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Home My WebLink About09-06-13 1 1505610101 � REV-1500 °`�°'.'°, �l 20f1 1ve11ie OFFICIAL USE ONLY PA Department of Revenue P mmsY Counry Code Year File Number Bureau ofIndividualTaxes �INHERITANCE TAX RETURN � � � PO BOX z8o6o1 Harrtsburg,PA iy179-o6ai RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMODYYYY Date of Birth MMDDYYYY na "L�2�v t ( 0 $ 2 I R3 DecedenPs Last Name Suifix Decedent's First Name MI suaF � oaN�3° T � (H Appileable)Enter SurvNing Spouse's Intormation Below Spouse's Last Name Sutfix Spouse's First Name MI � � � � Spouse's Social Securiry Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1. Original Return p 2.Supplemental Return p 3. Remainder Retum(date of death . pnorto 12-13-82) p 4. Limited Estate p 4a. Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) � 6. Decedent Died Testate p 7. Decedent Maintained a Living Trust � 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) p 9. Litigation Proceeds Received O �0.Spousal Poverty Cretlit(date of death O 11. Election to tax under Sec.9113(A) belween 12-31-91 and 1-1-95) (Attach Sch.O) CORRESPONDENT- THIS$ECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SNOULD BE DIRECTED T0: Name Daytime Telephone Number 6 nln SLIAF � E �. �� 1 � �. _. � id1 REGISTER OF WILLS USE ONLV First line of address a` � �� ,�, s N E o 0 o c � l. � v y,«�„� �.� Second line of address � ,t� ��,�, . � ffi� ^ . � � "�� . . . . �.�� n� ��m`��"� � DATE FILED City or Post O�ce � � State ZIP Code �. w,.�. �.�. . u. , ,v •, r a � ' ° � A � s ',E , �,D�!-� : �,,,�,.� ��, �„�� .� .m. g..,,� W .,,� .. �,�.r�,r � � .,�.N CorrespondenPs e-mail address: Qsh[c;c�`�1�.�Ct,d'•(.OM1n Untler penalties of pe�ury,I tleclare that 1 hava axamined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is We,correcl a complete.Declaretion ot preperer other than ihe personal representativa is based on all informetion of which preparer has any knowledge. SIGNAT RSON RESPONSIBLE FOR FILING RETURN DATE 41S�13 ADORES�S� �� nIY� �YVI��PA I /UZS Z l/ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 � 1505610101 15056101U1 J �\ J 1505610105 REV-1500 EX Decedent's Social Securiry Number �,t�s N�: �oaV� E� S1rw�C� ��?�- REC�►wruurww � �o � �...r.��, 1. Real Esfate(Schedule A). . .. .. . ... ... ... ... .. ... ... ... . ..... .. ... ... . 1. � . � r� l 2. StockB atd Bonds(Schedule B) .. .. . .......... . .. ... ... ... .. ...... ... . 2. � I �1 3. Closely Held Corporetion,Partrrership or SWe-Proprietoratdp(Schedule C) . . ... 3. {� . 4. Mortgages aM Notes Receivable(ScF�edule D). .. ... ... ..... ... ... .. . .. . . 4. 5. Cash,Bank Deposils and Miscellaneous Personal Property(Schedule E).. . .. . . 5. 3 � � � � 6. Jointly Owned Property(Schedule F) O SeperaAe Biping Requested .. . .... 6. p . 7. Inter-Vivos Trensfere&Miscellaneous Non-Probate Property /� (Schedule G) O ��te Billirg Requested... . . . .. 7. � p � 8. Tofal Gross Assats(totat Lines t through 7)...... .. . .. . .. . . . . .. ... . .. .. . 8. . I S '1 �� I � b � 9. Funeral Expenses and AdminisVative Costs(Schedule H). . .. . .. . .. ... . .. ... 9. n g' q S O 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule q .. . . . .. . .. ... . 10. � .3 0 11. Total Deductbns(totai lines 9 and 10). .. . .. . . . .. . . . . .. . .. .. . . . . .. . .. . . 11. - S . I H 6 1 � 12. Net Value of Estate(Line 8 minus Line 11) .. . . . . .. . .. . . . . . . .. . . . . . . . . . . . 12. ,- („� q .S 6 D � 5 13. Charitable and Govemmantal Bequests/5ec 9113 Trusts for which an election to tax has rrot been made(Schedule J) . . . . . .. . . . . .. .. . .. . .. . . . 13. 4 14. Net Valw Subject to Taz(Line 12 minus Line 13) . . . . . . . . . . . . . . . . .. . . . . . . 14. � .. � 6 p 1 S TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of line 14 taxable at the spousal tax rete,or transfers onder Sec.9116 � r (a)l12)X.0- ',. � 1 � Qf � 15. . . �. . 16. Amount of Line 14 taxable �� I q� at lineal rate X.0� ' � q S 6 �] �6� b 1 J �,. . . 