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HomeMy WebLinkAbout02-19-08 (2)15056041147 X1500 EX (06-05) OFFICIAL USE ONLY REV County Code Year File Number PA Department of Revenue Bureau of Individual Taxes INHERITANCE TAX RETURN 2 1 0 6 0 9 1 9 PO 80X.280601 RESIDENT DECEDENT Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOD to of Death Date of Birth Social Security Number 09 26 2006 10 11 1945 164 80 1745 nni Suffix Decedent's First Name Decedent's Last Name SAHA DERVISEVIC (If Applicable) Enter Surviving Spouse's Information Below MI Suffix Spouse's First Name Spouse's Last Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER ®F WILLS FILL IN APPROPRIATE OVALS BELOW ~ 3. Remainder Return (date of death ^ t lemental Return 2. Supp prior to 12-13-82) urn 1. Original Re romise t Com ~ 5. Federal Estate Tax Return Required 4. Limited Estate ^ p 4a. Future Interes (date of death after 12-12-82) xes it B Decedent Maintained a Living Trust ~ 0 o 8. Total Number of Safe Depos ^ ^ 6 Decedent Died Testate (Attach Copy of Will) ~ (Attach Copy of Trust) th f d ^ 11. Election to tax under Sec. 9113( ^ 9. Litigation Proceeds Received ea 10. Spousal Poverty Credit (date o between 12-31-91 and 1-1-95) (Attach Sch. O) BE DIRECTED TO: NDENCE AND CONFIDENTIA O CTION MUST BE COMPLETED. ALL CORRESPO CORRESPONDENT THIS SE ne Number Daytime Telepho Name (7 17) 2:x`9.3 14 D 0 NINA G. MILOVANOVIC E S H Q Firm Name (If Applicable) REGISTER OF WRLS USE.ONLY j t) First line of address 129 E. ORANGE ST., 2ND FL :" Second line of address ----- DATE FILED City or Post Office LANCASTER State ZIP Code pA 17602 Correspondent's a-mail address: n i n a m i l o v a n o v i c h@ v e r i z o n. n e t 'u I declare that I have examined this return, inc ~ doing accompanying schedules and statements, and to the best of my knowledge and belie , nal re resentative is based on all information of which preparer has any knowledge. Under penalties of perk ry, DATE it is true, correct and complete. Declaration of preparer other than the pe ~ //~~ p SIG TURE OF PERSON RESPONSIBLE FOR FILING RETURN $ejfudin Dervisevic 524 Thir eet Carlis A 17013 NTATIVE SIGNATURE P P OT ~-, Nina G Milovanovich DAT y U 129 East nge Street, 2nd Floor, Lancaster, PA 17602 Side 1 L 15056041147 15056041147 J 15056042148 REV-1500 EX Decedent's Social Security Number 164 80 1745 Decedents Name: S a h a D e rv i s e v i c RECAPITULATION ............... 1. 1. Real Estate (Schedule A) ........................................................................... ...... .. 2. 2. Stocks and Bonds (Schedule B) ....................................................................... 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3. 4. Mortgages & Notes Receivable (Schedule D).........••••••••••••••••••••~•••~~"""""""""'~•~~ 4. 6 9 ~ 9 $ ]_ 7 3 Schedule E)..•••••••••••••• 5. Cash, Bank Deposits & Miscellaneous Personal Property 5• Jointly Owned Property (Schedule F) ~ Separate Billing Requested ............. 6 6• . 7. Inter-Vivos Transfers & Miscellaneous Non-PrSo parater Biting Requested ............. 7. (Schedule G) 69,981.73 ................. ....... g• Total Gross Assets (total Lines 1-7 ...............••••••••••••••••••••••••••••••" 8. 1 7, 4 4 0. 7 8 ........................ 9. Funeral Expenses & Administrative Costs (Schedule H) ................. 9. 4 2 , 3 2 8 3 4 ............. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)..........••••••••• 10. 5 g , 7 6 9.12 ................................................... 11. Total Deductions (total Lines 9 & 10) ................... 11. 1 Q , 2 12.61 ...................................................... 