Loading...
HomeMy WebLinkAbout08-13-121505610105 REV-1500 EX (oz-li) (FI) j~ PA Department of Revenue p ytvania OFFICIAL USE ONLY enns Bureau of Individual Taxes oEPaR1ME",~F"ESE"°E County Code Year PO BOX 28o6oi INHERITANCE TAX RETURN ~ r Harrisburg, PA i~i28-o6oi RESIDENT DECEDENT L~ I ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 187-12-4024 05/31 /2012 03/13/1922 Decedent's Last Name Suffix Decedent's First Name Cousart Sara (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW MI N MI C~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of p 5. Federal Estate Tax Return Required death after 12-12-82) Cif 6. Decedent Died Testate (Attach Co of Will O 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes py ) (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 T0: Name Daytime Telephone Number Glenn A. Schaeffer (717) 545-4468 First Line of Address 3873 Laraby Drive Second Line of Address City or Post Office Harrisburg Correspondent's a-mail address: State ZIP Code PA 17110 REGISTER OF$ It~ USE ONI~s ~ .~`1 "L;: ~„ ~ _ ~' (:`:t ~ ~..~ __ .~ c~ -- , ~',.-- . t„a ~ ' ?-~ ~.__ O ._ _.,.... =.~ ` ~ D FILED ~7 r ~~ ,,; .. -?::, _. ..6 .. _Y..., ..~: ,.. ...~_ -_ +""-, ' ^ = ~~0 <.~ CW„~ _~._~ Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and 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 PERSON RESPONSIBLE FOR FILING RETURN DATE ~ ~ 8/12/2012 ADDRESS ~, A r j / • G~~- SIGNATURE OF PREPA ER OTHER T AN REPRESENTATIVE ATE / ~UUKtSS PLEASE USE ORIGINAL FORM ONLY 1505610105 File Nth ber 1,-~ .~ Side 1 1505610105 J hct) J 150561,0205 REV-1500 EX (FI) Decedent's Social Security Number Decedent's Name: COUSart, Sara N. 187-12-4024 RECAPITULATION 1. Real Estate (Schedule A) ......................................... .... 1. 2. Stocks and Bonds (Schedule B) ................................... .... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . .... 3. 4. Mortgages and Notes Receivable (Schedule D) ....................... .... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)... ... , 5. 139,862.70 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ... .... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested.... .... 7. 8. Total Gross Assets (total Lines 1 through 7) ......................... .... 8. 139,862.70 9. Funeral Expenses and Administrative Costs (Schedule H) ............... .... 9. 2,481.89 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ........... .... 10. 8,623.56 11. Total Deductions (total Lines 9 and 10) ............................. .... 11. 11,105.45 12. Net Value of Estate (Line 8 minus Line 11) .......................... .... 12. 128,757.25 13. Charitable and Governmental Bequests/Sec 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. 128,757.25 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_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 45 16. 5,794.08 17. Amount of Line 14 taxable at sibling rate X .12 17, 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ..................................................... ....19. 5,794.8 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1,505610205 150561,0205 REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Cousart, Sara N. EETADDRESS ----- Messiah Lifeways 100 Mt.Allen Drive -- - - - - _ CITY 'STATE ZIP Mechanicsburg, PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments 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. Total Credits (A + B) (2) (3) (4) (5) 5,794.08 304.94 5,489.14 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)J. 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 I?S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in [72 P.S. §9116(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-i5o8 EX+ (ii-lo) ~ pennsylvama SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Cousart, Sara N. 21-12-0632 Include the proceeds of litigation and the date the proceeds were received by the estate. Aft property jointly owned with right of survivorship must be disclosed on Schedule F_ it more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) ~ pennsylvan~a DEPARTMENT OF REVENUE INHERIi'ANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF Cousart, Sara N. FILE NUMBER 21-12-0632 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION A• FUNERAL EXPENSES: 1' 06-0412 Auer Cremation Service- Um, Book, Cards, Coroner Fee, Death Certificates 2 06-07-12 Patriot News Obituary 3 06-07-12 Harrisburg, PA Memoria! Service Rev. Ronald Parks $150 and JeffFisher $50 Music, Deb Benedict $100 and Steve Bollinger $50 Meal, Calvary Methodist Church 4 06-16-12 Burial Montandon,PA Rev. Thomas Marker, Country Cupboard 06-30-12 T&J Memorial Services -D.O.D. on headstone B. 1 ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Glenn A. Schaeffer street address 3873 Laraby Drive city Harrisburg Year(s) Commission Paid: None State Pi°- ZIP 17110 AMOUNT 436.00 337.86 200.00 150.00 391.95 147.58 103.00 Z~ Attorney Fees: 3• Family Exemption; (If decedent's address is not the same as claimant's, attach explanation.) Claimant 4. 5. 6. 7. Street Address City State Relationship of Claimant to Decedent ZIP Probate Fees: Accountant Fees: Tax Return Preparer Fees: Other Administrative Cost: Cumberland Law Journal, - advertisement of estate Paxton Herald, - advertisement of estate Register of Wills, -filling Releases Reserved far closing cost 327.50 75.00 48.00 15.00 250.00 TOTAL (Also enter on Line 9, Recapitulation) ~ $ ~ ~~ l ~`~' ~ ~ If more space is needed, use additional sheets of paper of the same size. REV-1512 EX-~ (1~-08) ~ pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS` OF DECEDENT INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Cousart, Sara N. 21-12-0063 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical eYnencPc If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) ~ pennsylvan~a SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Cousart, Sara N. 21-12-0063 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Nat List Trustee(s) AMOUNT OR SHARE OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1• Ruby A. Schaeffer Daughter 1/3rd of Estate 3873 Laraby Drive, Harrisburg, PA 17110 2. Barbara A. Beckley Daughter 1 /3rd of Estate 3119 Greenridge Drive, Lancaster, PA 17601 3 Frank H. Cousart, Jr. San 1 /3rd of Estate 3Acom Drive, Boiling Springs, PA 17007 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-15flfl COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. , ~ If more space is needed, use additional sheets of paper of the same size. COMMONWEALTH OF PENNSYLVA "" ^ COUNTY OF CUMBERLAND estate of SARA N COUSART SHORT CERTIFICATE I , GL ENDA FA RNER S TRA SBA UGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 6th day of June, Two Thousand and Twelve, Letters TESTAMENTARY in common form were granted by the Register of said County, on the l a t e o f UPPER A L L EN TO INNSH/P (First, Middle, Last) in said county, deceased, to GLENNA SCHAEFFER (First, Middle, Last/ and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office a t CARLISLE, PENNSYLVANIA, this 6th day of June Two Thousand and Twelve . Fi 1 e No . 