HomeMy WebLinkAbout05-17-13 J 15D5610140
REV-1500 EX (01-10)
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harcisburg,PA 17128-0601 RESIDENT DECEDENT 2 1 1 3 0 3 4 9
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
0 1 2 � 2 0 1 3 0 8 2 2 1 9 3 4
DecedenYs Last Name Suffix Decedent's First Name MI
C L A R K R U S S E L L E
�1f Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name ►N�
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Original Return � 2. Supplemental Return � 3. Remainder Return(date of death
prior to 12-13-82)
� 4. Limited Estate � 4a. Future Interest Compromise(date of � 5. Federal Estate Tax Return Required
death after 12-12-82)
� 6. Decedent Died Testate � 7. Decedent Maintained a Living Trust _ 8.Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
� 9. Litigation Proceeds Received � 10.Spousal Poverty Credit(date of death � 11. Election to tax under Sec.9113(A)
between 12-31-91 and 1-1-95) (Attach Sch.O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
R 0 G E R B • I R W I N 7 1 7 2 4 9 2 3 5 3
- ;�
� R ST�R OF WIL. _USE EiRLIf,;�
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First line of address ' �-r� - c- _`'
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I R W I N & M c K N I G H T , p . C . I -�'
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Second line of address ' �
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6 0 W E S T P 0 M F R E T S T R E E T � �
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City or Post Office State ZIP Code " � pATE FiLED �,�� �'������
-- - ----(--�-'�J
C A R L I S L E P A 1 7 0 1 3 � v�
CorrespondenYs e-mail address:
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,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGN T E OF PERSON,RESP NSIBLE FOR RETURN �ATE
���Gi�c_.��' . �1/C ���L�4rn.�/1�0-�x�x.J ,> / I— v?U/�3
ADDRESS
414 W- PENN STREET CARLISLE PA 17013
SIGNATURE OF PREPARER OTHER THA EPRESENTATIVE D TE
` 5 i7 /3
ADD ESS
60 WEST P� RET STREET CARLISLE PA 17013
_ PLEASE USE ORIGINAL FORM ONLY
Side 1
� 1505610140 1505610140 J ;�'
r
�
J 150561�24�
REV-1500 EX
DecedenYs Social Security Number
oecedent'sName: RUSSELL E• CLARK
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. 1 2 1 0 � . 3 4
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . _ . 6. •
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) � Separate Billing Requested . . . . . . . 7. 1 � 6 9 8 2 , 6 4
8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 1 8 9 0 8 2 , 9 8
9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9� 3 9 1 1 . 2 8
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule I) . . . . . . . . . . . . . 10. 1 8 3 3 2 . 2 0
11. Total Deductions(total Lines 9 and 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 2 2 2 4 3 . 4 8
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 1 6 6 8 3 9 . 5 �
13. Charitable and Governmental BequestslSec 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. 1 6 6 8 3 9 . 5 �
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 _ � . � O 15. O . 0 0
16. Amount of Line 14 taxable
at�ineal rate X.045 1 6 6 8 3 9 . 5 0 �6. 7 5 0 7 . 7 8
17. Amount of Line 14 taxable
at sibling rate X.12 � . 0 � 17. � . � �
18. Amount of Line 14 taxable
at collateral rate X.15 � • � � 18. � • � �
19. TAX DUE 19. � 5 � 7 . 7 8
20. FILL iN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
Side 2
� 1505610240 1505610240 �
REV-15�0 EX Page 3 File Number
Decedent's Complete�Address: 2� 13 0349
DECEDENT'S NAME
RUSSELL E. CLARK _____ � _ _
STREET ADDRESS
442 WALNUT BOTTOM ROAD
CITY STATE ` I ZIP
CARLISLE PA ! 17013
Tax Payments and Credits:
�� Tax Due(Page 2,Line 19) (1) 7,507.78
2. Credits/Payments
A.Prior Payments
B.Discount
Total Credits(A+B) (2) 0.00
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) 0.00
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 7,507.78
Make check payable to: REGISTER OF WILLS, AGENT
; ._ � .. :
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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: ...................................................................... ❑ 0
b. retain the right to designate who shall use the property transferred or its income: :::::.:::::.::.:::...::::.::.:: ❑ ❑
c. retain a reversionary interest;or .......................................................... . X
d. receive the promise for life of either payments,benefits or care? .................................................... .. ❑ �
2. if death occurred after December 12,1982,did decedent transfer property within one year of deakh
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? ......... ❑ �
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation?.................................................................................................. X❑ ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS 1S YES,YOU MIfST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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For dates of death on or after July 1,1994,and before Jan. 1,1995,the tax rate imposed on the net vaiue of transfers to or for the use of the surviving spouse is
3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)}.The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still appiicable 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 decedenYs lineal beneficiaries is 4.5 percent,except as noted in
72 P.S.§9116(1.2)[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedenYs siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined,under
Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
- - _
REV-1508 EX+(08-12)
. pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS 8� MISC.
INHERITANCE TAX RETURN
RESIDENTDECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
RUSSELL E. CLARK 21 13 0349
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. SOVEREIGN BANK-PREMIER CHECKING ACCOUIVT#1691016934 12,100.34
TOTAL(Also enter on Line 5,Recapitulation) $ 12 100.34
If more space is needed,use additional sheets of paper of the same size.
REV-1510 EX+(08-09)
. pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEOENT
ESTATE OF FILE NUMBER
RUSSELL E. CLARK 21 13 0349
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three o(the REV-1500 is yes.
