HomeMy WebLinkAbout02-04-1315~561~140
'-"" REV-1500 EX (°'-'°'
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 260601 INHERITANCE TAX RETURN 2 1 1 2 0 6 9 8
Narrisburq, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYW
0 2 0 1 2 0 2 2 8 1 9 2 1
Decedent's Last Name Suffix Decedent's First Name MI
G R A D Y D O R O T H Y E
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
1. Original Return ~ ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 1 8. Total Number of Safe Deposit Boxes
(Attach Copy of Wilp (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 Sclr._!~1) as
CORRESPONDENT - 7HI5 SECTION MUST.BE CONPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TPaj INFORMATIObL9H0U IRECTED T0:
Name ~ Da ~ ~elephon~mb~
M I C H A E L J G A R F I E L D 5~'~ ~7 ~'2 ~'~ 3 9
., ,
T"}tE0(5 OF WILLS t~ 6f8LY
~ U: ~ ^'1 'ri -rrt
V n Q ~ ~» -
First line of address ~7 Ga -'n - ~
r' r' m
c:
P O B O X 6 B 9 u~ ~, N~
Second line of address O F'-"~
l+
City or Post Office State ZIP Code ~ DATE FILED
A L B R I G H T S V I L L E P A 1 8 2 1 0
Corraspondent'se-mail address: MJGESQaVERIZON•NET
Under penalties of pequry, I clan that I have examined Nis return, including accompanying schedules antl statements, and to the best of my knowledge and belie)
it is true, wrrect and te. Declaration of pleparer other than 111grpersonal representative is based on all information of which preparer has any knowletlge.
Side t
1505610140 1505610140
1505610240
REV-1500 EX Decedent's Social Security Number
Decedent's Name: DOROTHY E• GRADY
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.
1 ~ 3 6 4 9 ~
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. 3 1 3 • 2 4
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property
(Schedule G) ^ Separate Billing Requested ..... .. 7.
8. Total Gross Assets (total Lines 1 through 7) ......................... .. 8. 1 7 6 7 8 • 1 4
9. Funeral Expenses and Administrative Costs (Schedule H) 9. 4 8 4 1 . $ $
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ....... .... .. 10. 1 4 6 1 • 4 6
11. Total Deductions (total Lines 9 and 10) ................. ........ .... .. 11. 6 3 ~ 3 • ~ 1
12. Net Value of Estate (Line,B minus Lire 11) .............. ... . .... .... .. 12., 1 1 3 7 $ . 1 3
13. Charitable and Governmental 8equestsiSec 9113 Trusts for whi ch
an election to tax has not been made (Schedule J) ........ ....... ..... .. 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) ........ ....... ..... .. 14. 1 1 3 7 $ . 1 3
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(12) X.0 _ ~ . D C1 15. ~ . ~ ~
16. Amount of Line 14 taxable
1 1 3 7
5
1
3
5
1
1
8
8
at lineal rate x .oas . 16. .
17. Amount of Line 14 taxable
~ 0
~
17
~
d
~
at sibling rate X .12 . •
18. Amount of Line 14 taxable
~ ~
Q
0
~
~
at collateral rate X .15 18. •
19. TAX DUE ........................................ ....... ..... ..19. $ 1 1 . 8 8
20. FILL IN THE OPAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^
Side 2
1505616240 1505610240 J
7EV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 12 X698
DECEDENT'S NAME
DOROTHY E• GRADY
STREET ADDRESS
C/0 P•0• Box 472
CITY STATE
Albrightsville PA ZIP
18210
Tax Payments and Credits:
t. Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments
B. Discount
3. Interest
4. 1f Line 2 is greater than Line 1 +Llne 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund.
5. If Line 1 +Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(1) 511.88
(3)
o.oo
(4) 0 •00
(5)
511.88
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1, Did decedent makes transfer acrd: Yes No
a. retain the use or income of the property transferred : ................................................................. ..... ^ X^
b. retain the right to designate who shall use the property transfened or its income : .......................... ..... ^ I]
c. retain a reversionary interest; or ........................................................................................... ..... ^
d. receive the promise for life of either payments, benefits or care? .................................................. ..... ^
2 If death occuned after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? .................................................................................. ..... ^
3. Did decedent awn an "intrust for" or payable-upon-death bank account or security at his or her death? .... ..... ^ 0
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? ............................................................................................. ..... ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN
For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
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 al death to or for the use of a natural parent, an
adoptive pareni or a sieppareni of the chiid is 0 perceni [i2 P.S. §9i i6(a)(i.2jj.
