HomeMy WebLinkAbout05-01-13 (2) � 15�561�105
REV-1500�`���_�i,�Ft, :.�
PA Department of Revenue p�nsytvarria OFFICIAL USE ONLY
Bureau of Individual Taxes �P�TMENTOFqEVENUE County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN : �\�' C��"" �
Harrisbur ,PA i7128-0601 RESIDENT DECEDENT �
ENTER DECEDENT INFORMATION BELOW
Socia�Security Number Date of Death MMDDYYYY Date of Birth MMDDYWY
__: ___
01/30/2013 11/16/1960
DecedenYs Last Name Suffix Decedent's First Name MI
Fullerton Wendy �
_ _ __ _
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Su�x Spouse's First Name MI
__ _
Spouse's Sociai Security Number __ _
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
_ _ _ REGISTER OF WILLS
FIL�IN APPROPRIATE OVALS BELOW
(� 1.Original Retum p 2.Supplemental Retum p 3. Remainder Retum(Date of Death
Prior to 12-13-82)
O 4.Limited Estate p 4a.Future Interest Compromise(date of p 5. Federal Estate Tax Retum 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)
CORRE5PONDENT— THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime TetepF�ie Number �"`y �p
Adam P. Fullerton (717)440-�I3� .� � c'��
�_� _ � __ e? c�
�
REGIST�O�yll�USE LY _ �
=�.7 y,. �-- � C�
� � � � �
First Line of Address � U? � �
, � � � "''C3 '�'!
443 West North Street ,,,.� � _� � -�
' Second Line of Address . _ __ _ � C :). 4;-�
.... .. .. ...... . .......... . . .. ... ..... . . ... . .. .. . ..... .. � � ~ y �
, . .... . .. . . . � � ` �
� ...._.. ......._..... .... . . .. . . . . . . . . . .. � t� �
City or Post Office State ZIP Code DATE FILED
Carlisle PA 17013
Co�espondent's e-mail address:fullertonA1 a�yahoo.COtY1
Under penalties of perjury,I declare that I have examined this retum,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Dedaration of preparer other ihan the personal representative is based on all information of which preparer has any knowledge.
SI TURE ERSON RESPONSIBLE FOR FILING RETURN DATE
05/01/2013
A DRESS
443 West North Street, Carlisle, PA 17013
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 1505610105 1505610105 �
f
� 1505610205
REV 1500 EX(FI)
DecedenYs Social Security Number
' �ecedent's Name: Fullertott,Wetldy L
RECAPITULATION
; 1. Real Estate(Schedule A). ............................................ 1. 140,000.00
2. Stocks and Bonds(Schedule B) ....................................... 2. 0.00
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. 0.00
4. Mortgages and Notes Receivable(Schedule D)........................... 4. 0.00
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 20,514.00
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 0.00
7. Inter-�vos Transfers 8�Misceltaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7. 60,000.00
8. Total Gross Assets(total Lines 1 through 7)............................. 8. 220,514.00
9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 19,170.89
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............... 10. 146,584.62
11. Total Deductions(total Lines 9 and 10)................................. 11. 165,755.51
12. Net Value of Estate(Line 8 minus l.ine 11) .............................. 12. 54,758.49
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) ........................ 13. 0.00
14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14. 54,758.49
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
�a)�1.2)X.0_ 15.
16. Amount of Line 14 taxable
at lineal rate X.0 45 54,758.49 �g, ' 2,464.13
17. Amount of Line 14 taxabfe
at sibling rate X.12 17.
18. Amount of Line 14 taxable
at collateral rate X.15 �g.
19. TAX DUE......................................................... 19. 2,464.13
20. FILL IN THE OYAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Side 2
� 150561,0205 15�5610205 �
' f2EV 1500 EX(Fl) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Vllendy�. Fullerton
------.-----_.�___-----------__�._.___._.....--____ _..._�_._
----___._..___..------------ -----_.----___---_._—___.----.__—__--- _...__.___.._._
' STREET ADDRESS
443 West North S#reet
. -------------------_._____------------_.�__.___---_—_..__--...._�___---.______---------_.___�T—_______.____._----------r----____________...__----___,
