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HomeMy WebLinkAbout08-30-12 4 150561U140 REV-1500 Ex (°'-'°' ~ PA Department of Revenue OFFIt'IAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po sox zaofiot INHERITANCE TAX RETURN Hanisbum, PA 17128.0601 RESIDENT DECEDENT 2 1 1 2 0 3 3 1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYI'V 7 1 4 1 8 2 2 1 1 0 3 0 2 2 0 1 2 0 2 0 7 1 '9 1 7 Decedent's Last Name Suffix Decedent's First Narne MI S A L I S B U R Y C H R I S T Y G (If Applicable) Entsr Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name: MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS Q 1. Original Retum ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-32) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required death after 12.12-82) © 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe DeposR Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty CredU (date of tleath ~ 11. Electionto tax untler Sec. 9113(A) between 12-31-91 and 1-1-95) {Attach Sch. O) CORRESPONDENT - THIS SECTION MUST 8E COMPLETED. ALL CORRESPONDENCE AND CONFIDENTUIL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number R O G E R B I R W I N E S& U I R E 7 1 7 2 4 9 2 3 5 3 First line of address I R W I N 8 Second tine of address 6 0 W E S T City Or Post Office C A R L I S L E CorreapondeM's e-mail address: Untler penaldes of perjury, l dedere that I h it is true, wmect arM complete. Declaration SIGNATURE OF PERSOMRESPONSBLI M c K N I G H T P C• P O M F R E T S T R E E T State ZIP Code P A ve examined this realm, d pneparer other than the FOR FILING RETURN ADDRESS 1 7 0 1 3 _~ D tV w schedules antl statements, antl to me hest of my knowledge and is based on all Informalian of which preparer has any knowledge. REGISTER OF WXJ,S USE ONLY r ~~ ~h ~~ S u.1 C~C) -t) rfl C ~ s.. F ~ G") c ~ ~ ~ _ _ w r ~~ cry' ~ c7c~.- -n - L L, 7 ~? _; T Side 1 L 1505610140 1505610140 ~ \ / 15^561^24^ REV-1500 EX Oeoedent's Social Security Number Decedent's Name: CHRI$TY G• SALISBURY 7 1 4 1 8 2 2 1 1 RECAPITULATION t. .............................. Real Estate (Schedule A) ........ .... . t ~ • 2. Stocks and Bonds (Schedule B) ................................. .... . 2. ' 3. Closely Hek1 Corporation, Partnership or Sole-Proprietorship (Schedule C) .... . 3. 4. Mortgages and Notes Receivahla (Schedule D) .................... ..... . 4. 4 4 5 2 3 , 6 ^ 5. Cash, Bank Deposits and Miscellaneow Personal Property (Schedule E). ..... . 5. 6. Jointty Owned Property (Schedule F) ^ Separate Billing Requested . ..... . 6. • 7. Inter-Vivos Transfers 8 Miscellaneous N -Probate Property (Schedule G) ~ Separate Billing Requested . ..... . 7. 8. Total Gross Assets (total Lines t through 7) ..................... ..... . B. 4 4 5 2 3. 6 0 9. Funeral Expanses and Administrative Costs (Schedule H) ............ .... .. 9. 1 2 6 3 2 . 5 1 10. Dehts of Decedent, Mortgage LiabilRies, and Liens (Schedule I) ....... .... .. 10. 1 1 ^ 3 . 4 5 t t. Total Deduetions (total Lines 9 and t 0) ......................... .... .. 11. 1 3 7 3 5. 9 6 12. Net Yalue of Estate (Line 8 minus Line 11) ...................... .... .. 12. 3 ^ 7 8 7 . 6 4 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) ................ .... .. 13. 14. Net Valw SubJect to Tax (Line 12 minus Line 13) ................ .... .. 14. 3 ^ 7 8 7 • 6 4 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATER 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 ^ ^ ^ 15 ^ . ^ ^ . (a)(1.2) X.0 ~ . 16 . Amount of Line 14 taxable 3^ 7 8 7. 6 4 ts 1 3 8 5. 4 4 at lineal refs X .045 . 17 . Amount of Line 14 taxable ^ ^ ^ 17 ^ . ^ ^ . at sibling refs X .12 . 18 . Amount of Line 14 taxable ^ ^ ^ t s ^ ' ^ ^ at collateral rata X .15 . 19. TAX DUE ...................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 15^561^24^ Slde 2 1 3 8 5. 4 4 15^561^24^ REV-1500 EX Rage 3 Flle Number Decedent's Complete Address: 21 12 0331 DECEDENTS NAME CHRISTY G. SALISBURY _ ---- -- -- STREETADDRESS 197 GOODYEAR ROAD CITY STATE ~ ZIP CARLISLE PA 17013 Tax Payments and Credits: 1. Tax Due (Page Z, Line 19) 2. Credits/Payments A. Prior Payments 1,349.09 B. Discount 69.27 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. (1) 1.385.44 Total Credits (A +13) (2) 1.418.36 (3) (4) 32.92 5. If Line 1 +Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5j 0.00 Make check payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS i. Did decedent make a transfer and: Yes No a, retain the use or income of the property transfened : ................................................................ ..... ^ 0 b. retain the right to designate who shall use the property transferred or its income; ^ XQ c. retain a reversionary interest; or ........................................................................................... ..... ^ ^X d. receive the promise for life of either payments, benefits or care? .................................................. ..... ^ Q 2. K death occurred affer December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .................................................................................. ..... ~ 0 3. Did decedent own an'in trust fob' orpayable-upon-death bank account or security at his or her death? .... ..... ^ XQ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ............................................................................................. ..... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)j. • 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-1509 EXH(N-10) Pennsylvania ' DEPARTMENT OF REVENUE , INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FATE OF: IRISTY G. SALISBURY Include the proceeds of I'rtigadon and the date the proceeds were received by All property jointly owned with ripM of survNorship must a diacbsed on ITEM UMBER DESCRIPTION 1. ACNB BANK -CHECKING ACCOUNT #159387 2. (ACNB BANK -CHECKING ACCOUNT #2498146 3. ACNB BANK -CERTIFICATE OF DEPOSIT #165180 4. PUBLIC SALE -SETTLEMENT SHEET ATTACHED 5. COINS -SETTLEMENT SHEET ATTACHED 6. GUNS -SOLD TOTAL (Also enter on Line 5, Recapitulation) I S space is needed, insert additional sheets of paper of the same s¢e LUE AT DATE OF DEATH 32,941.36 6,645.88 3,984.00 314.50 605.00 REV-7511 ERt (10-09) ' Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE: CHRISTY G. SALISBURY 21 12 0331 Decedent's debts must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A, FUNERAL EXPENSES: 1. EBY GRANITE WORKS -INSCRIPTION 119.