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HomeMy WebLinkAbout03-26-13 ESTATE OF : IN THE COURT OF COMMON PLEAS RUSSELL E. CLARK : CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIV§10N rn NO. 2I'j'1-Obq I cz' =' rn r ;iJ r 7'- r N PETITION UNDER SECTION 3102 OF THE PROB ;I' ; ESTATES AND FIDUCIARIES CODE FOR SETTLEMENT OF SMALL ESTATE TO THE HONORABLE JUDGES OF SAID COURT: Denise M. Thompson, your Petitioner, files this Petition for Settlement of a Small Estate under the provisions of Section 3102 of the Probate, Estates and Fiduciaries Code and in support thereof avers that: (1) Your Petitioner, Denise M. Thompson is a competent adult residing at 414 W. Penn Street, Carlisle, Pennsylvania 17013, and is the daughter of the above decedent. (2) Russell E. Clark died on January 20, 2013 at the age of 78 years, but prior thereto lived and was domiciled at 442 Walnut Bottom Road, Carlisle, Pennsylvania, Cumberland County, Pennsylvania. A copy of decedent's Death Certificate is attached hereto as Exhibit"A." (3) Russell E. Clark died with a Will. No Letters have been issued. A copy of decedent's Last Will and Testament is attached hereto as Exhibit"B." (4) Russell E. Clark had no probate estate when he died other than the following: Sovereign Bank with a balance of$13,141.14 as of December 18, 2012. A copy of the statement for the period November 22, 2012 through December 21, 2012 is attached hereto as Exhibit "C." (5) The sole heirs and relationship to the decedent are as follows: Denise M. Thompson, Daughter Russell E. Clark, Jr., Son Jacqueline M. Cox, Daughter Gregory A. Clark, Son Sherwood A. Clark, Son (6) Your Petitioner avers that the only outstanding debts of the Estate are the following: Thornwald Home - $9,146.11 Millennium Phcy Systems Mechanicst—$265.20 Funeral Expenses - $652.78 Federal Income Taxes in the amount of$8,778.00 Copies of all outstanding debts are attached hereto as Exhibit"D." WHEREFORE, your Petitioner respectfully requests that an Order be made authorizing Denise M. Thompson to act as Fiduciary for the Estate of Russell E. Clark and close the account with Sovereign Bank with the proceeds made payable to the Estate of Russell E. Clark pursuant to Section 3102 of the Probate, Estates and Fiduciaries Code. R ge B. Irwin, Esquire Supreme Court I.D. No. 6282 IRWIN &McKNIOHT, P.C. 60 West Pomfret Street Carlisle, PA 17013 (717) 249-2353 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND Denise M. Thompson being duly sworn according to law, deposes and says that the facts contained in the foregoing Petition are true and correct to the best of her knowledge, information and belief. (SEAL) Denise M. Thompson Sworn d subscribed before me this g ay of March, 2013. "!"3!MMONw0 n OF pENNgYl.VANIA Notarial Seel wrens.Noel,Notary Public t =ia Boro,Cumberland County eWr s Dec,8,2015 LVANIA ASSOCIATION OF NOTARIES otary P Aic COMMONWEALTH OF PENNSYLVANIA Notarial Seal Karen S.Noel,Notary Public Cadwe soro,Cumberland Ginty My Commission Expires Dec.8,2015 MEMBER,PENNSYLVANIA ASSMATION OF NOTARIES H105.805 REV(9/11) LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is Illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 This is to certify that the information here given is correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital 1, a, Records Office for permanent filing. P 2 .11. 1' 3 3 �'q�l 0���P~�,,, �W- JAA 2 1/2013 to Certification Number "°E ""A)j1�1 Local Registrar Date Issued Type/Print In - COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH VITAL RECORDS P.t kIII,t CERTIFICATE OF DEATH Black ink State File Number: i.Decedent's Lei!]Name(Firs[,Middle,Last,Suffix) 2.Sex 3.Social Security Number 4.Date of Death(Mo/Day/Yr)11S II Mo) Russel E. Clark Male 165-63-6307 January 20, 203 Sa.Age-Last Birthday(Yrs) 15b.Under 1 Year 5c.Under i Da 6.Oafe of Birth(Ma/Day/Year}(Spell Month) 7a.Birthplace(City and State or Foreign Country) 78 Months Days Hours Minates Aug 22, 1934 Harrlsbu FA 7b.Birthplace(County) Dzliunohln Sa.Residence(S to Fcireign Country) Bb.Residence(Street and Number-Include Apt No.) Sc.Did Decedent Live In a Township? Pennsy`.l vania 442 Walnut Bottom Rd_ QYes,d.c.d.nt lived in -P, 8d.Residence(County) Curteberland Be.Residence(Zip Code) 1 013 No,decadent lived within limits of Carlyle city/boro. 9.Ever in US Armed Forces? 10.Marital Status at Time of Death Q Married ] Widowed 11.Surviving Spouse's Name(If wife,give name prior to first marriage) Q Yes X1 No Q Unknown Q DW.,cad Q Never Married Q Unknaw 12.Father's Name(First,Middle,Last,Suffix) 13.Mather`s Name Prior to First Marriage(First,Middle,Last) Russell Clark Ruth Kinard 14a.informant's Name 14b.Relationship to Decedent 14c.Informant's Mail ng Address(Street and Number,City,State,Zip Code) Denise Thom son daughter 414 w_ Penn St_ , Carlisle, PA 17013 G .. .... .................................. .......-.. ...............,......,........isa. place or eat c ec ..!Y.one....-..............-....