12. Net Value of Estate (Line 8 minus Line 11)...... . ts/Sec 9113 Trusts for which 12. 13. Charitable and Governmental Beques not been made (Schedule J)•••••••••••••••••••••••• • h 13. as an election to tax 1 0 , 212.6 1 • .......................... 14. Net Value Subject to Tax (Line 12 minus Line 13) ....................... 14. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, of Q 0 0 transfers under Sec. 9116 0 0 0 15. (a)(1.2) X .00 4 5 9 5 7 16. Amount of Line 14 taxable 1 Q, 2 1 2 6 1 16. at lineal rate X .045 Q 0 0 17. Amount of Line 14 taxable 0 0 0 17. at sibling rate X .12 Q 0 0 18. Amount of Line 14 taxable 0 0 0 18. at collateral rate X .15 4 5 9. 5 7 19. 19. Tax Due ................................................................................................ G A REFUND OF AN OVERPAY VAL IF YOU ARE REQUESTIN MENT. 20. FILL IN THE O 15056042148 Side 2 15056042148 J File Number 21-06-0919 REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME Saha Dervisevic STREET ADDRESS 530 Second Street STATE ZIP CITY pA 17013 Carlisle Tax Payments and Credits: (1) 459.57 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A, Spousal Poverty Credit g, Prior Payments C. Discount 0.0 0 (2) 0.0 0 Total Credits (A + B + C) 3. Interest/Penalty if applicable p, Interest E. Penalty Total Interest/Penalty (D + E) (3) 2 is rester than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) 4, If Line 9 (5) 459.57 Check box on Page 2 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5A) A• Enter the interest on the tax due. (5B) 4 5 9.5 7 g. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check Payable fo: REGISTER OF WILLS, AGENT LOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS PLEASE ANSWER THE FOL Yes No 1. Did decedent make a transfer and: •••••.•,••• ................ ^ a .. ^ 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 :......................... ^ ^ interest; or ................................................................................................ ^ c. retain a reversionary ' ' , ,• ................................ d. receive the promise for life of either payments, benefits or care. ••••••••'~within one year of death without ^ ^ 2. If death occurred after December 12, 1982, did decedent transfer property receiving adequate consideration? ................. 3. Did decedent own an "in trust for" or payable upon death bank acco rnnon Srobate property whiahath .......... 4. Did decedent own an Individual Retirement Account, annuity, or othe p ^ ..................... . .......... contains a beneficiary designation? .................... . ____ ___ ___._ F THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE ___ ___ __ IF THE ANSWER TO ANY O - --- __ __ - -- - _ __ _ __ -___ _ __-- _ _ __ after Jul 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use o For dates of death on or Y surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)). r Janus 1, 1995, the tax rate imposed on the net value of tia nfessouse from taxsand the stat Itory requ rementsro For dates of death on or afte rY (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surv g p r disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. fo For dates of death on or after July 1, 2000: don the net value of transfers from a deceased child twenty-{ 72 P S s 9116e(a) (1 ~)] er at death to or for the use o a The tax rate impose natural parent, an adoptive parent, or a stepparent of the child is zero (0) percen [ the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, The tax rate imposed on except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)J. ercent (72 P.S. §9116 (a) (1.3)]. A The tax rate imposed on the net value of transfers to o whothas at least onde parent n common withlthe(decedent, whether by blood or adoption. sibling is defined under Section 9102, as an mdividual Rev-1508 EX+ (6-98) ,1 1 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ___._~.