in an Eastwardly direction,
twenty-three and six-tenths (23.6) feet to a stake; thence by other
l.a nds of Elizabeth A.Wentzel and through the party wall dividing
the double house erected on this lot and the adjoining loi; to the
East, in a Southwardly direction, eighty-one ($1) feet to a point;
thence by the street line of Simpson Street in a Westward:Ly direction,
twenty-four and four-tenths (2fy, 4) £eet to a point, the p:_a ce of
BEGINNING.
BEING the same premises which Wayne C. Weber and Mildred E.
Weber, his wife, by their Deed dated May 15, 1964, and recorded in
the Office of the Recorder of Deeds in and for .Cumberland County,
Pennsylvania, in Deed Book "F~~, Volume 21, at Page 59, granted and
conveyed unto Horace M. Hann and Elizabeth M. Hann, his wife, and
Mildred E. Hann, the grantors and grantee herein.
This conveyance is between parents and child, the grantors
herein being the natural parents o£ the grantee herein.
B:1C•K~GU PAGE47J
Poem SCNLGL-wMmrAl •>,mAi.w ~,«.,........ __.. ,.
r , ''
Tax Mae
Fqm MAPPLAT-RYmTOTAL• ap0iaibal software by a la ngEe, mc.- 7-806ALAMOOE
~.1
Building Sketch
13R
.ni
Sft
A
N
Basement ~
[776 Sq R]
d'_
N
SR 33R
~ I ~ I Kitchen
Bath
ut
~ Dining
N
Living
~~~>re
eR
qrz ~ ft ]it
eR
First Floor
[776 Sq R]
SR 13R
~, Bath
~ u
.~ ~
m
Bedroom
A A
m ~
~ ~
Bedroom
C
rn
N
Bedroom
'~?1 Ip M
8ft _I
Second Floor
[776 Sq R]
u..e F.~we...
a,ea tllwYlbee Sinevery
~'iea Ieu
~ ~ .. ... .:.:
'OIaYUen ueY'.
n6 ~ ft
ax3 p
uxn =ua
2A5 x Sa = A3
Smon6 Fbor
P6 sq ft
ex3 29
13 x 1) =221
29.5 x 19 = fll
ieb
I
IINep
(RaeMM):
~
~
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C9e1 wRi
BS Sgft :
~ Wrth Dxs
e5
955gft
9a O x s Bs
mment I)66gft
9xJ _ 2G
]3 : ll _ $21
_ 29.9x 1e=531
F9mi SKT.BItl51d- WinTOTpI' apprainl eottwaR by a V mode, inc.-1~BOO~ALgMOoE
A
Subject Photo Page
SubJect Front
9 E Simpson 3t
Sekt Para NA
Gross LIWnp Area 7,652
ToW Poona 6
Taal GeAppms 3
Tool fiaNrpoms 2
LOCalmn Average
Yin.' Averege
Sge 0.06 erne
Ouaary Averege
Aga 771 Years
Subject Bear
SubJect Street
Farm PIC3~5.SA -^NNTOTAL• appraisal sorware by a la rrwAe, ma -1-80o•ALAMOOE
A.1
a
Suhject Photo Paee
Interior
9 E SMpum 3l
Saks Price NA
Gmse lNhq Area 7,552
TriaINWIB 8
ToW Betlmams 3
TaW Saraaoma 2
lACatlaa AveregB
Vbw AvxaO¢
Sde 0.08 eae
Owldy Avmepe
Ape 711 YBers
Interior
Interior
Form P~3r5.Sfl -'VOnTOTAI` appraisal aMlwam OY a la mode. nc. -1-BO0.ALAMOOE
A.1
i ~ .
