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HomeMy WebLinkAbout10-17-12 (2) 1505610101 - REV-1500 Ex ~o~ _~o, Y OFFICIAL USE ONL PA Department of Revenue enns lvania °EPARTMEN.oFRE~EN~E P Y County Code Year File Number Bureau of Individual Taxes PO Box 28o6oi INHERITANCE TAX RETURN ENT DECEDENT S Harrisburg, PA 1y128-0601 RE ID ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY (~ Decedent's Last Name Suffix Decedent's First Name MI ~' 1 ' 6 ~'"[ R ~ r~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI C~R~ ~~z cry R~€~~ ~ Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~ a ~ '~ ~ ~ ~ ~ ~ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death O 4. Limited Estate Q 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received O 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) prior to 12-13-82) O 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes O 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ~ ~. ~ `~ ~ ~ ~-~ c ~ ~ rz ~ +~ ~ t `~ '~ a 3 ~ Cow ~° First line of address `~~a R~~CY~, ~~~~ Second line of address City or Post Office ~~~t P6~~Ns~~-@~ State P~ ZIP Code REGIST~ OF WILLS US~`ONLY ' ~. Q P.J ~.,t 7 '1 ;. 3 i-,- ~ ~ 7 ~~: ~ -' ~ -- ~-~~ i- S DDATE FIL Q i-w ~ ~ ED ~n •~ -M c Correspondent's a-mail address: 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. SIGN URE OF PERSON ESPO SIBLE FOR FILING RETURN DATE ADDRESS ~~~ ~i~~~~ R~ ~~~PP~s~~P.~ ~'~ i~a~ ~~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY 1505610101 Side 1 1505610101 J h~~~ 1505610105 - REV-1500 EX Decedent's Social Security Number ~. , . ' , -. ~ C- r .- i ; ~ ~ ~ Decedent s Name: ~ ,_e RECAPITULATION • . ~ . 1. Real Estate (Schedule A) ............................................. ~ ~ 1. x . . 2. Stocks and Bonds(Sdtedule 8) ....................................... 2. Y a 'Jtik~ ''j[~i4rG~1i'S i"fF~•r ~~4F4 . 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................... 4 ; ~, ) '~ ~ t~ 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... s ~j ` a 5 r ¢ ~ ~ ~ o O 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... _: 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property r ~''''~` °*"'~j9"-~ (Schedule G) p Separate Billing Requested........ 7. ' = _ ~ 4. 8 ~ ~ 3 ~ 8' ~ 8. Total Gross Assets (total Lines 1 through 7) ............................. ._ Q tt 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. s ~ ~ ` ` ~ C7 'U ~~~ 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10.3 ~ ~ .~ 11. Total Deductions (total Lines 9 and 10} ................................. 11. ~ ~ x ~' ~"~ 3 12. 13. 14. Net Value of Estate (Line 8 minus Line 11) ......................... Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................... Net Value Subject to Tax (Line 12 minus Line 13) ................... ..... 12. b ~~ ..... 13. ;, &- ..... 14. 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 _ 16. 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. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT k Side 2 L 1505610105 1505610105 O 1505610101 - REY-1500 °` ~~'-1O' 1~ PA Department of Reveruie P~ Bureau of Individual Taxes °.aE~E"°` Po Box s8o6oi INHERITANCE TAX RETURN Harrisburg, PA 1')128-o6oi RESIDENT DECEDENT OFFICIAL USE ONLY County Code Year File Number i~V n ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY Decedent's Last Name Suffix Decedent's First Name MI (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~ a~g`.''~~ ~±g~~ ~[ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW i 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 O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number •~ First line of address `~ g ~ ~~ 0 G~, RSA D Second line of address City or Post Office ~ ~-~ ~ P 6' ~ N s (~ v -~ Gj State P~ ZIP Code REGIST~OF WILLS US'~r+ONLY lV rn~ ~ ~ t _ ~ .._ - r.:, , i-, C3C>' a ..'''.' ~ _~ ~ ~ =;~ - ~ } = - .. _ o ;. . ~~ DATE FILED `~ run t ~~s~9~~ ~~. Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return, inGuding 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. IBLE FOR FILING RETURN DATE -~-~ - ~a A DRESS - n ^ 1 ~ ~ S ~$a 21 p~~ R~ S~t~PP~Sgv~ I" t'1 1 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 ~vv REV•1508 EX + (1-97) . SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHRESIDENTDECEDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~. c AS1~} old HRH D ~ ~~a •OC~ Q cN~c)-c~Nf~ f~ccu~ nr' A~ c c ~ t~~~s g~~K ~ C~~Ba•$~1 c~- oo-~ 9~~ 1-'-I RAP ~~s~ PR~v>Ip~~c~, R~ ~~q~® ~~~~L~~ ~ r~c~~~oo Q W~~RiN~ /~~P~IR~>~ ~ '3oa~~~ O ~j~t~5 J PAi i~7i N ~i~tcK-KN~cK5 ~ ~CSO ~©C~ ~ICK-~P TRUCK ~-- Nlss~}~ ~fZ~NT~~~Z, ~~`~~ ~ ~jQc~~.O~ C_:J f~ v~"o rn~ ~i ~, ~ - 1 ~ ~ ~ r ~ C ern R R ~ , ~~ 1 ~ ~ ~ 3 , r ~ ~ ~ `rl TOTAL (Also enter on line 5, Recapitulation) I $ ~ ~ ~ ~a~ , REV-1511 EX+ (10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER mRR~ ~-. c~~R ~o~a - oc~~~~ Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~ c: f Yl S L L ~ t~ ~~ nD ~..~ tAL ~ -yl ) fide,-~'~sP~rJ GAR-- $RtrK~2 ~~N~~L ~~m~~ 5~~ ~ ~7 ~(~.~~ t~J ~ ~. I--~ A ~ i -~ -~ ~ ~ ~ imp ~ ~ ~ ~., S s ~~, ~`T"~•rv1 ~ ~~D S i~,t ~ ~ v~ 1 ~ 00 l B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant ~_~{©©ti i ~.,2 f~-~. ('` ~-(Z~,/~. s ~. _ _ Street Address ___I g aC T1 t ~ ~ ~ 0 ~ ~__ city ~ ~ ~ P P ~~ S~j1~ fZ ~~ State r ~ Zip l ~ o~ Relationship of Claimant to Decedent Jc--~ Q~II S l~J! OO G.1~,(~. 4. Probate Fees 5. I Accountant's Fees 6. ~ Tax Return Preparer's Fees 7 State Zip TOTAL (Also enter on line 9, Recapitulation) $ ~3 ~ ~'i ~ ~ '3 (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF m ~ ~~ ~ y ~ ~~ ~ FILE NUMBER ~c~~a. - d~o89 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~ ta~ySs Qd Ba~C sus ~ c~,~~ L ~~ ~ ~-~ , ~ ~- ~o ~ 9 ~ ~~~At~ m~Dilc~t~ ~xP~rvs~s ~INP~~~ B;' i~s~~.~r~~~ 5~~: iT~m~ ~~d g~~s ~ ~~~5 a~ P ~ N,{~~ ~ Igssac ~~-~,S ~i c~~L~SL~ fl~~~s~,~~ ~J~s~~s 1 c~ Svmm ~ ~ PN~'s~ci~}~J 5~~~ ~ cis ~ 3p .~O ~ ~.,~.o~ Y1~1 ~0 i cf}-~ ~~.~~1Z ~•~ 1 Loa.. lob TOTAL (Also enter on line 10, Recapitulation) $ ~ ~ ~ Cp~ ~ • Q ~ (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (11-08) ~ pennsylvania SCHEDULE DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY po Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 2116 (a) (1.2),] i ~~~~~~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, A S APPROPRIATE, II NON-TAXABLE DISTRIBUTIONS; A, SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 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, insert additional sheets of the same size, my Executrix, then I appoint my daughter, BRENDA JOYCE FARROW, Executrix. No Executor~Executrix named hereiri shall be required to furnish bond or other security in any jurisdiction for the faithful performance of his/her duty, but if bond is nevertheless required, it shall be without surety. ARTICLE FIVE In addition to the powers conferred by the common law, statute, or any other provisions hereby, my Executor/Executrix is hereby empowered as follows: A. To sell at public or private sale, to exchange, to lease, to pledge, to mortgage, to transfer, to convert, or otherwise dispose of, or grant options with respect to, any and all property, real, personal or mixed, at any time forming a part of my probate or trust estates, in such manner, at such time or times, for such purposes, for such price or prices, and upon such terms, credits, and conditions as sha!! be deemed advisable or necessary under the circumstances; ; B. To make distribution in division of the probate estate in cash, in kind, or partly in both; C. To distribute .items of tangible personal property to a minor or to his or her guardian or to any person taking caring of the minor to hold for the minor within the limits authorized by statute or rule of law; D. To compromise any claim or controversy; E. To apportion between