HomeMy WebLinkAbout06-18-13 (2) � 1505610101
REV-1500 °`�°,-,°> �
Bnn lv0nta OFFICIAL USE ONLY
PA Department of Revenue P ri Counry Cade Year File Number
eureau oflndiv�dual7axes INHERITANCE TAX RETURN
' PO BOX z8o6oi 2 1 1 2 0 1 3 2 5
Harrisburg,PA iyu846oi RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW .
Social
09 182 O1 2� 110 71 952
DecedenPs Last Name Suffiz DecedenPs First Name MI
W e r t z � G w y n �M
(If Applicable)Enter Surviving Spouse's Infortnation Below
Spouse's Last Name Sultix Spouse's First Name MI
P o t t s � D a v i d �W
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
5 7 S 8 6 0 3 6 7 REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
m 1.Onginal Retum O 2.Supplemental Retum , , ,�..�, " .,, O� 3. Remainder Retum(date of death
priorto 12-13-82)
p 4. Limited Esfate O 4a. Future Interest Compromise(date of O 5. Federel Estate Tax Return Required
death afler 12-12$2)
�1 6. Decedent Died Testate O 7.Decedent Maintained a Living Trust � 8. Total Number of Safe Deposii Bozes
(Altach Copy of Will) (Attach Copy of 7rust) �
p 9.Litigation Proceeds Received O 10.Spousal Poverty Credii(dale of death O 11. Election to taz 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 INFORMATIQElySHOULD BE UIRE6TE0 T0:
Name Daylime TAIEp ne Nump�; � �
M a r 1 i n R . M o C a 1 e b 7 1 _� 9, 1�7 �_ d�"'0
R� WILt9VSEq L �
Z Cn � � � O
d n � O O
First line of address O C � 3 T1 '�l �
�- �i t
2 19 Ea st Ma i n St reet = z �. � c� •
--1 I17
� r +
Second line of address D _� � p
� �
P . 0 . B ox 23 0 . , ,,.
Cify Of Posl OffICB ' Slete ZIP COdO � � ' �DATE FILED
M e c h a n i c s b u r g P A 1 7 0 5 5
CorrespondenPse•malladdress: mdY'�111RICCd�2b�dff15f1. -ORI '
Untler penalties of perjury,I dedare that I�ave examined ihis retum,induding eccompanying schetlules and statements,and to the best of my knowletlge an0 belief,
it Is true,cortect and complete.DeGaration ot preparer other than ihe personal representalive Is based on all informalion of whiU preparer has any knowledge.
SIGNATURE PERSO RE PONSIBLE FOR ING RETURN • �AT
� �, ��/� David W.Potts � ��/7 /J
ADDRESS
21 Maple Nvenue, Cam Hill PA 17011
SICaNA OF P PA Tyf��FJkN��ESENTATIVE DATE
si�� c�r% Law Offices-Marlin R Mrfalah — /y-�
ADDRESS �-�
219 East Main Street Mechanicsburq, PA 1]�5�
PLEASE USE ORIGINAL FORM ONLY
$ide 1
� 1505610101 1505610101 �
��
J 1505610105
REV-1500 EX '
DecedenYS Social Securiry Number
o�oa�,5r,ame: Gwyn M. Wertz
RECAPITULATION ,
1. RealEstate(ScheduleA). ............ .... .... ..................... ... 1. � •�Q �
2. Slocks and Bonds(Schedule B) . .................. ... ............. .... 2. � , � �
3. Closely Held Corporetion, Partnership or Sols-Proprietorship(SchedNe C) ..... 3. � , � � .
4. Mortgages and Notes Receivable(Schedule D)......................... .. 4. � • � �
5. Cash,Bank Deposits and Miscellaneous Personai Property(Schedute E)...... . 5. Zi 5 3 6 7 .�1 2
6. Jointly Owned Properry(Schedule F) p Separate Billing Requested•........ 6. Q • Q Q
7. Inter-Vvos Transfers&Misce�laneous Non-Probate Property '
. (Schedule G) p Separete Billing Requested.... .... 7. $ 2 2 2 6 . 8 9
� � � 8. Total Gross Assets(total Lines 1 through 7).............. ....... ........ 8. 1 � � �� 9 Q •.� 1
9. Funeral Eupenses and Adminishative Costs(Schedule H)........... ........ 9. i � 4, 1 6 • 2 $
. 10. Debis ot Decedent,Mortgage Liabilities,and Liens(Schedule I) .......... .... 10. 2 4 0. 6 6 • 4� �
11. ToWI Deductlons(total Lines 9 and 10).... .................. ... ........ 11. 3 4 4 8 2 «7 5
12. Net Value of Estate(Line 8 minus Line 11) ........:...:................. 12. ] $ ], j 1 .i 2 (
13. Charitable and Govemmental BequestslSec 9113 Trusts for which
an eleaion to tax has not been made(Schedule J) ... .... ................. 13.
14. Net Value SubJect to Tax(Line 12 minus Line 13) .......... ........ ...... 14. J 3 j 1 1 •�2 (
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal Wx rate,or
trensters under Sec.9116
(a)(�z)x.o� - 7 3 1 1 1 . 2 6 �5. 0 . 0 0
16. Amount of Line 14 Wxable
� at lineal Fate X.0� 0 . 0 0 16. Q . 0 Q
17. Amount of Line 14 taxable •
, al sibling rate X.12 17. � . Q �
18. Amount of Line 14 taxable
at collateral rate X.15 . �e. 0 • 0 0
19. TAX DUE . .... ..... ....... ....... ....... .... .............. ....... . 19. O . O O
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT . :0 � • .
� � ♦ , . . � ' . `.\
� � .� . . ., . . . . '� . . a,•,
Side 2
� 1505610105 1505610105 J
n �`
_ �,
REV-1500 EX Page 3 Flle Number
DecedenYs Complete Address: 21-2012-1325
DECE�ENTS NAME
Gw n M. Wertz
S7REETADDRESS
21 Maple Avenue
��n STATE 21P
Cam Hill PA 17011
Tax Payments and Credits: ,,
1. Tax Due(Page 2,Line 19) . . (1) . 0.00
2. CreditslPayments
A.Priar Paymenls
B.Distaunt
Total Credits(A+B) (2) 0.00
3. Interest
.. �3� 0.00,
4. It Line 2 is greater than Line 1 +Line 3,enter the diHerence. This is ihe OVERPAYMENL
Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00
5. If Line 1 +Line 3 is grealer than Line 2,enter the difference.This is ihe TAX DUE. (5) 0.00
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 incame of the property hansferred�.......................................................................................... ❑ �
� b. retain ihe right to designate who shall use the property Vansferted or its income:............................................ ❑ �
c. retain a reversionary interesl,or.......................................................................................................................... ❑ �
d. receive ihe promise tor li(e of either payments,benefits or care7...................................................................... ❑ �
2. If death occuned after Dec.12, 1982,did decedenf transfer property within one year ot death
without receiving adequate consideration7.............................................................................................................. ❑ �
3. Did decedent own an"in Wst foP or payabte-upon-0eath bank aaounl or security at his or her death7.............. ❑ �
4. Did deoedent own an individual retirement account,annuiry or other non-probate property,which
confainsa benefiaary designalion? ........................................................................................................................ � ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE R AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan. t, 1995,the tax rate imposed on the net value of transters to or for the use of the surviving spouse is
3 percent[72 P.S.§9176(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 ot 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 disdosure of assets and ..
filing a tax retum are sGll applicable even.if the surviving spouse is the onry 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 ihe use of a natural parent,.an
adoptive parent or a stepparent of the chiid is 0 percent p2 P.S.§9116(a)(7.2)].
