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J 1505610105 REV-1500 °`t~-"'t~"' PA Department of Revenue tMae OFFICIAL U8E ONLY Bureau of Indivlduat Taxes ~n~ "`"""` County Code Year Flle Number Po BOx ~8o6ot INFIERITANCE TAX RETURN ~ NarrisburD, PA t9ue-o6os RESIDENT DECEDENT _ __ GZ~ I ~, Q eNTER DECEDENT INFORMATION BELOW Sodel Security Number Date of Death MMDDYYYY Dete of Birth MMDDYYW 187-60-7873 06/05!2011 02/02/1965 Decedent's Last Neme Su18x Decedent's Firet Name MI Goss Lisa ~ (H Applicable) Entsr SurvMnp 8pouu's InMrmatlon Below Spouse's Lest Name Suffix Spouse's Firet Neme MI None Spouse's Sodal Secudty Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL INAPPROPRIATE OVALS BELOW m 1. Oripinel Retum O 2. Supplemental Retum O 3. Remelnder Retum (Dale of Death Prior to i2-13.82) O 4. Llmitetl Eatete O 4a. Future Interest Compromisa (date of O 5. Federel Estate Tax Retum Requlretl deaM after 72.12.52) O 8. Decedent Dled Tealete O 7. Decedent Melntalned a Living Truat 0 B. Total Number of Safe Depoelt Boxes (Attach Copy of Wllq (Attach Copy of Tmat.) O B. Lltigatlon Proceeds Received O 10. Spousal Poveny Credit (Data of Death O 11. Election to Tax under Sec. 3113(A) Between 12-31-37 and 1-1-95) (Attach Schedule 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTL-L TAx INFORMATN)N SdOULD BE DIRECTED T0: Name Daydme Telep ho ne Number ~.~ Michael Cherewka, Esq. "" n~ (717) 232-n1~~1 ~ ,:,, z, Flret Line of Address 624 North Front Street SecorW Line or Address "a'i 2P ~ ry G~. t F r' _ r; rte' ~ ~ - ~ `~ ~ ~ r z~ T i r y LL~ City Or Poet ORica State ZIP Code L_ DATE FILED i Wormleysburg PA 17043 Corrupondent's rmsll address: Under paroNes of padury. I declaro tlret 1 have enndned ads rotum, Indudirp eocornWnYlnO schedules end etekWmsnb, and to are stof my knowledge sntl belkf, It la true, GOnedt and cornpleta. Deckrotlon of prepare other en the personal roprosantetlvs la based on all Informetbn of which propsror has any knowladse. 310NATURE OF PER P BIBLE F FIL O UR DATE ADDRESS 1457 Ryland Drive, Mechanicsburg, P 1 50 SI , F PREf~RE~OTH~t THAN REPRESENTATIVE DATE 624 North Front Street, Wormleysburg, PA 17043 FLBABE Uitd ORtO1NAL FORM ONLY Side 1 L 1505610105 150561D1D5 ~ J 150561205 REV-1500 EX (FI) Decedent's Social Security Number cecedent's Name: Lisa J. GOSS '167-60-7673 RECAPITULATION _.. _.. i. Real Estate (Schedule A). ......... 1 _ 200,500 00 2. Stocks and Bonds (Schedule B) ...... ........ . 2 0.00 ', 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... . 3. ,,, 0.00 4. Mortgages and Notes Receivable (Schedule D) .... ........ . 4 ,. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... . 5 , , 3,800.00 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... . 6 _ 371.19 ' 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property , 00 ' 0 (Schedule G) O Separate BillingRequested...... . 7 . . 8. Total Gross Assets (total Lines i through 7) ...... ........ ........ . 8 204,671.19 9. Funeral Ex enses and Administrative Costs Schedule H 9. '. 6,675.07 '. P ( ) ................... 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............... 10. 192,929.43 11. Total Deductions (total Lines 9 and 10) ......... ......... ......... 1i ~ 199,604.50 '. 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 5,066.69 13. Chadtable and Governmental Bequests/Sec 9113 Trusts far which an election to tax has not been made (Schedule J) . ......... ......... 13 0.00 ' 14. Net Value Subject to Taz (Line 12 minus Line 13) ...................... .. 14. ', 5,066.69 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax 2te, or _.. transfers under Sec. 9116 0.00 00 0 (a)(1.2) X .0_ 15 . 16. Amount of Line 14 taxable ~ ~ ~~ at lineal rate X .D 04 5 066.69 ', is. 228.00 ' 17. Amount of Line 14 taxable ...... ..... ........ ....._. at sibling rate X .12 ....._ 17. ....... _ ...... _.._ 18. Amount of Line t4 taxable ~ at collateral rete X .75 '. 18. 228 00 19. TAX DUE ............ ........ 19. _ ___ _. . 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 J REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME Lisa J. Godd STREET ADDRESS 740 Sterling Court CITY ;STATE ~ ZIP Enola PA 17025 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CredftslPayments A Prior Payments 8. Discount 3. Interest 0.00 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 28 W request a refund. 228.00 0.00 (3) (4) 3.34 5. If Line i + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5} 231.34 Make check payable to: REGISTER OF WILLS, AGENT. ,, ,. i ,,, 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 lransferred ........:........................................................................... ...... ^ b. retain the right to designate who shall use the properly 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 considerailon? ....................................................................................................... ....... ^ 3. Did decedent own an "intrust for" or payable-upon-death bank account or security al 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 R AS PART OF THE RETURN. -t:; i~.a! ~: :;?. i. ilia.t .-. -'i ~ v: :~'r .:. .:: .. 3t°i i ...:..q f , 4 o e(''. .. .. .. ... : .. ?l, ... .. ~... 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 Vansfer tc 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 Juty 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 naWral parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. The tau rate imposed on the net value of transfers to or fa the use of the decedent's lineal benefiaaries is 4.5 percent, except as noted In p2 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(aJ(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. 