-..... ... • ..............dS..... -- es tf Death Occurred in a Hospital: inpatient If Oath Occurred Som -----•• -------••••••-•••----•• ••----••- ••--- -•-••" ------ where other Than a Haspftai: `t�'-HasRlce Faciii£y �DacedanYs Hama Q Emergency Room/Outpatient Q Dead on Arrival al Nursing Hem./Lang-Term Care Facility Other(Specify) 15b.Facility Name(If not institution,give streak and number; •iSC,City or Town,State,and Zi Code Std.Court f Death- ovnwald Homer Carlisle, PA 7013 Cuf( evland 161.Method of Disposition 2Q Burial [] Cremation 16b.Data of Disposition 16c.Place of Disposition(Name of cemetery,crematory,or other place) Q Removal from state Q Donation Jan 25, 2013 Mt--- Holly Springs Cemetery Other(speci ) 16d.Location of Disposition(City or Town,State,and Zip) 17a.Slgnat of Funeral Servic or P t 17b.License Number Mt Holly Springs, PA 17065 138504 17c.Name and Complete Address of Funeral Facility Hoffman-Roth Funeral Home & Cremato , 219 North Hanover Street, Carlisle, PA 17013 38.Decedent's Education-Check the box that best describes the 19.Decadent of Hispanic Origin-Check the 20.Decedent's Race-Check ONE OR MORE races to Indicate what highest degree or level of school completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be. Q 8th grade or less is Spanish/Hispanic/Latino. Check the"N"' White Q Korean EI Na diplama,9th-12th grade box if decedent is not Spanish/Hispanic/L.Tno. Black or African American Q Vietnamese 30 Nigh"h at graduate o,GED completed No,not Spanish/Hispanic/Latina Q American Indian or Alaska Native Q Other Asian Some college credit,but no degree E1 Yes,Mexican,Mexican American,Chicano Q Asian Indian Q Native Hawa lion Q Associate degree(..a.AA,AS) Q Yes,Puerto Rican Q Chinese Q Gu nlan or Chamorro Q Bachelor's degree(e.g.BA,AB,BS) Q Yes,Cuban Q Filipino Q Samoan EJ Master's degree(e.g.MA,MS,MEng,MEd,MSW,MBA) Q Yes,other Spanish/Hispanic/Latino Q Japanese Q Other Pacific Islander Q Doctorate(e.g.PhD,Ed D}or Profassionaf degree (Specify)4_ E7 Other(Specify) Pacify) .Mp DOS DVM LLB JD 21.Oec.dent's Single Race Self-Designation-Check ONLY ONE to indicate what the decedent considered himself or herself to be. 22 a.Decedent's Usual Occupation-Indicate type of work [.X White Q Japanese Q Samoan done during most of working life. DO NOT USE RETIRED, Q Black or African American Q Korean Q Other Pacific Islander PL'Ofes8 -C MA erican Indian or Alaska Native Q Vietnamese Q Don't Know/Not Sure Q Asian Indian Q Other Asian Q Refused 22b,Kind of Business/Industry Q Chinese Q Native Hawaiian Q Other(Specify) C011ega Q Filipino Q Guamanian or Chamorro ITEMS 23.-773.45-2725.1-.T-701%LETED 23a.Dat.Pronounced Dead(MO Day Yr) 23b-Signature o Person Pronouncing Death Only when appiicabiej 23c.Cleanse Number CE PERSON """ `a� 3 CERTIFIES DEATH Q �r^) _ n�_ 23d Dat.Signal(MO/Day/Yr) 24.Time of Deat C.,..�(�f�L%F-'�r Q 25.Was Medical Examiner or Corona,Contacted? Q Yes No CAUSE OF DEATH Approximate 26.Part 1. Enter the chain of ever„§--diseases,Injuries,or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest Intervals respiratory arrest,or ventricular fibrillation without showing the etiology.DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary tO�ns[et to Death IMMEDIATE CAUSE -----'--------x' a- �CJ.i.,>rCY,V..I� �J C,K�W.+�L �L{,,,kQyF• _ 't R(7RJei-t (Final at seas.a I sc-d-r- Due ro(or as a consequ nee pf}; 3 resulting in death) b. --wart lz ally list conditions, Due to(or as a cons.qu nee of): If any,leading to the cause listed an line a. Enter the c. UNDERLYING CAUSE Due to(or as a consequence of): (disease or Injury that Initiated the events resulting d. in death)LAST. Due to(or as a consequence of): 26-Part ti. Enter thalsAmficant Conditions contributing to deat fbut not resulting in the underlying cause given in Part 1 27.Was n autopsy performed? Q Yes -(® No 26.Were autopsy findings available ka complete the cause of s death? m E3 va No 29.if Famaie: 30.Did Tobacco Us.Contribute to Death? 31.Manner of Death -� E Q Not pregnant within past year Q Yes C1 Probably [°Natural Q Homicide 19 Q Pregnant at time of death tQ No Q Unknown Q A.[dart Q Pending Investigation Q Not pregnant,but pregnant within 42 days of death Q Suicide Q Could not be determined Q Not pregnant,but pregnant 43 days to 1 year before death 32.Date of injury(Ma/Day/Yr)(Spell Month) ^..__ Q Unknown if pregnant within the past year 33.Time of Injury 34.Place of Injury(e.g.home;construction site;farm;school) 35.Location of Injury(Street and Number,City,State,Zip Code) 36.Injury at Work 37.If Transportation Injury,Specify: 38.Describe How injury Occurred: Q Yes Odver/Operator Q Pedestrian Q No Q Passenger Q Other(Specify) 39a.Certifier(Check only one): 19.Certifying physician-To the best of my knowledge,death occurred due to the cause(s)and manner stated IJ- E3 Pronouncing&Certifying physician-To the best of my knowledge,death occurred at the time,date,and place,and due to the causes)and manner stated Q Medical Examiner/Coroner-On the basis of examination,and/or investigation,in my opinion,death occurred at the time,date,and place,and due to the cause(s)and mann�er stated Signature of certifier: Title of certifier: License Number: hx�� '"� I+ 39b.Name,Address and Zip Cade of Person ComPieting Cause of Death(Item 26) 39c.Date Signed(it Day/Yr) G 6+"a 1�_ �nt i•,,,a w,n,,, b r-'. .rep '•t`l IIJ C"�^+�. 'fiyr tV 4 C.'L•' ..., fs l'7a\ J zr �i� �'o(3 40.Registrar's Dis#rict Number 41.Registrar's 51 42.Re�Q�\Istrar FI.pate Mo Day r) 43.Amendments a Dlsoositi..Permit Nn. \)T fir.��1� H1O5-143 FAST WILL AND TESTAMENT 1, RUSSELL E. CLARK, of the Borough of Carlisle, Cumberland County, Pennsylv,uiia, 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 Codi,;ils 1 ieretofore made by me. 1. I direct my Executrix or Substitute Executrix, as the case may be, 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 Executrix or Substitute Executrix of my estate. 2. My Executrix or Substitute Executrix may, at her discretion, compromise claims, borrow m aney, retain property for such length of time as she may deem proper; lease and sell property far such prices, on such terms, at public or private sales, as she may deem proper; and inves- estate property and income without restriction to legal investments unless otherwise provided l tereunder. 3. 