~~ ..rn~nCA1T SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY rlLt ivuino~~~ ESTATE OF 21-06-0919 nog-.~~cpvic. Saha Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM DESCRIPTION NUMBER Dervisevic V. Schriml No. 07-7450 - Cumberland~County Court of Common Pleas 1 Wrongful DeathlSurvival Action (See Exhibits A and B ne Market Account #8728-18 -Cornerstone Federal Credit Union, P.O.Box 1181, 2 Mo y 5 East Gate Street, Carlisle, PA 17013 (See Exhibit "C") Savin s Account #8728-01 -Cornerstone Federal Credit Union, P.O. Box 1181, 5 3 9 East Gate Drive, Carlisle, PA 17013 (See Exhibit "C") VALUE AT DATE OF DEATH 62,500.00 5,145.07 2,336.66 69,981.73 TOTAL (Also enter on Line 5, Recapitulation) (If more space is needed, additional pages of the same size) Form PA-1500 Schedule E (Rev. 6-98) Copyright (c) 2002 form software only The Lackner Group, Inc. REV-1151 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN __,.~..~.~T Wert nGNT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF n,,.-..~cnvir_ Saha flLt ryumo~r~ 21-06-0919 .r,,..._- - -- Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION NUMBER A. FUNERAL EXPENSES: See continuation schedule(s) attached g, ADMINISTRATIVE COSTS: ~, Personal Representative's Commissions Social Security Number(s) / EIN Number of Personal Representative(s): Street Address State Zip City Year(s) Commission paid 2. Attorney's Fees Nina G. Milovanovich Esq 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Seifudin Dervisevic Street Address 524 Third Street 17013 Carlisle state PA- zip city Son Relationship of Claimant to Decedent AMOUNT 7,320.00 6,508.78 3,500.00 112.00 4, ~ Probate Fees 5. Accountant's Fees g, Tax Return Preparer's Fees 7, ~ Other Administrative Costs 17,440.78 TOTAL (Also enter on line 9, Recapitulation) Form PA-1500 Schedule H (Rev. 6-98) Copyright (c) 2002 form software only The Lackner Group, Inc. Rev-1502 EX+ (6-98) Sf , COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE H-A FUNERAL EXPENSES continued ESTATE OF n,....,:~eair Naha FILE NUMBER 21-06-0919 ITEM DESCRIPTION NUMBER Coble-Reber Funeral Home, Ltd., 208 North Union Street, Middletown, PA 17057 - 1 Funeral Goods and Services - (See Exhibit D ) 2 Funeral Meal 3 James R. Gringrich Memorials - Grave~Marker - 5243 Simpson Ferry Road, Mechanics, PA 17055 (See Exhibit E ) AMOUNT 3,075.00 600.00 3,645.00 Subtotal 7,320.00 Form PA-1500 Schedule H-A (Rev. 6-98) Copyright (c) 2002 form software only The Lackner Group, Inc. Rev-1512 EX+ (6-98) g C H E D U LE ~ DEBTS OF DECEDENT, ` 1f MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF n...-..Gcnvirr Saha 1-ILC ivumv~~~ 21-06-0919 Include unreimbursed medical expenses. ITEM DESCRIPTION NUMBER 1 Broome Volunteer Emerg. Squad, P.O. Box 126 WVS, Binghamton, NY 13905 Cardiology Associates, P.C., 30 Harrison St., Suite 250, Johnson City, NY 13790 2 Court of Common Pleas, Cumberland County, PA -Filing Fee -Petition to settle 3 Wrongful Death and Survival Claims 4 Milovanovich & Espinosa, LLC, ew York State Pollice, Div.HQ./Central Records, Building 22, 1220 Washington, NY 5 N 12226.2252 -Police Accident Report Park Avenue Assoc. in Radiology, 32 36 Harrison Street, Johnson City, NY 13790 6 Richard C. Low, Esquire, 234 North Duke Street, P.O. Box nce ~ roceeds among 7 ortionemnt of Insura p 17608-1533 - Arbitrtation