HomeMy WebLinkAbout02-19-13 (3)L
1505610140
REV-1500 EX (01-10)
PA Department of Revenue
OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
Po sox 2sosol INHERITANCE TAX RETURN
Harrisburg, PA 17128-0601
RESIDENT DECEDENT 2 1 1 2 1 1 8 1
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
Decedent's Last Name Suffix Decedent's First Name MI
B O W E R S O X R O B E R T H
(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
Q 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)
Q 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 u~lgr Sec. 9113(A)
between 12-31-91 and 1-1-95) r~ttach Sch. O),~' ~
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX TION SIlI~LD BE'~DI TED T0:
Name Daytirr~T hone N~iber
R O G E R B I R W I N E S Q U I R E 7~ 7a ~ 4 I-~ ~~ 3
First line of address
I R W I N ~
Second line of address
6 0 W E S T
City or Post Office
C A R L I SL E
M c K N I G H T P C•
P O M F R E T S T R E E T
State ZIP Code
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G157E1FOF Vyj~S U9t~Nl~
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DATE FILED
P A 1 7 0 1 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.
SIGNATURE E ON RESPOIV~IBLE FO~ETURN
~~
2 TE
~~ l3
ADDRES
60 WEST
ET STREET CARLISLE
PA
17013
SIG ARER OTHER THAN REPRESENTATIVE n
~L
AD ESS
6 WEST PO RET STREET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140 J
J
REV-1500 EX
~ecedent'sName: ROBERT H - BOWERSOX
Decedent's Social Security Number
RECAPITULATION
1. Real Estate (Schedule A) ........................................... 1. •
2. Stocks and Bonds (Schedule B)
...................................... 2. 8 9 4 9 8 0. 9 9
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. 5 7 8 0 ], 8 . 8 9
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. •
7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property
(Schedule G) ^ Separate Billing Requested ....... 7. 0 . 0 0
8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 1 4 ? 2 9 9 9. 8 8
9. Funeral Expenses and Administrative Costs (Schedule H) ........ .......... 9. 9 6 3 0 3. 4 5
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ... .......... 10. 8 1 4 5. 8 9
11. Total Deductions (total Lines 9 and 10) ..................... .......... 11. 1 0 4 4 4 9. 3 4
12. Net Value of Estate (Line 8 minus Line 11) .................. .......... 12. 1 3 6 8 5 5 0 . 5 4
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ............ .......... 13. 3 7 8 5 4 1 . 0 8
14. Net Value Subject to Tax (Line 12 minus Line 13) ............ .......... 14. 9 9 0 0 0 9 . 4 6
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.
16. Amount of Line 14 taxable
at lineal rate X .0 0 0 0 1 g,
17. Amount of Line 14 taxable
at sibling rate X .12 0 . 0 0 17.
18. Amount of Line 14 taxable
at collateral rate X .15 9 9 0 0 0 9. 4 6 1 g.
19. TAX DUE .................. ........................... .. ..... .. 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L 1505610240
1,50561,0240
0. 0 0
0. 0 0
0. 0 0
1 4 8 5 0 1. 4 2
1, 4 8 5 0 1. 4 2
a
1505610240 J
REV-15Qfl EX Page 3
Decedent's Complete Address:
File Number
21 12 1181
„DECEDENTS NAME
ROBERT H. BOWERSOX
STREET ADDRESS
83 SCHIMMEL WAY
CITY STATE ZIP
CARLISLE PA 17015
Tax Payments and Credits:
~ • Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments _ 75, 000.00
B. Discount
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fifl in oval on Page 2, Line 20 to request a refund.