DESCRIPTION OF PROPERTY
ITEM INCLUDETHE NAME OF THE TRANSFEREE,THEIR RELATIONSHIPTO DECEDENT AND DATE OF DEATH %OF DECD�S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEEO FQR REAL ESTATE. VALUE OF ASSET INTEREST pF aaPUCns�e� VALUE
1. THRIVENT FINANCIAL FOR LUTHERANS 176,982.64 100.00 176,982.64
NON-QUALIFIED VARIABLE ANNUITY
BENEFICIARIES:
SHERWOOD CLARK
JACQUELINE COX
RUSSELL CLARK, JR.
DENISE THOMPSON
GREGORY CLARK
TOTAL (Also enter on Line 7,Recapitulation) $ 176 982.64
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(10-09)
� pennsylvania SCHEDULE H
DEPARTMENTOF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
RUSSELL E. CLARK 21 13 0349
DecedenYs debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. FUNERAL LUNCHEON 652.78
B. ADM{NISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s) DENISE M. THOMPSON 600.00
StreetAddress 414 W. PENN STREET
City CARLISLE State PA zIP 17013
Year(s)Commission Paid:
2. Attomey Fees: IRWIN &McKfVIGHT, P.C. 2,600.00
3. Family Exemption;(If decedenYs address is not the same as claimanYs,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees:
5 AccountanlFees:
6. Tax Retum Preparer Fees:
7. REGISTER OF WILLS- FILING FEE- PETITION TO SETTLE SMALL ESTATE 43.50
8. REGISTER OF WILLS- FILING FEE 15.00
TOTAL(Also enter on Line 9,Recapitulation) $ 3 911.28
{f more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
� pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT�
INHERITANCETAXRETURN MORTGAGE LIABILITIES&LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
RUSSELL E. CLARK 21 13 0349
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. PAUL D. DALBEY, DPM -MEDICAL 42.89
2. THORNWALD HOME-NURSI{dG 9,146.11
3. MILLENNIUM PHCY SYSTEMS MECHANICST- MEDICAL 265.20
4. INTERNAL REVENUE SERVICE-2012 INCOME TAXES 8,778.00
5. ASCENSION POINT RECOVERY SERVICES FOR CITI VISA-CREDIT CARD 100.00
TOTAL(Also enter on Line 10,Recapitulation) $ 18 332.20
If more space is needed, insert additional sheets of the same size.
;RE V-1513 EX+(01-10)
� pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
RUSSELL E. CLARK 21 13 0349
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 outnght spousal distnbutions and transfers under
Sec.9116(a)(1.2).]
1. DENISE M. THOMPSON Lineal 33,367.90
1l5TH REMAINDER
2. JACQUELINE M. COX Lineal 33,367.90
1/5TH REMAINDER
3. SHERWOOD A. CLARK Lineal 33,367.90
1/5TH REMAINQER
4. RUSSELL EL CLARK, JR. Lineal 33,367.90
1/5TH REMAINDER
5. GREGORY A. CLARK Lineal 33,367.90
1/5TH REMAINDER
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-15��COVER SHEET,AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
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.
LAST WILL AND TESTAMENT
I, RUSSELL E. CLARK, of the Borough of Carlisle, Cumberland County,
Penn�ylv;uua, being of sound mind, disposing memory and full legal age, do hereby make,
publish ;�n�d declare this to be my Last Will and Testament, hereby revoking all Wills and
Codi�,ils t�r,retofore made by me. _
1. I direct my Executrix or Substitute Executrix, as the case may be, to pay all of my
debts, fun eTal and administrative expenses as soon as convenient after my decease. Furthermore,
I direct t��a.t all state, inheritance, succession and other death taxes imposed or payable by reason
of m��de�t:h and interest and penalties thereon with respect to all property composing of my gross
estate for death tax purposes, whether or not such property passes under this Will, shall be paid
by the Ex�;��utrix or Substitute Executrix of my esta.te.
2. My Executrix or Substitute Executrix may, at her discretion, compromise claims,
borro w m c�ney, retain property for such length of time as she may deem proper; lease and sell
property f��r such prices, on such terms, at public or private sales, as she may deem proper; and
inves�: est ate property and income without restriction to legal investments uniess otherwise
provided 1 u�reunder.
3. l: authorize and empower my Executrix or Substitute Executrix to sell any realty and/or
personalty owned by me at my death and not specifically devised or bequeathed herein, at public
or private s.ale or sales and to give good and sufficient deeds and/or bills of sale therefore, in fee
simpl��, a;; I could do if living. My Executrix or Substitute Executrix is authorized and
empowered to engage in any business in which I may be engaged at my death, for suc�i��eri•�d of
time after my death as seems expedient to said Executrix or Substitute Executrix.
4. I give, devise and bequeath a11 of my estate of whatever nature and wherever situate as
follows: -
a. $5,000.00 to FIRST ITNITED CHURCH OF CHRIST, 30 North
Pitt Street, Cazlisle,Pennsylvania;
b. $2,000.00 each to CAITLYN M. GREEN,RUSSELL E. CLARK.
1V, and MICHAEL Z. COX; and
c. All the rest,residue and remainder to my three(3) sons, GREGORY'
A. CLARK,RUSSELL E. CLARK,JR, and SHERWOOD A. CLARK,
and my two (2) stepdaughters,DENISE M.THOMPSON and
JACQUELINE M. COX,share and share alike.
