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Home My WebLink About05-03-13 (2) 1505610105 REV-1500 w-n) FT OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Year File Number Bureau f Individual INHERITANCE TAX RETURN 2 I ' PO BOX ndivi Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social 02/17/2013 12/19/1917 Decedent's Last Name Suffix Decedent's First Name MI VYLghtman Dolores A (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW O1D 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death Prior to 12-13-82) O 4.Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 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.) O 9.Litigation Proceeds Received O 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 DIRECTED TO: Name Daytime Telephone Number Rosemarie Kehrle (71g 218-5441 l � 3MdfflISTER OF:!$LLS WILY CO � S rn a c; cn z First Line of Address X D r -1 r.�I Z nT 33 Alters Rd. r U? w ' C C7 Second Line of Address City or Post Office State ZIP Code -:j _j DATE FILED'" Carlisle PA 17015 cn Correspondent's e-mail address:jkehrie@comcast.net Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, lt is true,correct and complete.Declaration of preparer other Man the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN SATE ADDRESS 33 d �SC6 P61 / 70 N SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 r � 1505610205 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: Dolores Wightman RECAPITULATION 1. Real Estate(Schedule A). .......... . .... ............. . .. . .. . ......... 1. 2. Stocks and Bonds(Schedule B) . . .......... . . . . .... ........ . . ..... .. .. 2. 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ... .. 3. 4. Mortgages and Notes Receivable(Schedule D)... . . ... .. . .......... . .. ... 4. 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 3,099.57 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 89,406.74 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested... . .... 7. 8. Total Gross Assets(total Lines 1 through 7)... .. .. ... ................. .. 8. 92,506.31 9. Funeral Expenses and Administrative Costs(Schedule H). ............... .. 9. 4,006.80 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1). . . .. .. . . .. .... 10. 2,684.13 11. Total Deductions(total Lines 9 and 10)...... . . ............. .. . . . ... .. .. 11. 6,690.93 12. Net Value of Estate(Line 8 minus Line 11)........ ..... ................. 12. 85,815.38 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) .......... . . ... ......... 13. 14. Net Value Subject to Tax(Line 12 minus Line 13) . . ... . .......... . . . ... .. 14. 85,815.38 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_ 16. 17. Amount of Line 14 taxable at sibling rate X.12 17. 18. Amount of Line 14 taxable 85,815.38 12,872.31 at collateral rate X.15 18. 19. TAX DUE ....... .... . .............. .... . . .. .............. ......... 19. 12,872.31 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 L 1505610205 1505610205 J REV-1500 EX(F0 Page 3 Fib Number Decedent's Complete Address: DECEDENTS NAME Dolores Wightman STREETADDRESS - ------- --_. . Go Kehrle 33 Alters Rd. CITY -- _-- --T STATE ! ZIP Carlisle PA 17015 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 12,872.31 2. Credits/Payments A.Prior Payments B.Discount 643.62_ Total Credits(A+B) (2) 643.62 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) 12,228.69 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred............................................................... ........................... b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ c. retain a reversionary interest .............................................................................................................................. ❑ n d. receive the promise for Irfe of either payments,benefits or pre?...................................................................... ❑ 0 2. If death occurred after Dec.12, 1982,did decedent transfer property within one year of death without receiving adequate consideration?............................-................................................................................ ❑ 0 3. Did decedent own an'in trust for or payable-upon-death bank account or security at his or her death?.............. ❑ E 4. Did decedent own an individual retirement account,annuity or other non-probate property,which containsa beneficiary designation? ........................................................................................................................ ❑ 0 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 172 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 172 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 1,2DO0: • 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 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent 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. P REV-15o8 EX+(o&1 ) "i pennsytvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Dolores WhghtmanFuneral 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 OE DEATH 1. Prepaid funeral watrad with Dunn-Quigley Funeral Home 811 Grant St.Akron,OH 44311 3,099.57 See attached copy of original contract dated 211512001 for itemization(original cost$2390.63). TOTAL(Also enter on Line 5, Recapitulation) $ If more space is needed,use additional sheets of paper of the same size. REV-1509 EX+(01-Jo) pennsylvania SCHEDULE F ear INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Dolores Wightman If an suet heome jointly owned within one year of the decedent's date of death,R must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A.Rosemarie Kehrle 33 Alters Rd. Carlisle,PA. 17015 Niece B. C. JOINTLY OWNED PROPERTY: LETTER DATE DESMPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE WO.IAE NAME OF F94ANCLAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENTS VALUE OF NUMBER TEN Jolw IDHR6YING NUMBER.ATTACK OEM FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DCi»Hn5 KFWST 1. A. 11/01105 OMstownBank Checking Account#108008781 28,792.91 50% 14,396.46 2. A. 05/04/09 Omstown Banc Marcy Market Account#146001540 150,020.55 50% 75,010.28 TOTAL(Also enter on Line 6, Recapitulation) $ 89,406.74 If more space is needed,use additional sheets of paper of the same size. r iPZ'i-till o, fpv i pennsylvania SCHEDULE H DEPARTMENT W REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Dolores Wghtman Decedent's debts must be reported on Schedule T. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 11 Paid to Dunn-Quigley Funeral Home 811 Grant SL Akron Ohio 44311-see attached itemization 3,724.57 2. Paid to Richards Florists 21 Menlman Rd.44303-see attached ierfdzation for funerrtt flowers 282.23 B. ADMINISTRATIVE COSTS: 1. Personal Representative Coronowons: Name(s)of Personal Representative(s) Street Address----_—_ Cty _.._--- --- ___--- --- _.....__State----ZIP _...-- -._.-. Year(s)Commission Paid: Z. Attorney Fees: 3. Family Exemption:(it decedent's address is not the same as dalmant's,attach explanation.) Claimant Street Address _ State Relationship of Claimant to Decedent_ --,_ A. Probate Fees: S. Accountant Fees: b. Tax Return Preparer Fees: T TOTAL(Also enter on Line 9,Recapitulation) $ 4,006.80 �pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES 8t LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Dolores Wightman 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. Thomwald Home corrected bill for 211113.2/16/13$4740.87 less insurance reimbursement$2096.00 2,644.87 2. Millennium Pharmacy Systems Inc.Invoice 2/28/13 for prescxipf ions Tramaidol&morphine 34.36 3. Carlisle Borough Tax Collector for 2013 per capita taxes for Cumberland County&Carlisle Borough 4.90 TOTAL(Also enter on Line 10, Recapitulation) $ 2,684.13 Tf mnm cmrc iv neadnd incnrf addiflnnel vhmYe of Yhn eama ei.o GUARANTEED FUNERAL GOODS AND SERVICES OUR SERVICE DISPOSITION, Q Burial ;6 Cremation O Other Arrangement and Professional Staff Services $ 2 ` °o CASKET None Embalming $ _ Manufacturer: ❑ Batesville If you have selected a funeral that may require embalming,such ❑ Other___ as a funeral with viewing,you may have topay for embalming. You do not have to pay for embalming you didnot approve if you selected arrangements such as a direct cremation or immediate Model#and Name burial. if we charge for embalming,we will explain why below: Exterior Material &Color Use of Facilities/Staff/Equipment for: Interior Material&Color Visitation_Days @ $ /day $ OUTER BURIAL CONTAINER $ Funeral/Memorial Service $ Graveside Service $ Transfer of Deceased f_mi S,4 47o)," ,. Manufacturer Family Car(s)#_C�$ each $ Model#and Name Hearse $ ' a v:'raer Material Escort $ OTHER GUARANTEED iMER[FLAfi 0JW(Specify) Forwarding/ReceivingRemains $ Other Services/Facilities/Equipment: (Specify)(-,' r= :J,9U.