Fee (Re app several competing claims) nited Health Services Hospitals, P.O. Box 5214, Binghamton, NY 13902 -Medical g U Records nited Health Services Hospitals/Wilson Memorial Regional Medical Center, P.O. g U Box 5214, Binghamton, NY 13902 -Hospital Services 10 United Medical Associates, 346 Grand Avenue, Johnson City, NY 13790 - Physicians Services TOTAL (Also enter on Line 10, Recapitulation) VALUE AT DATE OF DEATH 645.00 122.92 19.62 20,833.33 2.25 913.00 118.87 37.11 18,575.90 1,060.34 42,328.34 (If more space is needed, additional pages of the same size) Form PA-1500 Schedule I (Rev. 6-98) Copyright (c) 2002 form software only The Lackner Group, Inc. REV-1513 EX+ (9-00) ,, COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN .-.~,. ~.~r.ir n~rCnFnIT SCHEDULE J BENEFICIARIES ESTATE OF Dervisevic, Saha NAME AND ADDRESS OF NUMBER PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS dilstributionsr~ antd tpransfers ' under Sec. 9116(a)(1.2)] 1 Lutvija Dervisevic 135 C. Street Carlisle, PA 17013 2 Lutvo Dervisevic 524 3rd Street Carlisle, PA 17013 3 Sejfudin Dervisevic 524 3rd Street Carlisle, PA 17013 FILE NUMBER 21-06-0919 RELATIONSHIP TO SHARE OF ESTATE AMOUN ($$~F)ESTATE DECEDENT (Words) Do Not List Trustee(s) Daughter 113 of Residuary Estate Son 113 of Residuary Estate Son 113 of Residuary Estate I Total ~ Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet III NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 0.00 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COF ErR PA 1500 Schedule J (Rev. 6-98) Copyright (c) 2002 form software only The Lackner Group, Inc. SEJFUDIN DERVISEVIC, as Administrator of the Estate of SARA DERVISEVIC 530 2A~ Street Carlisle, PA 17013 Plaintiff v. David A. Schrirnl 2713 Owego Road Vestal, NY 13850 Defendant IN THE COURT OF COMMON PLEAVANIA :CUMBERLAND COUNTY, PENNSYL : CIVIL ACTION -LAW No. o~r- Z~So- C,~~t TerM ORDER NOW on this ~~ day of , 200 upon consideration AND , of the fore oing Petition to Approve Settlement of Wrong 1 Death and Survival Actions, it is g hereb ORDERED that the Petition be, and the same is, GRANTED. The settlement of the Y above•ca tinned matter in the amount of two hundred fifty thousand ($250,000.00) dollars is P hereb APPROVED. It is further ORDERED and DECREED that the counsel for the Petitioner Y is to distribute the settlement proceeds as follows: 1. Attorneys fees and costs: a. To: Milovanovich & Espinosa, LLC, (attorneys fees -personal injury action} $ 83,333.33 b. To: Milovanovich & Espinosa, LLC, 508.78 $ 6 (attorneys fees -estate administration} , c. To: Milovanovich & Espinosa, LLC 1,]34.55 {reimbursement of costs) 2. Inheritance taxes on survival action proceeds: $(2 g 12.50) a. To: Pennsylvania Department o 1Rn of inheritance tax return} (to be escrowed pending preparat o , 3. Wrongful death and survival action proceeds ($156,210.84) to be distributed to: $52,070.28 a. Lutvo Dervisevic EXHIBIT a ~. • ; -• ~ b. To: Sejfudin Dervisevic c. To: Lutvija Cehajic $52,070.28 $52,070.28 TOTAL: $ BY THE COURT: DISTRIBUTION LIST: P e Street, Suite 2, - Nina Milovanovich, Esquire, (Milovanovich & Es inosa, LLC, l29 E. Orang Lancaster, PA, 17602) an ncom ass Ins. Co., 333 Glen Street, P.O. Box 5000, Glen Fa11s,NY 12801) _ _ Mary Altm (E P - Lisa Staff (Allstate Ins. Co., P.O. Box l Ob4, Buffalo, NY 14240) i ~ ..+ • ~_ • ~ .~~eo~, I here ~ ~~,~. ~:,, ~;:~~ ~,s~~d ~ r; Tra.:,.....'