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HomeMy WebLinkAbout02-27-13 1505610105 REV-1500 EX (02-11) (FI) PA Department of Revenue pennsylvania OEPAgTMENT OF NEVENVE Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 Harrisburg, PA i'J128-o6oi RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW OFFICIAL USE ONLY County Code Year File Number Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY £ 06/02/2012 :11/28/1926 O 4. Limited Estate ~ 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received O. 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust.) O 10. Spousal Poverty Credit (Date of Death Between 12-31-91 and 1-1-95) PnOr t0 1L-13-ttZj O 5. Federal Estate Tax Return Required 0 8. Total Number of Safe Deposit Boxes O 11. Election to Tax under Sec. 9113(A) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number ..., .... ...... ,.. ................ ~ E.,,.,....,...~...,.,..... ...,.,..,_...,,...,..,..,.,.,.„.....,.......,.~~ ..,..._. ;Stacy B. Wolf, Esquire _ ~ (717) 241-~36 First Line of Address 10 West High Street Second Line of Address 31S'i ~ WILLS U)~NL1K.^~ r j ~ ~"' r" ~ ~ ~-4 ~ ~ ~ '.~] ~ ~'C " ~ --~ ~ , ~~ y ~ `~ ~ C.J p C ~` DATE FlL ~D-~ t c City or Post Office State ZIP Code ' ...:............................... F ............. i 2 z PA :17013 :Carlisle i Correspondent's a-mail address: StaCybWOlf embargmail.com 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. NATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ~ra_ _~ __ .. ~ f~ ~1:..~ _4 d _ / ~ 02/26/2013 ADDRESS 10 West h Street, Carlisle, 013-2922 PLEASE USE ORIGINAL FORM ONLY L 1505610105 Side 1 1505610105 ~~ -- ` ADDRESS 221 Sunset .Drive, Carlisle, PA 170 3 J REV-1500 EX (FI) Decedents Name: Rene Alvarez 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. 6. Jointly Owned Property {Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 9. Funeral. Expenses and Administrative Costs (Schedule H) ................... 9. 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............... 10. 11. Total Deductions (total Lines 9 and 10) ................................. 11. 12. Net Value of Estate (Line 8 minus Line 11) ............................... 12. 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. 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 0 484,666.41 15. 16. _._...._._.~.~__,__~....._.~._.~.._._._.....~w.w..._~..~.V..~._..~~..,..,m.~._....~...~_w,._.......~.... Amount of Line 14 taxable at lineal rate x .0 45 ~0.~x~WSxh~~ 16. 17. Amount of Line 14 taxable ~~~~~.d..m<~,.,,.a~•m ~•`~~~~ xpc~ at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. Decedent's Social Security Number 247, 908.83 197,750.00 51,379.36 497,038.19 11,747.62 624.16 12,371.78 484,666.41 484,666.41 0.00 ._,..,~..._._.,..__...._...._._~~..-~..a..__~..~.~._~.~.,~,~..~.w~.M.........__.._.._.._.H...,.~..._._...~ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1505610205 O Side 2 1505610205 1505610205 REV-1500 EX (FI} Page 3 File Number Decedent's Complete Address: Rene Alvarez STREET ADDRESS 221 Sunset Drive CITI, STATE Carlisle Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount __ 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT, Fill in oval on Page 2, Line 20 to request a refund. ~: 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DU . ZIP pA 17013 (1) 0.00 0.00 0.00 0.00 Total Credits (A + B) (2) (3) (4) (5) 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 .......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income ............................................ ^ c. retain a reversionary interest ............................................................................................................~.................. ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 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? ........................................................................................................................ ~ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU-MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. a, v 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. §911ti(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(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. 