17. Amount of Line 14 taxable at sibling rate X.12 17. 18. Amount of Line 14 taxable at collaterel rate X.15 . {� 18. 19. TAX DUE .. .. . .. . .. . .. .. . .. . ... .. .. . . . . ... ..... . .. ... ... .. . .. . .. .. 79. 3 � 7. �b 20. FILL IN THE OVAL IP YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Slde 2 � 150561�105 15056101U5 � REV-1500 EX Page 3 File Num6er Decedent's Complete Address: DECFAENTS NAME � E• S�� STREETADDRESS 2� 51��wood GYCS�e, _ � cirr STATE ZIP GIW� �"1D2� Tax Payments and Credits: �7 1. Tax Due(Page 2,Line 19) (1) 6� I�J�� 2. CiedilslPayments A.Prior Payments B.Discount Total Credits(A+B) (2) � 3. IMerest �3� ��1 ,53 4. H Line 2 is greater than Line t+Line 3,en�r the diRerenoe. This is tha OYERPAYMENT. FlII M oval on Page 2,Line 20 to requeat a reTund. (4) f,� 5. If Line 1 +Line 3 is greater ihan Line 2,enter the difFerence.This is ttie TAX DUE. (5) ' Z� �,� ' Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWIN� QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income oi the property hansferted:.......................................................................................... ❑ [� b. retain the right to designate who shall use the property transferred or its income:............................................ ❑ � c. reNain a reversionary interest;or.......................................................................................................................... ❑ � d. receive the promise for I'rfe of ei�er payments,benefits or care?...................................................................... ❑ � 2. If death occurred after Dec. 12, 1982,did decedenl lranster property within one year ot deafh without receiving adequate consideration?.............................................................................................................. ❑ � 3. Did decedent own an"in Wst 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-probale property,which contains a beneficiary designation? ........................................................................................................................ � ❑ IF THE ANSYYER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or afler July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or fw the use of lhe survivirg spouse is 3 percent[/2 P.S.§9116(a)(1.1)(i)1. for dates of death on or afler 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 [/2 P.S. §9116(a)(1.1) (ii)]. The statute does not exempt a trensfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets arM filing a tax reNm are still applicable even if the surviving spouse is the only benefiaary. For dates of death on or after July 1,20�: . 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 natutal parent, an adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(12)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S.§9116(12)[72 P.S.§9116(a)(1)�• . The tax rate imposed on the net value of transfers to or for the use of lhe decedenYs siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined, under Sectlon 9102,as an individua�who has at least one parent in common with the decedent,whether by blood or adoption. . XEV.1560EX.(19)� SCHEDULE E COMMONWEAITHOFPENNSVLVANIA 4ASfiy BANK DEPOSIT$� of MItil4. INHREEWSIAN�TDECEOErr+uaN PERSONAL PROPERTY ESTATE OF `{+ , �i, �}�j{�yw� FH.E NURI�R ,Z r'I3 '�bb i .�l.:�la�, � ��'�ti b Indude the proceads of litigatbn and the da�the pmceeds were recened by the esta�.AN property jofntlyownsd wltM tAe rqM of sunivmshyr mwt ba dhstcsed on 5chadub F. ITEM VALUE AT DATE NUMBER pESCRIPTION OF pEA7H , {t�ht��t�e5}t,�r�-ASSO� �;Ct��r� ?l-btbt�5�-(, �31,1�i�. o3 �-� F�� G,tu�+bw 'R�vtik- c4�1c�� A�un�,+� � 3, �Sro.� � TOTA!