HomeMy WebLinkAbout11-05-12 (3)J 1505611185
REV-1500 EX (02-11)(FI)
OFFICIAL USE ONLY
PA Department of Revenue County Cotle Vear File Number
Bureau oflndivitlualTazes INHERITANCE TAX RETURN
Po soxzaosot 21 12 0228
Harrisburg, PA '17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Numbef Date of Death MMDDYVVV Date of Birth MMODVVVV
066-14-3193 02042012 06301920
Decedent's Last Name Suffiz Decedent's First Name M I
FYRSTER CYRIL B
(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
REGISTER OF WILLS
FILL IN APPROPRUITE BOXES BELOW
® 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (Date of Death
Prior to 12-13-82)
^ 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 Deposit Bones
(Attach Copy of Will) (Attach Copy of Trust.)
^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credit (Date of Death ^ 11. Election to Tax under Sec. 9113(A)
Between 12-31-91 and 1-1-96) (Attach Schedule O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
CRAIG A• HATCH, ESQ, CELA 717-731-9600
First Line of Address
1013 MUMMA ROAD
Second Line of Address
SUITE 100
City or Post Office
LEMOYNE
State ZIP Code
PA 17043
REGISTER OF WILLS USE R,N~Y
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Correspondent'se-mail address: C•HATCHaGATESLAWFIRM•COM
Under penalties of perjury, I tleclare that I have ezaminetl this return, inclutling accompanying schedules and statements, antl to the best of my knowletlge antl belief,
it is true, correct antl complete. Declaration of preparer other than the personal representative is based on all infonnalion of which preparer has any knowletlge.
VERONICA COLLIER, CO-EXECUTOR V-P,ts-u~LC:~. (~8--e-C/uti Il~~l2-
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE ? //l DATE
CRAIG A• HATCH, ESQ•, CELA ~~~`~ /O~ /~3dist
ADDRESS
1013 MUMMA ROAD, SUITE 100 LEMOYNE, PA 17043
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505611185 OM464]3.000 1505611185
J
1505611285
REV-1500 EX (FI)
Decedent's Social Security Number
066-14-3193
o de rsN a FYR9TER CY RIL 6
RECAPITULATION '.
1. Real Estate (Schedule q) - - - ~ 1. 0
2. Stocks and Bonds (Schedule B) . 2. 4 , 3 8 6. 3 3
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) , 3. ~ . Q Q
4. Mortgages and Notes f~eceivable (Schedule D) 4. ~ • ~ ~
5. Cash, Bank Deposits a~d Miscellaneous Personal Property (Schedule E) 5. 2 2 , 616. 4b
6. Jointly Owned Propert
~ (Schedule F) ^ Separate Billing Requested g_ 0 • 00
7. Inter-Vivos Transfers Miscellaneous Non-Probate Property
(Schedule G) '~, ^ Separate Billing Requested 7. 16 4 , 1 ~ 0 • 0 ~
8. Total Gross Assets (to ~al Lines 1 through 7) g, 191,1 D 2 • 7 8
9. Funeral Expenses and Administrative Costs (Schedule H). g. 15 ,105.66
10. Debts of Decedent, Md rtgage Liabilities, and Liens (Schedule I) , , , , , , , , , 10, 7 , 9 0 8. 3 7
1 L Total Deductions ([ota ~ Lines 9 and 10), .. 11. 2 3 , 014 • 0 3
12. Net Value of Estate (L neBminusLinell) 12. 168,088 • 75
13. Charitable and Gover mental Bequests/Sec 9113 Trusts for which
an election to tax has of been made (Schedule J) , . 13. Q • ~ Q
14. Net Value Subject to ax (Line 12 minus Line 13) . 14. 168 , 0 88.7 5
TAX CALCULATION - S E INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 to ble
a[ the spousal tax rate, or
transfers un~er Sec. 9 16
16. Amount of Line 14 x
~ ~ble
at lineal ratex.o 4 168,088.74 1s. 7,563.99
17. Amount of Line 14 to ble
at sibling rate X.12 Q. ~~ 17. ~'~~
18. Amount of Line 14 to ble
al collateral rate X .15 0, ~ ~ 1 g 0. 0
19. TAX DUE .i . 19. 7,563.99
20. FILL IN THE BOX IF IOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
1505617285 1505611285
oMasae a.aao
REV-1500 EX (FI) Page 3
File Number
,~ n»a
Decedent's Com late Address: ~ y y
DECEDENTS NAME
Y T R CYRIL 6
STREET ADDRESS
D STATE ZIP
an _
H R PA
Tax Payments and Credits: 7 , 563.99
1. Tax Due (Page 2, Line 99) (1) -
2. CreditslPayments
A. Prior Payments ~ '
B. Discount ~ ' 0
Total Credits (A+ B) (2) _ (J • a o
3. Interest ~ .
(3) _
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. O . Q O
Fill in box on Page 2, Line 10 to req{rast a refund. (4) -
5. If Line 1 + Line 3 is greater than Lin@ 2, enter the difference. This is the TA% DUE.
(5) _ 7,563.99
wlake check payable to: REGISTER OF WILLS, AGEf~T.
PLEASE ANSWER THE f~OLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a trarjsfer 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 Merest . . . . . . . . . . . . . . . . . . . . . ^
d. receive the promise f~r life of either payments, benefits or care? . . . . . . . . . . . . . . . .
2. If death occurred after f]~ec. 12, 1982, did decedent transfer property within one year of death x
without receiving adequ~te consideration? . . . . . . . . . . . . . . . . . . . . . . . .
trust for' or payable-upon-death bank account or security at his or her death?
3. Did decedent own an "ini
ll
4. Did decedent own an ingividual retirement account, annuity, or other non-probate property, which ^
contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . .
IF THE ANSWER TO ANY OF THE I~BOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN
For dates of death on or after July i, 194, 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, ~i,,1995, the tax rate imposetl 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 statutedoes 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.
Fa dates of death on or after July 1, 20010:
• 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 th child is 0 percent [72 P.S.§9116(a)(L2)].
• 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 p2 P.S. §9116(a)(1 )].
• The tax rate imposed on the net vatWe 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 4~ho has at least one parent in common with the decedent, whether by blood or adoption.
OM4611 2.000
REV-1503 E%a (698)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ATE OF FILE NUMBER
Cyril B Fvrater 21 12 0228
All property Jointly-owned with right of survlvorshlp must be disclosed on Schedule F.
3wasss i.ooo (If more space is needed, insert additional sheets of the same size)
REV-1508 E%t (1140)
pennsylvania SCHEDULE E
oeanarn~erarof aeveNUe CASH, BANK DEPOSITS, & MISC.
I EsioEM oEC ENTruRr~ PERSONAL PROPERTY
FILE NUMBER:
Cyril H Forster 21 12 0228
OwaaAD 2.000 If more space is needed, use addRional sheets of paper of the same size.
REV-1610 EX + (OB-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
Cyril B Fyrster 21 12 0228
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM
NUMBE DESCRIPTION OF PROPERTY
irvawer~wsnE OF nE mnrvsFSaae rasia aawnorvswa ro oECEOExr nrvo
rr~onre of musFaa nrrncnncovr of rHS Oaao FOa aaa~esrnrs.
DATE OF DEATH
VALUE OF ASSET
%OF DECDS
INTEREST
EXCLUSION
IF nPaucna~e
TAXABLE
VALUE
1~ Real Estate located at 508
Alleaview Drive, Mechanicsburg,
Upper Allen Township,
Cumberlaad Couaty,
Pennaylvaaia, Tax Parcel
Number: 42-28-2423-406,
Traasferred to The Fyrater
Family Trust dated November 20,
2006, by Deed dated November
20, 2006 and recorded oa
November 30, 2006 in the Office
of the Recorder of Deeds in and
for Cumberland Couaty, PA is
Deed Book 277, Page 3875. 164,100.00 100.0000 0.00 164,100.00
TOTAL (Also enter on line 7, Recapitulation) $
If more space is nestled, use additional sheets of paper of the same size.
9W46AF 2.000
REV-1511 E%. (1P-09)
pennsylvania
DEPAa1MENT OF REVENUE
INHERITANCE TA% RETURN
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF ' °' "'"°"'
aril B Fyrater 21 12 0228
Decedent's debts must be reported an Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
t Malpezzi Funeral Home 2,787.42
B.
1
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
Citv
State ZIP
Year(s) Commission Paid:
2. Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant
Street Address
a.
5.
6.
7.
1
2
5W46AG 2.000
City Slate ZIP
Relationship of Claimant to Decedent
Probate Fees:
Accountant Fees:
Tax Return Preparer Fees:
The Patriot Newa
Publication of Estate Notice
Cumberland Law Jouraal
Publication of Eatate Notice.
Total from coatinuation schedules .
TOTAL (Also enter on Line s, Recapil
If more space is needed, use additional sheets of paper of the same size.
4,000.00
123.50
130.31
75.00
7,989.43
Estate of: Cyril B. Fyreter 21 12 0228
Schedule H Part 7 (Page 2)
3 The Whimsical Poppy
Funeral flowers 318.00
4 Theo's Bar and Grille
Funeral luncheon 1,354.83
5 Various (receipts)
Food and driake for Military Memorial Service
luncheon. 410.56
6 American Legion
Military Memorial Service burial rites and military
honors donation. 160.00
7 Wegmaa's
Food for nursing home staff; clearing decedent's
room. 50.31
8 Rick Barr Plumbing, Iac.
Repair work at house needed to sell. 180.50
9 Rick Barr Plumbing, Iac. Repair work at house seeded
to sell. 182.50
10 Mumma's Appliances
Appliance Replacement of broken dryer at house
seeded to sell. 503.50
11 Lowe's
Toilet replacement at house needed to sell. 303.25
12 Rick Harr Plumbing, Inc. Toilet replacement at house
seeded to sell. 209.50
13 Deaais Zerbe, Tax Collector
County/Township real estate taxes 563.48
14 Dennis Zerbe, Tax Collector
School real estate taxes 1,895.51
15 Allenview Homeowners Association
Homeowner's Association dues (February 2012 through
November 2012 @ $100/month 1,000.00
16 State Farm
Homeowner's insurance premium 459.58
17 United Water
Water bill 11.00
Total (Carry forward to main schedule) 7,602.52
Eatate of: Cyril 8. Fyrater
Schedule H Part 7 (Page 3)
18 United Water
Water bill
19 Upper Allea Sewer
Sewer bill
20 PP&L
Electric bill
21 United Water
Water bill
22 Upper Allea Sewer
Sewer bill
23 PP&L
Electric bill
24 United Water
Water bill
21 12 0228
7.01
112.00
71.00
8.90
112.00
64.00
12.00
Total (Carry forward to main schedule) 386.91
REV-,6,zEX.„z-O6)
pennsylvania SCHEDULE
OEFPRTME"Tor REVENUE DEBTS OF DECEDENT,
INHEwTANCE TAx wETUHN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
c'yril B Fyrater 21 12 0228
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
~~ Pinnacle Health Hospitals
Medical bill service date 1/7/12 72.91
2 Medical bill service dated 1/9/12 78.85
3 Medical bill service date 1/11/12 29.04
4 Medical bill service date 1/13/12 51.80
5 Medical bill service date 1/18/12 86.44
6 Medical bill service date 1/25/12 86.44
7 Medical bill service date 1/6/12 72.91
8 Chaae Freedom Visa
credit card balance due 4,515.22
9 Messiah Village
Nuraiag home bill 4.66
10 Nursing home bill 913.00
11 Nuraiag home bill 1,392.98
12 Holy Spirit Hospital
Medical bill 469.98
13 Central Pa Pulmonary Asso c.
Medical bill 20.00
14 Dr. Rilmore
Medical bill 5.00
15 Alert Pharmacy
Pharmacy bill 59.75
16 pleat Shore 8MS
Ambulaace bill 49.39
B W J6AH 2.000
TOTAL (Also enter on Line 10, Re
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+(01-10)
Pennsylvania
DEPPATMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDEM
SCHEDULE J
BENEFICIARIES
ESTATE OF: FILE NUMBER:
C ril 8. rater 21 12 0228
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Llat Trustee(s) OF ESTATE
_ TAXABLE DISTRIBUTIONS pnclude ouMght spousal disMbutions and transfers antler
Sec. 9116 (a) (1.2).]
1, Veroaica Collier
526 Alleaview Drive
Mechanicsburg, PA 17055
One Third of Residue: 56,029.58 Daughter 56,029.58
2 Lorraiae Caffarella
542 Allenview Drive
Mechaaicsburg, PA 17055
Oae Third of Residue: 56,029.58 Daughter 56,029.58
3 Fyrater James
1773 South Meadow Drive
Mechanicsburg, PA 17055
One Third of Reaidue: 56,029.58 Son 56,029.58
EMER DOLLAR AMOUNTS FOR DISTRIBURONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 CUVi
ewaeAi 2.000 If more space is needed, use additional sheets of paper of the same size.
DEATH
CERTIFICATE
~^
li.30; 8E'J r9/I I1
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal 4o duplicate this copy by photostat or photograph.
•e for this certificate, $6.00
f' ~8~94370
Certification Number
~ i
5
mMMOxwuux op Y xxsnvxxM • ozrxnrMFxr or x9xF
CERTIFICATE OF DEATH
This is to certify that the information here given is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will be forwarded to the State Vital
Records Office forpeyrmQan~ent filing.
Local Re,gis[raz Date Issued
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3
LAST WILL
AND
TESTAMENT
C~Op~
LAST WILL AND TESTAMENT
OF
CYRIL B. FYRSTER
I, CYRIL B. FYRSTER, now of 508 Allenview Drive, Mechanicsburg, Cumberland
County, Pennsylvania 17055, do publish and declare this to be my Last Will and Testament, hereby
revoking all other prior wills and codicils made by me.
FIRST: Fa81iLy Background and Annointment of Executor.
(A) Family and Backgfound Information. I was married, my wife, WINIFRED V.
FYRSTER, having predeceased me on July 17, 2005. My children aze VERONICA COLLIER,
LORRAINE CAFFARELLA, and JAMES FYRSTER. Throughout this Wi11,VERONICA
COLLIER, LORRAINE CAFFARELLA, and JAMES FYRSTER will be referred to as "my
children". The word "issue" will include my children as well as my other descendants.
(B) Annointment of Executor. I appoint as my Executors (all hereinafter referred to as
Executor) under this Will, the following named persons to serve without bond and without being
required to account to any Court:
Executors: My children, VERONICA COLLIER, LORRAINE
CAFFARELLA, and JAMES FYRSTER, to serve jointly or individually.
(C) Inter Vivos Trust. The inter vivos trust agreement referred to in this Will is entitled
"THE FYRSTER FAMILY TRUST", byand between myself, CYRIL B. FYRSTER, as Settlor,
and myself, CYRIL B. FYRSTER, as Trustee.
SECOND: Funeral and Last Illness Exaenses: Taxes.
(A) ~xnenses of Funeral and Last Illness. I direct my Executor to pay my funeral
expenses and the expenses of my last illness from my estate.
(B) Taxes. I direct my Executor to pay any and all estate, inheritance, succession, legacy,
transfer and other death taxes or duties, by whatever name called, including any and all interest and
penalties thereon, imposed under the laws of any jurisdiction by reason of my death upon or with
respect to any and all property included in my gross estate for the purpose of such taxes, ywhe~ther
LAST WILL AND TESTAMENT
CYRIL B. FYRSTER
PAG
such property passes under or outside of this Will. Without any apportionment otherwise required
bylaw and without being prorated or apportioned among or chazged against the respective devises,
legatees, beneficiaries, transferees, or other recipients of any such property or chazged against any
property passing or which may have passed to any of them, I direct that any taxes so paid shall be
chazged against my residuary estate. My Executor shall not be entitled to reimbursement for any
portion of any such taxes from any such person. The foregoing provisions of this Article SECOND
shall not apply to such portion or portions of said taxes, interest and penalties which may be required
to be paid, or are actually paid or reimbursed, by the Trustee of the Trust described in Pazagraph
FIRST (C), above.
THIRD: Tangible Personal Property. Except for those items excluded below and those
items enumerated in the Letter of Instruction, I bequeath all my tangible personal property, including
but not limited to clothing, jewelry, heirlooms, furniture, household furnishings, personal effects,
motor vehicles, and all other similaz articles, which I own, and the insurance thereon, to my children,
VERONICA COLLIER, LORRAINE CAFFARELLA, and JAMES FYRSTER, living at the
time of my death, to be divided among them as they may select in as nearly equal shares as is
practical.
Notwithstanding any other provisions in this Article THIItD, I may leave a separate, dated
and unsigned Letter of Instruction, which I shall place with my Will, containing directions as to the
ultimate disposition of certain of the property bequeathed under this Article THIRD, and such Letter
of Instruction shall determine the distribution of such items.