1 authorize and empower my Executrix or Substitute Executrix to sell any realty and/or f perso ialt,y 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 simpl-., G,, I could do if living. My Executrix or Substitute Executrix is authorized and empowered to engage in any business in which I may be engaged at my death, for such-,)eri:)d of time after my death as seems expedient to said Executrix or Substitute Executrix. 4. I give, devise and bequeath all of my estate of whatever nature and wherever situate as follows: a. $5,000.00 to FIRST UNITED CHURCH OF CHRIST, 30 North Pitt Street, Carlisle,Pennsylvania; b. $2,000.00 each to CAITLYN M. GREEN, RUSSELL E. CLARK. IV, and MICHAEL Z. COX; and c. All the rest, residue and remainder to my three(3) sons, GREGORY A. CLARK,RUSSELL E. CLARK,JR. and SHERWOOD A. CLARK, and my two (2) stepdaughters, DENISE M. THOMPSON and JACQUELINE M. COX, share and share alike. 6. I nominate and appoint DENISE M. THOMPSON to be the Executrix (if th.s my Last Will and Testament. In the event she has predeceased me, failed to qualify or is itot alle or does not serve for whatever reason, I then appoint JACQUELINE M. COX to be the: Substitute Executrix of this my Last Will and Testament, whereby the said Substitute Executrix shall have the same powers as are given to the original Executrix hereunder. 7. No person(s) shall benefit hereunder unless such beneficiary shall survive me by sixty (60) days. 2 ACKNOWLEDGMENT AND AFFIDAVIT WE, RUSSELL E. CLARK, KAREN 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 years of age or older, of sound mind and under no constraint or undue influence. RYSSELL E. CLARK, KAREN .N EL SHARON L. SCHWALM COMMONWEALTH OF PENNSYLVANIA : : SS: COUNTY OF CUMBERLAND Subscribed, sworn to and acknowledged before me by RUSSELL E. CLARK, the Testator herein, and subscribed and sworn to before me by KAREN S. NOEL and SHARON L. SCHWALM,witnesses, this''day of May 2008. LA of ry Public COM NWEALTH OF PENNSYLVANIA Notarial Seal Roger B.Irwin,Notary Public Carlisle Boro,Curnberiand County My Commission Expires Oct.3,2008 Member,Pennsylvania 4ssociation Of Notaries ®v erei 11 Statement Period 11122/12 TO 12121112 PREMIER CHECKING For your convenience our Customer Contact Center is available from 7 am-8 pm EST,7 days a week. Call us at 1-877-768-1143. Hearing impaired may call 1-800-428-9121 (TTYffDD). www.sovereignbank.com 00005256 MSBR3778122 02 0000 RUSSELL E CLARK 0000 414 W PENN ST 70210 CARLISLE PA 17013-2234 1900001172 0 0 0 0 rs N CJt 1p O O N V OD to W O O O O O O N 9 Cn W V We wish you peace and prosperity V N N this holiday season. 0 N r Sovereign � 1212NOU N2270 "" Looking to give an easy and convenient gift this holiday season? Look no more. � �: The American Express Gift Card makes the perfect gift for the holidays.It can be used at millions of places—wherever American Express Cards are accepted.*This gift card is backed by world-class customer service and can be replaced if lost or stolen.** Stop by your local Sovereign Branch to purchase this great gift today! -The American Express Gift Card may be used at U.S.merchants that accept American Expressly)Cards.No ATM cash withdrawal.Some limitations apply,including restriction on use of the Gift Card at cruise lines or for recurring billing.See Cardholder Agreement for complete details.Card cannot be redeemed for cash.except where required by law.The American Express Gift Card is issued by American Express Prepaid Card Management Corporation.--idenMicabon and proof of purchase required. 1212AMEX N2270 12112 Sovereign Bank.N A.is a Member FDIC and a wholly owned subsidiary,of Banco Santander,S.A.®2012 Sovereign Bank,N.A.I Sovereign and Santander and its logo are registered trademarks of Sovereign Bank,N A.and page 1 of S Banco Santander.S A respectively,or their atbliales or subsichades in the united Stales and other countries 1691016934 IMPORTANT INFORMATION REGARDING CHANGES TO YOUR PERSONAL DEPOSIT ACCOUNT AGREEMENT THAT ARE NOW IN EFFECT Branch Transaction Cut-Off Time: In our Funds Availability Policy,we stated that the earliest cut-off time for branch transactions was 2:00 p.m.Now,there is no longer a cut-off time for branch transactions.This means that all transactions performed in the branch on a bank _ business day will be posted the same bank business day. Service Fee Period: The service fee period now begins on the day any monthly service fee is posted to your account and ends on the day before the next monthly service fee is posted.This change primarily impacts the timing of when your fees are calculated but not the amount of fees you may be charged.It also impacts how we count the number of certain withdrawals from your savings and money market savings accounts.This change affects section 7("Withdrawals")and 24("Fees and Charges")of your Personal Deposit Account Agreement. 0 oTiming for Calculating Combined Balance: rn N rn When we calculate the combined balance for your Premier Checking Account to determine if the monthly fee applies, o we will now use the balance of your certificate of deposit accounts,your outstanding loans and Individual Retirement � Accounts as of the last day of your statement period rather than two days before the last day of your statement period, m as previously disclosed in section 11 of the Personal Deposit Account Agreement.There is no change to how we calculate to °' the average daily balances to your other checking and savings accounts. 