2012- 00632 PA Fi 1 e No . 21- 12- 0632 Date of Death 5/31/2012 S . S . # 187-12-4024 .,~ ~ I^ ,,, r ., ~ f ~ , ,~ "ste f W-lsf \ ~, '~ ' ~ tj Deputy NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL LAST WILL AND TESTAMENT OF SARA 11~T. COUSART n cn ~,, `.== ,.~, .. ~- --- -. .~ c --- - -. ~ r. :% D ~~ ~'~ ~ ~ I, SARA M. COUSART, of Dauphin County, Pennsylvania, declare this to be my Last Will and Testament. I revoke all other Wills and Codicils that I may have previously made. Article I My just debts and expenses of my last illness, funeral, and administration of my estate shall be paid by my Executor from the principal of my residuary estate as soon as practicable after my death. Article i1 All inheritance, estate, and succession taxes (including interest and penalties thereon, but not including any generation skipping tax) payable by reason of my death shall be paid out of and be charged generally against the principal of my residuary estate without reimbursement from any person. This provision is not a waiver of any right which my Executor has to claim reimbursement for any such taxes which become payable as the result of any property over which I have the power of appointment. Arti~1P TTT I give, devise and bequeath in accordance with any memorandum which I have either handwritten or signed, located with my Will or with my valuable papers and found within 30 days of the probate of my Will. Gifts may only be to persons who survive me or to organizations which exist at my death, and if there is a conflict, the memorandum having the latest date shall govern. Artir.1P TV All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, I give, devise and bequeath IN EQUAL SHARES to my children, RUBY A. SCHAEFFER, of Dauphin County, Pennsylvania; FRANK H. COUSART, JR., of Cumberland County, Pennsylvania; and BARBARA A. BEAKLEY, of Lancaster County, Pennsylvania. If any of my beneficiaries predecease me or fail to survive me by thirty (30) days, I give, devise and bequeath his or her share to his or her issue who survive me, per stirpes, or if he or she have no issue, the share(s) are to be added equally to the other shares. ArtirlP V If a beneficiary under this Will has not attained the age oftwenty-five (25) years, the share of the beneficiary shall be placed in a separate trust, for the benefit of that beneficiary according to the terms in Article VI. -2- Article VI In the event that a Trust is created by or as a result of any part of this Will, the terms and conditions of the Trust shall be as follows: A. To expend and apply so much of the net income and so much of the principal of the Trust as the Trustee shall consider advisable for the support, health, care and education of the child until the child attains the age of twenty-five (25) years. B. Upon attaining the age of twenty-two (22), one-third (1/3) of the principal and accumulated income, of the child's share shall be distributed outright to the child. C. Upon attaining the age oftwenty-five (25), the remaining principal and accumulated income of the child's share shall be distributed outright to the child. D. No beneficiary or remainderman of this Trust shall have any right to alienate, encumber, or hypothecate his or her interest in the principal or income of the Trust in any manner, nor shall any interest be subj ect to claims of his or her creditors or liable to attachment, execution, or other processes of law. Artic-lP VTT In order to carry out the purposes of the Trust established by this Wiil, the Trustee, in addition to all other powers granted by this Will or by law, shall have the following powers over the Trust estate, subject to any limitations specified elsewhere in this Will: (a) to retain in the form received and/or to sell either at public or private sale, any real estate or personal property except that which I specifically bequeath herein, (b) to manage real estate, -3- (c) to invest and reinvest in all forms of property without being confined to legal investments, and without regard to the principal of diversification, (d) to exercise any option or right arising from the ownership of investments, (e) to compromise claims without court approval and without consent of any beneficiary, (f) to file fiduciary/income tax returns and pay the tax due for any year for which such a return is required, (g) to make distributions in cash or in kind, or in both, and to determine the value of any such property, (h) to employ any attorney, investment advisor, or other agent deemed necessary by my Executor; and to pay from my estate reasonable compensation for all their services, (i) to conduct along with or with others, any business in which I am engaged in or have an interest in at the time of my death, and (j) to receive reasonable compensation in accordance with their standard schedule of fees in effect while their services are performed. Article VTTT I hereby appoint my daughter, BARBARA A. BEAKLEY, as Trustee of any Trust(s) created in this Will. In the event of the renunciation, death, resignation, or inability to act, for any reason whatsoever of BARBARA A. BEAKLEY, I nominate and appoint my son-in-law, GLENN A. SCHAEFFER of Dauphin County, Pennsylvania, as Successor Trustee of any Trust(s) created in this Will. -4- ArtirlP TX I nominate, constitute, and appoint my son-in-law, GLElV'~i