FOURTH: Residuary Estate. I devise and bequeath all of the rest, residue and remainder
of my estate, real, personal and mixed, of whatever nature and wherever situated to which I am
legally or equitably entitled, to the then-acting Trustee of the Trust described in Paragraph FIRST
(C) of this Will, to beheld, administered and distributed pursuant to the terms thereof, as the same
may be amended from time to time. By this devise and bequest of my residuary estate I hereby
exercise all Powers of Appointment I possess at the time of my death except any power of
appointment which I possess under the Trust described in Pazagaph FIRST (C) of this Will.
FIFTH: Powers of Executor. in addition to the powers and duties as may have been
granted elsewhere in this Will, but subject to any limitations stated elsewhere in this Will, the
Executor shall have and exercise exclusive management and control of the Estate and shall be vested
with the following specific powers and discretion, in addition to the powers as may be generally
/~~~
LAST WILL AND TESTAMENT
CY L B FYRSTER
PA
conferred from time to time upon the Executor by law:
(A) In the management, caze and disposition of the Estate, the Executor shall have the
power to do all things and to execute such instruments, deeds, or other documents as may be deemed
necessary or proper, including the following powers, all of which may be exercised without order
of or report to any Court:
(1) To sell, exchange or otherwise dispose of any property at any time held or
acquired hereunder, at public or private sale, for cash or on terms, without advertisement,
including the right to lease for any term notwithstanding the period of the Estate, and to grant
options, including any option for a period beyond the duration of the Estate.
(2) To invest all monies in such stocks, bonds, securities, mortgages, notes, choses
in action, real estate or improvements thereon, and any other property as the Executor may
deem best, without regard to any law now or hereafter enforced limiting investments of
fiduciaries.
(3) To retain for investment any property deposited with the Executor hereunder.
(4) To vote in person or by proxy any corporate stock or other security and to agree
to or take any other action in regard to any reorganization, merger, consolidation, liquidation,
bankruptcy or other procedure or proccedings affecting any stock, bond, note or other
security.
(5) To use attorneys, real estate brokers, accountants and other agents, if such
employment is deemed necessary or desirable, and to pay reasonable compensation for their
services.
(6) To compromise, settle or adjust any claim or demand by or against the Estate and
to agree to any rescission or modification of any contract or agreement affecting the Estate.
(7) To renew any indebtedness, as well as to borrow money, and to secure the same
by mortgaging, pledging or wnveying any property of the Estate.
(8) To retain and carryon any business in which the Estate may acquire an interest,
~~ .~
LAST WILL AND TESTAMENT
CYRIL B FYRSTER
PAGE 4
to acquire additional interest in any such business, to agree to the liquidation in kind of any
corporation in which the Estate may have an interest and to carry on the business thereof, to
join with other owners in adopting any form of management for any business or property in
which the Estate may have an interest, to become or remain a partner, general or limited, in
regard to any such business or property and to hold the stock or other securities as an
investment, and to employ agents and confer on them authority to manage and operate the
business, property or wrporation, without liability for the acts of such agent or for any loss,
liability or indebtedness of such business if the management is selected or retained with
reasonable care.
(9) To register any stock, bond or other security in the name of a nominee, without
the addition of words indicating that such security is held in a fiduciary capacity, but accurate
records shall be maintained showing that such security is a Estate asset and the Executor
shall be responsible for the acts of such nominee.
(B) Whenever the Executor is directed to distribute any Estate assets in fee simple to a
person who is then under twenty-one (21) years of age, the Executor shall be authorized to hold such
property in Trust for such person until he/she becomes twenty-one (21) years of age, and in the
meantime shall use such part of the income and the principal of the Estate as the Executor may deem
necessary to provide for the proper support and education of such person. If such person should die
before becoming twenty-one (21) yeazs of age, the property then remaining in Trust shall be
distributed to the personal representative of such person's estate.
(C) In making distributions from the Estate to or for the benefit of any minor or other
person under a legal disability, the Executor need not require the appointment of a guardian, but shall
be authorized to pay or deliver the same to the custodian of such person, to pay or deliver the same
to such person without the intervention of a guardian, to pay or deliver the same to a legal guazdian
of such person if one has already been appointed, or to use the same for the benefit of such person.
(D) In the disbursement of the Estate and any division into sepazate trusts or shares, the
Executor shall be authorized to make the distribution and division in money or in kind, or both,
regazdless of the basis for income tax purposes of any property distributed or divided in kind, and
the distribution and division made and the values established by the Executor shall be binding and
conclusive on all persons taking hereunder. The Executor may in making such distribution or
division allot undivided interests in the same property to several trusts or shares.
ids
LAST WILL AND TESTAMENT
2
CYRIL B FYRSTER
PAGE 5
(E) The Executor shall be authorized to lend or borrow, including the right to lend to or
borrow from any trusts which I may have established during life or by will at an adequate rate of
interest and with adequate security, and upon such terms and conditions as the Executor shall deem
fair and equitable.
(F~ The Executor shall be authorized to sell or purchase at the fair market value as
determined by the Executor, any property to or from any trust created by me during life or by Will,
even though the same person or corporation maybe acting as Executor of my estate or as Trustee
of any of my other trusts.
(G) The Executor shall have discretion to determine whether items should be charged or
credited to income or principal or allocated between income and principal as the Executor may deem
equitable and fair under all the circumstances, including the power to amortize or fail to amortize
any part or all of any premium or discount, to treat any part or all of the profit resulting from the
maturity or sale of any asset, whether purchased at a premium or at a discount, as income or principal
or apportion the same between income and principal, to apportion the sales price of any asset
between income and principal, to treat any dividend or other distribution of any investment as
income or principal, or apportion the same between income and principal, to charge any expense
against income or principal or apportion the same, and to provide or fail to provide a reasonable
reserve against depreciation or obsolescence on any assets subject to depreciation or obsolescence,
all as the Executor may reasonably deem equitable and just under all the circumstances. If the
Executor does not exercise the above discretionary power, the cash or accrual allocation shall be in
accordance with Chapter 81 of Title 20 of the Pennsylvania Consolidated Statutes, or the
corresponding provisions of subsequent state law.
(H) If at any time the total fair mazket value of the assets of any Trust established or to
be established hereunder is so small that the corporate Trustee's annual fee for administering the
Trust would be the minimum annual fee set forth in the Trustee's regularly published fee schedule
then, in effect, the Trustee in its discretion shall be authorized to terminate such Trust or to decide
not to establish such Trust, and in such event the property then held in or to be distributed to such
Trust shall be distributed to the persons who are then or would be entitled to the income of such
Trust. If the amount of income to be received by such persons is to be determined in the discretion
of the Trustee, then the Trustee shall distribute the property among such of the persons to whom the
Trustee is authorized to distribute income, and in such proportions, as the Trustee in its discretion
shall determine.
i AST W i L AND TESTAMENT
4E
CYRIL B FYRSTER
PAGE 6
(n Except as otherwise provided in this Will, when the authority and power under this
Will is vested in two (2) or more Executors or Trustees, the authority and powers aze to be held
jointly by the Executors or Trustees, respectively. A majority of the Executors or Trustees may
exercise any authority or power granted under this Will or granted by law, and may act under this
Will. Any attempt by one such Executor or Trustee to act under this Will on other than ministerial
acts shall be void. The action of one such Executor or Trustee under this Will may be validated by
a subsequent ratification of the act by a majority of the Executors or Trustees.
SIXTH: RiP~-ts and Liabilities of Executor and Trustee.
(A) No bond or other security shall be required of any Executor.
(B) This instrument always shall be construed in favor of the validity of any act or
omission by any Executor, and any Executor shall not be liable for any act or omission except in the
case of gross negligence, bad faith or fraud. Specifically, in assessing the propriety of any
investment, the overall performance of the entire Estate shall be taken into account.
(C) Each Executor shall be entitled to receive reasonable compensation for services
actually rendered to my estate, in an amount the Executor normally and customarily chazges for
performing similaz services during the time which he/she performs the services.
SEVENTH: Tax Elections.
(A) In determining the estate, inheritance and income tax liability relating to my Estate,
the Executor's decision as to all available tax elections shall be conclusive on all concerned. In
accordance with IRC Section 2632(a) and without regard to whether a Federal estate tax return is
actually filed, my Executor shall allocate so much of the Federal Generation Skipping Transfer
(GST) exemption amount as will fully exempt any generation skipping transfer which may occur
under this Will.
(B) The Executor may, in its discretion, determine the date as of which my gross estate
shall be valued for the purpose of determining the applicable tax payable by reason of my death.
(C) The Executor may, in its discretion, decide whether all or any part of certain
deductions shall be taken as income tax deductions (even though they may equal or exceed the
~-
LAST WILL AND TESTAMENT
CYRIL B. FYRSTER
PA
taxable income of my estate and whether or not claimed or of benefit on my estate's income tax
return) or as estate tax deductions when a choice is available; and in the event that all or any part of
such deductions are taken as income tax deductions, no adjustment of income and principal accounts
in my estate shall be made as a result of such decisions.
EIGHTH: S~oendthrift Provision. No beneficiary shall have the power to anticipate,
encumber or transfer his or her interest in the estate in any manner other than by the valid exercise
of a power of appointment. No part of the estate shall be liable for or charged with any debts,
contracts, liabilities or torts of a beneficiary or subject to seizure or other process by any creditor of
a beneficiary.
NINTH: Defmitions and .eneral Provisions.
(A) 'val. Any beneficiary who dies within sixty (60) days after my death shall be
considered not to have survived me.
(B) Ca ns. The captions set forth in this Will at the beginning of the various articles
hereof aze for convenience ofreference only and shall not be deemed to define or limit the provisions
hereof or to affect in any way their construction and application.
(C) C ildr n. As used in this Will, the words "child" and "children" shall include
persons who are legally adopted and the issue of said persons, whether born in or out of wedlock,
so long as any person born out of wedlock is acknowledged in a written instrument executed by the
one of their natural pazents who is a descendant of mine to be the child of said descendant: The word
"issue" shall include descendants of all generations including adopted persons. A posthumous child
shall be considered as living at the death of his parent. The birth to me or the adoption by me of a
child or children subsequent to the execution of this Will shall not operate to revoke this Will.
(D) Code. Unless otherwise stated, all references in my Will to section and chapter
numbers are to those of the Internal Revenue Code of 1986, as amended, or the corresponding
provisions of any subsequent federal tax laws applicable to my estate.
(E) Other terms. The use of any gender includes the other genders, and the use of either
the singular or the plural includes the other.
~~
LAST WILL AND TESTAMENT
CY rr B FYRSTER
PAGE g
(F) Powers of Appointment are Exercised. By this Will I exercise any and all Powers
of Appointment which I possess at the time of my death except any power of appointment which I
possess under the Trust described in Pazagraph FIRST (C), above.
IN WITNESS WHEREOF, I, CYRIL B. FYRSTER, the Testator, have to this my Last
Will and Testament, typewritten on nine (9) pages, including the Acknowledgment and Affidavit,
set my hand and seal this ~~ day of November, 2006.
CY B. FYRSTER
Signed, sealed, published and declazed by the above-named Testator, as and for his Last Will and
Testament, in the presence of us, who have hereunto subscribed our names at his request, as
witnesses hereto, in the presence of the said Testator, and in the presence of each other. Each of us
further declares that he or she believes the Testator to be of sound mind and memory. The preceding
instrument consists of this and eight (8) other consecutively numbered typewritten pages including
the Acknowledgment and Affidavit.
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ACKNOWLEDGMENT AND AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF CUMBERLAND
The Testator and the witnesses whose names are signed and subscribed to the attached or
foregoing instrument, being first duly sworn and qualified according to law, do hereby acknowledge,
depose and say to the undersigned authority, that the Testator signed and executed the instrument
as his Last Will in the presence of the witnesses; that he signed it willingly or willingly directed
another to sign it for him; that he executed it as his free and voluntary act for the purposes therein
expressed; that each of the witnesses were present and saw the Testator sign and execute the
instrument as his Last Will; that each subscribing witness in the hearing and sight of the Testator
signed the will as witnesses; and that to the best of their knowledge the Testator was at that time
eighteen years of age or older, of sound mind and under no constraint or undue influence.
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Witness
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Sworn to or affirmed, subscribed to, and acknowledged, before me by the above-named
Testator and witnesses, this c~0 ~ day of November, 2006.
COMMONWEnf.a'H OF ?FNNSYLUANiei Notary ubhc i,~l ' ' I ;..,
ommission Expires:
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Ted L. Walker, Notary Public ( ~
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THE
FYRSTER FAMILY
TR T
v
THIS TRUST AGREEMENT is executed in triplicate on this ~~ day of November,
2006, by and between CYRIL B. FYRSTER, now of 508 Allenview Drive, Mechanicsburg,
Cumberland County, Pennsylvania 17055 (hereinafter called "Settlor") and CYRIL B.
FYRSTER, now of 508 Allenview Drive, Mechanicsburg, Cumberland County, Pennsylvania
17055 (hereinafter called "Trustee").
ARTICLE I. TRUST ESTATE
1.01. Initial Principal. Settlor, desiring to establish an irrevocable trust, does hereby
irrevocably transfer, assign and deliver to the Trustee and its successors, and assigns the assets
listed on Schedule A, attached hereto and made a part hereof. As further evidence of such
assignment, the Settlor has executed or will execute or cause to be executed such other
instnunents as may be required for the purposes of completing the assignment or transfer of title
to such property to the Trustee. The Trustee accepts such transfer and assignment to itself as
Trustee, and undertakes to hold, manage, invest and reinvest the assets of this Trust, and to
distribute the income and principal of the Trust in accordance with the provisions of this
Agreement.
1.02. Additional Principal. The Settlor and any other person or persons, with the
consent of the Trustee, shall have the right at any time to make additions to the corpus of this
Trust or any share thereof hereby established. All such additions shall beheld, governed, and
distributed by the Trustee in accordance with the terms and conditions of this Agreement. The
Trustee, in its sole discretion, may require, as a prerequisite to accepting property, that the
transferring party provide evidence satisfactory to the Trustee that (i) the property is not
contaminated by any hazardous or toxic materials or substances; and (ii) the property is not being
used and has never been used for any activities directly or indirectly involving the generation,
use, treatment, storage, disposal, release or discharge of any hazardous or toxic materials or
substances.
1.03 Disclaimer. The Trustee shall have the right to disclaim, in whole or in part, prior
to its acceptance by the Trustee, any interests in property for any reason, including but not limited
to a concern that such property could cause potential liability under any federal, state, or local
environmental law.
ARTICLE II. IRREVOCABILITY OF TRUST
2.01. Irrevocability. Settlor has been advised of the consequences of an irrevocable
trust and hereby declares that this Trust shall be irrevocable and shall not be altered, amended,
revoked, or terminated by Settlor or any other person or persons.
ARTICLE III. LIFE INSURANCE POLICIES
3.01. General Provisions. If any insurance policies are transferred into this Trust, the
Trustee shall be vested with all right, title, and interest in and to the transferred policies of
insurance, and is authorized and empowered to exercise and enjoy, for the purposes of the Trust
herein created and as absolute owner of such policies of insurance, all the options, benefits, rights
and privileges under such policies, including the right to borrow upon and to pledge them for a
loan or loans. The Trustee takes all rights, title, and interest in and to the above stated insurance
policies subject to any prior split-dollar life insurance agreement and assignments, which maybe
in effect at the time of transfer. The insurance companies which have issued policies aze hereby
authorized and directed to recognize the Trustee as absolute owner of such policies of insurance
and as fully entitled to all options, rights, privileges, and interests under such policies, and any
receipts, releases, and other instruments executed by the Trustee in connection with such policies
shall be binding upon all persons interested. in this Trust. The Settlor hereby relinquishes all
rights, title, interest and powers in such policies of insurance which Settlor may own and which
rights, title, interest and powers are not assignable, and will, at the request of the Trustee, execute
all other instruments reasonably required to effectuate this relinquishment.
3.02. Payment of Premiums. The Trustee shall be under no obligation to pay the
premiums which may become due and payable under the provisions of any policy of insurance
which maybe transferred or assigned to this Trust, or to make certain that such premiums are
paid by the transferor of such policy, or to notify any persons of the nonpayment of such
premiums, and the Trustee shall be under no responsibility or liability of any kind in case such
premiums aze not paid, except the Trustee shall apply any dividends received on such policies to
the payment of premiums thereon. Upon notice at any time during the continuance of this Trust
that the premiums due upon such policies aze in default, or that premiums which will become due
will not be paid, either by the transferor or by any other person, the Trustee, within its sole
discretion, may apply any cash values attributable to such policy to the purchase of paid-up
insurance or of extended insurance, or may borrow upon such policy for the payment of
premiums due thereon, or may accept the cash values of such policy upon the policy's forfeiture.