• 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)j.
• 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 def ned, unde
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
Total Credits (A +8) (2)
AEV-1508 EX~ (11-10)
pennsylvania SCHEDULE E
(IFPGRTMFNT (1F f>F\(F f.111F
CASH, BANK DEPOSITS, 8r MISC.
wrlERirnrvcErnxREruRrv
RESIDENT oecEOErvr PERSONAL PROPERTY
'ATE OF: FILE NUMBER:
FROTHY E• GRADY 21 12 0698
Include the proceeds of IiGgation and the date the proceeds were received by the estate.
All property jointty owned with ri®ht of survivorship must be discbsed on Schedule F.
ITEM
JMBER DESCRIPTION
1. Checking account Mauch Chunk Trust Co., Jim Thorpe PA
Account Number
2• US Treasury tax refund
3- US Treasury tax refund
4• Safe deposit box contents Mauch Chunk Trust Co
Pinme Point Plaza, Albrightsville, Pa 1821
5 Presbyterian Homes INc-
Dillsburg PA
refund for over payment of nursing home costs
VALUE AT DATE
OF DEATH
15,981•
833.00
47U.97
16.00
63.15
TOTAL (Also enter on line 5, Recapitulation) I $ 17 , 3 6 4 . 9 ^
It more space is needed, insert additional sheets of paper of the same size
~:~;_
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/l~auch Chunk
Trust Company
January 22, 2013
Michael J. Garfield
Attorney At haw
Rt. 903 Professional Bldg.
P.O. Box 609
A1bri~htsville, Pa. 1 82 1 0-0609
]RE: Estate of llorothy Grady
Soc. Sec. No.: 106-26-28Sa
Cumberland County #21-12-0698
Dear Attornev Garfield:
t,~a;r: oFr'~ce t i ~ t n~aTH STrzFET
uiN~ rN~apE, PA ~a??~
TEL. 570325-BAPJK
1-877325-BANK (2265;
w^mw,m.aurY:chunktn~st com
fhe following is the information that you requested on the account(s) of Dorothy Grady:
Account Title -- Dorothy H. Grady
Date Opened -- l O109J1992
Date of Death Balance - $15,981.78 (15,98134 principlel.44 interest)
No change in ownership
Account Title - Walteen Grady-"Truly or Dorothy H. Grady or W. Anthony Grady Jr.
Date Opened - 08/ I 1 /2006
Date of Death Balance - $y40. i 4 (9417.11 principlcr.03 interest)
No change in ownership
_If you have any questions, or. need any additional informationzplease do not hesitate to call me at
(570)325-2265.
~incerciy,
~~t c~~.~
Lori Cheslak
Deposit Operations
EncL
Account Purpose: Consumer
H. GRAD`S or W. ANTHONY 3RADV JR
ig SSN/TIN: 374-603139
Address: P O BOX 472, ALBRIGHTSVILLE, PA 18210
rte Numher: 1570) 722.9330 Work #: (5701 676.9217
OWNERSHIP TYPE Joint (Right of Survivorahipl
(ACCOUNT TYPE (ACCOUNT NUMBER
RO . 5C CHECKIN3 100?42352
Date Opened Date Revised Opened By Verified ey
OB-11-O6 223
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Si natures of Aut
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WALTEEN GRADY-TRUELY
, DOROTHY H. GRADY
C.+'/ ~ l~
X
W. ANTHONY GRADY JR
ISi rtaeures and rioted names of each account si nerl
The Authorized Individually) signing above agree(sl, jointly and severally if multiple signers, to the terms set forth in the Deposit Account Agreement
and Disclosure, the Time Certificate of Dapoaitor Confirmation of Time Deposit Agreement lif applicable), the Raie and Fee Schedule, the Funds
Availability Policy Disclosure, the Substitute Chack'Pol'rcy Disclosure, the Electronic Funds Transfer Agreement and Disclosure, (if applicable), and
acknowledge receipt of our privacy policy'li} applicable), as amended by the Financial Institution from time to time. Each of the Authorized
Individual(s) signing also acknowledges that the Financial Institution provided at least one copy of these deposit account documents.