0.00 (1) Total Credits (A+B) (2) Personal lncome Tax e-Services Center Penalty and Interest Calculations CALCULATION DATES- 03/05/12 TO 8/31/2012 TAX DEFICIENCY $ 228.00 CALCULATED INTEREST $ 3.34 BALANCE AS OF 8/31/2012 $ 231.34 Start Over_ https:(lwww.doreservicesstate.pa.us(pitservices(Default.aspx Page 1 of 1 8/16/2012 REV-1502 £X+ (i1-08) ,a ~ pennsylvania SCHEDULE A DERARTMENT Dr REVENUE REAL ESTATE INHERRANCE TA% REfURN RESIDENr DECEDENT ESTATE OF FILE NUMBER Lisa J. Goss 21-11-0718 All real property owned solely or as a tenant in common must be reported at fair market value. Falr market e~alue 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 property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common, VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1 740 Sterling Court, Enola, Cumberland County, Tax Parcel #09-14-0835-082 (assessed value) 200,500.00 TOTAL (Also enter on Line 1, Recapitulation.) $. 200,500.00 If more space is needed, insert additional sheets of the same size TaxDB Result Details Detailed Results for Parce109-14-0835-082.-U22 iri the 2010 Tax Assessment Database DistricWo 09 Parcel ID 09-14-0835-082: U22 MapSuffix HouseNo 740 Dtrection Street STERLING COURT Owned AIKEY, LISA J C/O PropType R PropDesc LivArea 1940 CurLandVal 0 CurlmpVal 200500 CurTotVal 200500 CurPretVal Acreage .00 CIGrnStat TaxEx 1 SaleAmt 179900 SaleMo Ol SaleDa 04 SaleCe 20 SaleYr 07 DeedBkPage 00278-01300 YearBlt 1989 HF File Date 01/23/2008 HF_Approval_Status A http://taxdb.ccpa.net/details.asp?id=09-14-0835-082.-U22&dbselect=l REV-iEO3 EX+ (~-u) ~Y Pennsylvania ~EPFPiMENT OF PEVENNE INHERITANCE TAX RETURN RESIDENT DECEDENT SCN~DULE B STOCKS & BONDS ESTATE OF FILE NUMBER Lisa J. Goss 22-11-0718 All property jointly owned whh right of survivorship must be disclosed on Schedule F. It more space Is neetled, insert additional sheets of the same size REV-1507 EX+ (g-gg) SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER Lisa J. Goss 21--11-0718 pi more space is neeaeq insert a001tional sneers of me same size) REV-i5o8 EX+ (u-io) ~ `~ Pennsylvania SCNEDI~LE E DEPARTMENT or REVENDE CASH, BANK DEPOSITS & MISC. ~NNERrrarvw TAx RETUaN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Lisa J. Goss 21-11-0718 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. 2 DESCRIPTION OF DEATH 1. 2003 Chevrolet Cavalier, Damaged in accident, Poor Condition Sold via Craigslist 400.00 2. 2002 Honda Accord, Fiar Condition, Needs Mechanical Work, Sold via Craiglist 600.00 3. 1998 Ford Contour, Sold via Craigslist 800.00 q. Furniture, Clothing and Personal Items 2,000.00 TOTAL (Also enter on Line 5, Recapitulation) ; 3,800.00 If more space is needed, use additional sheets of paper of the same si;~e. Yr Make Model 2003 Chevrolet Cavalier 2002 Honda Accord EX 1998 Ford Contour Miles $ Value Remarks 103000 400 poor, was in an accident, has "R" title Poor, front was scraped, auto transmission low gear is slipping baddly, Sold via 237250 600 Craigslist fair, having a problem with the ignition/Key, 83500 800 sok! via Craigslist REV-1509 E%+ (01aD) ~ pennsylvania DEPARTMENT OF REVENUE INHERRANCE TAX RENRN REBIDEM DECEDENT SCHEDULE F ]OINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: Lisa J. Goss 21-11-0718 If an asset hewme jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING ]OINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. Matthew I. Aikey 1457 Ryland Drive Son Mechanicsburg, PA 17050 e' Melissa a. Harris Deceased C. JOINTLY OWNED PROPERTY: ITEM NUMBER LETTER FDR 101M TENANT DATE MADE ]OINi DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTRMON AND BANK ACCOUM NUMBER OR SIMIWR IDEMIFYING NUMBER. ATTACH DEED FOR JOINRY HELD REAL ESTATE. ' DAl'E OF DEATH VALUE DF ASSET %OF DECEDENPB INTEREST DATE OF DEATH VAWE OF DECEDEM5INTEREBT 1. A. 06/26/06 Members 1st, Savings Account #276171-00 94.98 50% 47.49 2. A 06126/09 Members 1st, checking Account #278171-11 148.92 50% 74.46 3. A 06/26/94 Members 1st Savings Account #137980-00 54.95 50%. 27.48 4. A 02/07194 Members 1st Checking Acwunt #137980-11 127.19 50% 63.60 5. A 05/12/10 Members 1st Regular Savings Acwunt #384997-00 5.00. 50% '. 2.50 6. A 05112/10 Members 1st Checking Account#384997-11 291.25 50% 145.63 7. A 05112/10 Members 1st Holiday Club Account #384997-02 20.05 50% I 10.03 TOTAL (Also enter on Line 6, Recapitulation) $ 371 19 If more space is needed, use additional sheets of paper of [he same size. -~ ~ r z pLIG-ir2-2~1c ef3:cG p'r omr'^18T LEND Lr~b' S!FPT 7:'7955178 Tn:817'c7.3247 ? P•~ REGULAR $AVINGa ACCOUNT: Primary Owner ----- Lisa J Goaa Aw"uum Number/Suffix 376171-0U Date Account Established 12105f2005 Prindpai Balance at Gate nt Death O9a.49 AxNCd IntetCat tD DYte dt` DBa1h SO.DG Tuwl Prinupai and Axrved !merest 094.86 Name of Jdnt Owns Meliaaa A Marna Dmle Joint Eatabiiahed 6!261.009 O>+Ie Ardnunt f !Deed i 1f2S,"lG1 ! CNECHlNG ACCOUNT Prlmary thvnar Lias J Oasa Acpouni NUmoerlSuffk 276171-i1 Dew Acduunl Eatablighetl t 2/00l2ir05 Prlrtcipal Baianu Pt Dale of Death 145.92 Aeeruetl lntele9t to Date of Death SOHO Tavel Prir.Wpal antl Accruod Intartst 0148.92 Name at Jotnl Owner Melissa A Harris Caw Jeint Established 612$12009 Uate Account Closed ti/35/2D11 VISA ACCOUNT: Primary Owner Liaa J bass Aapunt Number/SuNIx 4673000000330377 Uate Opened 1I09/2DG6 Princpal Balance at Uate of Ueatn 960'1 G.46 Name of Joint Camhdder None Gate Charged Ott 1}f3g72017 LOAN A,,r000UNT: Prlmary Owner Lisa J Goss AG.OUM NUmbeN$ufflx 2761 7 1-0 2' Dato Opened 21t 0/2011 Principal Balance SB95B.62 wan Tye UnOacured/Contractual Pledge of Sharee Collateral Secured N/A Interest Rate 8.9070 Name of Go•9orrower None CFer9o•oN Dato 11/25/2011 'Caen does not nave as rosuranca. MEM9L=R$ ter FEDERAL CRC~R-EDIT UNIOfJ besa~ (i ~tr Lending Insurance SuppoR Specialist August I0, 2012 Estate ot: L.isa J Goaa Date of Death: 06106I20i 1 Sacial $eCUrlty Number: 1$7.60-7873 Sfh'JO Lotist I~rivt P.