In the event that the Trustee receives the cash value of such policy upon its forfeiture for
nonpayment of premiums, the amount received shall be added to the corpus of this Trust, and
shall be administered according to the terms of this Agreement. If the insured under such
policies of insurance, becomes totally and permanently disabled within the meaning of any
policies and because thereof the payment of premiums, or any of them, shall during the pendency
of such disability, be waived, the Trustee, upon receipt of such knowledge, shall promptly notify
the insurance company which has issued such policies, and shall take any and all steps necessary
to make such waiver of premium provision effective.
3.03. Duties of Trustee With Regard to Life Insurance Policies. The Trustee shall
be under no obligation or duty whatever except with respect to the safekeeping of such policies
of insurance and the duty to receive such sums as may be paid to them, in accordance with the
requirements of this Trust, by the companies issuing such policies, and to hold, manage and
disburse such proceeds subject to the terms of this Agreement. Upon the death of the insured,
the Trustee shall make reasonable efforts to carry out the provisions of this Agreement, including
the maintenance or defense of any suit, provided, however, the Trustee shall be under no duty to
maintain or enter into any litigation unless its expenses, including counsel fees and costs, have
been advanced or guaranteed in an amount and in a manner reasonably satisfactory to the
Trustee. The Trustee may repay any advances made by it or reimburse itself for any such fees
and costs from any corpus or income of this Trust.
ARTICLE IV. TRUST DISTRIBUTIONS
4.01. Trust Principal. The entire corpus of this Trust, including the assets initially
transferred to this Trust, subsequent additions to this Trust, and the proceeds of any sale,
exchange or investment of such Trust assets, shall be used for the purposes herein contained.
4.02. Income Distribution. During the Settlor's lifetime, the Trustee shall distribute all
of the net income of the trust to, or for the benefit of the Settlor, CYRIL B. FYRSTER. The
Trustee shall make no distributions of principal to CYRIL B. FYRSTER. Upon the admission
of CYRIL B. FYRSTER to a long term caze facility for a period of time in excess of thirty (30)
days, the Trustee shall cease the distribution of income from this Trust to CYRIL B. FYRSTER
and such income shall accumulate to the principal of this Trust.
4.03. Pr1IlClnal Distributions. Upon the death of the Settlor, CYRIL B. FYRSTER,
the Trust shall terminate. Upon termination of the Trust, the remaining Trust estate shall be
distributed in separate and equal shares to the Settlors' children, VERONICA COLLIER,
LORRAINE CAFFARELLA, and JAMES FYRSTER, per capita.
4.04. General Power of Appointment. Settlors' children, VERONICA COLLIER,
LORRAINE CAFFARELLA, and JAMES FYRSTER, aze hereby jointly or individually
granted the general power to appoint some or all of the principal of this Trust to themselves. The
Trustee shall present such written notice to the Settlor who, upon receipt, shall have a period of
time not to exceed ten (10) business days to veto the proposed exercise. If and in the event that a
veto is not received by the Trustee as described above, then the proposed exercise shall be
deemed valid. This power shall not be exercisable under their Wills.
ARTICLE V. POWERS OF TRUSTEE
5.01. General Powers. In addition to such other powers and duties as may have been
ganted elsewhere in this Trust, but subject to any limitations contained elsewhere in this Trust,
the Trustee shall have the following powers and duties:
A. In the management, care and disposition of this Trust, the Trustee shall have the
power to do all things and to execute such deeds, instruments, and other documents as maybe
deemed necessary and proper, including the following powers, all of which maybe exercised
without order of or report to any court:
(1) To sell, exchange, or otherwise dispose of any property, real, personal
or mixed, wheresoever located, at any time held or acquired hereunder, at public
or private sale, for cash or on teens as may be determined by the Trustee, without
advertisement, including the right to lease for any term notwithstanding the period
of the Trust, and to grant options, including an option for a period beyond the
duration of the Trust.
(2) To invest and reinvest all or any part of the Trust Estate in any
common or preferred stocks, shares of investment trusts and investment
companies, bonds, debentures, mortgages, deeds of trust, mortgage participations,
notes, real estate, or other property the Trustee, in the Trustee's discretion, selects;
provided that the Trustee may not invest in any stock or securities issued by the
corporate Trustee or issued by a parent or affiliate company of such Trustee; in the
manner that, under the circumstances then prevailing (specifically including, but
not limited to, the general economic conditions and the anticipated needs of the
Trust and its beneficiaries), persons of skill, prudence, and diligence, acting in a
similaz capacity and familiar with those matters would use in the conduct of an
enterprise of similar character and similar aims, to attain the Settlor's goals under
this trust ageement.
(3) To retain for investment any property deposited with the Trustee
hereunder.
(4) To vote in person or by proxy any corporate stock or other security
and to agree to or take any other action in regazd to any reorganization, merger,
consolidation, liquidation, bankruptcy or other procedure or proceedings affecting
any stock, bond, note or other security held by this Trust.
(5) To use lawyers, real estate brokers, accountants and any other agents,
if such employment is deemed necessary or desirable, and to pay reasonable
compensation for their services.
4
(6) To compromise, settle or adjust any claim or demand by or against the
Trust and to agee to any rescission or modification of any contact or agreement
affecting the Trust.
(7) To renew any indebtedness, as well as to borrow money, and to secure
the same by mortgaging, pledging or conveying any property of the Trust,
including the power to borrow from the Trustee (in the Trustee's individual
capacity) at a reasonable rate of interest.
(8) To retain any business interest transferred to the trustee, as
shareholder, security holder, creditor, partner or otherwise, for any period of time
whatsoever, even though the interest may constitute all or a large portion of the
trust principal; to comply with the provisions of any ageement restricting transfer
of the interest; to participate in the conduct of the related business or rely upon
others to do so, and to take or delegate to others discretionary power to take any
action with respect to its management and affairs which an individual could take
as outright owner of the business or the business interest, including the voting of
stock (by separate trust or otherwise regardless of whether that separate trust will
extend for a term within or beyond the term of the trust) and the determination of
all questions of policy; to execute and amend partnership ageements; to
participate in any incorporation, reorganization, merger, consolidation, sale of
assets, recapitalization, liquidation or dissolution of the business, or any change in
its nature, or in any buy-sell, stock restriction, or stock redemption agreements; to
invest in additional stock or securities of, or make secured, unsecured, or
subordinated loans to, the business with trust funds; to take all appropriate actions
to prevent, identify, or respond to actual or threatened violations o1' any
environmental law or regulation thereunder; to elect or employ with
compensation, as directors, officers, employees, or agents of the business, any
persons, including a trustee of any trust held under this instrument, or any director,
officer, employee, or agent of a corporate trustee of any trust held under this
instrument, without adversely affecting the compensation to which that trustee
would otherwise be entitled; to rely upon reports of certified public accountants as
to the operations and financial condition of the business, without independent
investigation; to deal with and act for the business in any capacity (including in
the case of a corporate trustee any banking or trust capacity and the loaning of
money out of the trustee's own funds) and to be compensated therefor; and to sell
or liquidate the business or any interest in the business.
(9) To register any stock, bond or other security in the name of a nominee,
without the addition of words indicating that such security is held in a fiduciary
capacity, but accurate records shall be maintained showing that the stock, bond or
other security is a trust asset and the Trustee shall be responsible for the acts of
the nominee.
(10) To set aside as a separate trust, to beheld and administered upon the
same terms as those governing the remaining trust property, any interests in
property, for any reason, including but not limited to a wncern that such property
could cause potential liability under any federal, state, or local environmental law.
B. Whenever the Trustee is directed to distribute any trust principal in fee simple to a
person who is then under twenty-one (21) yeazs of age, the Trustee shall be authorized to hold
such property in trust for such person until he becomes twenty-one (21) years of age, and in the
meantime shall use such pazt of the income and the principal of the trust as the Trustee may deem
necessary to provide for the proper support and education of such person in the standard of living
to which he has become accustomed. If such person should die before becoming twenty-one (21)
yeazs of age, the property then remaining in trust shall be distributed to the personal
representative of such person's estate.
C. In making distributions from the Trust to or for the benefit of any minor or other
person under a legal disability, the Trustee need not require the appointment of a guardian, but
shall be authorized to pay or deliver the distribution to the custodian of such person, to pay or
deliver the distribution to such person without the intervention of a guardian, to pay or deliver the
distribution to the legal guardian of such person if a guazdian has already been appointed, or to
use the distribution for the benefit of such person.
D. In the distribution of the Trust and any division into sepazate trusts and shazes, the
Trustee shall be authorized to make the distribution and division in money or in kind or in both,
regardless of the basis for income tax purposes of any property distributed or divided in kind, and
the distribution and division made and the values established by the Trustee shall be binding and
conclusive on all persons taking hereunder. The Trustee may in making such distribution or
division allot undivided interests in the same property to several trusts or shazes.
E. If at any time after Settlor's death the total fair mazket value of the assets of any trust
established or to be established hereunder is so small that the corporate Trustee's annual fee for
administering the trust would be equal to or less that the minimum annual fee set forth in the
Trustee's regularly published fee schedule, then the Trustee in its discretion shall be authorized to
terminate such trust or to decide not to establish such trust, and in such event the property then
held in or to be distributed to such trust shall be distributed to the persons who aze then or would
be entitled to the income of such trust. If the amount of income to be received by such persons is
to be determined in the discretion of the Trustee, then the Trustee shall distribute the property
among such of the persons to whom the Trustee is authorized to distribute income, and in such
proportions, as the Trustee in its discretion shall determine.
F. The Trustee shall be authorized to lend or borrow, including the right to lend to or
borrow from the Settlor's estate, at an adequate rate of interest and with adequate security and
upon such terms and conditions as the Trustee shall deem fair and equitable.
6
G. The Trustee shall be authorized to sell or purchase, at the fair market value as
determined by the Trustee, any property to or from Settlor's estate, the estate of Settlor's spouse,
or any trust created by Settlor or Settlor's spouse during life or by will, even though the same
person or corporation maybe acting as executor of Settlor's estate or the estate of Settlor's spouse
or as trustee of any ether such trusts and as the Trustee of this Trust.
H. The Trustee shall have discretion to determine whether items should be charged or
credited to income
deem equitable and
amortize any part o.
from the maturity o
income or principal
price of any asset b.
any investment as i~
chazge any expense
provide a reasonabl
depreciation or obs~
of the circumstance
r principal or allocated between income and principal as the Trustee may
air under all the circumstances, including the power to amortize or fail to
all of any premium or discount, to treat any part or all of the profit resulting
sale of any asset, whether purchased at a premium or at a discount, as
~r apportion the same between income and principal, to apportion the sales
ween income and principal, to treat any dividend or other distribution on
;one or principal or to apportion the same between income or principal, to
gainst income or principal or apportion the same, and to provide or fail to
reserve against depreciation or obsolescence on any asset subject to
escence, all as the Trustee may reasonably deem equitable and just under all
5.02. 'ons and Vo ' g,by Trustee. When the authority and power under this Trust
is vested in two (2) r more Trustees or Co-Trustees, the authority and powers are to be jointly or
individually held by the Trustees or Co-Trustees.
5.03. Trus es Po e • to Deal wi ~ vir nment I H s. The Trustee shall have
the power to use and expend the trust income and principal to (i) conduct Environmental
assessments, audits, d site monitoring to determine compliance with any environmental law or
regulation thereund ; (ii) take all appropriate remedial action to contain, clean up or remove any
environmental hazaz including a spill, release, dischazge or contamination, either on its own
accord or in respons to an actual or threatened violation of any environrne:ntal law or regulation
thereunder; (iii) insti to legal proceedings concerning environmental hazards or contest or settle
legal proceedings br ught by any local, state, or federal agency concerned with environmental
compliance, or by a rivate litigant; (iv) comply with any local, state or federal agency order or
court order directing an assessment, abatement or cleanup of any environmental hazazds; and (v)
employ agents, cons ltants and legal counsel to assist or perform the above undertakings or
actions. Any expens s incurred by the trustee under this paragraph maybe: charged against
income or principal s the trustee shall determine.
ARTICLE VI. SPENDTHRIFT PROVISION
6.01. Gene al Provision. No beneficiary shall have the power to anticipate, encumber
or transfer his interes~ in the Trust Estate in any manner other than by the valid exercise of a
Power of Appointmept. No part of the Trust Estate shall be liable for or charged with any debts,
contracts, liabilities ~'r torts of a beneficiary or subject to seizure or other process by any creditor
7
of a beneficiary.
ARTICLE VII. CONSTRUCTION OF TRUST
7.01. Chi of Law. This Trust shall be administered and interpreted in accordance
with the laws of the ommonwealth of Pennsylvania.
7.02. S_od~e. Unless otherwise stated, all references in this Trust to section and chapter
numbers are to those of the Internal Revenue Code of 1986, as amended, or corresponding
provisions of any supsequent federal tax laws applicable to this Trust.
7.03. Othe Terms. Unless the context otherwise requires, the use of one or more
genders in the text i cludes all other genders, and the use of either the singular or the plural in the
text includes both th singulaz and the plural.
7.04. Ca ns. The captions set forth in this Agreement at the beginning of the
various divisions h eof aze for convenience of reference only and shall not be deemed to define
or limit the provisio s hereof or to affect in any way their construction and application.
7.05. S'tu ~ f Trust. The Trust shall have its legal situs in Cumberland County,
Pennsylvania.
ARTICLE VIII.
COMPENSATION OF TRUSTEE AND
APPOINTMENT OF SUCCESSOR TRUSTEE
8.01. Corn en tion. The Trustee shall receive as its compensation for the services
performed hereund of money, based on an hourly charge or percentage rate, which the
Trustee normally an customarily charges for performing similaz services during the time which
it performs these se 'ces.
8.02. R m v I of Trustee. Settlor may remove the Trustee, at any time or times, with
or without cause, up n thirty (30) days written notice given to the cun•ent Trustee. Upon the
death of the Settlor,~majority of the current beneficiaries may remove the Trustee, at any time
or times, with or wi out cause, upon thirty (30) days written notice given to the Trustee. Upon
the removal of the T stee, a successor Trustee shall be appointed in accordance with the terms
set forth in Pazagrap118.03.
8.03. Appointment of Successor Trustee. The Trustee may resign at any time upon
thirty (30) days written notice given to the Settlor if Settlor is living, or in the event of Settlor's
death, upon thirty (3a) days written notice given to the current beneficiary or beneficiaries
(including a beneficialry's natural or legal guazdian or legal representative), hereunder. Upon the
death, resignation, ret!noval or incapacity of the Trustee, a successor trustee maybe appointed by
8
the Settlor during Settlor's lifetime, or, after Settlor's death, by a majority of the current income
beneficiaries. Any successor trustee thus appointed, or, if the Trustee shall merge with or be
consolidated with another corporate fiduciary, then such corporate fiduciary, shall succeed to all
the duties and to all the powers, including discretionary powers, herein granted to the Trustee.
Unless otherwise designated by the Settlor during his lifetime, the successor Trustee shall be the
Settlor's children, VERONICA COLLIER, LORRAINE CAFFARELLA, and JAMES
FYRSTER, to serve jointly or individually.
8.04 Exogeration of Trustee. No Trustee shall be liable for any loss or depreciation
in value sustained b~ the Trust as a result of the Trustee retaining any property upon which there
is later discovered to by hazazdous materials or substances requiring remedial action pursuant to
any federal, state, or! local environmental law, unless the Trustee contributed to the loss or
depreciation in value through willful default, willful misconduct, or gross negligence.
8.05 Inde~ttnification of Trustee Uoon Distribution. Notwithstanding any contrary
provision in this Trust Agreement, the Trustee may withhold a distribution to a beneficiary until
receiving from the beneficiary an indemnification an agreement in which the beneficiary agrees
to indemnify the TrWstee against any claims filed against the Trustee as an "owner" or "operator"
under the Comprehensive Enviromnental Response, Compensation and Liability Act of 1980, as
from time to time arriended, or any regulation thereunder.
ARTICLE IX. PERPETUITIES CLAUSE
9.01. General Provision. Notwithstanding anything to the contrary in this Trust, each
disposition I have made here, legal or equitable, to the extent it can be referred in its
postponement of becoming a vested interest to a duration measured by some life or lives in being
at the time of my dearth is definitely to vest in interest, although not necessarily in possession, not
later that twenty-one'(21) yeazs after such lives (and any period of gestation involved); or, to the
extent it cannot be relfened in any such postponement to such lives, is to so vest not later than
twenty-one (2 ]) yeazs from the time of my death.
ARTICLE X.
ACQUISITION OF UNITED STATES TREASURY BONDS
ELIGIBLC FOR TAX PAYMENT; PAYMENT OF TAXES, FUNERAL
EI~PENSES, AND EXPENSES OF ADMINISTRATION
10.01. AcquisitioT n of Bonds. The Trustee may, at any time, without the prior approval
or direction of the Settlor and whether or not the Settlor is able to manage Settlor's own affairs,
acquire United States. Treasury Bonds selling at a discount, which bonds aze redeemable at their
par value plus accrued interest thereon for the purposes of applying the proceeds to the payment
of the United States estate tax on the Settlor's estate; and the Trustee may borrow from any
lender, including itself, with or without security, to so acquire these bonds.