T1NIBACKUP WITHHOLDING - Repordng SSN: 374-60.3139
Important: Under penaltles of perjury, I certify that the number shown above is my correct taxpayer identification number, 1 am a U.S. person
(including a U.S..resident alien), and that (check appropriate hox):
®I am not subject to backup withholding, because I am exempt from backup withholding, or because I have not been notified by the IRS that I am
subject to backup withholding as a result~of f/ail/urJe to report all-interest or dividends, or because the IRS has notified me that 1 am no longer
subject to backup wkhhoiding. ~ L/v ~~ _,
^ 1 am subject to backup withholding.
Signature bf Authorized Individual: X
.. .. _.. Date ..... _ __
._.
The following information may be used to further identify individual(s) for telephone instruotions, large transactions, or it a signature varlas.
MMN =Mother's Maiden Name
Name: WALTEEN GRADY-TRUELY SSN: 374.60-3139
Street: 12 TENNYSON CIRCLE, ALBRIGHTSVILLE, PA 18210
Mailing : P O BOX 472, ALBRIGHTSVILLE, PA 18210
Phone: (HI: (5701 722-9330 IW): 1570) 675-9217
Job: TEACHER
DOB: 10.13-1951, HOUSTON
ID: Drivers Lleenea EXSISTING CUSTOMER MMN: HUNTER
Name: DOROTHY H. GRADY SSN: 108.26-2884
Street: 35 CEDAR CIR, NEWVILLE, PA 17241.9483
Mailing:
Phone: IH): (7171 776-8489 iW):
Job: RETIRED
DOB: 02-28-1921, MOORESVILLE
ID: - Drvars Llcsnsa PADL72468499
MMN:.HUNTER.
Name: W~ ANTHONY ORADV JR SSN: 658-OB-3426
Street: 3364 KINOWOOD FOREST LANE, DAYTON , OH 4¢440 _.
Mailing: .:. ....
Phone: IH)i 19731 361.3275 ~ (W):
Job:
GOB: 12-05-1955
ID: Drlvars Llcenae RS523804 MMN:
Original
orroen rxo.v..e.ea.eo.aoe c.>..wmr~+,wiuww.,. iro.,us, zoe. .x wrw..,..x. r. rn.,rovrc.:a .n., e,o
REV-a85 EX ~~~~ LJ~~~~~ i ~iJA ~i'l~~i'i 7 ~~ 7 Page 2 D( 2
i
~
INSTRUCT{ONS _
__
~
_
(1) Cash: Report total only.
(2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are tD be designated by
name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and lass of stock.
(a) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership,
i.e., jointly held, payable on death, etc.
(4) Bonds: Designate by name, amount, sedal number, or other designation. (Bearer Bonds)
(6) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank
and branch. and balance.
(6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as passible.
(7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible.
(a) All other contents. -
(9) Return completed form lo: DEPARTMEN70F REVENUE
' INHERITANCE TAX DIVISION
DEPT 280601
HARRISBURG. PA 17128-0601
ITEM
NO. ITEM DESCRIPTION
1.. varlous foreign coins - no known value
2.
- _. various foreign script - no known value
-- _--
3. $16.00 in coins
4. Certificate of Deposit -Mauch Chunk Trust Co in name of Romare Albert Truely grandson of decedent #70999
__
I CERTIF EN TY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECEIVING COPY OF
CORRE MP TE TO THE 8E3T OF MY KNOWLEDGE AND BELIEF. SAFE DEPOSIT BOX INVENTORY:
...NAr ._..... _, ._
~
_-~_ -___-__ ___. _._ _ _._-_.__
PR T N ~ - I
_-__._-___._-_- ______._._-___. __. _._ __
PRINT NAME AND CHECK APPROPRIATE BOX OELOW'.
!
rtield
Ic el J Ga
_
PRINT TLE DATE CHECK APPROPRIATE BOX'
^ ERepwpnvixl ~ Admleiaeamrimx)
Attorney 08/08!2012 ~y Estate Representative p Jo'mt owner pr safe deposit Dow
NOTE: Attach additional 8'/~" x tt" sheet(s) if necessary or use duplicates of this page of form.
