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HomeMy WebLinkAbout04-26-13 J 1505610105 REV-1500 Ex(02-I1)(FI) OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes aEPSa F County Code Year File Number PO BOX 28o6oi INHERITANCE TAX RETURN Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 12/31/2411 4111411986 Smith Kristopher A (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI __.. _. THIS RETURN MUST BE FILED IN __....... _�. DUPLICATE WITH THE Spouse's Social Security Number REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW CM 1.Original Return p 2.Supplemental Return O 3. Remainder Return(Date of Death Prior to 12-13-82) Q 4.Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) GS 6.Decedent Died Testate C=) 7.Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) C=) 9.Litigation Proceeds Received C=) 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE r'ECTED T0�a Name Daytime lephone Num3�r =1 r(I Nathan C. Wolf, Esquire (717) 1!0*436 2-' c-> RI STtER WILC'S.USE OkLY-11 First Line of Address Wolf&Wolf - Second Line of Address _j i ors 14 West High Street City or Post Office State ZIP Code RATE FILED Carlisle PA 17413 Correspondent's e-mail address:nathancwolf @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 bellef, 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. SIGNATU/R9 01 PERSON RE4PONSIBLE OR FILING RETURN DATE ADDRESS 1295 Oyster Mi oad, Camp Hill, PA 17411-1446 SIGNATURE ER OTHER THAN REPRESENTATIVE D TE zS 3 4 es H g4treet, Carlisle, PA 17413-2922 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 1505610205 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: Kristopher A. Smith RECAPITULATION 1. Real Estate(Schedule A). ................... ........ ................. 1. 0.00 2. Stocks and Bonds(Schedule B) ....................................... 2. : 0.00 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. 336.82 6. Jointly Owned Property(Schedule F) C> Separate Billing Requested ....... 6, 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) C7 Separate Billing Requested........ 7. 0.00 8. Total Gross Assets(total Lines 1 through 7). .. .. . .... . .. ........ .. .. . ... 8. 336.82 " 9. Funeral Expenses and Administrative Costs(Schedule H)............. ...... 9. `. 3,71 3.12 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1),. ...... 10. 1,204.07 11. Total Deductions(total Lines 9 and 10)................... .............. 11. 4,917.19 12. Net Value of Estate(Line 8 minus Line 11) .. .. .. . ..... . . . ..... .. . .... . .. 12, -4,580.37 11 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. -4,580.37 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_ 15. 16. Amount of Line 14 taxable - „ at lineal rate X.0 45 -4,580.37 16, 0.00 17. Amount of Line 14 taxable at sibling rate X.12 17, 18. Amount of Line 14 taxable at collateral rate X.15 18. 19. TAX DUE ............. ... ..................................... .. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT a Side 2 1505610205 1505610205 REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Kristopher A. Smith STREETADDRESS 1295 Oyster Mill Road CITY STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 3, Interest (3) 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. (4) 5, If Line I+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00 Make check payable to: REGISTER OF WILLS, AGENT. ..........-MV,", .. ..... Rbm "v"', T," ,sm X arrow 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....... ......... ..........................___......... 1:1 E b. retain the right to designate who shall use the property transferred or its income ......................................... ❑ N c. retain a reversionary interest ...............................................-............................... ...............-.................... F-1 0 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, V& W, 0 d, 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 RS.