9
10.02. Payment of United States Estate Tax by Bond Redemption. The Settlor
directs that any United States Treasury Bonds which may be redeemed at their paz value plus
accrued interest thereon for the purpose of applying the proceeds to the payment of the United
States estate tax imposed on the Settlor's estate, and which aze held by the Trustee, shall, to the
extent of the amount determined to be required for payment of the estate tax, be distributed to the
legal representative of the Settlor's estate to be used by the legal representative ahead of any other
assets and to the fullest extent possible to pay the estate tax.
10.03. P~y_ment of Death Taxes and Other Estate Settlement Costs. After the Trustee
has complied with paragraph 10.02, above, and ascertained from the legal representative that all
such bonds have beem redeemed in payment of the United States estate tax., the Trustee shall also
ascertain from the legal representative whether the legal representative has sufficient assets to
pay the remaining legacy, succession, inheritance, transfer, estate and other death taxes or duties
(except the additional estate tax imposed by Section 2032(c), or con•esponding provisions of the
Internal Revenue Cade of 1986 applicable to the Settlor's estate and imposing the tax) levied or
assessed against the Settlor's estate (including all interest and penalties thereon), all of which
taxes, interest and penalties are hereafter referred to as the death taxes, interest and penalties. If
the legal representative advises the Trustee that insufficient funds exist to pay all the death taxes,
interest and penalties, the Trustee shall then pay to the legal representative from the trust
property, an amount equal to all the death taxes, interest and penalties in excess of the funds
available to the legal representative for this purposes, which payments aze to be made without
apportionment. In making the payments, the Trustee shall use only those assets or their proceeds
which aze includable in the Settlor's gross estate for purposes of the United States estate tax and
shall not impair the marital portion without first exhausting the entire non-marital portion.
If the Executor of the Settlor's estate, in such Executor's sole discretion, shall determine
that appropriate assets of Settlor's estate are not available in sufficient amount to pay (1) the
Settlor's funeral expenses, and (2) expenses of administering the Settlor's estate, the Trustee
shall, upon the request of the Executor of the Settlor's estate, contribute from the principal of the
trust estate the amouTlt of such deficiency; and in wnnecrion with any such action the Trustee
shall rely upon the written statement of the Executor of the Settlor's estate as to the validity and
correctness of the amounts of any such expenses, and shall furnish funds to such Executor so as
to enable such Executor to dischazge the same, or to dischazge any part of all thereof itself by
making payment directly to the person entitled or claiming to be entitled to receive payment
thereof. No consideration need be required by the Trustee from the Executor of Settlor's estate
for any disbursement made by the Trustee pursuant hereto, nor shall there be any obligation upon
such Executor to repay to the Trustee any of the funds disbursed by it hereunder, and all amounts
disbursed by the Trustee pursuant to the authority hereby conferred upon it shall be disbursed
without any right in or duty upon the Trustee to seek or obtain contribution or reimbursement
from any person or ptoperty on account of such payment. The Trustee shall not be responsible
for the application of any funds delivered by it to the Executor of the Settlor's estate pursuant to
the authority herein granted, nor shall the Trustee be subject to liability to any beneficiary
hereunder on account of any payment made by it pursuant to the provisions hereof.
10
IN WITNESS WHEREOF, the Settlor and Trustee have hereunto set their hands and
seals as of the day and year first above written.
WITNESS:
~~i~~~
~~ a~ ~h(SEAL)
CYI L B. FYRSTE ETTLOR
COMMONWEA~~L~~;;T~~H OF PENNSYLVANIA
COUNTY OFi(~w~G~/CX~/K% SS:
On this, the day of November, 2006, before me, a Notary Public, the undersigned
officer, personally appeazed CYRIL B. FYRSTER, known to me (or satisfactorily proven) to be
the person whose name is subscribed to the within Trust Agreement, and acknowledged that he
executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I have set my hand and
COMMONWEALTH OF i'ENNSYLVANIA
NotarlalSeai
Teri L. Walker, Notary Publfc
Lemoyne 6oro, Cumberland Counttyy
My Commission Expires Jan, 20, 20U7
Member, Pennsylvania Assodatltin of Notaries
Expires
,_
t _
. ~.. ~
,,
. \
i
II
The foregoing Trust Agreement was delivered, and is hereby accepted, at Lemoyne,
Pennsylvania, on November ~O , 2006.
WITNESS:
~.~~iyt1%L (SEAL)
CY L B. FYRSTE `TRUSTEE
12
SCHEDULE"A"
SCHEDULE
f2RED TO IN THE ANNEXED
TRUST AGREEMENT
DATED: NOVEMBER, 2006
FROM CYRIL B. FYRSTER, SETTLOR
TO CYRIL B. FYRSTER, TRUSTEE
PROPERTY DESCRIPTION:
ALL THAT CERTAIN piece or parcel of land situate in Upper Allen Township, Cumberland
County, Pennsylvania, more particularly bounded and described as follows:
BEGINNING at a point at the dividing line between Lots Nos. 15-D and 15-E on the hereinafter
mentioned Plan of Lpts; thence North 43 degrees 10 feet 50 inches East, 24.06 feet to a point, the
dividing line between Lots Nos. 15-E and 15-F on said Plan; thence South 43 degrees 10 feet 50
inches West, 24.06 feet to a point, the dividing line between Lots Nos. I S-D and 15-E on said
Plan; thence along said dividing line, North 46 degrees 49 feet 10 inches West, 56.70 feet to the
point and place of BEGINNING.
BEING Lot No. 15-E, Plan of Units in Building No. 15, Section D of Allenview as recorded in
Plan Book 47, Page 43.
BEING known as No. 508 Allenview Drive.
UNDER AND SUBJECT, nevertheless, to easements, restrictions, reservations, conditions and
rights of way of record.
13
EXHIBITS
SCHEDULE B
~~
i;:,, ;.il i.l;v
July 17, 2012.
Company Name METLIFE, INC.
CYR1L B FYRSTER ----------- -------------- ---
508 ALLENVIF.W DR CUSIP Number 59156R10
MECHANICSBURG PA 17055-6] 50 Your Account Key FYRSTER--
CYRIB0000 ',
Investor J 806292599783
Identification
'Number
Dear Investor:
The above account holds a total balance of 117.00 shares of METLIFE, INC. stock as of
04/02/2012. The book balance is 117.00 shares and the certificate balance is 000.00.
You may use this letter as evidence of your holdings in METLIFE, INC. .
Sincerely,
BNY Mellon Shareowner Services
Page 1 of 1
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Market open --Real time quotes Oct 23, 2012 2:05 p.m. Previous close Day IOw
$35 12 _~~°2.2.82°'° $ 36.14 534.99
Volume 4.24m (^'~-'~"'-~--•
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EXHIBITS
SCHEDULE E
Aug. 2. 2012 2:04PM PNC Bank
August 2, 2012
Stacey L Nace
Crates Ilalbruner Hatch & Guise
1013 Mumma Rd Ste 100
Lemoyne; PA 17043
RE: Cyril B Fyrster
SSN: 066-14-3193
DOD: 02-04-2012
Dear Sir/Madam:
No. 4410 P. 1/2
In response to your request for Date of Death (DOD) balances for the customer noted above, our
records show the following:
Checking Account
Account # 5000636335 Established: OS-07-1996
CYRIL B FYRSTER
DOD balance: $ 4,290.18 non interest bearing
Savings Acconnt
Account # 5000680571 Established: 08-20-1996
CY1tZI, B FYRSTER
DOD balance: $ 18,325.56 + 0.71 accrued interest
Interest paid O1-Ol -2012 thru 02-04-2012 $ 1.41 YTD
Please note that this office provides date of death balances for deposit accounts (IRAs, CDs, Checking and
Savings). We do not process any financial transactions or provide statements, If you need assisranoe with
any of these items, please call 1-888-PNGBANK (1-888-762-2265) or stop by your local PNC Bank branch
office.
Sincerely,
Natiooal Financial Services Center
PNC Bank, N.A.
Member FDIC
Page 1 of 2
EXHIBITS
SCHEDULE G
< ~' ,
~ }, ,, 6
'~u~~ (;ll,U ~~ ?~
Prepared by and Return to:
Craig A. Hatch, Esq.
Gates, Halbruner & Hatch, PC
1013 Mumma Road, Suite 1100
Lemoyne, PA 17043
TAX PARCEL N0.42-28-2423-406
UPPER ALLEN TOWNSHIP
DEED
.~ n>h
THiS DEED is made the ' D day of November, in the year two thousand six (2006).
BETWEEN CYRIL B. FYRSTER, a widower, now of 508 Allenview Drive, Mechanicsburg, Cumberland
County, Pennsylvania, 17055, party of the first part, GRANTOR,
AND
CYRIL B. FYRSTER, Trustee. of TIIE FYRSTER FAMILY TRUST, now of 508 Allenview Drive,
Mechanicsburg, Cumberland County, Pennsylvania, 17055, party of the second part, GRANTEE.
WITNESSETH, that said party of the first part, for and in consideration of the sum of One ($1.00) Dollar, lawful
money of the United States of America, well and truly paid by the said party of the second part to the said party of
the first part, at or before the sealing and delivery of these presents, the receipt whereof is hereby acknowledged,
has hereby granted, bargained, sold, aliened, enfeofl'ed, released, conveyed and confirmed, and by these presents
does grant, bargain, sell, alien, enfeoff, release, convey and confirm unto the said party of the second part, his heirs,
successors and assigns,
ALL THAT CERTAIN piece or parcel of land situate in Upper Allen Township, Cumberland County,
Pennsylvania, more particularly bounded and described as follows:
BEGINNING at a point at the dividing line between Lots Nos. 15-D and 15-E on the hereinafter
mentioned Plan of Lots; thence North 43 degrees 10 feet 50 inches East, 24.06 feet to a point, the dividing
line between Lots Nos. 15-E and 15-F on said Plan; thence South 43 degrees 10 feet 50 inches West, 24.06
feet to a point, the dividing line between Lots Nos. 15-D and I S-E on said Plan; thence along said dividing
line, North 46 degrees 49 feet 10 inches West, 56.70 feet to the point and place of BEGINNING.
BEING Lot No. 15-E, Plan of Units in Building No. 15, Section D of Allenview as recorded in Plan Book
47, Page 43.
BEING known as No. 508 Allenview Drive.
UNDER AND SUBJECT, nevertheless, to easements, restrictions, reservations, conditions and rights of
way of record.
BEING the same premises which Betty J. Hoffineyer, by Deed dated December 21, 1993, and recorded in the
Recorder of Deeds Office in and for Cumberland County, Pennsylvania, in Deed Book Volume S 36, Page 321,
BUQK 2~ PACE~3~'~'S
granted and conveyed unto Cyril B. Fyrster and Winifred V. Fyrster, his wife. Winifred V. Fyrster departed this
life, thereby vesting complete title under operation of law to Cyril B. Fyrster, Grantor herein.
THIS IS A TRANSFER FOR NOMINAL CONSH)ERATION TO A TRUSTEE OF AN ORDINARY TRUST W HERE
TIIE TRAN SFER OF THE SAME PROPERTY WOULD BE EXEMPT IF THE TRANSFER WAS MADE DIItECTLY
FROM THE GRANTOR TO ALL OF THE POSSIIILE BENEFICIARIES THAT ARE ENTITLED TO RECEIV E'fHE
PROPERTY OR PROCEEDS FROM THE SALE OF THE PROPERTY UNDER THE TRUST AND IS THEREFORE
EXEMPT FROM THE PAYMENT OF REALTY TRANSFER TAX.
TOGETHER with all and singular the buildings and improvements, ways, streets, alleys, driveways, passages,
waters, watercourses, rights, liberties, privileges, hereditaments and appurtenances, whatsoever unto the hereby
granted premises belonging, or in any wise appertaining, and the reversions and remainders, rents, issues, and
profits thereof; and all the estate, right, title, interest, property, claim, and demand whatsoever of the said Grantor,
as well at law as in equity, of, in, and to the same.
TO HAVE AND TO HQLD, the said lot or piece of ground above-described, with all and singular the buildings
and improvements thereon erected, hereditaments and premises hereby granted, or tentioned and intended so to
be, with the appurtenances, unto the said Grantee, his heirs and assigns, to and for the only proper use and behoof'
of the said Grantee, his heirs and assigns forever.
ANB the said Craiitor, for liiitiself, liis licirs, execuiOfs atd aihttinislralurs, dues cuveuaul, pruuuae and agree, to
and with the said Grantee, his heirs and assigns, by these presents, that he, the said Grantor, and his heirs, all and
singular the hereditaments and premises hereby granted or mentioned and intended so to be, with the appurtenances,
unto the said Grantee, his heirs and assigns, against him, the said Grantor and his heirs, and against all and every
person and persons whomsoever lawfully claiming or to claim the same or any part thereof, by, from or under him,
her, them or any of them, shall and will, subject as aforesaid, SPECIALLY WARRANT AND FOREVER
DEFEND.
IN WITNESS WHEREOF, the said party of the first part has hereunto set his hand and seal, the day and yeaz first
above-written.
SIGNED, SEALED AND DELIVERED
IN THE PRESENCE OF
~/,___
_, ~ ~yTl~
COMMONWEALTH OF,GPENN~S~yY,L.V,,A/N'IA
COUNTY OF ~ti%4~"4iu w~~ c.J~
CY L B. FYRSTER ~/
SS:
On this, thec~D~day of November, 2006, before me, a Notary Public for the Commonwealth of
Pennsylvania, the undersigned officer, personally appeazed CYRIL B. FYRSTER, known.to me (or satisfactorily
proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed
the same for the purpose therein contained. ,,,; ,
IN WITNESS WHEREOF, I hereunto set my hand and official s alb 1' ', ~ ' , , ;
~qj [~f~/~ E ~ ..
JM mleSi i r,Ai; r ~"8J9.1'd i .~,~r:. ~~i~i'~ " ~~
fl!of7e~ s~„+.,i
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d4a~k o o;,fery ruu~e;, Notary blic - ,
- ti iF hJ ie.. n~tbar~aiPU w-.owu, .:: ,.
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. i'!ijr' IyfElY9•< p((I'yy IMP M 'y ~; ['. dIY ~P.
Ul+t.l1 1Mk1 Ni\l l't
CERTIFICATE OF RESIDENCE
I hereby certify that the present residence
of the Grantee herein is as follows:
Cyril B. Fyrster, Trustee
The Fyrster Family Trust
508 Allenview Drive
Mechanicsburg, PA 17055
[ Certify this to lie recorded
l~l Cl~rnbcrland County PA
.. ,~ ...,._ ? , m n
,,
r~.c~.< ~,~'er of ~ecds
e~n~ X77 1'r,G,`~ at `,'
a&e Q byV
QA IQ" IS
~
~
DENNIS ZERBE, TREASURER `
275 CUMBERLAND PARKWAY #325 !
MECHANICSBURG, PA 17055 c~'p t I~
z: ASSESS.NO -42003157
Q
q I l
I I~`
MAP NO: 42-28-2423-406. O b
t I
508 ALLENVIEW DRIVE
ACRES .030 DEED 277 /3875
ALLENVIEW
LOT 15•E RLD 15 PB 47 PG 43
RESIDENTIAL i FAMILY
FYRSTER FAMILY TRUST
ea 526 ALLENVIEW DR
MECHANICSBURG PA 17055-6168
ice WED,THURS, 9AM-11AM & 12PM-2PM
ins: CONSULT UPPERALLENTWP.ORG OR
CALL 717-766-4238 FOR EVENING
HOURS OFFICE:100 GETTVSBURG PEKE
t No,
A
~II ~~I III '~ ~~I III I ~II Control No: 042- 002135
R
o
2012 State ent of
Rea
E
ate Taxes Bill
7/01/2012
Avseseed Land 'Improvement NSneral Total
Valuec 1],500 146 600 0 164 100
MECHANICSBURG AREA S.D. Dismount Faoa Penalt
Roca. .olaa696o .blzaesoo z • to a
SCKOOL R E 1 976. a9 a, 016.61 2,118. as
TAX AMOUNT DUE -----> $1,657.60 $1,89s.51 $2,065.06
IE Paid On oY A£Cer ]/O1/1011 9/O1/203a 13/OS/7031
~
If Paid on or seEore a/31 1111 So it 1111 iz ai aola
OFFICE WILL BE CLOSED FEB 2013 d PARTS OF JUNE 2013
CONSULT UPPERALLENTWP.ORG FOR DETAILS
OFRCE AT TOWNSHIP BUILDING
100 GE7TVSSURG PIKE, PHONE 717-]66.4238
NOTICE OF PROPERTY TAX RELIEF
Your enclosed taz bill includes a tax reduction For your homestead and/or farmstead
property. As an e5gible homestead and/or farmstead property owner, you have received
taz relief through a homestead and/or farmstead exclusion which has been provided
under the Pennsylvania Taxpayer Relief Act, a law passed by the Pennsylvania General
Assembly designed to reduce your property taxes.
