Loading...
HomeMy WebLinkAbout01-18-13 1505610140 REV-1500 EX (01-10) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN I~ n Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 9 1 1 8 3 0 0 1 0 8 2 8 2 0 1 2 0 7 1 2 1 9 2 2 Decedent's Last Name Suffix Decedent's First Name MI S T O N E R V E S T A G (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 APPROPRIATE OVALS BELOW a 1. Original Return 2. Supplemental Return F~ 3. Remainder Return (date of death prior to 12-13-82) ❑ 4. Limited Estate 4a. Future Interest Compromise (date of E] 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 Boxes (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 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number R 0 G E R B I R W I N E S Q U I R E 7 1 7 2 4 9 2 3 5 3 REGISTER OF WILLS USE ONLY First line of address I R W I N & M c K N I G H T P C c~ rs~ a C__ (17) pa Second line of address 6 0 W E S T P 0 M F R E T S T R E E T F1 CO .1. d City or Post Office State ZIP Code DATE FIRED C A R L I S L E P A 1 7 0 1 !;l f V s "I't t a l Cd 3 Correspondent's e-mail address: Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAT E OF PE SON RESPONSIB FOR FILING RETURN Anna SS 211 STONE CHURCH ROAD CARLISLE PA 17015 SIGNATURE OF P P' RER OTHER THAN REPRE TATIVE DAT ~lv.•~l ADDRESS 60 WEST POMFR`d STREET CARLISLE PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610140 1505610140 J l i 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: V E S T A G- STONER 1 9 1 1 8 3 0 0 1 RECAPITULATION 1. Real Estate (Schedule A) 1 2. Stocks and Bonds (Schedule B) 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) 3. . 4. Mortgages and Notes Receivable (Schedule D) 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 0 . 0 0 6. Jointly Owned Property (Schedule F) ❑ Separate Billing Requested 6. 3 7 7 2 7 . 8 5 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested 7. 7 8 2 4 9 . 8 9 8. Total Gross Assets (total Lines 1 through 7) 8. 1 1 5 9 7 7 • 7 4 9. Funeral Expenses and Administrative Costs (Schedule H) 9. 1 1 0 1 4 . 0 0 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule 1) 10. 1 2 1 0 3 . 2 5 11. Total Deductions (total Lines 9 and 10) 11. 2 3 1 1 7 . 2 5 12. Net Value of Estate (Line 8 minus Line 11) 12. 9 2 8 6 0 . 4 9 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) 14. 9 2 8 6 0 . 4 9 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. 0 0 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate x .045 9 2 8 6 0. 4 9 16. 4 1 7 8. 7 2 17. Amount of Line 14 taxable at sibling rate X .12 0 0 0 17. 0. 0 0 18. Amount of Line 14 taxable 0 • 0 0 at collateral rate X .15 0 0 0 18. 19. TAX DUE ......................................................19. 4 1 7 8. 7 2 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT A Side 2 1505610240 1505610240 REV-1500 EX Page 3 File Number Decedent's Complete Address: 0 0 DECEDENT'S NAME VESTA G. STONER STREET ADDRESS 5 ALLIANCE DRIVE APT. 104 CITY STATE ZIP CARLISLE PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 4,178.72 2. Credits/Payments A. Prior Payments 4,000.00 B. Discount 208.94 Total Credits (A + B) (2) 4,208.94 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3) Fill in oval on Page 2, Line 20 to request a refund. (4) 30.22 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 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 ❑ ❑ d. receive the promise for life of either payments, benefits or care? ❑ ❑ 2. If death occurred after December 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? X❑ ❑ 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)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1509 EX+ (01-10) pennsylvania SCHEDULE F DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: VESTA G. STONER 0 0 If an asset was made 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. BARBARA L. SHELOW 211 STONE CHURCH ROAD DAUGHTER CARLISLE, PA 17015 B. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. WELLS FARGO BANK, N.A. 100.00 50. 50.00 PMA PREMIER CHECKING ACCOUNT #5970583521 2. A. WELLS FARGO BANK, N.A. 23,586.82 50. 11,793.41 CROWN CLASSIC BANKING ACCOUNT #1000324158815 3. A. WELLS FARGO BANK, N.A. 25,182.99 50. 12,591.50 HIGH YIELD SAVINGS ACCOUNT #5970587035 4. A. WELLS FARGO BANK, N.A. 26,585.87 50. 13,292.94 PREFERRED RATE SAVINGS ACCOUNT #1010141501295 TOTAL (Also enter on Line 6, Recapitulation) $ 37 727.85 If more space is needed, use additional sheets of paper of the same size. 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 VESTA G. STONER 0 0 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. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OFDECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATrACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IFAPPLICAME) VALUE 1. PERSONAL PROPERTY 839.50 100.00 839.50 SETTLEMENT STATEMENT ATTACHED 2. NEW YORK LIFE INSURANCE COMPANY 77,410.39 100.00 77,410.39 ANNUITY #N3 197 248 BENEFICIARY: BARBARA L. SHELOW TOTAL (Also enter on Line 7, Recapitulation) $ 78 249.89 If more space is needed, use additional sheets of paper of the same size, REV-1511 EX+ (10-09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND E TURN TAX RESIDENNT T D DECEEDEN DEN T ADMINISTRATIVE COSTS RESID ESTATE OF FILE NUMBER VESTA G. STONER 0 0 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOFFMAN ROTH FUNERAL HOME 8,429.00 2. CARLISLE MEMORIAL SERVICE, INC. 195.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2. Attorney Fees: IRWIN & MCKNIGHT, P.C. 2,000.00 3. Family Exemption: (If decedent's address is not the same as claimants, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 5 Accountant Fees: 6. Tax Return Preparer Fees: PATRICIA A. ROSENDALE, CPA 375.00 7. REGISTER OF WILLS - FILING FEE 15.00 TOTAL (Also enter on Line 9, Recapitulation) $ 11 014.00 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER VESTA G. STONER 0 0 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. CHAPEL POINTE - NURSING 11,792.44 2. MILLENNIUM PHARMACY SYSTEMS, INC. - MEDICAL 82,89 3. CENTURYLINK - TELEPHONE 39.53 4. ALERT PHARMACY SERVICES, INC. - MEDICAL 67.68 5. CUMBERLAND GOODWILL FIRE RESCUE - AMBULANCE 83.85 6. ALPHA DIAGNOSTICS LLC - MEDICAL 36.86 TOTAL (Also enter on Line 10, Recapitulation) $ 12 103.25 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: VESTA G. STONER 0 0 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. BARBARA L. SHELOW Lineal 92,860.49 211 STONE CHURCH ROAD REMAINDER CARLISLE, PA 17015 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. $ If more space is needed, use additional sheets of paper of the same size. DA-N EI Y AtWt04 $tk"l LLC 790 West High Street Carlisle, PA. 17013 (71.7) 532-4647 Steve Ege -717-385-5438 Cell Chris Bream .717-226-1920 Cell SELLERS NAME sc 1 DATE ADDRESS tip' ` 1 rrt=' PHONE =f l OTHER i' AUCTIONEER % AUCTION DATE/LOCATION CLERK % DESCRIPTION OF MERCHANDISE * Fes`g~q, L' r.s S F d F Y.e # > r 36 f~'`~ 4 f Y t='? • t }`-1 r J i s , 3 --;3`x!'1#d is}., # i~T i~°.sle a S-,: } Y a ' f ; - r p r shy . ttv'r q ?i# etri 3 ?'~es{3~ia8t£.. °sTet e~" f Sffl#. trl~E~rG kt 0,P~r.d+is. 3 Y3 hi:. vJit+atti_ rr"S t, x:c"' a Y:e: t.i?*r:: -r--. i, r .Sri r f: - .L 0. °3 rtk-':3 t k ,f : f^.,, r t 3 si. _ , 9f s t i t,;: rt G . {?:G t~ .:i s * 1 e t 6L y r r i`1 ~~.ess c 0., s_a L~ f" s~'fa•P; ~fE . r' ~aF° ~,t ! g~r° F tfa ~~r' 4 a1 ijl {~fS {r + . .r 3 i F .e: 3 _ ~ I ' s 4 ~ sf z a .ter' ! - - r •Y S ~ 1~[. .tee. t r 7,{i Z f^'f. ! t;? Fg q q : tab. js3:r a ?3,1 s.f: 4 x.t-tiw t J #~+re.. . f 1. ~t.S;I i.,.r' i I `f e r,^ ~e ; f ft 1 114, y.:~;,~ r } i Wjsa. i s Z(tai_ ( x, t 3 S t r t c(i1dCs l f-, t }j i L.