The Department is authadzed bylaw, 42 U.S.C. §405 (c)(2)IC)(i), to require disclosure of Social Security numbers in wnnecfion with administering stale Ux laws The Department uses the
Social Security number to idantfy the decedent and personal representatives of tl1e estate. The Commonwealth may also use the information in exchange of tax infarmaticn agreements
wih Federal and !awl taxing authorities. The state law prohibits the Commonwealtl's personnel tam disclosing confidential tax information except fGr oficial purposes
PRESBYTERIAN HOMES
ONE TRINITY DRIVE E SUITE 201
D/LLSQURC PA 17019
Bank of America NO. 74288
PAY Sixty-Three Dollars and 15/100 Cents
60-208
312
DHTE CHECK NO. ~- AMOUNT.':
6!01/2012 574288 $63.15
To THE ESTATE OF DOROTHY H GRADY
ORDER % WALTEEN GRADY-TRUEIY
OF
PO BOX 472 ~ ~ /J
ALBRIGHTSVILLE PA 18210 ~+'
I' ""_"4",J x', ~-~'JC^v' ^iH', J~~~: THE BACK OF THIS D~GUMEfJT CONTAINS AN AFlTIRCIAL WATERMARK-HOED AT AN ANGLE TO VIEW 3~IX'w~ glfpr gx~hm a
i~•0574288~1' 1:0 3 1 20 208 41:0038305i5487n'
15-51 S 682,874,493
~~-+~ ~~~ 000
., .,~. ,..w - Check No. ~~~
`~ 06 04 12 06 SAN FRANCISCO,. CA 3158 34673099
_ "'°°~ 3158 34673099 20090900 I3D OGRAD KANS CYTAX REFUND
e*. - Pay to 1191"111111.I:l:I~.~!I:!!.I!:~.!l::~Ilil'i`i•II!I:~~I!!~!I!~:: _
:~ ~"=_theordernf DOROTHY H GRADY 12/10
~_ _ 35 CEDAR CIR 99
,; NEWVILLE PA 17241-9483 $****470*97
~\ ouu..wnwuxeomw VOID AFTER ONE YEAR
o c ui i'T~* ~ ii ai 454" t i_ iw-r ag ~~
z°
1
'~ 15.97 INTEREST r~ ~ J~~~,~~`:11I~~}L.~~~-~- -L~'
~:. ~ . -u~ - Fd4L-u~t;~i, ~.~ ~I--xr~ - ~ 11 ~In~1il1
.. ~. ~ ,,.
il•3 i5811i•. ~:D000^05 i8~: 34673099~~ni• 0406 i 2
~ooot S 679, 005 , 126 ~~'~
P~
~„~n - - Check No. ~~
u
~; OS 10 12 68 SAN FRANCISCO, CA 3158 31450603
°^~''` 3158 31450603 20090800 I30 OGRAD ANDOVER7AX REFUND
'ray ~o }l'ii"~'III'I'I"'II"ii^Lli.i~lb.~illl'l'~'Ililn~liiiili ~~.
lieorder of DOROTHY H GRADY 12/11
35 CEDAR CIR 03
NEWVILLE PA 17241.9483 $****833*00
VOID AFTER ONE YEAR
w w~.~orrc.x
i='TIi~~~~~ f~IICi~:~ Illi~}_~y~•$_~~J'~rl ~I r-,rl ~,~ 1~ h_~ri I~`I~I~I
IiILi}}~jSl~_-~} _' ~,}(~'7 1+a: ~1/~]~/q! .~i: ~:i~-~il"ir.I Lll~
rilp'I r I~i:U„~T(?;~1!'~-f' ~"*ITi'II_~-~j Ili ~~-iTIII!_I
~ U i1~
i!~~uil:ic I_~ili~i~~~'i):!I:=ii~~~-i~}1Ttl-7iF'?~~Ii:T~:T_I'i1_i
~:000~~~ 5 i8~: 3 14 5060 38u' 04D S i z
REV-509 EX+(O Lid)
pennsylvania
~o,APrq~cN? nF aoic np i~
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEF
JOINTLY•OWNED PROPERTY
CJ I NI t V~: Fllt KUMCCK:
DOROTHY E• GRADY 21 12 0698
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.Walteen Grady-Truly
e.W• Anthony Grady
c.