• The tax rate imposed on the net value of transfers to or for the use oi the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S.§9116(12)[72 P.S.§9116(a)(t)1.
• The tax rate imposed on the net value of transiers to or for the use of the decedenfs siblings is 12 percent[72 P.S.§9116(a)(1.3)j.A sibiing is defined, under
Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
i, ;.. . . . _ . ..
f �
REV-1508 EX�(1-9'n
SCHEDULE E p
COMMONWEALTHOFPENNSYLVANIA CASH, BANK DEPOSITS� C[ MISC.
'NRESIDENTDE EDETTRN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Gwyn M. Wertz SS�� 09/18/2012 21-2012-1325
Include the Proceeds of litigation and the date the proceeds were received by the estate.All property jointly-owned with the right of
survivorship must be disclosed on Schedule F.
ITEM VALUE AT DA7E
NUMBER DESCRIPTION OF DEATH
1 Belco FCU Savings Account No. 844326-0001, - principal balance as 832.82
of D.O.D. : $832.82; no accrued interest.
2 Belco FCU Checking Account No. 844326-0040, - principal balance 1,137.80
as of D.O.D. : $1,137.80; no accrued interest.
3 Belco FCU Money Market Account No. 844326-0060, - principal 6,073.50
balance as of D.O.D. : $6,073.50; no accrued interest.
4 2008 Pontiac G6-V6 convertible, - 30,941 miles, good condition. 17,323.00
TOTAL(Also enter on line 5, Fecapitulation) $ 25,367.12
(If more space is needed, insert additional sheets of the same size)
Copyright(c)7996 form mttware only CPSystems,Inc Form REV-7508 EX(Rev.1-97)
, ,
REV-1510EX��,-9» SCHEDULE G
INTER-VIVOS TRANSFERS &
COM NHERTAN E�AXRETURNANIA MISC. NON-PROBATE PROPERTY
RESIDENTDECEDENT
ESTATE OF FILE NUMBER
Gwyn M. Wertz 55�� 09/18/2012 21-2012-1325
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
DESCRIPTION OF PROPERTY % OF
ITEM RELATIONSHIPTO�ECEDENTANDTHE DATE Of TRANSFeft. DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE
NUMBER pTTACHACOPYOFTHEDEEDFORREALESTATE. VALUEOFASSET INTEREST (IFAPPLICABLE)
1 4 1(k) Savings & Investment 63,477.34 63,477.34
Plan No.700800, - Merrill
Lynch & Co. , Inc. , paid to
surviving spouse, David W.
Potts , as designated
beneficiary.
2 Retirement Accumulation 18,749.55 18,749.55
Plan No. 700820, - Merrill
Lynch & Co. , Inc. , paid to
surviving spouse, David W.
Potts, as designated
beneficiary.
TOTAL(Also enter on line 7, Recapitulation) $ 82,226.89
(If more space is needed, insert additional sheets of the same size)
Copyright(c)1996 torm software only CPSystems,Inc. Form f�EV-7$70 EX(Rev.1-97)
. 7 ' .._. .._ . . . . _
REV-1511E%�(1-97) SCHEDULE H
CoMMONWEALTHOFPENNSYLVANIA FUNERAL EXPENSES 8
INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENTOECEDENT
ESTATE OF FILE NUMBER
Gwyn M. Wertz 09/18/2012 21 2012 1325
Debts of decedent must be reported on Sehedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERALEXPENSES:
1 Myers-Buhrig Funeral Home, Mechanicsburg, PA, - funeral expense. 4,688.00
B. ADMINISTRATIVE COSTS:
7. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
��' State Zip
Year(s)Commission Paid:
2. Anorney'sFees Law Offices-Marlin R. McCaleb 1,500.00
3. Family Exemption:(If decedent's address is not the same as claimanYs,attach explanation) 3,500.00
Claimant David W. Potts
StreetAddress 21 Maple Avenue
Ciry Camp Hill State PA Zip 17011
lielationship of Claimant to Decedent Spouse
4. ProbateFees Register of Wills 153.50
5. AccountanPs Fees
6. Taz Return Preparer's Fees
7. Other Administrative Costs
1 Cumberland Law Journal, - advertising Letters. 75.00
2 Register of Wills, - short certificate. 5.00
3 Register of Wills, - filing Inventory and Appraisement. 30.00
4 Register of Wills, - reserve for filing Account, Releases, etc. . 250.00
5 Register of Wills, - Short Certificates. 4.00
6 The Carlisle Sentinel, - advertising Letters. 210.78
TOTAL(Also enter on line 9, Recapitulation) S 10�416.28
(If more space is needed, insert additional sheets of the same size)
Copyrlghl(c)1996 form software only CPSystems,Inc Form flEV-75�1 EX(Rev.1-97)
_
, REV-1512EX+(b97)
SCHEDULEI
COMMONWEALTHOFPENNSYLVANIA DEBTS OF DECEDENT�
INRESI�ENTD EDENTN MORTGAGE LIABILITIES, AND LIENS
ESTATE OF FILE NUMBER
_Gwyn M. Wertz 09/18/2012 21 2012 1325
Inelude unreimbursed medieal expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
1 Camp Hill Physicians, - account payable, medical expenses of 508.20
final illness.
2 Holy Spirit Hospital, - account payable, medical expenses of 21,230.92
final illness.
3 Pennsylvania Gastroenterology Consultants, - account payable, 290.00
medical expenses of final illness.
4 Quantum Imaging, - account payable, medical expenses of final 36.00
illness.
5 Spirit Physicians, - account payable, expenses of final illnes. 667.25
6 West Shore EMS, - account payable, medical expenses of final 1,334.10
illness.
TOTAL(Also enter on line 10, Recapitulation) t 24,066.47
(If more space is needed, insert additional sheets of the same size)
Copyright(c)1996 torm software only CPSystems,Inc Farm REV-7572 EX(Rev.1-97)
, �
REV-1513 EX�(9-00)
SCHEDULEJ
COMMONWEALTHOFPENNSYLVANIA BENEFICIARIES
INHERITANCETAXRETURN
RESIDENTOECEDENT
ESTATE OF FILE NUMBER
G M. Wertz 09/18 2012 21-2012-1325
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Nat List Trustee(s) OF ESTATE
I. TAXABLEDISTRIBUTIONS[includeautrightspousaldistrihutlans,antl
transfers unde�Sec.9176(aX12)]
1 David W. Potts _ ____. . _. _ _ Surviving Spouse Entire Estate
21 Maple Avenue
Camp Hill, PA ll011 `
ENTER DOLLAR AMTS.FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18,AS APPROPRIATE, ON FEV 1500 COVER SHEET
II. NON-TAXABLE�ISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOF WHICH AN ELECTION TO TAX IS NOT BEING MADE
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DIS RIB TIONS ON L N 13 OF REV 1500 COVER SHEET 3 0.00
(If rtrore space is needed, insert addRional sheets of the same size)
Copyright(e)2000 form sottware only The Lackner Group,Inc. Form REV-1513 FJ((Rev.9-00)
., � . ,
LAST WILL AND TESTAMENT
I, GWYN M. WERTZ, of the Township of Hampden, County of
Cumberland and Commonwealth of Pennsylvania, being of sound and
disposing mind, memory and understanding, do make, publish and
declare this as and for my Last Will and Testament, hereby
revoking and making void all former Wills and Codicils by me at
any time heretofore made.