0.00 REV-i5o8 EX+ (08-12) ~ n'ennsYlvania SCHEDI~ILE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: F3LE NUMBER: Rene Alvarez 21-12-0787 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. VALUE AT DATE ITEM DESCRIPTION OF DEATH NUMBER 1. '2000 Cadillac DTS (See attached valuation per KBB) 4,445.00 ... 2 Morgan Stanley investment account, account no. 410-012549-015 243,463.83 TOTAL (Also enter on Line 5, Recapitulation} $~' 247,908.83 If more space is needed, use additional sheets of paper of the same size. REV-1509 EX+ (os-io) ~ pennsylvania DEPARTMENT Of REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDIJLE F JOINTLY-OWNED PROPERTY ESTATE AF: FILE NUMBER: . 21-12-0787 Rene Alvarez If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. ADDRESS RELATIONSHIP TO DECEDENT SURVIVING JOINT TENANT(S) NAME(S) If more space is needed, use additional sheets of paper of the. same size. RFV-1510 EX+ (08-09) ~ enns Lvania SCHEDULE G ~PARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC^ NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF Rene Alvarez __ ITEM NUMBER 1. FILE NUMBER 21-12-0787 TOTAL (Also enter on Line 7, Recapitulation) ~ 51,379.39 '' If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (ifl-fl9} SCHEDULE H ~ enns lvania p y DEPARTMENT OFREVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Rene Alvarez 21-12-0787 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. .. FUNERAL EXPENSES , 2 928 82 i. Hoffman-Roth Funeral Home , . 2 ' Westminster Cemetery 1, 521.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 6,300.00 2. Attorney Fees: 3. Family Exemption: (If decedent's address is nat the same as claimant's, attach explanation.) Claimant _ _ - Street Address ~-___ -- City State ZIP Relationship of Claimant to Decedent 173.50 4. Probate Fees: 5. Accountant Fees: 6. Tax Return Preparer Fees: ~• .. , ._ _ .. Register of Wills- inheritance tax return filing fee .. ._ _ 15.00 $ .. __ ,.. Reserve for outstanding expenses 00.00 9 _. Legal Advertising- The Sentinel 168 ~ 3© ~ o Legal Advertising- Cumberland Law Journal 75.00 ~ ~ Funeral refreshments-First Lutheran Church 220.00 ~2 Funeral flowers- George's Flowers 46.00 TOTAL (Also enter on Line 9, Recapitulation) $ 11,747.62 If more space is needed, use additional sheets of paper of the same size. REV-~siz Ex+ (12-os} SCHEDULE I ~ pennsylvania DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Rene Alvarez 21-12-0787 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 DE5CRIPTION OF DEATH 1 • '' Carlisle Regional Medical Center ~ 110.83 2' Quantum Imaging:. 17.13 3' Carlisle Medical Pathology 119.42 4' Dr. Phelan 13.40 5' ' Medco 92.81 ` 6 <Quantum Imaging 31.00 7' 'Carlisle Regional Medical Center 239.57 TOTAL (Also enter on Line 10, Recapitulation) 624.16 $ If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) If more space is needed, use additional sheets of paper of the same size. LAST WILL AND TESTAMENT I, RENE ALVAREZ, of North Middleton Township, Cumberland County, Pennsylvania, do hereby make, publish and declare this to be my last will and testament, hereby revoking all wills heretofore made by me. 1. I direct my personal representative to pay all of my debts, funeral and administrative expenses as soon as convenient after my demise. I direct that my bodily remains be cremated and . that there be no viewing. I direct that all inheritance taxes imposed or payable by reason of my death and interest and penalties thereon with respect to all property, whether or not such property passes under this Will, shall be paid by my personal representative out of my estate. 2. I authorize and empower my personal representative to sell any realty and/or personally owned by me at my death and not specifically devised or bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale therefore, in fee simple, as I could do if living. My representative is 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 representative. 3. ~ I give, devise and bequeath all of my estate of whatever -nature and wherever situate tom wife Elaine enb ' ht Alvarez. 