principle and income any receipts and disbursements and to ascertain income and principal in accordance with the statutes and rules of law of the Commonwealth of Pennsylvania; F. To make, execute, acknowledge, and deliver any and all instruments which may be deemed advisable or necessary to carry out any of the powers herein granted or provided by law; THIS !S THE SECOND OF FOUR PAGES OF THIS MY LAST WILL AND TESTAMENT .r-~ r ~7 MAR ANN ARR DATE OF EXECUTION G. To invest and reinvest the principal of the estate together with any accumulated income thereon in all forms of property without being limited by any statute or rule of law concerning investments by fiduciaries; H. To disclaim inheritances and interests in property. ARTICLE SIX Notwithstanding any other provision of this will, I direct that if any beneficiary of mine is under eighteen years of age, my Trustee shall retain whatever share such beneficiary otherwise would have received hereunder and apply so much of such share or the income thereof as my Trustee considers advisable for the beneficiary's support, education, and welfare, accumulating any income not needed for these purposes. When a beneficiary attains the age of eighteen years, the Trustee shall distribute to such beneficiary the then remaining principal and income of his or her share, discharged of the trust. My Executor/Executrix shall have the authority to appoint a trustee for any trust created under this will. IN TESTIMONY WHEREOF, I have hereunto subscribed my name to this, my Last Will and Testament, consisting of this and two preceding typewritten pages, and for the purpose of identification l have signed and dated each page, all in the presence of the persons witnessing it at my request on this the ~,~ day of September, 2007, at Shippensburg, Pennsylvania. MAR ANN RR THIS IS THE THIRD OF FOUR PAGES OF THiS MY LAST W1LL AND TESTAMENT ~- ~'- v_~ MAR ANN RR DATE OF EXECUTION The foregoing instrument, consisting of this and three preceding typewritten pages, was signed, published and declared by MARY ANN CARR to be her Last Will and Testament, in our presence, and we, at her request and in her presence and in the presence of each other, have hereto subscribed our names as witnesses on this the ~ day of September, 2007, at Shippensburg, Pennsylvania. REST ING AT ~ ~ ~~ ~~ D / -----~-- ITNESS RESIDING AT ~~ I THIS IS THE FOURTH OF FOUR PAGES OF THIS MY LAST WILL AND TESTAMENT r Qs.o~ MARY ANN ARR DATE OF EXECUTION • •. . COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND RE: WILL OF MARY ANN GARR The undersigned, who are witnesses to the Will of the above named Testatrix to which this Affidavit is attached, being duly sworn, according to law, may hold as follows: 1. That each of us is an adult resident of the Commonwealth of Pennsylvania and that we are witnesses to a Will executed by MARY ANN CARR on this the 5 day of September, 2007. 2. That the Testatrix declared the above-dated instrument to be her Last Will and Testament and requested that each of us be witnesses thereto. That the Testatrix signed the said Will in the presence of each of us and that we, in her presence and the presence of each other, signed the said Will as witnesses on the date and at the place indicated above. 3. That at the time of the execution of said Will, each of us is of the opinion that the Testatrix was of sound mind and over eighteen years of age. 4. That this Affidavit is executed on this the ,S~ day of September, 2007. WITNESS WITNES Sworn to and ubscribed before me on this the ~ day of September, 2007. NOTA UBLI t~totari~l Ss~l M commission ex Tres: ~+~t Nottman, ~~- Pubtk y p moron jati~rnahlp, Fre.nktt~ County ~yy ~C: - ~•.',~3[~!t Cxpifli Ma~rCh 2, 2009 ~ Citizens Bank PO Box 7000 -' ROP-450 Providence RI 02940 AT 01 079177 29127E251 A*'"3DGT I~II~~1~~~111111~11~1~11'~1~11~11~~'II'~~I~~III~II~~~I~~'~II~~~I~ CARTER H CARR SR 982 RIDGE