If paying in installments use the coupons below to submit payments. If paying in full ruse ONLY the 1STcoupon below to submit payment.
JULY 2012
PENNSYLVANIA DEPARTMENT OF REVENUE
REALTY TRANSFER TAX
COMMON LEVEL RATIO (CLR)
REAL ESTATE VALUATION FACTORS
FOR
CUMBERLAND COUNTY
The following real estate valuation factors are based on sales data compiled by the State Tax
Equalization Board. These factors are the mathematical reciprocals of the actual common level
ratios. For Pennsylvania Realty Transfer Tax purposes, these factors are applicable for
documents accepted for the periods indicated below. The date of acceptance of a document is
rebuttably presumed to be its date of execution, that is, the date specified in the body of the
document as the date of the instrument. 61 Pa. Code § 91.102
ACCEP
DA ANCE
E CLR
FACTOR ACCEPTANCE
DATE CLR
FACTOR
FROM TO FROM TO
7-2-1986 6-30-1987 9.52 7-1-2006 6-30-2007 1.14
7-1-1987 6-30-1988 10.00 7-1-2007 6-30-2008 1.22
7-1-1988 6-30-1989 10.53 7-1-2008 6-30-2009 1.26
7-1-1989 6-30-1990 11.11 7-1-2009 6-30-2010 1.26
7-1-1990 6-30-1991 12.05 7-1-2010 12-31-2011 1.25
7-1-1991 6-30-1992 12.35 3 1-1-2011 6-30-2011 1.00
7-1-1992 6-30-1993 12.50 3 7-1-2011- 6-30-2012 1.00
7-1-1993 6-30-1994 12.82 7-1-2012 6-30-2013 1.00
7-1-1994 6-30-1995 13.33
7-1-1995 6-30-1996 13.70
7-1-1996 6-30-1997 14.29
7-1-1997 6-30-1998 14.29
7-1-1998 6-30-1999 14.71
7-1-1999 6-30-2000 15.15
7-1-2000 12-31-2000 15.63
(1 1-1-2001 6-30-2001 1.00
(1 7-1-2001 6-30-2002 1.00
7-1-2002 6-30-2003 1.0]
7-1-2003 6-30-2004 1.05
7-1-2004 12-31-2004 1.11
2 1-1-2005 6-30-2005 1.00
2 7-1-2005 6-30-2006 1.00
(1) Adjusted by the Department of Revenue [o reflect an assessment base change effective January 1, 2001.
(2) Adjusted by the Department of Revenue to reflect an assessment base change effective January I, 2005.
(3) Adjusted by the 1>epartmen[ of Revenue to reflect an assessment base change effective January I, 201 I.
EXHIBITS
SCHEDULE H
Halpezzi Funeral Horne ~~` \~
,~,~~
8 Market Plaza Way
Mechanicsbur¢. PA 17055 _ _www.malpea
February 11, 2012
Roni Collier
526 Atlenview Drive
Mechanicsburg, FA 17055
(717)697-4696
This is the final statement for the funeral services of Cyril B. Fyrster
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way.
PROFESSiONAI, SERVICES:
Memorial Service
Anatomicat Donation
FUNERAL HOME SERVICE CHARGES
SELECTED MERCHANDISE: ~
Genuine Leather Register Package
THE COST OF OUR SERVICES, EQUII'MENT,
THAT YOU HAVE SELECTED
$550.00
$2,350.00
$2,900.00
$95.00
52,995.00
CASH ADVANCES:
Rt the time funeral arrairgements were made, we advanced certain payments to others as an accomodotion.
The followixg is an accounting of those charges.
Certified Death Certificates $60.00
Newspaper Notices -Patriot $262.42
Clergy/Mass Offering $150.00
Organist $125.00
SoloisUCantor $75.00
Altar Servers 520.00
TOTAL CASH ADVANCES ANA SPECIAL CHARGES
CONTRACT PRICE
HISTORY:
5692.42
$3,687A2
02/06/2012 DiseouM LifeLegacy ~,~f(~ $900.00
TOTAL AMOUNT DUE BY March 7, 2012 ~~nn ~^~ l~.-- S2,7S7.42
r kF ~i~1'"
~f~~'
If you have any questions or concerns regazding this bill, please call our office at (717) 697-4696.
d
(~~zn est6tte~
RECEIPT FOR PAYMENT
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Receipt Date: 2/21/2012
Receipt Time: 14:09:01
Receipt No.: 1068838
FRYSTER CYRIL B
Estate Fite No.: 2012-00228
Paid By Remarks: V NICA COLLIER
------------------ ------ Receipt Distribution ------ ------- ------- ----
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 60.00 CUMBERLAND COUNTY GENERAL FUN
WILL 15.00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 20.00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE
-
-
-- CUMBERLAND COUNTY GENERAL FUN
Check# 6760 ----
--
-- --
$123.50
Total Received.... ..... $123.50
The Patriot-News Co.
2020 Technology Pkwy
Suite 300
Mechanicsburg, PA 17050
Inquiries - 717-255-8213
GATES, HALBRUNER & HATCH, PC
1013 MUMMA ROAD
SUITE 100
LEMOYNE
PA
17043
c~he~latriot~~ews
Now you know
F,
THE PATRIOT NEWS
THE SUNDAY PATRIOT NEWS
Proof of Publication ;~
Under Act No. 587, Approved May 16 1929'"'-
Commonwealth of Pennsylvania, County of Dauphin} ss
Holly Blain, being duly sworn according to law, deposes and says:
That she is a Staff Accountant of The Patriot News Co., a corporation organized and existing under the laws of the
Commonwealth of Pennsylvania, with its principal office and place of business at 2020 Technology Pkwy, Suite 300, in the
Township of Hampden, County of Cumberland, State of Pennsylvania, owner and publisher of The Patriot-News and The Sunday
Patriot-News newspapers of general circulation, printed and published at 1900 Patriot Drive, in the City, County and State
aforesaid; that The Patriot-News and The Sunday Patriot-News were established March 4th, 1854, and September 18th, 1949,
respectively, and all have been continuously published ever since;
That the printed notice or publication which is securely attached hereto is exactly as printed and published in their regular
daily and/or Sunday/ Community VNeekly editions which appeared on the date(s) indicated below. That neither she nor said
Company is interested in the subject matter of said printed notice or advertising, and that all of the allegatiohs of this statement as
to the time, place and character of publication are true; and
That she has personal kngwledge of the facts aforesaid and is duly authorized and empowered to verify this statement on
behalf of The Patriot-News Co. aforesaid by virtue and pursuant to a resolution unanimously passed and adopted severally by the
stockholders and board of directors of the said Company and subsequently duly recorded in the office for the Recording of Deeds
in and for said County of Dauphin in Miscellaneous Book "M", Volume 14, Page 317.
PUBLICATION COPY This ad # 0002203506 ran on the dates shown below:
April 73, 2072
Apri120, 2072
-~, April 27, 2012
Sworn to
Notary
me tpfs 0,7/day of May, 2012 A.D.
M NWEALTFIOF ENNSYLVANlA
SheMe L. p Mal Sssl
wens, Nohry Publk
MV Comml~7Wp., Dauphin County
MEMBEN, ppNNSy~VgN1A ~'• 26, 2015
'1S50M1I0N OF NOrARfES
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, PA 17013
Tele: (717) 249-3188 Fax: (717) 249-2889
May 4, 2012
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: Craig A. Hatch, Esquire.
RE:
Cyril B. Fyrster 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:
April 20, April 27, and May 4, 2012
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
H:897-8018 254.3705
ORDER NO: 024525!1 `'
ACCT. NO: 0004303
COPY NO: 2
PRINTED: 2/1412012 9:47AM
CARDIOCCASION
omen
ORDER NOTES
CREDIT CARD INFORAAATION
ORDER DATE: 2!8/2012 4:23PM
DELIVERY DATE: Fri, 02/10/2012
ORDERED BY:
~~ ~,__
PAYIAENT:Hous
Lp1 °a'
SALESPER80N:Uavid- 3~•Li
PRODUCT QUANTITY PRICEIUT DISCOUNT EXTENDED
Delivery Charge 1 10.00 10.00
Av - A1Wr vases 1 90.00 90.00
HS - Hsngi~ SBray to ao-ordinate 1 200.00 200.00
rith altar vases 3 banners; Children,
Grand Children and
Great-Graadahildran
SUB-TOTAL 3~.~
Sales Tax 18.00
' TOTAL 318.00
ORDER NO: Elizabeth Ann Steon
St
02452~51.1of 1 .
310 HERTZLER RD
DEUVERYZONE: MECHANICSBURG, PA 17055-6115
Mechanicsbu
rg l---~---~-_.-.__..
Fri, 2N0l2012 THE WNIM$ICAL POPPY
RECEIVED BY ~
'~°v00'~'"B "°_-. s~-~
DELIVERY DATE: Fri, 2!10/2012
by 8;30 am.
conr No: 2
' I
~~~~ r`~
THEU's BAR A GRILLE \Y
737-6965
R
UO 1 Ua TBL u 29 >FParty 40
p SvrCk: 2 11:35 02/10/12
( OPEN FOOD, amount? 800.00 800.00
13 COFFEE 32.50
15 SODA 37.50
7 ICED TEA 17.50
i NO BEVERAGE O.OU
2 BLDUDY MARY 11.00
t SM LAGER 3.50
3 by cab, 1 -glass, 1 -glass,
1 -glass 19,50
2 VODKA, 1 *crar~erry jce,
u ranberry ]ce 10.50
. ~ is;~MAOE 2.50
wit grieio, -9)ass 6.50
t BACARDT 5.00
1 WHISKEY 4.00
5 NANh~P,I (A^:. t up, ~s@agramS 'r0,
J ~gl, :;.0~:.6lldmS VD, t up,
fiBagfo8i6 vi,, 1 Up,
xseagrams vo, 1 up, +;iartream 46.25
abY acacia pivot noir 18.00
t';i;+MriiR!1 SOUR 5.25
1 JACK UAr;IELS 5.50
1 MARTTNi-VODKA, ~, +ketel one 10.25
1 MILK 3.00
i ~.AP7 MORGAN 5.00
C !iT((. BUD (.TTE 6.00
3 BTTL CDINtS LITE 9.00
2 by chard, 1 -glass, 1 -glass 13.E
2 HOT TEA 5,00
2 HELLO 19.00
1 KETEL ONE, &rocks 7.25
Sub Tot.~i: 1102.50
T.AK: 53.88
18% GRATUIT 196.45
02/10 1 .51 TOTAL : 7 364 .83
HAPPY NEM YEAR 2012
IHANK YOU FON DINING WIT!i US!
W~ ~~ylal s(>, _ -~~
® ~ PawMx tspxnsuwe+
eMcxion. aovinys. Cvxry Doy. /
Vlatt w on the~Intarnet
yye.8fan4FoodStoraa.cog
PR WINE 8 SPIRITS STORE 2111
ERST PENN CENTER ENOLR
My goal la to ensure hour satlafactian 717_T2$_p579
every tine .you shop ulth us. Tf 4her.
la snythln9 acre I Can da :.~ ::::. ~ _______ __________________________________
your experience please call or yrlte.
Terry L. Alfrea. Store Manaeer 6/27/12 4:45 PN i
81en} Food §tore 116120 ~ Trans.: 3986 Store: 02111
255 Cunberland Parkyaa Res : 001 Till: MA81 ~
Mechanlrabura, PA 1T055 Cashier ID: 00536236
Stora.Telephone: 1717) 591-0979 SRLE
Pharaacy Telephone: (717) 591-0993
THANK VOU 9800046248 aIIIIIIIIIII~~INII~IIl~lI1i
GRZEBD GREEK ORS 3.69 F
HERSHEY KISSES BC 9.14 F 021110013486
~~?Z REG POT CHIP BC 4.29 F
SC 1~ONUSBUY SAVIN85 1.29-F
Prlu you Pay 3.00 .._----------------------------------.._---
SNYDERS SNRPS BC 3.29 r
SC BONUSBUY SAVIN85 .79-F Sailor Jerry Spiced Rum 19.99 T
Price you pea 2.50
CD TONIC WTR 6PK 4.55 B 000009091 t 4 14.99 _
C~ GINGEflRLE 6PK 4.55 8 SPR120625
CU TONIC WTR 1L 1.55 8
+B SPRNG WTRI2PK 2 94 F Subtotal 14.99
it B STRRWBERRY W P~
•! r. STRAWBERRY w Total Sales Tax ( 6.Ox tax rate ) 0.90
tRESN SAVINGS s_'=•
.%rlce ,m. .:;~, Total 15.89
d~ ~:'AN Lti Sll;w ~ '
TRKYHL TEt~ ..9 Fc - i .65 F
SC BONUSBUY .;nVINBS .25-F Crn- ' 15.89
Price ynu pay 1.40 _ Visa
PH I1. CRFP,M CHSE D' _count~ 9715
SC BONUSBUYSRVIN85 .90-F
Price aou pay 1.99 Ruth: 522197 (A)
SWISS SKIM 64F2 W NP 1.92 F
FETA CHUNKS 4.41 F Total Tender 15.89
FETR CHUNKS 4.23 F
70TRL BEFORE SRVLNGS 56.27 Chance Due 0.00
YOUR TOTRL SAVINGS 6.72
TOTRL RFTER SAVINGS 49,55
TRX PAID .64
saeeTOTAL 50.1 Total Nur~6er of Unit(s) Sold i
VF CREDIT CARD 60.1
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11:55 PiN USED
982 AP 595943
keep: AA
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ID 9`jU:i27i1
PPtN7`JED ~ 1R„ttASE
At~1NT: !649.78
327 n.•. ,~, i'F"~c)
V
a~wnlrsburg Beverage
IUt N. York St.
~^,tianicsburg PA 17055
717-766-5G71
i6 t
Each Tutal
~
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2U't CN
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0~ '}0.99 3G.99
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m
'', 5:28PM RsgB t STEVE
MI'T DRINK ANU DRIVE!!!
I
~~~~Ir' May/~rMar R/
b41~-16////f,ARL1 SLL" PIKE
MECc7AWICSBURG, PR 17050
(717) 791-4500
O6/2o/!2 OP8 300366
MTIN WNERT POTRIU
IH llIET GREEN TER
SWSSS PNEM f/F
WEG BLN CHRY G'RF.EK
WEG STRW GREEK YGT
WEG BLBRY GREEK YG
4 @ 7.49
WRCKY VicbG7E SP1RR
WEG E'Ni CRKR RSST
I'B S)'HS8STRIPES FU
P8 STRS8STRIPES CR
3e o.6s
IC GRNBRNZO KERNS
IC RRTICHOKE HERRT
3@ 1.29
WEG PITT OLI N
MC GRO CINNRMON
6PK GREEN PEPPERS
WEG GRP TOM QRT
1 @ 2/5.00
CUKES SEEDLESS
BLUEBERRIES 2LBS
FRESH LIMES
LEMONS
BRNRNRS
WEG MOUNTAIN MIX
TRX
a+++ BRLRNCE
VISR PURCHRSE
ACCT: ++++e+a*x++*9715
RUTH: 060155
RCPT: 20593
CODE: 0000
CREDIT CRRD
CNRNGE
/ Po1WMet rksimres
',V//
PR WINE 8 SPIRITS STORE 2102
WEST SHORE PLR2R SHOP CTR LEMOYHE
- - - ------- 717-731-7193
5.99 F
1,59 F
1,87 F
0.89 F
089E
0.89 F
5.96 F
6.49
7.49 F
7. U9 F
7.95 F
3.99 F
3.87 F
2.59
3.99 F
3.99 F
2.50 F
9,99 F
0.80 F
1 .00 F
1.18 F
12.99 F
D. 00
6/17/12 2:1
Trans.: 1928 S tore : 0
Res.: 002 Tt tl:
Cashier I0: 00657582
SR''ILE
'I
IlIIdpdp
I
I
1 ~~I~~~~~I~~~I~II~I~zNB~ 11
~III~I
Ketel One Vodka 24 .99
000006069 1 @ 29 .99
SPR720528
Maker's Mark Bourbon 26 .99
000008454 1. @ 26 .99
Mirasaou Pinat Grislo 8 .99
000006771 i @ 8 .99
SPR120528
Sterilns UC Chardonnay 9 .99
OOOOD7699 i @ 9 .99
SPR120528
Basle Chardannay 10. 99
000005026 i @ 10 .99
Fat Cat Plnot Noir 11. 99
ouG009376 1 @ 11 .99
Simply Naked Ptnot Grillo 7. 99
000003369 7 @ 7 .99
SPR120528
Mark West Pinot Nolr 25. 98
000007726 2 @ 12. 99
Subtotal 727,91
b7.99 Total Sales Tax ( 6.0% tax rate) 7.68
Total 135.b9
Credit 135 .59
Cerd; Visa
Recount: 9?15
Ruth: 575249 CR)
~6-1~y" ~ Total Tender (135.