Interior
9 E Simpwm Sf
Saks Price NA
Gmes LNbe Area 1,552
Tahl Homm 6
ToEJ Bedoone 3
Tolal Baemoms 2
LOeatlpl Average
Vkw gverege
61h 0.06 acre
Oleflly Average
AAe 117 Years
Basement Mechanlcals
Electric
Form PIC3r5.yt- WinTOTAL' appaisal saMxare by a la morie, inc-1-80PAfAM00E
Subject Photo Paee
F
1
Cemaarehle Phofe Paen
~ ~
Comparable 7
17 S HIAh St
Pmk b SPOkcI 025 males W
Sab PACE 44.000
640.45 LMnA Ama 7,092
ToNI NPam 5
Taal BeAmonw 2
Trial Balhmama 7
Lacaion Averege
rkw Equal
Sla 0.02 acre
Oualiry Equal
pre 777 Yeare
Comparable 2
23 E AAen St
PIaC b SPhpa 0.24 mien N
Sak PACE 53,900
Gf0a8 LNYp pmb 7,030
Tabl9Wllq 5
Taal BParans 3
Trial9aarroms 7.5
Locatlrn Averege
Vbw Equal
Sre 0.04 acre
Oueiy Equal
Ape 177 Years
Comparable 3
722 E Loot St
Prat b Suhba 0.74 miss NE
Sale PACE 58A00
Gmss Lhbg Area 1,308
Taal NOanw 5
Total Sedooma 3
Taal Batluaoms 1.5
Lowtlon Auere9e
Yew Equal
S~ O.OB acre
OueAly Equal
pre 711 Veam
Poml PIC3l6.C9 -'irbTOTAL' apPrdlaal mrware W a h moAe, uw. -1-r00.AlAMODE
e M
Comparahle Photo Paoe
Comparable 4
77 W Green Sl
Proic b SuO~ed 0.28 macs NW
Sales Price 80,000
Grosz ~A area 1,770
Totalflnma 6
Trial reWnOn6 3
Total eakrooms 1
Lawtlan Average
Ymw Equal
SM 0.07 acre
OuaAty EquY
Ppe 152 Years
Comparable 5
24 W Keller 51
Pac b Sugecl 0.10 mlos SW
Saks Price 74,900
GrOSS Livhp Prey 1,302
Tohl Boone fi
Takl &hooms 3
ToUl Batluooms 7.5
lacatlon Average
~' Equ61
SAe 0.06 acre
Ovaply Equal
ape 177 Veers
Comparable 6
Rmc b Suobd
Saks Rice
Gros IJvhp Pao
Told Boana
Takl Be6ome
Takl Batlawmt
Ylaw
Site
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Communications
IdtiralralhudikpggllltllllllrlhllltltulllqPlllllltl
MILDRED E HANN
9 E SIMPSON STREET
MECHANICSBURG PA 1055-3865
~omputershare
Computershare Trust Company, N.A.
PO Box 43078
Providence, RI 02940-3078
Within USA, US territories 8 Canada 877 770 0496
Outside USA, US territories & Canada 781 575 2382
www.computershare.co~nvestor
FRONTIER COMMUNICATIONS CORPORATION is
incorporated under the laws of the State of DE.
Holder Account Number
00004686098
Company lD
SSNITIN Certified
Transaction(s)
FRON
Yes
Date Transaction Description Total CUSIP Class
ShareslUnits Description
Oi Ju12010 Verizon Spin 06 Credit 28.000000 35906A106 Common Stock
ACCOUnt InfOrtnatlOn: Date: 12 Dec 2011 (Excludes Vansactions pending settlement)
Current ~ Current Total
Dividend Direct Sharesl Price Value (E) CUSIP Class
Reinvestment Registration Units Per Share Description
Balance Balance
0.000000 28.000000 28.000000 5.130000 143.64 35906A108 Common Stock
IMPORTANT INFORMATION -RETAIN FOR YOUR RECORDS.
This erNice is your record oflM share kansacfion in yaurexount on era books of the Company es earl of the Direct Regisgelion System. Thk advice's neithera negotiable irstrumentnaececudly entl deli~erydit does ratdikWlwMerarry
dghls to ge redpien[ Il slpdd be kept wish your lmparbm tloammis esa recerd dyour ownership of Uece shares. Na actlan on your partk required.
The IRS requhes Nat we report the mss basis of cedaln shares ecquiretl after January 1, gg11. gyar shares were coveretl by Ma kgislaWnandyou have sold or trensteped Ne shares and requeWetl a specifK wet bask calculatbn method, we
have proressed as requested. ttyw 6d rrot sperJly a cast basis ralmtlation mehod, we have dataulte0 b the first in, firs) out (FIFO) method. Please Wsil ourwebsiN or cerlauh ynv lax atlvkor X you need addtional 4lfornDtion about cast bask.