0 C 0 N O O O CJ3 If you have any questions on the above changes,please contact our Customer Contact Center at W 1-800-762-5895,or visit your local Sovereign Branch. At Sovereign,we appreciate your business and look forward to meeting your future financial needs. C? N N O N r Cn Cn D N7301 1712MP PREMIER Statement Perbd RUSSELL E CLARK Account#1691016934 DENISE M THOMPSON ATTY IFF Balances De osits/Credits +$11,154.10 Average Dailx Balance $12,601.95 ININIMA page 2 of 5 1691016934 S®vere1 iff ® - Interest Earned this Period $0.10 Paid Last Year $5.07 *The interest earned and the interest paid may differ depending on when interest is credited to your account. Checks Posted Check# Date Paid Amount Reference Check# Date Paid Amount Reference E 2463* 11/23 $50.37 RODALE INC BOOKS 2471 12/06 200.00 997411910 2466 11/27 1100.00 980858025 2474 12107 250.00 982832645 2469* 12103 $8,171.68 995413255 2476 12/20 $1,200.00 901044910 12 Checks)Posted=$11,222.05 An asterisk(*)indicates a skip in sequential check numbers. An(E)indicates check was converted to an electronic item. Account Activity Date Description Additions Subtractions Balance 11-22 Beginning Balance $12,720.84 11-23 RODALE INC BOOKS 6109675171121123 $50.37 $12,619.69 0 2463 o 0 (n N WE OF NA EMEN :y rn 11-26 CHECK 000000002454 $250.00 $12,339.69 0 0 ^� 11-26 CHK CARD PURCHASE Wal-Mart Super $60.35 $12,179.34 OD m CARLISLE/PA US .. �. . °w 11-27 MONTHLY MAINTENANCE FEE FOR PRIOR PERIOD $30.00 $12,128.61 0 0 c°n 11-27 CHECK 000000002466 $100.00 $11,778.61 Zn 00 X 11-28 CHK CARD PURCHASE KOHL'S#0188 $75.00 $13,357.61 m CARLISLE/PA US i°v 11-29 CHK CARD PURCHASE HOSS'S STEAK-CA $38`51 $13,255.86 CARLISLE/PA US D 12-03 CHECK 000000002469 $8,171.68 $5,064.78 h 12-05 NATL FIN SVC LLC EFT 121205 RY4162884 $9,500.00 $14,264.78 3BOC6 12-07 CHECK 000000002474 $250.00 $13,814.78 12-14 CHK CARD PURCHASE RITE AID CORP. $65.70 $13,649.08 CARLISLE/PA US �}+ 12-17 CASH WITHDRAWAL SOVEREIGN E152 $140.00 $13,259.08 CARLISLE/PA US 12-19 CASH WITHDRAWAL SOVEREIGN E152 $200.00 $12,941.14 CARLISLE/PA US 12-20 CASH WITHDRAWAL Sams Club 8175 SR009965 $81.75 $11,659.39 HARRISBURG/PA US v x F .i, �r. of t��. W ya ��.: ... ♦1 M. . nape 3 05 1691016934 Account Activity(Cont.for Acct#1691016934) Date Description Additions Subtractions Balance 12-21 CHK CARD PURCHASE PIZZA HUT 1006 $25.16 $11,580.53 CARLISLE IPA US IN CASE OF ERRORS OR QUESTIONS ABOUT YOUR ELECTRONIC TRANSFERS CALL YOUR CUSTOMER SERVICE CENTER AT THE NUMBER SHOWN ON THE TOP OF YOUR STATEMENT OR WRITE TO THE BANK FOR DEBIT CARD ISSUES: FOR ALL OTHER ELECTRONIC TRANSFER ISSUES: Sovereign Bank Sovereign Bank Attn:Card Disputes Team Attn:Client Relations - MAI MB3 02 05 10-421-CRI P.O.Box 831002 P.O.Box 12646 Boston,MA 02283-1002 Reading,PA 19612-2646 - Please contact us if you think information about an electronic transfer on your statement or receipt is wrong or if you need additional information about an electronic transfer on the statement or receipt. We must hear from you no later than 60 days after we.sent you the FIRST statement on which the error appeared. • Tell us your name and account number. •Describe the electronic transfer error or the electronic transfer that you are unsure about and • Tell us the dollar amount of the suspected error. explain as clearly as you can why you believe there is an error or why you need further information. If you tell us orally,we may require you to send your complaint or question in writing within 10 business days. 0 °o We will promptly investigate the matter and call or write to you with an answer within 10 business days.If we need more time,we may take up to 45 CM days to investigate your complaint or question.if we do,we will credit your account within this 10-day period for the amount you think is in error,so cNn you will have the use of the money during the time it takes us to complete our investigation.If we ask you to put your complaint or question in writing rn and we do not receive it within 10 business days,we may choose not to credit your account. 0 i° For errors involving new accounts,point of sale purchases or foreign transactions,we may take up to 90 days to investigate your complaint or 4 question.For new accounts,we may take up to 20 business days to credit your account for the amount you think is in error. co a' We will tell you the results of our investigation within 3 business days after completing our investigation.If we decide there was no error,we will °o send you a written explanation.You may ask for copies of the documents we used in our investigation. 0 a o IN CASE OF ERRORS OR QUESTIONS ABOUT OTHER TRANSACTIONS ON YOUR STATEMENT 0 You must contact us within thirty(30)days after you receive your statement if you think a transaction,other than an electronic transfer,shown on m your statement is wrong or if you need more information about the transaction. You may contact your nearest branch or our Customer Contact Center at 877-SOV-BANK. Customers with hearing impairments may call w 800-428-9121(TTY/TDD). We will investigate your dispute and tell you the results of that investigation. 4 V ib N N O N r W D page 4 of 5 1691016934 4 STATEMENT Thornwald Home Statement Date: 01/01/2013 442 Walnut Bottom Road Carlisle, PA 17013 Due Date: 01/25/2013 Telephone: (717) 249-4118 • Amount Enclosed $ Amount Due: $ 9,146.11 Account#: 1263 RE: Russell E Clark Denise Thompson 414 W. Penn St. Carlisle, PA 17013 Days Date;`` Desch.ton Qua nt Rate' Char e, ..'; Pa eats Balances Balance B/F 8,410.89 8,410.89 12/28/12 THOMPSON, DENISE 8,410.89 .00 12/24/12 Medical Supplies 19 .47 44.18 44.18 12/30/12 Personal Supplies 2 .09 .18 44.36 12/31/12 Cable Television 1 25.75 25.75 70.11 12/31/12 Beauty&Barber 1 14.00 14.00 84.11 12/01/12- 12/23/12 Room&Board-Semi-Private 23 267.00 6,141.00 6,225.11 12/01/12- 12/31/12 Room&Board-Semi-Private 31 267.00 -8,277.00 -2,051.89 12/24/12- 12/31/12 Room&Board-Semi-Private 8 276.00 2,208.00 156.11 01/01/13 -01/31/13 Room&Board-Semi-Private 31 290.00 8,990.00 9,146.11 Current 31-60 Days 61-90 Days Over 90 Days Amount Due 9,146.11 .00 .00 .00 9,146.11 Payments MUST be received BY the 25th,of each month. Attention: MA recipients Statement Date: 01/01/2013 Documentation MUST be received in order