4. If Elaine Argenbright Alvarez does not survive me by a period of at least sixty (60) days, then I give, devise and bequeath all of my estate of whatever naxure and wherever situate to John Lightner, Christina Marie Lightner, Rodney Wayne Lightner, Stacy Renee Lightner and Michael Rene Warmelink. 5. I herebynominate and appoint mywife, ELAINE ARGENBRIGHT ALVA.REZ, individually, to be my personal representative of my estate, to serve without bond. If ELAINE ARGENBRIGHT ALVAREZ cannot or does not serve, then I appoint JOHN LIGPiTNER to be my substitute personal representative also to serve without bond. __ ----. 6• I suggest that mypersonal representative retain the services of Wolf & Wolf Attorneys at Law of Carlisle, Pennsylvania in the settlement of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~ ~, ' ~ y of ~'t /~v , 2005. `e'`~t''Q"- (SEAL) r' Signed, sealed, published and declared by the above-named person as and for a last well and testament, in our presence, who at said person's request, in said person's presence and in the presence of .each other have hereunto set our names as subscnbing witnesses. _ ~, WE, RENE ALVAREZ, NICOLE H. MAU and STACY B WOLF, the testator and witnesses respectively, whose. names are signed to the foregoing instnunent, being fast dul sworn Y 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 volun tart' 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 years of age or older, of sound mind and under no constraint or undue influence. NE A.LVAREz N COLE H. MAU STACY B. W F COMMONWEALTH OF PENNSYLVANIA ss: COUNTY OF CUMBERLAND Subscnbed, sworn to and acknowledged before me by RENE ALVAREZ, the testator herein,. and subscn~ed and sworn to before me bylVICOLE I~ MAU, and STACY B. WOLF, witnesses, this ~_ day of Apri12008. COMMONWEALTH OF PENNSYLVANIA Notarial Seal Nathan C. 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N M ~ .-~ a~ M M M O 4J ~ '~sN _ +' N N LA ~ LL's ~ L!7 I .. ~ Z '-~ W N V ~ ~' M d4 M d4 M ~ N 'g Z `,' y .-; .~. ~.~.N O w ~~ tt O M ~ N N ~ c w ~ 'e 1° O C O G1 O O O1 1 0 D _ ~ t0 N ~ d' N r-i m " ~} ~ ~ .-i O pi ~t N ,~ ~ N O N '"'' O ~ O m .-~ ~ r-, ~ ~ o V N ~ ~ N ~ ~ N Q ~ ~ z > L~ O V U ~,,, ~ a ~ W ~ ¢ '~ ~ W ~ = > a o C ~ F- ~ ~ ti N Z ~ ~ o ~ •~ v ~a- ~' ° ~ ~ w° ~Q a ~ - 3 ~ a QW :~.~ ~ J Z N ~ W C ~ a o wcn v ~ L J a W H ~ Z .-+ ~ :~. ~ 0 U o ° a ~N = ~ Q1 M 01 m r--~ 01 m 00 N i~ ',M I~ 01 O N a~ 0 m O ~ ~ ~ N > .--i O 'J ,_,, o ~~ ~ J ~ Q w o Z > v O ~ Q F- ~~ ~o Qw ~~ J Z .~ H ¢~a w ~n ~ Z .-~ ~ N ~:5 dal Wtl~~ INIpIIIiNH~llldllll~l OOOZN6 Tax PazceL• 29-17-1576-183 THIS DEED MADE THE ~' 1 day of April in the year two thousand and nine (2009). BETWEEN Rene Alvarez, a widow, of North Middleton Township, Cumberland County, Pennsylvania, hereinafter called Grantor, AND RENE ALVAREZ and ELAINE A. ALVAREZ, husband and wife, of North Middleton Township, Cumberland County, Pennsylvania, hereinafter called Grantees, WITNESSETH, that inconsideration of One and no/100 ($1.00) Dollar in hand paid, the receipt whereof is hereby ackaowledged,.the said Grantor does hereby grant and convey to the said Grantees, their hens and assign: ALL that certain tract of land situate in North Middleton Township, Cumberland County, Pennsylvania, bounded and descn`bed in accordance with Subdivision Plan for Albert C. -Kuhn dated November 9,1979, prepared by Stephen G. Fisher, Registered Surveyor, recorded in the hereinafter named Recorder's Office in Plan Book 37, Page 47, and incorporated herein by reference as follows: BEGINNING at a punch mark in rock on the western line of 60-feet wide Pennsylvania Route 74, L. R 21032, known as Waggoner's Gap Road, at the dividing line between Lots Nos. 2 and 4 as shown on the above mentioned Subdivision Plan; thence from said punch mark in rock at the Place of BeglrLning along the western line of said 60-feet wide Waggoner's Gap Road, southwardlybya curve to the right having a radius of 848.51 feet an arc distance of 45.84 feet to a point on the western line of 60-feet wide Shatto Drive; thence southwardly along said western line of 60-feet wide Shatto Drive by a curve to the left having a radius of 728.05 feet an arc distance of 109.00 feet to a point; thence still along the western line of said 60-feet wide Shatto Drive, South 02 degrees 03 minutes 20 seconds East, a distance of 280.65 feet to a point; thence southwestwardly by a curve to the right having a radius of 40.00 feet an arc distance of 65.83 feet to a point on the northern line of 50-feet wide Sunset Drive; thence along the northern line of said 50-feet wide Sunset Drive the following two (2) courses and distances: (1) North. 