HomeMy WebLinkAbout11-20-121505620101
REV-150Q °`f~~~'
PA Department of Revenue ~ ~~' 1lBE ONLY
t3ureau of Individual Taxes Courtly Code Yew F8e Pbar~ber
PO BOX ~8otioi INHERITANCE TAX RETURN Q r
Hanisburg, FY1 t7i28-06oi REStt}ENT I~CEDENT ~ ~ ~ °1 ~ f
ENTER DEC®E1i1T MrFORMAT'ION BELOW ._._
Social Securftyt Number Date of Desch tdNDDYYYY ~e ~¢ !~ yl,IppYYYY
f}9/Q82012 05/29/'! 9Q8
Decedent s last Name SuHbc DecedenPs Fhst Narrre MI
DORAND CARMEN p
(K Able) Enter StavlvMp 8pouss's IMormsiion Bebw
Spouse's Last Name _ Su1Toc Spouse's First Name MI
_.. .
N!A
__ .
__ _ _..
Spouse's Soda{ Seauity Number... TH18 RETtlRN MUST i3E FitEfl NI DUf?'l.IC/1Tf WITH THE
REGIS'T'ER OF WILLS
FILL dr? APPROPRIATE OVALS BELOW
t~ 1. Origfial Retum O 2. Suppkmentat ReLum O 3. Remainder Return (date of dea8t
G 4. LYnYed Estate
~ 8. Decedent Died Tesfsle
(Attach COPY of Wi0)
O 9. Ufgatlon Proceeds Received
O 4a. Fulwe interest Compromise (dais of
death after 12~t2-82)
O i. Deoederk htsNtalned a lMng Tnr~
{Atlad't Copy of Tnrst)
O 10. Spousal Pove-ty Credit (dale of death
batwreen 12-91-91 and t-1~5)
prior b t2-13-82)
O 5. Federal Fatale Tax Retunt Reo~irelt
~ 8. Tofei Number of Sale Deposit fioxee
O 11. Election b tax under' Sec. 9113(Aj
(Aldch Sch. O)
rID@IT - Tips BECTIOM YtiSY t1E tb11Pl.E3E0. ALL AtIQ ~ftflDENTIAL TAX fiATi011 aliOtlLD tlE OtREGTEO TQ:
Na[rte Telephone Alurrfber
Andrew H. Shaw (717} 243-7135
First ikle of address
200 S. Spring Garden St
_..
Seoald Nne of address
Suite 11
City or Post OPAce - _ State Z~ Code
_..
CarNsie PA 17013
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CorrsspoNderrl'a a-rue address: andrew(p~asllawlaw.oom __
stfider darrdper)uy,1 dedere ttrst t nsve tndidng aooampanring acl~eduks and sAbnrerMS, ana b Ina test of my imoiwredge and belief.
ellwr ttwn tiw paeeorrei ropne 1s trawl on M (nfonnatior- of w!~ prspenr has ary krwwMdee.
~ E FOR FR.ttrCa RETtlRti t)ATE
AO~SS v
2654 ~84c~rdea~lix Beach Gardens, FL 33440
~ alblRR THAN REPRESENTATNE .~..~
..- SCI 7 ~'
204 S. Spring Garden Street, Sine 11, Carlisle, PA 17013
Pt.swsE tts~ o t: oRal orrg.Y
Side i
15D5610101 1505630101
1505610105
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: Carmen D. Dorand
RECAPITULATION
1. Real Estate (Schedule A) ............................................. 1. 0.00
2. Stocks and Bonds (Schedule B) 2. 0.00
.......................................
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00
4. Mort a es and Notes Receivable Schedule D
9 9 ( ) .......................