A. SCHAEFFER, Executor of my Last Will and Testament. In the event of the renunciation, death, or inability to act, for any reason whatsoever of my Executor, I nominate, constitute and appoint my daughter, RUBY A. SCHAEFFER, successor Executrix of my Last Will and Testament. In the event of the renunciation, death, or inability to act, for any reason whatsoever of RUBY A. SCHAEFFER, I nominate, constitute and appoint my daughter, BARBARA A. BEAKLEY, successor Executrix of my Last Will and Testament. I direct that my Executor or successor Executors be permitted to serve without bond and in addition to those powers granted by law, I grant them power to distribute in cash or in kind in like or in unlike shares and to file any qualified disclaimer I could have filed if living. My Executor and successor Executors shall receive reasonable compensation for services rendered to my estate. ArfiirlP X In addition to the powers conferred by law, I authorize my Executor and successor Executors, in his/her absolute discretion: (a) to retain in the form received and to sell either at public or private sale, any real estate or personal property except that which I specifically bequeath herein, (b) to manage real estate, (c) to invest and reinvest in all forms of property without being confined to legal investments, and without regard to the principal of diversification, (d} to exercise any option or right arising from the ownership of investments, -5- (e) to compromise claims without court approval and without consent of any beneficiary, (f) to file any federal income tax return for any year for which I have not filed such return prior to my death, (g) to make distributions in cash or in kind, or in both, and to determine the value of any such property, (h) to employ any attorney, investment advisor, or other agent deemed necessary by my Executor; and to pay from my estate reasonable compensation for all their services, (i) to conduct alone or with others, any business in which I am engaged in, or have an interest in at time of my death, and (j) to receive reasonable compensation in accordance with their standard schedule of fees in effect while their services are performed. IN WITNESS WHEREOF, I, SARA M. COUSART, hereby set my hand to this my Last Will and Testament, on ~--~ ~ ~ - 2002, at Harrisburg, Pennsylvania. SARA M. COUSART In our presence, the above-named SARA M. COUSART signed this and declared this to be her Last Will and Testament, and now at her request, in her presence, and in the presence of each other, we sign as witnesses. Nam e Address ~~ ., ._ -6- I, SARA M. COUSART, Testatrix, who signed the foregoing instrument, having been duly qualified according to law, acknowledge that I signed and executed this instrument as my Will, and that I signed it willingly as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by SARA M. COUSART, the Testatrix, on - ~ ,2002. ~~ N ublic ,~ ~ ~ c SARA M. COUSART .~ N~~'&~IA~. SEAL .lA~~ L BR0~3'~, ~atary P L4~~~~r Eaton Tom., ~u i~t Gou ~j ~~~ Cor~m~ ~t~s rch ~ ~~4 We, the undersigned witnesses who signed the foregoing instrument, being duly qualified according to law, depose and say that we were present and saw the Testatrix sign and execute this instrument as her Will; that she signed and executed it willingly as her free and voluntary act for the purposes therein expressed; that each of us in her sight and hearing signed the Will as witnesses, and that to the best of our knowledge, that she was at that time eighteen (18} years or more of age, of sound mind, and under no constraint or undue influence. Sworn to or affirmed and subscribed to before me by ~Je~~ ~ -~ ~. - ~ l(~ r l~~ and ~`. l witnesses, on ~~ - ~ ~ , 2002. n ~~ .-=-~ ,. Nara bl' n_ .~~ Witness ~,. i -~. ~.. ~ ' _ ~ Wit ess ~~ u is 1~OTARtAI. SEJ~L ~~i~ L @t~V~1, ~ P~b~ ~iwer Saxton fem., D~u~hl€~ C~u L9~ Gosttmi~tut Ex~l~ t~l~ Z€~ ~ -7- REV-i5o8 EX+ (11-10) ~~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: Cousart, Sara N. SCHEDt~ILE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY J FILE NUMBER: 21-12-0632 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of curvivnrchin much he .1:~..~..~..,.1 ,._ ~_~_.,..~_ .. ., ~ ~ ivi c aNa~C is ~ iCCUCU, use aaai~ionai sneers of paper of the same size. Q Msa'Bank 499 Mitchell Road, Millsboro, DE 19966 Adjustment Services Lily Nkrumah-Linglestown Re: Estate of Sara M. Cousart Social Security: 187-12-4024 Date of Death: May 31, 2012 ,..+" Phone 888-502-4349 F ax (302) 934-2955 Jufy 6, 2012 Dear Sir or Madam: Per your inquiry on July 2, 2012, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type of Account Checking Account Account Number 24238503 Ownership (Names of) Ruby A. Schaef~"er(POA) Sara M. Cousart Glenn A. Schaeffer(POA) Opening Date 08/28/1964 Balance on Date ofDeath $9,560.13 Accrued Interest $ . 03 Total _ _ - - - - $9, 560.16 2. Type of Account Savings Account Account Number 15004224500501 Ownership (Names o~ Sara 11~f. Cousart Glenn A. Schae~er(POA) Opening Date 06/02/2011 Balance on Date ofDeath $130, 000.00 Accrued Interest $ 30. S6 otal $130, 030.56 For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds, please call the Colonial Park at 717-255-2233. We were unable to locate any safe deposit box for the above-mentioned decedent. This letter does not include any accounts in which the deceased may have been listed as Power of Attorney, Custodian of Uniform Transfers, Representative Payee, or Trustee under a Written Agreement. S111CeI'ely, Valarie Mercer Adjustment Services ~cHn~wzKm Date: 06/12/2012 This Month Gross payment amount Net payment amount 114.40 114 .4 0 ~~~ ~ ~~ ~~ ~a ~ -~ ~~ ~ ~ ~~ 039379 Senior Maxkets l~lember Service ~epartrr~ent Y0037_11_0631 File & Use (09/26/2011) ~5 Highmark Blue Shield and Highmark Senior Resources are Independent Licensees of the Blue Cross and Blue Shield Association Welcome to M&T Online Banking JUNE 6, 2012 -« ACCOUNT SUMMARY Welcome, SARA M COUSART • Your last login was June 1, 2012 at 10:59 a.m. • Set up Your M&T Mobile Banki~ • Your email address: gschaeffer8@comcast.net Update • Message Cen#er~} • Con#act Us hops://onl inebanking.m andtbank.com/summary/AccountSummary.asp; Accounts Transfers Bill Pay ~`:~ , De osit Accounts Account# p (last 4 digits) Total Balance Available Balance Checking, Savings, and CDs Power Checking 8503 $2,649.56 $2,649.56 Power Money Market 0501 $130,031.45 $130,031.45 Total Deposits $132,681.01 $132,681.01 Related Links: Transfers_& Loan Payments (Parma Bill (Statements & Qocume nts Cleared TRS hacks ~ ATM ~ Debit Card Overdraft Choice ~ Finance Works__ ~ Credit Score 1 ~ Ll o°~~ .