87 degrees 45 minutes 20 seconds West, a distance of 150.74 feet to an iron pin; and (2) westwardly by a curve to the right having a radius of 200.00 feet an arc distance of 136.33 feet to an iron pin at the dividing line between Lots Nos. 2 and 3; thence along said dividing line between said Lots Nos. 2 and 3, North ~ F 26 degrees 18 minutes 03 seconds East, a distance of 331.34 feet to an iron pin set at comer common to Lots Nos. 2, 3 and 4; thence along the dividing line between said Lots Nos. 2 and 4, North 41 degrees 04 minutes 29 seconds East, a distance of 191.43 feet to a punch mark in rock on the western line of 60-feet wide Waggoner's Gap Road at the Place of BEGIN1vING. THE ABOVE descn~bed tract. of land is all of Lot No, 2 as shown on said Subdivision Plan for Albert G Kuhn dated November 9, 1979, recorded as aforesaid, and contains an area of 97,801.77 square feet. BEING a portion of the premises which Albert C. Kuhn and Edith B. Kuhn, husband and wife, bytheir deed dated Apri110, 1986, and recorded in the Office of the Recorder of Deeds in and for Cumberland County at Carlisle, Pennsylvania, in Deed Book "U", Volume 31, Page 944, granted and conveyed to Rene Alvarez and Rose 1VL Alvarez, husband and wife. AND where the said Rose 1VL Alvarez died on October 31, 1995, and said property transferred herein was held as tenancies bythe entireties at her death therebyvesting in full fee ownership title to the propertyto Rene Alvarez, Grantor herein. UNDER AND SUBJECT, nevertheless, to the following building and use restrictions which shall be binding on the within described tract of land only and shall not be deemed binding on other land of the Grantor, with which building and use restrictions the within Grantees, their heirs and .assigns, by the acceptance of this deed, agree to comply: 1. 'T'his tract of land shall be used for residential purposes only. No business, commercial, or industrial uses whatsoever shall be permitted on this tract of land. 2. Only one single family residence and accessory building maybe erected on this tract of land. 3. No livestock of any kind, cattle, sheep, hogs, goats or horses, and no poultry of any kind shall be kept on this tract of land, except household pets. which are housed in the principal dwelling house located on the within described tract of land and which pets shall not be permitted to roam about out of doors unleashed. 4. No breeding or training kennels for dogs shall be kept or maintained upon this tract of land, excepting a dog which may be a household pet which is housed in the principal dwelling house erected on the within described tract of land and which dog shall not be permitted to roam about out of doors unleashed. . 5. No building or.anypart or projection thereof shall be erected or maintained within fifteen (15) feet of any side property line or within thirty-five (35) feet of any rear property line, as shown on said Plan of Lots recorded in Plan Book 37, Page 47. 6. No wall of any building shall be erected nearer than forty-five (45) feet to the legal right-of- wayline of any public street or road abutting the within descrYbed tract of land. 7. No trailer, mobile home, or similar structure maybe located on this tract of land temporarily or permanently, for any use whatsoever. 8. No basement; tent, shacl~ garage, barn or structure of a temporary character shall be erected on this tract of land and used as a residence either temporarily or permanently. ~9. No cesspool shall be permitted on this tract, of land. The disposal of sewage shall be accomplished by use of a septic tank system or such other disposal system as shall comply with the requirements of local and state health authorities. No outside privy shall be permitted. 