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Home My WebLink About04-30-13 (2) COMMONWEALTH OF PENNSYLVANIA REV-1162 EXIT 1-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG,PA 171280601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 017520 MORROW ROBERT E 104 LAKE POINTE DR NEWPORT NEWS, VA 23603 ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- told ---------- -------- 13113582 $504.47 ESTATE INFORMATION: SSN: FILE NUMBER: 2113-0499 DECEDENT NAME: MORROW M L DATE OF PAYMENT: 04/30/2013 POSTMARK DATE: 04/30/2013 COUNTY: CUMBERLAND DATE OF DEATH: 02/19/2013 TOTAL AMOUNT PAID: $504.47 REMARKS: RECEIPT TO ATTY CHECK# 124 INITIALS: HEA SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS BUREAU OF INDIVIDUAL TAXES Pennsylvania Inheritance Tax pennSylvanla PD BOX 280601 DEPARTMENT OF REVENUE HARRISBURG PA 17128-0601 Information Notice REV-1543 170 EX D""` ' ' ' And Taxpayer Response FILE NO.2170 ACN 13113582 DATE 03-18-2013 Type of Account Estate of M L MORROW Savings Checking Date of Death 02-19-2013 Trust ROBERT E MORROW County CUMBERLAND Certificate 104 LAKE POINTE DR NEWPORT NEWS VA 23603-1375 o �7 c m m °C -- o X v M C> ::0 '�' = D r c.a rn nl r- V M ° "` n j � PNC BANK NA provided the department with the information below indicating t%t a the death OP45 above-named decedent you were a joint owner or beneficiary of the account identified. `-' _t Account No.5315429277 Remit Payment and Forms to: Date Established 05-10-2011 REGISTER OF WILLS Account Balance $50,139.00 1 COURTHOUSE SQUARE Percent Taxable X 50 CARLISLE PA 17013 Amount Subject to Tax $25,069.50 Tax Rate X 0.045 NOTE': If tax payments are made within three months of the Potential Tax Due $1,128.13 decedent's date of death, deduct a 5 percent discount on the tax With 5% Discount(Tax x 0.95) $(see NOTE') due. Any inheritance tax due will become delinquent nine months after the date of death. PART Step 1 : Please check the appropriate boxes below. 1 A F-]No tax is due. 1 am the spouse of the deceased or I am the parent of a decedent who was 21 years old or younger at date of death. Proceed to Step 2 on reverse. Do not check any other boxes and disregard the amount shown above as Potential Tax Due. B The information is The above information is correct, no deductions are being taken, and payment will be sent correct. with my response. Proceed to Step 2 on reverse. Do not check any other boxes. C The tax rate is incorrect. ❑ 4.5% 1 am a lineal beneficiary (parent, child, grandchild, etc.)of the deceased. (Select correct tax rate at right, and complete Part 12% 1 am a sibling of the deceased. 3 on reverse.) ❑ 15% All other relationships (including none). D dChanges or deductions The information above is incorrect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back of this form. E F�Asset will be reported on The above-identified asset has been or will be reported and tax paid with the PA Inheritance Tax inheritance tax form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. PART Debts and Deductions 2 Allowable debts and deductions must meet both of the following criteria: A. The decedent was legally responsible for payment,and the estate is insufficient to pay the deductible items. B. You paid the debts after the death of the decedent and can furnish proof of payment if requested by the department. (If additional space is required,you may attach 8 1/2"x 11"sheets of paper.) Date Paid Payee Description Amount Paid Total Enter on Line 5 of Tax Calculation $ PART Tax Calculation 3 If you are making a correction to the establishment date(Line 1)account balance(Line 2), or percent taxable(Line 3), please obtain a written correction from the financial institution and attach it to this form. 1. Enter the date the account was established or titled as it existed at the date of death. 