FZRST. I order and direct that all my just debts and
funeral expenses be paid by my Executor or my Executors, • as the
case may be, hereinafter named, as soon as conveniently may be
�
done after my decease.
sECOND. i give and bequeath my automobiles and personal
effects and such household goods, furniture and furnishings as
may be my individual property and not the property of my
husband or owned jointly by me with him, and other tangible
personalty of like nature (not including cash or securities) ,
together with any existing insurance thereon, unto my husband,
DAVID W. POTTS, if he survives me for a period of thirty (30)
days. Provided, however, that if my husband shall predecease
me or fail to survive me for a period of thirty (30) days, then
? give and be�sea�h such tzngible personalty and insurance
thereon unto my son, JESSE D. POTTS, if he survives me.
THIRD. I give, devise and bequeath all the rest, residue
and remainder of my estate, real, personal and mixed,
whatsoever and wheresoever situate, unto my husband, DAVID W.
POTTS, absolutely and in fee simple, if he survives me for
�nw orr¢Es
MARLIN R. McCALEB
thirty (30) days.
., T , :
FOURTH. If my husband, DAVID W. POTTS, shall predecease me
' or fail to survive me for a period of thirty (30) days, then
and in that event I give, devise and bequeath all the rest,
residue and remainder of my estate, real, personal and mixed,
whatsoever and wheresoever situate, unto my Trustees,
hereinafter named, IN TRUST, NEVERTHELESS, for the following
purposes:
A. My Trustees shall hold, manage, invest and reinvest
the same and the income therefrom and may use or apply from
, time to time as much of the net income therefrom and the
principal thereof as my Trustees, in the exercise of their
sole and absolute discretion, may deem reasonable or
appropriate for the comfort, maintenance, care or education
(including college or other post-high school education or
training) of my son, JESSE D. POTTS, or to assist my son in
the purchase of a home or in the purchase or establishment
of a business, and for the comfort and happiness oP my
daughter, JAMEE L. WERTZ, and for her funeral expenses upon
her death (but not for her support) , after considering all
other resources available to each child, including but not
limited to pLblic resources such as Social Security
Disability benefits, Veterans� Administration benefits,
Medicaid and Supplemental Security Income benefits and
available benefits from all other appropriate federal, state
or local agencies serving the disabled. Because the needs
L/1W OFFICES
MARLIN R. McCALEB
- 2 -
' • ' :
of my children may differ from time to time, distributions
to them or on their behalf need not be equal or
proportionate and either of my children may be wholly
excluded from one or more such distributions in the sole and
absolute discretion of my Trustees. Any income not
distributed shall be added to and become a part of the
principal.
B. Notwithstanding the provisions of sub-paragraph A,
above, any income or principal distributed to or for the
benefit of a child who is or becomes disabled and eligible
for any federal, state or local governmental financial
assistance or benefits shall not disqualify him or her as
the recipient of such financial assistance or benefits and
shall not supplant or replace such financial assistance or
benefits, but shall be for supplemental benefits or special
needs not otherwise provided for by governmental financial
assistance or benefits or by the providers of such services.
In making any distribution, my Trustees shall take into
consideration the applicable resources and income
limitations of any public assistance programs for which the
beneficiary is then eligible. As used in this instrument,
"special needs" refers to the requisites for maintaining the
beneficiary�s good health, safety and welfare when, in the
opinion of my Trustees, such requisites are not being
provided by any public agency, office or department of any
LAW OFFICES
MARLIN ft. McCALEB
- 3 -
_ . _
city, county or state government, or by the federal
government or any other public or private agency. Such
supplemental benefits or special needs may include, by way
of description and not by way of limitation, travel,
entertainment, recreation, programs of training, education
and treatment, spending money, supplemental dietary needs,
health or dental services not otherwise provided, special
equipment and gifts for family members. Entertainment and
recreation may include, by way of description and not by way
Y of limitation, vacations, trips, athletic contests, movies,
the purchase and/or rental of televisions, radios, record
players, compact disc players, VCR players, personal
computers, computer accessories and software, movies, video
tapes and other similar appliances or accessories. My
Trustees shall not be obligated to expend income for such
needs of any disabled child, but if my Trustees, in the
exercise of their sole and absolute discretion, decide to do
so, under no circumstances shall my Trustees reimburse any
amounts to any federal or state governments, agencies or any
subdivisions thereof.
C. My Trustees shall hold all income and principal
from this Trust herein free from all claims, attachments,
judgements, executions and liens of every kind and nature,
control or interference by or from the creditors of any
beneficiary or of any government agency providing aid or
LHW OFFICES
MAR�IN R. McCALEB -
- 4 -
benefits to the beneficiary, and no beneficiary shall have
any power to anticipate, assign, alienate, pledge, charge or
encumber the income or principal this Trust. For purposes
of determining a beneficiary's eligibility for Medicaid or
any similar program, no part of the principal or
undistributed income of this Trust shall be considered
available to the beneficiary.
D. Upon the death of my daughter, JAMEE L. WERTZ, or
in the event that the terms and conditions of this Trust are
.
challenged in Court by any governmental agency, this Trust
shall terminate and the remaining balance of principal and
accumulated income, if any, shall be paid over and
distributed unto my son, JESSE D. POTTS. Provided, however,
that if my son is not then living, then the share provided
herein for him shall be paid over and distributed unto his
then-living issue per stirpes, said issue to take the
ancestor's share by representation and not per capita.
FIFTH. I nominate, constitute and appoint my parents,
MARLIN H. FORRY and JANET L. FORRY, his wife, or the survivor
of them if either is not then living, Trustees of the Trust
created in Item FOURTH, above; provided, however, that if both
of them shall fail to qualify as such Trustees or cease so to
serve, then and in that event I nominate, constitute and
appoint PNC BANK, NATIONAL ASSOCIATION, to serve in their place
and stead, all to serve without bond in this or any other
LAW OFFICES
MARUN R. McGFLEO
- 5 -
jurisdiction.
SIXTH. Z nominate, constitute and appoint my parents,
MARLIN H. FORRY and JANET L. FORRY, his wife, or the survivor
of them if either is not then living, Guardians of the persons
of any of my above-named children who have not attained the age
of majority at the time of my decease, to serve as such
Guardians during their respective minorities.
SEVENTH. In addition to any other powers conferred by law,
� my Trustees are hereby expressly authorized and empowered at
all times, in their sole and absolute discretion:
A. To purchase, invest in or otherwise acquire and to
retain, whether originally a part of the trust estate or
subsequently acquired, any and all stocks, bonds, notes or
other securities, or any variety of real or personal
property, including stocks or interest in investment trusts
and common trust funds maintained by any bank, or interest-
bearing accounts in or certificates issued by any bank, as
they may deem advisable without being limited by any statute
or rule of law prescribing or relating to legal investments
by Trustees; and to hold or retain cash or readily
marketable securities of little or no yield for such periods
as they may deem advisable. The investments need not be
diversified and may be made or retained with a view to a
. possible increase in value.