~ 59
0.00
Chance Due 0. 00
06/26/72 06.Otpm 45 20 149 300366
Total Numher of Unitla) Smld 9
t~Qy yOLt get OUR best!
Cua}omer Copy
,.
a - ~
G
~uuNrY.aabcrion, ^avlnea. [wry Pay.
Vislt us on the Internet
7wr.6/emtFoodStorea.eon
Na coal /a to ensure sour sstlsfectlon
every tine sou shop rtth us. If there'
i !s anythlns Hors I can db to lnprove
sour ezparlenee please call or ante.
Terra L. Rlfrea, Store Nanaser
i
Giant Food Store >t5720
255 CunberlSnd Parkraa
Neehantrsbura, PA 77055
I Store Telephone: (77T) 591-0979
Pharnsca Telephone: (777) 591-0993
TNANK YOW ~ 48r 07670:?64
CUT-RITE 75 FT 1.29 T
REYNLO PRCRPRPER 2.79 T
S6 PPR RNG i.q9 p
58 PURE NPL SYR q,yg F
MUENSTER CHEESE 1,6g F
GENOR SALAMI 3.60 P
I SIICE PROVOLONE 2,gci t:
BH OVGLD RST TKY BC S.GO i-
I 0.50 lb @ T.99 /Ib • 4.00
SC FRESN SAVINGS 7.00
'i Pries sou pea 1.00
0.59 !b @ 1.49 /lb
LEAF LETTUCE W 7,17
~ 1.17 !b @ t.99 /Ib -
,.FUJI RPPIES W BC 2.33 F
1.t7 !b @ 7.69 /lb = 7,98
SC FRESN SAVINGS .35-F
Prlee auu pas 1.98
1.00 16 @ 2.99 /16
TOMATO ON VINE W BC 2,49 F
7.00 lb @ 2.49 /Ib 2.49
SC FRESN SRVINGS ,5p_p
Priee sou pas 2.49
CELERYSTICKS W 2,99.E
BRSIL 3/402 PKG 1,94 F
YHITE.BAGUETTE 2,24 F
WNIiE BRGUETTE 1..29 F
WNITE~BRGUETTE 2.29 F
SB ITRLIRN BREAD BC 1,99 F
SC FRESN SAVINGS ,7p_F
... "Prate auu pas i.19
CRUMBLED BLUE 6.99 F
MOZZRRELLA 5,y9 p
TOTAL BEFORE SRVINGS 5[•.60
YOUR TOTAL SRVINGS ~-2.55
TOTAL AFTER SAVINGS 59.05
7AX PAID .2q
aaaaTOTAI 54.
VF DEBIT CARD 4.29
1f^M3fkMrYrxxx.. ....... .........
Turkey Hill # 0240
2130 S. Market St.
Mechanicsbur PA 17055
717-597-7280
6/29/2012 1:51:47 PM
Register: 2 Tran Seq No: 74999
Cashier: Thank You. Bethany
2 NOMECITY ICE/'!B '$3.98
Sub. Total: $3.98
TaX': $0.00
Total: $3.
Master l:arC: cc
Change $0.00
Master Card
Card Num : XXXXXXXXXXXX6258
Terminal : 001456947
Approval :434958
Comments \ (duestions contact us at
Turkeyhilistores,com or 1-800-538-070.ri
Collier. Roni
IC
From: Fyrsier, James A
gars; Monday, July 02, 2012 9:51 AM
To: Collier, Roni
Subject: Itemized spending for Dad's memorial service
Hi Roni,
Here are the details. I'll leave the receipts I have on your dining table. Thanks
Date Store Items/Purpose Cost
06/28/12 Gia - on~Lems $54.29
06/30/12 /A Minist Services for burial rites 60.00
06/30/12 N/A American Legion donation for Military honors $100.00
06/30/12 Turkey Hill Ice 3.98
Total »»»»» $218.27
1im Fyrster (Highmark ~ Manager, Dental Membership & Billing Solutions (717.302.6033 (Work) ~ 717.877.4505.
(Mobile)
;
- - .. ~r S'~,~ ~IK,e ~u
~Q~bal~~`' ~~ ~~
J,, Ir ~ boil
i~V~
6416 CRRLISLE P1KE
MECfKINTCSBURfi, YR 17lJSO
(71 : r 77; -4GUU
U2/n,5/12 UPfI 375Ui~.r
WG HRMBIIRGER RULI,S I.r9 F
HG COLEY JRCK 2 39 F
2 @ 1.69
WFG PLRIN BRGGLS .~ ~$ P
RLT HORSGRRDI$H-I2U I.^9 i
KR JRR CH6k SE~-ENGI. 'N F
WEG GRR CH BUf tf:R 2.•14 T~
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WEB Jik CRCK "PEPI>R- ., I
KRStiI PTTR CRISPS ~ ~,
WEG SER SRLT GRih1U .:.99 t
WEG TK CLERk RRG 3.99 T
SC KFER TUWN HOUSE 2 99 F
SC KEEB 1 N FL BRERO 1.U0-F
2 '~~ 'f.49
SC iO:iIITOS SCDUPS CH 6.`:8 F
2 @ 0.50
SL' TQSYITOS RESTAURAN 1.U0-F
CI'h MILRN^ ;RLFlME .:. ~7 1
f.I TT SOPRESSR-PNU 2.99 F
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KOSHER PICKLF.U EGG b.!'~0 F
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0.45 16 @ 7.99 /lb
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,WG~MILO•~WHITE CHUR :f.98 f
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STRRWB[RkYHERRT' ~:.99 F
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TRX 0.24
~xxw BRLRNCE 123.64
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RCCT: xxxxnxxxxxxx6289
KCP1: 12069
DIRECT UEBIT 1<<.64
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MUMMA'SAPPLL9NCES
3820 TRINDLE RD
CAMP HILL, PA 77011-4336
(717)761-2080
www. mummasappliances. com
Mumma's Appliances
. `J~\`\ ~'a~` ~
1.~
~' /Z ~1`~
Cyril Fyrster
508 Allenvlew Dr.
Mechanicsburg. Pa 17055
Due on receipt I 02/18/2012
Will Call Ronnie 439-4320
Anulimrces. Sales and Service
_.. -.. . .
,..
~7ad~_~ i ~e-~ l ~e.--fZ-
LOWE''~'
"~~wING .
LWIE' i NONE :ENTEIIS. INC.
5500 CARLISLE PIKE ',
NECINYIICSBUAO, PA 17050 (7t7) 610.9230]
.00$ OFf MILITARY- PERSONAL USE DISCOUNT SALE -
- SALE -
3t: 52223NP1 017805 TAANSI: 14588858 02118-12
144420 PFOLIO 3LT PD TITTER 26.981
29.98 DISCOUNT EACH -9.OOj
(26947 35" CONTRACTORS PAPER 9.691
70.98 DISCOa7T FACII -1.10 j
355410 39090 CIN PO YNITE CS YCO 197.1
219.00 OISCOIMT EACN 41.901
322951 2 7/4" FROSTED RIBBED 6LA i6.1~
5.98 DISCOUNT EACN -0.801
9 A S.SB
169682 14" ES Oli RUBBED BRONZE 35.9$
39.98 DISCOUNT ERCN -4.00'x,
598T9TAL: 266. i,
TAX: 17.7
INVOICE 14115 TOTAL: 309.
TAL DISCOUNT: 81-BO
A: KYJ(XXXXXXXKX3B31 AMOUNf:90S.25 AUTHCD:B 1295
SYIPED REFID:80S909599 02/18/72 19:71:1
:iOAE: 7Y13- TERMINAL: 14 02/71219:1 :~
OP ITEMS PURCHASED: ~ 7
:CLUDES FEES, SERVICES AND SPECIAL ORDER I ENS
fNANK YOU TOR SHOPPIINI LOL4:'S.
~E REVERSE STS TOA RETURN POLICY.
' STORE NANABER: JIN DUNKELBEABER
''~. YE NRVE THE COYEST PRICES. 6UARaiTEEDy
YDU FIND q LONEfl PRICE, YE YILL BEAT IT BjY 108.
SEE STORE FOR DETAILS. ~I
KY##AY#i##ik##d##########ti###ii####i#!~##i######
YOUR OPINIONS COUNT! i Y
' .K....~. m ~... n ea Mn , n.e•c acct rrrfn+ r
I
I
Rick Barr
Plumb
inc.
PAOS9224
41 WMdsor WWaayy Date ~+~ 1
tool Mill, 0lt.1Tb11 Nurser
(~ 731 IS23
~'~°°~ "°~~°~~ InvoicQ
Bsth Remodeling • Service Work • Sewer Cleanings
New Instaila0ona • Resktential & Comrnerolal
24-Hour Emergency 3erv/ce
TERMS: ~r~w..pJe,,. ~orvK~er+ pow#t~er '}~~1~ +^
b~.s e,ne d'
DATE CHARaEB AND CREDITS
BALANCE FORYVAFAD- ETALANCE
X l~G.t~~ ( I •e c)
'~/ !! d~
~i~. ~~ ~ fJC )
i l~ ( =\
nr ~>
/1
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TilOAl1K YOtN `PAYL7l3T AMOUN7IN 1Yi13 COLUMN A /
~ • •' ~ 1 • •
Payable To: Offce Hours: Cumberland CounTy, PA
DENNIS ZERBE, TAX COLLECTOR WED. THURS 9AM-11AM & 12-2PM BILL # 2140
Township Of Upper Allen T8x Coll. EVENING HOURS CONSULT UPPERALLEN.ORG
275 CUMBERLAND PARK AY #325 OFFICE AT 100 GETTYSBURG PIKE '(200542002140'
MECHANICSBU G, PA 17 SCOUNT A A ENALTV AMOUN} MAILING DATE: 0 310112 0 1 2
TAXES TAX RATE Until 04130112 Between 05101112 Starting 07101112 ~ Discount: County ~ 2%, Twp ~ 2%
Antl 06130112 ~ Penalty: County @ 10 % , Twp ~ 10
COUNTY 1.902 ML 305.88 312.12 343.33
CNN LIB .143 ML 23.00 23.47 25.82 Control #: 42-42003157
TOWNSHIP 1.400 MC 225.15 229.74 252.71 Map #: 4;?-28-242306.
FIRE HYDRT .059 MC .00 00 .00 TOWNSHIP OF UPPER ALLEN
ST LIGHT 1000 MC 9 45 ~ 9.64', 10.60
TOTAL TAX DUE 4.97 I
632.46 i
J ALLENVIEW
LOT 7 5-E: BLD 15 PB 47 PG 43
Taxes are due and payable anq TREASURER __ Acreage 03 Deed Ref: 00278!04495
payment is requested from: n
FYRSTER FAMILY TRUST 3 I I ~ "! ~ I ~-+, ASSESSED LAND - 17500
ASSESSED IMPR - 146600
508 ALLENVIEW DRIVE
P A I D ASSESSED TOTAL - 164100
MECHANICSBURG PA 17055
UPPER ALLEN TOWNSHIP
Pay Tax Collector before 12/2/2012
On or after 01/01/2013, taxes re payable to Tax Claim Bureau,
One Courthouse Square, Cadi~le, PA. 17013
TAXPAYER OR MORTG GE HOLDER COPY
Return both copies with a s If addressed stamped envelope for receipt I Amount Paid Date Tax Collector
»»»»»»»» TEAR ALONG THIS LINE »»»»»««««« TEAR ALONG THIS LINE ««««««««
Payable To: '~. Office Hours: - Cumberland County, PA
DENNIS ZERBE, TAX COLLECTOR WED, THURS 9AM-11AM & 12-2PM BILL # 2140
Township Of Upper Allen T x Coll. EVENING HOURS CONSULT UPPERALLEN.ORG
275 CUMBERLAND PARK AY #325 OFFICE AT 100 GETTYSBURG PIKE '(200542002140"
MECHANICSBU G, PA 77 SCOUNT A ENALTY AMOUNt MAILING DATE: 0 310112 01 2
TAXES TAX RAT Until 04130112 Between 05/01/12 Starting 07/01/72 j Discount: County ~ 2%, Twp ~ 2 %
I And 06130/12 _ _ Penalty: County ~ 10 % , Twp ~ 10
COUNTY 1.902 MU. 305.68 312.12 343.33.
CNTY LIB .143 MIS 23.00 23.47 25.82 Control #: 4242003157
TOWNSHIP 1.400 M11 225.15 229.74 252.71 Map #: 4:?-28-2423-a06.
FIRE HYDRT .059 M~. .00 .00 .00 TOWNSHIP OF UPPER ALLEN
ST LIGHT 1.000 ML 9.45 9.64' 10.60
TOTAL TAX DUE ' 563.4 ~ 574.97 632.46 ALLENVIEW
_~ LOT 15-Ei BLD 15 PB 47 PG 43
Taxes are due and payable anb ,~ ENNIS ZERBE Acreage..03 Deeo Ret. 00278/04495
payment is requested from: TREASURER ASSESSED LAND - 17500
FYRSTER FAMILY TRUST, / ASSESSED IMPR - 146600
508 ALLENVIEW DRIVE ~ I + ~ 1 ~ ~ ASSESSED TOTAL - 164100
MECHANICSBURG PA 17055
PA[D
Pay Tax Collector before 12/2r/2bN3PER ALLEN TOWNSHIP
On or after 01/0112013, taxes re payable to Tax Claim Bureau,
One Courthouse Square, Carli le, PA. 17013
TAX COLLECTOR COPY
Retum both conies with a s If addressed stamped envelope for receipt Amount Paid Dale Tax Collector
~°"~q' ,5
axe DENNIS ZERSE, TREASURER 4I~J
MECHAN C BURG, PA1 7055Y ~~'~ 1 l~
e: ASSESS.NO -42003157 ' q ~~
MAP NO: 42-28-2423-406. lplb~l2-
508 ALLENVIEW DRIVE
ACRES .030 DEED 27F /3875
ALLENVIEW
LOT 15•E BLD 15 PB 47 PG 43
RESIDENTIAL i FAMILY
FYRSTER FAMILY TRUST
~n 526 ALLENVIEW DR
MECHANICSBURG PA 17055-$168
w;e WED,THURS, 9AM-11AM & 12PM- PM
ins: CONSULT UPPERALLENTWP.OR~OR
CALL 717-766-4236 FOR EVENING
HOURS OFFICE:100 GETTYSBUR PIKE
If paying in installments use the coupons
VII I I~ III C~ II II I I V III 2012 State ent tAReaR EsOtate Taxes Bi1lnDate: o. 047/01/20 2
Assessed Land
Values 17,500 ImBrovement
396 600 Mlnaral
0 Total
169 100
MECHANICSBURG AREA $.D. Discount Faca Ponalt
Rates .olaaesoo
SCHOOL R E .alaze9oo a a
1 976.29
2,016.62 io n
2,218.28
TAX AMOUNT DUE ----> $1,ss7.so $1,695.51 $2,065.06
If Paid On or A£teL
IE Pald Oh or Before 7/01/2011
B 31 Zola 9/01/2012
10 31 x032 11/01/2012
12 31 x012
OFFlCE WILL BE CLOSED FEB 2013 a PARTS OF JUNE 2013
CONSULT UPPERALLENTWP.ORG FOR DETAILS
OFFICE AT TOWNSHIP BUILDING
100 GEITYSBURG PIKE, PHONE 717-788-4238
NOTICE OF PROPERTY TAX RELIEF
Your enclosed tax bill includes a tax reduction for your homestead and/or farmstead
property. As an eligible homestead and/or Farmstead property owner, you have received
tax relief through a homestead and/or farmstead exclusion which has been provided
udder the Pennsylvania Taxpayer Relief Act, a law passed by the Pennsylvania General
Assemby designed to reduce your property taxos.
below to submit payments. If paying fn full use ONLY the 1ST coupon below to submit payment.
State Farm Flre and Casuahy Company
Prepared: March 16, 2012
Prepared for: FYRSTER FAMILY TRUST Prepared by: Klautlia Chilooat
526 ALLENVIFNv DR 301 S 32nd St
MECHANICSBl1RG, PA 17055-8168 Camp Hlll, PA 17011-5129
Phone: (717)761.3589
Property Location: 508 ALL~NVIEW OR
MECHA~IICSBURG, PA 17055-6150
Year Buift: 1885 ' Subzone: O6
TerNtory Zone: 38 Conslnlctlon: Frame
Rate Rr: 100%
Quote Description: 100% Rg'pWCement Cost
Quote Reeubs
Coverages
Dwelling (Coverage A) '.
Dwelling Extra Replacement Qost
Dwelling Extension
Personal Property (Coverage ~)
Business Liability (Coverage L~) each occurtence
Business Liability (Coverage 4) annual aggregate
Premises Medical PaymeMS ( overage M) each person
Loss of Rents (Actual Loss S stained)
Deductibles
Policy deduc5ble
Charges! Credits
Home alert '.