.... 4. 0.00
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)... .... 5. 67,801.50
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ... .... 6. 8,023.49
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested.... .... 7. 28,026.12
8. Total Gross Assets (total Lines 1 through 7) ......................... .... 8. 103,851.11
9. Funeral Expenses and Administrative Costs (Schedule H) ............... .... 9. 3,096.11
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .......... .... 10. 3,366.17
11. Total Deductions (total Lines 9 and 10) ............................. .... 11. 6,462.28
12. Net Value of Estate (Line 8 minus Line 11) .......................... .... 12. 97,388.83
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) .................... .... 13. 0.00
14. Net Value Subject to Tax (Line 12 minus Line 13) .................... .... 14. 97,388.83
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0_ 0.00 15. 0.00
16. Amount of Line 14 taxable
at lineal rate X .0 _ 0.00 1 g, 0.00
17. Amount of Line 14 taxable
at sibling rate X .12 0.00 17 0.00
18. Amount of Line 14 taxable 97 388.83
at collateral rate X .15 ~
18. 14,608.32
19. TAX DUE .........................................................19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610105 1505610105
14,608.32
O
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
DECEDENTS NAME
Carmen D. Dorand
STREET ADDRESS
770 S. Hanover Street
CITE'
Carlisle STATE
PA ZIP
17013
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) 14,608.32
2. Credits/Payments
A. Prior Payments 0.00
B. Discount 730.42
Total Credits (A + B) (2) 730.42
3. Interest
(3) 0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 13,877.90
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred :...................................................................................... .... ^ X^
b. retain the right to designate who shall use the property transferred or its income : ........................................ .... ^
c. retain a reversionary interest; or ...................................................................................................................... .... ^ x^
d. receive the promise for life of either payments, benefits or care? .................................................................. .... ^
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .......................................................................................................... .... ^ x^
3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .......... .... ^
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? .................................................................................................................... .... ^ 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN
For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary,
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
LAST WILL AND TESTAMENT
OF
CARMEN DORAND
I, CARMEN DORAND, residing at 1054 Hill Place, Carlisle, Pennsylvania, being of a
sound and disposing mind, over the age of eighteen (18) years, and under no legal disability, do
hereby make, publish and declare this to be my Last Will and Testament, hereby revoking all
other Wills and Codicils heretofore made by me at any other time.
Article I: I direct that my Personal Representative(s), hereinafter named, pay all my
just debts and funeral expenses as soon after my death as practicable, including all property, state
and federal death taxes assessed against me, my estate, or my beneficiaries, without proration
among my beneficiaries. However, all property bequeathed or devised hereunder, either outright
or in trust, is bequeathed or devised subject to existing mortgages, liens or encumbrances
thereon.
Article II: I confer on my Personal Representative andlor any Trustee appointed
herein and their successors the right to sell or otherwise convert any real or personal property at
public or private sale, at such time or times, in such manner, and for such price or prices, and on
such terms and conditions as my Personal Representative shall determine, and to execute and
deliver goad and sufficient conveyances, assignments, and transfers of the property, without
Liability of any purchaser for the application of any consideration; to borrow money and to secure
its payment by mortgage of real or personal property, pledge of investments, or otherwise,
Carmen Darand
without liability on the part of the lenders to see to the application thereof; to retain any
investments at discretion; to invest and reinvest at discretion, as permitted under Act 28 of 1999,
the "Prudent Investor Act"; to make distribution in cash or in kind; to allocate and distribute
different kinds or disproportionate shazes of property or undivided interests in property among
beneficiaries, in cash or in kind, or partly in each; and all other powers given under the statutory
and common law of Pennsylvania available at the time of my death and the power to do all acts
and things necessary or appropriate in the management, administration and distribution of my
estate.
Article III: At the time of execution of this Last Will and Testament I am a widow.
Article 1V: At the time of execution of my Last Will and Testament I have one child:
JOSEPH SEANN DORAND.
Article V: I hereby nominate and appoint my nephew, KENNETH J. COTE, as
Personal Representative of this my Last Will and Testament. My individual Personal
Representative shall not be required to fiunish bond or surety.
Article VI: I give, devise and bequeath THE SUM OF FIVE THOUSAND AND
00/100 ($5,000.00) DOLLARS to DONNA GABI,AK, absolutely and in fee simple.
Article VII: I give, devise and bequeath all the rest and residue of my estate of
whatever kind and description, wherever situate, absolutely and in fee simple to KENNETH J.
COTE, with the intention that he hold and distribute my estate as he may deem appropriate.
However, I understand that he is not under any obligation to distribute according to a pattern of
2 Carmen Dorand
distribution.
Further, it is my specific intention not to leave anything to my son, JOSEPH SEANN
DORAND.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~ day of
2010.