B. To sell at public or private sale, pledqe,
�AW OFFICLS
MAPLIN R:MCCFLEB
- 6 -
L
mortgage, lease, transfer, exchange, convert or otherwise
dispose of, or grant options with respect to, any and all
property at any time forming a part of the trust estate, in
� such manner, at such time or times, for such purposes, for
such prices and upon such terms, credits and conditions as
they may deem advisable, including the right to lease such
property for periods of time which may extend beyond the
termination of this Trust.
C. To borrow money for any purpose connected with th�
J
administration, protection, preservation or improvement of
the trust estate whenever in their judgment advisable, to
execute promissory notes or other obligations for amounts so
borrowed, as security for the amounts so borrowed, to
mortgage or pledge any real or personal property forming a
part of the trust estate upon such terms and conditions as
they may deem advisable.
D. To vote in person or by general or limited proxy
with respect to any shares of stock or other securities held
by them; to consent, directly or through a committee or
other agent, ta the reorganization, consolidation, merger,
dissolution or liquidation of any corporation in which the
Trust may have any interest, or to the sale, lease, pledge
or mortgage of any property by or to any such corporation;
and to make any payments and to take any steps which they
may deem necessary or proper to enable them to obtain the
LqW OFqCES
' MARLIN R. MtCALEB
� 7 �
1
benefit of any such transaction.
E. To hold investments in the name of a nominee.
F. To pay, compromise„ compound, adjust, submit to
arbitration, sell or release any claims or demands of the
Trust against others or of others against the Trust on such
terms as they may deem, advisable, includinq the acceptance
of deeds of real property in satisfaction of bonds and
mortgages, and to make payments in connection therewith
\ which they may deem advisable.
G. To decide all questions as to what constitutes
income or principal to apportion, allocate, charge or credit
as between income or principal all receipts, discounts,
premiums and expenditures.
H. To make distribution of the principal of this trust
estate in kind, including undivided fractional shares or
interests in any property constituting a portion of said
principal, or partly in kind and partly in cash, and to
determine the value of any property, so distributed.
I. To execute and deliver any and all instruments in
writing which they may deem advisable to carry out any of
the foregoing powers. No party to any such instrument in
writing signed by my Trustees shall be obliged to inquire
into its validity, or be bound to see to the application by
my Trustees of any money or other property paid or delivered
to them by such party pursuant to the terms oP any such
L4W OFFICGS
, MARLIN q. M[CALEB
1 _ ^ _
O
. -�1
wL , i -�., a - - - fY1 4.u- i � n t'�4a 1$r -L i ?��;�}LT
.r.,, s b o-, 'Vf " `i 1` s - ��a- ?; ' >.f �t+,�'ra.*#�'ii-y�7�',' .p[�,� k;spl�'s .A��"t 1n,�. �}ic �.�}N'�"s pF�q.cy
K } b CI.0 pY '�{♦�., Yl � }W �� t! .�. � �(,� �
n� �y�. �"!�'�Yist�' o �' ) a'��� ���3:��'�-i�j iTT'�'} `� '���ux Fry � y-Lx�$fl..M�,.�•il1? k''+si1�3i 1 .U..�+Ft✓ +�'I`t„ �t��io� "s� .�.C'�
i i1 f�b` wi 'G� i)+ vs`1 Q �'�'` �i f' i +,F�ti� �,i.-.,V.
�ra y 1 a� ,{',�,'a�y y�t.r, rtk� oi"�`�s�T ��k �;'SY".S�iTh `"�-E 4'�`",{7� - ,ts.�{.+ >t" , � ,�-.s, ±y341�E:��' ,, '�. },- ,
�y.;'����` �S'r 'd 'f `k. ��1 � 2+� k 't�, -0 ik' a' .-r+a�n. f ,.t
� �f � '
� ��� (
� if
I�J1.°:d U� 4..�.(�lif��fib'fi 9;AOJf1.I � ,F.�RB �[72�•�.�OTC,{ �517�i1� �RUU'_13Fi ^.Y,�E' � {:
i �'i<�Y �r9JIc".11.l�tfG"J, \(filI G:493Y.U'1'1' : :1 'UTAq� ^ij f;i �i
, Y. , . ;yx�:�,i3�rf�� , j{ i
� i
� � ti(;IGt.�i�:°1(T�(j .�1'�J '{�;-7t.0:"(f O.�'i.��9G5T 'r.",1TOi.=7/i�l;°�:9.^.C;9'Y 'f.9�':j�t�.?7�.d tit0 I{ {
tt
�
`?O ;S'(li;afrfb °[{.�' Uy i?6 .'�_99.�21J',",� '{R( �O e'f4�3(�T���i.7�' 9ii�? .F3Ts_: : j' {' � .
t �
'7:rC.?i�..fIJ.P�CIW �O.f . �1:3.iiCK) 9Cj' �if1:i . . f ' �
. 6c,2u aa Qmo�ni �a ��;aa.�an:.z:i �f f i �
i : f.ls aJ ar, �tr.C8s.C3ffCt1 3d .ii.artz E�n7sb,ian�� r�xs 7�orrtv��:s �
� t .
i �{
� � �� ,
. .fa�-t�.�t[k 'r31 r=.::44-.''�.r.,q ' i `�!�
�3 i_�•%/
- �-• ;1G1.;1°S.:,LS��: ;r_r, '(.�tTC!:�fIS �c"'"f?,.7c?C�� �.�b .2�u2JJ3_v,�3 Ci�}.' .q . ' _ ji �i" % ,.
'� 4
�-u°t`T' ��rr:s .`Ta ccoi��tii:;r7h:f st:; xe�3;, tIt47. ^iri.7 �c� �:�vt.�i �f j�,
{ � �y���jt
. � . . . . �'J9�UA1.7�ESf�� \�.�.IJJ� �::.�C 9mG:: °tli i,L:1f7[7 �:7I5:75f{ ��)EiS$4q:� " . :; ',l°f( -
� . `� f •
,tasf :��d .,b��x-x.a3noo e-xs�.roq .�z:¢tf.-;a kr:r, 'ot n�,s[4;»F• r:S .)i�a�.��� �l '
� � �
�
j�d3":9� ^1� �(;i�,?:It�P_' Y3�3bfii�'1�,Ci � 2Y07i::J�J:!:1. 'yi.T ,'�p' Y'C7fl'J�9X�-'�(P'f �� � '�j
1 �rj�'%%%"
� �. ::XIi�`.!t�c 36. :lT�eGfii� �e2SRL'r31JG� �ITfi'�UCi�'2ne '{(�i ITO �1[^L'Yk�3 f)y:`. b�3StTi'7lS:llSG �,� J� .
t �
:�r.i.r:# tL'a[i2. ��3ri� .YC . •�` �efi3 �o bo2��q s�v3:.r>rt�� z�l. ,"XO8 t��E��i•.; � �`,r�
e � t �
!ai�-,:..21'�r7E:.(���.`��Ci�i.�!+Fg� .uft& -SIi.fi�'�J't � 03� tyg'S'RY'JCj yr,ti��:.�ui� F3n�' s�C�7.w � —
� . _ . `Im. �::'..9.M�.y'...f`Ct�, �'� f7t9'T°l7;i D:?.�294'fYl �9Vbf� �ERf �� vfi!f:} ��F'i?l-iC7fi� �� .
j� �
:!(iC!:�� is`�.;'�'�c "�(3f(:)' "1,0 9F:.���S .�f�'.(CAfi� .IfirG1J2F��}6 C1'JLl� �.F;±�g �.�a:?59�h�
.; '.i'r.'.?AQ 3f.li..."�'=CW . 9�'.r*'i}i?O ;(Ili !17bT3 `1T:i.7 O�� 3RS3 'fi0�'3 a�rfiV��£.-✓.^.:1 :i.i� �� '
1 1r..i:�; If^[i� ysti_'. 't�W ur.i:� :�•: .