(1) 148, 501.42
Total Credits (A +B) (2) 75,000.00
(3)
(4)
0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 73, 501.42
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 : ...................................................................... ^ Q
b. retain the right to designate who shall use the property transferred or its income; ............................... ^ Q
c. retain a reversionary interest; or ................................................................................................ ^ 0
d. receive the promise for life of either payments, benefits or care? ....................................................... ^ X^
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ^ Q
3. Did decedent own an "intrust for" orpayable-upon-death bank account or security at his or her death? ......... ^ Q
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? .................................................................................................. ^ Q
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS/YE%S, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Y a. - - a..,Y ~ 4'~:~~ S~ ~ ~.. +h 2i~ 1 ~ ..: ~+e , d-- "A ,.S--~ i
For dates of death on or after July 1,1994, and before Jan.1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jan.1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)). The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1503 EX + (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
is I w I t OF FILE NUMBER
ROBERT H. BOWERSOX 21 12 1181
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. 16 SHARES OF FROG SWITCH STOCK 800.00
16 SHARES X $50 PER SHARE _ $800.00
2. SERIES EE SAVINGS BOND -INVENTORY ATTACHED 43.78
3. IJANNEY MONTGOMERY SCOTT LLC -DATE OF DEATH VALUATION ATTACHED I 894,13721
TOTAL (Also enter on line 2, Recapitulation) I $ 894, 980 99
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX+ (11-10)
Pennsylvania
• DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF:
ROBERT H. BOWERSOX
FILE NUMBER:
21 12 1181
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION _
VALUE AT DATE
OF DEATH
1. PERSONAL PROPERTY -SETTLEMENT STATEMENT ATTACHED 25,052.75
2. ORRSTOWN BANK -CHECKING ACCOUNT #106005860 66,564.06
3. ORRSTOWN BANK -MONEY MARKET ACCOUNT #106800675 103,501.55
4. ORRSTOWN BANK -CERTIFICATE OF DEPOSIT #4000042018 49,636.43
5. ORRSTOWN BANK -CERTIFICATE OF DEPOSIT #4000042019 53,817.64
6. CITIZENS BANK -CHECKING ACCOUNT #6100730751 59,050.47
7. NEW YORK LIFE -ANNUITY #75626432 220,395.99
BENEFICIARY: THE ESTATE OF ROBERT H. BOWERSOX
TOTAL (Also enter on Line 5, Recapitulation) I $ 578,018 89
If more space is needed, insert additional sheets of paper of the same size
REV-1511 EX+ (10-09)
Pennsylvania
~ DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
ROBERT H. BOWERSOX 21 12 1181
Decedent's debts must be reported on Schedule I. _
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. HOFFMAN-ROTH FUNERAL HOME 893.46
2. CUMBERLAND CROSSINGS -MEMORIAL 557.32
B
1.
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s)ofPersonalRepresentative(s) ROGER B. IRWI~
Street Address 60 WEST POMFRET STREET
pity CARLISLE
Year(s) Commission Paid:
State PA ZIP 17013
2. Attorney Fees: IRWIN & McKNIGHT, P.C.
3. Family Exemption: (If decedents address is not the same as claimants, attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: REGISTER OF WILLS
5 Accountant Fees:
6. Tax Return Prepared=ees: PATRICIA A. ROSENDALE, CPA
INCOME TAX RETURNS AND FINAL FIDUCIARY TAX RETURN
7. REGISTER OF WILLS -FILING FEE
8. ROWE'S AUCTION SERVICE -PUBLIC SALE COMMISSION
9. REGISTER OF WILLS -FILING FEE -QUALIFIED DISCLAIMER
10. NOTARY FEES
11. CUMBERLAND LAW JOURNAL -ESTATE NOTICE
12. THE SENTINEL -ESTATE NOTICE
13. REGISTER OF WILLS -SHORT CERTIFICATE
14. VITAL RECORDS -DEATH CERTIFICATES
42,500.00
43, 000.00
724.50
500.00
30.00
7, 782.25
5.00
25.00
75.00
178.92
5.00
27.00
TOTAL (Also enter on Line 9, Recapitulation) I $ 96.303.45
If more space is needed, use additional sheets of paper of the same size.