• r~ 1 'Ff t.s.: fir r d i T1 tf'i1 -I f. t'~,3sr .tss. r,_et I Commission the Auctioneers to sell the merchandise to the highest bidder by Public Auction. Merchandise to be sold as is & grouped' as necessaryto- obtain bids. I certify that I am the owner or authorized representa- tive of the merchandise, goods and/or property acid have good title and the right to sell and that they are free from all incumbrances. P agree to accept all' responsibility. for providing merchantable title and for delivery of title to the purchaser. I agree to hold harmless the Auctioneers against any claims of the nature referred to in this aSreeme Trash fee applied if applicable. ,i AUCTIO IGNATURE j SELLERS SIGNATURE Total. Sales (Clerking Tickets Attached) $ l f Less Sale Expense: . % . Commission Auctioneer $ °7o Commission Clerks $ "OTHER: TOTAL SALE EXPENSE DEDUCTED $ SELLERS NET. $ A17 O"I MATURE PMAaccount "5970583521 ■ August 1, 2012- August 31, 2012 ■ page 1 of 7 ® Wells Fargo® PMA Package PM Questions? Please contact us: Wells Fargo Premier Banking Team- Available 24 hours a day, 7 days a week Phone: 1-800-742-4932, 77Y. 1-800-600-4833 Spanish: 1-877-727-2932 Chinese: 1-800-288-2288 Online. wellsfargo.com Write. Wells Fargo Bank, N.A. DCPPIIDHAC 017175 P.O. BOX 69,95 '1111'lllllllllllllll~l~~llllll~l~llllll~l'I'llllllll'llll'lllll Portland, OR 97228-6995 VESTA G STONER BARBARA L SHELOW August 31, 2012 211 STONE CHURCH RD CARLISLE PA 17015-8397 Total assets: $75,554.84 Last month: $85,623.36 Change in $(10,068.52) o Change in (11,76)% n 0 Total liabilities: $0.00 1 Last month: $0.00 Z Change in $0.00 z Change in 0.00% z z - z qualifying Balance: $75,554.84 z Deposit Balance: $75,554.84 z z Contents Page z Overview ...............................2 0 PMA° Premier Checking Account ................3 0° tL Other Checking 4 A Savings (2) S o 10 0 0 w tn (0 fO m m N 1- 2 PMA account 5970583521 ■ August 1, 2012 -August 31, 2012 ■ Page 2 o N Overview of your PMA account Assets Percent Balance last Balance this Increase/ Percent Account (Account Number) oftotal month month decrease change PMA• Premier Checking Account (597o5s3s21) <1% 100.00 100.00 0.00. 0.00% Crown Classic Banking (1000324158815) ✓ 31% 23,338.32 23,757.02 418.70 1.79% Wells Fargo• High Yield Savings (5970587035) ~ 33% 62,182.99 25,192.14 (36,990.85) (59.49)% Wells Fargo° Preferred Rate Savings (1010141501295) 35% 2.05 26,505.68 26,503.63 92,860.00% Total assets $85,623.36 $75,554.84 ($10,068.52) (11.76)% Total asset allocation (by account type) Checking: 32% Savings: 68% Interest, dividends and other income The information below should not be used for tax planning purposes. Account Thismonth This year Crown Classic Bankinge (1000324158815) 0.20 1.62 Wells Fargo• High Yield Savings (5970587035) 9.15 9.66 Wells Fargo' Preferred Rate Savings (1010141501295) 3.66 42.17 Total interest, dividends and other income $13.01 $53.45 The "Overview of your PMA Account" section of your statement is provided for informational and convenience purposes. The Overview shows activity and information from (1) deposit, credit and trust accounts with Wells Fargo Bank, N.A., and (2) brokerage accounts with Wells Fargo Advisors, LLC, or Wells Fargo Advisors Financial Network, LLC (members SIPQ brokerage accounts are carried and cleared through First Clearing, LLC; (3) Wells Fargo Funds Management, LLC provides investment advisory and administrative services for Wells Fargo Advantage Funds; other