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Represenytive(s) DENNIS L. SALISBURY 2,100.00 SVeet Address 197 GOODYEAR ROAD aty CARLISLE sate PA ZtP 17015 Year(s) Commission Paitl: p, AtromeyFees: IRWIN & MCKNIGHT, P.C. 3,000.00 3. Famiry Exemption: (If decedents address is not the same as claimant's, adach explanation.) 3, 500.00 Claimant DENNIS L. SALISBURY Street Address 197 GOODYEAR ROAD Ciry CARLISLE State PA ZIP 17'013 Relationship of Caimant to Decedent SON 4. Probate Fees: REGISTER OF WILLS 137.50 5 Acceuntant Fees: 6. TaxRetumPreparerFees: PATRICIAA. ROSENDALE, CPA 375.00 7. REGISTER OF WILLS -FILING FEE 30.00 8. CUMBERLAND LAW JOURNAL -ESTATE NOTICE 75.00 9. THE SENTINEL -ESTATE NOTICE 189.54 10. NOTARY FEES 25.00 11. REGISTER OF WILLS -SNORT CERTIFICATES 8.00 12. ROWE'S AUCTION SERVICE -COMMISSION -PERSONAL PROPERTY 1,459.40 13. ROWE'S AUCTION SERVICE -COMMISSION -COINS 110.07 14. JOAN LESCALLEET -HOUSE CLEAN-UP 1,504.00 TOTAL (Also enter on Line 9, Recapitulation) S 12 632.51 If more space is needed, use add'Aional sheets of paper of the same size. REV-1512 EKE (12-08) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TA%RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8 LIENS CHRISTY G. SALISBURY _ _ 21 12 0331 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. DEBORAH W. PIPER, TAX COLLECTOR -PERSONAL TAXES 4.90 2. GREEN RIDGE VILLAGE -NURSING 662.11 3. CUMBERLAND-GOODWILL FIRE RESCUE -AMBULANCE 101.53 4. MILLENNIUM PHCY SYSTEMS -MEDICAL 283.04 5. MEMBERS 1ST FEDERAL CREDIT UNION -CREDIT CARD 51,87 TOTAL (Also enter on Line 10, Recapitulation) I S more space is needed, insert additional sheets of the same size. REV-1513 EX+(gi-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE) CHRISTY G. SALISBURY 21 12 0331 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY t)o Not List Tvuatee(s) OF ESTATE I TAXABLE DISTRIBUTIONS (Include outs' ht spousal distributions and transfers under Sec. 9116 (a)(1.2).] 2. 3. 4. 5. 6. MARY DELANCEY RR3 BOX 926 MIFFLINTOWN, PA 17059-9776 BETTY MENTZER 101 CONODOGUINET MOBILE ESTATES NEWVILLE, PA 17241 GARY L. SALISBURY 433 CROSSROADS SCHOOLHOUSE ROAD CARLISLE PA 17015 KENNETH C. SALISBURY 118 SPRINGFIELD ROAD NEWVILLE, PA 17241 DENNIS L. SALISBURY 197 GODYEAR ROAD CARLISLE PA 17015 THELMA FINK 298 STONEHOUSE ROAD CARLISLE, PA 17015 Lineal Lineal Lineal Lineal ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REEV-1500 NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 5,131.28 116TH REMAINDER 5,131.28 1/6TH REMAINDER 5,131.27 1/6TH REMAINDER 5,131.27 1/6TH REMAINDER 5,131.27 1/6TH REMAINDER 5,131.27 1/6TH REMAINDER TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S needed, use addlnonai same LAST WII.L AND TESTAMENT OF C1 CHRISTY G. SALISBURY I, CHRISTY G. SALISBURY, widower of West Penmboro Township (maiE~ r address: 197 Goodyear Road, Carlisle, PA 17015), Cumberland County, Prmsylvan being of sound and disposing mind, memory and understanding, do hereby :make, pu (nn and declare this as and for my Last Will and Testament hereby revoking and makingQ any and all Willa by me at any time heretofore made. ~ ~ 1. I direct my hereinafter-named Executor w pay all of my ,just debts~and funeral expenses as som after my death as may be found convenienrto do so. I direct that my funeral services be conducted by Egger Funeral Home, Newville, Pennsylvania, in aceordmce with arrangements which I have made there, andt bring to the attention of my Execuwr that funds for my funeral services are on deposit is a Newville Bank. 2. I direct that all inheri[mce, transfer, successooa, estate and death nixes, including interest and penalfies thereon, which may be payable on accomt of my death shall be payable from the residue of my estate regardless of whether the assets upon which such taxes are based are included in my probate estate. 