REV-151"1 EX+ (12-OS)
Pennsylvania
~ DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
ROBERT H. BOWERSOX 21 12 1181
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. ORRSTOWN BANK -REIMBURSEMENT OF SOCIAL SECURITY 5,447.16
2. MASLAND ASSOCIATES, INC. -MEDICAL 8.45 _
3. CUMBERLAND CROSSINGS -NURSING 397.61
4. WEST SHORE EMS -AMBULANCE 1,861.25
5. UGI -UTILITY 93.42
6. MEDICAL & COSMETIC DERMATOLOGY -MEDICAL 13.50
7. CAPITAL CARDIOVASCULAR ASSOCIATES -MEDICAL 113.25
8. MET-ED -ELECTRIC 142.51
9. CAMP HILL EMERGENCY PHYSICIANS -MEDICAL 68.74
TOTAL (Also enter on Line 10, Recapitulation) I $ $,145.89
If more space is needed, insert additional sheets of the same size.
REV-1513 €X+ (01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
ROBERT H. BOWERSOX ~.I ~ ~ A A OA
L I I L I I V I
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. CHARLES A. PASS Collateral 150,540.56
291 RIDGE HILL ROAD 11 % REMAINDER
MECHANICSBURG, PA 17050
2. DONNA BRENNEMAN Collateral 684,548.98
75 NORTHVIEW DRIVE 50.02% REMAINDER
MECHANICSBURG, PA 17050
3. SUSAN BAER Collateral 77,459.96
4951 MT. LA PLATTA DRIVE 5.66% REMAINDER
SAN DIEGO, CA 92117
4. DWIGHT WILSON Collateral 77,459.96
107 STRAYER DRIVE 5.66% REMAINDER
CARLISLE, PA 17013
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 18 OF REV-1500 COVER S HEET, 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. HOSPICE OF CENTRAL PA (11 %) 150,540.56
1320 LINGLESTOWN ROAD
HARRISBURG, PA 17110
2. FIRST EVANGELICAL LUTHERAN CHURCH (11%) 150,540.56
21 S. BEDFORD STREET
CARLISLE, PA 17013
'~ 3. INDEPENDENT LIVING RESIDENTS ASSOC. FUND /CUMBERLAND CROSSINGS 5.66 77,459.96
1 LONGSDORF WAY
CARLISLE, PA 17015
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 378 541.08
It more space is needed, use additional sheets of paper of the same size.
1
LAST WILL AND TESTAMENT
I, ROBERT H. BOWERSOX, of South Middleton Township, Cumberland County,
Pennsylvania, being of sound mind, disposing memory and full legal age, do hereby make,
publish and declare this to be my Last Will and Testament, hereby revoking all Wills and
Codicils heretofore made by me.
1. I direct my Co-Executors to pay all of my debts, funeral and administrative expenses
as soon as convenient after my decease.. Furthermore, I direct that all state, inheritance,
succession and other death taxes imposed or payable by reason of my death and interest and
penalties thereon with respect to all property composing of my gross estate for death tax
purposes, whether or not such property passes under this Will, shall be paid by the Co-Executors
of my estate.
2. My Co-Executors may, at their discretion, compromise claims, borrow money, retain
property for such length of time as they may deem proper; lease and sell property for such prices,
on such terms, at public or private sales, as they may deem proper; and invest estate property and
income without restriction to legal investments unless otherwise provided hereunder.
3. I authorize and empower my Co-Executors to sell any realty and/or personalty owned
by me at my death and not specifically devised or bequeathed herein, at public or private sale or
sales and ~ give good and sufficient deeds and/or bills of sale therefore, in fee simple, as I could
do if living. My Co-Executors are authorized and empowered to engage in any business in which
I may be engaged at my death, for such period of time after my death as seems expedient to said
Co-Executors.
~~6~
4. I give, devise and bequeath all .of my estate of every nature and wherever situate as
follows:
a. Ten Percent (10%) to HOSPICE OF CENTRAL
~
'~
PENNSYLVANIA; -
b. Ten Percent (10%) to FIRST EVANGELICAL l ~
LUTHERAN CHURCH of Carlisle, Pennsylvania;
c. Ten Percent (10%) to CHARLES A. PASS in lieu of an ~
Executor's fee;
d. Ten Percent (10%) to ROGER B. IRWIN in lieu of an
Executor's fee;
e. Forty-Five Percent (45%) to DONNA BRENNEMAN; ~~
f. Five Percent (5%) to SUSAN BEAR; ~ (p ~p
g. Five Percent (5%) to DWIGHT WILSON; and
5•~~
h. Five Percent (5%) to INDEPENDENT LIVING RESIDENTS
`~'
A
SSOCIATION FUND OF CUMBERLAND CROSSINGS.