affiliates provide subadvisory and other services for the Funds; and (4) insurance products offered through non-bank insurance agency affiliates of Wells Fargo & Company and underwritten by unaffiliated insurance companies. PMA account 5970583521 ■ August 1, 2012 - August 31, 2012 ■ Page 3 of 7 I~ PMA® Premier Checking Account Activity summary Account number: 5970583521 Balance on 8/1 100.00 VESTA G STONER Deposits/Additions BARBARA L SHELOW Withdrawals/Subtractions -0.00 Wells Fargo Bank, NA., Pennsylvania (Member FDIC) Balance on 8131 $100.00 < Questions about your account: 1-800-7424932 Worksheet to balance your account and General Statement Policies can be found towards the end of this statement. Overdraft protection Your account is linked to the following for Overdraft Protection: 0 ■ Savings-5970587035 v 0 Interest you've earned Interest paid on 8/31 $0.00 c Average collected balance this month $100.00 N Annual percentage yield earned 0.00% Z Interest paid this year $0.00 Z Z t Z } z z Effective November 7, 2012, debit or ATM card cash withdrawals made in person at non-Wells Fargo locations or in Z person using the cash advance feature at Wells Fargo banking locations will be subject to your daily ATM withdrawal Z limit. Z Z Z In addition, in the Terms & Conditions for Wells Fargo Consumer Debit Cards, the section titled "Authorization Holds N for Card transactions" and Consumer Account Agreement section titled "Authorization holds for card transactions" p are changing to clarify that the Bank is permitted to place authorization holds for up to 30 days on certain debit card p transactions. 0 0 Remember, an "authorization hold" is a "pending" transaction that will reduce the current available balance that you can withdraw or use to pay transactions from your account. If you do not have sufficient available funds in your w account, transactions may be paid with an overdraft protection advance, paid into overdraft or returned unpaid as applicable. IV The Bank is permitted to place an authorization hold on your account for purchases for up to three (3) business days on most transactions (or for up to thirty (30) business days for certain types of debit or ATM card transactions, including but not limited to, car rental transactions, cash transactions, and international transactions), from the time of the authorization or until the transaction is paid from your primary-linked checking account. Please note that if the transaction is not submitted for payment by the merchant within the three (3) business days (or thirty (30) business days, as applicable), the Bank will release the authorization hold, which will increase the available balance in your primary-linked checking account until the transaction is submitted for payment by the merchant and finally posted to your primary-linked checking account. The merchant may submit the transaction for payment after the Bank has released the authorization hold. If this happens, the Bank must honor the prior authorization and will pay the transaction from your primary-linked checking account. PMA account 5970583521 ■ August 1, 2012 - August 31, 2012 ■ Page 4 0 7 Crown Classic Banking° ' Activity summary Account number: 1000324158815 Balance on 8/1 23,338.32 VESTA G STONER Deposits/Additions 1,306.26 BARBARA L SHELOW Withdrawals/Subtractions -887.56 Wells Fargo Bank, N.A.,Pennsylvania (MemberFDiQ Balance on 8/31 $23,757.02 Questions about your account: 1-800-742-4932 Worksheet to balance your account and General Statement Policies can be found towards the end of this statement. interest you've earned interest earned this month $0.20 Average collected balance this month $23,756.36 Annual percentage yield