3. All of the rest, residue and remainder of my estate, real, personal and mixed, and wheresoever the same may be siwate, I give, devise and bequeath in equal shares w such of my six (6) children, their heirs and assigns as shall survive me by a period of ninety (90) days, but should any of them fail w so survive me then the share such deceased child of my would have received shall pass to such of his err her issue as shall survive me by a period of ninety (90) days, their heirs and assigns, per stirpes, and if there be no such issue the same shall lapse and be added w the remaining shares, per s[irpes. My six (6) children ere the following: (a) Mrs. MARY DEL~CEY, Box 926, RD 3, Mifflintown, PA ;17059-9776 (b) Mrs. BETTY MBNT2ER, 101 Conodoguinet Mobile Estates, Newville, PA 17241. (c) GARY L. SALISBURY, 433 Crossroads Schoolhouse Roatl, Carlisle, PA 17015. (d) KENNETH C. SALISBURY, 118 Springfield Road, Newville, PA 177x41. (e) DENNIS L. SALISBURY, 197 Goodyear Road, Carlisle, PFD 17015. (f) Mrs. THELMA FINK, 298 Stonehouse Road, Cadisle, PA 17015. 4. Should any person less than 21 years of age, be entitled to a distribution from my estate, in such event I nominate, constiwte and appoint the parents of such child as Guardim of the Estate of each such person, and authorize and direct them to receive and to invest the same, and to pay the income arising therefrom together with so much of the principal thereof as in their opinion is necessary or desirable to be expended for the proper mainronance, support and education of such person, to or for the benef:[ cf such person, and upon such parson attaining 21 years of age to pay to him or her the then remaining principal mgether with any undistributed income. !f the parents of such person less than 21 years of age are unable or unwilling or cease serving as Guerdi an of the Estate, then in such event I nominate, constiwte end appoint my hereinafter named Executor and his successors as alternate or successor Guardim of the Estate: of such person less than 21 years of age. 5. 1 hereby nominate, constitute and appoint my son, DENNIS L. SALISBURY, as Executor of this my Last Will and Testament, hut. should he predecease me or fail w qualify or cease serving as such, then in such event I nominate, constitute and appoint my daughter, MARY DELACEY, as alternate or successor E:zecutor, and 1 further direct that neither of them shell be required to post any bond to secure the faithful r...> rJ i N O S L~ -'l1 r~-~ C.< r.'~ ; ~-r, S' ~ ~~. -r•. ,?i ~~ O -ra Page / oJ3 ~9 ~. ~ ~• performance of his or her duties in the Commonwealth of Pennsylvania or in any other jurisdiction. 