2. Enter the total balance of the account including any interest accrued at the date of death. 3. Enter the percentage of the account that is taxable to you. a. First,determine the percentage owned by the decedent. i. Accounts that are held "intrust for"another or others were 100%owned by the decedent. ii. For joint accounts established more than one year prior to the date of death,the percentage taxable is 100%divided by the total number of owners including the decedent. (For example:2 owners=50%,3 owners=33.33%,4 owners =25%, etc.) b. Next,divide the decedent's percentage owned by the number of surviving owners or beneficiaries. 4. The amount subject to tax is determined by multiplying the account balance by the percent taxable. 5. Enter the total of any debts and deductions claimed from Part 2. 6. The amount taxable is determined by subtracting the debts and deductions from the amount subject to tax. 7. Enter the appropriate tax rate from Step 1 based on your relationship to the decedent. If indicating a different tax rate,please state your relationship to the decedent: 1. Date Established 1 2. Account Balance 2 $ 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 $ oZS '2 Sc� 5. Debts and Deductions 5 i 3, 1(0`/. 6. Amount Taxable 6 $ 600 7. Tax Rate 7 X 8. Tax Due 8 $ a/. 0 Z 9. With 5% Discount(Tax x .95) 9 X Step 2: Sign and date below. Return TWO completed and signed copies to the Register of Wills listed on the front of this form, along with a check for any payment you are making. Checks must be made payable to"Register of Wills, Agent." Do not send payment directly to the Department of Revenue. Under penalty of perjury, I declare that the facts 1 have reported above are true,correct and complete to the best of my knowledge and belief. j� Work Home 7/7 - 71�.6 - �/S "2��/Z Taxpayer Signature Telephone Number Date IF YOU NEED FURTHER ASSISTANCE, CONTACT CUMBERLAND COUNTY REGISTER OF WILLS, PA DEPARTMENT OF REVENUE DISTRICT OFFICE, OR THE INHERITANCE TAX DIVISION AT 717-787-8327. SERVICES FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS ONLY: 1-800-447-3020 Debts and Deductions Date Paid Payee Description Amount Paid 2/18/2013 Carlisle Medical Medical Services $59.11 Group, LLC 2/26/2013 David R. Galloway, Legal fees $500.00 Esquire 2/26/2013 Holtgate Podiatry, Medical Services $87.89 PLCC 3/8/2013 Alert Pharmacy Medical Supplies $131.92 Services, Inc 3/15/2013 East Pennsboro Transport $117.00 Ambulance Service, Inc. 4/10/2013 Rehabcare Group Therapy $30.53 East, Inc. 2/25/2013 Myers-Buhrig Funeral Funeral Expenses $14,254.00 Home and Crematory, LTD Total (Enter on Line 5 of Tax Calculation) 1 $15,180.45 Refunds Date Refund Refund From Description Amount Received 3/18/2013 ROBC Limited Move out refund $847.01 Partnership 3/15/2013 Myers-Buhrig Funeral Refund of funeral $1,064.34 Home and Crematory, expenses LTD. Total $1,911.35 CHECK CARE)USING FOR PAYMENT ® M❑ASTERCARD ® D❑ISCOVER vsR J VISA Central Penn Management Group Y CARE)NUMBER CVV CODE AMOUNT 1600 Cloister Drive Lancaster, PA 17601 SIGNATURE