Upon request, th Comparry will krm'sh ro any sharehdtler, wiMOUI charge, a lull sktemP01 of the tlesigretbns, dghk Ilalutlng dghls urrderam/ Company's R9h6 Agreement, II any), preferences and limitations of the shares of each class antl
series authaizetl b be kuueq acct the eulhorrty of the Board of Directors b divbe the shares into series antl b tletermire antl charge rights, preferences aid limitatbrs of any doss or series.
Assets are not tlapasik of Compu[ershare arM ere not insured by the Fetlaml Deposit Insurence Comoretion, the Sacudties Imesbr Protection Comoretion, or any alherfsderal a stale agerwy
If you tlo not kaap in coMaW with us or tlo not have any aclivay in your account for the gme grinds specilktl by elate law, your property could become aubJect to Web undaimW property lawn and trmsfenetl to tM appropriate state.
40UDR FRON
ooNSAe (Rev. vn7 Please see impodant PRIVACY NOTICE on reverse side of statement
Schariula R.1
OOICSOOOJ.D.F.MIX J95A00081]/004144
veriLn
hlrhrlhrlPuuII1111111hIlaIlltlrP161i1auIrIllPrlllllll
MIIDRED E HANN
9 E SIMPSON STREET
MECHANICSBURG PA 17055-3865
Holder Account Number
00007676816
in~asanmA~m
'~-
Transaction(s)
Date Transaction Description Toil CUSIP Class
ShareslUnits I Description
29 Jun 1998 Stock Split 60.000000 92343V104 Common Stock
ACCOUnt Information: Date: 12 Dec 2011 (Excludes transactions pending settlement)
Certificate Current Current Total
Balance Dividend Direct Price Class
Sharesl Value ($) CUSIP
Held by You Reinvestment Registration Units Per Share Description
Balance Balance
60.00 0.000000 60.000000 120.000000 38.350000 4,602.0(1 92343V104 Common Stock
IMPORTANT INFORMATION -RETAIN FOR YOUR RECORDS.
This atlvioe is your reoxA OitM Share transadion in ynuraaouM On the books Mlha Company as pad of the Direct Regislmtion System. This etlvices reiMare rwgotiable inMmmentnaesecuray, antl tlelivay Mil tloes ndditself mderamJ
fights b the redpient II shoultl M keptwiN your important tlowmems as a record of your onnership olthese shares. No acfion m your part k equiretl.
The IRS requires Nat we report the wst basis of cedaln shares acquiretl aaerJanuary 1, 2011. If your shares were covered by the legislatlon and you have sokf or vanderced Na shares aM requested a specifk cost basis calculatbn method, wa
have processed as requested. It you dd rot specify a wst basis ralnlarJOn method, we have dekulted m the firer in, first out (FIFC) method. Please Nslt our websita or mnsult yxmrtax advhor it ynu reed addfionel information about mst basis.
Upon request th CompaM will famish to any sherehdder, withoutcha-ge, a NII atatemenl of the designalbns, fights pndutlng rghts mtler arty Compalys Rights agreement, If any), preferences aM IimiHlims of Ne shares of each class ark
series autlronzed b Da 6eued, and the authody d the BoaN of OirecNrs to divide Hw shares into series end N determire antl change ryhts. prelarences era limilafions of any class or sores.
Assets are rat tlepasits o(Compulemha2 antl are not ireure0 by the Fetlerel Deposit Irr9umnce Corporation, the Securities Investor Pmtedbn Corporation, a any dher federel or slate agenq
If you tlo not keep in coMad with us or do not have am/ adWdy in your account fa the 6me pedals spedgad by sbte law, your proiwdy multl become sabred to slats imla'anetl property laws end Iranshned to Iha epPropdale aNte.
40UDR V 7_ N
DDHSA6 (Rev. 1/11) Please see important PRNACY NOTICEE or~raveCSe de of statement
C rhorill Ic R
~omputershare
Computershare Trust Company, N.A.
PO Box 43078
Providence, RI 02940-3078
Within USA, US territories 6 Canada 8D0 631 2355
Outside USA, US territories 8 Canada 781 5753994
vvmrw.computershare.coMveri:on
Verizon Cnmmunications Inc. is incorporated under
the laws of the State of DE.
001 CSp01pJl.F.MIX_345q/0008Ja/ep4321
, h ' '~.