6. I nominate and appoint DE1vISE M. THOMPSON to be the Executrix e�f th�s my
Last Will and Testament. In the event she has predeceased me, failed to qualify or is t�ot a�le or
does not serve for whatever reason, I then appoint JACQUELINE M. COX to be the; Sub�:titute
Executrix of this my Last Will and Testament, whereby the said Substitute Executrix �hall have
the same powers as aze given to the original Executrix hereunder.
7. No person(s) shall benefit hereunder unless such beneficiary shall survive rr�;by sixty
(60) days.
2
6 , o � . �
ACKNOWLEDGMENT AND AFFIDAVIT
WE, RUSSELL E. CLARK, KAREN S. NOEL and SHARON L. SCHWALM, the
Testator and witnesses respectively, whose names are signed to the foregoing instrument, being
first duly sworn, do hereby declare to the undersigned authority that the Testator signed and
executed the instrument as his Last Will and that he had signed willingly, and that he executed it -
as his free and voluntary act for the pwpose herein expressed, and that each of the witnesses, in -
the presence and hearing of the Testator, signed the Will as a witness and that to the best of their
knowledge the Testator was, at that time, eighteen years of age or older, of sound mind and under
no constraint or undue influence.
�,�'�1��� G( ��2
R SSELL E.CLARK
�
7
KAREN . EL
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�lY��l'�-G�C G�:' 1C�,G.%i�i����
' sa�oN i. scHwai,M
COMMONWEALTH OF PENNSYLVANIA :
. SS:
COUNTY OF CUMBERLAND .
Subscribed, sworn to and acknowledged before me by RUSSELL E. CLARK, the
Testator herein, and subscribed and sworn to before me by KAREN S.NOEL and SHARON L.
SCHWALM,witnesses,this'�'day of May 2008.
� -�
ot ry Public
COM NWEA�TH OF PENNSYLVANIA
Notadal Seal
Roger B.Irvuin,Notary Public
Carlisle�,Cumberland Counry
My Canmission Expires Oct.3,2008
Member,Pennsylvania 4ssociation Of Notaries
�O'���°�1�� . . i o -
Statement Period 12/22l12 TO 01/21/13
PRENIIER CHECKING
For your convenience our Customer Contact Center
is avaiiable from 7 am-8 pm EST,7 days a week.
Call us at 1-877-768-1143.
Hearing impaired may call 1-800-428-9121 (T7Y/TDD).
www.sove reignbank.com
00006838 MSBR3778012 O1 OOQO
RUSSELL E CLARK o 0 0 0
414 W PENN ST 7 0 2t o
CARLISLE PA 17013-2234 1900001172
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page 1 of 4 �� Ba�co Sanlander,S A res0eclively,or their alfiliales a su0sidanes m Ihe United Stales and olher r.ounlnes 169101 b9i4
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Account Activity (Cont.for Acct# 1691016934)
Date Description Additions Subtractions Balance
HILL/PA US
.::.�;
01-11 CHK CARD PURCHASE HOLY SPIRIT HOS CAMP $13.08 $12,597.04
HILL!PA US
01-15 CHECK 000000002518 $250.00 $12,331.04
01-17 CHK CARD PURCHASE NELL'S-WALNUT $30.70 $12,200.34
CARLISLE/PA US
01-21 Ending Balance � $12,100.34
IN CASE OF ERRORS OR QUESTIONS ABOUT YOUR ELECTRONIC TRANSFERS
CALL YOUR CUSTOMER SERVICE CENTER AT THE NUMBER SHOWN ON THE TOP OF YOUR STATEMENT OR WRITE TO THE BANK
FOR DEBIT CARD ISSUES: POR ALL OTHER ELECTRONIC TRANSFER ISSUES:
Sovereig�Bank Sovereign Bank
Attn:Card Disputes Team Attn:Client Relations
MAI MB3 02 05 10-421-CRI
P.O.Box 831002 P.O.Box 12646
� Boston,MA 02283-1002 Reading,PA 19612-2646
�
pPlease contact us if you think information about an electronic transfer on your sta[ement or receipt is wrong or if you need additional info�rnation about
;� an electronic transfer on the statement or ceceipt. We must heac from you no Later than 60 days aRec we sent you the FIRST statemem on which the
� error appea[ed.
� • Tell us your name and account number. •Describe the electronic ttansfer error or the electronic ttansfer�hat you are unsure about and
b • Tell us ihe dollar amount of the suspected error. explain as cleady as you can why you believe there is an error or why you need fucther
� inTormation.
a
r
� If you tell us orally,we may require you to send your complaint or question in writing within 10 business days.
�
^� We will prompdy investigate the matter and call or wcite to you with an answer within 10 business days.If we nced more time,we may take up to 45
� days to invest�gate yout comQlaint or question.If we do,we wdl cmdit you�account within this 10-day peuod for the amountyou think is in e[tot,so
P you will have the use of the money dunng the[ime it takes us to complete our mvestigation.If we ask you to put your complamt or question in wnting
�
and we do not receive it within 10 busmess days,we may choosc not to c�edit youc account.
�
p For errors involving new accounts,point of sale purchases o[foroign transactions,we may take up to 90 days to invesligate your complaint or
� question.For new accounts,we may take up to 20 business days to credit your account for the amoun[you thmk is in error.
a
pWe will tell you the results of our investigation within 3 business days after completing our investigation.If we decide there was no error,we will
� send you a wntten explanation.You may ask for copies of the documents we used m our investigauon.