(Aiso enter an litre 5,R�imiatian} 5 ,�y $��,tjj I ! {tF more space is needed,insert additionaf shaeis of fhe same size} L_—_ . REV4510 EX+ (OS-09) � �pennsylvania SCHEDULE G DEPAFTMENTOFFEVENUE INTER-VIVOS TRANSFERS AND INHERRANCETA%RETURN MISC. NON-PROBATE PROPERTY RESIDENT DELEDENT ESTATE OF �. e r � FILE NUMBER ��✓� 6. s�a�r 21-13-obG? This schedule must be completed and filed if the answer to any oF questions 1 through 4 on page three of the REVd500 is yes. ITEM DESCRIPTION OF PROPERiY IN[W�ETHENAMEOFTHEiAANSFEREE,THE1RftElAT10NSHIDTO�ECE�ENTNND DATEOFDEATH ^/oOFDECD'S EXCLUSION TAXABLE NUMBER TxeoahoFT�nsFea. nnACnacocvorTneoeeoroaa�n�esrnr�. VALUEOFASSET INTEREST �irncvuv,e�� VALUE i PYU��.1 g6.��--�('Yv,4b ?rl� AC(�r� 1�8aq.6ti 1��, 91 �Ilb''�B''t9•62 TOTAL(Also enter on Line 7, Recapitulation) $ ��qQ•bZ [f more space is needed,use additional sheets of paper of the same size. • r�v-isii ex+�io-os� SCNEDULE M COMMONWEALTH OF PENNSVLVANIA FUNERAL EXPENSES & , INHERITANCE TAX RETURN ADMINISTRATNE COSTS RESIDENT DECEDENT � � ESTATE OF � FILE NUMBER Jl�� , S1�a�✓ 2t-13-�o6b5 Debta ot decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT a. FUNERALEXPENSES: , C�re+n.,�,�0�� evV��.t -P�,�,�.c.�C �3 Wl�e�-�Ikn.e�fu�.l l�uua- �3�6F l,o� �o��6lw�\ B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) _ Street Address City � State Zip __. Year(s)Commission Paid: Z� Attorney Fees 3� Family Exemption:(If decedenPs address is not ihe same as claimanfs,attach explanation) Claimant Street Address City State Zip . Relationship ofClaimantto Decedent 4. Probate Fees �.23 �p /yQ41}R✓W�� S WW'0 UYOU1t�c� Vti-S�2�v�. � �6� .> � . � 5. AccountanPs Fees ' 6� Tax Retu�n Preparer's Fees 7. TOTAL(Also enter on line 9, Recapitulation) $ �j �{�,q ,S Q (H more space is needed,insert additional sheets of the same size) � � aEV-isiz�x+(rz-va7 '�i�pennsylvania SCHEDULE I �j nEPAflTMENT OF REYENUE pEBTS OF DECEDENT, INMERRANCETA%REf80.N MBRTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTAT€OF ,.,, FIIE NUMBER �� '. �►�-� �-t-t�-ob�� Report Aebts inarred by the decedent priar to dealh that remained unpaid at the date of death,includiny unreimbursed medleal expenses. � ITEM � VALUE AF DATE NUMBER DESCRiPTION OF DEATH i. �n1)/" � NUM�I� �, _qC.k',��,GUll�l`�-'�l�'�l �6��,(�O �. �� '��DU�lt�2 ��V�d�b- �G� Iri��ttt � {ZZ..� 3 . ��n�c� 4k�t� I�SP+�Is- �up�b�k 1�s�n� � Sco•Oo �k• �os��,,� ��an�$'�tiwhe. lskxk-�nvat�e �s 3P�t� r74-s�c3v � �b,pu TOTAL(Also enter on Line 10, Recapitulation) ; 1,33�� If mare space is needed,insert additionai sheeg of the same size. . i COMMONWEALTH OF PENNSYLVANIA SHORT CERTIFICATE COUNTY OF CUMBERLAND I, GLENDA FARNER STRASBAUGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 14th day of June, Two Thousand and Thirteen Letters TESTAMENTARY in common form were granted by the Register of said County, on the estate of JOANELA/NESHAFFER , late of EASTPENNSBOROTOWNSH/P lFHat,MMtlN,Gt4 in said county, deceased, to DERR/CK J SHAFFER (Fiixt,MMdb,Lesl1 and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 14th day of June Two Thousand and Thirteen. File No. 2013- 00669 PA Fi 1 e No. 21- 13- 0669 Da te of Dea th 9/27/2011 S. S. # 072-30-8645 � Crt q , .� � � - � � eg�ster i s / �, � � L , �, epu NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL • , , , , ' ' REGISTER OF WILLS CERTIFICATE OF CUMBERLAND COUNTY GRANT OF LETTERS PENNSYLVANIA No. 2013- 00669 PA No. 21- 13- 0669 Es ta te Of: JOAN ELAINE SHAFFER IFbst,MiCtl/s,Gaq La te Of: EAST PENNSBORO TOWNSH/P CUMBERLAND COUNTY Deceased Social Security No: 072-30-8645 WHEREAS, on the 14th day of June 2013 an instrument dated March I6th 2007 was admitted to probate as the last will of JOAN ELA/NE SHAFFER (Fivf,MitltlN,bsp la te of EAST PENNSBORO TOWNSH/P, CUMBERLAND County, who died on the 27th day of September 2011 an wHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDAFARNERSTRASBAUGH , Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARYto: DERR/CK J SHAFFER who has duly qualified as EXECUTOR/R/X/ and has agreed to administer the estate accordinq to law, all of which fully appears of record in my office at CUMBERLANO COUNTY COURT HOUSE, CARL/SLE, PENNSYLVAN/A. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my office on the 14th day of June 2013. �'� � t . . ey� e,o , s vJ V � eputy **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) __ , cs �; � c � � m � �' �_ rn c> c� ro c `? o n -.: cy =' c� �? r., _.; c1 r�— � tr; � s�i � � �O "` .., ._ � . «�; r, "� ^�} �'J — r�� . 4"� �.] -�; _.i ."t '`i {_" t--� ::i . =.t �..� �:..; ' 7 • f` !\? 41 �� . . C;.a 'T�4 LAST VFTLL AND TESTAMEI�T'I` OF JOAN ELAINE SHAFFER I,Joaa E.Shaffer of Enoia,Cumberland County,Pennsylvazua,being af sound mind, memory and understanding,da hereby make and publish this my Last Will And Testament hereby revoking all previous Wills and Codicils made by me. Item I. I deetaze far the purgoses of this Will that,as of the date of its exeeution, my family consists af the following: The name of my brother is Ralph Hone. The name of mq sister is Lucy I-Tone. The names of my children are Derrick 5haffer, Leslie Shaffer,and Devia Shaffer. All references to my family and chiidren are to them. My pazents and my husband predeceased me. Item II. I direot that all debts enforceable against me durin$my lifetime and duly aflawed in tha administration af my sstate,the expenses af my last iliness and funeral,incIuding the cost of a suitable monument at my grave,unpaid charitable pledges whether or not the same aze enforceable obligations against my astate,and the costs of adminisVation of my estate be paid as soon as practicable after my death. Iviy Personal Representative may, in his sole discretian, pa}'fTOP.1111�'L�O.T.i:li}^.'}'9°.C»t� '�i C: ".L'1��ponicn:, Of u�'1G" CQSt Ci w':L"��2N'd.'i�SllT21I2:�L•.`.4?'L'�'.Po$ in other jurisdictions. Item III. All of my estate,real, personal and mixed of whatever kind and wheresoever situated, I give and bequeath to my children Derrick Shaffer,Leslie Shaffer and Devin Shaffer in equal shares, per stirpes. Item IY. I hereby nominate and appoint my son,Derrick Shaffer,to be the Persrsnal Repmsentative of my estate. If he is unwilling,ar unable ta serve,then I naminate and appaint my daughter Leslie Shaffer. Page 1 of 4 Item V. I confex on my Personal fiepresentative, in addition to those powers granted by law,the following powers to be exercised in a prudent maivier and appIicabte to atl praperty constituting a part of my estate: A. To retain and to invest in all fasms of real and persanai property,withaut being confined to investments authorized by a statutory list, without being required to diversify and regardless of any princepa! of law limiting delegation af investment responsib'sti#ies by personai representatives or trustees; B. "1'o compromise claims and to abandan any property which, in my Fersunal Representative's opinion, is of little or no value; C. To seii ar private or pubiic sale,co excnange ar co iease ior any periad of time, any reat or personal property,and to give options far sales or leases; D. To barrow frorn anyone,even if the lender is a persanal representative hereunder, and to pledge property as security for repayment of the fiands borrowed; E. To join in any merger, reorganization,voting-trust plan or ather ooncerted action of sacurity hnlders, and to detegate discretion«uy dntias; F. To employ and to rely upon the advice given by investment counsel,to delegate discretionary authority to make changes in investments ta investmern counsel, and to pay investment counsel reasonable compensatian in addition to any fees otherwise paid to my Personal Representative(s); G. `k'o employ a custodian, to hatd property unregistered or in the narne of a nominee(including the nominee of any institution etnployed as custodian},and to pay reasonabie campensation ta the custadian in addition t�any fee,s ntherwise payahle to mv nersonat Representative(s); H. To pracure and carry at the�xpense af my estate insurance of kinds, forms and arnounts deemed advisab3e by my Personal Regresentative(s) to protect my estate and my Personal Representative(s) against any hazxrd; T. To commence or defend at the expense of:ny estate any litigarion affecting my estate; J. Ta conduct alone or with others any business in