~ . t ~.a '' , ~ n .' ~ r. ~ t „i~ R-`~ay o 2 ~iGi~4ftr1fi~1'Y Bt~taEnu OF INawa~Al TAXES IHHERRANCE TAx DIVISION Po Box 280b01 ~, PA 17128.0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE wEg AlZDRESS www stag December 4, 2007 Nina Milovanovich, Esq. Milovanovich 8~ Espinosa, LLC 129 E. Orange St., Ste. 2 Lancaster, PA 17602 Re: Estate of _Sah2 06 0919 c File Number Court Number: CCP Cumberland Co. No. Dear Ms. Milovanovich: royal of Settlement Claim to The Department of Revenue has received the Pe ~ to a°wrongful death and survival action. be filed on behalf of the above-refe u fo ethe Common ealth's approval of the allocation of the It has been forwardede the la Bonsa proceeds paid to sett) etition, the 60-year-old-decedent died as a result of a motor vehicle Pursuant to the P accident. Decedent is survived by her adult children. his that based upon these facts and for inheritance tax purposo the wrongful Please be advised , no ob'ection to the proposed allocation of the net proceed oe t of Inheritance Tax Department has 1 th action and 25°~ to the survival action. Please be aw thereforehwe would agree to the dea is not an allowable deduction for in this act on $1 9,267 51 to the wrongful death claim he breakdown of the net allocation for survival claim. Proceeds of a survival action are an eritan e t xe 42 Pa. C.S.A. $39,755.84 to the es as the decedent's estate and are subject to the impositio st be deduclted in the same percentag §8302; 72 P.S. §§9106, 9107. Costs and fees mu ted. In re Estate of Me man, 669 A.2d 1059 (Pa. Cmwlth. 1995). proceeds are ~II~M tter is a sufficient representation of the Department's P~he DDepartment of I trust that this le . As the Department has no objections to the Petition, an~n~Ci mf e f you or the Court >~as matter hearing regarding it. Please Revenue wilt not be attending any royal of this uestions or requires anything additional from this Bure sition (that the Department may take in any q allocation is limited to this estate and does of a weongful deathlsurvival action. any other proposed distribution of proce Since ely, • ~~~`C~1 ~s. ~~~CC,~ . ~ oily A. MgClintock ' Trust Valuation Specialist Inheritance Tax Division Bureau of tndividuat Taxes P"°"E: 7»-7s7•»9a • FAX: EXHIBIT R TONE . Box 118 I , 5 East Gate Drive, Carlisle, PA 170 13 o RN E PO ,~ Federal Credit Union Telephone (7 17) 249- 166 I FAX (7 17) 249-8208 Member founded -Service based www.cornerstonefcu.coop November 13, 2006 Milivanovich & Espinosa, LLC 129 East Orange Street, Suite 2 Lancaster, PA 17602 RE: ESTATE OF SAI-IA DERVISEVIC To Whom It May Concern: th Saha Dervisevic had a savings and money market account owned dated At the time of her dea , ' din Dervisevic. Listed below is the information requested per your lette jointly with Seifu October 23, 2006: Account # 8728-01 savings and account # 8728-18 money market aac°ount was opened #1. ##2. The saving was opened November 16, 2001 and the money mar et July 6, 2005. #3. There was no principal amount - Saha did not have aoluan.. #4 Accrued interest for each of the above referenced acc 8728-O1 - $10.01 8728-18 - $104.72 ' eon each account is Saha Dervisevic with Seifudin Dervisevic as Jmone market #5. The nam ccount # 8728-01 became a joint account on November 20, 2003 and e y #6. A was joint at the time it was opened. #7. There is no life insurance. #8. Account balances at time of death 8728-01 - $2,336.66 8728-18 - $5,145.07 ve a certificate of deposit, loans, credit cards or safe deposit box wse do not S aha did not ha e Federal Credit Union. If you requue any additional information, plea CornerSton hesitate to contact me at 717-249-1661 ext 240. Sincerely, ~~ ~~ ~~ Donna J. Mickey EXHIBIT Financial Services Administrato ~ ~ /~ .-___.,~ i I.~~~wi Anr..unI1CTRATION MEMBER SAVINGS ACCOUNTS FEDERALLY INSURED TO $I OO,000 BY THE NAT-ONA~ ~-rc~~~ ~ ~~~""' ' "" co~L~-x~B~~ ~~N~~~ ~ro~~, ~~.