C1TY � STATE � ZIP
Carlisie � PA 1 17013
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 2,464.13
2. CreditslPayments
A.Prior Payments ---___--------_____._--_,._ OAO
B.Discoun# 129.f>9
--__.__.---___---...___�_�.---.__�_------
Tatai�redits(A+B) (2) 129.69
3. lnterest
: (3) 0.00
4. If Eane 2 is greater�an Gne 1+Line 3,enter the di�erence. This is the t1VERPAYMENT.
Fill in oval on Page 2,Line 20 ta request a refund. (4)
5. If Line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 2,334.44
l�ake check pa�able ta: REGISTER OF VICILLS,AGENT,
PLEASE ANSWER THE FGLLCiWING 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 properEy transferred.......................................................................................... ❑ �
b. retain the right to designate who shail use the praperty transferred ar its income ............................................ ❑ �
c. retain a reversi�nary in#eresi.............................................................................................................................. ❑ �
; d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ �
2. 1f death occur�ed a�e�Dec.12,1982,did dec�dent trans#er p�erEy within one year of death
witl�aut rec�iving adequate consideration?.............................................................................................................. ❑ �
` 3. Did decedent own an�in�ust far"or payabie-upon-death bank accaunt or security at his or her death?.............. ❑ �
4. Did deceden#own an individual re#i�ement account,annui#y or other non-prQbate prc�erty,which
. contains a beneficiary designation? ........................................................................................................................ � ❑
iF TNE ANSWER TO ANY OF THE ABOVE QUESTI+�NS IS YE�,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART t�F 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 far the use of the surviving spouse
is 3 percent[72 P.S.§9116{a){1.1��i}].
For dates of death on or after Jan. 1, 1995, t�e tax rate imposed on the net value of transfers#� or for the use of the surviving s�use is 0 percent
[72 P.S.§9196(a)(�.1)(ii)j.The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements far disclasure af assets and
filing a#ax retum ars still applicable even if the surviving spouse is the or�ly bene�c�ary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value ofi trans#ers fr�m a deceased chiid 21 years of age or younger at dea�h to or for#he use of a natural parent,an
adoptive parent or a s#epparent af the child is 0 percent[72 P,S.§9116(a}(1.2�].
�. The tax rate impased 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 impased an the net vaiue af transfiers to or far the use of the de�edent's siblings is 12 percent[72 P.S.§9116(a)�1.3)J.A sibling is defined,
under Section 9142,as an individual whc�has at least one parent in comm�n with t�e decedent,whether by bl�od or adoption.
_�.�.�
RE11-15t12 EX+(12-12}
� pennsytvan�a SCHEDULE A
bEPARTMENT OF REVENUE
INNERITANCE TAX RETURN REAL. ESTATE
RESIOENT DECEDENT
ESTAi'E C►F. FII.E NUMBER:
' Wendy L..Fullerton 46-6616828
Al)reai property owned solely or as a#enant in common must be reparked at fair market vatue.Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller,neither being compe#led to buy ar selR,bath having reasonable knowledge of khe relevant facts.
Real praperty that is jointly-owned with right of survivorship must be discl+�sed an Scheduie F.
Attach a copy of the settlement sheet if the property has been sold,
I��M Include a copy of the deed shawing decedent's interest if awned as tenant in common. VALUE AT DATE
' NUMBER OF DEATH
E3ESCRIPTIflN
�• Single Family H�me,443 West Nor�t Str�et,Carlis�e,PA 9 7013 9 45,000.t}4
T4"[AL�Afso enter on Line i,Recapitulatian.) $ 145,OOO.pO
If mare space is needed,use additional sheets of paper of the same size.
�11�I�1 �
REV-irj0$EX#{0�-12)
� pennsylvania SCNEDULE E
DEPAR7MENTOFREVENUE C;ASH� BANK DEPOSITS &MISC.
TNHERITANCE TAX RETtJRN pERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE t1F: �I{.E NUMBER:
. Wendy L.. Fullerton 46-6fr16828
Include the prpceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disciosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTIC}N OF DEATH
�. PNC Bank,Chedcing Aoaaunt number 50-040&3758 3,658.00
�, PNC Bank,Premium Money M�rlcet Account number 51-132&2326 32�,pp
3. 2010 Ford Fusion 11,931.00
4. Ciothing 1,OQ�.00
5. Jew�elry fiOU.QQ
g, Household Fumishings 3,pQQ,pp
?. Shoes 34Q.00
TQTAL(Alsa enter an Line 5,Recapitulation} $ 20,815.00
If more space is needed,use additional sheets of paper of the same size.
