HomeMy WebLinkAbout04-30-13 1505610105
REV-1500 EX(02-11)(F1)
Yi OFFICIAL USE ONLY
PA Department of Revenue r�sytvaa - Court Code Year File Number
Bureau Individual INHERITANCE TAX RETURN
2
PO BOX 280601
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
01/06/2012 09/01/1915
Decedents Last Name Suffix Decedent's First Name MI
Garbright Alice I
(if Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffx Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE PILED M DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
(ED 1.Original Return C) 2.Supplemental Return C? 3. Remainder Return(Date of Death
Prior to 12-13.82)
[C 4.Limited Estate O 4a,Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
OID 6.Decedent Died Testate O 7.Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
C} 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death } It. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedlaie O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INF ATION SHOULUp DIR{ TO:
Name Da�e lephone.t lmbePT Cy
James P. O'Grady t7i ) 5 40 uz
a IW— R dFWILLSWEAN Lv
r5 C
First Line of Address
35 Bella Vista Drive = f 1
Second Line of Address -
City or Post Office State ZIP Code DATE FILED
Mechanicsburg PA 17050
Correspondent's e-mail address:
Under penalties of pe' ,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,contiq anTcorliplete.,Veclaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
GNATUR P ON S SLE FOR FILING RETURN DATE
m 0 Zv73
J ADDRESS
3 > ���� �0. � 1S �! 2 e � R� tf 3allZv
,\ lGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610105 1505610105
1505610209
REV-1500 EX(Fl)
RECAPITULATION
1. Real Estate(Schedule A). ......... .........
2. Stocks and Bonds(Schedule B) . .... ... ... ... ... .. ... ... .. . .. . 2. 12,010.50
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. 9,644.95
6. Jointly Owned Property(Schedule F) C=) Separate Billing Requested . . .. 6.
7, InterAtivos;Transfers&Miscellaneous Non-Probate Property
(Schedule G) C=> Separate Billing Requested........ 7. 20,000.00
8. Total Gross Assets(total Lines 1 through 7). . . . . ... .. .. ... .. . ... 8. 41,655.46
9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 135.50
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1). .. ... ... .. ... . 10. 22,781.77
11. Total Deductions(total Lines 9 and 10)....... ........... ......... ... 11. 22,917.27
12. Net Value of Estate(Line 8 minus Line 11) . ..... ... ....... . ...... . ... . 12, 18,738.18
13. Charitable and Governmental Bequests/See 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. 18,738.18
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec. 9116
(a)(11.2)X.0- 115.
16. Amount of Line 14 taxable
at lineal rate X.0 45 18,738.18 16, 843.22
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. 843.22
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C=D
Side 2
15135610205 1505610205
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENTS NAME
Alice I Garbright
STREETADDRESS
Forest Park Health Center, 700 Walnut Bottom Road
CITY STATE ZIP�
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1} 843.22
2. Credits6°ayments
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 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 843,22
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" W THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred ..................................--...............-................................... ❑ N
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ ■
c, retain a reversionary interest.................................................-.......................................................................... ❑ ✓r
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑
1 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?,............. 0 ❑
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation? ....--.....................................................--..................................................._ ■ ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan. 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(1)].
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)(it)].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 decedents siblings is 12 percent 172 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-1503 E%-{8-12)
i pennsylvania SCHEDULE B
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Alice Irene Garbright 2012-01233
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
I'
Vanguard Mutual Funds, Vanguard, P.O. Box 2600,Valley Forge,PA 19482-2600
9 9 Y 9 12,010.50
Account Number:0036-09927183360
i
TOTAL(Also enter on Line 2, Recapitulation) $ 12,010.50
If more space is needed,insert additional sheets of the same size
REV-1508 EX+(08-12)
R pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Alice Irene Garbright 2012-01233
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. Savings account with JP Morgan Chase Bank,N.A.,P 0 Box 659754,San Antonio,TX 78265-9754 2,813.08
Account Number 93631630948
2 Checking account with JP Morgan Chase Bank,N.A.,P 0 Box 659754,San Antonio,TX 78265-9754 6,771.87
Account Number 9360406049
3 Checking account at PNC Bank;249 Fifth Avenue,One PNC Plaza,Pittsburgh PA 15222 60,00
Acct Number:50-0500-9621
TOTAL (Also enter on Line 5, Recapitulation) $ 9,644.95
If more space is needed,use additional sheets of paper of the same size.