, , ,.t; �ssji.a 7v ,xr,.ie� ri_sua :rs ,�ad:�e�s c:.* ��
� ..... . . �
. { .. . �i:� ','`3f�.�.�.i fi ...�'S.�` .��3f:�'iD2'S3t3 'S�'fi;30 fJf[f� clTGI.:J.L�'lib,3:� Eo`((�!![ YO *_iSlO ��S .'. i� .
� i•J-Wf);� �;�.� �::`/I47 T31i�tnDGT �:'LJ!'(L$Il:� SCTC>"itS:i.7:'.9S �,^.; iC� �*�ubrso:^ :�ftt {� .
;'
f ".eJ 'y'S(5?.�.fiJC�f; flfyF.�:. ��91:,� 'SU �31'S ?�f'slf.°y j?fa �Jtl6 '{Il8 On'> G:i �� '
[ `:_Sl:i�::`_•;� 'J� T�l•?CiC� Et.i� �43U"t":GU, n:7 YElliOff 9f{i �:'[.LiJL'1.Jfi�.0 �_if'6l�CjCJY�<jE i�.
� F
�' i+
t. . .� ' , .. .�:silZ: �^.2�1''�:'t(�..YL7'J:iF;' FG 9:i'F.7'c3 C�fJc 70 '?_cAti.i.r'UCL j!i1f "C�.7 �'':433.?5 il
! 4 �
1
� G!:'E:f' �:Ft�:wc 1Q '.d.i�'^S'F1'f.L�iJ<���'.',:'?:JO '92.:].[:? iJ; 'Z9kTOC�' £il�:i-.f.i(Ifa .�«�1't'.f'alU:1C;C: �
� �
C I
� ' .
�, �-ii�'n .n�:.i
r
` BJ.:nttV R NI .i'i::M ,
1
'. •- Ci.: - t
E i! i
{i
,
�
., . ' �
business at such time and upon such terms as to him or them
shall seem best, and my Executor or Executors, hereinafter
named, shall be free from all responsibility for loss by reason
of the conduct and operation of my said business.
LA3TLY. I nominate, constitute and appoint my husband,
DAVID W. POTTS, Executor of this, my Last Will and Testament,
but if for any reason he shall fail to qualify as such Executor
or cease so to serve, then I nominate, constitute and appoint
my parents, MARLIN H. FORRY and JANET L. FORRY, his wife, or
the survivor of them if either is not then living, to serve in
his place and stead, all to serve without bond in this or any
other jurisdiction.
IN WITNESS WHEREOF, I, GWYN M. WERTZ, have hereunto set my
hand and seal to this, my Last Will and Testament which
consists of twelve (12) typewritten paqes to each of which I
have affixed my signature this
p7�day of ���P /� —'
A.D. , One Thousand Nine Hundred Ninety-Six (1996) .
(SEAL)
The precedinq instrument, consisting of this and eleven (11)
other typewritten pages, each identified by the signature of
�nw orFiC�s
N,qq�IN R. McCnLEB
— 11 —
�
. ; . .
the Testatrix, was on the date thereof signed, sealed,
published and declared by GWYN M. WERTZ, the Testatrix therein
named, as and for her Last Will and Testament, in the presence
of us, who, at her request, in her presence, and in the
presence of each other, have subscribed our names as witnesses
hereto.
�iiZ���i�
� / .
I
LAW OFRCES
� MARLIN R. McCALEB
- 12 -
�
' � BELCO
COMMUNITY CREDIT UNION
DECEDENT ESTATE INFORMATION(On Date ot Death)
1. Name(s) in which the account was held: GW� (Tl W�(�'f2-
2. Account number: � � � 3 e�� �
3. Balance as of date of death: S e fJ�"'�(71�e(; t B��0��
� Balance Accrued Div'rdends YTD Dividends Opened
RegularSaving; S1 83a. 8a x' s 1 • 36 a�Ja�� �d To 08�3��r1 py�o9�p4
Holiday Club S2 /V A '
MoneyMarket: S6 6.07 �. 50 al�•'i't o� or �aroa3f3��i� oy/o� f�o
Checking: S4 13'7. 80 ��A 04/Oq�oy
IRA: SS
Certificates: Balance Accrued Dividends Certficate Number YTD Dividends
� ��
4 Name(s)in which Safe Deposit Boxwas held: n1�R
5 Date the box was initially rented: N J(�
6 Branch atldress at which the box is located: �1 J�
7 Loan Information: Balance Accrued Interest Per Diem Int
A.. Unsecured Loans:
L94 Classic Visa Card
B. Secured loans:
C. Mortgage Loans: $ $
$ S $
g S S
8 Miscellaneous: �' (jAlAwt['P 5�'�Ow'�aQ iS wha,i- am«,.�t ii.a+ c�oula be Pa'a �-o
McmFk
SCHEDULE E. 1, 2 & 3
:��
- ,
. . 2008 Pontiac G6 GT Hazd Top Convertible 2D Trade In Values - Kelley Blue Book Page 1 of 3
,�21P CODE ll055 I Sign In(or Slgn upl
home � car values � cars for sale ' car reviews � kbb top picks � research tools
�14 I3YAUaus-' - �. $ � ' '. � ' PoPular at KBB.com
lacro - ' 2�9 AMb. Leesetw Sa �, •
�� .. . ' �ti000 catiuenc�asnim ' '_.' '". _
c.n+iCanwmv L�uan Rrst Pf6:New 2011 MoCett
I
t7.m 1v.dReet.lry+rG mwrcie
mJ�o�wblfi �•f�eiae5a�
MvMRa�b�t w�YaCSi `
Home> Wr values> Pontlac>G6> 2008>StNe>Optlpn> Pontla[_��__J',2008� 9�
GT Mard Top fnnvertlhle 20 .
YourBlueBook�Value �������Y�Ne�m�
- �- 2008 POntIdC G6 ( � �a�wN�o�� �' �
- - �, sy�e: GT HarA Top CanveNCle 2D�- / -
� � �Q/Q
■ AFR Financing�^
—�
� edlt q%krt�tl�atpe riyk J I Mpeage:35998 c�a^9e lN.e.` MKmr 7 '1 ���
___I
T�— rade-In Value I Private Party Value� ��MRe(qrt � � � I
: xfiar baMrq M et a Cev�ash'V �I wM�stlurq Ne w ywrsetf _: �.�a„"� -
r�_____ --� -
� �— — I �
tianNnb
1 Excellent ; ame,aseniex .tyeps> �
i $17,323 ` Shop for your next car p�ice a new car � a
�� ve7 Goad L---- � � ' -- �
� i�.%n' �
$16,823 r , M„�nvw+�„�,r,�„�,e�u�3r�.wr,�
� � InstantTrade-InOffer � i M THE2013HYIAJDAISONATA
1 �p� i get the oNer
$16,423 w�2
, ! � ti i � -
Fair � , 1
i $14,923 __ � Setlyourcurrentcar placeanatl � i =-� °^
� veriN conditlon i _ . i
� ; �
vaiues ward uncu ge the first to know � ��- �
� ���2�� whenvalueschange rouowen�sar i i .�.� ��'
� �
Helpful resources from kbb.com
WriteaReview ChttkSpecs SellYaurCar .