§9116(a)(1 • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1,3)],A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REV-i5o8 EX+(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: KristopherA. Smith 21-12-0409 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Citizens Bank Account Ending in 9484 136.82 2 Miscellaneous Personal Property 200.00 TOTAL(Also enter on Line 5, Recapitulation) $ 336.82 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(10-09) IM pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Kristopher A. Smith 21-12-0409 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Richardson Funeral Home 1,383.77 2 Bay Area Cremation&Funeral Services 1,478.85 B. ADMINISTRATIVE COSTS: 1, Personal Representative Commissions: Name(s)of Personal Representatives) Street Address City _State_--- ZIP— Year(s)Commission Paid: Z. Attorney Fees: 750.00 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation,) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 69.50 5. Accountant Fees: 6, Tax Return Preparer Fees: 7. Medical Examiner's Report _. 16.00 B inheritance Tax Return Filing Fee - 15.00 1i 10 11' 121. TOTAL(Also enter on Line 9, Recapitulation) $„j, 3,713.12 If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(12-08) �► pennsytvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER KristopherA. Smith 21-12-0409 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. Citizens Bank Overdraft Line of Credit Ending in 948-4 1,204.07 TOTAL(Also enter on Line 10, Recapitulation) $ 1,204.07 If more space is needed,insert additional sheets of the same size. ..._ ..._..... Bank- [Ac Number 6222149484 Account Title Kristopher Allen Smith Date Opened 10/22/2048 Account Type Checking Principal Balance as of DOD $136.82 Interest from Last Posting to DOD 1 6. Account Balan�as f DOD $$ .00 YTD Interest to $ .00 A1 ckardso b (guneral t/ tr ome, ( nc. ENOLA,PAN 02255 DRIVE (717)732-0587 MICHAEL G.MURRAY STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED SUPERVISOR Charges are only for those items that you selected or that are required.If we are required by law or by a cemetery or crematory to use any items,we will explain in writing,below. if you selected a funeral that may require embalming,such as a funeral with viewing,you may have to pay for embalming.You do not have to pay for embalming you did not approve if you selecte�d,! ents such as a direct cremation or immediate burial.If we charged for embalming,we will explain why below. For the Service of r! t?/�r'r A• ..S".av,le) Date of Death Charge to: G c ca deb- ci.'S7��. ��v:a{',�'. f. •za.t -. /'fire°7^ae^aS` NamAddress �1 City state A.CHARGE FOR SERVICES SELECTED: Other clothing 1. PROFESSIONAL SERVICES E Services of Funeral Director/Staff ....f.1f' A Embalming...................... f Cremation urn,56 .,!`_,.. '^e' f Other preparation of body (Description) G✓rdcw .�`'�,�dry. Gsr•.-x OTHER _ S .............. $ S SUB-TOTAL OF PROFESSIONAL SERVICES......... Al E $ TOTAL MERCHANDISE SELECTED..................B E 2.FACILITIES AND SERVICES C.SPECIAL CHARGES: Use of facilities and services for Forwarding of remains to viewing(YisitatiotttWake)........ E Use of facilities and services (Funeral Home) for funeral ceremony ...I........ S Receivipg of remains from Use of facilities and services for f Memorial Service t ,c ca (Fugal Home) t Use of equipment and services Immediate Burial................. f for graveside service.. ...... Direct Cremation........ ....,... f Other use of facilities f SUB-TOTAL OF SPECIAL CHARGES ................ C E D.CASH ADVANCED .....I—— f Opening Grave .................. E SUB-TOTAL OF FACILITIESIEQUIPMENT A2 S Cemetery Equipment.............. f Lot and Deed.................... E 3.AUTOMOTIVE EQUIPMENT Newspaper Notices—Local .........fZ? Vehicle to transfer remains to Funeral Home. Newspaper Notices—Out-of-town.... i Local........................... E Telephone&Telegrams ........... E Hearse(Casket Coach) Airfare......................... 3 Local........................... f r` Clergy/Mass Offering.............. E Limousine Pallbearers...................... f Local........................... S f° Certified Copies of the Death Family car Certificate ...................... f Local........._............... f Police Escort .................... E Flower car or floral disposition Flowers ........................ S Local........................... S Vault Service Charge.............. S Lead car/clergy car S Local........................... f # Car for pallbearers E Local........................... S E Out of town transportation......... E E f S f SUB-TOTAL OF ADVANCES., ................ D f ;T SUB-TOTAL OF AUTOMOTIVE EQUIPMENT........ A3 E We charge you for our services in obtaining: TOTAL OF PROFESSIONAL SERVICES, (specify cash advances that are marked-up) FACILITIES AND AUTOMOTIVE EQUIPMENT ................................... A S SUMMARY OF CHARGES B.CHARGE FOR MERCHANDISE SELECTED: A. Professional Services,Facilities and Casket.......................... f Equipment,and Automotive (Description) Equipment.............I.,...... E 6. B. Merchandise..................... f��2t v Other Receptacle................. S C. Special Charges............... ... E (Description) D. Cash Advances................... f TOTAL OF ALL SECTIONS,....................... f ............. i PAID AT TIME OF OR PRIOR TO Outer burial container (Description) ARRANGEMENTS. .............................. E��'' BALANCE DUE... .............................. S,.f.^''V`a Acknowledgement cards REASON FOR EMBALMING Register books Memory folders .................. 116c. If any law,cemetery,or crematory requirements have required the purchase Prayer cards..................... E of any of the Items li ird above the law or requirement is explained below. Temporary grave marker.,......... E Burial clothing................... f I agree that I have examined the items of goods and services selected above and found them to be correct and according to the arrangements 1 have requested.I acknowledge receipt of a copy of this Statement of Funeral Goods and Services Selected.I represent that have sufficient funds available for payment of the cash price for the goods and services selected.I also agree to m e payment of E within days.I agree to be.jointly and scverally fiable with.anyone else who signs below.A late charge of per month amounting to per year will be applied to the unpaid balance beginning days from the date of this agreement.I will also pay to the Funeral Director ail reasmtabk costs paid by the Funeral Director to collect amounts I owe under this agreement. Those costs may include attorneys'fees,court costs and other costs.Any additional services or merchandise ordered or requested after the dato of this agreement will be considered t of this agreern qt and the cos thereof will be reflected on the final bill or statement. �/'� (Purchaser) ( ) (Seal) (Purchaser) (Lic�d Funeral Directo&,� 6 Penmyl-12 Funeral Directors Aswctation WHM Fnnmt Director YELLOW Funeral Oirca- form -600 Revised 4/94 k 01/06/2012 10:44 2094601385 STOCKTON PAGE 02/08 Bay Area Cremation & Funeral Services Inc. 844()BContwoocl BIVd,Suite E.Brentwood,CA 94513 FD 1945 (925)ti 51,6-2710 (925)-510-2764'Fax Main Office 1189 Oddstad Drive,Redwood City,CA.94063 FD 1741 (650).3654909 (650)•365.3910 Fax by appointment 1555 Yosemite Ave..#23.San Francisco,CA.94124 FD 1775 (415)-;084823 (925)-516-2764 Fax by appointment 2845 Moorpark Ave.,Suite 111,San Joac,CA.95129 FD 1762 (408).851-0409 (925)-516.2764 Fax by appointment 1453 Embarodc o,Suite 2E Oakland,Ca 94606 FD 1846 (800)-91"888 (925)-510-2764 Fax by appointment 2449 Suction Drive,Stockton,CA.95215 FD 1950 (204)-93840669 (209)-460-1385 Fox STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Dcccaood: KOO sj her Smith FD 1776 Date of Death: 1213112012 Date of statement; 1/0612012 Charles are only for item that you sclectod or that are required, If we ate required by a cemetery or crematory to use any Items,rw will explain the reasons In writing below. If you selected a funeral that may require emWming such W a funeral with viewing,YOU may have to pay for embalming, You do not have w pay for embalming you did not approve if you selected artangernoncs such as a direct emotion or Immediate burial, If we charge for embalming we will explain why Wow, A.SERVICES SELECTED F.MERCHANDISE SELECTED 1.Basic Services of Funeral Director do Statr. 