pennsylvania SCHEDULE G
OFRARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Alice t. Garbright 2012-01233
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION I TAXABLE
INCLIHE AT NONE ANTIE TRANSFEREE,ON O REIATtO1D FOR DECEDENT MN
NUMBER THE DATE OF TRANSFER, ATTACH ACOPY OFTHE DEED FOR REAL ESrAIE. VALUE OF ASSET INTEREST IF APPDGBLE) VALUE
I. James P.O'Grady,Grandson,February 1,2011 13,000.00 3,000.00 10,000.00
2 Florence M.O'Grady,Granddaughter-in-Law,February 1,2011 13,000.00 3,000.00 10000.00
TOTAL(Also enter on Line 7, Recapitulation) $ 20,000.00
If more space is needed,use additional sheets of paper of the same size.
rle ngi
pennsytvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Alice Irene Garbright 2012-01233
Decedent's debts must be reported on Schedule F.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
I' My Grandmother had a prepaid funeral plan and as such there were no expenses relative to her
funeral.
We must still inter her ashes at her family burial plot in New Jersey and we must modify the existing
grave marker as well as pay to have the plot opened and closed.
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address ..._.-
CitY---�—_—..._ State---ZIP.-----
Year(s)Commission Paid:
1 Attorney Fees:
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
C Probate Fees: 135.50
S. Accountant Fees:
6. Tax Return Preparer Fees:
7.
TOTAL(Also enter on Line 9, Recapitulation) $ 135.50
If more space is needed,use additional sheets of paper of the same size.
i pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Alice Irene Garbright 2012-01233
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 Forest Park Health Center 22,22232
2 Guardian Elder Care Pharmacy 156.04
3 Time Warner Cable debt 391.03
4 Graham Medical Clinic,P.C. 12.38
TOTAL(Also enter on Line 10,Recapitulation) $ 22.781.77
If more space is needed,Insert additional sheets of the same size.
REV-1513 EX+(01-10)
pennsytvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Alice Irene Garbright 2012-01233
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS(Include outright spousal distributions and transfers under
Sec.9118(a)(1.2).]
I. James P.O'Grady,35 Bella Vista Drive,Mechanicsburg,PA 17050 Grandson 1/3
2 Eileen M.O'Grady-Miller,5016 Upchurch Lane Wake Forest,NC 27587 Granddaughter 1/3
3 Edward P.O'Grady,Unknown address Grandson 1/3
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE,
II
NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
i,
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space Is needed,use additional sheets of paper of the same size.
Inheritance Tax Return Resident Decedent(Explanation for Difference in Values)
Alice Irene Garbright, SSN: 141-10-1447
File Number: 2012-01233
Schedule B Statement
The Vanguard Statement included as documentary evidence of the value of the mutual fund
reported on Schedule B is as of December 31, 2011 which is 6 days prior to my Grandmother's
death. At the time of death the value of the mutual fund had increased to the figure reflected on
the Schedule B: $12,010.50
Schedule E Statement
For my grandmother's checking account(Checking account with JP Morgan Chase Bank,N.A.,
P O Box 659754, San Antonio, TX 78265-9754; Account Number 9360406049), I do not have
the statement that covers her date of death. What I have is the statement for the period
immediately after her death. The beginning balance value reflected on this statement($6,766.55)
plus the re-occurring payment to QLT Consumer Lease ($5.32) is the value of her checking
account on the date of her death: $6,771.87
Schedule G Statement
In February 2011 my grandmother decided to give a portion of her mutual fund to me,her
Grandson and to my wife, Florence O'Grady, her Granddaughter-in-law. My Grandmother did
this to thank us for helping her throughout the years and she maintained no interest in this gift
whatsoever.
My wife and I did continue to help my Grandmother with whatever she needed but my
Grandmother never maintained an interest in the gift she made in February 2011.
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316C OQOWO852307819 1.
CHASE O January 19,2012 through February 15,2012
Chase Hank,N.A.