SEAL)
CARMEN DORAND
Signed, sealed, published and declared
by the foregoing Testatrix as and
for her Last WiII and Testament,
consisting of three (3) pages, in the
presence of us, who at her request,
and in her presence, and in the
presence of each other, have hereunto
set our hands as witnesses thereto.
i
3
co1VIlVIONWEALTIa of PENNSYLVarria
COUNTY OF CUMBERLAND
I, CARMEN DORAND, Testatrix, whose name is signed to the attached or foregoing
instrument, being duly qualified according to law, do hereby acknowledge that I signed and
executed the instrument as my Last Will and Testament; that I signed it willingly; and that I
signed it as my free and voluntary act for the purposes therein expressed.
Sworn to or a. fumed and acknowledged before me by CARMEN DORAND, the
Testatrix, this a ~5 `~ day of _ _ o~ ~/ , 2010.
COINMONWEALTN OF PENNSYLVANIA
Natarlel Seal
Sarah D. Cox, Notary PubNc
lrmgme Baro, Qanbertand County
Commission Bgrkes Nw. 5, 7D23
Member. PermsyhraMa Assoditlan a~ Notaries
CARMEN DORAND
- ~
Notary Public
My Commission expires: n dV, S ~ ~ o / , j
COMMONWEALTH OF PENNSYLVANIA
COUN'T'Y OF CUMBERLAND
We, l ~ G /1 and ,,(~,~dr8~ kG.. J ~ ~
the witnesses whose names are signed t the attached or foregoing instrument, being duly
qualified according to Iaw, do depose and say that we were present and saw Testatrix sign and
execute the instrument as her free and voluntary act for the purposes therein expressed; that each
of us in the hearing and sight of the Testatrix was at the time 18 or more years of age, of sound
mind and under no constraint or undue influence.
worn to or ed and subscribed before me b~ 7~~ K ~'Dz~/.~.~i9 and
.,~~.. a~,t,rl . wrinesses, this ~_ day of 2010.
GOMMONWEAL7H OF PENNSYLVANIA
NotaNal Seal
sash D. Cory Notary PubNt
~OYne Sao, Cunbedand County
MyCommtsslon 6~Ires NOV. 5,1'023
Member, PennSvlVanla A~odatlon of NotaNes
-~~~~
Notary Public
My Commission Expires:
4
REV-1508 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCFIEDIJLE E
CASH, BANK DEPOSITS, 8~ MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Carmen D. Dorand 21-12-0981
Include the proceeds of litigation and the date the proceeds were received by the estate.
Ail property JolMly-owned with Nght of survivorship must be disclosed on Schedule F.
(If more space is needed, insert additional sheets of the same size)
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~.~0 2~Z00~0046~ i?00 2~ X94 2GE~47~t'
REV-1509 EX+ (oi-io)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDt~LE F
JOINTLY-OWNED PROPERTY
ESTATE OF: FILE NUMBER:
Carmen D. Dorand 21-12-0981
If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A• Kenneth J. Cote, Jr. 2654 Bordeaux Ct. Nephew
West Palm Beach, FL 33410
B.
C.
JOINTLY OWNED PROPERTY:
ITEM
NUMBER LETTER
FOR JOINT
TENANT DaTE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET ~o of
DECEDENT'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENTS INTEREST
1 A
. . Checking Account, Bank of America, Account #898037539277 16,046.97 50 8,023.49
TOTAL (Also enter on Line 6, Recapitulation) I $ 8,023.49
If more space is needed, use additional sheets of paper of the same size.
~~nk+afAmeri~ca
.~,,
Bank of America, N.A.
P.O. Box 25118
Tampa, FL 33622-5 1 1 8
6~IL~~II~~h~L~~NIf~~~~~~1l~hJlh„~~~t1~61,J,~6f~~lf
23075 001 SCM999 I1
CARMEN DORAND
KENNETH J COTE JR
2654 BORDEAUX CT
PJEST PALM BEACH, E'L 33410-1401
H
Page 1 of 3
Statement Period
07-21-12 through 08-22-12
B 13 O A P P A 1.3 0156612
Number of checks enrlncoA• ~
Account Number: X277
Platinum Privileges
Regular Checking
Platinum Privileges Relationship Account
CARMEN DORAND KENNETH J COTE JR
Your Account at a Glance
Account Number 9277
Beginning Balance on 07-21-12 ~ it,zs94.82
Deposits and Other Additions + 4,038.77
Other Subtractions - 886.62
Ending Balance on 08-22-12 S 16,046.97
Our Online Banking service allows you to check balances, track account activity and more.