RD SHIPPENSBURG PA 17257-9722 1-888-910-4100 Please call us anytime for answers to your questions, account information, current rates or to update your address & phone number. Checking Account Statement © OF 2 Beginning January 06, 2012 through February 03, 2012 Checking US102 SUMMARY CARTER H CARR SR MARY ANN CARR Balance Calculation Green Checking Previous Balance 7 , 791.17 XXXXXXX691-4 Checks 1,056.06 - Withdrawals 1, 603.92 - Deposits & Additions 3,930.47 -a- Current Balance 9,061.66 = You can waive the monthly maintenance fee of $4.99 by maintaining an average daily balance in your account of $1,500 or making 5 qualifying transactions. Your average daily balance this statement period is $7,636 Your number of qualifying transactions this statement period is 14 A Senior waiver is active on your account so monthly maintenance fees are not currently being assessed. TRANSACTION DETAILS Checks" There is a break in check sequence C he~~ # Amount Date Check # Amount Date ,, 36.23 (~'3155 01/06 3162 229.30 01/17 * 3158 43.74 01/11 3163, 67.40 ~ 01/31 31{9 465.00 01/11 16 '~ ~ ~ 13.56 01/25 3161* 163.30 01/13 16 ~ 37.53 02/02 _ ._ . ~ f ~„~._r._ . Withdrawals ATM/Purchases Date Amount Description 01/17 '~~ 00.00 0301 ATM Cash - M16270 Shippensburg West Drive-U, Shippensbu 01/24 • 500.00 0301 ATM Cash - M16270 Shippensburg West Drive-U, Shippensbu Other Withdrawals Date Amount Description 01/09 -~i 112.56 Discover Arc Pa menu 120106 1 k 01/18 /32:17 # 0000003 7 Chec Centurylink Bill Pymt 120117 01/31 19.38 heck # 000000 mcc ChecKpaymt 120131 6 02/03 / 139.81 Check # 000000316 Discover Arc }~ayymenu 120202 k - # 00000031b8 Chec ~-- Previous Balance 7,791.17 in Totat cne,~ Y 1,056.06 Total Withdrawals `'l 1, 603.92 Member FDIC Qs Equal Housing Lender ~,~ Citizens Bank 1-888-910-4100 Please call us anytime for answers to your questions, account information, current rates or to update your address & phone number. Checking continued from previous page Checking Account Statement © OF 2 Beginning January 06, 2012 through February 03, 2012 Deposits & Additions CARTER H CARR SR Date / Amount Description MARY ANN CARR 01/11 01/25 / 674.00 1,492.00 US Treasury 303 Xxsoc Sec 011112 US Treasury 303 Xxsoc Sec 012512 Green Checking 02/01 02/01 1 509.,47 255 00 T]'c83 Pennon Fu Pension-Ck 120126 a r US Tr 303 X S 020112 XXXXXXX691-4 . y e su xsoc ec ~ Total Deposits & Additions 3,930.47 Daily Balance Date Balance Date .Balance Date Balance 01/06 7,754.94 01/17 6,915.04 01/31 7,474.53 01/09 7,642.38 01/18 6,882.87 02/01 9,239.00 01/11 7,807.64 01/24 6,382.87 02/02 9,201.47 01/13 7,644.34 01/25 7,861.31 02/03 9,061.66 NEWS FROM CITIZENS --ImportantInformation: The Monthly Maintenance Fee on Green or Personal Savings accounts can be waived by maintaining a $300 minimum daily balance or via an automatic savings plan with a deposit in each statement period of at least $25. The Monthly Maintenance Fee on IRA Savings accounts can be waived by maintaining a $500 minimum daily balance or via an automatic savings plan with a deposit in each statement period of at least $25. Set up an automatic savings plan using Steady Save(R}, Goal rack Savings{SM} or Direct Deposit, or use Repeating Transfers through Online Banking to deposit the required minimum amount into your savings account to waive the fee on your account. --We all have savings goals. Whether it's a new home, a child's education, retirement or being prepared for unexpected expenses, Citizens Bank makes it easy and rewarding for you to start saving. Creating an emergency savings account can prepare you for unexpected events and help you reach your savings goals. No matter what you're saving for, we have a great savings solution. Ask your banker about what savings accounts and programs are right for you. We also offer money market accounts and CDs with competitive rates and the peace of mind of FDIC insurance. For more information or to open a new account, visit your local branch today or call 1-888-821-3900. Member fDIC. See a banker for FDIC coverage amounts and transaction limitations. --Give help. Give hope. Be inspired. Please join us in saluting our new Champion in Action at citizensbank.com/community. r"~ Current Balance 9,061.66 Member FDIC ~ Equal Housing Lender W. A. H A RTM AN Branch: 1301 E. Market Street MEMORIALS, L.L.C. Order No...................