�.�...�..
REV-1514 EX+(08-(39)
T �► ��penr�sy�vania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INNERITANCE TAX RETURN MISC. NON=PROBATE PRO►PERTY
RESIDENT DECEDENT
ESTATE 4F FII.E NUMBER
Wendy L.Fullerton 46-6fi16828
This schedule must be compieted and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM ��S��I�����������tt DATE OF DEATH °/o OF pECD'S EXCLUSION TAXABLE
INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSMIP TO DECEDENT AND
NUMBER THE OATE OF TRANSfER.ATCACH A CQPY QF 7NE DEED fOR RfAL ESTATE. VALUE QF ASSET INTEREST {IF APPlICABLE} VA�.UE
�• State Emplayees'Retirement System �p}000.00 1 aa 60tQ�0.a0
TOTAL{Alsa enter on Line 7,Recapitulatian} � 6Q,000.00
If mare space is needed,use additional sheets of paper of the same size.
RE1t-1511 EX+(1#�-t��)
_�► � �pennsylvar�ia SCH E DU LE H
DEPARTMENT OF REVENUE FUNEItAL EXPENSES AND
INHERIFANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE a� PII.�NUMBfR
Wendy L. Fulierton 4fi-6616828
Decedent's deb#s must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
R. FUNERAI.EXPENSES:
i' Hoffman-Roth Funeral Home�&Cemetary,Inc. 3,377.24
Account number 16785-029
219 North Hanover Street
Carlisle,RA�7�13
2. Edgell Grov�Cem�tary 1,10�.00
53 Grove Street
Fr�ningham,MA 01701
B, ADMINiSTRATIVE CO�TS:
l, Perst�nal Represerttatiue Commissians: �,80C�.00
Name{sl of Personal Representative(s} Adam_P._Fullex`tort _....�____.�_—._ -----._ ___
Street Address 443 West North Street
: city__Carlisle __----__..—_._.--------____---____—_____state__PA_z1P.17013
; Year�s}Commission Paid:_20'13___ ______.__
2. Attarney fees;
3. family�emption:(If decedent`s addres$is nok the same as claimant's,attach explanati�n.) 3,500.00
' Claimant Adam P. Fulferton
Street Address 443 West Narth St�eet
�f�y__Carlisle___-------____------_________-----_..._�_—_.state_ PA_ z1�_17013_
' Relatior�ship of Claimant to�ecedent_ SQ�__
4. Probate Fees: 208.50
5. Accountant Fees:
6. Tax Retum Preparer Fees:
�. St.Pauls Evangelical Church& Br�ss 704.23
s. Citi Martgage 3 paymen� 2,979.27
�. Utiiifies(UGI,PPL,Comcast&water) 1,287.41
��. BIS Home inspection,Leba's Plumbing,A team Chimney Sw�eep&Servic�Line Warranties 539.29
��. Joy Daniels Real Estate�isting fiees 395.00
�3. Taxes(Cumberl�nd County T��T�Act} 279.95
TQTA!(Alsa er�ter on Line 9,Recapitulation� � 19,170.89
If more space is needed,use additional sheets of paper of the same size.
^��
REV-15�2 EX+(12-12)
r� pennsylvan�a SCHEDULE I
DEPARTMENTOFREVENUE DEBTS OF DECEDENT�
INNERITANCE TAX REfURN MpRTGAGE LIABII.ITIES&LIENS
RESIDENT pECEDENT
EST�ITE 4F �ICE NUMBER
Wendy L. Fullerton 4fi-6fi16828
Report deirts incurred by the decedent prior to death that remained unpaid at the date of death,inciuding unreimbursed medical expenses.