~. UNION STREET MIDDLETG~~ P~' 17057 208 NORTH (71?) 944-7413 Brendan J. McGlone, Supervisor NT OF FUNERAL GOODS AND SERVICES SELECTED STATEME Ffk f: 41878 IV Merchaadlss IrtforwatloR Oo Deceased CsukctlCorrtaiacs: Names Saha Derviscvie Date err Dash: Sepeember i6, zoo6 Sues Address: S30 2nd Suoet Sate: PA Zip: 17013 City: Carlisle - This ABneauenl furnished ~ ~pGance with Soctioa 13.20A of Ute Rules aad Re;ulations of the Pennylvania Stste Hood o[ Funeral Directors. CparBes are only for those items that you selected or that are Rqu;t•.d. If we are requited by law or by a cemetery or aeraatory to use any items we will eaplain the eeasoas is wrida8 below. 1 PROFESSIONAL SERVICES 5830.00 ' of Fuaeral Direcwr aad Staff. ........................._..._ Basic Services Sptxial Serviw o[Fuaaal Dirtxtot and StaR(Specify) EmbaltniaY If you sclated ^ fwuial that may require eatbahstrrtg. such n a Ruural with viewing. you ~Y ~'e w PaY far embalmiaL You do not have w pay for embalming YRU ~ Rot appnwe if you seledcd utaagcmet-ts suck as a direct uamatioa err immediate buria4 If we chugcd for cmbalmia=. we will esplsin why below. Otber Prcpuataa of the Body Dreuiog/Caskctiaa is Cosmetote:y..........._..........._ ............. llairdreasia8----•--_..........._ .............._. S9S.00 Sanitary Cara (Topical Disinfection) ...................»_............... Atha (Specify) 5945.00 SUBTOTAL: lrofesaloaal Servlca _. r---- 11 OTHER STAFF AND RELATED FACILI'T'IES Use of Pacilitiea. Staff, aad Equipment for. Yisltation (viewia6}..........._....._ .............._..._......._..........:: Funcnl.........._......... _. _.. _.._ _. Final Corruaittal (Graveside or other) ...............».._...._._... Mcmorid Scrvioe......._.»........__........_ ................_.......... ~.._ Slultcrin~ of Rccsair-r._..»......_...........-__.._......._........-....._ Other (SpxifY) SUBTOTAL: Otber Stall aad Rslaled Faellltla so.oo _ llI TRANSPORTATION 5310,00 Tcamfu of rcasait-s to fuaual Iwmc»._......_ ................_..__... Use ot: 5110.00 Castel Coacb (IleaRe).. _....__....__.._......» ..................... Family LiorousiaeJievaa m Passenger..._._.._........._........ Family Vehide/Four (4~asseaEa........__.._ .................»... ~ lrofessioruUClaiy/Flower/UtiGty 7ransporutian..........._. - s ~ Otper (Specify} Mileage - SUBTOTAL: Traasportatlort 5770.00 SUBTOTAL FUNERAL CI[AAG[iS (I tbro III) 51,715.00 OPTIONAL PACKAGED SERVICES (I[ as optional paekased serviu is aeleeted, WesOtip I • III am not appliublo) 1. Direa t-rernauoe..._......_......--...__.._. 2. Irwnediate BurW....._.._..__._....._..».....».._..-.__.._..~.... 3. Other: SUBTOTAL: pptioaal lacka8ed Ssrvkes 50.00 REASON FOR EMBALMING: ( ) Family sutporisyd ( )Other. Palls I of 2 - ms.oo Vwlt: ~8k, Concrete Box. Concrete Burial Vault urA: Memorial Group_........ ............._...._.... _................._....__...._....... P„e8ister Boot ............._......................_.._.._......._......................_... Acjcttowled8ea'ent Cards.............._ ........................_...._..... Mea-orial Folders/Prsya Cacds .............................__.._.................... ~_ Mi RsaWaeous hems of Mestihandise acrd Serviu _ ....................__.. I. Flowerer ----- 2. 3. - -- 5725.00 SUBTOTAL: hterepaadfse and Other Servka ~_ TOTAL FUNERAL CHARGES A tbru IV) 52.440_00 V CASH DISHURSE1ttENT SS35.00 Crematory..~.....~.... ......................._....~..».~........_......_.~.__.._.. - ClerBy sadlorChurch.........._._.......» ..................__. . Protas~ioa~i1Pa11bcsrers~A ..............~...._._.»......»