ExP Dore STATEMENT DATE 7PAYTHISAMOUNT ACCT.If I 02/07/13 $59.11 0028000000004075 08954 0202 SHOW AMOUNT PAID HERE $ 6537221PCL Please check box if address Is Incorrect or Insurance Information has changed,and indicate changes on reverse aide l� ADDRESSEE: REMIT TO: MORROW, ROBERT CARLISLE MEDICAL GROUP, LLC 104 LAKE POINTE DR PO BOX 281651 NEWPORT NEWS, VA 23603-1375 ATLANTA, GA 30384-1651 hhllllflf lull(ulllllllHHuIIPIrruIdIIPIIrIIPuIIIIIi I'll 'll'I1I II1111111111111 II1I111 It'll Plrllpullrll I'll lIII 002800000000407500059110207137 , oiso.a Acierk c.,d rwr,tr;pa Bartion With rourpayment - Please detach and return top portion With your payment Date Description Amount Insurance Patient Line Item._. Balance Balance Balance ENCOUNTER TOTAL $59.11 $0.00 $59.11 $59.11 � , if - 13 Message: TOTAL ACCOUNT For Billing Inquiries Please Call 717-519-1550 BALANCE $59.11 PAYMENT DUE UPON RECEIPT -THANK YOU I1M11111YtSlI�Alll 440-MMASTM-1597047-1372123576-P; 7063749-1-13 A.mgaaa-� , LAW OFFICE OF DAVID R. GALLOWAY 54 E. Main St, Mechanicsburg, PA 17055 Telephone: 717-697-4650 Facsimile: 717-697-9395 david@r alters)alloway.com February 26,2013 Mr. Robert E. Morrow 104 Lake Pointe Dr. Newport News, VA 23603 RE: Mary L. Morrow, Deceased Engagement Letter Dear Mr. Morrow: All attorneys licensed by the Supreme Court of Pennsylvania are required to have a written agreement with clients as to the basis of the representation. To fulfill that requirement, this letter is to confirm that you have retained this office to represent you in connection with paying the inheritance taxes associated with the PNC accounts you owned jointly with your mother, Mary L. Morrow. This letter will also memorialize the terms upon which I have agreed to represent you. You have relayed your mother's only asset, at the time of her death, was the 'l2 interest in the PNC bank account. Additionally, you mentioned all debts were paid and your mother never received any Medicaid or other public assistance. As a result, we have agreed to assist you with preparing the Pennsylvania Inheritance Tax Information Notice and Taxpayer Response issued by the Pennsylvania Department of Revenue for a flat fee of$500. If these arrangements are acceptable to you, please indicate your acceptance by signing at the bottom of this letter under the words "ACCEPTED AND AGREED TO" and return a $500 retainer payable to "David R. Galloway." Finally, I want to thank you for entrusting this work to me. I truly appreciate the opportunity to act as your legal counsel and look forward to working with you. Very truly yours, DavrZ,-�allo Y ACCEPTED AND AGREED TO: Robert E. Morrow Date: February 26, 2013 115 STATEMENT Account#: PT00000902 Sr.No. Serv. Date Description Provider Charges Pat.Bal. 1 01/09/2013 CHARGES:11055 Debride/Cauterization (5) Holtz, Peter 45.00 MEDICARE PA PAID: 0.00 PA BLUE SHIELD PAID: 0.00 PATIENT RESPONSIBLE: 45.00 45.00 Patient Balance Note: Deductible Amount 2 01/0912013 CHARGES:11721 Debride Nails more than 5 Holtz, Peter 55.00 MEDICARE PA PAID: 0.00 WRITEOFF: 12.11 PA BLUE SHIELD PAID: 0.00 PATIENT RESPONSIBLE: 42.89 42,89 Patient Balance Note: Deductible Amount Total: 87.89 Amount Due: 87.89 Current Over 30 Over 60 Over 90 Open Credit Patient: 87.89 0.00 0.00 0.00 0.00 Please make check payable to Holtgate Podiatry, PLLC and send with top part of this statement. THANK YOU! Please call (717)731-1133 if you have any questions about this statement or amount due. �h tip .0 87.T? Page 1 of 1 ** ACTIVITY FOR MORROW, MARY L -MORRM4 - -58 01/15/13 9030405 118 GUAIFENESIN 100 M 01 * 1. 