10. No advertising or display sign shall be erected or maintained on this tract of land other than the customary "For Rent" or "For Sale" signs when the same pertain to the premises on which they are located. 11. Noth;ng shall be done on this lot which maybe or become an annoyance or nuisance to the neighborhood. 12. No hedge or fence shall be erected within ten (10} feet of any property line at a height in excess of four (4) feet. 13. The within described tract of land shall not be subdivided. 14. Free standing television and radio towers are prohibited on this tract of land, and any such antennae which are desired shall be installed on or against the dwelling house. 15. All plans and specifications for any proposed building must be submitted to Albert C. Kuhn, or his nominee, for approval as to size, style of architecture and materials to be used, and no construction shall begin until approval has been given, which approval will not be unreasonably withheld and will be based in part on the conformity of any proposed building with the size and style of existing buildings in the area, general character of the area, and commonly accepted building standards and practices. Approval or disapproval .shall be given in writing within thirty (30) days from the date of submission of plans. 16. After a dwelling house has been erected on the within described tract of land, the owner shall install an outdoor post lantern with electric light at least equal to a 100 watt incandescent bulb, controlled by aphoto-electric switch operating said light from dusk to dawn at the expense of the owner, located exactly fifteen (15) feet from the legal right-of-way line of the abutting street, and at least seven (7) feet above the ground. Should there be any conflict between the building and use restrictions imposed by applicable zoning ordinances of North Middleton Township or other governmental authorities and the above building and use restrictions, then the more restrictive provisions shall be applicable. AND the grantor hereby covenants and agrees that he will warrant generally the property hereby conveyed. THIS IS A TRANSFER FROM HUSBAND TO HUSBAND AND WIFE AND IS THEREFORE EXEMPT FROM PAYMENT OF PENNSYLVANIA REALTY TRANSFER TAX AND THE FILING OF A STATEMENT OF VALUE. IN WITNESS WHEREOF, the grantor has hereunto set his hand and seal the day, month and year first above written. Signed, Sealed and Delivered in the presence of / ~~ ~ 1 - ~ ~ ~ ''~ ~ (SEAL) ~~.% ""~' RENE ALVAREZ COMMONWEALTH OF PENNSYLVANIA as: COUNTY OF CUMBERLAND On this, the ~ ~~ day of April, 2009., before me the undersigned officer, personally appeared RENE ALVAREZ, known to me (or satisfactorily proven) to be the persons whose name is subscribed to the within instrument, and acknowledged that he executed same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and seal. • L f (SEAL) IuorARlAI s~ otary Public BONNIE L COYLE, NOTARY PUBLIC 8080 OF CARLISLE, CUMBERLAND CO. PA ~ COMMLSSION EXPIRES OCTOBER t 7, 201 Q w ~ I do hereby certifythat the precise residence and complete post office address of the within named Grantees is: 221 Sunset Drive, ~~a~; Zoo9 STACY B. WOLF, ESQUIRE Carlisle, Pennsylvania, 17013. n. Attorney r Grantees WOLF & WOLF, ATTORNEYS AT LAW 10 WEST HIGH STREET 1tLISLE PA 17013-2922 717-241-4436 4 d '~ ~ t F ROBERT P. ZIEGLER RECORDER OF DEEDS CUMBERLAND COUNTY 1 COURTHOUSE SQUARE CARLISLE, PA 17013 717-240-6370 Instrument Number - 200913781 Recorded On 4/29/2009 At 2:16:57 PM * Instrument Type -DEED Invoice Number - 42433 User ID - KW * Grantor - ALVAREZ, RENE * Grantee - ALVAREZ, RENE * Customer -WOLF * FEES STATE WRIT TAX $0.50 . STATE JCS/ACCESS TO $10.00 JUSTICE RECORDING FEES - $13.50 RECORDER OF DEEDS PARCEL CERTIFICATION $10.00 FEES AFFORDABLE HOUSING $11.50 COUNTY ARCHIVES FEE $2.00 ROD ARCHIVES FEE $3.00 CARLISLE AREA SCHOOL $0.00 DISTRICT NORTH MIDDLETON TOWNSHIP $0.00 TOTAL PAID $50.50 * Total Pages - 6 Certification Page DO NOT DETACH This page is now part of this legal document. I Certify this to be