November 16, 2011
LAW OFFICES OF MARLIN R MCCALEB
FRANKEBERGER PLACE
219 EAST MAIN STREET
MECHANICSBURG PA 17055
Estate of MILDRED E HANN
Date of Death: Oct Ol, 2011
SSN: 182-22-7674
Dear Sir/Madam:
One Citizens Drive
ROP112
Riverside, RI 02915
In accordance with your request, the attached information sheet has been provided in the above decedent's
name as of his/her date of death.
For Instalhnent Loans or Line of Credit accounts, contact our Loan Department at'1-800-708-6680. For
all other inquiries, please call 1-877-579-2667, option 2.
Sin~cere(lyy,p ~ f ~O/~1 n
Pamela Breton
Decedent Account Processing
REF#:517772
Schedule E.1
~'~
Account Number 6100705676
Account Title MILDRED E HANN
Date O erred 6/6/1966
Account T e Checkin
Principal Balance as ofDOD $18551.81
Interest from Last Postin to DOD $ .00
Account Balance as of DOD $18551.81
YTD Interest to DOD $ .00
~.4
T M
united american iinsurance company 5 0 3 4 9 4 8 0
P.O. Box 8080 • McKinney, Texas 75070-8080
November 15, 2011
573029414 1 21
MILDRED E HANN THIS IS NOT A BILL
9 E Simpson St
Mechanicsburg PA 17055-3865
Policy Number: 573029414
Our check #0057083929 for $14,480.00 is attached and includes benefits for the following:
Services from 05-04-17 to 06-U1-ft
Provider: Locust Grove Retirement Villag
Nursing Home 28 days at $ 80.00 per day $ 2,240.00
Total Benefits for These Services $ 2,240.00
Services from 06-01-11 to 07-01-11
Provider: Locust Grove Retirement Villag
Nursing Home 30 days at $ 80.00 per day $ 2,400.00
Total Benefits for These Services $ 2,400.00
Services from 07-01-11 to 07-23-11
Provider: Locust Grove Retirement Villag
Nursing Home 22 days at $ 80.00 per day $ 1,760.00
Total Benefits for These Services $ 1,760.00
Page 1 of 3 (CONTINUED ON BACIq
DETACH THIS PORTION AT DOTTED LINE BEFORE DEPOSITING CHECK
Schedule E.4
~ i ~
UNITED AMERICAN INSURANCE COMPANY
Insured: Mildred E Hann November 15, 2011
Policy: 573029414
Services from 07-23-11 to OS-01-it
Provider: Locust Grove Retirement Villag
Nursing Home 9 days at $ 80.00 per day
Total Benefits for These Services
Services from 08-01-11 to 09-01-11
Provider: Locust Grove Retirement Villag
Nursing Home 31 days at $ 80.00 per day
Total Benefits for These Services
Services from 09-01-11 to 10-01-11
Provider: Locust Grove Retirement Villag.
Nursing Home 30 days at $ 80.00 per da
Y
Total Benefits for These Services
Services from 10-01-11 to 11-01-11
Provider: Locust Grove Retirement Villag
Nursing Home 31 days at $ 80.00 per day
Total Benefits for These. Services
$ 720.00
$ 720.00
$ 2,480.00
S z,48a.oo
$ 2,400.00
$ 2,400.00
--------------
Total:$12,000.00
$ 2,480.00
$ z,48o.00- refunded
~,
This policy provides Qualified Nursing Home benefits after the policy Elimination Period of
seven days. As this confinement does not exceed the policy Elimination Period, benefits
are not available.
Stay from 04-O1-I1 to 04-OS-II Provider: Locust Grove Retirement Villag
Page 2 of 3
E'~
Jinn-2r^_-2012 0?'~2 r^' F~atec±~.ve 847-9?.0-E"25 ~~~
~ ~ r
['rotectlve Lire Inaurgnpe Company
Croviding Sezvtcea for Unlced lcveatora Life Inaunnu Company
Cuatarnar Service ClfSoc
1707 N Randall Rd Fce 310
F.lgia, IL 60123.9409
Marlin McCaleb
Fax No:717-691-7772
Mildred Hann, Deceased June 22,2012
ContrectNa.UD00725205
Claim No. CL 064806
Dear Mr. McCaleb:
As you requested, we're providing below infnrnration for estate tax purposes.