~~ J Sign Off Customer Service t~:r~f~ :~~s;c~, -~ 4~ ~~ti~~ _ . } ~: . .. .~ , ,. .. ~, W _._ , _ __ , .. ~, ~tA. _.... .. ' `!~r`~l [~JpW View your checks and statements online... View recent statements &_notices View checks that have cleared your account in_th~ last 30 dais View checks or statements ri ht from thi_S ~_a~e ~~I II I ~~ ©2012 Manufacturers and Traders Trust Company. Users of this web site agree to be bound by the provisions of the M8T Web Banking Terms and Conditions. Vew the Terms and Conditions, Privac~Poii~ or Secun~ty Information. of 1 l1~G/l1~1t~ 4•!-c wn~r Welcome to M&T Online Banking https:Uonlinebanking.mandtbank.com/history/HistoryChecking.aspx?Id= JUNE 6, 2012 Sign Off ~} ,~ . ~_- w Accounts Transfers Bill Pay Customer Service ACCOUNT SUMMARY > CHECKING DETAIL Power Checking _ Related Links: Transfers & I_ oar Payments ~ coming Transactions 0.00) Statements c~ Documents (E~ort Data ~ Order Ne~nr Checks ~ ATM-_&-_[Jebit Card Oy_erdraft Choice ~ Financet!V`orks~' ~ Applv_for a Loan ~sn Account Power Checking 8503 ~ Total Balance $2,649.56 Available Balance $2,649.56 how Last 10 Transactions vi Vi~v~_Cal~r~dar --_ _._ .- -- \/ievr C~l~nciar' ------------- _ or - ew From To GO Date Transaction Description Credits/Debits Total Balance 06/05/2012 CHECK NUMBER 6984 -3;~~.~~;~~.~, $2 649.56 06/01/2012 SERVICE CHG WAIVE_RELATIONSHIP , PRICING $24.00 $11,214.56 06/01/2012 MONTHLY SERVICE CHARGE -~;~~~~. ~~~~ $11 190 56 06/01/2012 INTEREST PAYMENT $0.04 , . $11 214 56 06/01/2012 CAPITALBLUECROSS INS. PREM -`~`~~ ~°~ ~ ~ , . $11 214.52 06/01/2012 US TREASURY 303 XXSOC SEC $1,812.00 , $11 372 13 05/31/2012 CHEGK NUMBER 6J82 -385.%8 , . $9 560 13 05/30/2012 CHECK ~tUMBER 698 ~~`' "n - ~. t ~ ~ =~ , . $9 646 89 05/25/2012 WEB XEER FROM SAV 150042245QQ50??_ $6,601.03 , . $9 761.29 05/03/2012 SERVICE CHG WAIVE- RBLATiONSH(P ~ , PRICING $24.00 $3,160.26 Depending on when your statement generates, you may not see a full 90 days of history. ff your statement has just been generated, you may get a message indicating that no transactions are available from 61 - 90 days. ©2012 Manufacturers and Traders Trust Company. Users of this web site agree to be bound by the provisions of the M8T Wreb Banking Terrns and Conditions. View the Terrn~ and Conditions, P~iv~cy Policy or ~e~urit4~ ,Information. of 1 n~m~i» Q.n~ n ~,r /come to M&T Online Banking JUNE 6, 2012 hops://onlinebanking.mandtbank_com/h istory/HistorySavings.aspx?Id=2 Accounts Transfers Bill Pay ACCOUNT SUMMARY > SAVINGS DETAIL Power Money Market ~q4~-: Related Links: Transfers & Loan Payments (U~caming Transaotions~~0.00~ Statements & Documents ~ E"x~~rt Data ~ Crder Ne~~a Cf~eci~s (Finar~c~_~~or_ks~.,' A ! for a Loan Si_.9~ Off Customer Service an ~~sy ~~y t0 save. Account Power Mone Market 0501 Total Balance $130,031.45 Y Available Balance $130,031.45 `/'I~tN Cslendar v18:"y_~i~i~(it'~8~ ~.E4"lttl ~~tCtE Show 1 act 1 n Transactions _ ,,. _ view From To GO Post Date Transaction Description Credits/Debits Total Balance 06/01/2012 INTEREST PAYMENT $31.45 $130,031.45 05/25/2012 WEB XFER TO CHK 00000024238503 - ~~,6Gi .~3 $130,000.00 05/02/2012 INTEREST PAYMENT $34.55 $136,601.03 04/23/2012 WEB XFER TO CHK 00000024238503 -~.C~GC~.~O $136,566.48 04/18/2012 DEPGSIT $3,396.37 $144,566.48 Depending on when your statement generates, you may not see a ful l 90 days of history. If your statement has just been generated, you may get a message indicating that no transactions are available from 61 - 90 days. ©2012 Manufacturers and Traders Trust Company. Users of this web site agree to be bound by the provisions of the M&T Web Banking Terms and Conditions. Vew the ~srrts ~nd_ Conditions, Pr,vac~ pelicV or Se~ur4Tv I~{.?rmat;~t,. „~ ~ 06/06/ 12 8:05 AM REV-1511 EX+ (10-Q9) ~ pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULER (~` C+ FUNERAL EXPENSES AND I yf ~~~3 ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Cousart, Sara N. 21-12-0632 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' 06-04-12 Auer Cremation Service- Um, Book, Cards, Coroner Fee, Death Certificates 436.00 2 06-07-12 Patriot News Obituary 337.86 3 06-07-12 Harrisburg, PA Memorial Service Rev. Ronald Parks $150 and JeffFisher $50 200.00 Music, Deb Benedict $100 and Steve Bollinger $50 150.00 Meal, Calvary Methodist Church 391.95 4 06-16-12 Burial Montandon,PA Rev. Thomas Marker, Country Cupboard 147.58 06-30-12 T&J Memorial Services -D.O.D. on headstone 103.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Glenn A. Schaeffer Street Address 3873 Laraby Drive City Harrisburg State PA ZIP 17110 _ Years} Commission Paid: None 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address 4. 5. 6. 7. City State _ Relationship of Claimant to Decedent Probate Fees: Accountant Fees: Tax Return Preparer Fees: Other Administrative Cost: Cumberland Law Journal, - advertisement of estate Paxton Herald, - advertisement of estate Register of Wills, -filling Releases Reserved for closing cost 327.50 75.00 48.00 15.00 250.00 TOTAL (Also enter on Line 9, Recapitulation) I $ ~ r ~,~' ~ , ~`~ ZIP If more space is needed, use additional sheets of paper of the same size. RECEIPT FOR PAYMENT ------------------- GLENDA FARNER STRASBAUGH Receipt Date: 6/06/2012 Cumberland County - Register Of Wills Receipt Time: 13:44:27 One Courthouse Square Receipt No.: 1070155 Carlisle, PA 17613 ~~~~ COUSART SARA N Estate File No.: 2012-00632 Paid By Remarks: GLENN A SCHAEFFER HEA ------------------------ Receipt Distribution Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 260.00 CUMBERLAND COUNTY GENERAL FUN WILL 15.