~~`~.~. 459 Noll Drive Charlottesville, Virginia ~\ ~ .`,~l,J/ HARRISONBURG, VIRGINIA 22802 Dial (434) 293-2570 C`"~,`~ ,` ~.~~-'C"' ,,~^' Dial (540) 434-2573 -~.........f~ wr-' -~-""~ hereby order of W. A. Hartman, Harrisonburg, Va., Monuments as per Size and Material given below. y ~."`'~. ...... Date .... 7 ~) .... Price $..~.~:,.'r.' °~...`4..~' `r.,J' Street ~ ...r-.~~..'°.......~~~~~:~--.......~~.~ ................................ ~ ~ ~ .. State Tax ........ Total $..~...:~".......i...~..:. ~:-~ .................. Balance $....................... ~'' Deposit $ ........................ ........... Terms :......................................................... . ~ ~ ` ~~ "~ To be erected in '~.,!.... .....:~.....~~~4„~ ................ Cemetery, located about .................................................................................................. ~~~~~... If the above cemetery charges floraerecting memorials this is to be added to the above price. r,, , Design No. or Description ........~..~-........~......!~~?[:'~,.........:~~........~,...~~~...:"'.~. ~`".~.....~~..:-~w~..::~:~?':rf.~..~,.... ~~ ....................................... .. . Delivery to be made on or about :°~..::::. .. DIE , Materia .1.~`:`~::..... Size .~:,... ~.....:..~... ~.... ~.'..!...`.~-':~ ................ Top ...~~~~^:,. . .......C~`!~.... y .......................................... ~ Enda :~.~. H x Front ~ Back ... ~-,~:~1'.~ .......................................... BASE ~ j Size .~.»>.N..~..~...~...............~~... •.~...5~...T...~......... Remarks : . ............................................................................ 11 .. Customer Phone ...t~...........~~........ LETTERING FAMILY NAME, Etc. Face ............... .........................,...~"......~t..~i............................................. Back ...............~-.....°""6..'!J.1..~.`t..............................................,.............................. INSCRIPTION AS FOLLOWS 3u~y ~~, 1439 i°~~c<y ANN F~~a 4, 1940 ACV ae~ a~1 a MARKERS Number ................................. Des. No. and Description ........................................................................................................................ Wanted ............................ Material .............................................:.................................... Size ........................................ Kind of Letters ................................................................ Top Finish ........................................................................................................ Sides Finish ............................................................................................. POSTS OR FOOT STONES I, or we hereby acknowledge this order is correct and agree that firm is to make delivery as near time specified as possible, but they are not to be held responsible for unavoidable delays, due to strikes, accidents, providential causes or other contingencies. This order is not subject to countermand nor are verbal agreements recognized. In any case where purchaser fails to comply with the terms of this contract, then it is agreed by and between the parties that purchaser shall pay to the fast party as liquidated damages Fifty per cent (50%) of the purchase price above recited. I further agree that the above mentioned work shall remain the property of the said W. A. Hartman, until paid for. I further agree if Lithochrome paint is used on above mentioned work it will not be guaranteed. There will be an additional charge for any engraving on above monument after erection in cemetery. "A finance charge of 1.5 percent per month will be added to your account when the same is past due for a period of ninety (90) days." ~ / -~.