Date of Death Date of Death Value Cott lsasli
zo/z/2oii gzz,eas.a9 $ia,ooo.oo
lfyou have any queatinns, please call our Claims Cepartment at 1-688-397-6485, We will be glad to
assist you to anyway possible.
Sincerely, /~!s/ /////~
1...-' cy' ~..~,2i~i u...Y
4eta A Chruadel
Claim Examiner
Schedule G.1
LOCUSZ; G#20VE RE7.'IREMEPIT VILLG
69 COTTAGE ROAD
MIFFLIN, PA 17058-9734
717/436-8921
^ ADDflESS CORRECTION
IF ADDRESS SHOWN IS
INCORRECT, PLEASE
MAKE THE
NECESSARY CHANGES
BEFORE MAILING VOUR
PAYMENT.
HANN, MILDRED
9 E SIMPSON ST
MECHANICSBURG, PA 17055
S'T/4TEIVIEIe1T
Please Indicate Amount Paid
Schedule I.5
'u12a (2/03) eAiccs, 0e. rnanm, in saws leaol zn-zaea rxixrso ix us.e. '
Your Prompt Payment
Is Appreciated.
THANK YOU!
FOR YOUR CONVENIENCE, WE ACCEPT MASTERCARD AND VISA PAYMENTS.
YDUR PAYMENT IS DUE UPON RECEIPT. THANS YOU. PLEASE DETACH ANU RETURN TOP PDflTION WRH YOUR CHECK TU ENSURE PflOPER CREDIT TO YOUR ACCOUNT.
~~~~ ~ ~ eccounL # : .4,169,0.0,1,3,77. FAC: F2=
SS#:
Bi11 Tracking #: ~ Hi
Da
e
,,,.,,, stoz-y: ~
t
:
°-°_°~_°°°°°°°__.._______= BILLING ACCOUNT INFORMATION =...a:.==__x~===_, _'
~
C,~IBNT INFO
~ CU'ARANTOR INFO BILLIIVG INFO
name:
HANK, MILDF.ED name: HANK, MILDRED BILLBD
account #: 4109001377 addr: 9 8 STMP90N ST fat: bal: 26,579.44
;init reg dt: 4/28/2011 lns bal: 68
07
1st vis dt: 4/28/2011 MECHANIC9BIIRG FA .
tot. bld: 26
647
51
dchg dt: 10/01/2011 zip: 17055 - ,
.
UNSILLED/Uh'POSTED
birth dt: 6/14/1928 home: 717-7,0,6-5587 rel i
spat bal: .b0
home phone: xork: ____-9I:LF gins bal:
00
work phone: .
unb bal: .00
ACCOUNT BTATIIS AGRBBMSNT INFO CURRPsNT SILL STATUS
sts: AR dsg sts: EX mthly agr amt: stmt: 11/25/2011 7
bus: LTC Ivc: SKL dunn no: 0 msg: p I
~ rbl: RUB fac: 4109 LOCUST GROVB RBTIREMENT V2LLG Crnb acc:
=°________=_°=_=_____ ~/~/ INSURANCB INFORMATION 1/~/ ==x===.=_=====x=======
?/C INSURANCFs NAME PAYOR PLAN POLTCY NL'MSER
268 MfiDIC B PA -~- _
~i00 18 227674A SICCED AMT QNBILLEp~
68.07
SP PRIVATE PAY 1 1 26,579.44
00
MA M?DICA&E A PA- 2
' 24107 182227674A ,
.00
00
k*** ~ d TJ
kk* .