12- .00 1. 12- 01/23/13 9032'725 6 TAMIFLU 75MG 01 6 . 60- .00 6 . 60- 01/23/13 9030404 3 FLORASTOR 250 MG 01 * 4 .18- .00 4 .18- 01/23/13 9032725 2 TAMIFLU 75MG 01 5.69 .00 5 .69c 01/24/13 9033'779 27 WARFARIN 1 MG 01 2 . 00- .00 2 .00- 01/31/13 9036691 22 VITAMIN D3 5, 000 01 * 3 .51- .00 3 .51- '.. 01/31/13 9036697 178 ACETAMINOPHEN 325 01 * 2 . 11- .00 2 . 11- 01/31/13 9036696 10 ONDANSETRON ODT 8 01 21. 17- .00 21. 17- !� 01/31/13 9036690 3199 BOOST VANILLA 01 * 19. 19- .00 19 . 19- 02/01/13 9036907 2 WARFARIN 2MG 01 2 . 00 .00 2 .00c 02/01/13 9036908 1 WARFARIN 1 MG 01 2 . 00 .00 2 .00C 02/05/13 9038415 4 FAMOTIDINE 20 MG 01 2 . 50 .00 2 .50c li 02/06/13 9038421 5 PRISMA MATRIX W.D 01 * 97 . 92 .00 97 . 92 02/06/13 9038443 10 ALLEVYN 3X3 GENTL 01 * 67 . 04 .00 67.04 02/06/13 9038444 250 SODIUM CL 0. 9% IR 01 2 . 00 .00 2 .00c 02/13/13 413171.5 2 LORAZEPAM 0.5 MG 01 2 . 00 .00 2 .00c 02/13/13 9041497 4 FUROSEMIDE 40MG 01 2 .00 .00 2 .00c 02/13/13 9041498 3 POTASSIUM CL 20 M 01 2 .00 .00 2 .00c 02/14/13 2049511 30 MORPHINE SULFATE 01 2 .65 .00 2 .65c 02/17/13 4131777 1 LORAZEPAM 1 MG 01 2 . 00 .00 2 .00c 02/19/13 Payment-Thank You 184 .16- .00 184 .16- 02/20/13 9042493 1 FUROSEMIDE 40MG 01 2 .00 .00 2 .00c 2 . 93- 134 . 85 LEGEND NON-LEGEND -TGTALTAX FOR MONTH FOR MONTH 'revious Balance Charges this month Finance Charge TOTAL CHARGES Total Payment a Cr.ans AMOUNT DUE 184 . 16 + 191 . 80 + . 00 = 375 . 96 244 . 04 - 131 . 92 FORALL PHARMACY RELATED INQUIRES PLEASE CALLAIert Pharmacy Services, Inc at 1-800-266-9954 Statement Terminology on reverse East Pennsboro Ambulance Service, Inc. Invoice- Plea a Remit Payment To: ast Pennsboro Ambulance Service Inc Billing Office 13-124314 3/4/2013 $117.00 PO Box 726 New Cumberland, PA 17070-0726 QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 717-214-6020 Email: info @ambulancebillingoffice.com Date of Service: 1/3'V2013 05:00 Please visit our website to provide insurance or make payment, and Patient Name: MORROW, M LOUISE L. for additional payment options and frequently asked questions: From: Holy Spirit Hospital www.ambulancebillingoffice.com To: BRIDGES AT BENT CREEK IMPORTANT rs type o servrce is not covere yam u ance mein ers rps, a ?care, a ?cat an most secon a?y insurances. ayment is your responsibility. J - _ f' v cw— t _ , .. _ —- ..., .. �•—.-_ aerkd7!;,j3t;'�g� '�6 fie£^ ..�::�� r.. �.,... 1131/13 Invalid Coach One-way A0130 1.0 84.00 84.00 1/31/13 Mileage S0209 11.0 3.00 33.00 Total 117.00 0.00 0.00 C' DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT. I agree to, o lent. TOTAL DUE Signature: Comments: Your payment is due upon receipt. Medicare and most insurances do not cover this service. If you need to check with your insurance company,please ask if your plan covers transportation code A0130. $117.00 Please Note: Unpaid accounts may be sent to a collection agency after 90 days. REHABCARE GROUP EAST INC CHECK CARD USING TO9 PAYMENT (- PO BOX 504469 0 MASTF.RCARD VISA ST LOUIS, MO 63150-4469 iCARDNUMReR — — SIGNATU MODE 32491-358X MNATURE _ EXR DATE TEMP-RETURN SERVICE REQUESTED STATEMENT DATE PAY THIS AMOUNT ACCLri �r FOR BILLING INQUIRIES: 9104112 CONTINUED 029085 15616 0606 888-808-8029 ENCOUNTER: 1473503 1473511 1535780 1535798 PAGE: 1 of 6 SHOW AMOUNT @@ 1625763 PAID HERE �P j(}, 2aaw2n iLl dtfiii!!!!