476.00 1.Casket, 2,Use of Facility;Equipment,and Shrff 2.Alternative Container *Cremation Container-Fiberboard 10.00 B,PREPARATION OF DECEDENT: 3,Uro: 1.Embalming • "Refrigeration Charge 196.00 + C.TRANSPORTATION G TOT MERCI,CANDISESELECTED S 10,00 *Transfer of Decedent into our care 595.00 'After Business hours or Second Attendant EL CASH ADVANCE ITEMS + +Certiflad Copies of Death Certificates 11.00 *Use of funeral hearse and driver to memorial service location #Permit for Disposition 286.00 "Transfer of decedent to crematory in utility vehicle "Crematory FCC "Delivery of cmematcd remains "Coroner's Fee 484.00 +PwA4ng and register mail of cremated romaine(within the US) (")We charge you for our services in obtaining: *Additional voles: Per mile:at,$3.40 v + L TOTAL CASHADY'ANC,L''S S 786.00 D.OTHER SERVICES ACCOUNT SUMMARY *Direect Cremation *Memorial service atthird party facility with staff pi-wont(2 hours) Total Funeral Home Charges:(E,G) 1278.00 +Forwarding of remains to another funeral home Sales Tax: 8,5 % .85 *Receiving remains from another fonerat home Total Cash Advances Charges(1) 786.00 Sub-Total 2061.85 DISCOUNT AND OTHER CHARLES G yTQM S.BRWM 8El~ECT73D S 1266.00 * Couttasy Discount .563.00 COMPLETECCHARGES S 1478.85 ACKNOWLEDGEMENT&AGREEMENT 40 THE ONLY WARRANTY ON THE CASKS-PP10LD IN CONNECTION WITH THIS SERVICE 1S THE EXPRESS WRITTEN WARRANTY,IF ANY, GRANTED BY THE MANUFACTU.RERATUS FUNERAL HOME MAKES NO WARRANTY.EXPRESS OR IMPLIED WARRANTY OF ML-RCiJANTABtt ITY AND AN iMPL11W WARRANTY 9RCTNESS FOR A PARTICULAR WITH RESPECT OF THE CASKET. I(we)audhoriziee Bay Area Crcri;o nn&Puneral Services Inc.to perform the services and provide the merchandise selected specified on this stetemcm: Form of Payment: Discover- Visa-Mastercard Last 3 Digits on Back of Card Exp.Date / I am assuming personal liability imposed by law upon the csM of tic decedent and th�.l duty to pay upon the closest rolative(s)ao set tllydh in SCCHOn 7100 of the CA Health and Safety Coda.1(wc)have road(or been road)the above,acopf and prove same a ointly and severally promise by make full payment 400 Please Initial. Signature: _ i i was given a General&Casket Price List. Date: & I was given a copy of this Statement. ACCEPTANCE:Th nor 11 CM0 cqtaffeq to provide all services.merchandise as A adva indicated on this VaIrtncm Funeral Cotuiselor: For more information on funeral,cemetery and cremation matters ci)ntact: DEPARTMENT OF CONSUMER AFFAIRS CEMETERY AND FUNERAL BUREAU 1625 NOR'T U MARKET BLVD.,SUITE S-208 SACRAMENTO,CA 95834 (916)574-7840 O 01/06/2012 10:44 2094601385 STOCKTON PAGE 01/08 Brentwood Redwood City San Francisco San,lose Oakland Stockton U U ❑ Page(2)o e Vital State Form: Decedent's Name: Kristopher Smith Cm-mated Remains: The process,on average,takes approximately 5_t9 8 business warWn&days once all paperwork and payment has been secured in full. We will notify you by telephone when the cremated remains of your loved one will be ready for pick up by appointment only in one of our offices if ydu have not chosen to registor mail the urn. Our office hours are Monday through Friday from 8 a.m.to 4 p.m. Death CedAgtes: Death Certificates will be ordered on the next business day after thy cremation permit or burial permit has-been Death Certificates may be acquired 3 different ways: Check box We can physically pick up death certificates from the local health department and via USPS overnight the F] Services certificates to you.The cost of death certificates is paid to Bay Area Cremation and Funeral Services plus a fee of$150.00 for the personal pickup and express shipment of these death certificates. Check box We can,via USPS mail,request death certificates from the local health department and mail them via © USPS to you.We cannot guarantee the time frame or receipt of death certificates with this option. The cost of death certificates is paid to Bay Area Cremation and Funeral Services. Check Box We can,via E•mall,notify you when the death certificates are ready at the local health department for you to physically pick up.The cost of the death certificates is paid directly to the county. ❑ Email for notification: Listed below is the current cost of each certified death certificate based upon the county where the death occurred: Alameda $15.00 Merced $14.00 San Joaquin $14.00 Solano $16.00 City of Berkeley $16.00 Monterey $14,00 San Mateo $16.00 Stanislaus $14.00 Contra Costa $17.00 