ivame: ,+~,rr~v,, ,~=,LpjiED, , , , , , Account #: 410,9,0,0,1,3,7,7, Line: F11_Ordez
From date: 4,/2, A,/2,0,1,1, To date: 1,2,31,/,2,0,1,1, Date Tyge: 3, Mon*_hiy or Total: ~
xnsu~ance: MEDI CARE A PA- VERITU3 RURAL Financial Class: MA
Payp rx 2 Plan: 24107 Policy: 182227674A Rank: .1,
____ _________=~ =rzammmmvmm a TOTALS BY SERVICE AEITE _:_:___°______=__==,==m.ae==
LINE
~ FROM DATE TO DATE TOTALS DESCRIPTION GROSS AMOUNT
~ ~FJ~S]'17TT1 17T73'TiT'ZOI1 * -"'^~-2r~-
* PAYMENT TOTAL * 1062.22-
'-' *ALLOWANCE TOTAL* 342.7B-
9. *p,EpU,CT,S,~C,0 - PI~Y,S,*,
5 04/28/2011 04j30/2011 *MONTHLY PALANCE* ~ ~~~~
5 05 O1 2011 05 * CHARGE T AL * 1421 .7
~ * PAYMENT TOTAL * 9252.34-
8 *ALLOWANCE TOTAL* 1002.45-
9
10
05/01/2011
OSf31/2011 *P,$DU,C,T,S,&,CA-,PhI's*
~~ *MONTHLY BALANCE
* . ,39b,2,.0,R-,
11 D6 O1 _
* CHARGE TOTAL * 16267.3
12 * PAYMENT TOTAL * 13335.90-
13 *ALLOtRANCE TOTAL* 1313.53
14 *p,Ep,V,QT,:,&,CO,-R~Y,S,*, 4
2
4
5
. D
0
-
15
06/01/2017.
06/30/2011
*MONTHLY SALANCE* .
,
,
,
.
,
,
Mora...
~. 5
._. <
Frem . ,~,f.F•,. ~~,+wicsu, ,
date: 4/2
8/2
0
11 To t~ccounc ~: , ,4,1U,9,0,U,13??, Lirie:
date: 12
/
31
/2
U
1
D
t
T Fil=Order
,
,
, ,
,
,
,
1
,
a
e
ype: S, Monthly or Total:
Insurance: MEDICARE A PA- VERITIIB RURAL Financial .Maas: MA
Payorx 2 Plan: 24107 Policy: 182227674A Rark: 1,
=4__ ______________________
- _ TOTALS 8Y SERVICE DATE m==s=~==°____=___=°_=_______
LIB FR0~17
AT,i
D~
TO TOTALS DESCRIPTION GROS
3
AM
UNT
~
E
1
011 - S
~
~~
17 * PAYMENT TOTAL * 9779.66-
18 "ALLOWANCE TOTAL" 2360.62
19 xp,Ep,IIGT$i~CO,-~~Y,S,*, , 3
1
1
3
.
0
0
-
/31/20
ll
/201
/
*MONTHJ,Y BALANCE" , ,
,
,
,
,
,
,
,
,
21 ]. 0$/31 p
08
01
11 * CHARGE * --
22 * PAYMENT TOTAL
23 "ALLOWANCE TOTAL"
24 *p$D,U,C,T,S,&,GO-P~yYS
*,
~~ ~ ~~~~
25 08/01/2011 08/31/2011 ,
"MONTHLY BALANCE"
26 04 01 2011 09 30 011 HARGE TOTAL * ~'
27 * PAYMENT TOTAL *
Z6 "ALLOWANCE TOTAT,*
0.-P,A,Y
~ , ~ "AEA,O,C,T,S,&,C
S
*
30 09/01/20
11 U9/30j2011 ,
,
,
,
"MONTHLY BAS,ANCE* .. , , ,
More...
=.5
-~-~• ~+yw-+~aW
Horn d.a*e: 4,%x'.8,/2,0,11 •'^o eiccount ~:
date:
1
2
/
3? 410,900,1.,x,?7 Line:
/2
J
11
D
t
T Fll=Order
Tnsurarce: PRIVATE PAY ,
,
,
,
,, ,
,
,
a
e
ype: S, Marathly or Total: M
PaYo"; I Plan: 1
Policy: Financial Clzss: SP
~~-`_! ~ =r~_~_~xt~-==,.:.=z ~ 1~
OTAL3 BY w
SERVICE D.-,TE ~_~~ Rank: 4•
L227S FROM DATS TO 7JATE
~~ ~1 71'~f3bTl•O11 ~,~
TOTALS DES'CP.IPTT02,T _=~~_s__~,~~__-____~_
GROSS ~
2
8 * PAYMENT TOTAL
4 *ALLGWANCE TOTAL*
5 04/28 2011 04/30/X1
1 ~ ~ ' ' ' ' ' *J1$D,T7,C,T,S,F~C,O,-,8~Y,S,*
*MQNTWT.V' nnT.nn~~r+'
' ' ~ ~ ~ •
6 O5 01 2011 OS
7
8
9
10 05/01/2011 O5,
11 06 C 2011 06,
12
13
14
15 05/OI/2011 06i
* PAYMENT TOTAL
*ALLOWANCE TOTAL*
7 ~ ._._____._ __
* PAYMENT TOTA.',:~ *
*ALLCW.ANCE TOTAL*
•
"s G l l __ _ +MONTHLY SALAT~ CF. *
3995.OU
~.5
3995 0p
4245.00
~, 4245.00
More...