which I am engaged or in which I have any interest ak my death,with all the pawers of any owner with respect thereto, including the power to deiegate discretionary duties#cr P�ge 2 of 4 others,to invest other properky held hereunder in such business and to organize a gaztnership ar corgaration Eo carry out such business; and K. To distribute in cash or in kind. Item VI. My Persanal Representative(s) shall be reirnbursed far all reasonable expenses inceured in the administration and management of the assets of my estate and shall be entitled ta receive a fair and reasanabls compensa#ion for his services,withoat pasting band. Item VII. Anyane named in this WiII who diss within 30 days after mp death(or dies undec circumstances such that it cannot be determined whether sueh individual died within 30 days after rny death) shali be deemed, ft�r gurposcs or"this Will,ta have predeceased me. IN WITNESS WHEREOF,I,Joan E.Shaffer,have ta this my Last Wilt And Testimony hereunto set my hand and seai this,j.(��'day of 1�v f'n ,2fld7. � �� y� Jq�— n h ffer � SIGNED;3EALED, PUBLISHED AND DECLARED by the above-named Testatrix, Joaa E. Shaffer, as and for her Will, in the presence of us who,at her request, in her presence, and in the presence of each other,all being present aE the same time,have hereta set our hand as witnesses: ✓' .--- , NAME� L,:�r�RESIDING AT ��'i'i_1Z; %rlrr�.1�� ;1 �.� ^1t_CL'f i�� 7c?ii -� NAM�-'`r r'/�'i"Is` RESIDFNG AT 1TtYr�l��/� �t`d �/'% l � ,,,�.suu lh// i��'/�u!� —T Page 3 of 4 STATE OFPENNSYLVANIA . : SS. COUNTY OF CUMBERLAND . I,Joan E. Shaffer,having been duly qualified according to law, acknowledge that I signed the foregoing instrument as my Will, and that I signed it as my free and voluntary act for the purposes therein expressed. , - iY,.,, �' _,�l.t,�^' �/ �,Joan E. Shaffer � � We,having been duly qualified according to law, depose and say that we were present and saw Joan E. Shaffer sign the foregoing instrument as her Will; that she signed it as her free and voluntary act for the purposes therein expressed;that each of us in her sight and hearing and at her request signed the Will as witnesses; and that to the best of our knowledge, she was at the time 18 yeazs or more of age, of sound mind, and under no constraint or undue influence. �,,, i'"..� '��^ -iJ� . •; _ Witness -`J . .. . � „=" /� .. /� Witness Subscribed, swom to, or affirmed, and acknowledged before me by the above- named Testatrix and by the witnesses whose names appear, on this jfL�$ay of ��r(1 , 2007. ,. c. , i ��(;,� 'v` � Not Public COMMUNWEALTH OF FENNSYLVANIA Nolanal Seal Hope A.AAattos.Nolary Public 1lampden Twp..CumbeilaM Counry . My Cammiasion Er,pires Oct 11,20p8 � Membe�.PpnrsyL;��.��. •_=.;n�iahan O�Notaries Page 4 of 4 __ _ _ _ _ RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date : 6/14 2013 Cumberland County - Register Of Wills Receipt Time : 13 :�9 : 52 One Courthouse Square Receipt No. : 1074527 Carlisle, PA 17Q13 SHAFFER JOAN ELAINE Estate File No. : 2013-00669 Paid By Remarks : DERRICK SHAFFER CJ ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name SHORT CERTIFICATE 5 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Cash 5 . 00 Total Received. . . . . . . . . �5 . 00 RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Receipt Date : 6/14 2013 Cumberland County - Register Of Wills Receipt Time : 13 :�7 :22 One Courthouse S uare Receipt No. : 1074525 Carlisle, PA 17�13 SHAFFER JOAN ELAINE Estate File No. : 2013-00669 - -- Paid By Remarks : DERRICK SHAFFER CJ ------------------------ Receipt Distribution -------- ---------__ _____ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 90 . 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 5 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check# 2175 168 . 50 Total Received. . . . . . . . . �168 . 50 _ _ S:AF�R. �0��-°n<. °-,20C57`03-•p^_�M�_a12�/2031 _='__er`. ?r'_end�.y g•a<°�pr.