{!!l lliullld{d!{"I!{!!{{I'tltiail{{I!s{es{{Il e{ii'Il{1{td'{!I{i'!{i{'{{N{tdt{Lqi{I{'{{{9{6!tltlt{{tilll M LOUISE MORROW REHABCARE GROUP EAST INC ROBERT MORROW PO BOX 504469 104 LAKE POINTE DR ST LOUIS, MO 63150-4469 NEWPORT NEWS, VA 23603-1375 Iullim1mul1■o■m/MI ___i- M LOUISE MORROW 123 ROBERT E MORROW 104 LAIC.POINTE DR W1273013 NEWPORT NEWS,VA ZM3-1376 P1 nk Pay to the Order of— �GkOACAP-457 Tg $ 3a ..,53 Dollars Q PNCBANK pwsw*tN.A. m �jCMdFA �t eetta For 77GG."�.'# 6. des- 1:0313127381: 50039793761t' 0123 A�� 39 Ease Moon Street w nhlmig,Jr. Mechadcsbnrg.P\170S5 Robert"Bob"L.Buhrig,Jr_FD.Supervaor Welt vv vvo.Mycrs-Buhrig.cent William"Bill"L.Christopher,FD Uirecmahi Mycn'-RUhri�non Phone:p 1]I 766 3421 Fay(719)99_i.]'-91 STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Chances arc only far coos.items Ihm pw sdmctl ur that ore repined,Ilwe ere required by Iwc or by o connote,or"n000ry to use any hmnss,nz will explain the reason in x ritinq helms. I you s11,red a luncral tlmt may regain embalm t ,such as a I'tmcral with via,in_,you may have to pay let embalming.You do not hose to pay for emimmim,you did not ap- pnt,c 11 WLI selected ormngcmente such as a direct cremation or Immediate hurod I I c chance In,mntbe loons.we 1111 explain„hy below. For the Sernoc of /' - Dateaf Deathl Preneed ' CLargctr vt n Addres, 7 ❑r_tv 1111 .. A.CHARGES FOR SERVICES SELECTED: C.SPECIAL CHARGES I.PROFESSIONAL SERVICES In.mnmd me Btral ......... 1111_.. Basic Srrv.ees of Rnerel Dnxmr&Solt. ___....5` - Direct Cre nation __._. ............. ........5_ 6nbsion"ECl'mcal Care .._._. -__.S - Anatomical Gilt 1111....... 1111_. ........_._..S _. Other Pncp:aRas n l B.dY -........... ....__.__S .' ' Rovvard'ngol Retains.. ....... _........._...S _ Dres>let,&Gmurthe 1111_.. .__...5 Retemn,of Remains.... ........... ___S Cuskeime ur Rcpns rag .....__... _.........5 SUB-TOTAL OF SPECIAL CHARGES... ... .. ........CS Ce,on -,Sr Basic R csmminn......... __..........._S D.CASH ADVANCES O-tity.5 , yC ......_ ._S - ife,ha,ef,ofin n rr.ter hn 111 _ Other Preparation o1 Bad, ,Ili D er ly/San mry Car. ...5 - Grave Open _ .1111. 1..... ..........S ``- Additional Care lot Allopsyand/or Donation _......_...5 Other Cemetery Charit........ .................. - - Additional ServLesolFlteralDirecor/Cmhlsr ...._..._...5 - Gmvaedc Equipment S Setp ._.._._.. _._.,,.S Additional Services of Non l-un.rd Anendanisl __......4 Clept -1111 ... .. .............S -{" Snb-Total of Professional Senses............................... .AIS Deacon/ASST.tat 1111... .. ......................... ._.......5_ '- 2.USE OF FACILITIES,CQUIPMENTAND SERVICES FOR: Altos Sense. 1111._ . .........._......... .__..,..5 Pnrcrccll V w nt 1111_.. 1111_ ..__....$ - Sccmn .. ............................................ .5 _ Vicwiny./V Simi nUGalhc to __.1111. _........_.S � Organist/Pimlisf......._.... ........................... _ . ...............5 -. FommlC rcnury........_. ....._._ .......__.S SoloisVConhar .._... 111..1....... ...............S ... Meteor al St,,,, .......... _......... ............5 - Imm...or ml'c. ............ 1111__ _................5 �. GravesdearCnn»ual Servt, .._...... _.__......5 - Fred r...r _............. ..... ._.......,S r - Cremat ,t ........ .___..4 -." Military Honer Guard.._ .......... ...__._._..S Sheltering and/or Robinerrationt _S - ...nor a Feed-1-11-1 .............5 ` Bonkht rFr'nois __. _._4 -` Certified Death Cenificxtes ... ._.....4 / S tda}& lolidayfrvonts 1111. _.S -- Floarr _ ..... 