� .h°7f Wyf $ „',0 (f J i +W19`�zkdfi!di TOTAL SERVICES i� NYllt�gir _ FUNF�y4l PRICE REQUIREDPURCHA .. aww� Charges are only for those items that you wlect oi"lC7�Ctare required. f wed o to usr any items, we will explain the r ealat)s in writing beloti At) legIIL cemetery «r cn 11T,11 wgmrt-tucul Utat we tep ynu as compelling the purchase of any goods-and sarvices called for b} this.Agreement isid&EiliCd and descn`bed below NON-GUARANTEED CASH ADVANGi-ITEms Acknowledgement Cards S Shipping Container $ Obituary Nouc.. Death Certificate) Ati� v S �,."p a t Sales Tax $ Flowers $ Other(Specify)Pf° " Clergy Honorarium �° $ "% 'C ' S `_?; r!+ C _ `_ $ „3 Music We charge,you for our services in obtaining: yw L $ { ALLOWANCE FOR CASH ADVANCE ITEMS jV Funeral Firm Name Funeral Recipient(Insured) Address- _ Telephone Number 1002-07 _ n 1993 Forethought "'WIRI ECOPIES-Rttcrh... hl YELLOWCOPT-I ,I".!Hone PINKCOPF 1193 t FUNERAL PLANNING AGREEMENT Performance Guarantee I eFune ,;. IHm will prnviderheplannedful"*ala,shuwnonthesratcmentoffaneral gooda and se rvice,unless factors b_,-ond :..itro}prescnti[±rcrmdoingsn. The Funeral Firm will turrfi,h the brands or makes of inelchandise showoor',if unavailable, n ,nalr Ali equivalent quality_ If the Funeral Firm is unable to provi&the planned funeral,another funeral establishment nlav be choler-. Price Guarantee The Funeral Firm will accept the Forethought Life Insurance death benefit es the full payment for the Guaranteed Funeral Goods and Service,.even if the rutail,pricefor those items at the time of need is greater than the death iienellk. If the at need retail price is less than the death benefit.the excess will be paid to the beneficiary_ The beneficiary may authorize payment. of the excess for additional items not listed in this agreement, The Funeral Firm is not entitled to receive the death benefits purchased to fund Non-Guaranteed Cash Advance Items to cover the retail price of'guaranteed items. The da0from wtiicla _ YOU . . purchase. 1. If you purchase a plan which will pay an immediate death benefit which equals or exceeds The Total Guaranteed Funeral Price for death from any cause,this guarantee is effective immar iiiteiy;or 3. If you purchase a plan which has a limited death benefit,this guarantee will become effective at the end of the limited, death benefit period;or... 3. If you purchase life insurance under a flexible payment plan,this guarantee will be effective wheat thpsItimmiumspaid equal or exceed an amount equal tothe Totat6uaranteed Funeral Price increased by 4%annually,compounded quarterly. For example,to ouaranree a$3.000 funeral price at the end of 3 years;you wauldliave paid Foretironghf Life Lsul,r„ �F'ex isle O: - ;;,'ff3,650 at the end of 5,yeirs;or$39,+8 at IN end of 7 years. This plan --- l n. Neither you ripe your survivors are c%Tigafedto make payments urq¢I.tbg,Qexible i plan. However,if the premium.s-paid are 'cis than the amount requil fa 5iat fee your i v t pay the FunQi a1 I ,rri Iha diffewAice between the at-need retail price and the death beggtItavailame from your total coverage. - qptriY„r x:.wrv3aiary�uv+nw.��: ,'."•'vI The Funeral Fim ;ru-st be designated to receive the deutl0minehts. guarantees will not apply if the Forethought life. insuranceisvoided,lapsed,borrowkr�"tiepdered,coveagetsnor t'ht;getiwjtgt}x frtsampa.ld under the sweidc,provision of the policy. Freedom of Choice Guarantee Designating the Funeral Firm to reeeivethe proceedsd ftheFmelbougbbiustirauoe.domnot restrict any-right to purchase funeral Merchandise or set ices in the open market,with the advantages of competition',at any time before the Funeral Finn delivers the funeral. _. Cancellation Guarantee This fuser aI plan can he cancelled at any time. Cancellation of this plan does not Cancel your Forethought Life;rl:turance.which may only beret mumted in accordance w i th its terns and conditions of the Forethought insurance documents.The certificateholder %vi11 receive die cash val tie if the coverage is surrendered more than '0.days from issue. In the early years.the cash value may be substantially less than the premiums pair]. Disclosures By completing this form and by signing the Forethought Life Group Insurance Enrollment Form,you acknowledge that: you were shown current General,Casket and Outer Burial Container price lists prior to