�
� 1N CASE OF ERRORS OR QUESTIONS ABOUT OTHER TRANSACTION5 ON YOUR STATEMENT
n You must contact us within thiriy(30)days after you receive your statement if you think a transaction,other tl�an an electronic transfer,shown on
p your statement is wrong or if you need more infocmation about the tcansaction.
n
You may contact your neatest branch oi ouc Customer Contact Center at 877-SOV-BANK. Customers with hearing impairments may call
800-428 9121(TTY/TDD). We will investigate your dispute and tell you the results of that investigation.
�?it`J�
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PaSe 3 af a 1691016934
Thrivent Financial for Luth � Securities offered through
erans Thrivent Investment Management inc.,
625 Fourth Ave.S., Minneapolis,MN 5541 5-1 665,
4321 N. Ballard Road,Appleton,WI 54919-0001 a wholly owned subsidiary of Thrivent Financial for Lutherans.
Thrivent.com•800-THRIVENT(800-847-4836) Member FINRA and SIPC.
April 12, 2013
SUMMARY OF ANNUITY LC4817741
1. Name of Annuitant: Russell Eugene Clark
2. Date of Death: January 20, 2013
3. Address of Decedent: 414 W Penn St
Carlisle PA 17013-2234
4. Kind of Contract: Non-Qualified Variable Annuity
Date of Issue: September 15, 2010
5. Date of Death Value: $176,982.64
6. Name of Owner: Russell Eugene Clark
7. Name of Beneficiary(s): SHERWOOD CLARK, JACQUELINE COX, RUSSELL CLARK JR,
DENISE THOMPSON, GREGORY CLARK
'r
I
. �
Kristi Sic er,Advanced Claims Examiner
Thrivent Financial for Lutherans
4321 N. Ballard Road
Appleton, WI 54919-0001
�PAUL D. DALBEY, DPM
' 5 KACEY COURT, SUITE 202 Closing Date: 03/08/2013
MECHANICS�'Bl�l' G, PA 17055-9222
(717) 591-13 � Balance Due: $42.89
Patient: RUSSELL E. CLARK 5662
Bill To:
RUSSELL CLARK PAUL D. DALBEY, DPM
C/O DENISE THOMPSON 5 KACEY COURT, SUITE 202
414 W PENN STREET MECHANICSBURG, PA 17055-9222
CARLISLE, PA 17013
Page; 1
PAUL D. DALBEY, DPM RUSSELL E. CLARK
5 KACEY COURT, SUITE 202 THORNWALD HOME
MECHANICSBURG, PA 17055-9222 442 WALNUT BOTTOM ROAD
CARLISLE, PA 17013
Account Number: 5662 Closing Date: 03/C�8/2013
Date: Code: Description: Charge: Credit•.
04-Jan-2013 11721 DEBRIDE MYCOTIC NAIL 6 OR MORE $55.00
� 01/22/2013($42.89 Applied to Deductible)
Paid by Insurance/Adjustments $12.11
---------------------------------------------------------------------------------------------------�-------------------•
DUE FROM PATIENT $42 g9
. ,���;.. .�
•�� S�';;•,.
c,.
_, ';`9.°i:`^�f...,, -
°yiYce
Total Due From Patient :- $42.gg
Charges Marked '` Have Appeared on a Previous Bill
Your prompt payment is appreci
Current Over 30 Days Over 60 Days Over 90 Days Total Balance
�42-$9 $0.00 $0.00 $0.00 $42.89
�
~ . ' � STATEMENT
Thornwald Home
442 Walnut Bottom Road Statement Date: Ol/O1J2013
Carlisle, PA 17013 Due Date: 01/25/2013
Telephone: (717) 249-4118
a Amount Enclosed$
Amount Due: $ 9,146.11
Account#: 1263
RE: Russell E Clark
Denise Thompson
414 W. Penn St.
Carlisle, PA 17013
I Days =
Date � �v�DeSC�i kion�:��,.-.'� �ant Rate Ghar es �� Pa qrents �Balances
Balance B/F 8,410.89 8,410.89
12/28/12 HOMPSON, DENISE 8,410.89 .00
12/24/12 Medicai Supplies 19 .47 44.18 44.18
12/30/12 Personal Supplies 2 .09 .18 44.36
12/31/12 Cable Television 1 25.75 25.75 70.11
12/31/12 Beauty&Barber 1 14.00 14.00 84.11
12/01/12- 12/23(12Room&Board-Semi-Private 23 267.00 6,141.00 6,225.11
12/O1/12- 12/31/12 Room&Board-Semi-Private 31 267.00 -8,277.00 -2,051.84
12J24/12- 12/31J12 Room&Board-Semi-Private 8 276.00 2,208.00 156.11
01/O1(13 - 01/31/13 Room&Board-Semi-Private 31 Z90.00 8,990.00 9,146.11
I
Current 31-60 Days 61-90 Days Over 90 Days Amount Due
9,146.11 .00 .00 .00 9,146.:11
Payments MUST be received BY the 25tFiof each month.
Attention: MA recipients Statement Date: O1/Ol/2013
Documentation MUSt be received in order to receive credit on a monthly
basis. - - _ Due Date: O1J25/2013
Russell E Clark- Account#: 1263
Thornwald Home
442 Walnut Bottom Road
Carlisle, PA 17013
Telephone: (717) 249-4118
Mlilennium I'hcy. Systems Mechanicsk
, •5020 Ritter Road, Suite 11 Ci
� • Mechanicsburg PA,17055
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INVOICE
01/31/2013 Account Number: �NCtisss
RUSSELL CLARK
c/o DENISE THOMPSON 1263
414 W.PENN STREET PVT
CARLISLE PA,17013
a:. a� .' .� a `TM3' '$ r�y�..: 1 � �vu � r t� �'
A�fOU#l���t�9M ��s����'� '; �`4�10�����'��`�' � $
rfx�...� �,� ;� ��1�, _,�_�_ ..