ITEM VAlUE AT DATE
NUMBER DESCRIPTION OF DEATH
1� CitiMortgage,Aa�unt Number 06347355148 101,142.56
2. Ford Credit,Account number�5183915,ViN 3FAHPOHA4R171708 10,402.15
3. Neinet,Account number E825744598 8,985.22
�. Sallie M�,Account Number 9459987734-1 26,454.69
Tt#TAL�Als�enter�n Line 10J Recapitulation� $ 146,584.�2
If more space is needed,insert additional sheets af the same size.
i
�����,`i,�-�� � 219 North Hanover Street
Cc�iiisle,Pennsylvania 17Q 13
< 717.243.451 1
; , ., ° . ° toil free 1.866.451.451 1
� � ���� �� � fax 717.243.3723
_ _ _ . www.hoffmanroth.com
` FUNERAL HOME � CREMATORY, INC. ;nfo��ot�manrot�,.com
March 20, 2013
Adam Fullerton
443 West North S#reet
Carlisle, PA 17013
Statement of Funeral Expenses for: Wendy Lynne Fullerton
Date of Death: January 30, 2013 AccoUnt!d: 16785-029
PACKAGE:
Immediate Cremation
OPTION 5-Cremation $ 1,990.00
Sub Total: $ 1,990.00
MERCHANDISE:
Urn: Crescent Marble Urn-Various Colors $ 180.00
Register Book $ 25.00
Memorial Folders $ 25.00
Sub Total: $ 230.00
TOTAL FUNERAL HOME CHARGES: $ 2,220.00
CASH ADVANCES:
10 Certified Death Certificates at$6.00 each $ 60.00
Newspaper Notice-Sentinel $ 106.94
Newspaper Notice-Patriot $ 559.26
Clergy $ 150.00
Newspaper Notice-Indiana Gazette $ 65.00
Urn Engraving $ 36.04
Coroner's Fee $ 30.00
Organist $ 150.00
Sub Total: $ 1,157.24
Totai Funerai Expense: $ 3,377.24
Total Payments Made: � 3,377.24
Payments Made:
Adam Fuflerton Check 127 Mar 20,2013 3,377.24
Balance: $ 0.00
� SERVIN � OUR CONIMUNlTY SINCE 1 9O7
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Account:STUDENT BANKING CHECKING(*1599)(Check Number: 127� Date Posted: 3/21/2013 j Amount:
` $3,377.24
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4A3 YYEST NQATH ST
CARUSLE,PA 17013 � � 6at84r3t3
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RE�EIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH Receipt Date: 2/20/2013
Cumberland County - Register Of Wills Receipt Time: 14 :42 :41
One Courthouse S quare Receipt No. : 1073151
Carlisle, PA 17613
FULLERTON WENDY LYNNE
Estate File No. : 2013-00208
Paid By Remarks: ADAM FULLERTON
HMW
------------------------ Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS ADM 135. 04 CUMBERLAND COUNTY GENER.AL FUN
RENUNCIATION 5 .00 CUMBERLAND COUNTY GENER.AL FUN
SHORT CERTIFICATE 10 . 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23 .50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5. 00 CUMBERLAND COUNTY GENERAL FUN
INVENTORY 15. 00 CUMBERLAND COUNTY GENERAL FUN
INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENER.AL FUN
----------------
Cash $208 .50
Total Received. . . . . . . . . $208 .50
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CHIMNEY SERVICE REPORT � � � � -
SERVICE PROVIDER: CUSTOMER:
Name
Chimney Sweep Address
; 132 tefever Rd :
.
� City State Zip '
� ���� Newville,Pa 17241 � �
717 243 0542 Phone( ) : �
E-mail
Technician Directions to home
Service date Time
SYSTEM IIdFORMATION �o�
yFireplaces,Number of............................. : _ _ _
; Construction �Masonry ❑Factory-built ❑Modular
........................................
�E . . �� �� �� �, �� �� FLFlE
. Firep face openmg s�zes.................... 1 x 2, x 3. x UNER
" Heating Appliances,Number of:........