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 24.00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5.00 ------------- CUMBERLAND COUNTY GENERAL FUN Check# 6767 --- $327.50 Total Received......... $327.50 ~2~~~ 6 f6tlZ T & J MONUMENT SERVI ~E S LETTERING, FOUNDATIONS, RESTORATION, CLSANING TERRY L. WILLOW 1480 MOUNTAIN ROAD NiIFFLINB[TRG, PA 17844 (570) 966 - 0721 June 28, 2012 INACCOUNTWITH: Estate of Sarah Cousart gbGlenn Schaeffer 3873 Laraby Drive Harrisburg, Pa. 17110 Date of death completed on the grave marker of Sarah Cousart in the Montandon Cemetery - (-May 31, 2012) - $103. .~p~i~ ~ ~(3 ~ / 12 CK 1~33l.3 PLEASE MAKE CHECKS PAYABLE TOT & J MONUMENT SERVICES Merest wiU be charged at the rate of 1-112% per month after 30 days ESTATE OF SARA N COUSART GLENN A SCHAEFFER, EXEC 3573 LARABY DR. HARRISBURG, PA 17110 sa-2~ 3,3 X25 1013 l"~~ 'r ~ o-~rder off' `~`T. ~1 ~, bt~.`~~~i~eC' ~i ~- V 1 ~ ~S I $ ~ ~ ~ • Q ~~~ J ~, /~1M8tT Bank ~, _ _ ____ _j x:03 L 30 2955: 98568? 246 LII' 10 13 V "` ""„ ` ~ ~a.Cva~zt~. 2CnetEd ~E~~ioc~~~t ~~iu~e~Z I 4700 Locust Lane u Harrisburg, PA 17109 Telephone 717-545-0021 ~`.o~.. Fax# 717-545-0392 E-Mail calvary®ca/varyumcl.org To: Ruby Schaeffer 3 873 Laraby Drive Harrisburg, PA 17110 RE: Funeral luncheon -Sally Cousart Meal Charges $ 391.95 TOTAL $ 391.95 ~~- t~~~~ e a rl o ~ e pus Now you know Ad Order Number Customer 0002213499 BEAKLEY Sales Req. Customer Account aleeds 236099 Order Taker Customer Address aleeds 812 market St Order Source Harrisburg PA 17101 USA Phone Customer Phone 717-875-2864 PO Number Ordered By Barbara Customer Fax Customer EMail Order Confirmation Pavor Customer BEAKLEY Pavor Account 236099 Pavor Address 812 market St Harrisburg PA 17101 USA Pavor Phone 717-875-2864 Special Pricing None Tear Sheets Proofs Affidavits Blind Box 0 0 0 Invoice Text Materials Net Amount $337.86 Promo Tyge Tax Amount Total Amount $0.00 $337.86 Payment Method Payment Amount Amount Due dit Card - MasterCard:9l $337.86 $0.00 Ad Number Ad Type Ad Size Color 0002213499-01 Obits Paid : 1.0 X 82 Li <NONE> Production Method Production Notes Ad Booker External Ad Number Ad Attributes Ad Released pick Up No 6/2/2012 1:51:25PM 1 Sera {Sally} Covs~rt Sara llfurr.:~= Cc~usart (Sall), 9p, of I;o~~•cr P~r~tton '1'tit~~n~hip, rrisidin~~tt I~lcss iah L i.fc~~ ~i~ s i n l~fr~ch{inicsburg, ~~n#c°rfi~cl ht~i• hca~=cnl~F ho~nG on Thur~itx~,•, ~ta~= 31, ?O1?, follov~'itig a long ill~,ess. S~ll!~= t4 as born i~tarcl~ 1.3, 1~?~ in lbfontanclon, ~lorthun~bcrland Col~nt~=, try she late 1~`illilrn r~lbert (~lurra~ and >:.l~lt~ lleinlbach lt~turrac. Sally= nlarriQd frank ilicl~Inan Cvusart on ~~at; 28, 1319 and rnv~=ed to Iiarrisbul~ in 1956. 1 ter grey#est accolnplishmentsm=eve those of mother, glalullnvther, and honlemaker. She la~ecl cooking €~or her tamilS=, adOr i71I1~ her gard8ll ~=1[11 beautiful tlvti~Ters and tt~ as an active Illenlber of ~Cairary GnlteCt IvletllC)(tlSt C'ltur~cll lIl if.oc~;er Pa~tan Tovr~nship. Sur~ii~=i~Ig are leer chre~2 children: Rub~r ~_ Scllaetfer. ~cii~ of Glenn of Harrisburg; Barbara Gousart Beakle~~, c~ife of Eci~~tard ai' I.~allcastel•: arld Fray H. Gt,usc~I•t Jr. t111Sbdild Ol~ I.c`tlirii ROS~O Guusal`t of Boiling Springs; ~,randctlildren: Kilnverl}= Scliar~ff'er ~~cri uFEtters, ~~if~ of Kenneth: ~'t~a~ne ~~~. SchaeFl'er of Harriibt~t•~; Captain Sara ~ _ Newell. Lc~il"e ref Capt~iitt Raman c7f Git; Harbor, ~V_l; F. Ross Cr~ttsar`t of Pittst~ur•t;h; .irtcl F~rrsi~t~ .'~tnanda L.1~4r~rri~, t~, ife cff Ftrtii~;n F31a1:~ of 1}r~rt:~rnautl3, ~~:'1.; tine ~rer~t-~rartd4tr3t, R~tattht~u :~. Su~c=~c1r of Fttc°r5; hr~r log=ink tii~ter, t~ticc~ F. Snyder ref 1~1r~ntandc~n.1~A =end tit~~=tin nit~c~~s sjnd n C~tl1 G~~ ~,. Sl~t~ u=as .~rr~°~cec~dt.=d in cl~i~rirh b~= hc.r husband, parents, b~•vtt~cr, V4'ill'aam r~. ll~furrttr~ 11, and a sister, Jane R~turr~aE= ~na~c~~ , r~ ancmorial scr;~icG ~~ill bt' held vr~'1"hltrsda~, ,lone ~, ?Ol'?, I~:OQ noon, at fah=~I'y' lIaitcd 1vSethvdist Cillurch, ~f ~ Lid Lacltst Lr1ne, llal•risbul~, l{`arlallt= ~~ jll greet friends fi~oln 11:04 anl- 1~.~1 noon, prior tv the seY~ ice. In lieu of flo~~-ers, nlelnvri~tl d+~nacivns can be mn~i,n {,~, f'.~ r~r.7ti.~+ T Tai i{n.r1 6/2/20121:51:25PM [1Q219RG lV l.rAl6lll Y U4lllGtl 14iethc~dist ;hut cll ae the above address. The fainil~ Mould like to e:~tend much ~rati.tude to her ti•ieluls and taan ilti v~Tho kept close co~ttact o~~er the last see era! gears anti Messiah Liie~~ays and Hospice of Central P.r1 Cor heartfelt care and suri~ort_ Product Information PlacementlClassification Run Schedule Invoice Text Sort Text PNCO::Full Run 893 -Obituaries-Paid Sara (Sally) Cousart Sara Murray Cousart (S~ SARASALLYCOUSARTSARAMURRAYCOUS # Inserts Cost 1 $337.86 Run Dates 6/3/2012 __ - Online::Full Run 893 -Obituaries-Paid 6!3/2012 Sara (Sally) Cousart Sara Murray Cousart (S~ SARASALLYCOUSARTSARAMURRAYCOUS, # Inserts Cost 1 $0.00 6/2/2012 1:51:25PM 4 '`~ AUER CREMATION SERVICES OF PENNSYLVANIA, INC. ~~A .~~G' 4100 Jonestown Road • Harrisburg, PA 1710) • 1-800-720-8221 • Fay 717-541-)943 • Shawn E. Carper, Supervisor En'NSI'LVA1~11~' C~ ~~ "T~~~~ ~ ~... `7 • ~"v ~ ~ ~ ` ~ ~~~'' ,~- c,~~-~- ~~~ ~~ ~~- Mrs. Ruby A. Schaeffer 3873 Laraby Drive Harrisburg, PA 17110 Tun 1, 2012 Sara N. Cousart - Deceased SPECIAL CHARGES X Direct Cremation Nationwide Guarantee Program A1orldwide Travel Protection TOTAL SPECIAL CHARGES PROFESSIONAL SERVICES X Services of Funeral Director & Staff Other Preparation of the Body Facilities ~ Staff for Memorial Service Staff & Equipment for Memorial Service Witnessing the Cremation Private Family Viewing/0~itnessing Cremation Packaging And Forwarding Cremated Remains Personal Delivery of Cremated Remains Scattering of Cremated Remains ;Medical DocumentsjCourier Fee TOTAL PROFESSIONAL SERVICES AUTOMOTIVE EQUIPMENT X Removal Vehicle Lead Car/Clergy Car Family Car Service Vehicle TOTAL AUTOMOTIVE EQUIPMENT $1,595.00 Included 120617 SP-S $1,595.00 $0.00 Included $0.00 ~~~~ i4f ERCHAND I S E Register Boole Memorial Cards Thank ~Tou Cards Remembrance Package Cremation Container X Cherry Finish Tall Scattering Urn Urn Burial Vault Veterans Flag Case Grave/Memorial Marker X Deluxe Remembrance Package TOTAL MERCHANDISE CASH ADVANCED ITEMS Grave Opening Cemetery Equipment Newspapers Netivspaper Vault Service Charge Clergy Church/Organist/Soloist Flowers X Crematory Charge Cumberland County Coroner Fee k 6 Certified Copies of Death Certificate TOTAL CASH ADVANCED I TE14iS SUMMARY OF CHARGES Special Charges $1,595.00 Professional Services $0.00 Automotive Equipment $0.00 Merchandise $375.00 Cash Advanced items $61.40 $375.00 $61.00 SUB TOTAL $2,031,00 CREDITS _$900,00 AMOUNT PREPAID Date Jun 19, 1995 -$695.00 ~ ~ ~~ ~~ TOTAL $ 4 3 6 . 