to receive credit on a monthly basis. Due Date: 01/25/2013 Russell E Clark-Account #: 1263 Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013 Telephone: (717) 249-4118 Themwaid Home CORP - Billing Detail Report 1/8/20131:39:20 PM Detail Facility Id: Facility Name: Resident Name: Resident Id: Room: Item GL Code: Date: Item Description: Item id: Quantity / UOM Price: 200 Thornwald Home Clark,Russell E 1263 E001L 12/10/2012 10:38AM Bag Urinary Drainage W/cover TH-0513 1 / EACH 12.45 12/19/2012 11:49AM Dycem slip grip TH-0222 1/ EACH 7.90 12/21/2012 12:40PM Ensure Plus Vanilla 4oz TH-0205 2/ EACH 0.94 12/21/2012 10:03PM Ensure Plus Vanilla 4oz TH-0205 1 / EACH 0.47 12/22/2012 12:33PM Ensure Plus Vanilla 4oz TH-0205 1 / EACH 0.47 12/22/2012 02:18PM Ensure Plus Vanilla 4oz TH-0205 1 / EACH 0.47 12/22/2012 10:29PM Ensure Plus Vanilla 4oz TH-0205 1/ EACH 0.47 12/23/2012 09:54AM Ensure Plus Vanilla 4oz TH-0205 1/ EACH 0.47 12/23/2012 01:35PM Ensure Plus Vanilla 4oz TH-0205 1 / EACH 0.47 12/23/2012 09:56PM Ensure Plus Vanilla 4oz TH-0205 1 / EACH 0.47 12/24/2012 01:59PM Ensure Pius Vanilla 4oz TH-0205 1/ EACH 0.47 12/24/2012 01:59PM Ensure Plus Vanilla 4oz TH-0205 1 / EACH 0.47 12/24/2012 10:51 PM Ensure Plus Vanilla 4oz TH-0205 1 / EACH 0.47 12/25/2012 12:20PM Ensure Plus Vanilla 4oz TH-0205 1 / EACH 0.47 12/25/2012 02:44PM Ensure Plus Vanilla 4oz TH-0205 1 / EACH 0.47 12/25/2012 10:14PM Ensure Plus Vanilla 4oz TH-0205 1 / EACH 0.47 12/26/2012 12:33PM Ensure Plus Vanilla 4oz TH-0205 -1 / EACH -0.47 12/26/2012 02:25PM Ensure Plus Vanilla 4oz TH-0205 -1 / EACH -0.47 12/03/2012 11:46AM Glove Medium Vinyl Powder-Free TH-0089 1 / BOX 3.63 12/13/2012 11:12AM Glove Medium Vinyl Powder-Free TH-0089 1 / BOX 3.63 12/27/2012 04:09AM Glove Medium Vinyl Powder-Free TH-0089 1 / BOX 3.63 12/24/2012 12:19PM Lube Jelly Packettess TH-0124 1 / EACH 0.09 12/30/2012 11:23PM Lube Jelly Packettess TH-0124 1 / EACH 0.09 12/19/2012 04:05PM Wipes Adult Premium(96/box) TH-0084 1 / BOX 6.83 Totals for GL Code: 21 44.36 Totals for Russell E Clark 21 44.36 CC_ActivitybyResident.rpt Page 8 of 65 Millennium Phcy.Systems Mechanicst 5020 Ritter Road, Suite 110 Mechanicsburg PA, 17055 "Q1 'S�Wnvk' Fz- INVOICE 01/31/2013 Account Number: TWNC1583 RUSSELLCLARK c/o DENISE THOMPSON 1263 414 W.PENN STREET PVT CARLISLE PA,17013 0A Please Detach Here and Return Top Portion With Your Payment --- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Invoice Date:01/31/2013,Acct#:TWNC1 583,CLARK,RUSSELL E,Thornwald NC,L,BRANSCUM,GEORGE -X MV-4 01/01/2013 6564023 39.00 Carbidopa-Levodopa Oral Tablet 25-250 MG $ 10.00 c $ 0.00 $ 10.00 RX 00093-0294-05 01/01/2013 6587971 13.00 Escitalopram Oxalate Oral Tablet 20 MG $ 10-00 c $ 0.00 $ 10.00 RX 65862-0375-01 01/01/2013 6643904 26.00 Lamotriqine Oral Tablet 150mq $ 10.00 c $ 0.00 $ 10.00 RX 00093-7247-06 01/04/2013 6646198 28.40 Triple Antibiotic External Ointment 3.5400-5000 $ 9.44 $ 0.00 $ 9.44 OTC 51672-2016-02 01/12/2013 6653733 2.00 Levofloxacin Oral Tablet 250 MG $ 5.71 c $ 0.00 $ 5.71 RX 65862-0536-50 01/13/2013 6653735 2.00 Levofloxacin Oral Tablet 250 MG $ 5.71 c $ 0.00 $ 5.71 RX 65862-0536-50 01/14/2013 6652186 5.00 Levofloxacin Oral Tablet 500 MG $ 9.88 c $ 0.00 $ 9.88 RX 65862-0537-50 01/14/2013 6652185 3.00 Bisac-Evac Rectal Suppository 10 MG $ 0.45 $ 0.00 $ 0.45 OTC 00713-0109-01 01/14/2013 2035438 30.00 Morphine Sulfate $ 24.48 c $ 0.00 $ 24.48 RX 00054-0404-44 01/14/2013 6652180 24.00 Mapap Oral Tablet 325 MG $ 0.36 $ 0.00 $ 0.36 OTC 00904-1982-80 01/14/2013 6652181 24.00 Mapap Oral Tablet 325 MG $ 0.36 $ 0.00 $ 0.36 OTC 00904-1982-80 01/14/2013 6652183 4.00 Bisacodyl EC Oral Tablet Delayed Release 5 MG $ 0.08 $ 0.00 $ 0.08 OTC 00904-7927-80 Aw'i -7gg"w- jk qz"' I g" ala% 178.73 $ 0.00 is 0.00 is 0.001s 0 1$ 0.001$ 0001 265.20 $ )1[$ 75!4"" "' i ■ 1 i i locally Owned& Operated SUPERMARKET Stonehedge Shopping Center 950 Walnut Bottom Road Carlisle, PA 17013 717-2451-2345 1/24/2013 TERM 11 3:35:26 PM HELLO, MY NAME IS 534 Danielle Welcome GOLD SAVINGS ID: 41101174208 SHURFINE WHOLE B 1 @ 29.06 $29.96F Gold Savings 13„12 lbs 9 -1.8111b -$14.70F SUBTOTAL. 1 $15.26 **DISCOUNT 1 $0.76 ADJ TOTAL 1 $14.50 TAB; EXEMPT $0.00, TOTAL $14.50 DUE==:> $14.50 *CHARGE* $14.50 CHANGE DUE $0.00 YOU EARNED $$14.70 IN GOLD SAVINGS WITH THIS TRANSACTION IT IS MY HOPE THAT YOUR SHOPPING EXPERIENCE WAS AN ENJOYABLE ONE! ANY COMMENTS OR CONCERNS FEEL FREE TO CONTACT ME KEITH HOFFMAN ****4************0 4*00*040*00 NELLS RETURN POLICY ALL RETURNS MUST BE MADE WITHIN 7 DAYS RECEIPT ARE REQUIRED FOR REFUNDS Wa I m a r t '0";I'f%. Save money.Live better, ( 717 ) 258 - 1250 MANAGER CHAD ROETING r� 60 NOBLE BLVD 4vality,Selection,scnvings,Every Day. CARLISLE PA 17013 ST# 2574 OP# 00002052 TE# 13 TR# 01381 Visit us on the Internet CHIPS 003304900039 F 7.50 N www,GiantFoodStores.com S My coal is to ensure sour satisfaction everw time you shop with us. If there CL LEMONADE 004300095065 F 2.68 X Is anwthins more I can do to improve wour experience please call or write. WHPD VANILLA 001600037430 F 1.58 N Mike Youns, Store Manaser R C MILK CHC 001600045900 F 1.58 N CAKE MIX 001600040989 F 1.28 N Giant Food Store #6112 CAKE MIX 001600040989 F 1.28 N 255 S. Spring Garden Street CAKE MIX 001600043054 F 1.28 N Carlisle, PA 17013 CAKE MIX 001600043054 F 1.28 N GVTSQz RELISH 007874243474 F 0.92 N Pharmacw Telephone: {717? 