' TYPe......................................................... ❑Insert ❑Freestanding ❑Furnace ❑
Fuel................................................................. C�Wood ❑Coal ❑Gas ❑Oi! ❑ _ _
Chimney _ -----
Construction....................................... ❑Factory-built ❑Masonry C Other
` 00 SMOKE
, Chimney height................................ : feet 0 SHELP
Liner.................................................. ❑Flue tile ❑Stainless ❑Cast ❑Uniined o
,
""` DAMPER
F{ue sizes ❑8"x 8" �8"x 13" ❑13"x 13" ❑8"x 17" ❑13"x 17°
❑6"Round ❑8"Round ❑ o0
Last cleaned........................................ year(s)ago ❑Never ❑Unknown �
0
urrr� o
0
COMM ENTS FiREBeictc—�
ASH DUMP
' ANNUA�INSPECTION ' - INVOICE 1 RECEIPT
The National Fire Protection Association(NFPA)recammends annua) DESCRIPTION PRfcE
inspection of all fireplaces,chimneys,and vent5.The next inspection - :
of your system is scheduled for:
CUSTOMER VERIFICATION
This report is the result of a visuai inspection done at the time of
cleaning.lt is intended as a convenience to our customer,not as certi- - -�,
fication af fire worthiness or safety.Since conditions of use and hid-
den construction defects are beyond our control,no warranty is made
for the safety or function of any appfiance and none is ta be implied. ,
i have read this form and understand the apparent condition of my i
firepface,appliance,chimney,and/or vent system.Furthermore 1 Subtota!
understand the limitations of this report as given in the paragraph
above.
Customer .
Signature � Date Total '
Item#99450 c�2009,CCS
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� � � ' � ` Date ir�voice#
�c;�'���''�����������r, ���,
4/29/2013 l 693$
���t�estnut Ave. Pt�ne 71�'-243-8��45
Carlisle Pa 17�13 Fax 717-2�3-?655
Bill To
Adam Fullerton
443 West 1'+torth St.
Carlisle,PA 17013
P.O.No. Terms
�� Desrription Rate Amount
�usto�ner requested repair flf smoi�e pipe at water heat�r.
Mechanic adjusted smoke pipe on gas water heater and secured
pipe.Flue was sealed with cement to prevent exhaust gas from
coming intc�the house,aS 2'CCOlI3IIl�TI{��t��?�'C}f��lOtltC tIIS�CZi011
re�port.
Labor,Kris Service Call 7�� ���
Contractor#PA018016
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-Thank You,V�e appreciate your business�
' 1 4��� $75.40
i.5%Interest will be applied after 3Q days
717-243-8345
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Official Payments-Pay Taxes,Utility Bilts,Tuition&More Online https:/Iwww.officialpayments.comlpc_step6_print jsp?JSESSIONL..
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Earrted Income Tax
�anfirmation Number: �k ,- ' ;��
Payment Date: . � :�� �
Payment Tir�e: � � ���� � �
Pay�r#nfor�natio�
Name; Ad�m P Fulle�#an
Street Addr�ss: 443 West North Stre�t
Carlisle,PA'!7013
Unitecf S#a#es
Daytime Pt�one (717}44Q-2115
Numb�r:
, E-mail Address: fuitertonal a�,"7yahao.com
Tax Year(4-dic�it ltear): 2011
P��alty Amc�unt�3�e: $Q.00
Interest Amount Due: $O.00)
Tax Amaunt C►ue: $�6�.00
Card Infnrr�nation
Card Type: Debit Card
' �ard Number: ***'"��*"�*�*8835
�xpiratio�Date: C12/2014
Payrnent Informatio�
�aymen#Type: Eamed lncome Tax
Payment Amount: $2fi5.f}0
Cc�nvenienc��"e�: $7,95 :
Tc�#al Payment: $272.95
Thank you for using CNficial Payments.if you fiave a question regarding your payment,please call us toll ftee at
't-800-487-�45fi7.To make payments in the fc�ture,ptease visit Qur website at www.off�cial�ayments.com.
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TaxACT C)nline https://www.taxactc►nline.com/s online tax2012/taxmanager.dtl/Prin...
Pa�ym�nt �c�nfirm�tion
`�our credit card payment t�as been appraved far Ta�cACT Online Free-Federal and Pennsylvania Retums.