With Online Banking you can also view up to 18 months of this statement
online and even turn off delivery of your paper statement.
Enroll at www.bankofamerica.com.
H
CARMEN DURAND
KENNETH J COTE JR
Page 2 of 3
Statement Period
07-21-12 through OR-22-12
B130APPA 13
Number of checks enclosed: D
Account Number: 9277
Regular Checking Additions
Deposfts and Other Additfons Date Posted Amaant($)
US Treasury 312 Des: Tax Ref ID:Xxxxxxxxx IRS 08-01 4,038.77
Indn:Dorand, Carmen D Co ID:3 1 1 1036170 Ppd
Total Deposfts and Other Additfons 54,038.77
Regular Checking Subtractions
Other Subtractions - Date Posted Amount($)
Online Banking transfer to Ghk 7737 07-30 862.65
Confirmation# 1448412177
Online Banking transfer to Chk 4905 08-20 23.97
Confirmation# 3830f56256
Total Other Suhtractfons $886.62
Daily Balance Summary
Date Balance($) Date Balance{$)
Begginning 12,894.82 08-01 16,070.94
07-30 I2,032.I7 08 20 16,046.97
B~nkof America ~.~,~
~"'
Bank of America, N.A.
P.O. Box 251.18
Tampa, FL 33622-5118
t~~tt~~~tl~~t-~t~~~titl~~~~~~lt~t~.ftt~~~~~~it~l~l~~l~~t~t~~lt
aoo~s ooi ScM999 =ia o
KENNETii J COTE JI2
2654 BORDEAUX CT
NEST PALM BEACH, FL 33410-1401
H
Page 1 of 3
Statement Period
08-23-12 through 1)9-19-12
B ]3 0 A P PA 13 0143667
Number of checks enclosed: U
Account Number: 9277
Platinum Privileges
With Bank of America Mobite, you have the flexibility to bank on your schedule from your smartphone or
tablet. To download the free Mobite Banking App, text APP1 to 226526.
~. ~~
BanttAmeriDeals puts cash back deals right into your account.
Visit Online Banking and click the new Cash Back Deals tab to choose those deals that are relevant to
you. Use your debit or credit card, then get cash back into your account at the end of the next month.
Visit www,bankofamerica. com/deals to learn more.
Our Online Banking service allows you to check balances, track account activity and more.
With Online Banking you can also view up to I8 months of this statement
online and even turn off delivery of your paper statement.
Enroll at www.bankofamerica.com.
H
KENNETH) COTE JR
Page 2 raf 3
Statement Period
08-23-12 through 09-19-12
B 13 0 APPA 13
Number of checks enclosed; 0
Account Number: 9?77
Regu{ar Checking
Platinum Privileges Relationship Account
KENNETH J COTE JR
Your Account at a Glance
Account Number 9277
Beginning Balance on 08-23-12 $ 16,046.97
ATM and Debit Card Subtractions - 600.00
Other Subtractions - 1,367.11
Ending Balance on 09-19-12 $ 14,079.86
Regular Checking Subtractions
ATM and Debit Card Sahtrat~tions Date Posted Amoant($)
BkofAmerica ATM 09/08 #000006233 Withdrwl 09-10 600.00
Palm BEACH Garde Palm BEACH GA FL
Total ATM and Debit Card Subtractions $600.00
Other Subtractions Date Posted Amount($)
Online Banking transfer to Chk 4905 09-12 1,3b7.11
ConE.rmation# 1.7474664$3
Total Uther Subtractions $1,367.11
Dally Balance Summary __ _
Date Balance($) Date Balance($) Date Balance($)
Beginning 16,045.97 09-10 15,446.97 09-12 14,079.86
REV-1510 EX+ (08-09)
pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Carmen D. Dorand 21-12-0981
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
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND
THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET
% OF DECD'S
INTEREST
EXCLUSION
(IF APPLICABLE
TAXABLE
VALUE
1• IRA
Contract # 8500418914
, 28,026.12 100 0.00 28,026.1;
TOTAL (Also enter on Line 7, Recapitulation) $ I 28,026.12
If more space is needed, use additional sheets of paper of the same size.