Total Annual Premium
Monthty Premium (Service cryarge not Included)
t]uote Effective Date: 03/19Y2012
Number of Unbs: 1
LImR Premium
197,000 537.00
Excluded
19,700
9,850
300,000
000,000
1,000
1,000 37.00
(27.00)
~~
541.00
This example of available cove}ages entl limits is not a contract, birMer, or recommendadon of coverage. This quota assumes you inwre for 100%
of the estimated replacement cyst of your rental dwelling. Higher limits are available at a higher premium. Coverage i3 available in a lesser
amount. subject to restrid'wns $nd limitations. If iMOrtnaSOn used for rating changes or different rates are eNedive at the time of policy issuance,
this raN quote maybe revisetl. i All wverages are wbJea to the terms entl contll0ons wntainetl in the policy entl entlorsements. Yau must moose
your limits and coverages. '~
1000010 Page 1 of 1 2008 128883 208 07-27-2011
EXHIBITS
SCHEDULEI
PINNACLEHEALTH
HOSPITALS
CYRIL B FYRSTER
100 MOUNT ALLEN DR #X08
IdECHANICSBURCi PA 17055.8171 ~/ n
t-`7-IJ~ `l$.~1
1- `~ - I J. .'18.85 cd:
I-II-Ia ~h.c~ (~
i-13_la, SI•So ~
I - ! 8-la ~5~. ~~I' ~
~~.~~F ~
1-ate-r a.. _
~~~~~~
j~a4~ ~~ I'7~2D11-
~f c5 ~F8
'~~
Patient Name: Fyrster+,Cyril
Statement Date: .... 1112
S pnte g . _ 01107/12
l~hrmher. 4670138
Primary piegrrosis Codle: 428.0
II _
Total Charges: 1221.00
Payments/AdJustments° 1146.09-
Arx:ount Balance: 172.91
Patient Balance: 172
Please Pay This Amt: 572.
Ins. 1: HIGHMARK FREE .00 For questions, call air Billing Help IB1e at:
Ins. 2: MEDICARE A .00 717-2303717 for local ~ or
$ Ins. 3: 1-800-8038064 for Out of Area.
°o Ins. 4:
Customer Servia3 Hours:
Mo»-Wed-Fri 7:00 AM to 4:00 PM
Tues-Thurs 7:00 AM to B:00 ~1
Please Nde: Your phylside» xdl! 6W sepsretery Ior professional servN~es.
V
PINNACLEHEALTH
HOSPITALS
Trans. Date t>ascriotion
Patient Name: Fyrster ,Cyril
Statement Date: D2/01/12
Service Date(s): ~01 0/ 7 12
Account Number. 461013888
Primary Diagnosis Code: 428.0
Please Pay This Amt: 572.91
01/07/12 1 BpppSSS~~~IC METABOLIC PANEL 00048
01/07/12 1 B NATURIETIC PEPTIDE 83080
01/13/12 NEDICA E PPO DISCOUN 269 NIGHMARK FREE
02/01/12 MEDICA E PPO DISCOUN 269 HIGHMARK FREE
Amount
47.00
174.00
140.03-
.06-
~-
PINNACLEHEALTH
HOSPITALS
CYRIL B FYRSTER
1~ MOUNT ALLEN DR #X09
MECHANICSBURG PA 17055.8171
~ II .,
Patient Name: Fyrstef ,CyAI
Statement Date:~_+- 12
--'-Servx:e Date(s): 01/09/12
Account Nwnbar. 481014044
PAmary Diagnosis Code: 428.0
Insurance Information
Important Message
YOUR ACCOUNT ~ CURREN'iLY DUE.
ForACCOUnt Information,
Please Call (717) Z30-3717 or
1-800^803-8064 for Ouk of Area Calls.
if payment has been cent, please dLsrega~d.
Pay online at:
http:J/www.plnnaciehealth.org/bilipay/
Total Charges: !239.00
PeymeMS/Ad)ustmerKs: l160.15-
Account Balance: !78.85
Patient Batanc:e: !70.85
Pleasa Pay This AmC 178.88
Contact Us
Ins. 1: HICiFg1AARK FREE .00 For questions, tali our B81ing Help line at:
Ins. 2: MF~ICARE A .00 717-230.3717 for local calls or
fns. 3: 1-800.803064 for Out of Area.
Ins. 4:
Customer Service Hours:
Mon-Wed-Fri 7:00 AM to 4:00 PM
Tues-Thais 7:00 AM to 8:~ PM
i~se Mote: Yo~phyisician w0!b~separatelyibrpofessionalservices.
4~
P[NNACLEHEALTH
HOSPITALS
Patient Name: Fyrster ,Cyril
Statement Date: 02/01/1
Service Date(s): 01/09!12
~
-
Account Number: _-
451014044
Primary Diagnosis Code: 428.0
Trans. Date Descripti2n Amount
01/09/12 1 VEN PUNCTURE CNAROE 36415 10.00
01/09/12 1 BAS C METABOLIC PANEL 00048 47.00
01/09/12 1 B N TURIETIC PEPTIDE 83880 1]4.00
01/15/12 l~DICAR PPO DISCOUN 269 NI6HMARK FREE 160.08-•
02/01/12 MEDICAR PPO DISCOUN 264 NIGHMARK FREE .07-
t
PINNACLEHEALTH
HOSPITALS
CYRIL B FYRSTER
100 MOUNT ALLEN DR tf X09
MECHANICSBL~RG PA 17055.8171
Account Summary
-:~:
Statement Dale: 02!01/12
~ '`Service Date(s): 01/
Account Nwnbsr: 461015072
PAmery Di~nosis Code: 428.0
Insurance Information
YOUR ACCOUNT IS CURRENTLY DUE.
For Account Information,
Please Ceil (717) 230.3717 or
1-800.8038094 for Oust of Aree Calls.
If payment has been sent, please disregard.
Pay online at
hrip:/lwww.pinnaciaheatth.org/billpay/
Totes Charges: 088.00
PeymeMs/Adjustrnents: 058.96-
AocouM Balance: !29.04
PatseM Balance: 029.04
Please Pay This Amt: 8.0
Ins. 1: HIGHMARK FLEE .00 For questions, call our Billing Help line et:
Ins. 2: MEDICARE A :00 717-230.3717 for local calls or
Ins. 3: 1-800.8038084 for Out of Area.
Ins. 4: Customer Service Hours:
Mon-Wet1•Fd 7:00 AM Zo 4:00 PM
TuesThurs 7:00 AM to 8:00 PM
Please Nate.' YourP~Xs+~+r soybN aeperatsJy forpraAass/onel services.
~::
d>
PINNACLEHEALTH
HOSPITALS
Patient Name: Fyrster ,Cyril
Statement Date: 02/01/12
Service Date(s): 11
Account Mumber: 451015072
Primary Diagnosis Code: 428.0
Please Pay This Amt: 29.04
Tens, pare Descd ion ou
O1/11/12 1 VEN~PUNCTURE CHARGE 36415 18.00
01!11/12 1 CBC CHEMOGRAM) 85027 23.00
O1/11/12 1 HAS C METABOLIC PANEL 80048 47.00
01/17/12 MEDICAR PPO DSSCOUN 269 HIBHMARK FREE 58.94-
02/01/12 NEDICAR PPO DISCOUN 269 HIGHNARK FREE .02-
a
a
c
c
PENNACLEHEALTH
HOSPITALS
CYRIL B FYRSI'ER
100 MOUNT ALLEN DR ~ X09
NIECHANICSBURG PA 170558171
• •~
PaSe-K Name: Fyrstert ,Cytll
State~terrt Date: ____ 02!01!12
Service Dated D1/13H2
AccoaM Number. 461018061
Primary Diagnosis Code: 428.0
Insurance Information
Important Message
YOUR ACCOUNT 18 CURRENTLY DUE.
ForAccoum Information,
Please Call (717j 230-3717 or
1-8~•80:~-8064 for Out of Area Calls.
If payment has been sem, please disregaM.
Pay online at:
httpJ/www.pinnaclehealth.org/biNpay/
~~ Charge Summary
~~
Payments/Adjustmerrts: 0105.20-
Acxount Balance: 051.00
Paf1eM Balance: 051.80
Please Pay This Amt: 1.80
Ins. 1: HIGHMARK FREE .~ For questions, ca0 our BdlGlg Help line at:
hrs. 2: MEDICARE A .00 717-230.9717 for local calls or
Ins. 3: 1-800.803.6064 for Out of Area.
Ins. 4: CuNomer Servtoe Hours:
Moo-Wed-Fri 7:00 AM to 4:00 PM
TuesThurs 7:00 AM to 8:00 PM
Please Note: Yorr physician w1N bN separately far pmfes~o--el servkes.
L~J ',
4~
jrana. Date
01/13/12
01/13/12
01/13/12
01/13/22
01/13/12
01/13/12
01/13/12
01/14/12
02/01/12
PINNACLEHEALTH
HOSPITALS
1 VEN~P
1 CBC,B
1 cBC B
PPO
:_- '!
Patient Name: Fyr~er ,
Statement Date:
Service Dale(s):
Account Nwnber:
Primary Diagnosis Code:
Please Pay This Amt:
36415
87086
CRO 81001
DIFF A 85027
DIFF B 85807
IN 269 HI6HNARK FREE
tN 269 HI6HMARK FREE
Cyril
o2~t,~sz~
~~~i~3r~z-
451016061
428.0
553.80
As.U9.~i
18.00
23.OD-
23.00
38.00
23.00
20.00
58.00
105.16'
.04-
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PI NNACLEHEALTH
HOSPITALS
cYRIL FvRSTe cro caLLIeR
526 ALLENVIEW DR
M@CHANICSBURCi PA'17055-6188
•MName: Fyrster,~yril
Stplement.Date• _ _ _ 03407112
Service Date(s): 01H8H2
ytF~.eowtt Number: _._ 451
Primary Diagnosis Code: 428.0
Insurance Information
Ins. 1: HK3HMARK FREff .00
Ins. 2: MEDICARE A .00
Ins. 3:
itur. 4:
Important Message
YOUR ACCOUNT IS CURRENTLY DUE.
YOUR PROMPT ATTENTION MVOULD BE
C3RATEFULLY APPRECL4TED.
Finendaf assistance is available for the uninsuretl
or underinsured who apply and qualify, For more
irdonnatlon, please call or see ourwetushe at
www.pinnedeheaRh.oiglbiilpay.
ForAcxamt IMomiatbn,
Please Call Customer Service (717)230-3717 or
1-600-803-8064 for Out of Area Calls.
Sae details on the bade of this statement.
ff payment has been sent, please disregard.
Pay online at:
htt~ay~ clahe
Total Charges: .
!262.00
PaymerrfrJAtlJustmerds: 4175.56-
Account Balance: 486.44
Patient Balance: 486.84
Please Pay This AmC CL`,~:1+
_ r «~ ~
For questions, call our Bi0ing Help Tine at:
717-230-3717 for local calls or
1-800.8088084 for Out of Area.
Customer Service Hour::,
Adoo-Wed-Fri 7:00 AM to 4:00 PM
Tues-Thurs 7:00 AM to 8:00 PM
Please Note: Your physidian wN b,8 separffieN her protesadona! servkes.
Patient Name: Fyrster ,Gydl
Statemem Data: 03/10/1
Service Date(s): 01/25/1
Account Number. 451078848
Primary Diagnosis Code: 401.9
Please Pay This Amt:
Trans. Date Description Amount
01/25/12 >; VENIPUNCTURE CHARGE 36415 18.00
01/25/12 1~CBC B AUTO DIFFERENTI A85025 23.00
01/25/12 1 EASIC METABOLIC PANEL 60048 47.00
01/25/12 B NATURIETIC PEPTIDE 83880 174.00
01/31/12 ~
ME ICARE PPO DISCOUN 269 HIOHMARK FREE 175.49-
02/11/12 ME ICARE PPO DISCOUN 269 HI6HMARK FREE .07-
PINNACLEHEALTH
HOSPITALS
-~
PINNACLEHFALTH
HOSPITALS
CYRIL B FYRSTER
100 MOUNT ALLEN DR # XD9
MECHANICSBURG PA 17055.8171
Statement Date: 01/24!12
Service Date(s): 01!08112
Account Number: 481013633
Primary Diagnosis Code: 782.3
I~- ~
Important Message
YOUR ACCOUNT IS CURRENTLY DUE.
For Account Information,
Please Call (!17) 2303717 or
1-800-803-8004 for Out of Area Calls.
ff payment has been sent, please disregard.
Pay Downs at;
http;l/www.pinnaciahealth.ar9lbilipuy!
~~~
~,~~, 0257.00
PaOerrt Name: FY~er ,Cyril Total Charges:
Payments/Adjustmerms: 4184.09-
Account Balance: 472.91
Patient Balance: _472.91
Phase Pay This Amt; 572.8 j ,
•• '
Ins. t: HIGHMARK FREE .00 For questions, call our Billing Help Yoe at:
fns. 2: MEDICARE A .00 717-230-3717 for ioml calls or
in Ins. 9: 1-800-803-8084 for Out of Ares.
~ Ins. 4: Customer Service Hours:
Mon-Wed-Fri 7:00 AM to 4:00 PM
Tues-Thurs 7:00 AM to 8:00 PM
Please Aloe: Yax' pHysiclen wyl bUl ~parefely ifx' pofessionai services.
J
PINNACLEHEAL7H
HOSPITALS
Trams. Date
01/06/12
01/06/12
01/06/12
01/06/12
01/12/12
01/18/12
01/24/12
Patient Name: Fyrster ,Cyril
Statement Date: 01!24112
Service Date(s): ~1/OBI
Account Number: 461013633
Primary Diagnosis Code: 782.3~
Please Pay This Amt: ~ 072.91 i
Description
1 VEN PUNCTURE CHARGE 36415
1 VEN~PUNCTURE CHARGE 36415
1 BAS C METABOLIC PANEL 80048
1 B NqTURIETIC PEPTIDE 63880
MEDICARH PPO DISCOUN 269 HIBHMARK FREE
PAYMENT PA BLUE SHIE 269 HIGHMARK FREE
MEDICARE PPO DISCOUN 269 HIBHMARK FREE
Amount
18.00
18.00
47.00
174.00
172.14-
11.88-
.O7-
U
N
J
J
CHASE ~
r~~~//~~y~° Manage your a00ourN adkw: Ceatealer 8ervke Atlddiowrlowttxt
~i~i{JV//I www.dlase.oart~eeeaom t-9ao-eaa-aeeo inromrtlan on sack
4 OUNT SUMMARY PAYMENT INFORMATION `--I
Aeoount Number: 4286 a470 8088 New Balance $4.5}5.22
Paynrent Oue Gate 04IO6I1
reViprs Balance $4,515,22 Minknum payment Due ~
a ant. Credits t)D
Y
vrcheaes ~.~
~aeh Advances $0.00
aance7renekre ~.~
eee Charged $0.00
dereet Charged $0~~
law Balance rn
$4,5}5.22
perungKAOeirfg pate 02/(19/12.091ON12
oat treat une sasog
wadable Credit $3.984
:ash Access Line $1,700
,wadable for Cash $0
Late Payarent Waminy: II we do not receive your minimum
payment M d1e date dead above, You may have to pay a late fee of
up to 9135.00 and your APR's will be subject to increase ~ a
maximum Penally APR of 28.88%.
Minimum Payment Waminy: Il you make only d1e minimum
payment each pedod, you wiN pay more In irlareat and it wid take
you longer tc pay tit your balance. For example:
It you make ra You will pay oU d,e Mtl you wid and up
additional charges balance shown on paying an estknsad
uedlg this card and this earement in foal d...
each month you about--.
pall...
~ the minimum 25 years $8,816
payment
$tw 3yegre 9s,4os
(BaWr~s=$3,412)
If you wouk! fike kdomia8on atxxd credit couneedng servkes, call
1.886797-2886.
YOUR ACCOUNT MESSAGES
71a account ~ dosed and no longer availahle for use. If you have a balance rerrginklg on the acoouot, Please continue to make
wndtly payments try the due ties. Thank you.
CHASE FREEDOM: ULTIMATE!,REW_ARDS SUMMARY
heviaw pe~q bglgnpq 23,875 Fpm 8r11m1imiad 1 %Ca917 back on ad your
Back
~
binb earned an purchases
ionue poime hen Utimare Rewards Trevel 0
0 t~q ~~ ~~
cgre~dga that change.
Signing up Is free and easy) 9°6 Ceah Bede
ionue poina eemetl at lJltimare Rewards Mell 0
876
23 aq era subject to a quenerty maximum.
oategod
'dnis brdaited 8lk pedod .