JOINTLY•OYVNED PROPERTY:
N•o• kiox 4r~
Albrightsville, PA 18210
364 Kingswood Forest Lane
Dayton, OH 45440
daughter
son
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 FORJOINTLY-HELD REAL ESTATE
DATE OF DEATH
VALUE OF ASSET % OF
DECEDENT'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
~. q, 206 Bank account Mauch Chunk Trust Co 940.11 16.66 156.62
1111 North Street
Jim Thorpe, PA
2 b 2006 Bank account Mauch Chunk Trust Co 94.11 16.66 156.62
1111 North Street
Jim Thorpe, PA
TOTAL (Also enter on line 6, Recapitulation) I $
If more space is needed, use add'Rionai sheets of paper of the same size.
~~~
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/!~lauch Chunk
Trust Company
lanuarv 22, 2013
Michael J. Garfield
Attorney At Law
Rt. 903 Protzssional Bld,.
P.O. Bos 609
Albrightsville, Ya. 18210-0609
RE: F,state of Dorothy Gracly
Soc. Sec, ltio.: 106-26-283a
Cumberland County #21-12-0698
Dear Attornev Garfield:
rG~_. s~o-azs-ear;K
,v"N~,v.mnur,-hchunu'ru~t.~.nrn
"l he following is the information that you requested on the account(s) of Dorothy Grady;
Account Title -Dorothy H. Grady
Datc Oper_cd - 10/09! 1993
Date of Death Balance -$1,981.78 (1,981.34 principle1.44 interest]
No change in ownership
Accotmt Title - ~\'alteen Grady=truly or Dorothy H. Grady or W. Anthony Grady J r.
Date Opened - 08/11/2006
Date of Death Balance - x440, i ~ (940.11 principlci.03 interec+.)
No change in ownership
1f you have airy questions, or need any additional information, please do not hesitate to call me at
(~70)33~-226.
~incerciy,
Lori Cheslak
Deposit Operations
Lncl:
REV-1511 EX+ (10-09)
pennsylvania
DEPARTMENT pF RFVF_NUE
INHERITANCE TAX RETURN
RESIGENr DECEDENT
SCHEDULE H
FJNERAL EXi'ENSES AND
ADMINISTRATIVE COSTS
__.... _ _. ~ i~c n~moan
DOROTHY E• GRADY 21 12 ^698
Decedent's debts must be reported on Schedule 1.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
~. Egger Funeral Home, Newvilee PA 2,996.55
2 Funeral Dinner and incidental funeral expense 250•DD
8. ADMINISTRATIVE COSTS:
t. Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State ZIP _
• Year(s)CommissiomPaid:
2. AttomeyFees: Michael J• Garfield, Esq•
3, Family Exemption: (If decedents address is not the same as claimant's, attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
a. Probate Fees: Register of Wills of Cumberland County
5 Accountant Fees:
6. Tax Retum Preparer Fees:
~. Mauch ChunK Trust Co new key far safety deposit
1,20D•DO
375.00
20.0
TOTAL (Also enter on Line 9, Recapitulation) I S ^ n u , ~ r
more space is needed, use adtlitional sheets of paper of the same size.
i ~ liig Spring Avenue
NEWVILLE, PENNSYLVANIA 17241
F CHARLES EDGER, Supervisor 717-776-3414 FRANK C. EDGER, Funeral Director
May 31, 2012
Funeral bill for Dorothy Grady
Date of service May Z0, 2012
ProOfessional Services $2,260.00
10 Death Certificates $6.00 a piece $60.00
Allentown Morning Call $472.21
Pocono Paper $80.00
Carlisle Sentinel $124.34
Total $2,996.55
REV-1512 Ex. (72-0a)
pennsylvania I SCHEDULE I
~e~.~orfE,,. ~~ _~~:~>:u~ I DEBTS OF DEDEDENT,
iNHERITnNCETaxRETUaN MORTGAGE LIABILITIES, & LIENS
RESIDENT OECEpENT
ca ~ Nr c yr FILE NUMBER
DOROTHY E• GRADY 21 12 0698
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical a:penses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Cumberland Goodwill Fire Co 101.53
Ambulance service
2• Millennium Pharmacy 450.27
last medical bills
3• Commercial Acceptance Co 360.00
ambulance services Newville Ambulance
4. Presbyterian Homes Inc 549.66
Nursing Home services
TOTAL (Also enter on Line 10, Recapitulation) I $
If mot space is needed, insert additional sheets of the same size.
leese Remit Payment 5'a 1 ~ _ ~ ~ K
Cumberland Goodwill Fire Rescue EMS ~ .