Product; Flexible Premium Deferred Qwner Name:
Annuity - MNL Capstone
Contract Type; IRA
Issue Date: 09~28~2010
Agent Name: RICHARD S BHELLEY
Agent Phone: 561-588-8293
X-Cel !l0 Year pith Ext QDti
Total Premium;~'~
Withdrawals;``'
Interest and Index Credits:
Qutstanding Loan Balance;
Accumulation Value:'``
CARMEN! D D4RAND
Qwner Address: 285 BDRDEAIiX CT
~~E~T PAlhi BEACH FL 33410
Annuitant: CARMEN D D~ORAND
X41,129,45
X13,106,94
X3,61
X0,00
X28,026,12
~A~ All premium bonus amounts are included in the Premiums amount,
(B~ Iyithdraauals include any surrender charges incurred,
(C~ Amount payable upon surrender maybe less.
REV-1511 EX+ (10-09)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s) Kenneth J. Cote
ESTATE OF FILE NUMBER
Carmen D. Dorand 21-12-0981
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' Ewing Brothers Funeral Home 197.61
Z. St. Patrick Church, Carlisle, PA 150.00
3. Baughman Memorials 219.00
B.
1
Street Address
City
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
State ZIP
0.00
Year(s) Commission Paid:
2• Attorney Fees: 1,200.00
3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant
Street Address
Ciry State
Relationship of Claimant to Decedent
4.
5.
6.
~.
ZIP
Probate Fees:
Accountant Fees:
Tax Return Preparer Fees:
Kenneth Cote (reimburse travel costs for funeral and probate)
TOTAL (Also enter on Line 9, Recapitulation) I ~
If more space is needed, use additional sheets of paper of the same size.
164.50
0.00
0.00
1,165.00
3, 096.11
Ewing Brothers Funeral Home, Inc.
630 South Hanover Street
Carlisle, PA 17013-
. (717)243-2421
September 19, 2012
Kenneth J. Cote
2654 Bordeaux Ct.
West Palm Beach, FL 33410
The Funeral Service for Carmen D. Dorand
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can.. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING 15 AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
I. PROFESSIONAL SERVICES
Basic Services of Funeral Director/Staff $1200.00
2. FACILITIES/SERVICES/STAFF/EQUIPMENT
Basic Use of Facility , , $200.00
Document Prep/Permanent Recording, $325.00
3. AUTOMOTIVE EQUIPMENT
Vehicle to transfer remains to Funeral Home, $295.00
Utility Car , $135.00
C. SPECIAL CHARGES
Direct Cremation , $345.00
FUNERAL HOME SERVICE CHARGES $2500.00
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THAT YOU HAVE SELECTED $2500.00
Cash Advances
Opening Grave, $600.00
Sentinel Obituary , $97.61
Certified Copies of Death Certificate $60.00
Clergy Honorarium $150.00
Organist Honorarium, $150.00
Cantor/Singer Honorarium $75..00
Flowers. $80.~3`~
Altar Servers $60.00
TOTAL CASH ADVANCES AND SPECIAL CHARGES . $1~72.6t
Total
Total Cosl , $3772.61
r.
~~ ~ ~~ ~
SUB-TOTAL $3772.61 _ 1-~}cr,Y
INITIAL PAYMENT /DISCOUNT /CREDITS 3147.21 l
TOTAL AMOUNT DUE $6 LQ~v
The unpaid balance over 30 days is subjected to a 1.50 % service charge per monUi - 18.0000 % per annum. ~ ~ ~ ~dLc.~
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Print
Subject RE: engraving
From: Baughman Memorials -Carlisle Office (carlisle@baughmanmemorials.com)
To: kcote22C~4yahoo.com;
' Date: Thursday, October 4, 2012 11:36 AM
Mr. Cote,
41 South Bedford Street
Carlisle, PA 17013
From: Kenneth Cote jmailto: k cote22@yahoo.com
Sent: Thursday, October 04, 2012 9:58 AM
To: carlisle@baughmanmemorials.com
Subject: Re: engraving
That's fine. Need your address so for check. Thank you.