discussing price,, services or mereflandisc;you have cad,understood I 1 tgceived a caAeaf"Agreement;thepers ur presenting this document is a representative of the'Funetat Finn and”merit ofForethiaught Life Insurance Company to whom commissions maybe paid. 1001-05 Page of Funeral.Planning Agreement - 0 1993 Forethought 1193 3-WHIT[COPIES-Forethought YELLOW COPY-F...]Honw,. .. PINK COPY-IS ,,Iy ��II�IN�II�I��I��IIHI�InIilpNl� I� I�II �II� IMI �AIII� IIN� �I� CIF# W025187 Orrstown Bank ACCOUNT Hanover Street. Office NUMBER 108006781 22 South Hanover St — Carlisle, '0A 17013 ACCOUNT OWNER(S)NAME&ADDRESS (888) 677-7869 Dolores Wightman BR. 8 Rosemarie Kehrle 33 Alters Rd OWNERSHIP OF ACCOUNT-PERSONAL PURPOSE Carlisle PA 17015 ❑ INDIVIDUAL ❑ CXI JOINT-WITH SURVIVORSHIP land not as tenants In common) ❑ JOINT-NO SURVIVORSHIP has tenants in common) ❑ TRUST- SEPARATE AGREEMENT: Revised Date: 04/29/13 reprint signature card karam ❑ REVOCABLE TRUST DESIGNATION AS DEFINED IN THIS AGREEMENT Name and Address of Beneficiaries: ❑ NEW KI EXISTING TYPE OF ® CHECKING ❑ SAVINGS ACCOUNT ❑ MONEY MARKET ❑ CERTIFICATE OF DEPOSIT ❑ NOW ❑ This is your(check onel: 50+ Interest Check ReSubmit It: N ® Permanent ❑ Temporary account agreement. Combine: N Number of signatures required for withdrawal 1 Eyewire: FACSIMILE SIGNATURE(S)ALLOWED? ❑ YES ® NO OWNERSHIP OF ACCOUNT-BUSINESS PURPOSE r ❑ SOLE PROPRIETORSHIP L ❑ CORPORATION: 1:1 FOR PROFIT El NOT FOR PROFIT X ❑ PARTNERSHIP SIGNATURES)-The aWegmM condition the summary of tar idemmtia hatalo has pmlrWd and ach reedpt d a anpMW copy d Ob form. TM ❑ aMansipaM aatlmrites tlme of hatbtehr to only eredk and u*Wymwl BUSINESS: wry aed)or line a oroM raparlh, prepare a CmNt lapM M tar COUNTY&STATE eM�rMmthe terms The=m=� IMp tlN/eglp[d a copy OF ORGANIZATION: mhp aproehhaga)ead(eldbcbaerolsl: AUTHORIZATION DATED: ® Terms&Conditions IN Truth in Savings ® Funds Availability ® Electronic Fund Transfers ® Privacy ❑ Substitute Checks DATE OPENED 11/01/05 By Kristin A Ramsa.3 Common Features ❑ INITIAL DEPOSIT a �X HOME TELEPHONE❑ CHECK(7 7) ��'441CCOAN'P (11: BUSINESS HONE# Dolores Wightman DRIVER'S LICENSE# RL302703 I.D. # 275-01-9411 D.O.B. 12/19/17 E-MAIL EMPLOYER retired MOTHER'S MAIDEN NAME 9411 (2)' X Name and address of someone who will always know your location: Rosemarie Kehrle I.D. # 288-40-1197 D.O.B. 08/16/45 BACKUP WITHHOLDING CERTIFICATIONS (3): IX ] TIN: 275-01-9411 ® TAXPAYER I.D. NUMBER - The Taxpayer Identifiation Number shown I.D. # D.O.B. above(TIN)is my correct taxpayer identification number. ® BACKUP WITHHOLDING - I am not mow to backup wilNrolding either 1 because I have not been notified that I am subject to backup withholding in a result of a (4): J failure to report all interest or dividends,or the atemal Revena Service has notified me X that I am no longer subject to backup withholding. ❑ EXEMPT RECIPIENTS -I am an exempt recipient under the kltemal Revenue I.D. # D.O.B. Service Regulations. ❑Authorized Signer(Individual Accounts Only) SIGNATURE:1 corny aW pace"at perlmy the stahemab clocked in this �X sort hap and the I am a U.S. citb® or Mho U.S. person Ian deNnmd b tkA Instruction). X (Date) I.D.# D.O.e- signature Cantl PA MPW-LAZ- A 10/1/2009 sim4e rs Symms ry W olues Kluwer Reandal Services 0 1992,2009 Pave 1 of 1 F# W025187 OTr id "own Bank ACCOUNT Seven Cables office NUMBER 146001540 1 Giant Lane I C-ir�-Lsle, PA 17013 ACCOUNT OWNER(S)NAME&ADDRESS (8 89) 6'77-7869 Dolores Wightman BR.- 46 Rosemarie Kehrle 33 Alters Rd OWNERSHIP OF ACCOUNT -PERSONAL PURPOSE Carlisle PA 17015 ❑ INDIVIDUAL 171 5C] JOINT-WITH SURVIVORSHIPIanonotasterwasicom..) JOINT-NO SURVIVORSHIP I,ix t.oants in common) TRUST-SEPARATE AGREEMENT: Revised Date: 04/29/11 reprint si REVOCABLE TRUST DESIGNATION AS DEFINED IN THIS AGREEMENT gnature card kararn Name and Address of Beneficiaries: ❑ NEW K EXISTING TYPE OF 91 CHECKING ❑ SAVINGS ACCOUNT ❑ MONEY MARKET ❑ CERTIFICATE OF DEPOSIT ❑ NOW ❑ This is your(check onel: Money Market ReSubmitTt: N E Permanent ❑ Temporary account agreement. Combine: N Number of signatures required for withdrawal 1 RXewire: FACSIMILE SIGNATURE(S)ALLOWED? ❑ YES 91 NO OWNERSHIP OF ACCOUNT -BUSINESS PURPOSE ❑❑ SOLE PROPRIETORSHIP IX I CORPORATION: 0 FOR PROFIT D NOT FOR PROFIT ❑ PARTNERSHIP SIGNATUREIS)-Tkul ounhossipall cor0loso Our inuourocy of On Isdoorourdies be has proaddad and raNriR of a