`_ - 2/3/2012 - � po � .a r • . , . . - � "�''1 NNACLEH�ALTH YOUR ACCOUNT IS CURRENTLY DUE. HOSPITALS Far Acxaunf informafron, Please Call (717) 230-3717 or JOAN SHAFFER 1-800-603-6064 for Out of Area Calls. 944 WAINUT BOFTOM RD �(pay��nt has bean sent, piesse distegarci. CAR�ISLE PA 17035-G926 Pay anline at: http:!lwww.pinnactehealfh.orglbi Itpay> , � � _ PatientName: 8haffer,JOan TotalCharges: 5250,477.78 StatemeMDate: 4?t03112 PaymenistAdjustments: 5244,477.78- Service Date(s): 08/27/11-09127/11 Account Balance: 8500.00 Accdu�t Number: 72006�703 Patient Balance: 5500.00 Primary Diagnosis Code: 996.74 P6ease Pay This Amt: $500.00 • . . Ins. 1:GEISINGER GOL ,pp For questions,cail our Billing Help line at: Ins. 2: MEDICARE A 00 717-23p-3717 for local calls or Ins. 3: 1-800-6p3-6064 for Out of Area. tns.4: Customer Service Hours: Mon-Wed-Fri 7:00 AM to 4:00 PM Tues•7hurs 7:00 AM to 6:00 PM PJessa Note: Your phys'rcian wrll bilt separately fnr Arofessional services. -----------------°_---------°---------------------°---------------°------------------°------------------------------------------------------------------- Make Checks Payable To: Pi0118GCH¢21th HOSpitalS ^«�'^x�mw.�. "" � ni....>b Tn�.w�M: � � w�ax .n.: - Shaf�er,Jaan Due Now j PinnacteHealtri Hospitals ❑ � ❑ � ❑ � � � Q�, PO Box 2353 .,,,,,�„�. �,i Np,• �.�,: FlarrisDurg PA 27t05 Sio��n: Amnum 9�ia�. ❑ CbIWk Oox ifynpr Nllnn er iNUrYrs��inh�mpiun M1u SMaHt. %�ue rtuYa cNMME n�Gck. ^T1N Gi^!2 XumMt it YN iut 3 Ci pi on tiu OM Oi G Y�crsitt<�tY.M1YY�r N9�tun JOAN SHAFFER 944 WALNUT BC7TTOM RL7 ��w��u��o��un��Et��n) CARLISLE PA 17015-&926 PINNACLE HEALTH HOSPITALS P.O. BOX 2353 HARRISBURG, PA 1 7 7 05-2353 0000�1200577Q300d0005000CI00000t7008 Iaae 1 cf 2 �ua�r>, JOAV-cnr, 'e20C5'?03-'_°-A�J-9l21/2CL"�. Pa^_-=�; F-5_x'"_y c`stemgn� - 2/E/2C'_2 - py . . -• .r, . i � � PINNACLEHFALTH P�tientName: Shaffer,JOan HC}SPITALS Statement Date: 021p3(12 Service Date(s): D8/27t1 t-09127/t 1 Account Number: 12pq67T03 Primary Diagnosfs Cade: 996.74 Piease Pay This Amt: SSOU.Oo . • a . Trans. Date Descriotion Amount 10/17l11 MEDICARE PPO DISCOUN G13 6EISiNGER �OL 144,155.E6- 2�l18t21 MEDSCARE PPO DSSCOUN 613 6EISINGER GOl 400.00 20118/11 MEDICARE PPO DISGOUN 613 OEZSIN�ER 601 115.29 10/18/11 MEDICARE PPO DISCQUN 613 GEISINLiER 60L 12$.26 10/18/11 MEDICARE PPO DISCOUN G13 �EISIN6ER GOL 28U.93 10/31J11 PAYMENT-GETSFN6ER HE G13 i3EISINGER 60l 112,80- 20J31l11 PAYMENT-6EISINC�ER NE �13 GEISZABER G�L 125.49- 10131l11 PAYFlENi-C,ETSIN6ER HE G13 6EISSN�ER �OL 214.95- 11/02/li PM7-MEDICARE A 705 MEDICARE A 1,268.85- 11/Q4/11 MEDICARE DTSCOUNT 705 MEDICARE A 1,268.85 U1/30l12 PAYMENT-6ETSINCaER HE 613 GEISINCaER GOL 55,103.17- Q2101l12 MEDICARE PP4 DISCOUN G13 �EZSZNGER 60L 530.14- Please tia,e t1�is spaee ta nzxka cameotioos to yous address or insurai�ce i�farmation. N+�ine- Acxouni.t�o: PLene: .qildress: BetcinessFh�.wt: ___�____—_"._..— _ Emp?eve��. ___..___—_—_.,.__. —_.__'--.—_'_—_._____ Y,mFioyer Addtess_ . I,nSar:mce Company:_ E2"�ecti�-e f}1 e, Insiira��ce Ca�mpsay�9ddress_� .._-,----..T_ Phmae: SYGSUiance Poltcy or Conttict No; QraGip No�_ '_ ____ _ . Pal�CV Heldcr':=Nnine- PbonE[ _._.. _..._._ ..._..__ . ......__ ' _"'__ ' ' .__ _- _. ' .__' Pe�lic}°HoideC'>Uate qt Buf75 Pnlley Hoide,r'g Gender �M �F P�Iicy Hclderc iociai SeCar'ity'90 _... _. _._ __.. Pn;;e.ne's Re1uf{on�hip r�e Itiyured�. � Se1; � ypouse :] C`hild � Oilxer ____ ___ _ Pa�= 2 Gf ? Relianoe Standard insurance Services#701 P.O Bax2310 Asset Cherry Hill, NJ 0$434 Account Surn.mary dOAN E SHAFFER Fage 1 27 SHERWOOD CIRCLE ENOLA PA '1�025-183$ Y '710104586 5/4/2012 FRItI71RY STATEMENT ACCOVNT NVMBER CL632NG 4ATE TAX ID NO: - - — RSL ASSET ACCOUNT Np. 7I0104585 8ALANCE CREDIT3 CHECK3 AND DEBITS HALANCE LA3T 3TATEP�NT NO. TOTAL AMC)UNT NO. TOTAL AMOVNT THIB 3TATP:t+�NT 3I,954.36 2 43.6T 1 31,998.03 Q.DO ACCOUNT TRANSACTIpNS DATS,. . . . . . . . . . . AMOUNT. . . . . . . . . . . . .BALANCE. . . SJLSCRIPT20N Q4j1+1 27.Q7 31,981.93 CREDIT-INTEREST 05/04 16.50 32,948.03 CREDIT-2NTEREST OS/04 31,998.03- 0.00 DEBIT-CVST REQ CLOSE� RATE HISTORY DATE. . . . . . . . . . . . RATE DATE:. . . . . . . . . . . . RATE DATE. . . . . . . . . . . . RATE 03/16 1.0008 ****** CURRENT INTEREBT RATE 1.0004 ****** ****** INTEREST CREDITED YEAR-TO-DATE 123.03 *++,rk* THE ZNTEREST RATE CRED2TED TO THIS ACCOUNT WILL SE CHANGED Tp 1� EFEECTIVE QCTOBER 16, 2q11. +*tr+t,rrr+ ENA OF STATEMENT rtt**r+++,r NOTICE: see reverae side for reconciliation of this statement and S�ortant infoxmation. 