..__....._............. _~~ Certified Copier of Death Certificatq do Pcmtit Fees»......»............ Newspaper Notices (Estimates) I. 2. 3. Gratusties._.._.._...._..__ .................»...».._._..».................................. _,_.__ Other (Specify) ------- 04ta (Spceity) 1. t„^,ocrtraercial Transportation._.._ ................_..._-»__............ 2. Out of Town Funeral Dirretor......._.._......._............._........... 3. Toot 4. '_."__ S. -- f633.00 SUBTOTAL: Cash Dyburscrosats 53,075.00 TOTAL ESTA-tATE (l -Vic Paciuged Servlcs) 1F ANY LAW. cemetery or cramuocy requiremeats pave required the purchase of any o[ tha items listod above, the law or nquirernrnt is described belo+r. ( )Crematory requires container t0 surround the remains. (X) Your eamaesY require an Dour burial eenuiner. ( ) Otl-er: P Selected: Brendan 1. McGloac ~A) FD 014714E Name of Practiuoaer and License M 1 pave read received a coPY o[ the Statesaeat of Fuaenl Goods and Services Saleaed: a r o Case Woeker P do Sabit Sisee 5010 Lesiker St Bind Bldg. tract Mec4,uricstnagPA (7055 ry (7!n 439-1010 Ppeae Number EXHIBIT EXPLANATION OF PAYMENT ARRANGEMENTS All of the stsl'Fettembas u tl-e COBLE"~~ FUNERAL HOME, LTD. fro ready to auisl your family is any way than you desire. We take this opportunity so shank Y~ far the trust and coafideaee tint You have placed is us. Thera are two types of expaeses ieteurred in eonnoetioa with a tuaetal. F'ust, arc cash disburxatents. Thane arc sums paid to third pubes suds n the certtctery, clergy, newspaper. These are listed is Seuioa V of the Stateatea of Funeral Goods aced Setvicef Selaled. COSLE•REBER FUNERAL HtOw third to non your behalf at no additional wst to you. However. You roust payment of cash disbetrtxetttat Pay or to the fungal service. These charges era N07 rtnke payttsad of these Cash disbursentaats, by cash or dtak oatY. P^ GUAMNTEED, sad are subjat to price changes that my occur between Date o[this Funeral Purchase Agreement and the date of service. A written sutemeat of adusl charges will be proveded for such ittm-s e-storo the final biU is presented Sewed. era our professional charge for the services performed or goods provided by us. la as effort to make things u easy to possebie for you, we offs the following options fa Leta Payment of our professional charge. A. Payment by cash, chock. Visa or MastaGrd before or oa tbs day of the funeral service. B. Payment through the assignment of iatwatece poticy(ia) that are in good standing. lathe event that the feu amount of the ittsweutee potiey(ies} doe trot oqusl the total funeral charges. the balance must ba paid through option A or D. C. Payment io full thaoetgb s pre•oeed funeral erttst fund established with our fitnenl kottu- In the event that the amount is the trust fund doe not sgtnl the foul funeral charges, the baltutes ens be paid through apsioas A. B or D. D. Credit tirunciag available through'Family Assistamt:e.' No maser which payment option You sclec4 Y°Y aro rapons-ble for the payment of the funeral expanses. If you utticipau thu the funds for the fuaersl wUl bs received from the deceoed's estate, You era regwrod 1o pay for the funual std then leek reimbtusamaet from the estau. If you expect that the other family members will watnbuu to the paymrnt oathe funeral cxpatsa, You ue requited to pay for the fungal and then wllat from she other family members. The Funeral Purchase Agreement set forth below will be signed by rwo (2) Gtnily members (ehe'Purehase~s') Bah 6tnily tnsmben wiU each be responstbk for the entire amautt of the htaeral obligation incumcd in conntxtion with the [uttersL FUNERAL PURCHASE