(1. IIux 4f) ' Meclta>ucsburl;, Patnsclvanis 17055 (RO(1) i89-232rJ www.tutnthc:rals;.i~rk REV-1511 EX+ (10-09) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAx RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Lisa J. Goss 21-11-0718 Decedent's debts must be reported on Schedule I. A. 1. B. 1. FUNERAL EXPENSES: Sullivan Funeral Home 2. Pastor 3. Sound for Service a. Organist 5. Custodian ADMINISTRATIVE COSTS: Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address 2. 3. City _-.-.-.__ _.-..___.-__- __._______.-.-.-._- __ State- ___.-. ZIP Year(s) Commission Paid: Attorney Fees: Family &emption: (lf decedent's address is not the same as claimant's, attach explanation.) Claimant 2,500.00 Street Address City _ State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 370.50 5. Accountant Fees: 6. Tax Retum Preparer Fees: ~ Patriot News -Obituary 383.85 a. Daily Item -Obituary 120.00 s. The Sentinel -Obituary 155 50 ~ o. Register of Wills - Re-Issue Short Certificates 44.00 ~ ~. Cumberland Law Journal -Estate Advertisement. 75 00 iz. The Sentinel -Estate Advertisement 189 22' _ TOTAL (Also enter on Line 9, Recapitulation) ; 6,675.07 2,502.00 125.00 10.00 100.00- 100.00 [f more space is needed, use additional sheets of paper of the same size FROM Sulli~.an Funeral Home PH7NE N0. 17177322162 RUu. 15 2012 ©2:46PM P1 .~i~i„ >ul!Iva u. f?.m-.~~r ~, ~ i t u~. BUI.LIVAN FL'~F.RAI~ H()yi~; ~"'. ~"7d:> 7 i. fti h ! ~ n !, t a n r u• rx i ~ .< ; :. 1 t ~ .5anc rac. i'Y167 tS~E1e2 Tuesday, tittle ~, 20l I Rebecca AOtey 1457 Ryhod Dr. Mecbmicabutg, YA 17030 Dar Rebectx, Thwic you far aeleUing our thnerpi home W pravidc sQViaro fat }roar family during your time ofheravcmert I hapc ffist you faatd oar servieaa so SF; ro be of the h3gdest standards That we always try to achieve. 'rhe tallawin$ isr summary of the acrvioc as ptaviousfy axplahnd and pmrided in wtitan tbrm on the setviore fm: LISA J~ GOSS PI~FLSifONAL SSRVICfiS Adler PrcppMtion of Body S LSO Total Funeral Serviob Selatitad TOTAL PROFESSIONAL SERVIC&4 SlSR00 OTlIEIt. ME[tCNANDL4E SELECT$D Other Reaeptaalc Blue Crescent 1Im S :i00 S Fokims 250 S I10 TOTAL IYfNER MfRCHANDL4E SEI.r;CTAD 3153.00 SPECtA45RRVlCES Direct erOtltaElOn 5 1'~9~ TOTAL 5PEGIALCFIARCES S1r793.Y0 CABN ADVANC63 CaatiRed Copies of Deatb tkrtlflcate S 72.00 c:ASN ADVANCE TOTAL 572.00 TOTAL OF 9ERVICCS 42,!02.00 BALANCE DII& 52.'~2A0 If there arc any quationa or concerns that rolnafn unanswered, please call me. Sit>cacly, Mario A. Bilbw $:D.,CFSP Patriot News 383.85 Daily Item 120 Sentinel 155.5 Progressive 169.5 Register of Wills 370.5 Custodian 100 Sound 10 Organist 100 Pastor 125 Register of Wills 44 1578.35 RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 GOSS LISA J Estate File No.: Paid By Remarks: ------------------- Fee/Tax Description 2011-00718 KARL S AI KEY DB PETITION LTRS ADM SHORT CERTIFICATE JCS FEE AUTOMATION FEE Check# 1441 Total Received......... Receipt Date: 6/27/2011 Receipt Time: 13:46:24 Receipt No.: 1066098 Receipt Distribution ------------- ------- ---- Payment Amount Payee Name=_ 310.00 CUMBERLAND COUNTY GENERAL FUN 32.00 CUMBERLAND COUNTY GENERAL FUN 23.50 BUREAU OF RECEIPTS & CNTR M.D 5.00 ---------------- CUMBERLAND COUNTY GENERAL FUN 370.50 370.50 The Sentinel www.<umberlink,com Q~ <.nRUSE 9t?PEnS&:aC--: Pf?RR'CC'llnrv MICHAEL CHEREWKA 624 NORTH FRONT STREET WORMLEYSBURG, PA 17043 717-232~d701 AD NUMBER PAGE NO. 400742 1 of 1 BILL DATE SALESPERSON OS/23J71 wolfs START DATE STOP BATE 08109111 08123111 Publication Insertions Rate Net Amount Gross Amount 3 THE SENTINEL -LEGAL 3 LGL $148.68 TOTAL AD CHARGE $148.68 3 PROOF OF PUBLICATION OtPRF $7.00 3 MOBILE SITE MOB2 $2.00 Purchase Omer Est. Lisa Goss PAY THIS AMOUNT $157.68 $189.22* 'AFTER 09117111 THE SENTINEL Thank you for advertising with The Sentinel! Deadline for c/o LEE NEWSPAPERS in-column legal ads is 4:00 p.m. two business days prior to PO BOX 540 date of insertion. For questions, call (717) 240-7130. WATERLOO IA 50704-0540 ~~ CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717)249-3166 Fax: (717)249-2883 September 2, 2011 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Michael Cherewka, Esquire RE: Lisa J. Goss Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on the following dates: August 19, August 26, and September 2, 2011 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 0 .00 Total Amount Due $ 75:00 Payment received by, RECEIPT FOR PAYMENT ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17813 GOSS LISA J Estate File No.: 2011-00718 Paid By Remarks: KARL S AI KEY HMSO Fee/Tax Description PETITION LTRS ADM SHORT CERTIFICATE Check# 1398 Total Received......... Receipt Date: 10/11/2011 Receipt Time: 10:55:14 Receipt No.: 1067249 Receipt Distribution ------------------------- Payment Amount Payee Narne 20.00 CUMBERLAPdD COUNTY GENERAL FUN 24.00 CUMBERLAP7D COUNTY GENERAL FUN $44.00 $44.00 REV-1512 EX+ (12-OS) i, Pennsylvania SCHEDULE I DEPARTMENT DE REVENDE DEBTS OF DECEDENT, `""EUT^"ceT'~aET°R" MORTGAGE LIABILITIES & LIENS RE9DENi DECEDENT ESTATEOF FILE NUMBER Lisa J. Goss 21-11-0718 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 Bank of America, N.A., Account #148063473 Mortgage on 740 Sterling Court, Enola 159,354.29 2. Members 1st Credit Union, VISA Account#4672-0900-0022-0277 6,103.37 3. Pennsylvania American Water Company 279.12 4. .Progressive Insurance, Automobile Insurance 412.96 5. PPL Electric 727.54 6. Laurel Hills North, Homeowners Association, Outstanding Dues g2g.72 7. East Pennsboro Township, Outstanding & Current Water, Sewer and Trash 289.80 8. Hershey Medical Center 36.59 9. Verizon Wireless 109.62 10. Quest Diagnostics 48.06 1 t Citibank Mastercard Account Enging 1168 1,876.45 '. 