P 0 Bo x 659754
Account Number: 000009360406049
P O Bo
San Antonio,TX 78265-9754
CUSTOMER SERVICE INFORMATION
I IIII 1111111 III IIII 11 II IIII I 11 IIII 1 11 III
Service Center: 1-800-935-9935
00014372 DRE 802 142 04712 NNNNNNNNYNN T 1 000000000 31 0000 Hearing Impaired: 1-800-242-7383
MRS ALICE GARBRIGHT Para Espanol: 1-877-312-4273
OR MS ALICE M O'GRADY International Calls: 1-713-262-1679
OR MR EDMOND GARBRIGHT _—
C/O JAMES O'GRADY —_
35 BELLA VISTA DR
MECHANICSBURG PA 17050-1880 —_
CHECKING SUMMARY Chase Total Checking
AMOUNT
Beginning Balance $6,766.55
Electronic Withdrawals -5.32
Ending Balance $6,761.23
TRANSACTION DETAIL
DATE DESCRIPTION AMOUNT BALANCE
Beginning Balance $6,766.55
02/14 Olt Consumer Lea ACH PPD ID: 5330903620 -5.32 6,761.23
Ending Balance $6,761.23
A monthly Service Fee was not charged to your Chase Total Checking account. Here are the four ways you can avoid [his
fee during any statement period.
• Have direct deposits totaling$500.00 or more.
(You did not have a direct deposit this statement period)
• OR keep a minimum daily balance in your checking account of$1,500.00 or more
(Your minimum daily balance was$6,766.00)
• OR, keep an average qualifying deposit and investment balance of$5,000.00 or more
(Your average qualifying deposit and investment balance was$9,578.00)
• OR, pay at least$25.00 in qualifying checking-related services or fees.
(Your total qualifying checking-related services or fees paid were$0.00)
F.,,i of 4
CHASE 0 October 01,2011 through December 30,2011
P 0 Box Bank,N.A. Account Number: 000093631630948
P O Box 659754
San Antonio,TX 78265-9754
CUSTOMER SERVICE INFORMATION
Web site- Chase.cona
Su vice Center: 1,900-935-9935 _
00326228 DRE 802 142:36511 YNNNNNNNNNN T 1 000000000 52 0000 Hearing Impaired: 1-800-242-7383
MRS ALICE I GARBRIGHT Para Espanol: 1-877-312-4273
OR MR EDMOND GARBRIGHT International Calls: 1-713-262-1679
C/O JAMES O'GRADY _—
35 BELLA VISTA DR —
MECHANICSBURG PA 17050-1880
We are making some changes that affect Chase personal and business checking, savings
and Certificate of Deposit (CD) accounts, including retirement accounts'. Enclosed with
this statement is a rewritten Deposit Account Agreement (formerly known as the Account
Rules and Regulations). The new design of this booklet will make it easier for you to read
and find the information you need quickly.
Please review the information and keep this as reference with your other financial
documents.
Please note: If you would like to receive the Deposit Account Agreement in Spanish,
they will be available at your nearest Chase branch, starting February 1, 2012.
'For checking and savings accounts, all changes are elfective on February 1. 2012.
For CD accounts, the changes are effective on the first CD maturity date occurring
on or after February 1, 2012.
Important Information about Chase Personal Checking and Savings Accounts
We are working to simplify our Chase checking-and savings accounts by eliminating or
reducing some of our fees. The following changes to the Additional Banking Services and
Fees for Chase personal checking and savings accounts are effective December 14, 2011.
All other terms of your Deposit Account Agreement remain the same. If you Have any
questions, please call us at 1-800-935-9935 or visit your branch.
We will no longer charge fees for the following services:
- No fees for Checklltem Copies and Urgent Item Copies -for example,we will not charge
you when you need a copy of a cancelled check or deposit slip.
- No fees for Immediate Notification of wire transfers
- No fees for Account Reconciliation
- No fees for Account Research
- No fees for a Failed Payment when using Chase Online Bill Pay or Quick Pay
- No fees for Online Banking Services - Financial Management Software Service
( SAVINGS SUMMARY Chase Savings
AMOUNT
Beginning Balance $2,813.02
Deposits and Additions 0.06
-----'---------------------_._...
Ending Balance $2,813.08
Annual Percentage Yield Earned This Period 0.01%
Interest Earned This Period 11,0.013
Interest Paid Year-to-Date $0.24
a r1.14
February 28, 2011, monthly transaction statement
Page> 1 of 1
Voyager Services > 600-2847245
JAMES P O'GRADY ATTY-N-FACT
ALICE I GARBRIGHT www.vanguard.com
35 BELLA VISTA DR
MECHANICSBURG PA 17050-1880
GNMA Fund Admiral Shares 0536-09927183360
Average Cost Total Cost
30-day SEC yield as of 02/28/2011` 3.70% $10.39 $25,627.22
Date Transaction Amount Share Pnce Shares Transacted Total Shares Owned Value
Beginning balance on 1/31/2011 $10.73 4,894.672 $52,519.83
02/01 Checkwriting 1001 -$26,000.00 10.71 -2,427.638 1,467.034
02/28 Income dividend ACH 71.74 2,467.034
Ending balance on 2/28/2011 $10.73 2,467.034 $26,47127
*Based on holdings' yield to maturity for last 30 days, distribution may differ. For updated information, visit vanguard.com.