c000ldoted coley at this lium The ❑ vadonsiMai to vadly ova and WOeYWAN bM" MWIOF bM VION" OM pFqMg 8 020 YIW 04 dul BUSINESS; toodusirlod,as iniffivar,71,=on"Mmiledip Out=do of a on COUNTY &STATE- aAagrntatbsttatml Of#WfGftWMIN§r=M@N*)WAVKdWCWMr@K OF ORGANIZATION: AUTHORIZATION DATED: 91 Terms&Conditions [A Truth in Savings 91 Funds Availability 91 Electronic Fund Transfers IN Privacy ❑ Substitute Checks DATE OPENED 05/04/09 By Kristin A Ramsa) common Features INITIAL DEPOSITS El CASH 0 CHECK FF] RECALL ACCOUNT HOME TELEPHONE # (717) 218-5441 IX BUSINESS PHONE# Dolores Wightman DRIVER'S LICENSE# RL302703 j,D, #275-01-9411 D.O.S. 12/19/17 E-MAIL EMPLOYER ret ired MOTHER'S MAIDEN NAME 9411 (2): Name and address of someone who will always know your location: Rosemarie Kehrle I.D.IL # 288-40-1127 o,o.B, 08/16/45 BACKUP WITHHOLDING CERTIFICATIONS (3): L TIN: 275-01-9411 Fn] TAXPAYER I.D. NUMBER - Tice Taxpayer Wwffatim likaider shown I.D.# D.O.B. above(TIN)is my correct taxpayer identification madvor. 91 BACKUP WITHHOLDING - I am not subject to Wall vividdlidlifing either because I have not bear notiliall Unit I=subject f backup withhuhling as a rissift of a (4): failure to repon ON interest ar dividends,or the kdo"Revenue Service has Aefiled mr, that I ove no kinger subject to backup withhaklinq. ❑ EXEMPT RECIPIENTS -I am in rospest redound under the Internal Revenue I.D. # D.O.B. Service Regulationts. ❑Authorized Signer(Individual Accourm;Only) SIGNATURE:I cwt ft under posaftes of porlary the Sloillsonsift do"In this section and told I ases a U.S. clfim or otbor U.S. person (a disfisoul In flia WAMXOOMI. L X (Date) &,masur Card-PA MPSC LAZ�A 11011r2009 8e.ke,s=- Wolfte,KWww Financial Services C,1992,2009 Pap I of I 2/1,9113 Deposit inquiry 10: 14:09 Dolores ylightman Account number: 108006781 Messages Passport ATM/Dr Card 1 of 1 Last stmt balance: 19 , 343 . 83 Last stmt date: 1/27/13 Current. balance: 28,792 ,23 Statement cycle: 25 1=View 6=Print T=Tset Control: From To Posted Check No S T/C Debit Credit Balance _ 1/16/13 P 020 10, 000. 00 1/16/13 151 .05000000% 1/23/13 P 020 4, 007 . 00 1/25/13 C 183 52 .33 1/27/13 160 .32 1/27/13 151 . 05000000% 19, 343 .83 _ 1/28/13 1800 P 091 8, 874 .19 10, 469 . 64 2/01/13 C 163 1, 618 . 00 12, 087 .64 2/05/13 C 183 227 .25 11, 860 .39 _ 2/05/13 1801 P 091 53 . 54 11, 806 . 85 2/05/13 C 183 39 .40 11, 767 .45 _ 2/06/13 P 020 12, 971 .78 24, 739 .23 2/06/13 C 183 8 . 00 24, 731 .23 _ 2/11/13 P 020 4, 061 . 00 28, 792 . 23 Bottom F4=Redsply F6=Bal Inq F7=Scan Fwd F8=Scan Bkwd Fll=Prior bal F15=EFT F16=Sort F17=Top F18=Bottom F19=EDI F20=Unfold F22=T/C F23=C�hecgks r r'� /j ! ti r' 2119/13 Deposit Inquiry 10 :14 :34 Dolores Wia_htman Account number: 146001540 Messages 1 of 1 Last stmt balance: 162 , 971 .78 Last stmt date: 1/27/13 Current balance: 150, 000. 00 Statement cycle: 25 1=View 6=Print T=Tset Control : From To Posted Cheek No S TIC Debit Credit Balance 8/26/12 151 .25000000% 9/25/12 160 37 . 45 9/25/12 151 .25000000% 10/25/12 160 37 .47 10/25/12 151 .25000000% 11/19/12 P 053 . 10, 000 .00 11/25/12 160 38 .24 11/25/12 151 .25000000% 12/25/12 160 35 . 43 12/25/12 151 .25000000% 1/16/13 P 066 10, 000 . 00 1/27/13 160 38 .25 1/27/13 151 .25000000% 162, 971.78 _ 2/06/13 P 066 12 , 971 .78 150, 000 . 00 Bottoms F4=Redsply F6=B& Inq F7=Scan Fwd F8=Scan Bkwd F11=Prior bal F15=EFT F16=Sort F17=Top F18=Bottom F19=EDI F20=Unfold F22=T/C F23=Checks ORRSTOWNBANK A Tradition of Excellence ORRS P.O. Box 250 Shippensburg,PA 17257 Temp-Retum Service Requested Date 2/25/13 Page 1 Primary Account 108006781 Enclosures 11111111111"lI'111111 111411111 111111111 111 000534 0.6500 AV 0.360 TR00003 _ Dolores Wightman Rosemarie Kehrle 1 33 Alters Rd Carlisle PA 17015-8969 A C C O U N T S U M M A R Y Account Number Account Title Current Balance Enclosures 108006781 50+ Interest Checking 28,793.13 146001540 Money Market Account 150, 030.59. C H E C K I N G A C C O U N T S Account Title Dolores Wightman Rosemarie Kehrle 50+ Interest Checking Check Safekeeping Account Number 108006781 Statement Dates 1/28/13 thru 2/25/13 Previous Balance 19, 343.83 Days In The Statement Period 29 3 Deposits/Credits 18, 650.78 Average Ledger 22, 673.66 5 Checks/Debits 9,202.38 Average Collected 22,537.07 Service Fee .00 Interest Earned .90 o Interest Paid . 