5. I nominate and appoint ROGER B. IRWIN and CHARLES A. PASS to be the Co-
Executors of this my Last Will and Testament.
6. No person(s) shall benefit hereunder unless such beneficiary shall survive me by sixty
(60) days.
2
• ° i
7. No Co-Executor acting hereunder shall be required to post bond or enter security in
this or any other jurisdiction.
8. No beneficiary may assign, anticipate or pledge his, her or its interest in any income or
principal held or distributable hereunder, and no beneficiary's creditors may levy, attach or
otherwise reach any such interest.
9. If any person entitled to share in any distribution under the terms of this my Last Will
and Testament becomes an adverse party in any proceeding to contest the probate of this Last
Will and Testament, such person shall forfeit his or her entire interest inherited hereunder and all
provisions in favor of such person shall be declared void and of no effect. The share of such
person so forfeited shall be distributed as part of the residue pursuant to Paragraph No. 4 hereof,
as the case may be, except that if such person is entitled to share in the said residue, that interest
shall be distributed proportionately to the other residuary beneficiaries.
10. I hereby suggest that my personal representatives retain the services of Irwin &
McKnight, P.C. as attorneys in the settlement of my estate.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 5~' day of March
2010.
C ~ ~ (SEAL)
ROBERT H. BOWERSOX
3
Signed, sealed, published and declared by ROBERT H. BOWERSOX, the above-named
Testator, as and for his Last Will and Testament, in our presence, who, at his request, in his
presence and in the presence of each other have hereunto set our names as subscribing witnesses.
4
0
a
ACKNOWLEDGMENT AND AFFIDAVIT
WE, ROBERT H. BOWERSOX, I~:AREN S. NOEL and SHARON L. SCHWALM,
the Testator and witnesses respectively, whose names are signed to the foregoing instrument,
being first duly sworn, do hereby declare to the undersigned authority that the Testator signed
and executed the instrument as his Last Will and that he had signed willingly, and that he
executed it as his free and voluntary act for the purpose herein expressed, and that each of the
witnesses, in the presence and hearing of the Testator, signed the Will as a witness and that to the
best of their knowledge the Testator was, at that time, eighteen yeaxs of age or older, of sound
mind and under no constraint or undue influence.
ROBERT H. BQWERSOX
/ ~ ;.
;;.
,r
N S. EL
SHARON L. SCHWALM
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SS:
Subscribed, sworn to and acknowledged before me by ROBERT H. BOWERSOX, the
Testator herein, and subscribed and sworn to before me by KAREN S. NOEL and SHARON L.
SCHWALM, witnesses, this 5~' day of March 2010.
~y~._~ ~.
N to Public
~d~liNi~NW~AL1'I~ ®i= PENNSYLVANIA
Notarial Seal
Roger B. Irwin, Notary Public
Carlisle Boro, Cumberland County
5 My Commission Expires Oct 3, 2012
Member, Pennsylvania Association of Notaries
a
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Janney Monfigomery Scott LLC
Lemoyne OfFice
20 Erford Road Suite 315
Lemoyne, PA 17043
717-731-4400 800-622-7200
Fax: 717-731-4411
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Re: f ~~' ~~/c~sa~!'
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Pages:
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CC:
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Rowe's Auction Service
2505 Rimer Highway
Carlisle, PA 17015
717-574-1008 215-1044 249-1978
To: Roger B. Irwin, Attorney
Irwin & McKnight PC
60 W. Pomfret St.
Carlisle, PA 17013
From: Rowe's Auction Service
2505 Ritner Highway
Cazlisle, PA 17015
Re: Estate of Robert Bowersox
Personal Property Auction
J [yp ppk~
:; tb .
~~1fVi~i ~ iticKf~iG
;~1IV OF~!CF`~
November 18, 2012
Total Sales $32,835.00
Less Commissions -7592.25
Less Trash Removal & Cleanup -190.00
Net Due $25,052.75
Check Forwarded to Roger Irwin $26,000.00
Net Due Rowe's Auction Service $947.25
William G. Rowe
r
~sTO~uN
B~~
A Trada~ion of Excellence
December 20, 2012.