12. Pennsylvania Turnpike Commission, E-Z Pass 25.00 13. CVS/Caremark 75.00 14. Erie Insurance 62.00 15. Capital One Credit Card, Account #4003-4425-3061-1022 14,394.83 16. Members 1st Credit Union. Loan Account #276171-02 8 958 62 TOTAL (Also enter on Line 10, Recapitulation) $ 193,681.97 If more space is needed, insert additional sheets of the same size. ~ - st ~~-~~ ~ 6~~ ~ sl ~~.MEMBERS 1St VISA FIDER9L CREDTT UNION LISA J GOSS Account Number: 4672 0900 0022 0277 (Includes Past Due Amount of 6491.00) Payments - OtherCredits - Other Debits + Purchases + Cash Advances + Fees Charged + Interest Charged + Credit Limit Available Credit Available Cash Amount Disputed Statement Closing Date Davs in Billino Cvcle Statement Closing Date: August 28, 2011 16''r New Balance $ fi,1o3.37 Total Minimum Payment Due $ 707.37 0.00 (Includes Past Due Amount of $481.00) 0.00 payment Due Date 09!21111 0.00 Late Payment Warning: IF WE DO NOT RECEIVE YOUR 0.00 MINIMUM PAYMENT B'f THE DATE LISTED ABOVE, YOU MAY 0.00 HAVE TO PAY A LATE FEE UP TO 530. 25.00 0.00 Minimum Payment Warning: If you make only the minimum payment 03.37 each period, you will pay more in interest and 0 will take you longer to pay off your balance. For example: $G,000.00 ~~~~' ,~ D.DD '~a1 o.DO e~, O.OD 062fl/11 Only the minimum 32 oavment 12 years ~ $6,103.00 If you would like information about credit counseling services, call (866) 791-4360. c~ Customer Service: (800) 28&2328 Ext: 6035 ~p Report Lost or Stolen Card: (866) 839-3485 ~ Please send Billing Inquiries and Correspondence ta: `t~ CUSTOMER SERVICE PO BOX 30495 TAMPA , FL 33630-3495 Visit us on the web at: vvww.memberslst.org Please Mail Yaur Payments ta: PO BOX 4517 CAROL STREAM IL 60197-4517 OBTAIN ACCOUNT INFORMATION 24 HOURS A DAY CALL 800-2995942, OR ACCESS ONLINE AT E2CARDINFO.COM. NOTICE: CONTINUED ON PAGE 3 Page 1 of 3 szts VU - ASE DETACH COUPON ANO RETURN PAYMENT USING THE ENCLOSED ENVELOPE -ALLOW 5 DAYS FOR MAIL DELIVERY MEMBERS IST FEDERAL CU st "7-°Reao~nt PLnober+~„^" 5000 LWISE DRIVE ~~ ME~~$ )." 4672 0900 0022 0277 MECHANICSBURG PA 17055-4899 raD6RALCAFDm mm~N Check bm to indicate ^ namdaddress change on back of this coupon wg , _,_ atCil ~i - AMOUNT OF PAYMENT ENCLOSED lR~y ~ ar`~~E ~,1 me tug ~ `~ ~~t~0ai~~" 08/28/11 $6 103 37 $707.37 09/21/11 ^ fvlAKE CHECIS PAYABLE TO: LISA J GOSS ~ m 1a57RYLANODRIVE ~ ~ Irllrrllrr,.rrllltirrlrrrlrlrrltl,Irrrrllirrrlrrrlllrrrlrrlrll MECHANICSBURG PA 17050-1977 -_ VISA PO BOX 4517 CAROL STRI_AA4A IL 60197-4517 IrrtlllrrrlllrrrtlrLlLrrrrrllltLrlnJlrrJrLlrL~rlrrJll 21 4672 0900 0022 0277 0070737 0610337 7 00024182541J47~0000~0000027912001 Pennsylvania American Water PO Box 371412 Pittsburgh, Pa. 15250-7412 For Service To: 740 Sterling CT II'91111'lllill'111111.ILJI.II,lhlllllhll"IIII'I'lllllll~l 0163]1 1 AT 0.36203]1/16371/0003]1 063 1 NCD9TA LISA GRBSS 740 STERLING CT. ENOLA PA 17025-2655 ~~ 24-1825404-7 AMOUNT DUE $Z7911Z Due Upon DUE DATE Recei t AMOUNT PAID Please return this portion with check or money order payable to PENNSYLVANIA AMERICAN WA PO BOX 371412 PITTSBURGH, PA. 15250-7412 IIIIr11611I~Ihllulldlnu1~1~11111~rPlh4rldl4hlhl1l Dear Customer: Your bill for $279.12 is overdue. Because your bill is overdue we will shut off water to 740 Sterling CT on or after8:00 AM on Tuesday, October 11, 2011. 1. Pay the total amount of the overdue bill and call 1-866-358-3429 to verrfy the company received your payment. 2. Call 1-866-358-3429 regarding a possible payment arrangement, to let us know that you made a payment; or to dispute the overdue till. 3. Call 1-866-358-3429rf you or someone in yourhome has a serious illness or a medical condition. Read the Medical Emergency Notice at the bottom of this form. If we shut off your water, you may have to pay the following charges or the full outstanding balance to have your water burned back on. Overdue Amount 5279.12 Tum-on-Charge 33 0 . 0~ 0 Total Amount Due 5 3 0 9.12 If you have any questions or need more information, please call us at i-866-358-3429. during the hours of operation M-Th 7am-9pm CST, Fri lam-7pm CST, Sat 7-11 am CST. AAA INS/AGENCY 2301 PAXTON CHURCH RD HARRISBURG, PA 17110 ooot5i LISA J GOSS 740 STERLING CT ENOLA, PA 17025 I'1111"II'lllllll,l.ll1.111111'IIIIIIIIIIIIII..I.Irll,l..11'llll Final Bill PROGRfJllf/E~ OR/YE"/nsurance LISA 1 LOSS Palicy Number: 66008728.2 Underwritten by: Progressive Preferred Insurance Co Date of Mailing: September 23, 2071 Policy Period. Mar 5, 2011 -Sep 5, 201 t Page 1 of 1 AAA INS/AGENCY 1-717-657.1027 Online Service progressiveagent.com Customer Service 1-800-87B-5581 Your policy ended because we did not receive your payment to renew your policy by its due date, tlowever, there is still a balance due on your expired policy term. Please see your payment summary below for more information. If you already sent your payment, thank you, but please know that your payment will not renew your policy. Poll remium for coven a until Se tember 5, 2011 $1,052.00 ~.P .........................._9 F....... Installment fee 14.00 Late fee 5.00 Insufficient funds fee 20.00 ?otal $ 1,091.00 Total amount paid -678.04 If you have any questions, please call Customer Service. .................................................................. Policy Number: 66008728-2 Payment Coupon LISA, GOSS ................................................................ .._............................ Forimmedkatepayment.Pleasegoto TOtaI amount due $412.96 progressives§entcom or call ....... .............................................._... Due date .........................._P., 1-800-87Cr51i81. Upon recel t Amount enclosed ............ $ If you pay kry check, please allow fve to ......................................._........,.............. .,..........................,... seven days for your payment to reach us. Write your policy numher on the check and make it payable to Progressive Preferred Insurance Co, "1111111'Illll'I'I'11II1111...1111.1 I11111111111'Ill'lllllrlll.. PROGRESSIVE PO BOX 7247-0311 PHILADELPHIA PA 19170-0311 Da notwtirc6elawthissectionatcoupon. GC-05114 Form Z707107/OB) ^311660f]8728 37064 041296 X041296 SOC1~447 4695:L78 0[]20C130511~5 PPL Electric Utilities 827 Hausman Road Allentown, PA 181049392 Te1.800.342.5775 (BOO.DIAL.PPL) Fax 484.634.3484 pplelecfdacom AT 01 004127 691378 16 A`"3DGT Prl~lhul~~l~ulllllll~ll~rd°IdI~IP~hll~dluhhl~~hd LISA AIKEY 740 STERLING CT ENOLA PA 17025 Bill Account No: 06170-72072 For: 740 Sterling Ct Enola Pa 17025-2655 SECURTI'Y DEPOSTT WARNING IM117~DIATE ACTION REOUIItED Dear Customer: ':;~:: , PPS •~:== PPL F1eelrie UtI11Ua~ September 27, 2011 ~7 a7 . sN Several times over the past yeaz, you paid your electric bill after the due date. • We will require a security deposit if another bill is paid late. • You can avoid a security deposit by paying any overdue balance by the neat due date and all future bills on time. We understand that payments are sometimes late because of our busy lifestyles. PPL offers a convenient program called Automatic Bill Payment, which ensures that afl your payments arrive on time. To enroll in the Automatic Bi1lPayment Program, complete the attached form and mail it to 827 Hausman Road, Allentown, PA 18104-9392. When you enroll, your bank will automaticallydeduct the amount due each month from your checking or savings account and send it to PPL on the due date. You will still receive a monthly bill statement from PPL just as you do now. If you have any questions or need additional infortnationon this matter, contact us at 1-800-342-5775 between 8 a.m. and 5 p.m., or write to us by sending your wrrespondence to the Customer Contact Center at the above address. Sincerely, PPL Electric Utilities LAUREL HILLS NORTH statement 717-566-8550 P O Box 233 Account: laurel - 0740sc - aik07 Hummelstown, PA 17036 Goss, Estate of Lisa J.Aikey 740 Sterling Court Enola, PA 17025 REMINDER NOTICE: Please send IMMEDIATE payment to: Laurel Nills North, P O Box 233, Hummelstown, PA 17036 Date Description Balance Forward 05/01/11 Dues 05/01/11 special assessment i 05/09/11 chk# 984 042911 06/01/11 Dues 06/01/11 special assessment 07/01/11 Dues ii 07/01/11 special assessment 08/01/11 Dues i 08/01/11 special assessment 09/01/11 Dues 09/01/11 special assessment Date: -09/27/11 Payment: Charges 182.18 50.00 182.18 50.00 182.18 50.00 182.18 50.00 182.18 50.00 I 232.re8 t 232D18 s 623DZa~8 Payments I Balance 0.00 182.18 232.18 232.181 0.00 182.18 232.18- , 414.36 464.36 ~ 646.54 696.54 i 878.72 928.72 90 Days 232.18 Amount Due 928.72 i J p p ~ i m r N ~ a z ¢a< r W U ti O E 6 y d W W ~ m a LL ~ .-' }- ~~ ' LC1 FW a fl TV F N ~ u ~ r °' ma ~wr W ~- ~ ff7 -~ u ~W w F- U7 r ~ q J [] C } J a ~ H 4F f k F1 c WAa 0 Q ~ J c c J = J1-~~ ~-+ U ~ ~ _n O ~-- C `c a E S ~ 2 ~ W m Z d n ~ poor3 ~g~~~ p ¢o mza~t zWgwao N W m O W N 1 m W N N C W ~ N Q ~r ~ ~ o~~ m ~ u iu i o maa~~a a e ~ a er m Ti Cli { n [ E ~ t U, i . t +-~ L ri~ -' O t ~; ril G ` c , ; o _ ` ~ ~ a . rl c _*jz m! a o v°°. _ m. _'o'• mE ° af a- i - a J U H U ' c7 [0 t'J -m., .-~ .y ., .-~ +. p ~ +-~*++-~00 < 0 0 +-~-+['J CTf m r NmtV til : O U3 X1700 O '.t" D -~ ~0 Lf7 ~ m G ; mar-+~ ac ¢: C? V ~ ~ F- ~- a ~ and m b` mU p1 . :. ~~~c3m`m m ~, • m , d6QdNF$JE 0 N¢ ~ Ta ' d6R ~ E 4 Liz N C = ;. - ,~ _ F-4 ?a = n V - U3C9 UZ c~ _- L'J W '7f- -- - V1 Q C~t30~ ~+d'~ - Jt~W - -~- M O L _ .. ._ PENNSTATE Milton S. Hershey Medical Center PO Box 643291 Pittsburgh, PA 15264-3291 LISA AIKEY lvoone 740 STERLING CT ENOLA PA 17025-2655 3rd Statement Pa e1of2 This account is past due and is a serious matter for you and for us. To avoid arty further collection activity, please send your payment for the full amount immediately. If you are experiencing difficulty in understanding this statement or making payment, plf:ase refer to the Financial Responsibility section cif this statement or contact our office for further assistance. IiiilllnillliiiiilrlilJnJJrILnLliiLliilnllliiiiillil Patient Name AIKEY REBECCA E Statement Date 09/09/11 Service Date(s) 05/26/11 Type of Service OUTPATIENT Account Number 15993299 New Charges/Adj $ 0.00 New Payments/Adj $ 0.00 Account Balance $ 36.59 Amount Pending Insurance $ 0.00 Amount You Owe $ 36.59 This new statement has been specially designed with you in mind. Let us know what other improvements we should make. Please a-mail your ideas to: Statemeniideas(~hmc~su.ed u or write to us at: Penn State Milton S. Hershey Medical Center Statement Ideas, PO Box 854, MC A410 Hershey, PA 17033 Please Note: Your p/rysiciazzs will bi!