0 0 ~ C ~ l~ ., ~ ~~ ~ AMOUNT PAID Date Jun 5, 2012 -$436.00 ~ ~ BALANCE DUE $0.00 $225.00 $150.00 included $25.00 $36.00 THIS STATEMENT t1RAY NOT REFLECT ALL NEWSPAPER CHARGES Check Images https://online.mymetrobank.com/af(wei2EarkbjavWOlt0yr4)/Account _ ~~ Check ~~~ ~''~ Account: 50 PLUS CHECKING (*5932) ~ Check Number: 6759 ~ Date Posted: 6!5/2012 ~ Amount: $436.00 Zoom In Q Zoom Out Q Print flLENN A. SCH/IE~FER ~ RUBY A. SCHAEFFER 5759 SdT3 LARABY [~. d0~1d113t3 HIIRRI8EtJACi. PA iT110 ` of PH. Tt7~646i~ - - o`wtt PAY To THE ~ ~ aRbER OF ___,_J $ ~~~ ~ D ~ • / ~"~-~--~3~ttARS L! METRE BAtVK «„, ~~~ 17 i i:Q3130 i~846~: 5 i3 LQ593 2ND 6?59 ~.~,,. >031301846< Metro Bank Hub #01 g 0133995595 ~~ ~~ No. (COMPANY NAME (ADDRESS) Received from Dollars LAST BALANCE $ Payment For NEW BALANCE $ Date B Y ~~Ll~z.~ G~a-~ ~ ~~UER ~ ~ l ~ l~.E.~~A~'IOI~ ~-~~.~I~E~ ~F ~~ ~~SYL~Al'~ ~A I~V~. 4100 Jonestown Road, Harrisburg, PA 17109 1-800-720-8221 Fax 1-717-541-9943 Shawn E. Carper--supervisor Charges are only for items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items you ha~•e not selected, we will explain the reasons in ~~Titing belo~e. If you ha~•e selected ser~•ices that may require embalming, you may ha~•e to pay for embalming. You do not ha~•e to pay for embalming that you did not appro~•e. Embalming is not required for direct cremation or immediate burial. Embalming is not required by law, except in certain special cases. If you are charged for embalming, we will explain why below. STATEMENT OF GOODS AND SERVICES SELECTED ~ ~ '' `` Deceased • _ ~' ` ~ Date of Death ` .:~ ., _ ~ . - ate of Arra m ' D n e is - .. Charge to. ._ , .. :. . - - -- - , Name Address City State Zi Code t P Phone Number A. SPECIAL SERVICES: D. AUTOMOTIVE EQUIPMENT: Direct Cremation............ Removal Venicle ............... Nationwide Guarantee Program..... """""""""" • • - • • • • • - • • Lead Car and/or/Clergy Car.. . Worldwide Travel Protection ................ ""•"""""" TOTAL SPECIAL CHARGES ..................... Family Car (Sedan ar Limo)..................... Service Vehicle ................................... TOTAL OF AUTOMOTIVE EQUIPMENT........ B. PROFESSIONAL SERVICES: Services of Funeral Director and Staff......... ` , Dressing and/or Cosmetizing .................. Facilities and Staff for Memorial Service...... Crematory Charge ....................... ...... `. _~_ -. -, :. Staff and Equipment for Memorial Service.. Private ID Viewing ...................... Wifiessing the Cremation ..................... Packaging and Forwarding Cremated Remains by Registered Mail .................. Personal Delivery of Cremated Remains.... . Scattering of Remains over Land or Sea...... TOTAL OF PROFESSIONAL SERVICES....... ~ ` ~ - ' -~ E. CASH ADVANCE ITEMS: Grave Opening ...................................... Cemetery Equipment ................... Newspaper , . Newspaper ,.. Newspaper .._ Clergy .......................... .. .. ChurchlSexton/Organ i st/Soloist ................ . Flowers ...................... ........... . County Coroner Fee ........:.............:......... .. Certified Copies of the Death Certificate....:.. - TOTAL OF CASH ADVANCES ....................... C. MERCHANDISE: SUMMARY OF CHARGES: Register Book .................................. Memorial Folders/Prayer Cards ............... Thank You Cards ............................... Rememberance Package ..... .... : ............... . ~ - (Description) ~~ - ' . _ .. .. _ Urn Burial Vault Container .............. A. Special Charges ................................ B. Professional Services .......................... C. Merchandise ........................ ::~ D. Automotive Equipment .......................... ._ E. Cash Advanced Items .................. ~~~ - . (Description) + ::. _ ; .... SUBTOTAL ... ................................................ Veteran Flag Case .......................... ... CREDITS ..................................................... `; ~ ~ ; Grave Marker/Mont.anent ........................ - ~, :.: TOTAL DUE ................................................ ...... PAID ......................................................... - __ _ .. .: _ _ ~.. _ _ ....... BALANCE DUE ........................................... TOTAL MERCHANDISE - ""' ~~ .. .~ ; Because our packages are sold at a reduced fee, no refund will be given for changes. If any legal, cemetery or crematory requirement has required the purchase of any of the items listed above, we wilt explain the requirement below. ,~ ~ • ., ,. .. _, 1 agree that 1 have examined the items of goods and services selected above and found them to be correct and according to the arrangements I have requested. 1 acknowledge receipt of a copy of this Statement of Goods and Services Selected. I represent that I have sufficient funds available for a p yment of the cash price for the goods and services selected. I also agree to make payment of $ • - - within ~' days. I agree to be }ointly and severalty liable with anyone else who signs below. A late charge of -- F' ."per month amounting to ' per year will be applied to the unpaid balance beginning ~ days from the date of this agreement. I will also pay to the Funeral Director all reasonable costs paid by the Funeral Director to collect amounts I o~ve under this agreement. Those costs may include attorneys' fees, court costs and other costs. Any additional services or merchandise ordered or requested after the date of this agreement will be considered part of this agreement and the cost thereof will be reflected on the final bill or statement. - c s (Seal) -~ ~ - i •• ~ _ (Purchaser) (Seal) (Date) (Licensed Funeral Director) (Date) ~~ T H E P A x T N H R A L D _ :.: Fax rti r~.w~ w.aw •.o,u ~.