701-71 1 F� Y4�t Cfl�i��IM1�i4E THIS FORM IS PROVIDED TO HELP YOU VEftIFY YOUR BA�ANGE ON THIS STA7EMENT �" BANK BALANCE SHOWN Np, DOLFRRS CENTS ON THtS STATEM6NT $ � TRANSFERS-IN NOT CREDtTEO 1N THIS 5TATEMENT (IF ANY) +$ SUBTOTAE. $ SUBTRIACT GHECKS, TRANBFEftS-OUT AND DEB3T5 OUTSTAFIt3IN� (IF At�7Y} -$ TOTAI. � �ALANCH THtS SH4tJ�D GORRESPOND WITH THE BAIANGE IN YOUR RECORDS AF7ER YOU ADD THE INTEREST CREDiTED QF ANYj AND DECYUCT : THE CHARGES (IF ANYj T11AT ARE Sht4WN ON THIS STATEMENT. NOTE; PLEASE NOTIFY US IMMEDIATELY OF RNY NAI4AE, ADDRESS OR OTHER CtiAhtGE ON THi5 ACCOUNT. IP YOU HAVE QUESTIONS, NEED ADDITIONAL INFORMATION 4R HAVE CHANGES, � PIEASE CAII: ; OUR TELEPHONE # 1-877-849-D030 w � OR WRITE p o ASSET ACCOUNT � INSURANCE SERVICES- 7D1 ° TOTAL $ P.O. BOX 2310 CHERF2Y H1L�, NJ 4$034 � �d�� Z0� 11 Form 54981RA Contribution Intormation PRUDENTIAL BANK & TRUST, FS$ r� • �• - � •• 280 TRUMBULL STREET HOSR F62-347298 8695 1 of 2 HAA'FPORD CT Q6103 �� Federal ID Number: 58-1861313 ozouse22 Envelppr,5245 010475 10 JdAN E SFfAFF�R � 27 SHERWOOD CIR "� ENqI.A PA 170251838 Customer 5ervice: 888-244-6237 �� ..�� r� Ftum 5498 ��1 IRA GOittffbtN�011 IMOlttiB�IOC1 OMB No.1545-8747 This information is being furnished!o t#se Intemai Revenue Service. ]lcoount Nnmbar P62-347248 S.Fair market valne of account. .. . ..... . .. . ... . . . .. . . . . .. . .. . . . . .. . . . . . . . . . . . . . .$118,899.fi2 7.IRA. Type. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .IRA• 11.Required Minimum Distribution £or 2012. . . . . . . . .. . .. . . . . . . . .. . . . . . . . .. . . . . . . . . . . . .. . . ..� 12a.AMD date. . . ... .. ... ... .• . ... .. . . . . .. . .. . ... . . . ... . .. . . . . . . . . . . .. ... .. . . .. . . . . ..12I3112012 'tt is en IRS rsq�V�emenf to ropaf TndYfnnd/RAs and Rabver/FG4s as IRAs. Please sea the IRA PaitAW�o secdon in fh(s sfatement ro IwMxldsMMy your eccount. Yon May Need ta Taka a(Sistribution fram Your IRA 6ur reaords iadk;ate that yau will be 70'h or o1d�in 2412. Once you reach�ge 70',4, the lnternal Revenue Service {If2S}rbquires fhe�t you fake a i2equired MinimUm Distribution(RMD}each year from your IRA(s}. You are required to begin withdrawala by ApNI 1st of the year foitowing the ye�r you tum 70'h, and complete all subs�quent withdrewals by December 31 avery year thereafter.An RMO must be caloutated a�arakely for every IRA you may ovvn, but you can take a distribution far Me�m#»ned 42AAQ amounts fram any!RA you own. Generaily,these rutes do not appiy to Roth IRAs, during your ti#eAime, and to IRA Beneficiary Disttibution Accounts{tRA-BDAs}. To have your RM4 calculated for the IRA account noted on this form, or it our records are inwrrect, please cp�fad yaur'tnvastment representative. IRA Pottf01i0 8S O#DeCStetbBr'31 , 2t}11 {not repprted ta IRS} Account Type Security CU5IP QuanYity Price Market Value $t7LIAV&Tt ZRI� Z62-3k72{$ PRUDENTIAL BANKB TRUST MMKT FDIC INSURED FDIC00902 42,935.540 1.0000 $42,935.54 PRUDENTIAL JENNISQN GROWTH CL A 74437E107 408.502 18.0800 $7,34fl.56 PRUDENTIAL GOV{NCt7ME CCASS A 7�W39Vt07 2,861.732 iQAt W 529,848.$4 PRUDENTIAL TOTA1.RETURN BdF1O CiASS A T4416Bt� 2,312.$87 13.990Q $32,356.69 PRUDENTIALJENNISONVAWECLASSA 74440N102 479252 13.7900 EB,Bp8.89 Fetr Zfiarket YaZue of yovr IRA Portfolin as of 12J31I2011 $118,899.62 Fair Market Value of your IRA Partfolio as of 12/31/201q $118,354.02 I �110812012524501fl075 � 2011 Form 54881RA Cantribution Irafarma#�ffn � �{}gn�jg� �� ,�� PFODENTIAI, BANK & TRUST, FSB E62-347248 *^*-**-gH94 2 �{_ � Zf0 TRUMBULL STREET Hq5R HFRTP4RD CT Of.103 F'ederal ID Number: 56-1861313 @nvalopo 5245 0161174 IU JOAN E SHAFFEF2 27 SHERWOOD CIR ENOLA PA 17025-1838 Custamer Seevice: 888-299-6237 � '� , 1�Y�fl�iAll�I.: Nl�'�µ' t+�t' . r �. . . ' 7lccount Primary or Name 3hrR�,�e Hd�� .af Relationship 1.