from: Baughman Memorials - Carlisle Office < carlisle@baughmanmemorials.com >
To: k cote22 aQyahoo.com
Sent: Wednesday, October 3, 2012 9:08 AM
Subject: engraving
Mr. Cote,
Page 1 of 1
Let me know if you receive this please. Stone engraving for Carmen D Dorand at St. Pats cemetery 1928 -
2012 . Price of this engraving is $219.00.
Thank you,
Michealle Wright
http://us.mg6.mail.yahoo.com/neo/launch?.rand=31omn35nfim~1~ t 1 /7/2p t 2
REV-1512 EX+ (12-08)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
ESTATE OF FILE NUMBER
Carmen D. Dorand 21-12-0981
Report debts Pncurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
it more space is needetl, insert additional sheets of the same size.
WAIC UCJVIU~1,1~7 i\ - V171t3 4f1I11~VL3 VRGIJI I-J: GliLMI'7VG-.:.
Balance Forward 7,950.00
08/14/2012 Hair Care - Set/Comb Out 1 9.25 7,959.25
09/0112012 Room and Board Private-HC 09/01-09/30 30 7,950.00 9.25
09/08/2012 Room and Board Private-HC 09/01-09/08 8 2,120.00 2,129.25
RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 12~M-~ TOTAL AMOUNT DUE
13354 0.00 2,129.25 0.00 0.00 0.00 $2,129.25
NAME Mrs. Carmen D. Dorand oa a 10/01/2012 F°""P&°'
CHAPEL POINTE AT CARLISLE, 770 SOUTH HANOVER STREET, CARLISLE, PA 17013-4105
Millennium Phcy. Systems Mechanicst
5020 Ritter Road, Suite 110
Mechanicsburg PA, 17055
f3Ue by 1~-13 ?2 Bt~rlg^G~`ce boon: Man-Fri 9at~# ~ t~fi'-. '~b(f ht~i: i~-8+66<4~6-7~7A
INVOICE
09/30/2012 Account Number: CHAP1131
CARMEN DORAND
c/o KENNETH COTE 13354
2654 BORDEAUX CT. P~
PALM BEACH GARDENS FL, 33410
AmOt,lllt UU8' ~ ~fit>~~I~~,,:
Please Detach Here and Return Top Portion With Your Payment
-- - - - ------------------------------------------------------------------------------------------------- ------------------------------------
Invoice Date:09/3012012, Acct#:CHAP1131, DORAND, CARMEN D, Chapel Pointe NC, A, Guistwite, Darryl _X
. O~J701/20T2 __6485488 ~fa:00 HydrAtAZthiE HCt OraFTa6let 25 MG _ $ 2,3,5 c $ 0.00 $ 2.35 RX
50111-0327-03 __ _ _.
09/01/2012 6490322 33.00 QUEtiapine Fumarate Orel Tablet 50 MG $ 10.00 c $ 0.00 $ 10.00 RX
55111-0169-05
09/01/2012 6553409 113.00 Calmoseptine External Ointment $ 5.01 $ 0.00 $ 01
5 OTC
00799-0001-04 .
09/01/2012 6563531 11.00 levothvroxine Sodium Oral Tablet 75 MCG $ 2.21 c $ 0.00 $ 2
21 RX
00378-1805-01 .
09/01/2012 6563608 11.00 Citalopram Hydrobromide Oral Tablet 40 MG $ 2.20 c $ 0.00 $ 2
20 RX
55111-0344-01 .
09/01/2012 6563644 11.00 Ranitidine HCI Oral Tablet 150 MG $ 1.63 c $ 0.00 $ 1
63 RX
53746-0253-05 .
09/01/2012 6563660 22.00 GlipiZlDE Oral Tablet 5 MG $ 2.34 c $ 0.00 $ 2
34 RX
00781-1452-10 .
09/01/2012 6563669 22.00 Gabapentin Oral Capsule 300 MG $ 3.63 c $ 0.00 $ 3
63 RX
16714-0662-02 .