earned 0.01% interest paid this year $1.62 Transaction history Deposits/ Withdrawals/ Ending Daily Date Description Check No. Additions Subtractions Balance Beginning balance on 811 23,338.32 1 8/1 US Treasury 312 Xxciv Serv 080112 Vesta G Stoner 966.06 24,304.38 8/3 US Treasury 303 Xxsoc Sec 080312 Vesta G Stoner 170.00 24,474.38 8/7 Check 3300 797.25 8/7 Centurylink Bill Pymt 120806 3299 0000000000000313438211 A3299 39.99 2363714 8/9 Check 3298 50.32 23,586.82 8/31 US Treasury 303 Xxsoc Sec 083112 Vesta G Stoner 170.00 '`yp 8/31 Interest Payment 0.20 23,757.02 Ending balance on 8/31 23,757.02 Totals $1,306.26 $887.56 Keytosymbols: A Convertedcheck. Papercheck converted to an electronic format byyourpayee ordesignated representative. Convened checks cannot be returned, copied orimaged. Summary of checks written (checks listed are also displayed in the preceding Transaction history section) Number Date $Amount Number Date $Amount Number Date $Amount 3298 8/9 50.32 3299 8/7 39.99 3300 8/7 797.25 PMA account 5970583$21 11 August 1, 2012 - August 31, 2012 ■ Page 5 of 7 Wells Fargo° High Yield Savings Activity summary Account number: 5970587035 Balance on 8/1 62,182.99 VESTA G STONER Deposits/Additions 9,15 BARBARA L SHELOW Withdrawals/Subtractions -37,000.00 Wells Fargo Bank, N.A., Pennsylvania (Member FDIC) Balance on 8/31 $25,192.14 Questions about your account: 1-800-742-4932 Worksheet to balance your account and General Statement Policies can be found towards the end of this statement. Interest you've earned Interest earned this month $9,15 Average collected balance this month $35,924.92 0 Annual percentage yield earned 0.30% Interest paid this year $9.66 g V Transaction history N z Deposits/ Withdrawals/ Ending Daily z Date Description Additions Subtractions Balance z Beginning balance on 8/1 62 z .11J12 0 z 8/10 Transfer to Sav # 001010141501295 37,000.00 25182.99 z• 8/31 Interest Payment 9.15 2.14 z Ending balance on 8/31 z 25,192.14 z Totals $9.1S $37,000.00 z 0 0 w 0 0 A w A N O f0 O N O w N ~O <O O IV PMA account 5970583521 ■ August 1, 2012 - August 31, 2012 ■ Page 6 of 7 Wells Fargo° Preferred Rate Savings ' Activity summary Account number: 1010141501295 Balance on 8/1 2.05 VESTA G STONER Deposits/Additions 37,003.66 BARBARA L SHELOW Withdrawals/Subtractions -10,500.03 Wells Fargo Bank, NA., Pennsylvania (Member FDIC) Balance on 8/31 $26,505.68 Questions about your account: 1-800-742-4932 Worksheet to balance your account and General Statement Policies can be found towards the end of this statement. Interest you've earned interest earned this month $3.66 Average collected balance this month $21,534.60 Annual percentage yield earned 0.20% Interest paid this year $42.17 Transaction history Deposits/ Withdrawals/ Ending Daily Date Description Additions Subtractions Balance Beginning balance on 8/1 2.05 8/10 Transfer From Sav # 000005970587035 37,000.00 37,002.05 8/15 Check 4,768.50 8/15 Check 1,736.00 _ 8/15 Check 67.68 30 8/23 Check 3,844.00 26 5 8/30 Check 83.85 6 8/31 Interest Payment 3.66 26,505.68 Ending balance on 8/31 26,505.68 Totals $37,003.66 $10,500.03 vcN G~ ~ iv.v is .+uiiica v vay / I /~OVOOVV f.1.G New York Life Insurance Company New York Life Insurance and Annuity The Company You Keep@ Corporation (A Delaware Corporation) MYLIFE Insurance Company of Arizona (Not licensed in every state) P.O. Box 130539 Dallas, TX 75313-0539 I -800-695-1314 www.newyorklife.com September 13, 2012 James D. Day, LUTCF, CHFC, CLU New York Life Insurance Company 4231 Carlisle Road Gardners, PA 17324 Deceased: Vesta G. Stoner Policy: N3 197 248 Dear James Day: I am pleased to reply to your request for policy information on the above annuity. The