90 Annual Percentage Yield Earned 0.05'3 '^ Current Balance 28,793.13 2013 Interest Paid 1.22 v n 0 0 o _ N o Deposits and Additions n -� Date Description Amount 0 2/01 XXSOC SEC SSA TREAS 310 V, 618.00 0 PPD $ 2/06 Deposit Ik,2, 971.78 2/11 Deposit 4,'061.00 c 2/25 Interest Deposit LX o� o� N O O T O fp ° Electronic Debits and Withdrawals 0 Data Description Amount 2/05 PREMIUM UnitedHealthcare V27.25- PPD ORRSTOWNBANK A Trartifion of Excellence Date 2/25/13 Page 2 Primary Account 108006781 Enclosures T Dolores Wightman Rosemarie Kehrle r� 33 Alters Rd -•� Carlisle PA 17015 50t Interest Checking 108006781 (Continued) Electronic Debits and Withdrawals Date Descrapt:lon Amount 2/05 MedInsPymt UnitedHCMedicare d9.40- PPD 2/06 ELECT PYMT CARDMEMBER SERV t ''00- PPD --- CHECK SUMMARY -- Date Check No Amount Date Check No Amount 1/28 1800 4, 874.19 2/05 1801 1,S'3.54 * Denotes missing check numbers o Daily Balance Information Date Balance Date Balance Date Balance 1/28 10,469.64 2/05 11,767.45 2/11 28,792.23 0 2/01 12, 087. 64 2/06 24,731.23 2/25 28,793.13 0 0 e N N C Interest Rate Summary 0 1/27 0.0500003 0 0 e+t N O O ° Account Title Dolores Wightman o Rosemarie Kehrle 0 y z s 0 ®RRSTOWNBANK A Tradition of Excellence Date 2/25/13 Page 3 Primary Account 108006781 Enclosures Dolores Wightman Rosemarie Kehrle 33 Alters Rd Carlisle PA 17015 Money Market Account Check Safekeeping Account Number 146001540 Statement Dates 1/28/13 thru 2/25/13 Previous Balance 162, 971.76 Days In The Statement Period 29 Deposits/Credits .00 Average Ledger 154, 025.72 1 Checks/Debits L x2, 971.78 Average Collected 154,025.72 Service Fee .00 Interest Earned 30.59 Interest Paid _ 30.59 Annual Percentage Yield Earned 0.25% Current Balance (150 030.59_' 2013 Interest Paid 68.84 Deposits and Additions Date Description Amount 2/25 Interest Deposit 30.59 8lectronic Debits and Withdrawals Date Description Amount 2/06 Money Market Withdrawal 12, 971.78- Daily Balance Information Date Balance Date Balance Date Balance 1/28 162, 971.78 2/06 150,000.00 2/25 150, 030.59 Interest Rate Summary 1/27 0.2500004 THANK YOU FOR BANKING WITH ORRSTOWN BANK STATEMENT OF Dunn-Quigley Funeral Homes FUNERAL GOODS AND SERVICES SELECTED Akron Chapel Charges are only for those items that you selectethat or e required by 811 Grant Street 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 Akron, OH 44311 If you selected a funeral that may require embalming,such as a funeral (330)253-8121 with viewing you may have to pay for embalming. You do not have to pay James McKnight Jr. for embalming you do not approve if you selected arrangements such as a direct cremation or immediate burial. if we charged for embalming,we will explain why below. D.CASH ADVANCES NO. 42p366 Certified Copies of Death Certificate Burial Permit 25.00 DECEASED Dolores Wightman Certified Copies 48.00 DATE OF DEATH February 17 2013 Crave Coming&Closine 1.133.75 inertpntiy OfGravc Marker 115.00 PLACE OF DEATH Thomwald Home Newspaper Notice 343.40 DATE OF STATEMENT April 26-2013 Church rneanist I5o.00 Soloist 100.00 A.CHARGE FOR SERVICES SELECTED Mass Stipend IK00 1. Professional Services: Basic Services of Funeral Director&Staff-___.__. 1,190.06 Embalming---- ----- --------------- TOTAL OF CASH ADVANCES(D)------ $ 2,OtS.1S Other Preparation of Body------ ------ 125.00 We charge you for our services in obtaining(specify cash advance items:) !.315.00 2. Faciiitfes,Equipment&Staff: Summary Use of Facilities&Staff for ViewingtVisitation--- 150.00 Total Funeral Home Charges--------- $ 2.290.00 Use of Facilities&Staff for Funeral Ceremony --- Sales Tax(if applicable)----------- $ 22.75 Use of Facilities&Staff for Memorial Service --- Total Cash Advances-------------- $ 2.015.15 Use of Facilities&Staff for Graveside Service ___. GRAND TOTAL $ 4327.90 Use of Facilities&Staff for Church Service----- PAYMENTS RECEIVED: Paid at Time,of Arrangements --------- $ 525.00 -?F 150.00 AnticiQated Premed Fuads ________--_ $ 3.099.57 3. Transportation: Preneed shortfaLL write off $ 503.33 Transfer of Remains of Funeral Home--------. 225-00 BALANCE DUE 0, $ 0. Hearse--------------------------- Billing To Rosemarie Khric Limousine- _____------------------ -33 Alters Rd, Sedan - -------------------------- Carlisle PA Service/Utility-------------- --------- 250.00 i, 7015 (330)375-7549 47500 DISCLOSURES 4. Other Services/Facilities/Equipment: Reason for embalming: -- ------- ----------------------------- If any law,cemetery or crematory requirements have required -------------------------------------- purchase of any items listed,the law or requirement is explained below. TOTAL OF SERVICES SELECTED______________ $ 1,940.00 Reason for Vault: S.CHARGE FOR MERCHANDISE SELECTED Casket(or other reeeptacie)-.