(separately for their professions! services. PENNSTATE Statement Date: 09!09/11 Milton S. Hershey Medical Center DATE DESCRIPTION AMOUNT 08/12/11 "BALANCE FORWARD" 36.59 TOTAL 36.59 For billing c)uesfions or'insurance changes: Para preguntas acerca de su factum o cambios de seguro contamos con representantes disponibles pare asisty a la comunidad hispana. Phone: (717) 531-5069 or (B00) 254-2619 Available Hours: Monday, Tuesday & Wednesday 8:00 am to 5:30 pm Thursday &. Friday 8:00 am to 4:30 pm Written Correspondence: Penn State Milton S. Hershey Medical Center Patient Financial Services Department PO Box 854, MC A410 Hershey, PA 17033-~D854 PO Box 643291 Pittsburgh, PA 15264-3291 CHECKS SHOULD BE MADE PAYABLE AND SENT TO: MS HERSHEY MEDICAL CENTER PO Box 643291 Pittsburgh, PA 15264-3291 liii~lil ili rili~illi nln~nllnili l~ilninlllin ll HERSHEVST-D7 ~L Check here if your address or insurance informah~on has changed. ~••1 Please indicate chan4res on the back of thrs page. To pay by credit card: For your convenience, you may pay by Usa, MasterCard or Discover Card. Please indicate your credit card preference, provide the acwunt information, and sign below. ^~ ^~ ^0 Account No. Expiration Signature CW Code 0~0000015993299~~i2611~9~9110000~03659 1247 Broadway Sonoma, CA 95476 1111 HIII III IIIII III1111III IIII III III PERSONAL & CONFIDENTIAL Address Service Requested #BWNFTZF #CHRB31281110060# I'IIIIIII"IIIIIII~I~III,IILI~IIII'III11111'lllllllll'lllll'III, LISA GOSS 05082326-36 1457 RYLAND DR MECHANICSBURG, PA 17050-1977 CHASE RECEIVABLES A Professional Collection Agency e77-2ss-251o PLEASE CALL BETWEEN Monday-Friday 6:OOam to 6:OOpm PST Saturday Gam to 2:30pm PST October 7, 2011 RE: VERIZON WIRELESS-NORTHEAST For: 0012 N E=RG Chase# 05082328 TOTAL BALANCE: S 108.82 To make a payment you can call our phone number at 877-256-2510 or pay online with your Cradit Card at www.chaserec.com using your Pin#. To make a payment or to speak to a customer service representative you can call 877-256-2510. Dear LISA GOSS, Your Verizon cellular account, with the cellular number ending in 4186, is delinquent and has an amount owed of $ 109.62. At times a bill might have been lost or forgotten and we are here to help clear this up. You can Bo through our Aubmatbn System b submit a Credit Card Payment by calling (BBBH83-8183. If yyoou would like b submit a dispute you cen gob WWW.CHASEREC.COM. UNLESS YOU NOTIFY THIS OFFICE WITHIN 30 DAYS AFTER RECEIVING THIS NOTICE THAT YOU DISPUTE THE VALIDITY OF THIS DEBT OR ANY PORTION THEREOF, THIS OFFICE WILL ASSUME THIS DEBT IS VALID. IF YOU NOTIFY THIS OFFICE IN WRITING WITHIN 30 DAYS AFTER RECEIVING THIS NOTICE THAT YOU DISPUTE THE VALIDITY OF THIS DEBT OR ANY PORTION OF IT, THIS OFFICE WILL OBTAIN VERIFICATION OF THE DEBTOR OBTAIN A COPY OF A JUDGMENT AND MAIL YOU A COPY OF SUCH JUDGMENT OR VERIFICATION. IF YOU REQUEST OF THIS OFFICE IN WRITING WITHIN 30 DAYS AFTER RECEIVING THIS NOTICE THIS OFFICE WILL PROVIDE YOU WITH THE NAME AND ADDRESS OF THE ORIGINAL CREDITOR, IF DIFFERENT FROIvI THE CURRENT CREDITOR. Thia.s an atrempt ro r a debt and any imo~ot o6teNted t~ be used 1br triatpurpcse. DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT. Home Phone: Work Phone: PAY ON LINE www.chaserec.com~pnymethod.php To access your account online use the following PIN# 19016 Payment Methods Available: Credit Card, Electronic Payments over the phone, Post-Dated Electronic Payments, Money Orders, Certified Checks, Western Union-(City Code=Chase Receivables, Score CA.) VERIZON WIRELESS-NORTHEAST 052037905800001 Chaseff 05082328.98 VZ CHASE RECEIVABLES 1247 BROADWAY SONOMA CA 95476 LISA GOSS 1457 RYLAND DR MECHANICSBURG, PA 17050-1977 AMOUNT: $ 109.62 OHR129-1006-19305304913] Quest ~ ~ Diagnostics 17025007 5306063 7220%40252 7 czoeeu 11230 it23o I-r o0 GOSS LISA J 7457 RYLAND DR MECHANICSBURG, PA 77050-1977 ~ ~r u~~~u t~~~uu~r~i~~ruut~~~r~u~i u~~u r~r~r~i~u r~m ~~~ Page 1 Laboratory Invoice For services not included in your physician's bill. Invoice Number 7220840252 Lab Code KOP FINAL PAST DUE NOTICE This is the final notice you will receive from our office To inform you this invoice is seriously past due. Please make payment immediately }o prevent your account from being forwarded to a licensed collodion agenry for further collodion action. If further action is necessary; you may also be liable for additional expenses and cosh, as permiHed by law, which can substantially increase the amount you owe. Patient Name Date of Service Amount Due Payment Due Date Responsible Party Requested by: Invoice Date GOSS LISA J Pk:ase tooted us today and do not ignore this notice. Thank you for using our laboratory. P14'I'tEleti't7i#it~LltJt+E~~t~~. iRTFb. Tax ID # 38-2084239 May 10, 2011 $as.os 1,0/14/2011 GOSS LISA J '~;DAVIS,LISA September 23, 2011 If you have Medicare, Railroad Medimre or Medimid as your primary or sewndary insurance, please sand ua the information - eee reverse aide ® Please fold and tear payment coupon along pedoration and romit with payment in the envelope provided ~ . _. _. __ __. Payment Coupon Please make check payable to: Quest Diagnostics. Please include invoice number on your check. Quest Diagnostics also accepts MasterCard, Visa and American Express. Please complete credit card information on reverse or visit our website at www. QuestDiagnostics. tom/bil I. MAIL PAYMENTS ONLY TO: Amount Due $48.06 Payment Due Date 10/14/2011 Invoice Number 7220840252 Lab Cade KOP Patient Name GO;SS LISA J Amount Enclosed IXX N YYYNYY roan 30B Quest Diagnostics PO BOX 740775 CINCINNATI OH 45274-0775 ~ ^ Check here if address has changed. Indicate change on back. _ Ouest Diagnostics reserves the right to assign this receivaGe to any of ih aFiliefes. Irlrrlrlrlr,tlrllrrrlrlrrlllrrrlrr,lltrrlrlrlrlrrrlrlrlrlrrrll 01KOP48~17220840252000048~68092341701910135890000001 The CPT codes prodded ore based on AM4 guidelines and without regard to specific payor roquiremenfs. Estate Information Services, LLC ~~~~ 2323 Lake Club Drive Suite 300 ~rer°'°f°rma"°° s°`T`°°s' It°. COl13iTlbuS, OH 43232 Hours: Mmi-Thu Sam-9pm and Fri Sam-Spm EST Toll Free: (877) 714-3739 Phone: (614) 322-2758 Fax: (614) 322-2761 www.probate-caze.com 09/09/2011 MICHAEL CHEREWKA, ESQUIRE 624 N FrontSt Wormleysburg,PA 17043-1022 4 ~u~~~~u~~~~~u~~~~~~~l~u~~~~~~~~~~~~~~~~~~~u~~~~~~~~~~~~~~ RE Estate 0£ LISA J GOSS Creditor Name:Citibank NA Account Type: CITI MASTERCARD Amount of Debt:$1,876.45 Account Number: * ***** * ***** 