09/01/2012 6563677 11.00 Clonidine HCI Oral Tablet 0.2 MG $ 1.99 c $ 0.00 $ 1
99 RX
00228-2128-10 .
09/01/2012 6563692 11.00 Metoprolal Succinate Oral Tablet Extended Release 24 Hour 25 MG $ 9.02 c $ 0.00 $ 9
02 RX
49884-0404-01 .
09/01/2012 6563711 11.00 Loratadine Oral Tablet 10 MG $ 3.31 $ 0
00 $ 3
31 OTC
45802-0650-87 . .
09/01/2012 6563733 11.00 Isosorbide Mononitrate CR Oral Tablet Extended Release 24 Hour c $ 4.57 c $ 0
00 $ 4
57 RX
62175-0128-37 . .
09/01/2012 6568069 11.00 Furosemide Oral Tablet 20 MG $ 1.36 c $ 0
00 $ 1
36 RX
63304-0624-10 . .
09/04/2012 6565009 4.00 CIoNIDine HCI Transdermal Patch Weekly 0.1 MGl24HR $ 10.00 c $ 0
00 $ 10
00 RX
00378-0871-99 . .
09/07/2012 6566938 12.00 Acetaminophen Rectal Suppository 650 MG $ 16
5 $ 0
00 $ 5
16 OTC
45802-0730-33 . . .
$ 193.21 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 51.30 $ 13.48 $ 0.00 $ 0.00 257.99
Bank of America ~ Online Banking (Accounts ~ Account Details {Account Activity Page 1 of 1
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Adv Tiered Interest Chkg - 8558 Transaction Details
Check number: 00000000105
Posting date: 10/16/2012
Amount: -511.66
Type: Check
Description: Check
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DARRYL GUISTW[TE, DO
56 ASHTON STREET
CARLISLE, PA 17015-6914
Carmen D. Dorand
C O Kenneth Cole
2654 Bordeaux Court
PALM BEACH GARDENS, FL 33410
(717)609-2639
Account Number Billing Date Pace Office Use Only
1833 09/20/12 1 MED
Service Date CPT4 Des~ri lion Prov ni Mese. Charee Ins. P id Adjustment Patient Paid Balance Due
07/17/12 99308 Nursing Home Est. Patient Level 2 DG 1 80.00 12.72
Patient: Dorand, Carmen D - 1833
Servicing Provider: Darryl K Guistwite DO
08/30/2012 Medicare 50.86 15.78
08/30/2012 Medicare 0.00 0.64
07/31 / 12 99309 Nursing Home Est. Patient Level 3 DG 1 ] 05.00 17.55
Patient: Dorand, Carmen D - 1833
Servicing Provider: Darryl K Guistwite DO
09/06/2012 Medicare 66.86 20.59
08/06/12 99309 Nursing Home Est. Patient Leve13 DG 1 105.00 17.55
Patient: Dorand, Carmen D - 1833
Servicing Provider: Darryl K Guistwite DO
09/12/2012 Medicare .66.86 20.59
08/07/12 99309 Nursing Home Est. Patient Leve[ 3 DG 1 105.00 17.55
Patient: Dorand, Carmen D - 1833
Servicing Provider: Darryl K Guistwite DO
09/12/2012 Medicare 66.86 20.59
08/10/12 99308
___ Nursing Home Est. Patient Leve12 DG 1
___ __ 80.00 13.36
Patient: Dorand, Carmen D - 1833
Servicing Provider: Darryl K Guistwite DO
09/12/2012 Medicare 50.86 15.78
Comments: Please Pay --> 78.73
Please pay within 30 days...thank you
Carmen D. Dorand
1833 900.00 108.01 302.30 78.73
Account Number New Charges New Payments New Ins. Pmt. Curcent Due Past Due Finance Charge Scheduled Amount
Since Last Bill Since Last Bill Since Last Bill /Billing Fee
Darryl Guistwite DO.56 Ashton Street • CARLISLE, PA 17015-6914 22
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Adv Tiered Interest Chkg - 8558 Transaction Details
Check number: 00000000}.08
Posting date: 11/05/2012
Amount: -136.56
Type: Check
Description: Check
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~~ YOUR INFORMATIC
• •• •
Patient Name Carmen D Dorand
• Account Number 9531442
Date of Service August 06, 2012
Service Type Emergency Room Services
Insurance Name Medicare Outpatient
Name of Insured Carmen D Dorand
Policy Number 582585400A
Amount Due From You $23g,g8
® ~ ~ ..