Bil�ing �nf�rmatic►r� P'ayrr�ent Inft�rmatic�r�
Date: 0+�l08/2l�1311.28.28 AM Name: Ad�m P Fulier�on
Qrder Number: 0�12-41Q7fif3S-9 Credit Card: VISA
�acx-�a�ac-x�ocx-8835
Billing Name: Adam P Fulierton
Price $14.95
Biliing Address: �43 west north street
Carliste,PA 17013 Descriptian Ta�kCT�}nline Free-Federal ar�d Pe�nsyEvania Re#ums
1 of t 41$IZ(}13 12:29 PM
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Listing method of Payment for Fees
Name: `��� � �-- t! i.�� ,�,
.,�;',�f t i,• i,� �
Billing Address: ���1 � �.��.��- �e'�:�,t!-��=�.-�, �,��-;.r �. �-
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The follo�ving fees�vill be paid by the method selected belo�v.
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I wish to pay my listing fees totalingl� y:
0 Personai check attached
�Chare to m credit card:
g Y
Note:Charge 4��i11 appear as"Mtntop Retr"on your statement.
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Account Number Expiration Date CVV code
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Account Number Expiration Date CW code
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I acknowledge that if the sale of my home does not close,fees are non-refundable unless
otherwise spqcified in the Listing Agreement.
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Owner's Signature Date
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Property Address:
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� ����lE 3/25/2013 1139
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70fi Samerset Drive ��
11�Iechanicsburg,PA 17455 '
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Realty Firm �'"�`"� � ���
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Joy Daniels Real Est�te Graup,i.td. _.___.�___-- ? �� � ' �
3800 Market�treet,5te. 100 - '� `� ''���
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Camp Hiil,PA 17011 �' -
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Client Name
Adam Full�rton
Description Amount
Whole Hause Inspection 325.00
For inspection services performed at�43 We�t North Street,�artisle,PA on March 25,2013
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If yc�u want to laok up yaur 5EF2S member accoun#data or get
H+��tt�lnsurance Premium $�.�� copies of previous Persona!Sfatements or�099=R forms,v'rsit
Other Authorized Amounts ��,�� SERS'nev,r Online Member Services. The system is new,
sc�--even if you used the previous oniine s�ervices—you'll need ta
Total Net Annuity �,��q,��,�� create a new account to access yc�ur information.
► ! - ! • ! ! � •. •
New I�S Tax Tables May Affect Yaur Withholding
New Federal income Tax Tables went into effect January 1,2Q�3. You may choose to change the amount of money withheid from
your retirement ber�efit fc�r Federal Incame Tax or choose not to have maney withheld by submitting a 1Nithholding!Cer�ificafe-
Pensian orAnnuity Paymenfs(SERS-W-4P)farm or a Withholding Certi�cate-Pension orAnnuity Payments(IRS W-4P)form. if
you do not submit a new form,�ER�will withhold taxes frc�m your retirement payment based on the"New Table"col�tmn below,
effective with your January 2013 payment.
� . .� - � � • ' '.
S
� Tabte in Effect New?able
Through 12/31112 Effective 1/1/13
j Gross Monthly Annu�ty ��$$��� $���.�5
�ess Deductians and Withholdings
Federal income 7ax �4.9� 20.55
� Health Insurance Premium �o�� ��00
� t}ther Autl�arized Amounts t�.0� t}.tDO 3
(
Ne�Monthiy Annuity $3����� $3�'�.9a
���r��t�s�1dV4-��orr��n�!��i���Ei�S���ts������9�����'�����������������v�th9���s������►s���a����ns:
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�El�s�� �����s a4t���r����� ��d�������
������ � ����u�� :
$O.QO '
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tCeep Yc�ur M�mber �nforr�a�ion Up-Ta-Date �
1f ycw receive your benef+t paymer�t by maii and"rt is nat received by the 1 a�'working day of the foilowing mon#h,contact SERS'toil-free g
number, 1-8CltI-fi33-5�4�'i. �kt that time,SERS car�stap payment on the last check and reissue a new one. To avoid the possibility of a f
Ir�st ch+�ck,sign up for dir+ect deposit by submitting a Direct Deposit ofAnnuity Payments Form�'SERS-923�. �
Ev�n if your monthly p�yments are m�de by direct dep4sit ta your financial institution rather than by a check mailed to yaur home,it
"��t�►�t�t f�tr y�iu tt�nt�tify��RS a#any changes#t�your mailing address. For your cc}nver►ience,we have included an Arrnuifant
C�i����►vfAddnass�orm. �'ar yaur pratection,S�RS cannot accept address changes by phone or e�maiL