recorded in Cumberland County PA ~ o~ CU~yefi , ors ~~ ~~~ ~ ~ ° RECORDER O D EDS ~~~so * -Information denoted by an asterisk may change during the verification process and may not be reflected on this page. iiiiiiiiifiliiiuiiiiiiiuii ~~ = ~~"®` '. ;,~ `~ FUNERAL HOME ~ CREMATORY, INC. 219 North Hanover Street Ca~iisle, Pennsylvania 17013 717.243.4511 toll free 1.866.451.4511 fax 717.243.3723 www.hoffmanroth.com info@hoffmanroth.com July 10, 2012 Mrs. Elaine Alvarez 221 Sunset Drive Carlisle, PA 17013 Statement of Funeral Expenses for: Rene' Alvarez Date of Death: June 2, 2012 _ Account ld: 16560-126 PACKAGE: Immediate Cremation, Memorial Service at Another Facility OPTION 4 -Cremation ~ $ 2,190.00 Sub Total:. $ 2,190.00 MERCHANDISE: Urn: Centurian (without Lip) Roman $ 180.00 Sub Total: $ 180.00 TOTAL FUNERAL HOME CHARGES: $ 2,370.00 CASH ADVANCES: 10 Certified Death Certificates at $ 6.00 each $ 60.00 Newspaper Notice -Patriot $ 298.82 Clergy $ 50.00 Coroner's Fee $ 25.00 Organist $ 125..00 Sub Total: $ 558.82 Total Funeral Expense: $ 2,928.82 Total Payments Made: $ 2,928.82 Payments Made: Elaine Alvarez Check 3891 Jul 10, 2012 2,928.82 Balance: ~ 0.00 Please return this portion with your Remittance. 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C y ~ ' Q i ~ A ~ ~ a' ~ ~~ r ~ ~ ~ ~ ~ o C °r ~ ~~ `c ~ CrJ r o ~ ~ ~ ~ r ~ ~ o ~ ~ H y Z ~~~~w~ ~a O~ rte., ~ "' . ~-o ~ ~~ ~~ r ~ -r O' C ~ C'' ~ ~ ~ ~ ~ ~ _ ~ ~,~ ~~ ~ `° ~ ~ ~~ d~ o °~ w ~ ~ y ~ c ~ G v ~+ !'~ O °C ,.t O Z ~ ~ ~ ~ ~ ~ ~ ~~ ~~ c~ °~ ~ O `~ a o z z o o ~ ~• ~ ~ y a ~,~„ w ~. ~. ~ ~ b b o c o ~ ~ y C~ d ~~ ~ ~ ~ ~~ ~ ~ ~ ~ ~~ ~ ~ o ~~ a O~~ n ~~~ ~ rn ~~ ~;-G C ~ co ,C r °~~~ ~~~~ w w °a UQ ~r `° ~~~' ~ Q. c o w rl'I b ~~~ o~~~ ; w N a ~ .~ ~~~~. ~ ~ ~ c~ ~~ ~.~ ~.-, o ~. y ~ ~ coo w a.a~ o ao o n. ~ ~ o y ~ ~ ~ /. ~ ~ `° c.~ ~ . ~ A' ~ y ~ "d p C ~~ M ~ ~ ~ O. y p O y ,~.'• ~ H3 &9 '~ ~ O. ~' ~ c o w ""'~ ~ ~ ~ .+, o iy ,~~' a °, y a ~ ~_ o' ~ a. j. ~ °, ~ ,r M~ ~, ~ a p ~~ ~~~ ~~ a p ~ b ~ ~. ~ w ~, a s* ~ y r ~ '~' '' A Q a~ n ~. ~; O ~ rt ~' a o 3 p ~ ~~ ~ ~. o ,~~~ O a m Z c <D m N O c ~. 0 m m v m v a;, m -~ D (D ~D YTT \V ~.~:n ~ r ~ o ~~ 0 v~o ~ ~:~~. o~;~ ~ ~ rn p ~ rt ~ n y ~°~ ~' ~ w ~ ~ c~ m ~~ ,r ~r Q f. ~: fw/J w N d CD 0 v ,~ g ~ m `~ ~, 0 c ego o,C ~~ ;-~' ~ `~ z ~' ~ a ~g z ~ a n ~v o 0 GA ~ ~f~ ~ ,~' ~_.°, :' ~ ~a ."' ~ 1 N ~ ~ ~ m fl: ~~~ c_ ~ ~. o C ~~ ~~ s ~ ~ ~~ ~ -~ o ~ a w r ,~r'' ~ ~_ 1 m ~~ a RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse S uare Carlisle, PA 1713 ALVAREZ RENE Estate File No.: 2012-00787 Receipt Date: 7/19/2012 Receipt Time: 11:31:55 Receipt No.: 1070682 Paid By Remarks: WOLF AND WOLF HEA ________________________ Receipt Distrib ution ----- -------- -------- --- Fee/Tax Description- Payment Amount Payee Name PETITION LTRS TEST 90.00 00 15 CUMBERLAND CUMBERLAND COUNTY COUNTY GENERAL GENERAL FUN FUN WILL SHORT CERTIFICATE . 40.00 50 -23 CUMBERLAND BUREAU OF COUNTY GENERAL RECEIPTS & CNTR FUN M.D JCS FEE AUTOMATION FEE . 5.00 CUMBERLAND COUNTY GENERAL FUN Check# 3578 173.50 Total Received......... 173.50 RECEivED auG 27 2012 '~l~he Sentinel www.cumberlink.cam i~~~~x~v'P% cast}s~ ~-~~~vss~:ec ~~a~ ccauN~ WOLF & WOLF ATTORNEYS 10 WEST HIGH STREET CARLISLE, PA 17013 717-241-4436 AD NUMBER PAGE NO. 412798 ~ 1 of 1 BILL DATE SALESPERSON 08/20/12 woifc START DATE STOP ATE 08/04/12 08/18/12 AD NUMBER AD DESCRIPTION CLASS ~ UNtS 412798 EXECUTOR'S NOTICE LETTERS TESTAMEN 10 PUBLIC NOTICES 30 * 2 cols Publication Insertions Rate Net Amount Gross Amount 3 THE SENTINEL -LEGAL 3 LGL $159.30 TOTAL AD CHARGE $159.30 3 PROOF OF PUBLICATION 01 PRF $7.00 3 MOBILE SITE 4 MOB2 $2.00 Purchase order Est.ReneAlvarez PAY THIS AMOUNT $168.30 $201.96* *AFTER 09/14/12 THE SENTINEL Thank you for advertising with The Sentinel! .Deadline for c1o LEE NEWSPAPERS in-column legal ads is 4:00 p.m. two business days prior to PO BOX 540 date of insertion. For questions, call (717) 240-7130. WATERLOO IA 50704-0540 CUMBERLAND LAW JOURNAL 32 SOUTH. BEDFORD STREET CARLISLE, PA 17013 Tele: (717) 249-3166 Fax: (717) 248-2663 August 24, 2012 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the -legal newspaper for publication of legal notices. TO: Stacy B. Wolf, Esquire RE: Rene, Alvarez Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on the following dates: August 10, August 17, and August 24, 2012 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 0 .00 Total Amount Due $ 75.00 Payment received by ELAM~ A. ALVA~ eo- $ $ S ~ CYNTHIA C. $1MONS PZi BUNSET DR. 717•l6E~8221 CARLISLE. PA 17013 DATE ~~i2_- ' - ~ 4LAR5 L~ ~-~^ Bi~At . Y~MO - ~ ~A- ~j 38Lr3893 ~ i3? 