249-8836 CL ICED TEA 004300095064 F 2,68 N THANK YOU 48001727558 COOKIES 007874206872 F 5.28 0 COOKIES 007874206872 F 5.28 0 SB MAR CHERRY COOKIES 072552651100 F 3,18 0 1 .05 lb @ 3,99 /!b 1 .99 F COOKIES 072552651100 F 3.18 0 WHT SDLESS GRAPE W COOKIES 072552651100 F 3.18 O 1 .68 lb @ 3.99 lib 4.19 F PD RSTO TKY 020835211050 F 10.50 0 RED SDL5 GRAPE W BC 6.74 F PD FR HAM 2743833303 F 1.88 0 1 .68 lb @ 2.49 /Ib = 4.18 R C MILK CHC 001600045900 F 1.58 N SC FRESH SAVINGS 2.52-F I R C MILK CHC 001600045900 F 1.58 N Price wou paw 4.18 1 .92 lb @ 1 ,99 /ib PLUM TOMATOES W 3.82 F 0.57 lb @ 3.99 /!b EURO YELLO PEPPR W 2.27 F SUBTOTAL 110.37 CITRUS SALAD 7.99 F TAX 1 61000 % 1.66 HARZ FF RANCH DP 3.99 F TOTAL 112.03 RELISH TRAY LG 29.99 F ,y DEBIT TEND 112.03 CELLO LETTUCE 24 W d CHANGE DUE 0.0 2 @ 4.99 2.99 F t'. CORED PINEAPPLE W 9.98 F EFT DEBIT PAY FROM PRIMARY ` 3 STRAWBERRY W @ 112.03 TOTAL PURCHASE 3 @ 1 .60 BC 14.97 F ACCOUNT # **** **** **** 2979 S 5C FRESH SAVINGS REF # 302400383880 4,50-F NETWORK ID. 0076 APPR CODE 312888 Price for 3 10.47 TERMINAL # MX060891 BLUEBERRIES 18[ W BC 8.99 F SC FRESH SAVINGS 5.00-F 01124/13 09:55:41 Price wou paw 3.99 10 @ 3,49 # ITEMS SOLD 32 MRTY POT DNR RLL 34.90 F TC# 6600`6694 2866 0225 8244 1 TOTAL BEFORE SAVINGS 132.27 l�I �NII�� ����IIl���I �tIN#NN YOUR TOTAL SAVINGS 12.02 Low pri I III�IIQ �t1�IAN1Nltl��N� Itll ****TOTAL AFTER SAVINGS 120.25 TAX PAID .04 ces. Every daw. On everwthins, TOTAL Backed bw our Ad Match Guarantee. ACCT RECEIVABLE 120,2555 01/24/13 09:55:43 CHANGE .00 TOTAL NUMBER OF ITEMS SOLD = 25 I 0d 1/24/13 10:26 AM 6112 17 0017 114 t0' I m clad you shopped here today. Your Cashier -- WANDA too-10 DECEASED RUSSELL E CLARK 01/20/2013 Department of the Treasury—Internal Revenue Service (99) //� A/ Form 1040 U.S. Individual Income Tax Return 201 L OMB No.1545-0074 IRS Use Only—Do not write or staple in this space. For the year Jan 1-Dec 31,2012,or other tax year beginning 2012,ending 20 See separate instructions. Your first name and initial Last name Your social security number RUSSELL E CLARK 165-26-6307 If a joint return,spouse's first name and initial Last name Spouse's social security number Home address(number and street).If you have a P.O.box,see instructions. Apartment no. . Make sure the SSN(s)above 414 W. PENN STREET and on line 6c are correct. City,town or post office,slate,and ZIP code.If you have a foreign address,also complete spaces below(see instructions). Presidential Election Campaign CARLISLE PA 17 013 Check here if you,or your spouse if filing Foreign country name Foreign province/5tate/county Foreign postal code jointly,want$3 to go to this fund?Checking a box below will not change your tax or refund. You Spouse Filing Status 1 Single 4 ❑Head of household(with qualifying person).(See 9 instructions.)If the qualifying person is a child 2 Married filing jointly(even if only one had income) but not your dependent,enter this child's Check only 3 Married filing separately.Enter spouse's SSN above&full name here N- one box. name here. .' 5 ❑ Qualifying widow(er)with dependent child Exemptions 6 a Yourself.If someone can claim you as a dependent,do not check box 6a. . . . . . Boxes checked on 6a and 6b 1 b Spouse No.of children (2)Dependent's (3)Dependent's 4 if on 6c who: c Dependents: chit under •lived social security relationship a 17 with you . (1)First name Last name number to you quell rcrr did not (see insirs) live with you due to divorce or separation If more than four (see Instrs) dependents,see Dependents instructions and ❑ on 6c not . • ' entered above check here . Add numbers d Total number of exemptions claimed. . . on 1/e . above . ' 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Wages,salaries,tips,etc.Attach Form(s)W-2 . . . . . . . . . . . . . . . . . . . . . . . . . 7 Income 8 a Taxable interest.Attach Schedule B if required . . . . . . . . . . . . . . . . . . . . . . . . 8 a b Tax-exempt interest.Do not include on line 8a . . . . . . . 8 bl 525. Attach Form(s) 9 a Ordinary dividends.Attach Schedule B if required . . . . . . . . . . . . . . . . . . . . . . . 9 a 3,791. W-2 here.Also b Qualified dividends. . . . . . . . . . . . . . . . . . . . . . . 1 9 bl 1,287. v," attach Forms 10 Taxable refunds,credits,or offsets of state and local income taxes. . . . . . . . . . . . . . . 10 W-2G and 1099-R if tax was withheld. 11 Alimony received. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 12 Business income or(loss).Attach Schedule C or C-EZ. . . . . . . . . . . . . . . . . 12 get aW-2, ere . . . . . . . . . . . . . . 0,you did not 13 Capital gain or(loss).AIR Sch D if reqd.If not reqd,ck h 11 13 -3,000. see instructions. 14 Other gains or(losses).Attach Form 4797 . . . . . . . . . . . . . . . . . . . . . . . . . 14 15 a IRA distributions . . . . . . 15al b Taxable amount . . . . . . . . 15b 132,952. 16 a Pensions and annuities . . 16al b Taxable amount . . . . . . . . 16b 17 Rental real estate,royalties,partnerships,S corporations,trusts,etc.Attach Schedule E. . . . 17 Enclose,but do 18 Farm income or(loss).Attach Schedule F . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 not attach,any 19 Unemployment compensation . . . . . . 19 please use Also, 20 a Social security benefits. . . . . 20a� 21,047. �bTaxableamount . 20b 17,890. Form 10404. 21 Other income ------------------------------------- 21 22 Combine the amounts in the far fight column for lines 7 through 21.This is you r total income. . . ► 22 151,633. 23 Educator expenses . . . . . . . . . . . . . . . . . . . . . . 23 Adjusted 24 Certain business expenses of reservists,performing artists,and fee-basis Gross government officials.Attach Form 2106 or 2106-EZ . . . . . . . . . . . 24 Income 25 Health savings account deduction.Attach Form 8889 . . . . . 25 26 Moving expenses.Attach Form 3903. . . . . . . . . . . . . . 26 27 Deductible art of self-employment tax.Attach Schedule SE . . . . . . . 27 Tx P 1,;rt'. 28 Self-employed SEP,SIMPLE,and qualified plans . . . . . . . 28 29 Self-employed health insurance deduction . . . . . . . . . . . 29 30 Penalty on early withdrawal of savings. . . . . . . . . . . . 