SacrraW memo $14.00 Santa Clara $14.00 Marin $14.00r an Francisco $14.00 Santa Cruz $14,00 -' 1 authorize Bay Area Civination&Funeral Services,Inc.to obtain the death certificates of the above Decedent and send them via USPS to the below address. Yes x NO if you marked YES on the line above,please state the number of death certificates you want us to order: 10 Address Death Certificates are to be sent by USPS if you want us to provide this service: Alice Jacobs, 1295 Oyster Mill Road, Enola, PA 17025 Email of Next of Kin: Telephone:717-737-3161 Name of Caller:Alice Jacobs Relation:Mother Date of Call:01 /05/2012 Fax#if arrangements are done by fix: Order 2 DC's as "Pending" and order the remaining 8 when amended ell Z-1a Signature (! ___. _____ __ 'Jrw7,t r.� r a`�r'I n1L°�3# `aa-a lL!f.7'g"s'6'ttl�'��.,..•a"r`ie�'MIIIiW�S r"._�.W^a't ril.l I *,9-,3gn Bank 3706 WOLF&WOLFu.a � , ATTORNEYS AT LAW 10 WEST HIGH STREET 60-726912313 CARLISLE, PA 17013 1/10/2013 (717)241-4436 ORDERTHE FE Medical Examiner $ **16.00 t Sixteen and 00/100wwwwwwwwww*w*wwwwwwwwwwww*wwwwwwww*wwwwwwwwwwwwwwwwwwwwwwwwwww*twwwwwwwww*wwwwwwwwwwwwwwr►www*wwwww►wwwwww+ DOLLARS Medical Examiner IOLTA ACCOUNT XV, MEMO Ref#2011-1328 Report Smith 11'000000370611' 1: 2313726911: 16 7 10 2 101313 RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Receipt Date : 4/04/2012 Cumberland County - Register Of Wills Receipt Time : 08 : 20 :48 One Courthouse Square Receipt No. : 1069383 Carlisle, PA 17613 SMITH KRISTOPHER A Estate File No. : 2012-00409 Paid By Remarks : WOLF & WOLF DMB ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS ADM 20 . 00 CUMBERLAND COUNTY GENERAL FUN RENUNCIATION 5 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 16 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check# 3472 $69 . 50 Total Received. . . . . . . . . $69 . 50 Citizens Bank Checking Account Statement 1-888-910-4100 © or 3 Please call us anytime for answers to your questions,account information,current rates or to update your address&phone number. Beginning December 06, 2011 through January"05, 2012 L Checking continued from previous page KRISTOPHER ALLEN SMITH M E M 0 (continued) Green Checking statement,this table,if shown, provides information about two distinct time periods.Any XXXXXXX948-4 amount listed in the"Total for This Period" section includes fees paid during your current statement period. Dates for this period are listed at the top of this statement.Any amount listed in the"Total Year to Date" section includes fees paid in Calendar Year 2011. Any fees paid in January 2012 are not listed in the"Total Year to Date"section of this statement, but will be listed in this section beginning with your February 2012 statement. Overdraft Line of Credit SUMMARY KRISTOPH ER ALLEN SMITH Balance Calculation Balance Overdraft Line of Credit XXXXXXX948-4 Previous Balance 1,210.08 Average Daily Balance 1,190.67 Advances .00 + Credit Limit 1,500.00 Fees .00 + Available Credit 295.93 INTEREST CHARGED 18.19 + Interest Payments&Credits 24.20 - ANNUAL PERCENTAGE RATE 18.00% Current Balance 1,204.07 = Daily Periodic Rate .04918010 Days in Billing Cycle 31 Payment Statement Beginning Date 12106111 Statement Closing Date 01105112 Past Due Amount .00 Payment Due Date 01131112 Minimum Payment Due 24.08 Current Balance 1,204.07 Previous Balance TRANSACTION DETAILS 1,210.08 Interest Charged Date Amount Description 01/05 18.19 Interest Charged n Total Interest Charged 18.19 Payments&Other Credits Date Amount Description 01/03 24.20 Payment From Checking n Total Payments&Other Credits 24.20 nCurrent Balance 2011 Totals Year To Date 1,204.07 Total Fees Charged In 2011 30.00 Total Interest Charged In 2011 222.94 - NEWS FROM CITIZENS --As part of our continuing commitment to keeping you infq;med about relevant topics we are providing you with this information on Identity Theft. What is Identity Theft?Identity theft occurs when someone uses information, like your name,Social Security number, or credit card number, without your permission,to commit fraud or other crimes. Identity theft is serious and may have long term affects on your life. Learn more about what you can do to protect Member FDIC 0 Equal Housing Lender