~ Purchaser ...~,~!~~~!~::....~~ ..............!l:`.......................................Salesm ....~........... ,, o .. ,-. m U ~;'„~. ~ ~ . ,i ~ C } a d^~ ~ m m c , :g ~ `' ~ .. ~ [`~/ C w3 F :~5 ~ fn 4 ~~ a e ~.._. '::k 1 N O ~ o . 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Li. ORIGINAL 4110 .o,~, F ER D ~ F~ ACCT. NO. ~~ ~ ~~ Funeral Services ~ ~ ~~ ~ 1 ~ V`,~- C~~~ l.~ Name of Deceased C~ CHECK # ~ ~ FOGELSANGER-BRICKER ^ CREDIT FUNERAL HOME, INC. CARD ^ OTHER LAST BALANCE $ ~ f/ j"" INTEREST LATE PAYMENT ^ H R E SUB TOTAL CREDITS LESS PAYMENT ~~~~ NEW BALANCE Q~®~~ 5784 Greenmount Rd. Harrisonburg, VA 22802 (540)833-2891 STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED ECEASED Mary Ann Carr NO. 12-009 ATE OF DEATH January 20, 2012 ATE OF STATEMENT January 21, 2012 rofessional Services Basic services,_of.funeral.director and staff $ -0- Service..Package,_Price...,....... $ _0_ . Embalming _.N..ormal...Rema.ins........._ ................... ............. -0- Autopsied Remains _p_ $ -0- If you selected a funeral that may require embalming, such as a Hera! with viewing, you may have to pay for embalming. You do it have to pay for embalming -you did not approve if you selected rangements such as a direct cremation or immediate burial. !f we urged for embalming, we will explain why below. Reason for embalming: Authorization for embalming by : I. Other Preparation of ,A:.,..Reconstructive..Restoration.,,,, . -0- ..................................................................... .. B. Hairdresser ...... _0_ ,C... Washing..and.,Disinfecting .............................•...._• - ................................................. 0- D. Dressing and Casketing _0_ ~. Funeral Home Facilities $ -0- _A.,,..Facilities,_&..staff_for_viewing.,&/o,r,visitation..,.•..,._,,,,,,,,,,,,,,,,•. -0- ,B,;.,,,,Facilities..&..staff.for.service„in,.church/chape.l,,,,,,,,,,,,,,,,,,,, 375.00 -C;,..,Facilities._&_staff_for memorial service -0- D. Equipment & staff for graveside service -0- .E..,,,,Equipment..&„staff,for.viewin,g..in,.another,facility,,,,.,.,... -0- F. Shelter of Remains _p_ . Automotive Equipment A. Removal vehicle to transport remains $ 375.00 to funeral establishment -0- .8,....,Hearse ............................... ........_.........._............. . -0- C......Limousi.ne/family.car .................... ....................................................._.................. _ 0- .. D. Flower vehiclelutility vehicle ... • ....... ........ ............ ..._................................................._..,..................................,..... -0- E. Lead/service vehicle .........................._......................:......................._.................................._...._................................................................ ..._ -0- F. Extra mileage charge for out of town ........._use............ rr!!......@.$.:.........._/mi:..each_vehicle -0- $ -0- I. 'FUNERAL MERCHANDISE A. Casket ............._ ................. -0- DescriptionCasket B. Outer burial container ..................................._................_..........._. ............................... 850.00 Description: Concrete Box C. Cremation urn °~-0- D......Guest„Registe,r,Book ................. ......................._ -0- E. Temporary Grave Marker _,.,.,..,,,. -p- F. Acknowldgement cards at $ _0.0000 _/box of 25 ............................... ....................._..... -0- G. Air Shipment._Tra.Y...._.-...................._..._ ............... -0- H. Casket Spray _p_ I. ...Me.morial...Folders .............................. ................ -0- J. Bulletins ............. -0- $ 850.00 II. DIRECT CREMATION $ '0- * See General Price List for complete description III. IMMEDIATE BURIAL $ -0- '` See General Price List for complete description ;. FORWARDING REMAINS TO ANOTHER $ -0- UNERAL HOME "See General Price List for complete description . RECEIVING REMAINS FROM ANOTHER $ 1,395.00 UNERAL HOME * See General Price List for complete description ~TAL FUNERAL HOME .... ,,... $ 2,620.00 XIII. CASH ADVANCES .A:.....Q.pen.ing.. &..closing...grave ..................................................... ......... 550.00 .8.:.....Cemete.~!..charges ........................................................................... ........ -0- -~:.....1-1.onora_rium_for.clerg.Y ............._..............._........................ . ........ ........ -0- .D:.....S.pedal,.m.usic ........................................................_..........._.................... ........ -0- E. Paid obifuary notice .................................................................................................._............................_..........._,..._.. ........ -0- F. Certified copies of death certificate 0 @ $ 0.00 each -0- _G:.....Flowers.and,.sales.tax ............................................................... ._........ -0- .H.: Orga.nisi ........................................ -0- .I....•....Lon.g..distance_•phone _calls .................................................... ....... J..•..Commercial, trans.portatio,n._service ...................... ....... -0- .K,.....Cremato.ry,.charges ......................................................................... ....... -0- L. State Medical Examiner's fee -0- .M...•„Out. of,town,, fu,nera l,_home__cha rges .................... ....... -0- ,N.:..,,.,Weekend/Holiday...va.ult._ch_arges ........................ -0- O. Tent .......... .....:..... -0- ........... -0- ........... XIII. CASH ADVANCES ........................_.,..................,. 550.00 SUMMARY Total Funeral Home Charges.__..,•••....••..•..•..._..•....•..•....,_. $ 2,620.00 State Sales Tax (if applicable) •••••~•~~ ~~~~~~~~•~•~•~•~ $ 42.50 Total Cash Advances ..................................................,........................ $ 550.00 GRAND TOTAL ............................_.........._...._........................ ............ 3,212.50 ....$ Less Credits and Prepayments Less Guaranteed Funeral Amount $ -0 Less Preneed Payment $ -0- BALANCE DUE..........._....._ ........................ ............ 3,212.50 .....$ Billing To DISCLOSURES: '`Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will explain reasons in writing below. " We may charge you for our services in arranging the following Cash advance items: WARRANTY: The only warranty on the casket or outer burial container,or both,sold in connection with this service is the express written warranty if any granted by the manufacturer. This funeral home makes no warranty, express or implied ,with respect to the casket or outer burial container. ACKNOWLEDGEMENT AND I hereby acknowledge that I have the legal right to arrange the final services for the deceased, and I authorize this funeral establishment to perform services, furnish goods, and incur outside charges specified on this General Price List and have been offered for review the Casket Price List and the Outer Burial Container Price List. I also acknowledge execution and receipt of a copy of this Statement. TERMS OF PAYMENT: January 22, 2012 The Balance Due is payabl After 30 days a finance charge oflntere monthly (ANNUAL PERCENTAGE RATB~F18.0('/o)will be added to the unpaid portion of the Balance Due, which is the AMOUNT FINANCED, I agree to pay and/or guarantee payment of the charges listed on this Statement, plus any applicable unanticiaped late fee. In the event of default of payment, I agree to pay reasonable attorney's fees and court costs. I agree that the--.liability is