Law Offices of Irwin & McKnight, P.C.
Roger B Irwin
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, PA 17013-3222
Fax: 249-6354
Re: ~ Estate of Robert H. Bowersox
Social Security Number 201-16-2746
Date of Death 9/10/2012
IT IS HEREBY CERTIFIED THAT THE ABOVE NAMED DECEDENT HAD THE
FOLLOWIlVG ACCOUNTS WITH ORRSTOWN BANK:
CHECKING ACCOUNT
Account No.-
Account Type-
Date Opened-
Joint Account (name/date)-
Balance-
Accrued interest-
Account No.-
Account Type-
Date Opened-
Joint Account (name/date)-
Balance-
Accrued Interest-
106005860
Relation Interest Checking
3/24/2011
No
$66,564.06
$1.37
106800675
Money Market
6/21 /2012
No
$103,501.55
$10.64
CERTIFICATE OFDEPOSIT
Account No.- 4000042018
Account Type- 12-17 Month Income CD
Date Closed- 6/22/2012
Closing Balance- $49,636.43
2695 Philadelphia Avenue • Chambersburg, PA 17201
`~~O~t N0•- 4000042019
Account Type- 12-17 Month Income CD
Date Closed- 6/22/2012
Closing Balance- $53,817.64
Best Regards,
~,~
ill R. Worthington
D-e~srit ~ rocessing Jerk
Citizens Bank
Account Number 6100730751
Account Title ~ ROBERT H BOWERSOXBETTY B BOWERSOX
Date O ened 6/6/ 1966
Account T e Checkin
Princi al Balance as of DOD $59050.47
Interest from Last Posting to DOD $ .00
Account Balance as of DOD $59050.47
YTD Interest to DOD $14.29
.. ~~.~.
t
~ 'ate cobtPnxtr rou icetjr•
January 15, 2013
Irwin & McKnight
Attorney at Law
60 West Pomfret Street
Carlisle, PA 17013-3222
~~
~~~ ~~ ~~,
I~V~IF! ~ lUlc~t(UIGE(?
~~~~ QFF(C~S
Policy Number: 75626432
Decedent: Robert H. Bowersox
Dear Mr. Irwin,
We have received your request for information on the above referenced policy. Please find the
information requested below:
• Owner/Annuitant: Robert H. Bowersox
_Product Type:_New York_Life.Lifetime..Income__(Non_qualified)_A.nnuity__
• Issue Date: 05/20/2011
• No change in ownership
• A search of our systems indicates that the decedent held no other accounts with New
York Life Insurance Company. .
• Commuted Value as of 09/10/2012 is $220,395.99
• Gain Amount as of 09/10/2012 is $177,200.23
If you have any questions, our Client Services Representatives are available Monday through
Friday from 8:30a.m. to 5:30p.m. Eastern Time at 1-800-762-62.12.