6. In addition to the powers conferred by law, my hereinhefore named Executor sari Guardian of the Estate of a person less than 21 years of age, and their successors, are hereby empowered: a. To invest any part of the oust corpus in such securtes, investments, or other property as may be deemed advisable and proper, irrespecfive of whether the same are authorized for the investment of trust foods under thr, laws of any governing jurisdiction. b. With respect to any corporation, the stocks, bonds, or other securities of which may be held, to vote in person or by proxy on any shares of stock; to consent to the merger, consolidation or reorganizadan of such corporations; to consent to the leasing, mortgaging or sale of the property of any such rnrpomtions; m make any suvender, exchange or subsflmtion of each stocks, bonds or other securities as an incident to the merger, consolidation or reorganization of such corporations; to pay all assessments, subscriptions and other sums of money which may be deemed wise and expedient for the protection and maintenance of the proportionate interest of the investment in such wrporations; to exercise any option or privilege which may be confered upon the holders of such stocks, bonds, or other securtes of such. corporations either for the conversion of the same into other securities or for the purchase of additional securities, and to make any and all necessary payments which may bt: required in connection therewith; and generally to Gave and exercise as to all such stocks, bonds and other securities, the powers of an individual owner who is not under oust obiigation. c. To hold the oust corpus in one or more consolidated funds in which separate shares shall have undivided interests. d. To sell at public or private sale for cash or upon credit, or pertly for cash and partly on credit, and upon such terms sari conditions as shall be deemed proper, any part or parts of the estate, and no purchaser at any such sale shall be bound m inquire inm the expediency or propriety of any such sale or to see to the appkication of the purchase moneys arising therefrom. e. To keep on hand and uninvested such money as may be deemed proper and for such period as may be found expedient. f. To compromise, settle or arbitrate any claim or domand in favor of or against the trust estate. g. And authorized in the discharge of fiduciary duties, to employ counsel and to determine and to pay such counsel reasonable compensation which shell be charged against the principal or income of the trust fund, and shall further be entitled to charge against the principal or income such other reasonable expenses and charges as may be necessary and proper to incur for the proper discharge of fiduciary duties and for the proper rrumagement and administration of the trust estate. h. In making any division of property into shares for the purpose of mry distribution thereof directed by the provisions of the tt'ust, to make sw:h division or distribution, either in cash or in kind, or pertly in css6 sari partly in kind, as shall be deemed most expedient, and in making any division or distribution in kind may allot any specific security or property or any undivided interest therein to any one or more of such shares, and to that end may appraise any or all of the property so to be allotted and the judgment as to the propriety of such allotment and as to the relative value for purposes of distribution of [he securities or property so allotted shall be final and conclusive upon all persons interested in the trust ar in the division or