0 See ~ ~~ at cheae.oomRreedom.
:anent pdna balance
iedeerrltrq your points for Dash bade a ae$Yl For example, 2000 points = 9x0 cash back. You ov1 receive a check, sabrtlent
aedlt or even dked deposit inW your Cheae Che<irMg account Oki you know 81st you Dan gat a diawunt when you redeem your
biota for select gdt catds9 J1xat vistt www.chaea.oomflreerbm b eee ed d your redamptbn optlone or cell Die number on d,e back
,t your card.
i
Tool f13es dlarged in 2012 $0.00
Tool inareet the kt 2072 $0.00
year- ties }ties reflect aM charges mkwa any refunds
~ppliedW your ac~unt.
1oo00ot Fle5Si39 D t0 000 N 2 na /aian.08 Paps 1 d 2 08!10 tdA M4 46627 aBe1000D10o1940e2~0f '
M09
DATE DR. PATIENT PROCEDURE r DESCRIPTION. AMOUNT
CODE U.~r~
<, nyJiMV~tr PREV1gU~ BALANCE--? 0.00
'
6/12 ncs
01/0 Cyril 71Qi0 Chest iV •00
~-'-
,
tD3/14(iCt Glan Payment:10S.3384958 7.81-
03/14/i2 Adjustment..,. Gennsyly 1,3.32-
'
Bill ,Balance--} 0. 8
7
01/11!12 ncs Cyr^i,1 71010.... Chest iV 22.0kr
03113/12 Plan Payment:992G3034i 7,81-
03/13/12 Adj'stment F'ennsyly 13.32r
Bill Balance--? 0,.87
01!13/12 .ncs Cyrxl. 741®0, Lumbar.2-3V 34.00
03/14/1 _ .R1an.P.c?Yment:.:1053384958. i0. 29-
03/14/12 t~djustment Gennsyly '22..57-
0111:3f12 ncs Cyril _72170 I''elvis 1-c:V, 25.00
03/14/12 Flan payment :_1053384958 8.20-
03/14/12. Adjustment Gennsyly 15.89-
Bill Balance-->
~ ~ _ 2.05
01/25/1^cnc2 Cyril '71010~~ Ches.t,_1U
~ c^_c•00
2
03/13/.1 Flan G~,yment:.99263C~341 _7.81-
.
03f13/12 Adjustment. Gennsyly. 13,.32-
~
~
~ 1I I~~fy~,Q~
.
Ul U~`"'
~ _,,.:..: 8111 Balance--} -.0.87
(~~q
W- bllR (1J ~. /
I" `cJ~1 if
.. .
WE ACCEPT VI SR, MC 8 DISCOVER.
CRLL .OR SEND INFORMATION, ~--~-
PAY THIS AMOUNT ,
IF FULL F'AYMEN7 15 NOT RECEIVED ii
MONTHLY SERVICE CHARGE: WILL. BE f-dDDED
TO YOUR BALANCE.
'DATE pESCRIPTIan
Balance Forward
AXMENT RECEIVED - THANi{ YOU!!!
*** Nursing Care ***
M/ BRA -NURSING -SEMI-PVT
t/O1-02/01
AILY PHONE CHARGE (WAGNER)
M/ BRD -NURSING -PRIVATE
L/02-02/03
,~ /,
,~-~~ ,~
V`
1.00
3.00
2.00
RESIDENT tt CURRENT OVER 30 OVER 60
121122 913.00 0.00 0.00
E CYRIL B FYRSTER
RESIbENT NAM Mr.
I ~ Please make check payable to Messin6 Village.
A ih finance charge maybe assessed on accounts for which payment bas not be
If you have any questlons or rnncerns about your bill, please address them d
~.c
• .u~ar ~ 2. i .~RYRIfCJ 1 VACV..J 1 tIMLM.YY.-
DA: E .~~.,........._._
Balance Forward ~5, ttx 5
913.00
03/21/2012
03/3Il2012 PAYMENT RECEIVED -THANK YOU!!!
MEDICARE PART A CO-INSURANCE
~~~ ~
1,392.98
l 913.00 0.00
1,392.98
~~ `~~~~
1 ' `~~~
RESIDENT # CURRENT
121122 0.00 OVER 30
0.00 OVER Ci0
1,392.98 OVER 90
0.00 OVER'12{'M~'.
0.00 TOTAL AMOUNT DUE
$1,392.98
NAME Mr. CYRIL B. F'YI~STER Date ~~~~ ~ ~~~ ~ ~ _
Please make check payable to Messiah Lifeways at Messiah Village.
A 1% finance charge maybe asBessed on accounts for which payment has not been received by the due date. Thank you!
It you have any questions or concerns about your bill, please address them direct-y to Fiscal Services at 790-8220. Thank Yout /
r
rag12 2 ul ~
',
~11~GHM~RK. ~ Claim Detail
Type: INSTIeVRONAI/ iPEEDOM BLUE MlDICARE t CHOICE (M+C) PPO MEOIGUSURGIrAL
pMm Nnmbx: 13555836]26 PWeM Ata Numbx: 131122
Pet91ry Numbx: 1)50x32019 Peet6ry Name: MESSIAH YILLSGE
MemwrID NUmbx: 11395x966001 MemMrOroup Number: 01999505
Type ar 601: 2la AtlmWlPrt Dew: 32/27!2011
Bwwment Prom/Te: OtN1)2012-01/2]/2D32 ttpkal P:erord Number.
PafNM Name; PVRSTER, CYRIL pet4nt Dew of aktl:s 06/Iry1910
Petknt Rex: MW Pstknt Rektbwhip: SEtF
Repreteasetl pYm: PaYw: NtOViOER
geeelwtl Dew: 01/2x/2012 Prows Dab: 02/27/2012 LRal9tl k~ "
8~
IwmHbnw Dew: 03/0]12012 Q:ack Number: 09926192/5 PWent UabllRy Amount: f1,J92.9
Tobi pmr9e Amweh 61],611.53 Daduebbla AmWr:D fD.OD tltlCmwtnh '~
NMmMUel A0lVatmeM: 63,661.80 Ninsuranw Amowt: 61,392.96 Penally Amount: 60.00
Albwea AmWnR 633.929.]3 Npey Amwnh 60.00 Payment AmbuMt f13,536.75
Intmest A31ed DeysRYw: 0012/ Inwres PaymenC 60.00
Rev Pmcaduw SeMw Nen-CeYentl floe Allewetl tine Remark
Code Cade/Raw pew UMb Charw Charys type Amount Bmtw Cede
001 023 0.UC10 01/Ol/Z012 0006 0.00 0.00 O.OD RElEC1ED 85199
002 022 RU620 01!0]/3012 0016 0.00 0.00 0.00 0.E]EC3E0 89199
003 022 RUB30 01/03/3013 0006 0.00 0.00 0.00 0.PJKT[D 85199
OOL 120 01)01)2012 0026 6169.00 0.00 0.00 APPROVED 85199
005 250 01/01l201i OD30 1630.00 0.00 0.00 APPROVED 85199
006 2g7 01/OL2012 0909 62.91 0.00 0.00 AMYtOVED R5t99
Om 3T0 01/01/2012 0133 ]1.x0 0.00 0.00 APPROVED 85199
006 app 01/01/3032 0001 ]1.79 0.00 0.00 APPROVED 85199
OD9 330 03(01/2012 0001 630.92 0.00 O.OD APPROVED 85199
010 420 01/01/2012 00]3 D13.Ifi 0.00 0.00 APPROVED 85199
'
pll I:W 01/01(2022 00]1 2]01.50 0.00. 0.00 APPROVED 85199
013 910 01/03/2012 OOIS 1505.55 0.00 0.00 APPROVED 85199
RemxkaJ Remerb/
RyetHOn Re)attlon Destdptbn
Colo
Twx sarvkes were pnHOm+ep by a wr6tlpstlng provl0x. Tw albwanW w01 w axeptstl M tM PmWdOr s3 wYnunt N N11. CO
85199 x5
Mbr
peter ID Numbx peYment
A. NIGHNAAIf 0661x3190 60.00
B.
C.
PatleM Pre-CaWlcatlen Nambee; Cbwraa Dayb: 000
Admisslon Types 2 Non-Covered Deya: 0000
MmkMw Neur. OB Colnsraew Data:
Mmtaskn Beards 4 LlhUma Rewrva Days:
OkNarW Hwrt 00 PatNM 6tews: 30
Nknary
gQandlnp Plryllden:
Othx PbyNekn 1:
Owx PhyaltlM 3:
2
Owurmtlw fsae Daw
1, Sp 11/39/2011
3. sD oule/3o1z
6pen Nee 1: ]0 Prom:
Vehe Nde Amount
i. fD fx6.oo
Atlmbabn Dlybeal& >2w>
Dla9:lwk ar Netrm a1 Dlnes x le3ury
SvbwRted Cede Prloed Ntle
vNnnrv nom
l ]6722
PmwOum Noes s:a Dataa
SebmRSYd Code Dab PrkxO Code
oaurrenw Nae ww
2. 59 01/06/2012
4.
12/!6/2011 To: 12/31!2011
Value Code Anment
2.
tb:wrnal awe of Ipury NM:
9ubmktetl Code Pawn Ntla
1 Tl9]
a 51661
Submitted Code DMe Prked COtle
3912967611
fatlOry Remerha:
]nPU[ Vemiw tMkawn .00 PHwO Yamton IMiwwrt .00
ReMrel/Emerwnry IMintm: Prbtluxt ID: 310
NeMOrk lndiwter: ] Prevlax Biw NUmWr: a
Retmburcement Method Code: M3 Spetlel are Pereenwpm 1.00
Prid::9 TaPh
https://navinet.navimedix.com/controller.aspx
4/16/2012
MESSIAH
Lfewa s~~
~V ~
at MESSIAH YII.tAGE
100 MT. ALLEN DRIVE, MECHANICSBURC'i, PA 17055
RONI COLLIER
526 ALLENVIEW DRIVE
MECHANICSBURG, PA 17055
j.., y 5 -
Fam PBOt
RESIDENT# UNIT STM'f.DATE
121122 032 P 04/30!2012
RESIDENT S
Mr. CYRIL B. FYR3TER
TOTAL AMOUNT DUE $0.00
DATE DUE 05/31/2012
DATE DESCRIPTION RATE ~8ts CHARGES CREDITS BALANCE
04/30/Z012 Balance ForvVard
PAYMENT RECEIVED - THANK YOUSt!
1,392.9 1,392.98
0.00
RESIDENT #
121122 CURRENT
0.00 OVER 30
0.00 OVER 60
0.00 OVER 90
0.00 OVER 12rMT,
0.00 TOTAL AMOUNT DUE
$0.00
NAME Mr. CYRIL B. FYRSTER -~aie Daisotzut z wn^'°-°'
Pease make check payable to 1ljtesaiah Irfeways at Messtah Village.
A 1 % finance charge may be assessed on accounts for which payment has not been received by the due date. Thank yout
If you have any questlans qr concerns about your bill, please address them directly to Fiscal Services at 790.8220. Thank Xout
DATE ~ PATIENT ~ DOCTOR ~ CPT4 I DEBCRIPTION
01(27112 Cyxil Dineaarapu 99223 INITIAL aDSPITAL CARE
O1J 27/12 Cyril Dinaaaeapu 1123E ACP DISCUSS/DSCN MER DOC'
01/26/12 Cyr3I Vahora 99232 SUBSEQUENT ROSPITAL CARS
01/29/12 Cyril Vahora 99232 BVBSEQUENT ROSPI2AL CARE
01/30/12 Cyc12. Vahora 99232 SUBSEQUENT ROSPITAL CARE
01/31/12 Cyril Vahoxa 1123E ACP DISCUSS/D9CN MHIi DOC'
Q 01/31 J12 Cyril Vahore 99232 SUBSEQUENP EOSPITAL CARE
$@ 02!01/12 Cyril Yahoxa 99238 tlOSPITAL DISCRARGE'DAY
Thank yo for Your romp payment.
~,t~ l`~
~v ~1'~°
~, .h
~~ RECEIPT RECEIPT INS. PAT.
HARGE FROM INS. FROM PAT. ADJ. BAL BAL
¢289.00 ¢0.00 997.12 80.00 $191.98
go.o0 $o.oo go.oo
810!.00 90.00 $9x.61 $0.00 $68.39
¢109.00 80.00 g3a.63 90.00 $68.99
¢303.00 ~ 90.00 996.61 $0.00 $68.99
$o.oo ¢o.oo $o.oo
¢10!.00 ¢2.26 $9d.61 90.00 $66.13
8302.00 - 861.20 831.00 90.00 86.80
~' CURRENT 30.80 DAYS 60-80 DAYS 80-120 DAY8 OVER 120 DAYS TOTAL ACCOUNT I
$469.98 $0.00 $0.00 $0.00 $0.00 $489.98
Thank You For Your Payment. For Blldng Questions, Please Cad: (717) 972-A490.
SALANCE
DU M PA NT
$469.98
i~lil~~^l~~~®®~II®®Q
~. __... ~ ~n 3~1 ~~y Statement 4qulrias Number: 17+7)7242791 ettt 230
Contrd~PAPuimonaryAssoc.L.L.C. d~ -.
i
Cyril Fynsler (FYRCYR000+)
7127H1 FAI(sob, 1'pkiural atfusbn/ap • Itw #58+53 (Hl6)
727!11 Patient Copayment-VISA
10/301'1, Insurance Payment-Fiighmark
10130/11 Inwrence Adjustment - HlghmaAc
ktwran~Flled-Highmark _ ~-
Patlent Due
This Is your third statement please temp Payment
Cyr9 Fyrsler (FYRCYR0001)
12M5H+ ptf(pneumontaQd)- bv.*56702(H10)
12115111 Patient CopaymeM-VISA
ON2 , Inwrence Payment - Highmark
10H2 I~unmce AdluaOneM ~ Hlghmadc
Ireutanca Filed • Highmark
Patient DUe
r
$152.00 I
$15200
o3/+2no+z ~ oln4no~z ~ FvHCr~ooo,_ I
Please make checks peyat~to Central Penneylvanfa Pulmonary Assoc.
$110.52 ~
$170.52
~~
3~y
$15.00
$18.48
$10.00 I
$15.00
$16.48
Patient CYRIL FYRSTER Case Descrip:OV/BS/01-11-12 Primary Ins. PA HIGHMARK BLUE SHIELD 1J20/2012
Amount Paid by Amount Paid By
Dates Procedure Procedure Description Charge Insurance Guarantor Ad)tistments Remainder
01/11/12 99213 OFFICE VISIT, EST PT 80.00 -52.70 -25.00 -12.30 -10.00
Patient: CYRIL FYRSTER Case Descrip:OVBS/1/26!12 Primary Ins. PA HIGHMARK BLUE SHIELD 2/20/2012
Amount Paid by Amount Paid By
pates Procedure Procedure Description Charge Insurance Guarantor Adjuatmerds Remainder
01126/12 99213 OFFICE VISIT, EST PT 80.00 -52.70 0.00 -12.30 15.00
~ ~®A1i'i1~1`!6~~~ ik
~~ ~,tv
LAST PATIENT PAYMENT 1/18/2012 -$25.00 ~
•' Before you are billed, charge$ ere submitted to any insurance carriers you provided. This balance
is now the patlent'a responsibility. Payment b due Wittrin 18 days from the statement date.
_ We Thank You for paying your account pompfly!
.__-__.
.EUGENE KILMORE, JR. MD PC
Amount Due
5.00
-. LEf3END~ -NON-Lt;EiJSNL. ~~TB3.1
FOR;MONTH'.. FOR .MONTH AMOUNT DUE
eee'cMrae ~T0Tl14CNARGE3. .7ewra~.a-sw.aw.
° 94.33 33.5;8 ~ ~4r/Z~5--f~'/'
ASE CALL Alert PharmecY Services, inc at 7-BOU-Y86=8951 ~- `S~i . [J
wiog) Wimwrw
. y
1
CHARGE
-"~"`-- A0428
BLS NON EMERGENCY 80425
BLS MILEAGE A0422
OXYGEN ADMINSTRATION
DESCRIPTION DP pAYMENT~
Medicare AssignmentAdjwatment
Medicare Part B Payment
Inggrynce Payment - HIGWMARK -FREEDOM BL
Insurance Payment - kIGNMARK -
QUANTITY
~'~-
5.9
1.0
RECEIPT
886547117
14587659
14229225
UNIT PRICE
--~-
13.73
85.01
PAYMENT DATE
08/01/2012
08101/2012
05212012
0223!2012
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ~
RETURNED CHECK FEE -$31.00
GALL NUMBER: 1202084R
FYRSTER, CYRIL 09/O6I2012
pA"t1ENT NAME:
nm.+.n..
~~
497.18
81.01
65.01
Total Charges 643.20
AMOUNT
39828
187.53
-185.99
185.99
Total Credits 593.81
549.39
~.
pMpiJNT ,~
This count is past dueltl The balance amount is your
IMPORTANT MESSAQ ant must be made now.
~ponsibflity. Paym
___---, /
,.. _.. ~/
WEST SHORE EMS ^ BLS 20 GRANDVIEW AVE SUITE 211 CAAAP HILL, PA 17011-170