Own It7�ovc It'+T¢II us. � KnDn your mr Insltle Use wr Tips&TodS. �
MM aR. �
_. .. .—.-..._- � ,
Cars for Sale j Get a Used Car Report i
near Mechanicsburg __ i
2008 Pontiac G6 I GM the Infortnatlon You Neetl on Thls ,
. I 2008 Pontlac Before You Buy '
33tnsa�er+earrw view �
' En(er V/N(oplrone/f 9� '
28eebwBluesookvalue• New � �
. �..�„ CPR � MY 53red Urs save cer � t� i
SCHEDULE E.4
http://ww�v.kbb.com/pontiac/g6/2008-pontiac-g6/gt-hard-top-convertible-2d/?vehicleid=l9... 12/5/2012
, � 2008 Ponriac G6 GT Hazd Top Convertible 2D Trade In Values-Kelley Blue Book Page 2 of 3
,g��yK S�Oqa[m rtnmi vawe Eutlimt No VIH7 No Probkm!Buy an UNLIMSTED � ,
cvnoAOn aM ne hse vMkk conlW�ration. �" report tnday and run VINS as you research. "
.. .._____".—..._'__—_'_'_,_"__"
i....—NBRS"__'"_ . ,
10 Mast Fuet-efi�ficient
SlJVs and Crossovers
2022 Mini Gdape!Caunkrymnn '
;-�thecros I ', ...... ........_.. �.
_....._...._._ ,. . .
._ ....zc.Em�mea ........... "�nv'�Yi �'.
_...._ up
3 Easy Ways to Sell Your Car Fast t�ol
Hii
MF
, List It for Sale Online piace you�ad ��
Reach miLLions of shoppers on kbb.com � �
antl AutoTrader.com. �
� ......... .......... . � ��.. i
Get a Free Trade-In Offer qec insean�oner i ! '
� Localdealersarereadyto6uyyourcac �. ��
Use Seller s Toolkit get toolkit � ,
� , Share to Facebook.C�aigslist and more. �� ' .
�ck aA�/�s h�isrory before Know YW� ! A�ppl�y�or an���'
yw,ow.
before you buy� 1Wn sbrtir�g at 1.99W� . ,
' � ___�-�-� ' .
. 2013 FINT 500 2012 SmaK fortwo 2012 MINI Coopz� �.
� .
.,,.,,_ ..,� .
. ` �'..�'?�. � G'� f�
�`� �`r .-r� {.; �
0, � :r
� .nw��x�rrs
.�wrma 9
MPG Clty 31(Hwy 40 MPG:Gty 34/Hwy 38 MPG:Qty 2�/Hwy 35 �
' Englne:3-Cyl,SA L Englne:4-Cyl,ib L
Engine:4-Cyl, SA L Consumer Rating:8.4 �
' Consumer Rating:8.8 Consumer Ratlng: 8.4 .
viewthiscar viewthiscar �
view this car ,
. Read Expert Revlew Reatl E�er[Review Reatl E�ert Revlew
��. compare these vehicles � .
'. M bulltl your m�n mmpare set
��, .... ..._. . ....._ ... ......... ........ ......._ ......_..
._ .......__.
RprentlY Viewed Cars I MY°�v��rs save wr �: � .
SCHEDULE E.4
http://www.kbb.com/pontiac/g6/2008-pontiac-g6/gt-hard-top-convertible-2d/?vehicleid=l9... 12/5/2012
�
Summary With NADA Values
NADA Used Car Guide
Tuesday,December 04,2012
Guiste Edition: Eastem Used Car Guide-November 2012
Vehicle Description: G6 V6�C n ertible 2D GT Sport
Weight: N/A
�; 1G2ZH361X84294971 MSRp; $30,835
Stock#:
Clean Clean Clean
Rough p'�g• Loan Retail
NADA Trade-In Trade-In Trade-In
Base Values 59,850 $11,050 $12,025 $10,825 $14,900
$2,075 $2,075 $2,075 $2,075 $$500
Mileage: 30941 $450 $450
Accessories
$450 $450
NADA
Adjusted Values $12,375 $13,575 $14,550 $13,3$0 $17,47
Appraiser
$0 $0 $� � —
Adjustment $17,475
Adjusted Values $12,375 $13,575 $14,550 $13,35
Trade Loan Retail
Accessories: w/bod w/body
y��iymjnum/A11oyWheels�� W$�� $450 $500
Leather Seau Wrood Wroody u,�ody
Power Seat Y
j l,�B RUry
Appraiser Item: -�—
Appraiser Item: �'�Ue DIdLSBURG, PA
� SCOrrTrturr
SaJes Consultant: .
�
' `_N US Ro.g"ta"`
Grg,Bp{`
���dealere"`
Nppp assumes no responsibility or liability for any erro�s or orttissions or � 14�Ce��(]i�
any rev�sions or addi[ions made by anyone on ttus report. �F3X 1
��N�A�a�����pMted wfth pe�mission of NADA Used Car Guide,NAD � 3 �I,J
SCHEDULE E.4
� _
. .
BankofAmerica'��I
Merritl Lynch
. , . �
David Potts
21 Maple Ave.
Camp Hill, PA 17011
Important Notice �aYZ8,2o,3
RE: Requested Account Information
Below is the account balance information that was requested for Gwyn M. Wertz as of close of
business September 18, 2012.
Merrill L nch 401 k Savin s 8 Investment Plan
Investment , ,: .: . . . . ... ..::.S mbol, _ Shares. Balance .;
BRC Com Stk Fund BACSTK , 643.3575 -.:$3294.00 ,
Blaekrock Capital Appr CF BUFTT 1104,07 $ 11316.75
Dod e& Cox Stock Fund . DODGX 119.5016 $ 14526.62
LM Batte march U.S. Small Ca LMBMX 1071.20 $11847.47' `
T Rowe Inst Lar e-Ca Growth TRLGX 282.8121 $549220
Blackrock Giobal Alloc I MALOX 857.7377 $ 17000.35
Tofal Account Value 4078.6771 $63,477.34
Merrill L nch Retirement Accumulation Plan
Investment S mbol Shares Balance
Blackrock Capital Appr CF BUF'fT 905.526 $9284.72
Blackrock Global Alloc I MALOX 477.5392 $9464.83
Total Account Value 1383.3652 $18749.55
If we may be of further assistance, please do not hesitate to contact us at our toll free customer
service number, 800.637.4015 Monday through Friday from 7am to 8pm Eastern on all business
days that the New York Stock Exchange is open.