following should be of assistance to you: Annuity N3197 248 Issue Date of Annuity: 02/26/1992 Date of Death: 08/28/2012 Cash Value as of Date of Death: $77,410.39 This Deferred Retirement Annuity was issued to the decedent providing for life income payments to commence at a future date of maturity. Since the annuitant died prior to the maturity date, the full proceeds are payable to the beneficiary(s). I hope this information will be helpful to you. If you have any questions, please contact one of our customer service representatives at 1-800-695-1314. Sincerely, Customer Service Claims r- 1026 VESTA G. STONER 3-50/370 5 ALLIANCE DR., APT. 104 O1~ CARLISLE, PA 17013 at ppa~yy ( e order of' the ~C/ , i $ 8y~90p dR7 W„iyr.u.. A , a»~ ou -Z 4w C& Le, 0~ HIGH RFORMANCE MONEY MARKET WACHOVIA Wachovia Bank, N.A. wachovia.com For 1:03 L000503i: LO LO i4 L50 L 29511' 1026 BARBARA. L. SHELOW 3302 VESTA G. STONER 3-5013109263 5 ALLIANCE DRIVE, APT. 104 10=24158815 CARLISLE, PA 17013 ate a Pay to the Order of em, J/l ao f vk-bFargo%nkuk nkuk A, tl /I z, ly For jo>, l:0310.00 031: 10003241 SE ,5003302 3-X1310: 1027 VESTA G' STONER 5 ALLIANCE DR:. AK.. 104 . CARUSLE; PA 17013 ' 46 A0,42/ e. to f l7.IJ~ ~+p g 6 ISM E PERFORMANCE MONEY MARKET W1AUCHO-VIA Wachovia Bank, N.A. wachovia wm For _ _ . r ~ A 1:03LOGO 50 l:10LOi4 429511` 1027 ChapelPointe FonnPS-01 l'at Carlisle 770 SOUTH HANOVER STREET, CARLISLE, PA 17013-4105 QUES710NS~`.GALC; , (717) 249-1363 RESIDENT # UNIT _ STMT: DATE 13103 BER 104 10/01/2012 Mrs. Vesta G. Stoner - RESIDENT S Barbara Shelow Mrs. Vesta G. Stoner 211 Stone Church Rd.;~ i Carlisle, PA 17015 TOTAL AMOU[ DUE .50 DATE DUE U on Recei t DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE $ __UNT REMITTED_ DATE : DEStrRIPTI©hf uDays/ CEfARGES CREDITS BALANCE Balance Forward 11,254.86 09/11/2012 Payment - Thank You!! 803.52 1Q451.34 09/11/2012 :Payment- Thank You!! 11994.84 ,456 50 Y 1t- IL-71 It J i NESTA G. STONER 3-50310 1029 5` ALLIANCE DR., APT. 104 / ~7r CARLISLE, PA 17013 y f~ 0 1. Date order o e t/'j/J o ~ 5a 'H IL PERFORMANCE MONEY M WACHOVIA Wachovia Bank, NA. wachovia.com For J 6Ll tz-1 ~q -101ih; b-- Jtvr ':0 3 1000 50 3t: L0 L0 14 L SO L 29 5uf &029 jAMOUNT RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 12tMT DUE 13103 775.00 24456.50 0.00 0.00 0.00 NAME Mrs. Vesta G. Stoner 3TMr Date 10/01/2012 FOR"B-01 . CHAPEL POINTE AT CARLISLE, 770 SOUTH HANOVER STREET, CARLISLE, PA 17013-4105 MINE. ChapelPointe FormPB-01 Tat Carlisle 770 SOUTH HANOVER STREET, CARLISLE, PA 17013-4105 QUESTId ?ItALI (717) 249-1363 . ?RESIDENT# UNIT STMT. DATE 13103 HER 104 11101/2012 Mrs. Vesta G. Stoner -RESIDENT S Barbara Shelow Mrs. Vesta G. Stoner 211 Stone Church Rd. Carlisle, PA 17015 TOTAL AMOUNT DUE $537.58 DATE DUE Upon Receipt DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE $ - AM__UNT REMITTED - DATE DESCR its IPTION Oaysl CHARGESCREDITS BALANCE Un Balance Forward 3,231.50 10/19/2012 Payment - Thank You!! 2,456.50 775.00: 10/11/2012 Therapy Deductible/Co-Ins. 1 537.58 1,312.58 Patient Responsiblity for 8/12 Therapy per Mail Handlers 10/31/2012 Monthly Fee 1 775.00 537.58 VESTA G. STONER a-so/slo 1032 5-ALLIANCE DR. APT. 1o4 CARLISLE, PA 17013 Me Pa to the 171 ~ orderof ~/f7/yiTo , 55-8 WAC11®V IA HIGH PERFORMANCE MONEY RKET Wachovia Bank, N.A. X wachovia.com 1:0310005031: 10&OL4L50i29511' 1032 RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 =OVER12tMT. TOTAL AMOUNT DUE 13103 0.00 537.58 0.00 0.00 $537.58 NAME: Mrs. Vesta G. Stoner at l l /01 /2012 Form P8-01 CHAPEL POINTE AT CARLISLE, 770 SOUTH HANOVER STREET, CARLISLE, PA 17013-4105 Millennium Phcy. Systems Mechanicst 5020 Ritter Road, Suite 110 Mechanicsburg