30 31 a Alimony paid b Recipient's SSN .' 31 a 32 IRA deduction . . . . . . . . . . . . . . . . . . . . . . . . . 32 33 Student loan interest deduction . . . . . . . . . . . . . . . . 33 R 34 Tuition and fees.Attach Form 8917 . . . . . . . . . . 34 35 Domestic production activities deduction.Attach Form 8903. . . . . . . . 35 36 Add lines 23 through 35 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36i4 37 Subtract line 36 from line 22.This is your adjusted gross income. . . . . . . . . . . . . ►1 37 151,633. BAA For Disclosure,Privacy Act,and Paperwork Reduction Act Notice,see separate instructions. FDIAO112 01/11/13 Form 1040(2012) S Form 1040(2012) RUSSELL E CLARK. 165-26-6307 Page 2 Tax and 38 Amount fro ne 37(adjusted gross income) . . . . . . . . 38 151,633. Credits 39 a Check You were born before January 2,1948, HBI1nd. Total boxes if: Spouse was born before January 2,1948, Blind. checked ► 39a W, Standard L b If your spouse itemizes on a separate return or you were a dual-status alien,check here . . . . . ► 39b ,`f Deduction 40 Itemized deductions(from Schedule A)or your standard deduction(see left margin). . . . . . . . . . . . 40 96,571. for— 41 Subtract line 40 from line 38. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 55 062. •People who 42 Exemptions.Multiply$3,800 by the number on line 6d . . . . . . . . . . . . . . . . . . . . 42 3,800. check any box on line 39a or 43 Taxable income.Subtract fine 42 from line 41. 39b or who can 9 line 42 is more than line 41,enter-0 • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 51,262. be claimed as a 44 Tax(see instrs).Check if any from: a Forms)8814 c F1962 election dependent,see instructions. b Form 4972. . . . . . . . . . . . . . . . 44 8,717. -All others: 45 Alternative minimum tax(see instructions).Attach Form 6251. . . . . . . . . . . . . . . . 45 Single or 46 Add lines 44 and 45. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ► 46 8,717. Married filing 47 Foreign tax credit.Attach Form 1116 if required. . . . . . . . . 47 6. separately, 48 Credit for child and dependent care expenses.Attach form 2441 . . . . . . 48 $5,950 49 Education credits from Form 8863,line 19. . . . . . . . . . . . 49 Married filing 50 Retirement savings contributions credit.Attach Form 8880 . . . 50 jointly or Qualifying 51 Child tax credit,Attach Schedule 8812,if required. . . . . . . . 51 j $11,900 52 52 Residential energy credits.Attach Form 5695 . . . . . . . . . . 52 Head of 53 Other crs from Farm: a ❑3800 b $$01 c 53 household, 54 Add lines 47 through 53.These are your total credits. . . 54 6. $8.700 . . . . . . . . . . . . . . . . . . 55 Subtract line 54 from line 46.If line 54 is more than line 46,enter-0- . . . . . . . . . . . . ► 55 8,711. Other 56 Self-employment tax.Attach Schedule SE . . . . . . . . . . . . . . . . . . . . . 56 Taxes 57 Unreported social security and Medicare tax from Form: a �4137 b �8919. . . . . . . . . . . . . 57 58 Additional tax on IRAs,other qualified retirement plans,etc.Attach Form 5329 if required . . . . . . . . . . . 58 59 a Household employment taxes from Schedule H . . . . . . . . . . . . . . . . . . . . . . . . 59 a b First-time homebuyer credit repayment.Attach Form 5405 if required . . . . . . . . . . . . . 59 b 60 Other taxes.Enter code(s)from instructions _____________________60 61 Add lines 55-60.This is your total tax . ► 61 8,711. Payments 62 Federal income tax withheld from Forms W-2 and 1099 . . . . . 62 r° If you have aL 63 2012 estimated tax payments and amount applied from 2011 return. . . . . 63 qualifying 64 a Earned income credit(EIC) . . . . . . . . 64 a C hild,attach b Nontaxable combat pay election . . ' I 64 b Schedule EIC. 65 Additional child tax credit Attach Schedule 8812 . . . . . . . . 65 . 66 American opportunity credit from Form 8863,line 8 . . . . . . . 66 67 Reserved . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 68 Amount paid with request for extension to file . . . . . . . . 68 , 69 Excess social security and tier 1 RRTA tax withheld. . . . . . . 69 70 Credit for federal on#ueis ch Farm rm: 70 "r 71 Credits from Fo a2439 b Reserved c 8801 d 8885 . 71 72 Add Ins 62,63,64a,&65.71.These are your total pmts . . . . . . . . . . . . . . . . . . . . . . . ► 72 Refund 73 If line 72 is more than One 61,subtract line 61 from line 72,This is the amount you overpaid. . . . . . . 73 74 a Amount of line 73 you want refunded to you.if Form 8888 is attached,check here. . . ' 74 a ► b Routing number. . . . . VXXXXXXXX ' c Type: Checking Savings Direct deposit? ► d Account number . . . . KXXXXXXXXXXXXXXXX See instructions. 75 Amount of line 73 you want applied to your 2013 estimated tax. . ► 75 Amount 76 Amount you owe.Subtract One 72 from line 61,For details on how to pay see instructions . . . . . . . . . ► 76 8,778. YOU Owe 77 Estimated tax enal see instructions 77 67. Third Party Io you want to allow another person to discuss this return with the IRS(see instntctions)? . . . . . . KI Yes.Complete below. ❑No Designee name Karl►Karl R. Thorn, Jr.,CPA none ► number(PIN) ► (717) 218-0214 number(PIN) 20869 Sign Under penalties of perjury,I declare that I have examined this return and accompanying schedules and statements,and to the best of my knowledge and belief,they are true,correct,and 1e.D oration o�.preparer(other than taxpayer)is based on all information of which preparer has any knowledge. Here Your signature L f _ Date Your occupation Daytime phone number Joint return? ^'� See instructions. RETIRED Keep a copy Spouse's signature.If a joint return,both must sign. Dale Spouse's occupation If the IRS sent You an Identity Pro- tection PIN,enter for your records. it here(see matte) Printrrype preparer's name P ar si cc�- Date Check if PTIN Paid Karl R. Thorn, Jr.,CPA r PA 03/05/2013 self-employed P01068066 Preparer Firm's name ► Karl R Thorn Jr. , CPA Use Only Firm'saddress ► 37 S. Hanover Street Firm'sEIN ► 46-1276859 Carlisle PA 17013 Ph—no. (717) 218-0214 Form 1040(2012) FDtA0112 01/11113 OMB No.1545 Farm 8$79 IRS e-file Signature Authorization -0074 2012 Depa,lrn=c,l Do not send to the IRS. This is not a tax return. Internal Keep this form for your records. Declaration Control Number(DCN) ,00-238385-00001-3 Taxpayer's name Social security number RUSSELL E CLARK 165-26-6307 Spouse's name Spouse's social security number IF4-it , ft ITax Return Information-Tax Year Ending December 31,2012(Whole Dollars Oni 1 Adjusted gross income(Form 1040,line 38;Form 1040A,line 22;Form 1040EZ,line 4) . . . . . . . . . . . . . . 