Merrill Lynch, Pierce, Fenner&Smith Incorporated isa regisYered broker-dealer and wholly owned subsidiary of
Bank.of America Corpocation.
MeY�ill Lynch makes available investment products sponsored, managed,distributed or provided by companies
thatare a�liafes of eank of America Co�poration w,in which Bank of America Corporation has a substantial
economic interest,including Columbia Management,BlackRock and Nuveen Investments.
Investment Products:
Are Not FDIC Insured Are Not Bank Guaranteed May Lose Value
�02009 Merrill Lynch, Pierce, Fenner&Smith Irtcorporated.All rights reserved.
SCHEDULE G. 1,2
:. __ _ _ _ _ .
• p
„ ' .. �w.�..aun'�aa:wTiA
t uhrz�l
'at1Y
vw.:W,.:'::'nw' i .
....e•a:.°mp.o..,....n...e.�.�� �.
STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED .
Cha�ges are only for those items�ha[you seletted or that are requ'ved.7f we are requ'ved by law or by a cemerery or aematory ro use any i[ems,we wJl
esplairi the reason in wrifing below.
If}rou selected z funeral rhac may ttqu've embalrtting,such ys a fwenl viewing,you may Itave ro pay for embaMing.You do mt have ro pay fin embalm- .
ing you did not 3pprove if you ed amngemrnts such az d'vect cremauon or immediate bunaL ff we cM1a�ged fin embalrtting,we will explain why below.
AM[heServlceof �H ✓Y10/.-f. (ti/P �".t ofDeatL9'7F -ZOIZ. ' .
c�.ge�:1�a u d �J• g-fk ?i w�apG /�u Ca�u.n I-� 1� �� ��o ,t .
Name Address City Stare
A CHARGE FOR SER{1CF5 SaF.C7ID: Other do0wwg �
1.PROFESS]ONAL SERVICFS '
Services o(Funml DimcwJSUR:.....f= Cremation ur A.. x ...'.�,f —
Embalrtiing'.....................5 ` (DeacoP�on'�fLL� $C0�✓ �
Ocher preparerion of body �
� p�HER y
' f_ r
.......................I.......S T07AL IrffiICFIANOLSE$HP.G7ED ................,H 3 o e
SU&70T.11 OF PROFESSIONAL SER{7CF5.........A1 S —
G SPE(]dI.CEIARGFS:
2.PACMIES AND SpNICES ' Fomu�ing of remaire to .
❑u of fatlliuu and xrvi<a for s
- viewing(Visi�auopMake) .........E ` (Ponml Home) .
Ux of hdiues and savices ! Receiving of remtins(rom
(or fwrnd ceremany ............f
Use of hdlities and smims for �, (Funval Hrnne) 5 .
Memo�ial Servi¢ ...............5_ ImmMiare Hunal .���i` �`� $�{
Uu M equipmen�and services �. Dven CremauonlV .... '�"O S J + +",
forAavuideservire .............5 . .. .. ..{ —
Other use of fadlitia �„ SU6'1'OYAL OF SPEQAI,GAARGFS ...............C 53��
D.CASA ADVANCED
.......:........... ..........S '� OpeNng Gnve ...... ....$—
50B-70L1L OF FAQlTTffS/EQONMCNT ........A2 5 � Cemerery Equipment ..............3 '
3.AUTOMOTIVE EQOIPMENT In�and Deed ...................5�r" .�
VeNde�o[rznsfa�emavix m Ponenl Home Nrnspaper No[iresWr 1 ...........§ ->>'�'
� Newspaper Noums-0m-o4mwn ......5=
Lanl .........................E Telephone @ Telegnms ..f �
Hearse(Casktt Coach) Arfare ........... ............$_
lorel . ....... ......... f . — . Cle�gyMus OI(enng .. ..5_ �
_"_"_r'fimws �v ._. ' - . ,-:t _ �'_-.: '2. .. :. —�a06eiiers ' - , ' -.
.. _ . _ . - _ . ". s !. .. . . ..
. . .. .-.: { —/��� � -. .�
Lonl .......... ........5= CenJied G�P es o!the Oearh (,O ...5 Vfi'
Pam�y mr
laal .5 - Cmifa�e ......................5—
........................ Polim Fsmrt .. ...5_
Flown�r m iloral disposioon Flowers..................... ...§ '-
luml .5 � . ............. .
........................
�a'car/dagy�r VaW�Serv�a Cluge...............f "
wvi ...._._................ a— °_
Car.fm pallbearers � 5 '
,«�i ....... ...... ......_..a— 5=
ou�or�oam uzrisponauoo . ......a= s
E f=
f ._ SUB-TOLV.OF ADVANCFS .............. ........D f G�U�
SI]&TO'GL OF AVCOMO'f'IVE EQUIPMF.Ni'..........� 5 -
We charge you!or our servims in obraiNng�
TOT.U.OF PROPESSIONAL SERVICES, ��.y����
rted-up) �
FACILTT�S AND AVfOMO'IYPB � �{,tg,�,M1��i �(r( �Gc� +9 F.r�.r
EQUfPMF.NC ..................................A f_ �A s �ef.I� /Ce G 6«-e-.� �
B.QWtGE POR MERQIANDI$g SELECI'FD: SUMMARY OF CHARGPS
Caskel............ f �^ A.Pmfessio�al Services,Facdiuw and
........... .
mesaiptlon7 Equipmem,and Au[omotive i
r
Eqmpme� .... .. f
ONer Receptade . H.Merdundiu ... .3
.......5 � C.SOecial Chargu .... ... 3 � �
(Desuipuon) � p.Ush Ad ces .... ...y.(� �/ ,,.
�
Ouea Weal mnuiner ........f '� T07AI.OF AI.L SEGT[ONS ............ ... f !v�
(Description) — PAID AT 7'¢dE OF OR PRIOA TO
— ARRANGF.n�N79 .................._,_...... E�y�--/-�;
ncknowlNgemrn�mrds.. ....5= &11ANCE DllE ................................ E ��'p� .
aegian bookCs)..................5 — RSASON FOR F.A1BALhIDVG
Memory folders .......... .......5= /?02�-l._.
P�"^Ye�m� �������..�����.��...5_ U any law,ame[ery,or cremarory requ'vemrnts Aave requ'ved the purduse
Tauporery grave marker............E o(any M the i�ems lis4d above,the law or re u'vemM�is� Gined below.
a��w aow�8...................a — .'t^/3�il/ <�.Gf,.......� u hL._^ �..avt�
(.'c..�'I��r. y . li�.F.u.'-
I agee tha�I have eaaminM the i�ems o(Foods and servicu selmed above�nd found them to be cortea a�d according ro�he xmngements I Aa reques�ed.I arknowledge
rtteip�of a<opy of this Sraeementpppfff Funenl Good.s and ' $elec[ed.I repres �I luve suliicirn�funds available for paymen�o(the msh pnce for tl�e goods
and services seleaed.t also agree�ymrn�of S w�� days.I agree w be iointly and xveally liable vnN aryN�else who
signs below.A late charge of per mon�h amountlng ro per year will be applie�m rLe unpaid balanre beguwng -� �yy
(rom the da�e of this agreemmt.I will also pay[o the FuneN Directo�a0 reaw�uble costs paid by�he Funerzl Dvmor�o mllett amounts I owe under Nis agreement.