. ~r,•, ~-,~-~-~~ ~ccou.Ati A: 4,1,0,9,0,0,13,77, Linec
From Sate:4;lZ$/2611 Co date: 1;2,/31 2GZ1, Date ~ L, F21=Order
insurance: PRIVATE PAy /•~~ "~yPe: ,,, Monthly or Total; ~
Payo~o 1 Plan; Financial Class: Sp
1 ~olicv: Raak.: q,
c°~`=-=L "_;__===__'='=______ TCTALS~HY SERVICE DATE
LINE FRO~Yd~~Til T0~~011 TOTALS D8.4GRYPTION•==~-~_--___-_=__~•___=
GROgg AMOIINT
19 * PAYMENT TOTAL
7.9 *ALT,OWANCE TOTAL*
20 07/01/2017. D7/31/207.1
zl oa D1 all aei3 11
22
23
24
25 08/07./2011 08/31/2012
26 D9 O1 2 11 09 301
27
28
29
30 09`/G1%2DI1 _09/30/2611 ~~
,~ *MONTHI.Y BAI,A,NCE*
c as OTAL *~_
* PAYMENT TOTAL
*ALLOWANCE TOTAL*
.. , *A~P,tTC,T,S,&C,O,-•p,A,Y,$*
* PAYMENT TOTAL
*ALLCWANCE TOTAL*
*MONTHLY a.A7 aur'~*
. ~ , se4~a'.'GO ,
665.
6665,00
6626'.4
. 66s6.44
More...
~- 5
..u~..c. ,~,,.,..f,., taiLUfSc;N, , , ,
Prom date: ,/23/2
0
1
1
~TO KCCOUn[ iF: ,41090p1377 Line:
date
12
/37
/2ni1 D
T P11=Order
Insu ,
,
,
,
rance: MEDICARE 8 PA { .
,
.
ate
ype: a
V73RSTU5) Monthl4~ or Total: M
Pao 12
k ~~. Plan: 24100
Fin
Poli
cy: 182227674A
ancial Class: ~
Rank
----
LINfi
- _ _
--"_---
PROM DATE
'
-
' _
__--
TO-DATE - : ,1,
= TOTALS SY SERVICE DATE a=_~==s~====__,:_____=`-
~__-_
TOTALS DESCRIPT20N'
~
ff77~
37
~
611
'dT/'3Tli'O11 GRO5S At400NT
---
T ~,
* PAYMENT TOTAL * -.,.,_
3
4 *ALLOWANCE TOTAL*
5
07/23/2011
07/'31/2011 !~ D,EpO,C,T,S,&,CO,- P~i,Y,S,*,
*MON":HLY BALANCF*
'''''''
6 08 1 0 1 08 31 201 * C8A AL * -`-
~
8 * pAYMEPdT TOTAL
9 *ALLOWANCE TOTAL*
10
08/Ol/20i1
08/31/2011 *A~P,ffQT,B,&C,O,-,P,AY,S,*,
~~ ~ ~ *
~
" " " " "
11 9 O1 2011 3 2 1 MONTHLY BALANCE*_
* -"
12 CHARGB TOTAL * ~~-
13 * PAYMENT TO'^AL * 637.77-
14 *ALLOSPANCE TOTAL* 277.72_
11
OA/01/2011
09/3D/2011 ?',D$D,U,C,T,S,$C0,-P,11Y5,*, ,
~ ~~ *MONTHLY $ALANCE* 1,76.44,-,
~
68.07
More ..-.
__~__ •~
FYC]rit da~e: ,Cx~%~,~R •-~-~,° `w~.vuit4 k: . '4,1,U,yU,~,:L,3,7,7, L1170: k'].ZcOL'QBY
%2,0,' i, To ~~ate: ;12,/,3,1,/2,017., Aa.Ce :'ype: ,S, Monthly or Total: ~
Insurance: PRIYATR' PAY
Payar: 1 Plan: 1 Hc1iC Financial Class: SP
=4~.=~"`a=-===_=°_= Y ~ Rank : 4.