disvibution thereof. i. And authorized to register any shares of stock or other assets of any trust in their own names or in the name of a nominee. To retain and invest in shares of stock of my Trustee. Paae2of3 /~ QF ~~M1^ .L k. To retain any investments including mutual funds which 1 may own at the time of my death and in addition to invest any part of the Trvst corpus in such mutual fund or mumal funds es may be deemed advisable or proper, irrespecfive of whether the same are authorized for the investment of trust funds under the laws of any governing jurisdiction. 1. To determine from time to time whether all or some portion of realised capital gains shat) be treated as ordinary income for distribution tee a beneficiary or treated es principal to be retained as part of the corpus, and sucb designation need not lx consistent from one year to another. IN WITNESS WHEREOF, I have hereunm set rtry head and eat to this my Last Will and Testament written on tluee (3) pages, this /5 day of ~Wa~J , 2067. (SEAL) CHRISTY SALISBURY Signed, sealed, published, and declared by CHRISTY G. SAI.ISBUR~ the Testator above named, as and for his Last Will and Testament, in our presence, w o, in his presence, at his request, and in the presence of each other, have hereunto subscribed our names as attesting wimesaes. -~~~, ~9 oi~~ Page3 of3 ACNB BANK March 29.2012 Irwin & McKnight PC Attn: Roger B Irwin 60 W Pomfret St Carlisle PA 17013 RE: Estate of Christy G Salisbury Dear Mr. Irwin: The following information is being provided as per your request: Acct. Type Account No. Balance at Accrued D.O.D. Interest to D.O.D. Esteem ]59387 $32.86 $0.00 Checking Account Esteem 2498146 Checking Account Certificate of 165180 Deposit $32,941.36 $1.16 $6,645.88 $2.45 Ownership Date Opened/Joint Individual 3/4/05 Individual 1/3/12 Irrevocable Bm•ial Account 2/17/05 Inquiries concerning ACNB Corporation stock information should be directed to the Registrar and Transfer Company at 1-800-368-5948. If you need any additional information, please contact me at (717)339-5122. Sincerely, Barbara J Warner / ACNB Bank ~/ Deposit Services Representative II PO Box 3129, Gerrvse~ac, PA 17325 I vxoxs 717.334.3161 I rou,°== 1.888.334.2262 I acnb.com I a<nbbusinus.com ROWE'~ AUCTION SERVICE (RH 79L) 2505 Ritner Highway Carlisle, PA 17015 Bill Rowe (AJd~1538L) 249-1978 215-1044 574-1008 Dave Rowe (AU 2295L) / '~~ v. Auction Is Action Call "Rowe" For Satisfaction ~~ (" SELLERS NAME ~ ' ~ r ~~~ ~' ' ~' `"° ~ / DATE `~,L~ ~ ~ t _' ADDRESS ' ':- F , , ,,. ,. _~ ,. ~....~, PHONE I ~ L. OTHER ~+ AUCTIONk:ER % ~.` AUCTION DATE/LOCATION CLERK % DESCRIPTION OF MERCHANDISE. ,' ~ ~ , ~', ' ' ~ , , , .. /:, .. I Commissions the ~vctioneers to sell the 5ie chandise to the highest bidder by Public Auction. Merchandise to be sold as is &/grouped as necessary to tain bids. I certify that I am the owner or authorized represen- tative of thte m~fchandise, gdods and or pcrty and have good title and the right to sell and that they are free from all irjcunibrancee:~T;-ggree to ac~S 11 responsibility for providing merchantable title and for delivery of title to the purcha"ser. I agree tad h niless the Auctioneers against any claims of the nature referred to in this a~rreeFnent. ""~ %~ j i AUCTION SIGNATURE 5ELLER~ SIGNATURE Total Sales (Clerking Tickets Attached) ~ Less Sale Expense: ~ .o S % Commission Auctioneer $ it `?