9i~: 28gL03 i:23 - 2 • ~~., 2891032381 # 3893 07/25/12 $220.00 :~~~ R~~~.rf~~i eLrtJl..~. i ~~0~ M~pICAL CANTER ..~ ~ ~ ~ ~ .~ ~.+_, .. ~~,4 ~"A ~ 7,~Y-,, ?lhc+~ ~ '~d°$~ z` _s~1 •L -•. h d <..ja~ - ~ ,~1 At Services Reric#ere~ - . CSR fi . _ , Payiments 8 '~ Y ~ r~' ~'esc~i~t~4~ ChargE * Ad`ustrriertts ~B~alar~~.~_ L,~O ~` 4/:1~ '7°1;77` CT AB~k~IVI~fV AN4 P~LVlS.11S~1 C:aNT~2AST 264.00 17'.13 - ~ 57r291~®12 ,~ .._,.... , F~M~ MEpI~AFtE NO~/aTAS SOLUTIONS .: _ ,. ~ ~ .53 4 ~$ - .. ~ ._ . ~n ,,.. , ~/2912~Q72 ~ - C~-_ ~ = g . 1CARE N:O1/ITA~~<.SOLUTION R~Adjt~S'~trni?nf=`M~D n ~~ .~_. t ~ ~ - ~~ * 17$.3 ~ bIJi2012 -4700p . RERC~~~}EEDL-E.,~1OPS~~LIVER~ _ ~ 3 46 .OQ ,. .OQ-~~.. ..;. a~46 3 ~/s12012 T70'12 CT GUIDANCE F"4R NEEDLE PLACEMENT Y35.00* * 235:00 00- 296 5/9!2012 99144 CONS SED ~5 YRS OLD1ST~=30 MINUTES ~ 296-OQ . f ~, ,r J. {t .i 1 Current 31 - 60 61 - 90 91 -120 Over 120 BALANCE DUE x17.13 17.13 0.00 0.00 0.00 0.00 PAY BY Due Upon Recei A 3 ~ ; ~ ~~~~ ~; f ~ ~ ~ ~! ~~,~ ~ ~ t `~:g~i °r ~ ~r For billing questions call: (717)932-5955 ~~, ~,~ ~~-~~~~:°~5>} ~~~ ~ ~~;~r or: (877)932-5955. ~,~ ~,. . ~` ~ ' ` f ~ `~ °' ~ "`-~ ~ '~~ ~ ~~~ ~~ Fax: (717)932-4856 } y R~ f~ Office Hours: 8:00 AM - 4:30 PM <.: ~ ~ . '~`r~an ~~~~°~~i~~f~c~~~`e~pendi~ltig' Wr~s~~r~~Q~:` To pay your bill online and register for eStatement STATEMENT please visit us at: www.gita.com SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION ~ss~o - ssa IIIIII IIIIIIIIIII~IIIIIIII~IIIIII I (IIIIII (III VIII VIII I CARLISLE MEDICAL PATHOLOGY PC P. O. BOX 188 LANDISVILLE PA. 17538-0188 TEMP-RETURN SERVICE REQUESTED PATIENT: RENE ALVAREZ LOCATION: CARLISLE REGIONAL MED CNTR PIN#: 026702040517 ADDRESSEE: BILLING I NQUI RI ES: MONDAY THRU FRIDAY 8: 00 AM TO 5: 00 PM (EST} TOLL FREE PHONE: 1-888-223-5649 STATEMENT DATE PAY THIS AMOUNT 07-03-12 RB 137 OP 0 0 01 DUN M $119. 42 SHOW AMOIiNT PAID HERE RENE ALVAREZ CARLISLE MEDICAL PATHOLOGY PC 221 SUNSET DR P. O. BOX 188 CARLISLE, PA 17013-2130 LANDISVILLE PA 17538-0188 ~~~~~~'~'~~I " IIIII'IIII~~II~11'~~~II~~I~~III1~~1'~~~1~~'II~II~1' 0 0 0 1 1 ~i~~i~iilii~~~ii~~~~~i~~ii'I~'I~~~~111'I~III'II'~II~III~~'~~I1~~I Q Please check box if above address is incorrect or insurance information has changed, and indicate change(s) on reverse side. ~ PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT KEEP THIS PORTION FOR YOUR RECORDS The balance is for your co-insurance/copayment amount. If yyou have additional insurance, please provide us with the information syoWnmalbeoting Unlessailing the back of this form or calling the phone numbent ohhf our balance. is due. additional information is provided, prompt payme y .: ~~~:• .~ N :: . :.:::.::.: :::::::;:: :.::. ... .. ~::D.I'G~~:.. ;.~~ :::. ::.~:.~::::. :.. ::: ... :..::....... ... ~G >::: >:~:~: ....... PLAN;`<:::: SECONDARY I NS URApHONE: 8 8 8 6 7 5 7 2 4 5 UrTtTED HEALTHCARE ATLANTA GA 30374 PO BOX 740800 POL: PLAN GRP: 22 8 7 7 6 :..:.::....... :::..~::.:::.:::.:::::,.:.. ~ ........ ~h1~8.~~~..~:::::. •:.~ :::..: . ........ .......................:. .. •::.::; :.::::::>:::~:: <:<~ ~:::::>:~ <:<.:: ;:::::: ~::::~>::::;<: • - ..111?'fr:l>~I:;.::•:::::<:::;;.:::.: ~::.::::.::.::;.::::::•:::.:...::.::. ~ . TOLL FREE PHONE: 1-8 8-223-5649 THIS I S A BI LL FOR P OFES S I ONAL LAB SERVICES, SUPERVISED BY ABOARD ERTI FI ED PATHOLOGI T. THESE ERVICES WERE REQUESTED BY YOUR ATTE ING PHYSIC AN. * * * * I F YOU H 88307 VE ALREADY MADE PAYMENT PLEASE DI S TISSUE EXAM BY PATHOLOGIST ~ ARD THIS 2,53.00 TI CE. 253.00 05-09-12 05-09-12 88342 IMMUNOHISTOCHE1vBSTRY 125.00 00 125 378.00 503.00 05-09-12 88342 88342 IMMUNOHISTOCHENBSTRY INIl~lUNOHISTOCHENIISTRY . 