being personally imposed by law upon the estate, and this agreement does not constitute a release of liability. By my signature below, acknowledgement and agreement of the above is hereby made. Signed ° Dated Co-Signed Dated Co-Signed Dated ACCEPTANCE Our funeral establishment agrees to provide all services, mercha dise and cash adv n es indicated on this Statement. ay .. Receipt for Payment McMullen Funeral Home, Inc. 5784 Greenmount Rd. ~" ,., :~~ Harrisonburg, VA 22802 ~~~ ''" R eceived from Carter Carr The sum of $3,212.50 on 02/25/2012 Contract Balance $0.00 BILLING STATEMENT For customer service, please call Toyota Financial Services at (800) 874-8822, or visit us online at www.toyotafinancial.com. Statement Date Account Number SUMMARY OF CHARGES 2/15/2012 027 6431295 Past Due Payment Amount $0.00 Unpaid Late Charges $0.00 Miscellaneous Charges $0.00 Current Payment Due $319.38 Total Amount Due $319.38 Payment Due Date 3/03/2012 To avoid a late charge of $6.39 your payment must be received before 3/ 14/2012. ACCOUNT INFORMATION Regular Payment Amount $319.38 Last Transaction Amount $319.38 Date of Last Transaction lY/30/2012 Monthly Payments Made 22 Maturity Date 4/03/2015 Outstanding Balance* $12,136.44 'Outstanding Balance is not your payoff amount. To obtain your payoff amount and payoff instructions, ple ase visit us online at www.toyotafinancial.com or contact Toyota Financial Services at (800) 874-8822. Please refer to the back of this statement for important information on negative credit reporting, check processing and the specially designated address when sending any communication regarding disputed payoffs. TOYOTA t. ~. F; ,: O J~~~ ~~ ~ ~ •~ .~I- P .. ~Op R~ ~,. :..;~~"~ Plus 1.9% APR for u to 5 ears p Y on ALL new Toyota vehicles. Visit toyotafinancial.com/militaryusa Offer good through March 5, 2012 I~F~ Nave an iPhone? Download and open the F • ,~. TFS mobile app, then scan this QR code to help you quickly register your TFS account ~~ and pay your bill online. ~ ~ ^ Visit the Apple App Store and download the free myTFS app today! IMPORTANT: To ensure timely delivery, please detach this portion and mail in the enclosed envelope with your payment. Make check or money order payable to Toyota Financial Services. Include your account number and name on the front of your checkor money order. __ __ - TOYOTA AB 01 049109 39677 B 159 C II"I"IIII'I'I'Illlll"III'I'II~~IIII"I'Ill~llllllll'Illllllll' CARTER CARR 982 RIDGE RD SHIPPENSBURG PA 17257-9722 Account Number 027 6431295 Payment Due Date 3/03/2012 Total Amount Due $319.38 Amount Enclosed $ . Please fill in circle completely if you're '" using the form on the reverse side to update your address or phone number. III1~111~1111~1"II"III'IIIIIIIIIIIIIIIIIIIIIIIIIII'Il~llll'1111 TOYOTA FINANCIAL SERVICES PO BOX 5855 CAROL STREAM IL 60197-5855 027643],295 1 0031938 0032577 REV-1500 EX Page ~ File Number Decedent's Complete Address: ~ ©~ ~ - ©v ~ ~9 DECEDENT'S NAME t~~ ~ ~~ ~~ STREETADDRESS ~ ~ ~ ~ 1 D ~~ n ~ CITY _- - - ~1~IPP~~~~~~G ', STATE 'ZIP 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. (1) -~- Total Credits (A + B) (2) ~' (3) .~' (4) -~' (5) ~" 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; or .......................................................................................................................... ^ 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 ar security at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ........................................................................................................................ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(x)(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(x)(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(x)(1.3)]. Asibling is defined, under Section 9102, as an individual vrho has at least one parent in common with the decedent, whether by blood or adoption.