Please Detach Here and Return Top Portion With Your Payment
-- ------------------------- -
_:-- - - --- -- ---------------------------------------------------------------------------------------------------------------------
Invoice Date:01/31/2013,Acct#:TWNC1583,CLARK,RUSSELL E,Thornwald NC,L,BRANSCUM,GEORGE -X -
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01/01/2013 6564023 39.00 Carbidoua-Levodopa Oral TableT25-250 MG $ 10A0 c $ 0.�0 $ 10.00 RX �
00093-0294-05
01/01/2013 6587971 13.00 Escitalopram Oxalate Oral Tablet 20 MG $ 10.00 c $ 0.00 $ 10.00 RX
65862-0375-01
01/01J2013 6643904 26.00 Lamotripine Oral Tablet 150mp $ 10.00 c $ 0.00 $ 10.00 RX
00093-7247-06
01/04l2013 6646198 28.40 Triple Antibiotic External Ointme�t 3.5-4�0-5000 $ 9.44 $ 0.00 $ 9.44 OTC
51672-2016-02
01/12/2013 6653733 2.00 LevoFloxacin Oral Tablet 250 MG $ 5.71 c $ 0.00 $ 5.71 RX
65862-0536-50
01l13/2013 6653735 2.00 Levofloxacin Oral Tablet 250 MG $ 5.71 c $ 0.00 $ 5.71 RX
65862-0536-50
01l14l2013 6652186 5.00 Levofloxacin Oral Tablet 500 AAG $ 9.88 c $ 0.00 $ 9.88 RX
65862-0537-50
01/14/2013 6652185 3.00 Bisac-Evac Rectal Suppositorv 10 MG $ 0.45 $ 0.00 $ 0.45 OTC
00713-0109-01
01/14/2013 2035438 30.00 MorphineSuifate $ 24.48 c $ 0.00 $ 24.48 RX
00054-0404-44
01/14/2013 6652180 24.00 Maaap Oral Tablet 325 MG $ 0.36 $ 0.00 $ 0.36 OTC
00904-1982-80
01/14l2013 6652181 24.00 Mapaa Orai Tablet 325 MG $ 0.36 $ 0.00 $ 0.36 OTC
0090�1-1982-80
01/14/2013 6652183 4.00 Bisacodvl EC Oral Tablet Delayed Release 5 MG $ 0.08 $ �.00 $ 0.08 OTC
00904-7927-80
$ 178.73$ 0.00 rvH $- 0.00 $ 0.� � Y
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00 $ 0.00 $ 75.78 $ 10.69 $ 0.00 $ 0.00 265.20
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717-245�-23�5 -
1/Z�y`013 TCRM 11 3:35:26 PM
HE:LLO, MY NAME ]S 534 D��nielle
� U�elr,ome GOLD SAVTNG�� ID: 41101174?..08
SHIIR�INE: 4VHOLE B 1@ 29.36 �29,9�F
Gold �avit�gs
B„12 ibs @ -1,81/lb -�14.7CF
SUEtTO��AL. 1 �j�.��
�*DISI.DUNT 1 $fJ.7'6
ADJ IOTE!L 1 �1�.5i7
TA�; E;�EMPT $Q.C�C
TOTkL �l�.J�
DUE==�> $i4,��0
�CHARI�E�� $1�.5�J
CH��NGC [lUE �G.GO
YGII EARNED �;$14.70 IPI GOL.D SAVTVGS
�VITH THIS �f Z�N���1CTI0hd
IT IS MY HOP� TFIAT YOUR Y
SI�OPPING EXPEF'IENCE WAS AN
ENJOYABLE ONE! ANi COMMENTS
OR CONCERNS FFEL FREE TO
CONTACT ME KEITFI HOF�FMAN
�:�:�*�:�:�***�***��**�*�**�:��*�::�**�:*�.�:*:r•x*
NELI.S RETU�N F'OLIC�Y
��LL. RE:7URNS MUST BE MADE WI�fHIN 7 DAYS
IiE(%EIPT ARE REQU]RED FOR REFUNDS
Walm�r `�'
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Save money.Live better.