~ o~.., ~~,,.9, w~ n„z - sass (717) 657-3523 East Share Office 8~ Plant - (PO Box 6310) 101 Lincoln Street (717) 545-s54o Harrisburg, PA 17112 (717) 545-8762 PROOF OF PUBLICATION STATE OF PENNSYLVANIA COUNTY OF DAUPHIN Before me, the subscriber, a Notary Public in and for the said County, personally came Lisa M. Carnes who, being duly sworn, doth depose and say that she is CLERK of THE PAXTON HERALD, a newspaper of general circulation published in ~Iarrisburg, Pennsylvania; That THE PAXTON HERALD was established on the 28th day of June, 1960, and has been published continuously since that date; That the advertisement, of which a copy is attached hereto, was published in the advertising columns of THE PAXTON HERALD in all respects as ordered in the issue(s) of ~ -~-~-, f / ( j=J p titer;,, Aunt further deposes that she is not interested in the subject matter of the aforesaid notice or advertisement, and that the allegations in the foregoing statement as to the time, place and character of publication are true. f ~~ ~Z~ --- (Si ture of the Affiant) Sworn and subscribed before me this day of lic ESTATE NOTICE NOTICE IS HEREBY GIVEN that Letters Testet~er~taryr--4rr- the Estate of Sara N. Cousart late of Upper Allen Township, Cumberland County, Pennsyl- vania {died May 31, 2012) have been granted to the un- dersigned. All persons indebt- ed to said Estate are request- ed to make immediate pay- ment and those having claims or demands to present same for settlement without delay to: Executor: Glenn A. Schaeffer' 3873 Laraby Drive Harrisburg, PA 17110 7-4, 7-11, 7-18 TARtAL SEAL DAVID M. •LDSTEIN, Notary PubdiC Cth- ~i Harrisrtu0, Daupl>~n County MY Conurds~i~n E>~ins ~Y 2i, 2014 ~ ...- FaX The Paxton Herald • 4910 Earf Drive, Harrisburg, PA 17112.545-9540 (717) 657-3523 East Shore Office & Plant - 101 Lincoln Street, PO Box 6310 (717) 545-9540 Harrisburg, PA 17112 (717) 545-8762 ACCOUNT STATEMENT/INVOICE 07/18/2012 GLENN SCHAEFFER Account No: 7996 Phone No: 3873 LARABY DR Tear Sheet: N HARRISBURG PA 17110 Attention: GLENN RETURN TOP PORTION OF STATEMENT WITH PAYMENT Account No 7996 Ad Pg & Ad Disc Disc Cont Penalty Bill Serv Net Adjustment Bal Date Description Size Sec Cost ~ Amt wk 1.25 Char e m g Cost or Paym~rt Due 2012/06/27 CR# 1010 COUSART Balance Forward: 2012/07/04 SN: S. COUSART 1.00 P07S1 00 .00 .00 48.00 -48.00 2012/07/11 EN: . S. COUSART 1.00 P05S1 00 .00 .00 -48.00 2012/07/18 EN: . S. COUSART 1.00 P07S1 48.00 .00 .00 .00 -48.00 48.00 .00 WE ACCEPT VISA - MASTERCARD - AMEX PAYMENTS -CALL THE OFFICE TODAY. RETURNED CHECK FEE $20 PAY THIS AMOUNT .00 PLEASE PUT YOUR ACCOUNT NUMBER ON YOUR CHECK WHEN PAYING YOUR BILL OR REFERRING TO YOUR ACCOUNT PLEASE USE YOUR ACCOUNT NUMBER LATE CHG: 1.25% added to Bal. Due after 30 days BILLING SERVICE CHARGE: $3.50 added to Bal. Due for each additional billing for unpaid balance PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, V1Z: July 6, July 13, and July 20, 2012 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. Cousart, Sara N., deed. Late of Upper Allen Township. Executor: Glenn A. Schaeffer, 3873 Laraby Drive, Harrisburg, PA 17110. Attorney: None. ~- .. A L' a Marie Coyne, Edit SWORN TO AND SUBSCRIBED before me this 20 of July, 2012 Notary NOTARIAL SEAL DEBORAH A COLLINS Notary Public CARLISLE BOROUGH, CUMBERLAtJO COUNTY My Commission Expires Apr 28, 2414 REV-1512 EX-~ {12-08} ~ Pennsylvania SCHEDULE I ~ ~-~- DEPARTMENT OF REVENUE J. ~' ~ ~ DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT C~tA1C Vt FILE NUMBER Cousart, Sara N. 21-12-0063 Report debts incurred by the decedent prior to death that remained unnairt at tt,o .~~+e .,o ae~•~, :.._~..~:__ ..______~___ ., ,,,~~~ aNp~c ~a ~~CCUCU, insert aaataonai sneers of the same size. . ~ - "LE `T P~~ARiVIACY SERVICES IIVC. 219 North Baltimore Ave Mt Holly Springs, PA 17065 800-266-9954 (717)486-8606 w~vw alertpharmacy.com STATEMENT OF ACCOUNT A FINANCE CHARGE OF 1.50 °s PER MONTH (AN ANNUAL PERCENTAGE RATE OF 18.0x) OR A MINIMUM SERVICE CHARGE OF $ 1.00 WILL BE CHARGED ON ALL AMOUNTS 30 DAYS OR MORE PAST DUE Date 07/31/2012 PMT DUE 08/28/12 -~~ COUSART, SARAN \'i COUSS2 30 DAYS. 13.13 ±1 GLENN SCHAEFFER GRP-7W 3 8 7 3 LAR.ABY DRIVE '; PAGE 1 l HARRISBURG " PA l 7110 ~ Amount Paid PLEASE DETACH AND RETURN TOP PORTION WfTH YOUR PAYMENT ALERT PHARi~1ACY SERV. INC.219 NORTH BALTIMORE AVE. MT HOLLY SPGS, PA 17065 ** THIS AMOUNT PAST DUE ** ~'c~ ~~ T 8 ~~. ~~ l~, _ ___ ~, - -- -- ~evious Balance Cha ~ - - - -- rges this month Fi;nanace Char a --ii- ------ TOTAL CHAfZfaES Totat Payment & Credits 13.13 + .00 ~ 1.00 - 14.13 .00 FOR ALL PHARMACY RELATED INQUIRES PLEASE CALL Alert Pharmacy Services, Inc at 1-800-266-9954 Statement Terminology on reverse IF YOU RECEIVE ANEW INSURANCE CARD FOR YOUR PRESCRIPTIONS BE SURE TO SUPPLY US WITH A COPY . 0 0 TOTAL TAX AMOt~NT DUE r 14.13 05 /3/12 ?951238 30 PANTOPRAZOLE *20M O1 7.00- ,~„ ,_~~_ _ ~OS/23/12 7923772 60 CARVEDILOL 12.5 M Ol 7.00- .00 7.00- ; 05/23/12 7951238 7 P~,NTOPRAZOLE *20M Ol 6.59 ~---~~~ . 00 6. 59c _ '05/23/12 7923772 13 CARVEDILOL 12.5 M O1 6.54 ~ .00 6.54c ; ;05/30/12 7956856 23 ISOSORBIDE *MN* 3 O1 7.00- .00 7.00- "06/25/12 Payment-Thank You 60.23- .00 60.23- `~ ~~..~ ~u , , \ G~ __ ____~___~ _ . o o LEGEND ~ TOTAL TAX FOR MONTH ---~_ ___ _ _ _ _ - AtV10UNT ®UE evious Balance Charges this month Finance Charge T®TAL d±Ii~IARGE$ Tetat Payment 8 Credits ®..~,_ 81.23 + 13.13 + .00 - 94.36 81.23 - 13.13 FOR ALL PHARMACY RELATED INQUIRES PLEASE CALLAIert Pharmacy Services, Inc at 1-800-266-9954 - Statement Terminology on reverse ~~~ C~ RV. INC.219 NORTH BALTIMORE AVE. MT HOLLY SPGS, PA 17065 ~~* ACTIVITY FOR COUSART, SARA N G5/02/12 7941797 480 GUAIFENESIN 100 M 05/07/12 7941797 480 GUAIFENESIN 100 M ;05/07/12 7941797 480 GUAIFENESIN 100 M ;05/11/12 7951238 12 PANTOPRAZOLE *20M 05/18/12 7953096 11 SENNA PLUS TABLET ~OS/22/12 7954257 28.40 TRIPLE ANTIBIOTIC 05/23/12 7951238 30 PANTOPRAZOLE *20M !05/23/12 7927065 15 SPIRONOLACTONE 25 '05/23/12 7929570 150 FUROSEMIDE 40MG ,05/23/12 7923772 60 CARVEDILOL 12.5 M 05/23/12 7908892 15 ISOSORBIDE *MN* 3 05/23/12 7953096 60 SENNA PLUS TABLET 05/29/12 Payment-Thank You :05/30/12 4126897 30 LORAZEPAM 0.5 MG 05/30/12 7897132 15 ARTIFICIAL TEARS 05/30/12 7956856 23 ISOSORBIDE *MN* 3 .