Raida Jo~fnson
Representative
New York Life Annuity Service Center • P.O. Box 9859 • Providence, RI 02940.1-800-762-6212
Annuities are issued by New York Life Insurance and Annuity Corporation (NYLIAC) (A Delaware Corporation)
Variable annuities are distributed by: NYLIFE Distributors LLC, Member FINRA/SIPC
NYLIAC and NYLIFE Distributors LLC are wholly owned subsidiaries of New York Life Insurance Company
51 Madison Ave, New York, NY 10010
Winner of the
DALBAR Service Award
from X000 20~ 1
Irwin & McKnight Attorney At Law
60 West Pomfret Street
Carlisle, PA 17013
Statement of Funeral Expenses for: Robert Harman Bowersox
Date of Death: September 10, 2012_
219 North Hanover Street
Carlisle, Pennsylvania 17013
717.243.4511
toll free 1.866.451.4511
fax.717.243.3723
www.hoffmanrothcom
infoC~lhoffmarxoth.com
October 18, 2012
Account Id: 16657-218
PACKAGE:
Immediate Cremation, Memorial Service at Funeral Home
OPTION 3 -Cremation
MERCHANDISE:
Outer Container: Universal Um Vault
$ 2,490.00
Sub Total:
$ 2,490.00
$ 450.00
Sub Total:
S 450.00
TOTAL FUNERAL HOME CHARGES: $ 2,940.00
CASH ADVANCES:
Letort Cemetery $ 500.00
12 Certified Death Certificates at $ 6.00 each $ 72.00
Newspaper Notice -Sentinel $ 75.36
Newspaper Notice -Hanover $ 93.00
Clergy $ 100.00
Flowers $ 75.00
Stone Lettering/Baughman $ 231.00
Coroner's Fee $ 25.00
Sub Total: $ 1,171.36
Total Funeral Expense: $ 4,111.36
Total Payments Made: $ 4,111.36
Payments Made:
Homesteaders Check 469689 Sep 26, 2012 3,093.94
PreNeed Discount Discount PrN/Coot Sep 26, 2012 23.96
Cumberland County VA Check 857251 Oct 8, 2012 100.00
Estate Of/lrwin 8z McKnight Discount Oct 18, 2012 (100.00)
Estate Of/irwin ~ McKnight Check 32576 Oct 18, 2012 993.46
Balance: $ 0.00
Please return this portion with your Remittance.
Amount Enclosed
Robert Harman Bowersox
Service ID#: 16657-218
SERVING OUR COMMUNITY SINCE 1 907
Diakon External Catering Worksheet
~ Billinit Information ~EE SECTION BELOW
Menu coat c.,o~:~~ ~.,~......:,..,~
Event Date 9/16/2012
Time to be set u 1 m
Event Start time 2:30 m
Clean u time ~
T e of Service -
Hors d'oeurves
Date Com leted 9/15/2012
Count 50 J
Cheese Tra w/Mustard
Brownie/Cookie Tra
Caffee/TealWater Service i
BBQ Meatballs ~
Ve stable E Rolls w/Sweet 8~ Sour sauce
Fruit Platter W/Chantilly diA
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I
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_ Biliin information must be filled out com late/
_ Customer Name•
Address:
C~.StateZi code
~ .- -_---.---._-----.._
_ Tele hone
I
L--_- - _ Customer Si nature
I _
-
1
Deluxe or China ~ Pa r ~ Adake check-Qavable~to:a Cumtierland~Gro'ssin s~'~ '-~ Food Cost
~
$525.78
i
Color of Tablecloth I
Color of Na kin _ ~ _ -~
Returned checks are sub'ect to $50 fee.
___ __ __ _
__
-~-
Other Cost-Labor ~
SALES TAX _ ~
$31.54
Administrator Si nature ~
~ __ ___
_ - _-
Minus De osit Received ~ -
Total Cost i
~ $557.32
Special Instructions
1. This Outside Catering worksheet is to be used for any function for which the Facility is NOT paying
2. Completely fill out information requested in each section
3. Please make sure to get all billing i~onnation and an 80% deposit when completing this form
4. Culinary Manager will get signature from client responsibile from event the day of the event
5. Upon completion of event, Culinary Manager will collect remaining balance of event from client
6. Culinary Manager will give copies of all Outside Catering Worksheets to Executive Director for signature
7. Executive Director will retain a copy of worksheet and forward all Outside Catering invoices to Diakon Corporate,
Attn: Bonnita Napoli
8. Culinary Manager is responsible for giving monies and copy of Outside Catering Worksheet to Facility FSC for processing
A
~ ~ r~ n
~RRSTON'VN
B,~N1~
A Trnd~tio~~ of Faccelle~tce
~fr"YAJt ItL91LUU'}
January 3, 2f113
LAw Offices of Irwin & McKnight, P.C.