Biding Ofiiice ~ 12-140752 ~ 5/3112012 ~ 8101.53 -
FO Box 726 ~
New Cumberland, PA 17070-0725 --
QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 717-214-6020 Email: info@ambulancebillingoffice.com
Date of Service: 4/28/2012 16:03 Please visit our website to provide insurance or make payment, and
Patient Name: GRADY, DOROTHY for additional payment options and frequently asked questions:
From: Carlisle Regional Medical Center
To: Green Ridge Village www.ambulaneebillingoffice.com
* *Final Notice * * If we do not receive payment within 10 days, your account maybe referred to collection Contact our
to make payment arrangements. This service is not covered by mast insurance carriers.
4(28/12 Stretcher Van One-Way Trans A0130
4/28/12 Mileage S0209
Total
sk....:~lw~.,,,^'~' it t..a at'' ? ..,.w.'"b rx~'.ua4r.:.~bu~-~4 -r~fAJ~ I:. twTt~~ fill-dt"~~~
1.0 80.00 80.00
12.3 1.75 21.53
101.53 0.00 0.00
O ETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT.
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We accept payment m full by check* credit card or Ef~ctrgni~ ~ tcir'S8 ake ~~fk ~a'ya¢le"'TO:
check deduction. Please indicate your paymenk cBn[ce pelOV4 r'r+a '~ '~~• '
and fill m required information. If other arrengements are Gumlertand `Goodwlll~i=ire..
necessary, please call us at 877 214 6018. ReSCUe EMS
~. y- ® DI6COVER
Credit Card: ^ MASTERCARD a VISA ^ AMERICAN EXPRESS ^ DISCOVER
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taro nwmeer
12-140762
Amount Paid:
$ 101.53
Please make any corrections to address helow.
i.ame on CerJ E':,:.a cn
Electronic Check Deduction
Please send a ~roided check CR provide iNOrma[ion below
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1]OROTHY GRADY
Green Ridge Village
210 81G SPRING ROAD
NEWVILLE, PA 17241
Millennium Pharmacy Systems ~ ` w ~
100 E Kensinger Dr ~ ~ ~ ~j~ ~ ~ { ~ ~ ~'"~ ~ { r
Bldg 120 Suite 500 C llj11s~~~~s !! aaS , S 4.~
Cranberry Twp, PA 16066 -~' ~ 1 ~ ~ r ri : ~ C`S ~ ~' S t E t?l 5 I ~t C .
1-866 - 466 - 7779 Opt. 4
INVOICE DATE:
GRADY, DOROTHY
June 15, 2012 GRADY-TRUELY, WALTEEN
Account Number
P. O. BOX 472 G RVA1298
Balance Due: $450.27 ALBRIGHTSVILLE, PA 18210
Pharmacy Location:
MECH 1
Please Detach here and Return Top Portion with Payment
Re: GRADY, DOROTHY
Facility: Green Ridge Village AL -PHI
Account #: GRVA1298
Pharmacy Loc: MECH
Dear Valued Millennium Customer,
Invoice Date: 6/15/2012
Balance Due: $450.27
Last Payment: $250.69
Last Payment Date: 4/12/2012
Millennium Pharmacy Systems is committed being the best pharmaceutical supplier in the industry.
Our records indicate that Mr. / Ms. GRADY, DOROTHY'S account is no longer active as of
5!15/2012.
This is just a friendly reminder in regards to the aforementioned account. Please remit payment today
to keep their account in good standing. If payment arrangements have been previously established
please remit your monthly agreed upon amount.
If you feel there is any discrepancy in regards to this balance please feel free to contact us and ask to
speak with a collection specialist.
We look forward to working with you and thank you for your anticipated cooperation
Sincerely,
Millennium Pharmacy Systems
Tel: (724) 940 - 2490
Fax: (866} 228 - 8267
You can now pay your Bill Online!!
vvww.MPSRx.com
~ Contact
-~ Pay your bill
PHONE
(717~yU'1-4557
(800)640-3857 Commercial Acceptance Company
Extension:
207--
DOROTHY GRADY
35 CEDAR CIR
NEWVILLE, PA. 17241-9483
CLIENT-NAME AGENCY CLIENT-#
NEWVILLE COMMUNITY AMBULA 619236 NEWV-1038
TOTAL
REMIT PAYMENT T0:
L.A.L.