PA, 17055 E"y d WE ~-1-111-1001.11 - INVOICE 10131/2012 Account Number: CHAP1192 VESTA STONER clo Barbara Shelow 013103 211 Stone Church Rd PVT Carlisle PA, 17015 _Please Detach Here and Return Top Portion With Your Payment - Invoice Date:10/31/2012, AccWCHAP1192, STONER, VESTA G, Chapel Pointe NC, A, Wood, Bradford -X 08/06/2012 4024691 1.00 HWrocodone-Acetaminophen Oral Tablet 5-500 MG $ -1.05 $ 0.00 $ -1.05 RX 08106/2012 4024646 30.00 Hydrocodone-Acetaminophen Oral Tablet 5-500 MG $ 2.52 c $ 0.00 $ 2.52 RX 00591-0349-05 R '~A. L Q~-104J 3-W310 1033 G. STONER 5 ALLIANCE DR., APT. 104 CARLISLE, PA 17013 Cf.~ ol~~~ D ~ ate o d r the e HIGH PERFORMANCE MO IG ARKET WACH®VFA /W,achovia Bank, NA.~ p rte' For C X17~~a.~T 9oZ ~IJ1G(/'I~r/~c~ 1:0310005.031° 101014150129511' 1033 y+ s t. t `,~^F 17yuM~~"` . C s i ~ l - r n~ .1..~::, • .'Y ' ~ ~ t\ro $ 0.00 $ 0.00 0.00 $ 0.00 $ 1.47 $ 0.00 $ 0.00 $ 0.00 1.47 BARBARA L: MEW 3304.' VES;TA•G STONER.:: i ssaaaaszss 5 ALLIANCE.DRIVE, APT 104 10=4168815 GARLFSLE, PA'l7013 -©fq tee: v Paytothe 7 9 Order of !r Ua 3~.: Fort 'ilk J ii 0.3 4000 50 31:4000 1.216 k 5:>&S 15u'0 3-3.0 1 3-WMO : 1,02-8 . VESTA: G STONER. 5 ALLFAF+ICE AR AP?i' t04 ~1 CARLISLE PA 17873 gol a ~ D AMA ata oar, .o HIGH.PERFORMANCE MONEY MARKET WAC$OFA Wachovia Bank; N..A. wachovie.com: . _M. or J ~P~19a o~~~.03GF1'I .1 :0 3 L000 50 3t:4i0 i04 4 Is 0 i 29.51,1'' A0 28. CARLISLE MEMORIAL SERVICE INC. Invoice 41 SOUTH BEDFORD ST. CARLISLE, PA 17013 DATE INVOICE ]1#1 10/29/2012 32-094 BILL TO BARBARA SHELOW 211 STONE CHURCH RD. CARLISLE, PA 17015 Terms Due Date Net 15 11/13/2012 DESCRIPTION AMOUNT BRONZE DEATH SCROLL INSTALLED ON 10/19/2012 FOR 195.00 VESTA STONER IN CUMBERLAND VALLEY CEMETERY. IIIIIIIISMIMEM loom f► ci~ L SIB LQGIW 3-50/310 1034 G:: TONER 5 ALLIANCE DR:, APT. 104 CARLISLE, PA 17013 Daze ~ ord eolf l /r f V © ~~f![d L' $ 012 J DD HIGH PERFORMANCE MONEY R~ICEf F WACHO~A Wachovia Bank, N.A. c ovia.com~j j~ ~ n l~ Q 1 For 5 i 0 f~ /0/11 /,2 ~ G, Ol_ 11:0 3 1000 50.31: LO L014 L 50 L 29 511' 1034 All work is complete! Total $195.00 Payments/Credits $0.00 Balance Due $195.00 219 North Baltimore Ave A FINANCE CHARGE OF 1. 5 0 % PER MONTH IXJLJE1 '1 PHARMACY SMMCES,INC. Mt Holly Springs, PA 17065 (AN ANNUAL PERCENTAGE RATE OF 18.0%) OR A Responsive. Innovative. Reliable. 800-266-9954 (717) 486-8606MINIMUM SERVICE CHARGE OF $ 1.00 WILL BE CHARGED ' www.AlertPharmacycom ON ALL AMOUNTS 30 DAYS OR MORE PAST DUE STATEMENT OF ACCOUNT I IF YOU RECEIVE `A NEW.;INSURANCE CARD FOR YOUR PRESCRIPTIONS. BE SURE TO SUPPLY US WITH A COPY. Date 07/31/2012 PMT DUE..08/28/12 STONER, VESTA STONVI BARBARA SHELOW GRP-60 211 STONE CHURCH ROAD I PAGE 1 f7, ~p CARLISLE PA 17015 J Amount Paid PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT ALERT PHARMACY SERV. INC.219 NORTH BALTIMORE AVE. WHOLLY SPGS, PA 17065 ACTIVITY FOR STONER, VESTA STONV1 - -60 07/18%12 - 8212.923 2. MEDISET ADMINISTR 01 15.00 07/18/12 7971115 60 CALCIUM CARD 500 01 * V 00 15.00 6.35 .00 6.35 07/18/12 7971116 90 NAPROXEN 250 'MG 01 8.14~~ seQ~2vn. 00 8.14c 07/18/12 7.971118 527 POLYETHYLENE GLYC 01 10.00 _aZZL 07/18/12 7971119 30 .00 13.00c VITAMIN D 1,000 U 01 * 3:08 .00 3.08 07/18/12 7971121 100 PREVIDENT 5000 BO' 01 3.37 07/27/12 7973656 6 AZITHROMYCIN 250 01 00, CL 00 3.000 07/27/12 7973658 20 CEFUROXIME 250MG 01 .00 19.17c 9.17 ~.