~~ ~ ^_ % Commission Clerks $ . ~•- OTHER: '~L-A1u-~-KkL- ~i ~ ~y ~- TOTAI. SALE EXPENSE DEDUCTED $ _~_'~{- ~ -( ~~- SELLERS NET $ ~-'~ ~ ~ Sett lem,ent 5eller`: 26 Rnwe's R~.ICi:ign Ser`v i.ce rims Ritner liwy Carl isl e, GR 17215 71 7--574-1mm8 L ind errha118ao 1. r_oin Salisbury Est. L'!Q Roger Irwin Item Descri gtinn - Lot #i Framed State Quart er•s - #2 F'res. Proof Coins Wash/Rdams - #3 Same, Madison/Monroe - 114 Same, Rtlams/Jackson - #i Same, VanD~.lren - #6 State y~.lart ers - #7 To4<er~s lMedal s, plated - #8 Misc. eq rosy Silver Certs - #9 F'res. tokens - #im Statue Lib. plated - #1.1 1921 Silver Dollar, color - #i2 2228 Silver Eagle - #13 Token s4 plated - #14 II~<e clollar, plated - #IS Copy Coin, 1'338 R 1.861 plated - #16 copy coins, 18249 St. Gaudens - #17 Copy coin: 1877 plated - #18 Copy cninr 191.3 nicl<e1 - #19 Copy cn inq 1849-1933,, eag:Le - #241 Copy coin, 1749, 1824 - #2i L75 Comm. Pres. coins fn:Lder - #2c' 7'he qm. Coins - #23 Jefferson - #c4 Wash ingsan - #2i US Founding Fathers - #26 Franklin - #~?7 Linco an - #28 Quart er^ frame - #30 Pres. Ro l.is (6) price Qty _....1 1 i 7. 1 t I i 1 1 i. 1 1 1 i 1 i 1 i 1. 1 1 i r. 1. i Ztems; 29 Rmount: Commission at 35.@@2"/• 11m. ~b7 Less adjustments: IVet due to sel ler•:~ Date: m7-18-?_@i2; 13:31:47 Rowe's Ruction Serv ire 2525 Ritner Hwy Carlisle, PR 17mi5 717-574-1mm8 Lin[lenhall@aol. cnm Settlement Salisbury Est. C/O Roger Irwin Seller: 26 Faye: ,. Total. I @. @0 4. @m 6. mm E. m@ i. @@ s. mm i.@m t 4. 22 ,'_', m0 s. mm 3m. mm 35. mm 3. miD 7. @m 4.. @@ 5. mm 4. @@ 2.. m@ 5.. mm 5.. mm 6. mm 17. iQ1 i.@@ s. m@ s. 2a 18. 4i@ 14.@m 1.41@ 72. me 314. im -1 i2. m7 2m4. 43 Page: ._ Thank yo~.1 for your business! ~o ~- M _i w 1 h I ~~m a %;'; "~` n nD~ ' Q ~Wa nN y; '~~~~ ;~ Z ,. iii m a ~Q T. L~ ~~ N ' RJ T Q 0 a ~! C~ 0 ~, 0 .. 0 a N d 3 w fJl 0 n e ... ~ -n v D ~ ,'~ ~• o a ~ '~ ~ m m ~ ~ o' ~ ~ obi ~ m m ~ ~ m ~ b N ~ ~ a~ ~ ~ N ~ , N p G •2 ~, sq ~ ~ '~ ~ ~~ I~~ ; ~~ d~ ~~ ro d a ~v Q ESTATE TRUST SALlS9URY,C V TATE - .~~ Reorder: ~'SOilware Corporation ~-9215800. TS-04~LT~ ~o n m `' W r ~ r ,~ ` ,~,., ` v N G~ n ~~ ~ = '0 ~m~ ~ Z ~ ~ ~'~ V % ~ Z r N N~V O '~ O ~ ~ O ~ 119.00 wum~enw If you have any questions regarding your statement please contact the Business Office at (717)776-ft256. 03/29/12 - 03/29N 2 02/25/12 - 02/26/12 02/26/12 - 02/26/12 03/01!12 - 03/01/12 03/01/12 - 03101/12. 03/01 /12 - 03/01 /12 PM STMT D2/12 Check # 31524 ed Med Equip-Concentrator Rented Med Equip-Concentrator Oxygen Daily Lemon Glycerine Swabs Dressing Allevyn 1 3/4 X 13/4 $502.95 Balance Forward $5(12.95 TOTAL BALANCE DUE: ,, ~ ~~ 6~ ~~ ~~ ~i~ ~ ~~ 2 $70.00 $140.00 1 $(70.00) $(70.00) i $7.50 ;17.50 1 $2.36 (12:36 1 $9.30 :69.30 $89.16 ~ ~,: ltii A 4.~ +` FACILITY NAME RESIDENT NAME ACCOUNT NUMBER SWAIM HEALTH CENTER CHRISTY G SALISBURY 61772GRV~ wuunenw f y u have anY questions regarding Your statement, please contact the Business Office at (7171776-6256. 