1168 Reference #:2956611 Dear Attorney MICHAEL CHEREWKA, ESQUIItE: As attorney for the estate, you are aware that an estate claim was filed on behalf of Citibank NA in the above- referenced estate. We aze requesting that the estate provide to us a copy of the estate's inventory that was filed with the probate court. It is imperative that we inform Citibank NA if the estate has recognized the estate claim as valid. In matters such as these, the executor or executrix has access to supporting documentation such as cancelled checks, statements or check registers indicating past payments made by the late LISA GOSS without dispute:. We can provide this information if absolutely necessary. We would appreciate the estate requesting the above information before issuing a disallowance if all that is needed is supporting documentation to determine the validity of the claim. If you wish to discuss an eazly settlement of the estate claim, please feel free to call our office at the toll free number listed above and ask to be connected to the proper legal assistant handling the claim. Thank you for your assistance toward a prompt resolution of this matter. Estate Information Services, LLC is a debt collection company. This is an attempt to collect a debt from the assets of the estate of LISA GOSS and any information obtained will be used for that purpose. Calls may be monitored or recorded for quality assurance purposes. Very Truly Yours, %~,,~c~~ Andrew C. Hall, Esq. Estate Information Services, LLC E~~J~ 5-, LISA GOSS 1457 RYLAND DR MECHANICSBURG PA 17050-1977 ..i.Il.nl...I..I..nll.i..pl.gl.I.i.I..IIIPhILI.Plnnhn 08/28/2011 Dear E-ZPass Customer: Pennsylvania Turnpike Commission E-ZPass Customer Service Center 7631 Derry Street Harrisburg, PA 17111 Attn: CSC Account # 937571 Ref: 13776434 We have attempted to notify you by telephone and/or mail that your E-ZPass account is not in good standing due to an insufficient balance. It is important that you contact our office immediately to settle your insufficient balance and to bring your account into good standing. Continued use of E-ZPass will result in violations, which are subject to additional fees. If your account is referred to collection, you will be unable to resolve the matter with the Pennsylvania Turnpike Commission and $25.00 will be charged to your account for the cost of collecting the unpaid balance. Because we value you as a customer, please take the time now to bring your account up to date so that you can continue to enjoy the convenience of E-ZPass. If you have any questions about this letter, please call the E-ZPass Customer Service Center immediately at 1-877-PENNPASS (1-877-736-6727). At the prompts select 1 fc~r E-ZPass Customer Service Center/Violations, and then 5 for the Accounting Departmennt. Sincerely, •~z~s• FINAL NOTICE PTC E-ZPass Customer Service Center Accounting Department Transworld Systems° ~a0o1 VVt.el OVLV IL <VUJNI CW I"I Wl" 2235 Mercury Wav. Suite 275, Santa Rasa, CA 95407 Phone 18881 446-4733 ...REGIONAL OFFICE.. . 980 HARVEST DRIVE,#202, BLUE BELL PA 19422 TEL. 866-689-8937 r'14,h,,,Ilhll,uglll.,ulldlllhPlr'hrl"hllldlllr' INIIIIVIIwI1111111NN~II~IIIIIIIVl1111111 LISA J GOSS 1457 RYLAND DR MECHANICSBURG PA 17050-1977 Lisa J Goss AMOUNT DUE $75.00 IMPORTANT - -The 30-day FDCPA dispute period commenced when you received our first letter. Our client still shows an unpaid account in the above stated amount appearing due and owing by you. TSI is a nationwide collection agency authorized to pursue collection of this debt. You may make continued collection efforts unnecessary by resolving this matter. Our demand for payment does not affect your right to dispute this debt as described in our first letter. Please mail your payment, along with this letter for proper identification, to our client's address below. Send correspondence, other than payments, to this collection agency at P.O. BOX 12103, TRENTON, NJ 08650 CVS/CAREMARK PO BOX 659539 SAN ANTONIO TX 78265 Our Clients Phone: 800-556-8631 Transworld Systems Inc. is a collection agency attempting to collect a debt and any information obtained will be used for that purpose. This communication is from a debt collector. We are required under some states' laws to notify consumers of certain rights as detailed in the list on the back of this notice. Consumers have rights under state and federal law that are not described in this letter or in the list on the back of this notice. SAN FRANCISCO, LOS ANGELES, NEW YORK, CHICAGO, DALIAS, PHILADELPHIA, DENVER, SEATTIE, PHOENIX, HONOLULU, ATIANTA, BOSTON, MIAMI AND OTHER MAIOR CITIES SEPTEMBER 12, 2011 CVS/CAREMARK ACCT NO.: 7557P-5068735651 CLIENT REF.: 506873565 COLEEC ORSL COLLECTION AGENCY SRVIr'F 77 Hartland Street, Suite 401 P.O. Box 260431 East Hartford, CT 06128-0431 R•M•S Reeervable R9anagemen[ Sen~ices B19DC50100053101' LISA J GOSS 740 STERLING CT ENOLA PA 17025-2655 I~~~III~~~Iilr~~~~l~l~l~lll~l~l~ll~~11~1~~1r1~~l~~lll~~1111111 Dear Policyholder: DEBT=-- =°T~ Phone: 800-969-8340 Current Date: November 15, 2011 RMS Claim Number: 471865514 Account Number: 0490306530 Amount Due: $62.00 Erie Insurance cancelled the policy(s) listed below as you were previously notified. They provided insurance from the effective date to the cancellation date and have indicated they are entitled to the unpaid-named premium of $62.00. Policy Number Effective Date Amount Due Cancellation Date 0490306530 01/03M2011 $62.00 09/09Y2011 If ydu replaced your coverage or sold the item insured, please attach proof of the insurance or a record of the same of the item. If jus(and correct, please return your payment or necessary documentation to resolve the unpaid premium balance. You may fax the documentation