----------------------- 200A0 ACKNOWLEDGEMENT AND AGREEMENT NoradNo. Cremation Um 1 hereby acknowledge that I have the legal right to acreage the final Exterior services for the deceased,and I authorize this funeral establishment m perfomr services,famish goods,and incur outside charges specified Interior on this Statement I acknowledge that I have received the General Curter Burial Container Price List and the Casket Price List and the Outer Burial Container Price List Namc/No. Material Cremation Container------- ------------------- 100,00 Tetras of Payment: _Prayer Clods__ .---------PAID-- ------- ______-___ -a_ ff'''�- 7 -__ _ if anynymeientis due an of pailater dtan r . _f Ij if any pa}�nrent is not paid witch duo,.rm ananticipate LATE C,URGE of ---- - ----- - TOTAL OF CASH ADVANCES(D)------ S 2015.15 CICacr Prglaratio]1 0 Body ______ _________ 125.00 We charge you for our services in obtaining(specify cash advance items:) 15.00 2. Facilities, Equipment&Staff: Summary Gse of Facilities&Staff for ViewingNrsitation_..__ I SOAO Total Funeral Home Charges_..------. $---2,22_000 Use of Facilities&Staff for Funeral Ceremony --- Sales Tax(if applicable)--- ----- --- $ 22.75 Use of Facilities&Staff for Memorial Service --- Total Cash Advances---_- -.. _ __ $ 2.015.1 Use of Facilities&Staff lbr Graveside Service GRANDTOTAL $ 4-32790 Use of Factitics&Staff for Church Service __ PAYMENTS RECEIVED: Paid at Time of Arrangements --------- $ 625.90 150.00 Anticipated Prenced funds -- - ------ _ $ 3,099.57 ,yc 3. Transportation.* Freneed short#all. write off S 603.33 17ansfer of Remains of Funeral Home._______,.._ 225.00 BALANCE DUE h Hearse ---------------------------- Limousine Billing To Rocentric Kehrte Sedan 33 Alters Rd. Service/Utility--- --- --------_--------.._ 250.00 Carlisle PA 17015 (3301376-7649 475-M DISCLOSURES 4. Other Services/Facilities/Equipment: Reason for embalming: --------- ------------------------------ If any law,cemetery orcrematory requirements have required ----------------------- ------------__ purchase of any items listed,the law or requirement is _.--------,------__ -----__.-_- explained below. TOTAL OF SERVICES SELECTED_____---------------- $ L940.00 Reason for Vault: B. CHARGE FOR MERCHANDISE SELECTED Casket(or other receptacle)____________________.-._- 200.00 ACKNOWLEDGEMENT AND AGREEMENT Nam&No. Cremation,Um I hereby acknowledge that I have the legal right to arrange the final Exterior scrvices for the deceased,and I authorize this funeral establishment to Perform services,famish goods,and incur outside charges specified Interior on this StatancaL I acknowledge that I have received the General Outer Burial Container Price List and the Casket Price fist and the Outer Burial Container — — -- - - Name/No. Material _Cremation Container _______ 10000 'terms of Payment: _Prayer Cards__ --__ PAID __ 10.00 ---------- ---- ----------------------- -- -____ _ __ _ �° _l_----- ---- -- Full Payment is due no Inter than ------__ ._.. ___ _.__ 1�/t�tg - --_ __ If any Payment is not paid when duce,an rmadicipa to LATE CHARGE of APR I fit+ 1.5-1. PER MONTH(ANNUAL PERCENTAGE RATE 18%)on the _..-----'- -- --------'------ ---- -- mmpaid balance will be due. 1 agree to pay the Balance Due listed on this -..--------- --- -- ----- Statemen plus LateC n.��.,., /t�,: J..v- --- - t,p y barge. In the even[I default in payment to ------DL"l'isterrgLt -------- -- this establishment,I agree to pay reasonable attorneys Band cunt TOTAL OF mr+CHANDIS11-WWMM in addition to any Late Charge applicable. I understand and agree that I am assuming personal liability for the charges set forth in this C. SPECIAL CHARGES Statement and that this is in addition to the liability imposed by law upon the estate of the deceased. By my signature below,I hereby agree ❑Forwarding remains to: G(Rcceiving remains from: to all of the above and acknowledge receipt of a copy of this Statement. Dated Social Security Number TOTAL OF SPECIAL CHARGES..................... $ 0,00 signed Dated TOTAL FUNERAL HOME CHARGES__ ----------------- S_ 2290.00 ACCEPTANCE: This funeral establishment agrees to provide all (This total does not include Cash Advances) services,merchandise and cash advances indicated on this Statement. Prl By /v'tc.6hg es Fr caC�s;s -_ SOLD TO ADDRESS . . . . . . . . . . . . . . . i . . . . . . . . . . . . . —D . . . • . . . . • . DELIVERY DATE CAY / ZIP t - .F y f.