1111.. .......... ' Other ua of fatTi vs,C V n.tl and Sell _...S - _ _ Reception ........ 1111. .........S—r .. Sub-Total of Facilities,Equipmentand Services .AtS !I_ Mommenl Purchase...... 1.1.....1............ ...__S_ i.AUTOMOTIVE EQUIPMENT Monument Inscription ......._._. 1111..._.b Care Transport VChblc S S...rC to Funeral l to rte _.__...0 Pmrim News ... 1111...".". .. ...................5 r I_mad/CI m_y Vehicle 1111 ........ .._.........S Corlele Seninel 1111._ ..1..11.....1 ..................5 a-- It....h ' curl Conch__ _. .................S _ Newspaper 1.111_ .................. ....._.....,,,5 Limit rte _ _. _._..S_ Newspaper 1111. _....._:.... __....5 •' Plower SmNE ..._t Vehicle ..............S -1't - Other ..1111 .. Tmrulbr Vehicle 1111_ _ ...__5 -- Other ..1111. ............ ........_._._E Additional v],,clo,)Time CI ru .._ ...._S _. Other ...........1....11......... _._....... ...._...5 ;,.. Additional Vchielrlsl Mileae Chars _. S _ SUB-TOTAL OFCASH ADVANCES.........................11 .11 DS Sub-Total of Automotive Equipment..........."............................A3S "= �� SUB-TOTAL FOR SERVICES SELECTED .... . n8 `'1 - SUM MARY OF CHARGES B.CHARGE FOR MERCHANDISE SELECTED' A.TOTAL FOR SERVICES SELECTED.. .........S 7 u Cnskcl ...H :..C_ t� .._..._S1 B.TOTAL FOR MERCHANDISE SELECTED .........S [C ,C'_ Other Ret'eptrid,Ahcnai yr Conbinerlca dh and l........_.__S - C.TOTAL FOR SPECIAL CHARGES._... ...........5 Cremation Uri fall size) 1111 .......E D.TOTAL FOR CASH ADVANCES 1111. 1111_.. .5 / P I'>" TOTAL OF SECTIONS A+B+C+D... ...... �rN lr Outer Britoil COtm'mr._ "':.. ....._S ......... Ejy< - ' Ke..mmvohwdry....._... 1111... ___...5 - Y N'Price Guara ntee Premtmn:A........... ..__..S KeepsakC/IewelrY ......... 1111 _...._......._S Y IN: Price GuamnteePenium:B................................_....S ._ Keeps k/1 wclry. ...._.. .__.....ST� Y ;N" Price Guarantee Premium:D................... __._..5 Medicinal Lee _ ............S 'r• TOTAL OFALL PRICE GUARANTEE PREMIUMS.................E Recife,B k _. ........S Menderial Folders Pay.Girds 1111.S - GRANDTOTAL.............................................. ................................ ..S Serv'ic B Ilems............ 1111_ ......._.._.S 'ICdge ncm 1111.1111 PAVPAYMENT ............................................................... 1111 _S Atknn., Cards __ Printed Obuvm __._.. .......S _ BALANCE DUE .... .. .......................................................... S - r DVDs 1111. _._._4 ... Portraits 1111._ 1111 1111.. __._..S -' _ REASON FOR EMBALMING Flay Ca., _.1111. ......._..... .__...S �Vclidtrily Authorized by Family Tcnspurary Grave Marker _.1111. ...._._..S -'- g0iewing Burial CJm1'ma 1111.._.. 1111_. ............._E - ❑Other: Other Cloth na 1111. - _- _ 1111. _............4 W,l it Service, 1111._.. ........_..... ...._.........4 Irany law,cemetery or crematory requirements have required the purchase ofany ofthe ,%oil /Vieuel Use.__...... 1111.. ._._...5 - Items listed above,the law or requirement is explained below.At amount Other: 1........... 1111 ._..._.S _ L'1-11m cemetery requires the use oft bast enter burial come n d....c liner. SUB-TOTALOF MERCHANDISE SELECTED..........