MANAGER�CHAD ROETIN� � ,�
60 N08LE BLVD QuGlify,Selecfion,Savin�s,E�ery Day.
CRRLISLE PA 1T013
ST# 25T9 OP# 00002062 TE# 13 TR# 01381 Vlstt us on the Internet
CHIPS 00330q900039 F 7.50 N www.GiantFoodStores.ca�n
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My 9oa1 is to ensur•e aour satlsfactlon
.GV U€f B� A8�8�42�3��g6r-F--3-gg-{�}-, evera ttme aou shoP wlth us. If there
CL LEMONADE 004300095065 F 2.68 X is anythins more I can do to imProve '
aour exPertence Please call or wrlte. -
.WHPD VANILLA 00160003�430 F 1.58 N Mike Yauns. Store Manaser
R C MILK CHC 001b000�5900 F 1.68 N •
CAKE MIX 001600090989 F 1,2$ N Giant Food Store #6112
CAKE MI}t Q01o00040989 F 1,28 N 255 �. 5arina Garden Streefi
CAKE MIX OO1b00p1305� F 1,28 N Carltsle, PA 17013
CAKE MIX 001600043054 F 1.28 N
SWT RELISN 0009300000qq F 1.78 p Store TelePhone: (717) 249-2323
GV SQ2 MSTR4 007874243474 F 0.92 N Pharmac� TelePhone: (717) 249-8836
A erv��QL'jLAfl'/O7 f'V71NJ � �,�t}
CL ICED TEA OOq30009b064 F 2.68 N THANK YOU 4800172T558
COOKIES 007874206872 f 5.28 0
COOKIES 007874206572 F 5.28 U SB MRR CHERRY
COOKIES 0726b2661100 F 3.18 0 1 .05 !b @ 3.99 /lb � 99 F
COOKIES 0T2552651100 F 3.18 0 WHT SDLESS GRAPE lJ q.�g F
CQOKIES 072552661100 F 3.18 0 1 .68 16 @ 3.99 /lb
PD RSTD TKY 020$35211050 F 10.60 0 REO SDLS GRRPE W BC 6.70 F
PD BK FR HRM 02G83�830903 F 9.03 0
EGGS OOZ7q3833303 F 1.86 0 t �68 llh @ 2.49 /lb = q. �g
R C MILK CHC 001600045900 F 1,5$ R SC FRESH SAVINGS 2.5Z_F j
R C MILK CHC 001600046900 F 1.58 N Prtce bou Pay 9, 18 ;
1 .92 lb @ 1 .99 /lb
PLUM TOMATOES W 3.82 F
0.57 !b @ 3.99 /!b
EURO YELLO PEPPR W z Z? F ~
SUBTOTAL 110.3T CITRt1S SRLAO ? 99 F ;�!;`
TAX 1 b,QOQ % 1.66 MARZ FF RANCH DP 3.99 F �
TOTAL 112.03 RELISH TRRY LG 29.99 F �
DEBIT TEND 112.03 CELLO LETTUCE 29 lJ 2.99 F I
�� � � CHANGE DIIE 0.00 2@ 9,99
��- ��' `� ' CORED PINEAPPLE W 9.98 F
EFT DEBIT PRY FROM PRIMARY '° / � 3@ 9.99
112.03 TOTAL PURCHASE 1L8 STRAWBERRY W B� �q g7 F
ACCOUNT # ***� �r�r** �r*** 2979 g 3@ 1 .50
REF # 302900383880 SC FRESH SAUINGS 9.50-F
N�?��RK I�. 00't6 APPR CO�JE �?2888 Price for 3 10.q7
TERMINAL # Mx050891 BLUEBERRIES �sz w ac s.�y F
SC FRESH SAVINGS 5,00-F
O1/29/13 09:66:91 Prtce you Pay 3.99
10 @ 3.99
# ar�MS so�n 32 MRTY POT DNR RLL 39 90 F
TC# 6600 669q 2866 0225 83q4 1 TOTAL BEFORE SAVINGS 132.27
IIIIIINIINIIUIIII�IIIIIIIINIIN�IIIIII�IIIIIIIIIIIIIIIIBINIIIIIhiIiIIIIIIIIIIIIII YO�R TOTRL SAVINGS ,z p2
TOTRL RFTER SAVINGS 120.25
TAX PAI� .00
Low Prtcea. Every daa. On everythlns. ***�TOTRL 120.25
Backed by our Ad Match Guarantee. ACCT RECEIVABLE I
01/2q/13 09:55:43 CHANGE �Z�.00 ;&
TOTAL NUMBER DF ITEMS SOLD =� 25
`��� 1 1/29/13 10:26 AM 6112 17 0017 119
�� K�� `V�/`0� I�m 9lad you shopped here today.
G�. �� Your Cashier - WRNDFl �
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G�c� Q�.� -, 7��� _
C-ln,�'c.l� - (3S�
� nal
� DECEASED RUSSELL E CLARK 01/20f2013
DepaAmant of the Treasury—Inlemal Revenue Servica (J9� /� I�
FOfR11040 U.�. individuaf Income Tax Return `O ■` pMBNo.1545-0074 IRSUseOnly—Donolwriteorsfapleinthisspaca.
For the ear Jan 1-Dec 31,2012,or oiher tax ear be innin ,2012,endin ,20 See separate instructions.
Your first name and inilial Last name Your socfal securNy number
RUSSELL E CLARK
If a Joint retum,5pouse's first name and initial Last name Spouse's soclal securlty num6ar
Home address(number and street).If you have a P.O.box,see inslructlons. Apartment no. � Make sure the SSN(s)above
414 W. PENN STREET and on line 6c are correct.
c�ry,town or post otfice,state,and ZIP code.If you have a toreign address,aiso comPiate spaces be�ow�see inswcsons�. Presidential Election Campaign
CARL I SLE PA 17 013 Check hare it you,or your spouse if filing
Foreign counlry name Foreign provincelstatelcounry Foreign postal cale loin0y,want$3 lo go to tt�is fund7 Chacking
a box below wiil not change your tax or
re/und. YoU SpOU52
1 Single 4 �Head of household(with qualifying person).(See
Filing Status instructions.)1f the qualitying person is a child
2 Married filingjointly(even if only one had income) but not your dependent,enter this child's
Check only 3 Married fiGng separately.Enter spouse's SSN above&full name here ►
one box. name here. .' 5 ❑ Qualifying widow(er)with dependent child
Exemptions 6 a Yourself.if someone can claim you as a dependent,do not check box 6a. . . . . . , soxo5 cne�kaa
on 6a and 6b . 1
b SpOUSE . . . . . . . . . . . . . . . . . . . No.ot chlidren
(2)DependenYs (3)DependenYs 4 ir onscwho:
c Dependents: cnii under •i��ea
social security relationship a B» Wiihyo� . .