03/01112-03/01/12 RentedMedEquip-Concentrator 1 $70.00 $7~D.00 TOTAL BALANCE DUE: $70.00 ~~~,~~ FACILITY NAME RESIDENT NAME ACCOUNT NUMBER SWAIM HEALTH CENTER CHRISTY G SALISBURY 61772GRV Balance Forward $89.16 04/19/12 - 04!19/12 PMT FRM STMT 03/12 Check # 31618 $89.16 riease Remrt Payment to: ~Cum6erland Goodwill Fire Rescue EMS Billing Office PO Box 77 New C berland, PA 17070-0726 QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 717-214-6020 Emaif: info@ambulancebiilingoFFce.com Date of Service: 3/1/2012 11:42 Please visit our website to provide insurance or make payment, and Patient Name: SALISBURY, CHRISTY G. for additional payment options and frequently asked questions: From: Carlisle Regional Medical Center To: Green Ridge Village www.ambulan~cebillingoffice.com .~ This type of service is not covered by ambulance memberships, Medicare, Medicaid and most secondary insurances. Payment is your responsibility. 3/01112 Stretcher Van One-Way Trans 3/01/12 Mileage Tota! A0130 1.0 80.00 S0209 12.3 1.75 60.00 21.53 101.53 0.00 0.00 DETACH ANO RETURN BOTTOM PORTION WITH YOUR PAYINENT. -xa-~.-• _-____,--.- _-.__..,.. __-"_•~.. _~___., ~. _._ ____~.- of--. .....,..r. 4 .,,.,,,,,o vme:u,vZORU12, Acct#:GRVN1744, SALISBURY,CHRISTY G, Green Ridge Village NC -PHI, B, GUISTWITE, DARRYL 0113112012 6393427 26.00 Therems M Ural Tablet $ 1.50 $ 0.00 $ 7.50 OTC 005364881-10 0113112012 6393426 26.00 DOK Orel Capsule 100 MG $ 1 50 $ 0 00 $ 1.50 OTC 009047809-80 . . 01/31/2012 33586 21.00 Pnloaec OTC Oral Tablet Delayed Release 20 MG $ 12.06 $ 0.00 $ 12.06 OTC 37000-0455-04 02/26/2012 6433099 5.00 LevoMVroxlne Sodium Oral Tablet 200 MCG $ 0.89 c $ 0.00 $ 0.89 RX 00378-1819A1 02/2612012 6446573 5.00 Mirtarapine Oral Tablet 15 MG $ 0.87 C $ 0.00 $ 0.67 RX 00093-7205-56 02/2812012 6453086 5.00 DOK Oral Capsule 100 MG $ 1.50 $ 0.00 $ 1.50 OTC 00904-7t189.80 02/2612012 6453089 5.00 7erezosin HCI Oral Capsule 5 MG $ 0.87 c $ O.DD $ 0.67 RX 00781-2053-01 02/26!2012 6453090 5.00 Furosemide Oset Tablet 20 MG $ 0.59 c $ 0.00 $ 0.59 RX 83304-062410 D212612012 6453091 5.00 Metoprolol Succinate Orel Tablet Extended Release 24 Hour 100 M~ $ 1.45 C $ 0.00 $ 1.45 RX 49864.0408-01 02!28!2012 _6453092 5.00 Therems M oral Tablet $ 1.50 $ 0.00 $ 1.50 OTC 005384681-10 02/26/2012 6453093 5.00 Celebrex Orel Capsule 400 MG $ 11.78 c $ 0.00 $ 11.78 RX 00025-1530-02 03/01/2012 2024209 5.00 FeManN Trenademtal Patch 72 Hour 26 MCGMR $ 6.79 c $ 0.00 $ 8.79 RX 00591-3798-72 03/01/2012 6454012 15.00 Metoprolol Succinate Orel Tablet Extended Release 24 Hour 100 M~ $ 3.22 e $ 0.00 $ 3.22 RX 49864-0408.01 03/01/2012 8454030 15.00 Metoprolol Tartrete Orel Tablet 25 MG $ 0.68 C $ 0.00 $ 0.88 RX 00378-0018-Ot 03/01/2012 2024197 30.00 Morphine Sulfate $ 2.89 c $ 0.00 $ 2.89 RX 00084040444 03/01/2012 6454388 1,00 ZYNO 2-BOONPIkAP $ 10.00 $ 0.00 $ 10.00 IVPR No NDC -Item Order 03101(2012 8454389 3.00 ZYNO 2-BOO IV PUMP $ 30.00 $ 0.00 $ 30.00 IVPR No NDC -Item Order 03101/2012 6454391 1.00 DRESSINGKIT-CENTRALLINE $ 3.06 $ 0.00 $ 3.06 IVSP No NDC -Item Order 03/02!2012 6453985 7.00 Pdbaec OTC Oral Table[ Delayed Release 20 MG $ 4.02 $ 0.00 $ 4.02 OTC 37000.0455-04 03/02/2012 6453986 7.00 Teremain HCI Oral Capsule 5 MG $' 0.71 c $ 0.00 $ 0.71 RX 00781-2053-01 03102/2012 6453987 7.00 Levothvroxine Sodium Orel Tablet 200 MCG $ 1.03 c $ O.DD $ 1.03 RX 00378-1819-01 ,,,...,..c va~o.vY~cwav ~<, rwar:ortvrv i na, JALIJtlUKY, GHKISTY G, Green Kitlge Village NG -PHI, 8, GUISTWITE, DAKRYL ~I 'l li '. $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 20.57 $ 0.00 $ 0.00 $ 0.00 20.57