to 1-860-282-6691. Failure to respond will result in further collection activity. You can also pay online at www.erieinsurance.com or by phone at 1-800-387-1492. Any qquestion about your account should be directed to the Erie Insurance Collection Unit at 1-800-969-8340. However, if you wish to dispute this, refer to the notice on the reverse side of this letter. Receivable Management Services Please use Account Number in all communications to Erie Insurance NOTICE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION WE ARE ACTING AS A DEBT COLLECTOR. THIS LETTER IS AN ATTEMPT TO COLLECT THIS DEBT AND ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. IMPORTANT: TO INSURE PROPER CREDIT. PLEASE RETURN THIS LOWER PORTION TOGETHER WITH YOUR REMITTANCE. LISA J GOSS 740 STERLING CT ENOLA PA 17025-2655 RMS Claim Number: 471865514 Account. Numbe r: 0490306530 Amount Due: $62.00 Mail Payment to: ERIE INISURANCE Collection Department 100 Erie Insurance Place ERIE, PA 16530 before you SIGN IT! Races as low as 2.99% APR* C0 _ Auto Finance 'See revere far imPartairt d'ncloaures regeNirg ihv aaer. Pagel W 3 14100.965.7070 www.capitalone.com Jun. 06 - Jul. OS, 2011 30 Days in Billing CyGe Ysa Platinum loocx-xJOa-locxx-tD22 NEW BALANCE MINIMUM PAYMENT DUE DATE 514,394.83 5349.00 Aug 02, 2011 flfitgMVATIFASfiHSAM WM Credd Limit: E20,000.00 Cash Credit Limit: $10,000.00 Available Credo: $5,605.17 Available Credit for Cash: E5,606.17 Previous Balance $12,578.96 MINIMUM PAYMENT WARNINfa: ttyou make Doty the minimum payment each pedod, you will pay mare in ime2st end R x111 take you longer b pay ofi yar balance. For ezample: Payment Amount Fach Pedod' If No Appmzimam Time m Pay Off Estimated AddhiomlCharges Are Made Statemem Balance Total Cost Minimum Payment 32 Years $35,530 $520 3Vears $18,709 Your estimated savings O you logy off this balanre in 3 years: 516.621 If you would Ilke infmma8w abcart credtt wunseling services, wll 1-668-3268055. LATE PAYMENT WARNING: Owe do nM receive your minimum payment by your due date, you may have to pay a late foe of up b $35.00 and your APRs may be increased up to the Penalty APR x(29.40%. Payments and Credits Fees and Interest Charged ~Transafions New Balance - $62fi.47 + $206.05 + I S:?,236.27 = $14,394.83 TRANSACTIONS PAYMENTS, CREDITS & ADIUSTMENTS FOR KARL S AIKEY #1022 1 161UN TARGET 00@2020MECHANICSBURGPA ($26.47) 2 01 JUL CAPITAL ONE ONUNE PYMTAuthDate 27-lUN ($600.00) TRANSACTIONS FOR KARL S AIKEY #1022 1 03 JUN WEGMANS #45MECHANICSBURGPA $22.26 2 04JUN TURKEY HILL #280ENOfAPA $21.00 3 OS IUN TARGET 00@2020MECHANICSBURGPA $35.93 4 OS JUN DICKS SPORTINGGOODSHAMPDEN TOWNSPA $100.97 5 06 JUN TURKEY HILL #260ENOLAPA E26.40 6 06 JUN TARGET 00022020MECHANICSBURGPA $75.61 7 061UN WEGMANS #45MECHANICSBURGPA E16.24 B 07 JUN TARGET 00022020MECHANICSBURGPA ~ $57.84 9 07 JUN WAL-MART #1886MECHANICSBURPA $20.20 10 071UN STAPLES 00116442CAMP HILLPA E42.39 11 O7JUN WEGMANS#45MECHANICSBURGPA $36.28 12 07 JUN WEGMANS #45MECHANICSBURGPA $12.30 13 DB IUN TURKEY HILL #280ENOlAPA E42.SD 14 09JUN TARGET OOOZ2020MECHANICSBURGPA $7,94 15 09 JUN Bes[Buy OD014767MECHANICSBURGPA g52,gg Tra nsactions continue on page 2 REWARDS INFORMATION PREVIOUS AVAILABLE REWARDS BAL4NCE $127.24 REWARDS EARNED THIS PERIOD $27.61 (reflects transactions posted during this killing ryde) AVAILABLE BALANCE AS OE 07/f15Rm 1 $154.85 For up•to-date rewards tracking, visit www.lapftalone.com CNQf/A$$/C+ Pewdrd5' or almply call tA00.220.1001 INTEREST CHARGE CALCULATION Your Annual Percentage Rate (APR) isthe annual interest rate on your aanunt. Type of Balance Annual Percentage Balance Subject to Interest Charge Rate (11PR) Interest Rate Purchases I 17.90%~ D $14,DD6.53 $2D6.D5 Cash 24.90%~ D $D.DD E0.00 PLEASE RETURN PORTION BELOW WITH PAYMENT OR LOG ON TO WWW.CAPITALONE.COM TO MAKE YOUR PAYMENT ONLINE. 1 4003442530611022 05 0000000600000349004 Account Number: 4003-4425-3061-1022 Due Date New Balance Minimum Payment Amoum Enclosed Aug 02, 2011 $14,394.83 $349.00 PLEASE PAY AT LEAST THIS AMOUNT PAPERLESS STATEMENTS Stop waiting for the mailman. View up to 13 months of statements anytime-online. Sign up at www.capitalone.com aooom PUC-10-2012 2fy:25 Frum: MIST LEND~iNS SUPRT 71 T955179 Tn: BS i'17=324774 P.2~3 REGULAR SAVINO$ (,y~,Qau,H,T: Primary Owner Usa J Goas Ancaom Numbor/SuNu 276171 A0 Date A({Oynt Established 1900/2000 P,indpal Balance at Date of Death $94AF Accrued Interest to Dat¢ pi Death SD.OC Total Pmtupal and Axrued !nteraet $04.¢6 Name nt Jdnt Owne~ Meliaaa ,4 Harris Dmle Joint Established 6128?:009 Date Arcnunt CIO%fd i 1126•'2011 ~Mf~CI(!NQ ACCOUNL, Drlmiry Owner Liaa J Ooaa ACCOUni Number/SuHtx 2701 %L11 Data Acppynl Edabliahatl 12/05123ro5 Principal Habnce at Oale of G¢ath 146.92 Accrued Interest to Dale of Death ao.oD Total PrmWpai and Ars:ruotl interest $148.92 Name of Jdnt Owner Meliae0 A Harris Oau Jeint Established 6/25/2009 Cate Acwunl Closed 11 /25/'GO1 VISA ACCOUNT: Drimsry Owner Lea J Ooss ACCeunt NVmbp/SyNie 46729¢0000220277 DatO Opened 1/09!2906 PrindDel Balance al Data of Deatt $007040 Name Cf Jomt Cardhdder None Date Charged Of( t 1!20!2011 LOAN ACCOUNL Primary Owner Lisa J Boss ACCOyM, NumbaNSUffix 27617102' D¢U ODanad 2!1012014 Principal BFIa11Ce $69$6,6 LVin Typ¢ UO¢ppUred/COm(aaU¢I PIBQge Of ShBree Ccllateral Se:cwed N/A Int¢re¢t RaW 8.99Wc Noma of Co•Borrawer None CharOe-off Ostp 11/20/2011 'lean do¢a not nav¢ sae InaVran A. ,My/EM3L•RS ter FED/,~E/,~R~ApL4O/REDIT UNION T®saa~ ~~ ~/ Londiny Insurance Suppod 5'~Decialist August 10, 2012 Eatsle oh L.ias J Goas Date oP Death: 06?0&2Ms Social S¢CUrlty NumW r: 1 b7-Ij0-7b73 5(/fJ~ Louise llnvr. P.O. IIrnc 4(f MechtUncsbury„ Pennsylvania 17055 (AG(1) i$'1-2328 www.mnmbcr+lr.orK