125.00 628.00 05-09-12 OS-09-12 88342 INIl~STJNOHISTOCHEMISTRY 125. 00 00 125 753, 00 878.00 05-09-12 88342 88342 IMMUNOHISTOCHEI~IISTRY IMMUNOHISTOCHE1vaSTRY . 125.00 1003.00 05-09-12 05-09-12 88342 INIl~![JNOHISTOCHEMISTRY 125.00 00 125 1128.00 1253.00 05-09-12 2 88342 88342 IMMETNOHISTOCHENaSTRY INIl~IUNOHISTOCHENBSTRY . 125.00 1378.00 05-09-1 05-09-12 88342 IMMUNOHISTOCHENaSTRY 125.00 00 125 1503.00 1628.00 05-09-12 88342 88342 IMMUNOHISTOCHEI~IISTRY IMMUNOHISTOCHENaSTRY . 125.00 1753.00 05-09-12 05-09-12 88342 IMMUNOHISTOCHENaSTRY 125.00 416.26 1878.00 1461.74 06-07-12 06-07-12 PAYMENT CO-INS PMT-MEDICARE S ATS D URANCE ED A O-IN IC IN AMOUNT OF $10 4 _0 0 FOR PIN#: 026702040517 I PLEASE PAY THIS AMOUNT' I CONTINUED Date of Last Pa ment: 6/6/2012 Amount: -53.62 ~~1.~_ Y `r,. .Patient: Rene Alvarez Chart Number: ALVRE000 Case: OV 5115/12 Paid by Paid by Applied to Paid By Dates Procedure Charge Primary Secondary Deductible Guarantor Adjustments Remainder 05/15/12 99213 85.00 -53.62 0.00 -17.98 , ~' 13.40 ** subscriber liability 4 Past Due 30 Days Past Due 60 Days Past Due 90 Days 0.00 0.00 0.00 06 ~f ~~ Amount Due 13.40 Invoice Review your order. Keep the top portion for your records. Return the Payment Slip (at bottom of page) with payment: -'° 06-23-2012 26874883250001 Invoice number: ~ 17-123692613 Plan member: ELAINE ALVAREZ Order process date: 06/21/2012 17 123692613 000009281 00 6 Cost for this package: ~~ $ 55.48 Cost for prior order(s): = $ 37.33 Shipping for this order: Pa ment(s) or ad'ustment(s) a lied: $ 0.00 TOTAL AMOUNT DUE IN 10 DAYS : $ 92.81 medco° D ~ Two of our medications will 7O m Y N D be refilled through X Worry-free Fills®, our automatic refill service. . f ~~~~' ~ l~ ~• ~, ~~ , ----y - - -- - - ---- .._ _.. ---~ Visit www.medco.com or call 1877 5b'S-3I~4 to enroll eligible medications, or manage your mea~cat~ons currCr~~~y Cr~-~~~CU ~~~ `~ Worry-free Fills®, our automatic refill service. You can update your shipping address, billing information, or next scheduled ship date-all online. REVIEW YOUR ORDER AND WHAT YOU NEED TO DO NEXT. DRUGS INCLUDED IN THIS ORDER WHAT YOU NEED TO DO NEXT BYSTOLIC TABS Your next refill is estimated to ship on 09/06/2012through for ELAINE ALVAREZ Worry-free Fills®, our automatic refill service. If your Strength: 5MG Oty: 90 shipping address changes, please call us at 1877 505-3184 Rx # 113650438917 You can cancel at any time by calling us at least 48 hours NDC # 00456-1405-30 before the date above. 1 refill(s) before 12/26/2012 AZOR TABS Your next refill is estimated to ship on 09/06/2012through for ELAINE ALVAREZ Worry-free Fills®, our automatic refill service. If your Strength: 10/40MG Oty: 90 shipping address changes, please call us at 1877 505-3184 Rx # 113650439017 You can cancel at any time by calling us at least 48 hours NDC # 65597-0113-90 before the date above. 1 refill(s) before 12/26/2012 Cost for this order: [__Ie`ar_ Offthe_Qaum_en~~luzl~elQmc._Mai~i:_~c~ci_t.~ivszur__~~~tmentin_fh~..iZl~.~.e~v.~l.~e..._Ke_en the-toD_nc~iQb ~or_YOUr_r_~c~r~... ~.. e_ ~. ~ _. , , Patl+en~`FtEI~E A~V~-~tEZ , ,~rx. - ~~ ~- _,_ Account: 547569 Services Rendered At :''CAR ~ Date Proc Code Descrlptan Charge '` a~t~ent~ ' Ad~,u~trYtent~ .~,~~ ce 5/9/2012 47000 RERC. NEEDLE BIQPSY LIVER 463.00 20.12 6/15/2012 PMT MEDICARE-NOVITAS SOLUTIONS 80.45 6!15/2012 ~ CR Adjustment. MEDICARE-NOVITAS SOLUTIONS 362~~0 5/9/2012 77012 CT GUIDANCE FOR NEEDLE PLACEMENT - 235.00 10.88 6/15/2012 _ PMT MEDICARE-NOVITAS SOLUTIONS 43.50 6/15/2012 ~ CR Adjustment MEDICARE-NOVITAS SOLUTIONS 180.62 5/9/2012 99144 CONS S'ED >5 YRS OLD1ST 30 MINUTES 296.00* 296.00 ~.. Current 31 - 60 61 - 90 91 -120 Over 120 BALANCE DUE $31.00 31.00 0.00 0.00 0.00 0.00 PAY BY Due Upon Receipt ir~~~w~~~~~wi~ni ,, . ~= } /~ ~ 1 V~J~J~ ),~' ,~ ~'t~ MEDICAL CENTER 3B1 Alexander Spring Road • Carlisle, PA 17013-9129 • (717) 249-1212 CREDIT RECEIPT N O : 1050446 DATE: 0 1 2012 T 12:56:39 ALVAREZ, RENE 1228025 09/21 /12 239.57 ::•E~A?CE:.1~M. :~ ~ fi k •:~s:: :.; .. r :?:::::. ~ :a:: f~:;:::::::>::::~ ..... :: COMMENTS: PYMT. BY CHECK 1017 For service rendered on: 05/09/2012 . THANK YOU Cashier Signature 8991210 1228025