Per your request, a copy of this statement has been sent to:
JAMES OGRADY
35 BELLA VISTA DR
MECHANICSBURG PA 17050-1880
RECEIPT FOR PAYMENT
GLENDA FARNER STRASBAUGII Receipt Date : 11/28/2012
Cumberland County - Register Of Wills Receipt Time : 11 : 34 : 46
One Courthouse Square Receipt No. : 1072196
Carlisle, PA 17613
GARBRIGHT ALICE IRENE
Estate File No . : 2012 -01233
Paid By Remarks : JAMES P O ' GRADY
HMW
- - - - - - - - -- - - - - - - - - - Receipt Distribution
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 60 . 00 CUMBERLAND COUNTY GENERAL FUN
WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 32 . 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
- - - ---- -- -- - - ---
Cash $135 . 50
Total Received. . . . . . . . . $135 . 50
STATEMENT
Forest Park Health Center Resident: Garbright, Alice(23235)
700 Walnut Bottom Road Location: -
Carlisle, PA 17013-3699 Statement Date: 111/2012
(888) 880-7090
ALL TRANSACTIONS PROCESSED AFTER Dec 31, 2011
WILL APPEAR ON YOUR NEXT STATEMENT
James O'Grady
35 Bella Vista Drive
Mechanicsburg, PA 17050
Amount Due $22,222.32
PLEASE DETACH AND RETURN WITH YOUR PAYMENT Amount Enclosed $
Forest Park Health Center Resident: Garbright,Alice(23235)
700 Walnut Bottom Road Location: -
Carlisle, PA 17013-3699 Statement Date: 1/1/2012
(888)880-7090
Effective
Date Description Units Unit Amount Amount
BALANCE FORWARD $16,322.32
12/1/2011 Room & Board charges Dec 1-25 2011 (STD) 25 $271.00 $6,775.00
12/1/2011 **Room& Board charges Dec 1-312011 (STD)** -31 $271.00 ($8,401.00)
12/26/2011 Room& Board charges Dec 26-27 2011 (STD) 2 $271.00 $542.00
12/28/2011 Room & Board charges Dec 28-31 2011 (STD) 4 $271.00 $1,084.00
1/1/2012 Room& Board charges Jan 1-5 2012 (STD) 5 $271.00 $1,355.00
12/29/2011 Oxygen 1 $17.00 $17.00
6/1/2011 Insurance paid subscriber. $1,839.50 $1,839.50
7/1/2011 Insurance did not allow as much as
Medicare,therefor patient responsible. $2,688.50 $2,688.50
BALANCE DUE $22,222.32
QUESTIONS REGARDING BILL PLEASE CALL
888-880-7090
Destiny Ext: 856
dshank @guardianelderca re.net
WE ACCEPT
VISA/MASTERCARD/DISCOVERIAMERICAN EXPRESS
PLEASE SEE BACK OF BILL
WE APPRECIATE YOUR PAYMENT MADE IN NOVEMBER, HOWEVER, YOU HAVE INSURANCE CHARGES
THAT HAVE NOT BEEN PAID UP TO DATE. PLEASE FORWARD PAYMENT.