~i4.,~i2.Ub~Q. JI, 0 0 9.17 c 07/27/12 4127964 30 HYDROCOD-APAP 5/5; 01 V 2.57 p,,~([~yt JtLYA~.L`GLh 0 2.57c low I -I i r' l } 3-50/310 1023 VESTA G. STONER 5 ALLIANCE DR., APT. 104 CARLISLE, PA 17013 ~0112, ate - 17 P%rof e O l 1Y C1016 =F .c HIGH PERFORMANCE MONEY KET ACHOVIA. Wachovia Bank, N.A. wachovia.com For "~oy U/ (^,tge-Lea s I:0 3 1000 50 31: LO &0 L 4 L 50 L 29 SIIN L023 I 58.25 9.43 I 00 LEGEND NON-LEGEND FOR MONTH FOR MONTH TOTAL TAx revioda Balance Charges this month Finance Charge TOTAL CHARGES Total Payment & Credits MOUNT D E 00 + 67.68 + .00 = 67.68 - _ .00 I 6-OR ALL PHARMACY RELATED INQUIRES PLEASE CALLAIert Pharmacy Services Inc at 1-800-266-9954 Sfafnmanf T r.n.n ~ ricox m,=amt roynicnL iu. Cumberland Goodwill Fire Rescue EMS ,Biiling Office PO Box 726 12-178007 8/8/2012 7-- New Cumberland, PA 17070-0726 QUESTIONS 85 ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 717-214-6020 Email: info@ambulancebillingoffice.com Date of Service: 8/6/2012 13:30 Please visit our website to provide insurance or make payment, and Patient Name: STONER, VESTA G. for additional payment options and frequently asked questions: From: Carlisle Regional Medical Center www.ambulancebillingoffice.com To: CHAPEL POINTE AT CARLISLE .0 . This type of service is not covered by ambulance memberships, Medicare, Medicaid and most secondary insurances Payment is your responsibility. 8/06/12 Stretcher Van One-Way Trans A0130 1.0 80.00 80.00 8/06/12 Mileage S0209 2.2 1.75 3.85 Total 83.85 0.00 0.00 3-501310 1025 'VESTA G. STONER 5 ALLIANCE DR., APT. 104 - CARLISLE, PA 17013 _ y 'Date orderof L 1~ 1 .t i / ••s ^y v~r f j j HIGH PERFORMANCE MONEY MARKET WACH®VIA Wachovia Bank, N.A. wachovia.com For 1:03 L000 50 31: 10 LOLL, L SO L 29 Sill 10 2 5 We accept payment in full by 'check* credit card or electronic Please Make Check Payable To: check deduction. Please indicate your payment choice below Cumberland Goodwill Fife • and, fill in required, Information. If other arrangements are Rescue EMS necessary, please call us at 877-214-6018. 12-178007 $ 83.85 o-, - 72Sz a DISCNeV it Credit Card: Q MASTERCARD Q VISA ❑ AMERICAN EXPRESS ❑ DISCOVER Amount Paid: Please make any corrections to address below. Electronic Check Deduction VESTA G. STONER Please send a voided check OR provide information below: 5 ALLIANCE DRIVE APT 104 CARLISLE, PA 17013 L., _ CHECK CARD USING FOR PAYMENT 945 EAST PARK DR. ® MSCOVER ~❑VISA Mpg ErranErs SUITE 102 CARDNUMSER TUNE HARRISBURG, PA 17111-2804 SIDNATURE EW. DATE 35346 r• o 10/15/12 213246 05514 0101 PAGE: 1 of 1 I. e EEO g 1 H 9 r $36A6 65:P598 (PCI ) ADDRESSEE: REMIT TO: I~rll~lr~rrrlll~lrlrl~~lrrllr~ll'~'1111~11~1'1~III~Ir~rrrl~~lrl11 ~1~I111~1.111rIll~~lrr~Irlr~lr~1~11'1'I~Illlld~lr~111~1~11rr~1111 VESTA STONER ALPHA DIAGNOSTICS LLC 770 S HANOVER STREET 945 EAST PARK DR. CARLISLE, PA 17013-4105 SUITE 102 HARRISBURG, PA 17111-2804 35346'TMEOMVX3M000789 Please check box if incorrect or insurance information has changed, and indicate change(s) on reverse side. ~ a PLEASE DETAC I.4ERE AND RETURN TOP PORTION VWTH YOU PAYMENT 0~0 If you have any questions or concerns about you statement please call 1-800-420-9729 07/27/12 VESTA Set Up Fee Q0092 780.60 ADXP..A 28.60 4.12 Patient: STONER, VESTA - 21.3246 Servicing Provider: ALPHA DIAGNOSTIC LLC 08/22/2012 Novitas Medicare Pennsylvania Medicare 16.46 8.02 09/04/2012 Mailhandlers Benefit Trust Not a covered service 07/27/12 VESTA Transportation. Xray R0070 780.60 ADXPA 250.00 32.74 • Patient: STONER, VESTA - 213246 Servicing Provider: ALPHA DIAGNOSTIC LLC 08/22/2012 Novitas Medicare Pennsylvania Medicare 130.96 8630 09/04/2012 Mailhandlers Benefit Trust Not a covered service i 3-50/310 1031 VESTA G. STONER ~j 5 ALLIANCE DR., APT. 104 j (J r f' i r , CARUSLE, PA 17013 Date .t Pay to the 'i lr r r n 7 ordderof )'_j_ ; rJi ( i i qty . is HIGH PERFORMANCE MONEY MARKET I ACH®NdA )E . . I rE. I Wachovia Bank, N.A. ,~wacgovia.com ~ ~ ' Rs $36.86 For n r. o&000 f X ,i r ~ ~:0 3 &000 50 31: LO LO L4 1 SO 12 9 SO L031 213246 ` 36.86 i