P.O. BOX 3268
SHIREMANSTOWN, PA 17011
05/21/12
TOTAL-PAID BALANCE
$40.00, $360.00
$-iu.Cv~ $3 o'O.Cv
------------------------------------------------------------------------
Our records indicate that your check in the amount of $40.00
is due to be deposited on 06/01/12. Please see that the funds are
available for this check on the date of deposit. There will be a
$20.00 fee for all checks returned by your bank.
This communication is from a debt collector. This is an attempt to collect
a debt and any information obtained will be used for that purpose.
THE REPRESENTATIVE ASSIGNED TO YOUR FILE IS: CHRIS LEMANSKE
AT EXTENSION: 207--
RESIDENT STATEMENT
GREEN RIDGE VILLAGE
SWAIM HEALTH CENTER
210 BIG SPRING ROAD
NEWVILLE, PA 17241-9481
717-776-8256
DOROTHY H GRADY
c/o DORCTIiY H GRADY
210 BIG SPRING RD
NEyWILLE, PA 17241
Statement Date Due Date ACCOUNT NUMBER l
05/31/2012 Upon Receipt 106262GRVAL
• ~ : ~ ~ $549.66
AMOUNT PAID $
Please make check payable to GREEN RIDGE VILLAGE
Remit To:
- Presbyterian Homes Inc/Green RidgelSwaim
P O Box 416825
Boston MA 02241-6825
Please detach and return this portion with your remittance to the address above.
Comments
uL , u have any questions regarding your statement please contact the Business Office at (717)776-8256
Balance Fonrrard $(63.15)
04/29/12 - 04/29/12 REFUND -PRIVATE 1 $63.15 $63.15
04/30/12 - 04/30/12 Catering 1 $518.55 $518.55
04!30112 - 04/30/12 Sales Tax -PA 1 $31.11 $31.11
TOTAL BALANCE DUE: 5549.66
FACILITY NAME RESIDENT NAME ACCOUNT NUMBER
SWAIM HEALTH CENTER DOROTHY H GRADY 106262GRVAL
nEV-1513 E%+(01-00)
pennsylvania
~«~R,~,~r~~ ~~ n~.~.~~
INHERITANCE 7A% RETURN
RESIDENT DECEDENT
DOROTHY E• GRADY
SCHEDULE)
BENEFICIARIES
FILE NUMBER:
21 12 0698
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
( TAXABLE DISTRIBUTIONS [Include outright spousal distributions and Vansfers under
Sec. 9116 (a) (12).]
1. Walteen Truely Lineal 5,687.56
P•O• Box 472
Albrightsville Pa 18210
2 Walter A• Grady, JR• Lineal 5,687.56
3364 Kingswood Forest Lane
Dayton, OH 45440
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
-(. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: ,
TOTAL Of PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S
If mare space is needed, use additional sheets of paper of the same size.
ATTORNEY AT LAW
February 3, 2013
Honorable Glenda Farner Strasbaugh
Register of Wills
Cumberland County Courthouse
3 Courthouse Square Room Lot
Carlisle, PA 1013
2588 State Route 903, Suite 5
P,O. BOX 609
ALBRIGHTSVILLE, PA 18210-0609
TEL. (570) 722-3839
FAX (570) 722-3989
e-mail mjgesq@verizon.net
In Re: Estate of Dorothy Grady, Deceased
Dear Ms. Strasbaugh:
Enclosed please find my check in the amount of $i5.oo for the additional filing
fee for the Rev-i5oo in regard to the above referenced.
Thank you.
MJG/jw
enclosure
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ATTORNEY AT LAW 2588 State Route 903, Suite 5
P.O. BOX 609
ALBRIGIITSVILLE, PA ISZtO-0609
TEL. (570) 725-3839
FAX (570) 722-3999
e-mail mjgesq®verizon.ne[
January 28, 2013
Honorable Glenda Farner Strasbaugh
Register of Wills
Cumberland County Courthouse
i Courthouse Square Room l02
Carlisle, PA i~oi3
In Re: Estate of Dorothy Grady, Deceased
Dear Ms. Strasbaugh:
Enclosed please find two (2) original REV-15oo Inheritance Tax returns in regard
to the above referenced estate, along with a copy, that I ask that you time s tamp and
return to mein the enclosed self addressed stamped envelope.
n
Thank you. c o r.:
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