Attention; Itaron '
West Pomi~et Professional Building
60 W Pomfret Street
Carlisle} 1'A 17013-3222
Fax:24~-6354
Re; Estate of Rob~.t H. Bowersox
Social Security Number 201- l 6-2746
Date of Death x/10/2012
Social Security has notified Orrstown Bank that Mr. Bowersox received benefits after his
death in the amount of $5147, ] 6, Please send a oheok to Orestown Bank in this amount
so ti~at we nay said these funds bank to Social Security. Yvu ~~iay sGiicl ilua ~1iCUk lu:
Orrstown Bank
Attention: Kristin Retnsay
22 S Hanover St
Carlislc PA 17013
Thank yvu for your attention to this matter,
Kristin Ramsay
Custouiar Service Reprzseiilati vz
Orrstown Bank
22 S Hanover St
Carlisle PA 17013
n:7~ 7-24t _2nm.
F:717-241-2004
rrr^r~~~
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1.888,ORRSTOWN
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^ WEST SHORE EMS -ALS
205 GRANDVIEW AVE v~ a~ve:
~ ~ ~~~ ~ CAMP HILL, PA 17011-1708
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ON REVERSE SIDE
EMERGENCY MEDICAL SERVICES
PATIENT NAME: ROBERT BOWERSOX
CALL NUMBER: 1215758A
ROBERT BOWERSOX
83 SCHIMMEL WAY
CARLISLE, PA 17015
INSURANCE: FEP 2Pp
PP1
DATE OF CALL: 09/05/2012
FROM: TJ ROCKWELLS
TO: HOLY SPIRIT HOSPITAL
ACCOUNT SUMMARY
TOTAL CHARGES:
PAYMENTS/ADJUSTMENTS:
PLEASE PAY THIS AMOUNT: 1861.25
DETACHdLCNP PF_RFARaT/AN Alum QcT~~eiu cri~~ unto nwvne~.~r
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
ALS EMERGENCY LEVEL 2 A0999 1.0 1043.55 1043.55
20GTT TUBING A0394 1.0 14.72 14.72
COMBO PADS ADULT A0392 1.0 ~ 80.00 80.00
DOPAMINE VIAL 400MG A0394 1.0 3.92 3.92
ENDOTROL ET TUBE A0422 2.0 40.32 80.64
EPI 1 MG 1:10000 PFS A0394 6.0 8.16 48.96
EPI 30MG VIAL A0394 1.0 17.92 17.92
ET TUBE HOLDER A0422 1.0 11.40 11.40
ETC02 (ADULT) FILTERLINE SET A0422 2.0 36.00 72.00
EZ-10 25mm NEEDLE A0394 1.0 297.00 297.00
EZ-10 STABILIZER A0394 1.0 16:00 16.00
KING AIRWAY A0422 1.0 117:20 117.20
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ~
RETURNED CHECK FEE - $31.00 Continued on Next Page
PATIENT NAME: BOWERSOX, ROBERT H CALL NUMBER: 1215758A AMOUNT PAID:
10/15/2012
IMPORTANT MESSAGES: This account is now PAST DUE!!_Payment must be received
WITHIN 10 DAYS. Collection process will begin.
WEST SHORE EMS -ALS 205 GRANDVIEW AVE CAMP HILL, PA 17011-1708
Capital ardi 'ascular Associates STATEMENT DATE: 11/15/2012
PO Box 1292 ACCOUNT#: 158666
Camp Hill, PA 17001-1292 PAY THIS AMOUNT: 113.25
SHOW AMOUNT
FORWARDING AND ADDRESS CORRECTION REQUESTED ~ PAID HERE $
FOR BILLING INQUIRIES, PHONE 717/724-6450
-------------------------------------------------------------------------------------
ADDRESSEE:
ROBERT BOWERSOX
60 W POMBERT ST
CARLISLE, PA 17015
PATIENT NAME: ROBERT H BOWERSOX
ACCOUNT NUMBER: 158666
~~~
~;
~0~° 2 Q 2012
~~u~~~ ~ ~~~c~«~
~W OF~ICE~
DATE OF DOCTOR CHARGE INSURANCE PATIENT
SERVICE NAME CODE DESCRIPTION CHARGES RECEIPT RECEIPT ADJUST BALANCE
09/05/12 KIM 9345926 LHC W/ CORONARY&BYPASS I 550.00 467.50 .00 .00 82.50
09/06/12 ERKI 99232 SUBSHOSPMOD COMPLEX25 125.00 58.14 .00 56.61 10:25
09/07/12 LIGHTFOOT 99232 SUBSHOSPMOD COMPLEX25 125.00 58.14 .00 56.61 10.25
09/09/12 LIGHTFOOT 99232 SiJBSHOSPMOD COMPLEX25 125.00 58.14 .00 56.61 10.25
PLEASE PAY THIS AMOUNT: 113.25
*********************************** STATEMENT MESSAGE **~*~**************************
****************~************~r*********************~********~**~**~******************
MAKE CHECKS PAYABLE TO: FOR BILLING QUESTIONS, CALL: 717/724-6450
Capital Cardiovascular Associates OFFICE HOURS: 8:OOam - 4:OOpm
PO Box 1292
Camp Hill, PA 17001-1292
:STATEMENT OF ACCOUNT (1
)
CAMP HILL: EMERGENCY PHYSICIANS .