�qs3��.YDe�,z" continganC 1�8,9G Ent �.��1�. t . .. i,k, t�. FAeLLOYiA IRA a'62'3t�2iS , No beneliciecy-Nrvfatmeti0n tln-raCnod. �dp�I�pt��NT:M . If you make any IRA +ror�t��lir�i� . +�� , � an upi�t�H'mr�M� . .- . ��IY 3�te��. � _ �. � . � � . . .. . . . ' . _ . . . , bp . . , .. . . - . . . UFp : tly. . . ., . . . .M � ! "�� 6110612t)42 524581 W75 MY�:KS-HnaNSii Fu�veR�L}-IoMe. INC. ',�'{��'. 1903 MARKET SiREET ♦ CAMP HILL, PENNSYLVANIA 17011 3.y W^�'� 717-]S]-996] 717.D7-4618 �B6RTA.HARNEN . ','i��'� �`,'a V � PHONE FAX SUPERVISOR � � ��"� Dlt97IN 0.BAKLR " � FUNERAL DIRECTOR LpCA�.I_Y O�ti.NF,:D ASD OPN:RA7'ED October 14, 2001 Mr. Derrick J. Sha£fer 27 Shen�rood Circle Enola PA 17025 Services for Joan E. 5haffer October 8, 2011 Cre�nation Package #3 $ 2�g5p,pp Cremation Gontainer $ 140.00 Cash Advanced Newspaper Notice/Local $ 199.00 Newspaper Notice/Out-of-Town 195.00 �-�8Y 100.00 Certified Copies 7z,pp Coroner Fee 25,pp 591.00 Total due within thirty days, please: � 3� ,,�,/p�, �,,� ��„^' � /�'W"' " '� // �- o�0/l Lr/G -7� �Q�a�02 O / Monthly Staterr�ent • • i Statement pate 01/31/2012 Account Number 000372A9457 Inpatient Amount Due S67S.Od Outpatient Amount Due $4.40 If you are interested in receiving ynur monthly Tdtal Amount Due �g75.QQ statement eiectronically via email, please speak ta the bus+ness af�ce at your facility for more infotmation. Balance Due Upon Receipt If you would like to pay your bill online, visit www.myzpay.com/MCHSCariisle � QuestionsT , Please cal!717-249-0085 fo reach the business o�ce during o�r regular business hours Fiease contirm that the infartrratian is correct fpr. Maii Cheek Payabie and Remit Ta: Patlent Name dOAN SHAPFER AACHS CARIISLE Medical Record No. 000372-9946� 940 WALNUT BQTTOM RD A!R Representative QERICK SHAFFER CARLISLE PA 17015-5926 Q Primary Paysr. C#Ei3iNGER HEALTH PLAN a Secondary Payer. �lt� VJ�� C�'�' } � Insurance information and payment activity �y� �� { 13 on individuai accounts are inciuded in the � attached detail. � PaymeMs by check wiN he wmreried iMo electronic tund translera.Funds may be aebitetl han your accouM as soon as the srna day paymeM is receive East Pennsboro Ambutance Service,Ina. Sta#ement Post Office Box 47 Enola,PA 17025 DATE {?]7}132-5552 FAX(fi17}728-9502 ioisizoi r Federal Tax Nurnber 23-2464545 BIIL TO sh�rr�„ra� 2?Sbenvood Circle Enola,PA 17014 �ue DATe AMOUNT DUE AMfJUNT ENC. 1015l20I1 5122.40 DATE DESCRIPTiON AMOUNT BALANCE OS/16/2011 ]NV#11•1600.Due OS/]6/2011,prig.Amowt 5122.40. 122.40 122.40 —STRI WAY-N�Member S&4.� —Sfretcher Mileage,24 @ SI.bO=3$.40 V � �� 1�� t�� CURRENT 1-30 DAYS 31-60 DAYS 61-90 DAYS OVER 90 DAYS AMOUNT DUE 0.00 0.00 122.40 0.00 0.00 S 122.40 ' YOUR PAYMENT IS DUE UPON RECEIPT OF TtiIS STATEMENT. MEDICARE,MEDiCAID AND MQST INSURAtdCES DO NOT PAY FOR TtitS SERICE. APPRC?PRIATE COLLECTtdN ACTION MAY BE TAKEtd ON ACCOUN7S OVER 90 DAYS OLD. THANK YpU. VISA-MASTERCARD-DISCOVER ACCEPTED � � �+` •� � HOSPlTALTELEPHQNE AND TELCOM, LTD. P.O. Box 39127 Cleveland. OH 44139 Customer Service: (866)362-3880 8AM-SPM, M-F \��:A�" � �}� JOAN SHAFFER Invoice#: 3 PHli U9-58i30 27 SMERW000 CIR y�� . Date: 12/12/2011 ENOI.A, PA 17Q25 y�� '��,i^G, BalanuE�ue: $40.00 t7 � THIRD NOTICE PLEASE Q�SREGARD !F PAYMElVT HAS BEEIV SENT PatieM Name: Jt}AN SHAFFER Admissbn pate Discharge Date Service Daya Description of Servica Balwnce Due: 7131/2012 $J 12!2Q11 12 NlP�4NE $40.00 '1'!��am�s�e tasr the conven3�enca e# uze of te snd J ar — � d�li�vkac duri�,�rwrr Fwspitai stey at aicrt�t. These sawvi�e�s awr�r not bay a�ty�rsurance pian.' PWt��e us with aeyr questions at our totl fwsa numbe�, 1-868-382•�880, �tn thrt af S:OU A�II and 5:�t1 RM. Mondsy throc�gia Friduy.Thank}ra�. Pay Online at paypatientbill.com