number to you quali x,9ra
(7)First name Last name �e�e i su5j IWe wlth you
due to dlvoree
or separatlon
It more than four Is�instr5► . .
dependents,see on6c oets
insiructions and entered above.
check here . . '� Add numbers
on Ilnes
d Total number of exem tions claimed. . . aaoYe . . ' 1
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7 Wages,salaries,tips,etc.Attach Form(s)W-2 . . . . . . . . . . . . . . . . . . . . . . . . . 7
Income g a Taxable interest.Attach Schedule 8 if required . . . . . . . . . . . . . . . . . . . . . . . . 8 a
b Tax-exempt interest.Do not indude on line 8a . . . . . . . . � 8 b� 525. -_._
Attach Form(s) 9 a Ordinary dividends.Attach Schedule B if required . . . . . . . . . . . . . . . . . . . . . . . g a 3,7 91.
W-2 here.Also b Qualified dividends. . • . . . . • . • • • • • • • • • • • • • • � 9 b� 1,287. _
ailaCh Forms �0 Taxable refunds,credits,or offsets of state and local income taxes. . . . . . . . . . . . . . . .70�
W2G and 1099•R
if tax was withheld. » Alimony received. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Business income or(loss).Attach Schedule C or C-EZ. . . . . . . . . . . . . . . . . . 12
If you did not 13 Capital gain or(loss).Att Sch D if reqd.I(no[reqd,ck here • . • . • . • . • . . . • � ► ❑ 13 -3,0 0 0.
gel a W2,
see instructions. 74 Other gains or(losses).Attach Form 4797 . . . . . . . . . . . . . . . . . . . . . . . . . 14
15 a IRA distributions . . . . . . . 15a �b Taxable amount . . . . . . . . 15 b 132,952.
16 a Pensions and annuities . . . 16 a b Taxable amount . . . . . . . . 16 b
17 Rental reai estate,royalties,partnerships,S corporations,trusts,etc.Attach Schedule E. _ . . 17
Enclose,but do 18 Farm income or(loss).Attach Schedule F . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
not atlach,any 19 Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1g
payment.Also, 20 a Social security benefds. .
pleaseuse • • � • � 20a� 21,047. �bTaxabfeamount . . . . . . . . 20b 17,890._
Form1040•V. 21 Otherincome ------------------------------------- 21
22 Cambine ihe amounLS in ihe far ri ht column(or lines 7 throu h 21.This is our total income. . . ► 22 151,6 3 3.
23 Educator expenses . • • • • . • • • • • • • • • � • • • • • • 23
Adjusted 24 Certain business expenses of reservists,performing arGsts,and{ee-basis
GPOSS govemment officials.Attach Form 2106 or 2106-EZ . . . . . . . . . . . 24
Income 25 Health savings account deduction.Attach Form 8889 . . . . . 25
26 Moving expenses.Attach Form 3903. . . . . . . . . . . . . . 26 '
27 DeduGibte part oF self-employment lax.Attach Schedule SE . . . . . . . 27
28 Self-employed SEP,SIMPLE,and qualified plans . . . . . . . 28
29 Self-employed health insurance deduction . . . . . . . . . . . 29
30 Penalty on early withdrawal of savings. . . . . . . . . . . . . 30
31 a Alimo�y paid b Recipienl's SSN . .' 31 a
32 IRA deduction . . . . . . . . . . . . . . . . . . . . . . . . . 32
33 Student loan interest deduction . . . . . . . . . . . . . . . . 33
34 Tuition and fees.Attach Form 8917 . . . . . . . . . . . . . . 34
35 Domes[ic production acGvities deduction.Attach Form 8903. . . . . . . . 35
36 Add lines 23 through 35 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
37 Subtract line 36 from line 22.This is your adjusted gross income. . . . . . . . . . . . ► 37 151,6 3 3.
BAA For Disclosure,Privacy Act,and Paperwork Reduction Act Notice,see separate in5tructions. Foia,oiiz oinvi3 Form 1040(2012)
ry
� ' Form 1040(2012) RUSSELL E CLARK Page2
Tax and 38 Amount frottt--- 'ne 37(adjusted gross income) . . . . . . . . . . . . . . . . . . . . 38 151,633•
Credits 39 a Check � You were born before January 2,1948, Blind. Total boxes ;
�f: Spouse was bom before January 2,1948, �Blind. checked ► 39 a 1 ` `
Standard L b�f your spouse itemizes an a separate re[urn or you were a dual-status afien,check here . . . . . ► 39 b `"��`�',
Deduction 40 Itemized deductions(from 5chedule A)or yaur standard deduction(see left macgin}. . • 40 � 96,571.
for— 41 5ubtract line 40 from line 38. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 55 062.
• People who 42 Exemptions.Multipiy$3,800 by the number on line 6d . . . . . . . . . . . . . . . . . . . . 42 3,S 0 0.
check any box 43 Taxable income.Subtract line 42 from Gne 41.
on line 39a or I(line 42 is more than fine 41,enter•0•. . . . . . . . . . . . . . . . . 43 51,2 6 2.