statement Date: October 12; 2012.
PO BOX-43693
PHILADELPHIA, PA 19101-3693 ACCOUNT NUMBER: HYP43307461
Patient Name: ROBERT H BOWERSOX
Tax !D #: 20-4667340
Account i3al~nce: $68.74
Amount Pending
Insurance: $0.00
I1~~11~1'1'I'I '1~~„I~III~I'~1"'I~1'I11'III1111~~1~11~~1~1~1~ Amount Due From
08251.6-000043307461-06 Patienf (Current): $68.74
A
#BWNJFDB mount Due From
Patient (Past Due); $0
00
~ #OOOOOOHYP6605350#
w .
Pay This Amount: $ss.74
ROBERT H BOWERSOX
$3 SCHIMMEL WAY
CARLISLE PA 17015-7620 PLEASE REMIT PAYMENT BY "PAYMENT
DUE BY" DATE. THANK YOU. Please refer
to coupon below:for payment
Instructions.
Pay your bill securely online anytime at www.MyMedicalPayments.com
Date # Description Charge Paid By Paid By Paid By Amount Due From PATIENT
First Ins. Other Ins. Patient Adjusted Insurance BALANCE
09!05!12 1 99285-25 EMERGENCY EVAL 8 MGMT (LVL 5) 51
246.00
,
0X:410.90 DR. FAJARDOMOLY SPIRIT HOSPITAL
10/05/12 BLUE SHIELD CONTRACTUAL ALLOWANCE
10!05!12 BLUE SHIELD PAYMENT
09/05/12 2 -92850 CARDIOPULMONARY RESUSCn"ATION ~
00
~~/ 5-1,079.09
$-141 ~~ 525.03
•
DX`410.90 DR. fAJARDO/HOLY SPIRIT HOSPITAL
10/05N2 BLUE SHIELD CONTRACTUAL ALLOWANCE
10/05/12 BLUE SHIELD PAYMENT
09/05/12 3 31500 ENDOTRACHEAL INTUBATION
5890
00 5-665.37
5-1b4.39 527 24
.
DX:410.90 DR. FAJARDOMOLY SPIRIT HOSPITAL
10/05/12 BLUE SHIELD CONTRACTUAL ALLOWANCE
10/05/12 BLUE SHIELD PAYMENT a „~ ,,,, $-780.20
TOTALS: 52,983.00 -$389.60 $0.00 50.00 -$2,524.66. SO.oo 566.74
Important Messages: 1
This statement is for the direct treatment and/or supervision of care you recently received from an Emergency Physician at Holy Spirit Hospital. The fees for this private
physician are lHlled separately from any hospital charges or other professional.feesfOr which you may also be responsible
Therefore
hospital or other
sh
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you receive a bill from the
or charges in connection with this visit, it will not include the items listed on this statement.
0
"Payment Plans" Accepted 0
N
Questions about this statement?/Llame de Lunes a Viernes?
Call 1-800-355-2470 Monday through Friday 9:30AM - 4:OOPM
.
Your automated system access code is 0801-43307461, or you can send email to
°
billin _ uestions
9 q @emcare.com. "
a
9,384-0,-20633 ~~ Please detach and return bottom portion with your remittance. ~~ °
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