~ .. i.; ' -COUSS2 - -091003 01 * 6.84 _ . u0 n""; g4- O1 * 4.56- .00 4.56- 01 * 6.84 .00 6.84 01 7.00 .00 7.OOc O1 * 2.45 .00 2.45 Ol * 3.06 .00 3.06 OZ 7.00 .00 7.OOc O1 7.00 .00 7.OOc O1 7.00 .00 7.OOc O1 7.00 .00 7.OOc O1 7.00 .00 7.OOc O1 * 3.36 .00 3.36 86.76- .00 86.76- 01 9.52 .00 9.52 Ol * 4.72 .00 4.72 O1 7.00 .00 7.OOc ~ ~ ~~~ j !.t 9~ ._` ~'~~re ~..y `t..t,'^gtra ..~ws ~d ~n:R ~.f, ~ L r ., ~~~.-_ f __~ 58.52 22.71 LEGEND NON-LEGEND _ __ ___ __ __FO_R_ MONTH FOR _MONTH _ revious Balance Charges this month i:inance Char a TOTAL Cll•1ARGES Iota! Payment 8 Credits 86.76 T 85.79 ~ .00 172.55 91.32 FOR ALL PHARMACY RELATED INQUIRES PLEASE CALLAIert Pharmacy Services, Inc at 1-800-266-9954 Statement Terminology on reverse AMOUNT DUE 81.23 ALERT PHARMACY SERV . INC . A FINANCE CHARGE OF I.50 o PER MONTH 219 NORTH BALTIMORE AVE , jAN ANNUAL PERCENTAGE RATE OF 18.0 ) OR A MT HOLLY SPGS, PA 17065 MINIMUM SERVICE CHARGE OF $ I.00 WILL BE CHARGED ON ALL AMOUNTS 30 DAYS OR MORE PAST DUE IF YOU RECEIVE A NEW INSURANCE CARD FCR YOUR PRESCRIPTIONS BE SURE TO SUPPLY US WITH A COPY. 05/31/2012 r~~iT DUE..06/28/12 COUSART, SARA N COUSS2 RUBY SCHAEFFER GRP-7W 3873 LARABY DRIVE PAGE 1 HARRISBURG PA 17110 ALERT PHARMACY SERV. INC.219 NORTH BALTIMORE AVE. MT HOLLY SPGS, PA 17065 800-266-9954 *~ FCTIVITY FOR COUSART, SARA N -COUSS2 - -091003 05/02/12 7941797 480 GUAIFENESINI 100 M Ol * 6.84 .00 6.84 G'S/07!'12 7941797 480 GUAIFENESIN 100 M O1 * 4.56- .00 4.56- OS/07/I2 7941797 480 GUAIFENESIN i00 M O1 * 6.84 .00 6.84 05/11/12 7951238 12 PANTOPRAZOLE *20M Ol 7.00 .00 7.OOc u5/18/12 7953096 11 SENNA PLUS TABLET O1 * 2.45 .00 2.45 05%22/12 7954257 28.40 TRIPLE ANTIBIOTIC O1 * 3.06 .00 3.06 x5/23/12 7951238 30 PANTOPRAZOLE *ZOM' ~ O1 7.00 .00 7.O,Oc 05/23/12 7927065 15 SPIRONOLACTONE 25 O1 7.00 _00 7.OOc G5%23/12 7929570 150 FUROSEMIDE 40MG Ol 7.00 .00 7.OOc t75/~3/12 7923772 60 CARVEDILOL I2.5 M_ Ol 7.00 .00 7.OOc 05/23/12 7908892 15 `ISOSORBIDE *MN* 3 Ol 7.00 .00 7.OOc 05/23/12 7953096 60 SENNA PLUS TABLET 01 * 3.36 .00 3.36 :)5/29/12 Payment-Thank You 86.76- .00 86.76- 65/30/12 4126897 30 LORAZEPAM 0.5 MG O1 9.52 .00 9.52 05/30/12 7897132 15 ARTIFICIAL TEARS O1 * 4.72 .00 4.72 05/30/12 7956856 23 ISOSORBIDE *MN* 3 Ol 7.00 .00 7.OOc 58.52 LEGEND FOR MONTH 86.76 85.79 e r, ~~ ~- .00 172.55 ,~ 6~ ' ~/ ~ ~~V~~ '~ 5~ ~ ~ ~~ u 22.71 NON-LEGEND FOR MONTH .00 91.32 81.23 ~._ ~~ } ~~. ~.~ ~ ~~~~ ~' ~~. ~e,~g ,~= _ `~`~.-_f I'v~ESSlAH ~~ ~~n~SSiA` ~ ~~~~A~~ 100 MT. ALLEN DRIVE, MECHANICSl3URG, PA 17055 RUBY SCHAEFFER 3873 LARA,BY DRIVE h[ARRISBURG, PA 17110 Form PB-01 n; , RESIDENT # UNIT STMT. DATE 91003 093 D 05/31/2012 RESIDENT S Mrs. SARA N. COUSART TOTAL AMOUNT DUE $8 550.20 DATE DUE 06/30/2012 DQiTE - ~ DESCRIPTION Days/ RATE Units CHARGES- - CREDITS BAL,4yCE Balance Forward 8,565.00 05/31/2012 PAYMENT RECEIVED -THANK YOU! ! ! xXx Nursing Care xxx 8,565.00 0.00 05/30/2012 RM/ BRD - NI;TRSING -SEMI-PVT OS/01-05/3 282.00 30.00 8,460.00 8 460 00 OS/30/ZOi2 PREVAIL BRIEF 1.40 52.00 72.80 , . 8 532 80 05/31/2012 HEALTH SHADES (PER CONTAINER) 0.30 58 00 17 40 , . . . 8,550.20 ~~~~~~~ C ~~ ~O a,~ RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 91003 8,550.20 ~ 0.00 0.00 0.00 0.00 $8,550.20 RESIDENT NAME Mrs. SARA N. COUSART Form Pa-o1 Please make check payable to Messiah Lifeways at Messiah Village. wA A 1% fnance charge may be assessed on accounts for which payment has not been received b y the due date. Thank you! If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You! REV-1513 EX+ (O1-1Q) ~ Pennsylvania SCHEDULE ~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES ESTATE OF: FILE NUMBER: Cousart, Sara N. 21-12-0063 NUMBER NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUM' OR SNARE OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1• Ruby A. Schaeffer Daughter 113rd of Estate 3873 Laraby Drive, Harrisburg, PA 17110 2. Barbara A. Beckley Daughter 1/3rd of Estate 3119 Greenridge Drive, Lancaster, PA 17601 3 Frank H. Cousart, Jr. Son 1/3rd of Estate 3Acom Drive, Boiling Springs, PA 17007 !~ 1. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. , $ If more space is needed, use additional sheets of paper of the same size. Welcome to M&T Online Banking AUGUST 13, 2012 :x : ~ M ;. ~: Accounts Transfers Bill Pay ACCOUNT SUMMARY > CHECKING DETAIL https://onlinebanking.mandtbank.com/history/HistoryChecking.aspx?Id= I Alerts Customer Service SK1n Off MyChoice Checking y ;~~ _: Related Links: Transfers & loan Pa menu :`~'~ ~~~ - -- --- _ _ _ - Y - - 4, -;: Statements & Documents ~ Export Cata ~ Order New Checks ~ ATM & Debit Card ~ ~ ~; -- _ ___ ~£ , Overdrafit_Choice ~ Finance~liorks _ ~ Apply for a_Loan `-, ~s~.' ,~ ~' _ _ ~ ~~~ ~, r,., •_LVg E'f,~, Account MyChoice Checking 2461 snow Select Range - or - Total Balance $120,417.35 Available Balance $120,417.35 ,., ?~; e find t~rJk ~~~~ td Date Transaction Description 07/11/2012 DEPOSIT 07/10/2012 CHECK NUMBER_1013 07/09/2012 CHECK NUMBER_1012 06/28/2012 CHEC_K_NUMBER_1010 06/27/2012 CHECK NUMBER 1009 06/25/2012 CHECK NIJMBE__R__ 100.1 06/25/2012 DEPOSI ------------- 06/22/2012 CHE~K_Nl!_MBER 1006 06/21/2012 DEPOSIT 06/20/2012 CHECK NUMSER ~i008 06/20/2012 CHECK_NUME3ER_1_~03 06/19/2012 CHECK_IVUMBER 10G4 06/19/2012 CH_EGK NUM_BE_R_1~07 06/19/2012 CHEC_K_ N_UMBE_R 1002 06/18/2012 CHECK NU_MB_ER 1005 06/13/2012 CHECK_NUMBE_R 00.96 06/11/2012 CHECK 06/07/2012 DEPOSIT VIEW Caiondar View CalErtciar - -- _ - ___ View From 06/07/2012 To 08/13/2012 GO Credits/Debits Total Balance $100.00 $120,417.35 -$103.00 $120,317.35 -$75.00 $120,420.35 -$48.00 $120,495.35 -$60.23 $120,543.35 -$50.00 $120,603.58 $157.61 $120,653.58 -$8,550.20 $120,495.97 $20,952.05 $129,046.17 -$40.00 $108,094.12 -$50.00 $108,134.12 -$100.00 $108,184.12 -$107.58 $108,284.12 -$150.00 $108,391.70 -$391.95 $108,541.70 -$337.86 $108,933.65 -$763.50 $109,271.51 $110,035.01 $110,035.01 Depending on when your statement generates, you may not see a full 90 days of history. If your statement has just been generated, you may get a message indicating that no transactions are available from 61 - 90 days. ©2012 Manufacturers and Traders Trust Company. Users of this web site agree to be bound by the provisions of the M&T Web Banking Terms and Conditions. View the Terms and Conditions, Pri_v_acy_Policy or S__ecuri~ Information. 1 of l 08/13/12 7:18 AM