AGREEMENT Purchascts agree to pwcbase fmm COBLE-REBER FUNERAL NOME, LTD. {'Futtaal Name'}, w'~ a8T00cs to pmvide lama. the stxvicss and foods sd forth on the Sutettteat of Funeral Goods and Sarrias Sslaud far Sttha pervisevie which iaeludes cash d'ubursaneau of (635.00 peceased, i4 the amount of f1,07s.00 (the "Purchaser Price'), The Purchase Pries shall be paid oo the day of the service. in the event ~ ba[ Price is not paid oa the day of the funeral service, interest shall atxrtte on the uttps' u the rate of 12S•ti per matNb (I SY. per tuuutm). The purchase» ackttowtedge end agree by signing this Ftanersl Purcluse Agrexrae°~ the Funeral Horns sus eat waived its fights to file a claim against the estate of the Deceased from the fltneral upettsa. The Purtbasas agree shat is the event that the Funerd Hoene is requited to rcuia ao attorney to collect the purchase Price. or any prat thereof, the purehtuen stress be rcspoasible to pay all rcnonabk attorneys' fees. including coact eau, iawrrod by Fuaerol Hoots w coll«t the purchase Pitoe. hereueder. Accordingly, tits Funeral Nome The Fnnersl Hams is not the msnufaaura of any goods being purchassxi disclaims all warranties. eapras a implied, of mpcbauubUity or fitness Wr a particular P`tcPorc. Both Purr users agree to be jointly sad severally liable to[ she payment of the Purchase Prin. 'Ibis Fttnsnl Purchase Agteetneat wataias the entire sgrouneet between Pvr~sen and the Fttttual Home sad caoaot ba raodiftod or amettdod except in a vvrittw insuumeot signed y This Fungal Purchase Agreement dull be bitding upon ach paAy's wcccssors, antigen sad personal reprcseautives. We love red sed received a copy of tl-e statement of Funual Goods and Servira. WcA vc read We ~ read fwd received of the psplanation of Paytttetu Arraagr:meau sad have ebosea payment opsion - s copy of she statwaeat of flu Futarttal Purchase Agteea-eot and atre6 to the trxau and eooditions. SL440 ~ COBLE-RY.1sER FUNERAL 110111E, LTD. TOTAL FUNERAL CHARGES (i Ibrtr ry) ................»...-..-... ~". ---- SQ.f~ By. Las Prc•Paid Fusds.__....»..........___........_ ................_.._....... _60.00 less DiscouMs.......__..._._...»......»..........._.._........»........._... 52.440.00 Ptuehascn BALANCfi .............__._... ................................_...............- Ptus Cas4 pisyursemeau_..._ _......._..,._......._ ...............»....._. -~'~ PNH 4 ataee ter Las Dcposis.._._.._._..._•DUE..........._........._........_....._......... ES116U1TE OF BALANCE ...._ ..................._....._......... Page 2 of Z ~~~asa~ danea R ~...........~ Bt1Ri~E G~ EXHIBIT MEM~Rt~ e sZ43 Sinspean Forty Rom, Mec~~ank~abui~3. PA 17x55 • (?I7; 76E-,ifi22/ .1 C ~ ~}u tly~ ~ Gar t~ ~ t° y r '. tr . ~ ~ $ ' ~ ~1' ~E' f . ~ ~ '~^ ©~ __ PtQ~as9i svbrnittcd ta: Pt~s~e: hh Dale: ~+dd7ess: -_ .__._ ?;amG of tnemoriel: Name Jf Ceii-d!OTy': ''yy tiieruaya: Gons;titant ~' F li i iY • • Y • t • • • • • • • • • • Y • • • • + • • w M - M • A O N J •1 • ~' • • M • r • y • M • 4 • • ~ • • • • • • • t t • • ir•••• r • ••s•• •r • • J • • •+•• r,••M•w• • •• ••••~M#irt #1r•~J ••••Ywrr.~J ••w• tiNe harthy submit :recif:cxt:ans #<~r: ~ __S r r '' f~--~: t____~f ~_~--- ._...11 v'. ]` _ { n C ~•~ ~.~~ C t't t4 i'r~.~ •-ix•ri~r•irs••r• •• Jya•aos• ••ss •tsss•avas•sasr~~-s¢••+s1 t••••v•~is The above memorial is of the fins: w~arkmsstshlp. The ~o~t i~tcl~d~°s m.:raorinl, letterinb and cen:e'.~~ fa~,~~tiort. Eo:ure lett~er~r-~ is extra. {`'' . a d (r.~ ¢ricc ai ~ ~ ~ J _ .. ~s ~LZrat~teecf r 3U ~zys frcr:t thu date. Auth~riue si$ratur~e: /~~~~~ --~ .. _. _ _ _.__ . _--y~ Cestomer signature: r... '~ ~ ~ ..---- ~, r.