1 351,633. 2 Total tax(Form 1040,line 61;Form 1040A,line 35;Form 1040EZ,line 10) . . . . . . . . . . . . . . . . . . . . . 2 8.711. 3 Federal income tax withheld(Form 1040,line 62;Form 1040A,line 36;Form 1040EZ,line 7). . . . . . . . . . . . 3 4 Refund(Form 1040,line 74a;Form 1040A,line 43a;Form 1040EZ,line 11a;Form 1040-SS,Pan 1,line 12a). . . . . . . . . . . . . . 4 5 Amount you owe(Form 1040,line 76;Form 1040A,line 45;Form 1040EZ,line 12). . . . . . . . . . . . . . . . . 5 8,778. ITaxpayer Declaration and Signature Authorization(Be sure you get and keep a copy of your return) Under penalties of perjury,I declare that I have examined a copy of my electronic individual income tax return and accompanying schedules and statements for the tax year ending December 31,2012,and to the best of my knowledge and belief,it is true,correct,and complete.I further declare that the amounts in Part I above are the amounts from my electronic income tax return.I consent to allow my intermediate service provider,transmitter,or electronic return originator(ERO)to send my return to the IRS and to receive from the IRS(a)an acknowledgement of receipt or reason for rejection of the transmission,(b)the reason for any delay in processing the return or refund,and(c)the date of any refund.If applicable,I authorize the U.S.Treasury and its designated Financial Agent to initiate an ACH electronic funds withdrawal(direct debit)entry to the financial institution account indicated in the tax preparation software for payment of my federal taxes owed on this return ancifor a payment of estimated tax,and the financial insfitudon to debit the entry to this account,This authorization is to remain in full force and effect until I notify the U.S.Treasury Financial Agent to terminate the authorization.To revoke(cancel)a payment,I must contact the U.S. Treasury Financial Agent at 1-888-353-4537.Payment cancellation requests must be received no later than 2 business days prior to the payment(settlement)date.I also authorize the financial institutions involved in the processing of the electronic payment of taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment I further acknowledge that the personal identification number(PIN)below is my signature for my electronic income tax return and,K applicable,my Electronic Funds Withdrawal Consent. Taxpayer's PIN:check one box only ©I authorize Karl R Thorn Jr. , CPA to enter or generate my PIN 82234 ERO firm name Enter five numbers,but do not enter all zeros as my signature on my tax year 2012 electronically filed income tax return. ol will enter my PIN as my signature on my tax year 2012 electronically filed income tax return.Check this box only if you are entering your own PIN and your return is filed using the Practitioner PIN method.The ERO must complete Part III below. Your signature ♦ CQ� 00 Date b. Spouse's PIN:check one box only F1I authorize to enter or generate my PIN ERO firm name Enter five numbers,but do not enter all zeros as my signature on my tax year 2012 electronically filed income tax return. 01 will enter my PIN as my signature on my tax year 2012 electronically filed Income tax return.Check this box only if you are entering your own PIN and your return is filed using the Practitioner PIN method.The ERO must complete Part III below. Spouse's signature ► Date F Practitioner PIN Method Returns Only—continue below IP, le x Certification and Authentication — Practitioner PIN Method Only ERO'S EFIN/PIN. Enter your six-digit EFIN followed by your five-digit self-selected PIN 23838520869 do not enter all zeros I certify that the above numeric entry is my PIN,which is my signature for the tax year 2012 electronically filed income tax return for the taxpayer(s)indicated above.I confirm that I am submitting this re in accordance with the requirements of the Practitioner PIN method and Publication 1345,Hand o or It iz S e-rile P dividual Income Tax Returns. ERO's signature Date,- 03/05/13 ERO Must RetWThis Form—See Instructions Do Not Submit This Form to the IRS Unless Requested To Do So BAA For Paperwork Reduction Act Notice,see your tax return instructions. Form 8879(2012) FDIA1701 10108/12 t a Mail Form 1040-V to the Internal Revenue Service Center at the address listed below. Form 1040-V(2012) Detach Here and Mail With Your Payment and Return -------------------------------------------------------------------- Intern Internal Revenue 2012 Form 1040-V Payment Voucher Internal Revenue Service (99) 1� Use this voucher when making a payment with Form 1040. Do not staple this voucher or your payment to Form 1040. Make your check or money order payable to the'United States Treasury.' Enter the amount Write your social security number(SSN)on your check or money order. of your payment. . . . . . 8-t778. FDIA8601 06/28/12 1030 RUSSELL E CLARK INTERNAL REVENUE SERVICE 414 W. PENN STREET P- O- BOX 37008 CARLISLE PA 17013 HARTFORD, CT 06176-0008 165266307 WX CLAR 30 0 201212 610