Thase cosu ma}'indude aaomeys'Iees,mw car+s and wher msts.My addiuoeal servica or merchandiu ordned or requu�ed aher�he da�e of Nis agreanent will
be mnsidered p rt of�his..ageemene and[he con rAereof will be rellecmd on[he fmal bill or sla[ement.
(Srzp ��� i l.. �:J � 4
.� rfi �� I . L.G'/ Z
(PUrchased� " /// � (��{f/�� ' /�(Da )�l;-� '
(S�p �C`� ._ / , ��'" �K.iC-N'Ar-J�� i L/�5'd"�
�P°'�'��� "(WCensed Funerel D renoJ
OftmnyManuFWnalOLenorsAiuvtimi W162rypeyprt[�m YELIDWFUVmlqrtaa pWK(u,vonrtr
eo�-�oo s��aiioa SCHEDULE H.A.1
IUPd%ll;?��i��iiti3 11 � i0 A7�,h � �.aX PI��. F�. 00i
� �
a---._:
� �.� Y `� t
�� �
��}������
,'V a�`e � ��`'"
� €
� �� �� �
�-- r�°�Trl S1'ST"L�;�_
J �L� .J�.��i Y.L U�J �✓CLI��L�
�
t't.ct�E`�`t(�'�LT1E .— � �� �_—_—_._.-__...`. ..
c Cr:.___�_�__,, =�r�rJt:`.,.71± nx SYl`o I•s�' �„� _ .
�a��n�'st'; /�' '�.c.-Z�_'!s=_�L"� E]��ts�C4;i-��:5�_i^'C �1l�i�.6vCG�_%. ��.��F��..M4
r�:: ( ) � � � - 7 7 '7,:Z. �a.,�� !717) 7u:,-3C i?
` _ .� -..... ..
��,�;7s: �,. .�.�.... . .. ....._... p���=: �� 9 ra— � <G
�_— —__ _. �"L___—�_ _�� _.
��; � a�i.,��c� f -,ciu�i;,n c,,,er sh°u_
P'�ez:.-confirm ���>iptoi[hl�iaY.k�y: � �
� �
� D;SCI,SIIuLR:ThYS fdcsinile rnuy cui�iain'�ra'Lc1rd;lealth Iniorm23on°.hat is as a sens'rriv6 sr�d inriid:�n2ial rra7ure. �
1i 1s tefi3 f�:�c! a)�cu wi�4he sufhori�:ton o'tr�e gx«ent ^r ur.dar cirt:um�Yancss voher•s�uYbori:.sclan I� r,o? �
feq.!ited. Y�u srF requird�Ga mainiatn�'us 'n;crm�5�n Sr�secura and aotrideniiai mar,�sr and ar€nrnhibJi2d frcrn
rs-[iisdosin9 � evitr,out Tir>: o�aa'viing i��e p3fien2s conseni �r rs ofherv,5�s p�rmit�d by iaw. L7av�J�arizad ;a �
disr�osure may sUbir:ctycu to;eder�!and s4�4e iaw r.�:r.2lres.. . . .
�IMP�`JRi��l`Y( "N1'tr�l.NI1V�'^.:��F}IS;fl%?5d98 Ib .'f�:eT;da�x01'ing L'3° Oi t�')��bra"Jih :]] ef]Tlk,y i4 V'�]IC`1 ii 15 a[�[jYesSBC. @�C
ir,ay conutn�in'nrena�or�;ha;i� r.cnilden�ei or�^�ivilelz�:ii-i. disclosu;e u`vahic.`,is gavv.rrv;d 6y s�pii_zhi� lsv+_ Ic
tha roader m ihis rne.=,age is n!n rhe !n�nded rec�ipian�,yuu are hereoy n�7�ed�St ar.y dlssan;ir,atfcry Gi�:Nb���tian, �
nr c�pying oi 4his iaform�ifon is sYrSr.'I.F proY:lbl:ed. li you h'�vk reu�fved:his ;rrP.3sege by 2rr�r, plsase nniiiy� u;
imm.n+li.�+o.IvanN rlaa.rrn�thc.e!��rn�;me�e+�o
Schedule I.2"
_ _
^ J�:�Vi�l �%'_'�I�%i�L', �il : � r �ii��l . f4�t ��C�., .°. �L1
r.
�ELECTED DETk2L DATA StrC FHC: HO^aG 06/11/1j 1047
�T PIO: �13v94L�37 1�7E'P.T� ,GWYN M MF2 NU: _31�09 FSC!".T T'IPE; B
RE�: Q9/li/1G DSCN: D9/1:/1<^ FC: 5 FT: . �;XP 1;VG: ° liCCT' BA."..: .00
_'_"______"__'________'_"'_.._'__...'_"___"'__.'___ _'.".' FRGE N0� 1
PCCT 8h� D70 V --_.__._,...__.._� p:' BA,",
.00 .00 pp
SVG ;°OST' SiiC CU ;:'�S C'D-uESCRSFTLON/CO�IC,ER�T�-AEF D?7'E A�90�]NT
iU1'ii12 101812 910403'� 1 MA r_/A HOS? - IP -17f23.2E
11i21i :3�?.12 91Q9C9'l 0 N�A C/H �LOSP - IP 1'76S3.L6
121.ii.� �71i12 ICQ735 0 T:b PATTEY'f' PY;�T -21230.92 '
121.i7.'_ 'I.`e_112 2180J06 0 :)TH ?T nDJ-L]T9C�UT.?T -3'756.6,i
--`--�....__..�.-_-__�.__'-'__..�..,.__._�.._.,_,...._-`--"-'
----'----"-`-----"----------------`-
. i2F24) S�L YT ! {YF'?J $3L?CT G'T�1.
. (Pti15) R.:"fti�ht�` TO Y7.' U�lk;cVIEN; Fr'16 GiE
YI?QDTLC3
Schedule I.2
_ _ _ _ _
�
� DESCRIPTION OF CHARGE OUANTITY UNIT PRICE AMOUNT
ALS EMERGENCY LEVEL 1 A0999 1.0 967.62 967.62
20GTT TUBING A0394 1.0 14.72 14.72
ANGIOCATH(1424) A0394 2.0 6.72 13.44
EKG ELECTRODES(1) A0398 4.0 0.80 3.20
EXTENSION SET 8"NEEDLELESS A0394 1.0 12.52 12.52
EZ-10 25mm NEEDLE A0394 1.0 297.00 297.00
EZ-10 STABILIZER A0394 1.0 16.00 16.00
INF CONTROL GLOVES(PR) A0382 1.0 1.00 1.00
NSS 0.9% 1000cc 6ag A0394 1.0 3.48 3.48
SALINE PREFILLED SYRINGE A0394 2.0 2.56 5•�Z
Total Charges 1334.10
DESCRIPTION OF PAVMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT-INVOICE DUE UPON RECEIPT -► $1334.10
RETURNED CHECK FEE-$31.00 �
PATIENT NAME: W ERTZ, GWYN M CALL NUMBER: �2�s479A - pMOUNT PAID: -
10/15/2012
IMPORTANT MESSAGES: THIS ACCOUNT IS PAST DUE! Send your payment now or contact
our office to make payment arrangements.
WEST SHORE EMS -ALS 205 GRANDVIEW AVE CAMP HILL, PA 17011-1708
Schedule I.6 •