Guardian LTC Pharmacy
(814)503-7400
i
123 Brubaker Road CUSTOMER NO.: 503
Brockway,PA 15824 PAGE: 1
United States DATE: 313/2013
REMIT TO ADDRESS:
SOLD OGRADY,JAMES -- -- - - - - --
TO: 35 BELLA VISTA DRIVE
Guardian LTC Pharmacy
MECHANICSBURG,PA 17050
123 Brubaker Road
Brockway,PA 15824
j USA
I I
IN000000874 9/3012011 IN - 10/30/2011 17.8711
IN000001435 10/31/2011 IN !. 11/30/2011 '.. 54.34
'INOOOOD1981 11/30/2011 IN 1213012011 48.36
IN000003039 12/31/2011 IN 113012012 18.441,
IN000003986 113112012 IN 3/1/2012 17.03
I
I i I
I ' I
I
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,
IN Invoice PY-Applied Receipt UC-Unapplled Cash ACCOUNT OVERDUE.ALL CREDIT ON Total: 156.04''
DB-Debit Note ED-Earned Discount RF-Refund
:CR-Credit Note AD-Atllustmenl HOLD. Credit Limit 0.001,
SIT-Interest Payable PI-Prepayment
, Credit Available: 0.0011
1-30 DAYS O/DUE 31 -60 DAYS O/DUE !, 61 -90 DAYS O/DUE OVER 90 DAYS O/DUE
0.00 0.00 0.00 156.04
ooa
Garbright, Alice
35 Bella Vistn Dr
RC Po1IJ»«Ma,J�, ut Mcchanicsbur,. PA 17050-1880
20816 441h Ave W
I.rnmvood.WA 98036
Dear Customer:
Your account has been listed with Receivables Performance Management for payment processing and collection. If you have any
questions or need assistance,please call TOLL FREE 866.212.740$.
Reference Number: 37478543
Creditor: Time Warner Cable
Creditor Accounttl: 8150150011413899
Date: 12-27-11
Amount $391.03
Amount Due: $391.03 (U.S. FUNDS ONLY)
In the event that your payment is by check, we may present your check electronically. In the ordinary course of business, your
check will not be provided to you with your bank statement,but a copy can be retrieved by other means.
Unless you notify, this office within all days alter receiving this notice that you dispute the validity of this debt or any portion
thereof, this office will assume this debt is valid If you notify this office in writing within 30 days front receiving this notice,
that you dispute the validity of this debt or any portion thereof, this off ice will: obtain verification of the debt or obtain a copy of
it judgment and mail you it copy of such judgment or verification. If you request this office in writing within 30 days after
receiving this notice, this office will provide you with the name and address of the original creditor, if different from the current
creditor.
This coin inunication is from a debt collector. The purpose of this notice is to collect a debt. Any information obtained
will be used for that purpose.
Estimado Clienle:
Su cuenta ha side lislada con Receivables Performance Management-Parn procr:a. -.nt.;
pregunia o neceslta ayuda.sirvase Ilmnar GRATIS at numero 866.212.to+38.
lane 111anicr 1,41-le
: 27-11
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GRAHAM MEDICAL CLINIC, P.C. 01/09/12 250125
100 SOUTH HIGH STREET
NEWVILLE, PA 17241-1409 ;
12.83''°
_MC _VISA _Disc Security
Card# Code
Sign — — EXp —/_
—
20733
ALICE I GARBRIGHT
C/O JAMES O'GRADY GRAHAM MEDICAL CLINIC, P.C.
35 BELLA VISTA DRIVE 100 SOUTH HIGH STREET
MECHANICSBURG PA 17050-1880 NEWVILLE, PA 17241-1409
iirtrt PLEASE PAY UPON RECIEPT, IF BILLINGS QUESTIONS PLEASE CALL 717-776-3114
'•i EXT. 103
i;>•"k YOU MAY RECEIVE 2 STATEMENTS FROM US. WE ARE CONVERTING TO A NEW SYSTEM i0**
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Insurance Charges pending to Prv: 505.00
Ins Pay/Adj against Ins pending 187.30 -92.70 225.00
12/15/11 1 1 L SUB NURSING CARE EVAL/MAN 99308 789.00 75.00
01/03/12 Medicare Payment 51.33
01/03/12 Accept Assign Adj . -10.84 12.83'
L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make payment.
�nATF I,!1$T PAIT 1!..plfC IXF • 1 • - .t • •1 • - 1
00/00/00 ( 0.00 12.83 0.00 0.00 0.00 0.00 225.00 0.00 1 237.83
" GRAHAM MEDICAL CLINIC, P.C. - ` l
cricc�: 100 SOUTH HIGH STREET f -'
IAYAaL.e lo. NFWVTLLF, PA 172111-7409 12,8311
Ph: (717)-776-5114
PAT# 1-ALICE I GARBRIGHT PRV# 1-TOWNSEND, JAY A. , MD Acctlt: 250125
Date: 01 1091,12
Page 1 of 1
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LAST WILL AND TESTAMENT
OF
ALICE GARBRIGHT
I, ALICE GARBRIGHT, residing at 39-30 52nd Street, Apt.