�;a✓.._. . .CODE J c.= CUSTOMER( — ORDERED A.M. P.M. PHONE NO. . . . . . . . . . . . . . . . . . . . BY. . . . . . . . . . . . . . . . . . . . . . . . . . NC V OC CB AX EXR CARD NO. CUSTOMER NO. DATE CODE DESCRIPTIVE INFO ,,,,,,j__(--LL PHONED F.T.D. TF OTHER CASH PERSON QO.D �yCS � _ IM I OOF M! OIR 8! OUT DEL.CN�- CHG RELAY I r, `,PHONE SUS�TOTAL TAX Thank You! CD DIE w i SALES r j � BIRTHDAY ANNIVER. CONGRAT. BABY CONGRAT. NOLIDAV SYMPATHY SPEEDY Fl OTHERS SOY GIRL CARD r FIRST NAME LAST NAME DELIVER TO '6 L f t�f n f ADDRESS APT__— " V CITY STATE--.-- PHONE ZIP NO.°. ---...__....._.��,_..._....—_� CODE__.. VD0154 2pl, V00159 3.1 C:98 STATEMENT Thornwald Home Statement Date: 04/01/2013 4)F2 Walnut Bottom Road Carlisle, PA 17013 Telephone: (717) 249-4118 Amount Enclosed $ Amount Due: $ .00 Account #: 1257 RE: Dolores Wightman Rosemarie Kehrle 33 Alters Rd Carlisle, PA 17013 Days Date _ Description Ruant Rate Charges Payments Balances Balance B/F 4,740.87 4,740.87 03/07/13 KEHRLE, ROSEMARIE 4,705.69 35.18 03/25/13 KEHRLE, ROSEMARIE 35.18 .00 FCunent 31-6D Days 61-98 Days Over 90 Days Amount Due 0 .00 .00 .00 ,00 Payments MUST be received BY the 25th of each month. Attention:MA recipients Statement Date: 04/01/2013 Documentation MUST be received in order to receive credit on a mobility basis. Dolores Wightman-Account#: 1257 Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013 Telephone: (717) 249-4118 `, -- — - Days Date _ Description Ouant Rate Charges Payments Balances Balance B/F _ 4,748.15 4,748.15 02111/13 Incontinence Supplies -1 7.28 -7.28 4,744.87 7 .5 - 7 V i�aaI Current 31-60 Days 61-90 Days Over 90 Days Amount Due 4,740.87 .00 .00 .00 4,740.87 Payments MUST be received BY the 25th of each month. Attention: MA recipients Statement Date: 03/02/2013 basis. Documentation MUST be received in order to receive credit on a monthly Due Date: 03/25/2013 Dolores Wightman - Account #: 1257 Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013 Telephone: (717)249-4118 CC_A ctivitybyResident.rpt Page 46 of 52 Oat's Date .�� Balances t Balance B/F 8,065.69 02,%01113 -02/28/13 Room&Board - Semi-Private 28 280.00 -7,840.00 225.69 02(01/13 -02/16/13 Room&Board-Semi-Private 16 280.00 4,480.00 4,705.69 Ilk �e add% Current 31-60 Days 61-90 Days Over 90 Days Amount Due 4,705,69 �, .00 ;00 .00 4,705,89 Payments MUST be received BY the 25th of each month. Attention: MA recipients Statement Date: 42/28/2013 Documentation MUST be received in order to receive credit on a monthly Due Date: 02(28(2013 basis. Dolores Wightman -Account #: 1257 Thornwald Home 442 Walnut Bottom Road Carlisle, PA 17013 Telephone: (717) 249-4118 CC_ActivitybyResidentrpt Page 466 of 52 Invoice Dwe:02128/2013. ?r. -.-t^.'NCtfi44,W!GH– .. ?�'. TFornwald NC,L.E v"C--._.' -X-X ' .5'Sner, uantit a ai i n T_b—MG-1ri _L 02/04i2013 667414f. Ci Oral Tablet 511 MG _��--- $ 5.:; � , R1; 65 62-0-27 50 02/0512013 6674146 3.00 ?rn ma fot HCI Oral Tablet 50 MG $ 5.5:' _ - 6 P 6.'62 O 27-50 02/06/2013 667414-t 4.00 'T la lo,HU Oral Tablet 50 MG $ 5.� F,n 6F Aa_t7627-50 02/06/2013 2036476 30.00 N' -, --°uifale $ 24 3 i A I 6f._1 u:_c4 Jjp i 1 t IF—, 40.76 $ 0.00 r 3a,3f➢ v ��5c3 3//y/13 CARLISLE BOROUGH TAX COLLECTOR TAXPAYER'S COPY C/O CARLISLE BOROUGH KEEP THIS PORTION FOR YOUR RECORDS 53 WEST SOUTH STREET CARLISLE,PA 17013 TEMP -RETURN SERVICE REQUESTED f tyll3 •yi'Ilfii��Il'IIfI��'d�IIE,+Itr��BEIIII�aIII(IIIIIIhPfI"( & 040296"""`"'"""""'AUTO^5-DIGIT 17016 DOLORES WIGHTMAN 33 ALTERS RD CARLISLE PA 17015-9969 Payable To: CARLISLE BOROUGH TAX COLLECTOR Office Haas. MONOAY.FRIOAY 7:30AM-4:30PM BBill No.ill Date: 3977 C/O CARLISLE BOROUGH CLOSED SAT.SUN 1 JI6113 HOLIDAYS Control No:02-023965 53 WEST SOUTH STREET CASH ONLY AFTER 12/16/13 CARLISLE,PA 17013 PHONE(717)249.4422 OCC i Discount Face Penalty COUNTY PC $4.90 $6.00 $5.50 $1.00 FEE FOR ADDITIONAL RECEEPTS Tax Payer: DOLORES WIGHTMAN TAX AMOUNT DUE $4.90) $6.00 $5.60 33 ALTERS RD If Date of Payment Is on 311113 thru 47TO113 611113 thru 6130113 711113 Or Late CARLISLE PA 170154WO �