39b or who can • • • • • • • • • • • •
be claimed as a 44 Tax(see insirs).Check if any from: a Form(s)8814 c ❑962 election
dependent,see
instructions. b BForm 4972. . . . . . . . . . . . . . . . 44 8,717•
•All others: 45 Alternative minimum tax(see instructions).Attach Form 6251 • - • • • • • . • • • • • • • • 45
Single or 46 Add lines 44 and 45. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ► 46 8 717.
Married fifing 47 Foreign tax credit.Atlach Form 1116 if required. . . . . . . . . 4T 6. ;ti;:�;;'�;
separately, 48 Credit for child and dependenl care expenses.Attach Form 2441 . . . . . . 48
$5,950 49 Education credits from Form 8863,line 19. . . . . . . . . . . . 49
Married filing 50 Retirement savings contributions credit.Attach Form 8880 . . . 50 � ' '
jointly or
Qualifying 51 Child tax credit.Attach Schedule 8812,if required. . . . . . . . 57 '� :�
widow er, 52 Residentiat energy credits.Attach Form 5695 . . . . . . . . . . 52 `' `� -
$11,900, '
Head of 53 Olher crs Bom Form: a ❑3800 b �ggq} c � 53 ��r;.
household, 54 Add lines 47 through 53.These are your total credits. . . . . . . . . . . . . . . . . . . . . 54 6.
$8,700
55 Subtract line 54 from line 46.If line 54 is more than line 46,enter-0- . . ► 55 S,711.
Othel' S6 Sel(-empioymenl lax.Attach Schedule SE . . . . . . . . . . . . . . . . . . . . . . . . . 56
7aXeS 57 Unreported social security and Medicare tax from Form: a �q�37 b �8919. . . . . . . . . . . . . 57
58 Addi[ional tax on IRAs,olher qualified retirement plans,e[c.Attach Form 5329 if required . . . . . . . . . . . 58
59 a Household employment taxes from Schedule H . . . . . . . . . . . . . . . . . . . . . . . . 59 a
b First-time homebuyer credit repayment.Attach Form 5405 if required . . . . . . . . . . . . . 59 b
60 Other taxes.Enter code(s)from instructions _____________________ 60
61 Add lines 55•60.This is our total tax . . ► 61 8,711.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pa ments 62 Federal income tax withheld from Forms W-2 and 1099 . . . . . 62
If you have a 63 2012 estimated tax payments and amount applied from 2011 return. . . . . 63
qualifying 64 a Earned income credit(EIC) . . . . . . . . . . . . . . 64 a
chiid,attach b Nonlaxabie combat pay elecGon . . ' 64 b�
Schedule EIC. =�-
65 Additional child tax credit.Attach Schedule 8812 . . . . . 65 J
66 American opportunity credit from Form 8863,line 8 . . . . . . . 66 � �;
67 Reserved . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 �. ;r i �'
68 Amount paid with request for extension to file . . . . . . . . . . 68 �� "
69 Excess social security and tier 1 ftRTA tax withheld. . . . . . . 69
70 Credit for federal t on fuels. s ch Form 6 . . . . . 70 �' '��'
71 Credils from Form: a�439 b�?n�Reserved c�8801 d ❑$885 . 71 _
72 Add Ins 62,63,64a,&65-71.These are aur total mts . . ► 72
. . . . . . . . . . . . . . . . . . . . .
Refu nd �3 If line 72 is more than line 61,subtract line 61 from line 72.This is the amount you overpaid. . . . . . . . 73
74 a Amount of line 73 you want refunded to you.If Form 8888 is aitached,check here . . . ' � 74 a
► b Routing number. . . . . XXXXXXXX ► c Type: Checking �Savings
Direct deposit? . d Account number . . . . XXXXXXXXXXXXXXXX
See�nstruGions. 75 Amount of line 13 you want applied to your 2013 estimated Wx. . ' 75 I
Amou nt 76 Amount you owe.Subtract line 72(rom line 61.For details on how to pay see instructions . . . . . . . . . ► 76 8,7 7 8.
YOU OWe 77 Estimated tax penal (see instructions). . • I 77 ( 67. '? t, ,
Third Party Do you wan[ro albw another person to discuss lhis re[urn with lhe IRS(see instructions)? . . . . . . �Yes.Complete below �No
Designee ome�ee's .Karl R. Thorn, Jr. ,CPA no�e ' (717) 218-0214 numbet(PIN)tificalion � 20869
i,`1 n Under penalUes oi perjury,i declare ifiat I have examined this return and accompanying schedules and slatements,and to ihe besl of my knowledge and
9 belief,fhey are true,correcl,and e.D eralfon o.preparer.(other than laxpayer)is based on alf information of which preparer has any knowledge.
Here Your signaWre `L� i � Data Your occupalion Daytime phone number
Joint return?
See inslructions. 1 � � RETIRED
Keep a copy Spouse's signature.If a joinl relum,both musl sign. Dale Spouse's occupation it tha IRS sanl you an Idenlity Pro-
fOf OUf feCOfdS. tecGon PIN,enter
y , it here(see insvs�
PrinVType preparef's name P r si Date Check ii PTIN
Paid
Karl R. Thorn, Jr.,CPA r , , PA 03/05/2013 self-empioyed P01068066
Preparer Firm's name � Karl R Thorn Jr. , CPA
Use Only Firm'saddress ► 37 S. Hanover Street FimisElN► 46-1276859
Carlisle PA 17013 Phoneno. �'717� 218-0214
Form 1040(2012)
FDIA0112 01I11l13