Amount due from you is $239.98 as of 90/22/2.012 for
Emergency Room Services performed on August 06,
2012.
Total Charges $7,507.54
Discounts/Adjustments Given -$6,634.93
Insurance Payments Received -$632.63
Amount You Paid $0.00
Amount Due From You $239,88
e Online at www.carlislermc.com
(available 24/7)
By phone - 717-960-1680
® By credit card -complete section below and retum
® By check -return section below with check
a ..
The charges.listed below do not reflect the. discount that
you and your insurance company received.
Pharmacy 63.64
Supplies 160.07
Cat Scan 3,551.18
Lab 961.43
Pharmacy 35.88
Emergency Room 2,735.34
TOTAL CHARGES $7,507.54
' - ' • ' ~ ~~~ 3269-HMASTMT-1491721-1314666046-P; 6709015-1-200; 32726334-1; 1
The amount shown on this statement is outstanding at this time. Your prompt
payment will be greatly appreciated.
. ~~~~~~
~a~w
Account: Dorand, Carmen D (405640)
Program: Consult-Older Adult
Admit llate: US/16/ZU11 Discharge Date:
Statement Date: November 6, 2012 Please Pay This Amount: $11.20
Due Date: November 21, 2012 Amount Enclosed: $
KENNETH COTE
2654 BORDEAUX COURT
PALM BEACH GARDENS, FL 33410
4948-175
I~^
Card Number:
Expiration Date: Security Code:
Signature:
Printed Name:
Please check this box if your address or insurance has
chanced and then complete the form on the back of this pace
Payment Arrangement Exists? No
< Detach Here and Return Top Portion with Your Payment. Bottom Portion is for Your Records>
Please mail yoru~ payment and this payment stub using the supplied pre•addressed emeJope.
(If you are paying for mulk'ple accounts with one paymenS please occlude all payment stubs.)
Summary Statement of Services (Detail on Reverse Side)
Account: Dorand, Carmen D (405640) ~ Due Date: November 21, 2012
Program: Consult-Older Adult Statement Date: November 6, 2012
Admit Date: 05/16/2011 Previous Statement Balance: $0.00
Discharge Date: Payments Received Since Last Statement: $0.00
Total New Charges: $11.20
Amount You Now Owe: $11.20
The account balance for the services received is now due. All insurance activity, if any, has been processed and the
remaining balance is due from you. If your balance is zero, please retain detail for your records.
Services provided in the new calendar year may be subject to additional patient liability over and above the usual
co-payment and co-insurance amount. Co-payments, co-insurance, deductibles and non-covered services will be your
responsibility according to your health insurance coverage Please contact your insurance carrier with questions regarding
deductible and co-insurance amount (s).
Please remit the balance in full within fifteen (15) days using the enclosed reply envelope. Our office accepts checks
and credit cards. If you are unable to pay your balance in full or need assistance in understanding your statement, please
contact our office at (717) 270-2413 or toll free at 1(888) 302-4710, Monday -Friday 8:OOAM - 4:30PM. Someone will be
glad to assist you..... _ _ _ .
Thank you for choosing Philhaven for your healthcare services.
0-59
~`~ ~ r,
• fir, 283 South Butler Rd Mt Gretna, PA 17064-0550 ;Phone (888) 302-4710 or (717) 270-2413
~~i~~~~~ Business Office Hours: Monday through Friday 8:00 am - 4:30 pm
REV-1513 EX+ (O1-10)
Pennsylvania SCHEDULE ~
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Carmen D. Dorand 21-12-0981
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec. 9116 (a) (1.2).]
1• Donna Gavlak, 1044 Hill Place, Carlisle, PA 17013 Friend 5,000.00
2. Kenneth J. Cote, 2654 Bordeaux Court, Palm Beach Gardens, FL 33410 Nephew 78,510.93
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $
If more space is needed, use additional sheets of paper of the same size.
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