#3F, Woodside, NY 11377, County of Queens, City and State of New
York, being of sound mind and memory, do hereby revoke all former
Wills, Codicils and instruments of a testamentary nature by me heretofore
made, and I do hereby make, publish and declare this to be my Last Will
and Testament in manner and form following:
FIRST: I order and direct that all my just debts, funeral
and administration expenses be paid as soon after my death as may be
practicable.
SECOND: All the rest, residue and remainder of my
property, both real and personal, of every kind and nature, and
wheresoever situated of which I may die seized or possessed or over
which 1 may have testamentary power (collectively referred to as my
"residuary estate"), I give, bequeath and devise as follows:
a) 50% to my daughter, ALICE O'GRADY, residing at 12 Lily
Lane, Levittown, NY 11756; or if she does not survive me,
then equally among her children, JAMES O'GRADY,
EILEEN O'GRADY and EDWARD O'GRADY, or the survivor
or survivors; and
b) 50% to my friend, MARY OLA-WOOLSEY, also residing at
39-3052 nd Street - #3 F, Woodside, NY 11377.
THIRD: 1 nominate and appoint my grandson, JAMES
O'GRADY, residing in Pennsylvania, to be the Executor of this my Last
Will and Testament; or if he does not survive me or fails to qualify
hereunder or, having qualified, ceases to serve, or alternatively in any
event, I nominate and appoint my daughter, ALICE O'GRADY, to be my
Executrix, and I direct that no bond or other security shall be required of
either of them for the faithful performance of their duties hereunder.
FOURTH: Should any individual mentioned herein die
together with me or as a result of a common accident or disaster or under
such circumstances as to render time and sequence of death uncertain,
then and in that event or in any of those events, it shall be deemed that
said individual did not survive me.
FIFTH: If at the time of my death there should be no
surviving legatee or surviving alternate legatee for any bequest set forth in
this will, said bequest shall lapse and become part of my residuary estate
and be divided among my surviving residuary legatees in the proportions
designated.
IN WITNESS WHEREOF, I have hereunto subscribed and
signed my name at the end hereof this 30th day of November, 2005.
64
U'�o �
ALICE GARBRIGHTTu
WITNESSES:
1
a Cra or Leavi
April De ly
SIGNED, SEALED, PUBLISHED and DECLARED by ALICE
GARBRIGHT, the Testatrix above named, to be her Last Will and
Testament, consisting of this page and two other typewritten pages, in our
presence, and we, at her request, and in her presence, and in the
presence of each other, have hereunto subscribed our names as attesting
witnesses this 30th day of November, 2005
Residing at 39-75 46th Street
aApril Sunnyside NY 11104
Residing at 45-29 47th Street
DeDely Woodside. NY 11377
STATE OF NEW YORK)
COUNTY OF QUEENS ) -S.S. :
Each of the undersigned, being
individually and severally sworn, deposes and says:
That they witnessed the execution of the within Last Will and
Testament of ALICE GARBRIGHT on the 30th day of November, 2005 at
45-29 47th Street, Woodside, NY 11377 ; that each of the
undersigned were acquainted with the Testatrix and make this
affidavit at her request; that said Testatrix in their presence,
subscribed her name to said Will at the end thereof and at the
time of making such subscription declared the within instrument
so subscribed by her to be her Last Will and Testament; that
each of the undersigned, at the request of said Testatrix and in
her presence and sight of each other, thereupon witnessed the
execution of said Will by said Testatrix by subscribing our names
as attesting witnesses thereto.
That the Will was executed as a single original instrument and
was not executed in counterparts; and that the Will was executed
by the Testatrix and witnessed by each of the undersigned under
the supervision of MARC CRAWFORD LEAVITT, an attorney-at-law-
That said Testatrix at the time of the execution was upwards of
eighteen years of age and in the opinion of each of the
undersigned was of sound mind, memory and understanding and was
not under any restraint or in any respect incompetent to make a
Will and could read, write and converse in the English language
and was not suffering from any defect of sight, hearing or speech
or from any physical or mental impairment which would affect her
capacity to make a valid Will.
That this affidavit was made and executed simultaneously with the
execution of the aforesaid Will.
Q'c rawfo Le itt
it Del Y
Severally sworn and subscribed to
before e this th ay of November, 2005
LORNAHUGHHS
COI1 MISSIoner of Deeds
Cit pt New York/No 4.39345
CBrU�i j Filed in
r Q n
April 1,2
e mm�s 4 x¢