"°-°=a=-== TUTALS BY 9F.??t~ICE DATE =___='===a======____°{_~_!_
LINE FROM DATB +T{~O-~D+~A.~T$ TOTA~ CRIPTIODT
~''~ ~Tl T~O1Z ~.. GROS~ S~ T
Bottom
Z..5
OMNICARE OF YVILLIgMSPORT
w .yt,~r 6990B SNOWDRIFT ROAD
~~ ~ ALLENTOWN, pq 76106
RETURN SERVICE REQUE£ITED
oo,ess oioi
PHONE: 877.670-6323
You may also view/pay your bills at:
httos://mvomniview.omnicare ~m
MILDRED HgNN
MECHANICSBURG Pq 17055-0230
35254 WVOIOCE NO (~
DX NO:
INVOICE DgTE
FACILITY;
PATIENT NO:
PATIENT NAME
AMOUNT DUE:
Idd~ TAX:
KEEP TOP ppRTION FOR YOUR RECORDS -
RETURN BOTTOM STUB WITH PgyMENT
HANN MILDRED
1046-706
~~
oATE RX NOC [TRANS
09/18/17. R1926626 ~ OESCRIP,L(ON°~,. -
RETURN lPRAiR01~1UJ~-A~gUTEROL 0,5 3MGf3,~ "
09/22/11 R3080549 CRP'eDUONEB ALBUIEROC)'~` '' AML?UL NEB
RETURN LEVOFLOXACIN SOOMG TABLET (gp u.
09/22/11 81933084 RETURN «EVDFI.OXACIN))
09/22/ii.R1933084 METOPROLOL TARTRATE 25MG
09/25/11 R3080535 RETURN METOPROLDL TARTRATE 25M
RETURN AMLODIPINE BESYLgTE 5MG
CAML00(PINE)) •NORVA
ssa0es
1614,56 CHARGE;
-142.28 - -. ,,,~
~~' TOTA
SURE PROPER CREDIT, D D•00
ETACN AND --- 14
!se check It above edd RETURN THIS p -
ress Is Incovect entl Indlrate chap a ORTION.IN THE ENCL
=COUNT NO' 1 e pn reverse sloe.
I lc wvw.•
./DICE NO:
NO: 046-706
PH651401
'OICE DATE; KOPDX
:ILITY: 10/31H 1
'LENT NO: 7066 LOCUST GROVE RETIREMEN
TENT NAME:
AUNT DU T VILLAG
HgNN, MILDRED
E: 1472.28
28
0.00 ~ AMOUNT pp
35254.•T0009VpD000067q 1472 28
1NT ENCLOSED $ IIJI"I~g1111JuIII~~~~J1-,JIIII~~~'gJr~L~,l'1II1111J~Jhlhh
OMNICgRE OF WILLIAMSPORT
PO BOX 740381
101046-706300P CINCINNATI, OH 45274-0391
H6514011000KOPDX90pp1472286
1046 LOCUST GR- p- V~~
RETIREMENT VILLAG
ui-
10/31/11 ~~
" PHYS(C(AN NDC'N0.
CUANT AMOUNT
~ ..- COX 00185-7372-60.. 1YPE
.15 -9.75 RX
COX 00781-5791-50
-4 -68.67 RX
COX 00378-
OX ~ ~ 0098-OS ~ -30
- b037$-,001$-p5 `6.48 RX
00378-5'209 OS .30 -6.48 RX
~, .. s ,;..` . ' =50.90 RX
I
~ FINANCE. CHARGES are oabulated at a MONTHLY pERIODfr
1'50% (ANNUAL RATE OF 18.OOy,) based upon an ud
outstand=30_ d or~re RATEOF
paitlbalance
STgTEMENT OF gCCOUNT
PAGE: 1 of 1
1046-706
PH651401
KOPDX
10/31/11
1046 LOCUST GROVE RETIREMENT
706
HgNN, MILDRED
1472.28
0.00..
DUEDATEa 11/25
/2011
AMOUNT DUE:1472 28
35254•T0009VP00000674
30009YAVZ:L1
I~NMA~BI1~®~II!l~~~B`9N
Schedule I.6