____8 S ❑the crematory requires the use ofan alternative(cardboard)container. ;wnv.ha.1 11u base evmJned the items id noel.ls nnJ Cash aJrances seleamd above and limed them tohcorta.and In naoNance with IM1e artangements l/n'e M1ave requested. l/Wea- ka"'Wile receiptni a comer this Statement orFuneral Gh and Se,,,,s Selened.Mile represent Nt IAchavesir lfondfunds evelahle for payment or the cash price farthe good services and cash adva adenvJ. IAVt also:rao¢In make payme .n onto wi.hin do'mYIIDldays. I/Wee ee to M jointly and severally liable with anyone and everyone else who signs this agreement Alate choose of 1j'lap,r month noon......mIA'%:ter yvar.vill Mnapplletlm Ne unpaid balance hyinning] days IronIM1e tlawof Nis aereemcnl. I/We will also pay Myers-Ruling Funeral Home and Crematory.LId. all rvaeonaide Casts InonnaJ his Mvers Bit bria Funeral I Ionia and Comment.Ltd to couvri any amount INe owe under this agreement,Those those may include but are not limited to memcy'a lies. andsI.11... cAny aJJldnal ve merchandise ordered or requested niter the doe andsor staining of this agreement will be considered pan of this agreement and the cost intent ill M1e n�demed nn.he final MllsonJ/or ate at, m.bjm othe PVYmmnarm.specified herein. IN Winfses W HERCOF.;od Inratdlni,In be Ienedly bnmtd 1/u a have cosseted this control lot Funeral Goods and Services Selened. (Purclmscrl ' (Purchaser)_ Parelosery (Date) G ahascrl- -- (Formal Ducua-li r \,'on, lnsummv C,trcryor 1m,nr Foam ll.mv Yell., If, s-Hahne Funeral Be-and Creamery,Lid Pink_Client Family Rev.11/12 ROBC Limited Partnership Statement 202 Black Matt Road Douglassville, PA 19518 Account: horobc-0213- homowmar Date: 03/18113 Mary Morrow Payment: c/o Robert Morrow 104 Lake Pointe Drive Newport News,VA 23603 Date Description Charges Payments Balance Balance Forward 4.12 01/01/13 Rent 3,505.00 3,509.12 01/01/13 Level of Care Plus 1 550.00 4,059.12 01101/13 Season's Program 450.00 4,509.12 01/04/13 chk#ACH 4,509.12 0.00 01/17/13 Guest Meal - 12/31 Supper 5.50 5.50 01/17/13 Personal Care Items 12/16-1/15 58.28 63.78 01/18/13 Transport- 1/11 Dr. Smith w/staff 27.00 90.78 01/18/13 Transport- 1/15 Dr. Smith 7.00 97.78 02/01/13 Rent 3,505.00 3,602.78 02/01/13 Level of Care Plus 1 550.00 4,152.78 02/01/13 Season's Program 450.00 4,602.78 02/05113 chk#ACH 4,602.78 0.00 02/15/13 Credit Seasons Program 2/15/13-2/28/13 -210.00 -210.00 02/18/13 Transport- 1/22 Dr. Smith 7.00 -203.00 02/18/13 Personal Care Items 1/16-2/15 19.29 -183.71 02/26/13 Credit Rent 2/24/13-2/28/13 -576.00 -759.71 02/26/13 Credit Level of Care 2/24/13-2/28/13 -92.00 -851.71 03/01/13 Rent 3,505.00 2,653.29 03/01/13 Credit March Rent -3,505.00 -851.71 03/14/13 Personal Care Items 2/15-3/14 4.70 -847.01 03/18113 Amount to be refunded 847.01 0.00 03118/13 (Pay# 132275) Move out refund -847.01 -847.01 03/18/13 Check#32013469 paid out -847.01 0.00 Current 30 Days 60 Days 90 Days Amount Due 0.00 0.00 0.00 0.00 0.00 Myers Jquhrig Funeral Hom� ... Crematory March 15, 2013 Robert E. Morrow 104 Lake Pointe Drive Newport News, VA 23603 Dear Mr. Morrow: Thank you for allowing us the privilege of serving you and your family. Please find enclosed a refund check for$1,064.34,which reflects an overpayment on your mother's funeral expenses. Please call us at anytime that we may be of service. With Warm Regards, Michel Enclosure Walking with Those in Grief Robert"Bob"L.Buhrig,Jr.,FD.s,p,,,,o,•William"Bill'L.Christopher,FD Phone: nri 7663 421 • Fas 795.7291 • 37 East Main Street • Mechanicsburg,PA 17055 • w%%%%.Myers-Buhrig.coin • Directors(Myers-Buhrig.cDin