HomeMy WebLinkAbout11-08-13 � � � � 1505610101
REV-1500 �`�°'_'°, 4�''
enns OFFICIAL USE ONLY
PA Department of Revenue P ylvania
Bureau of Individual Taxes �""p'""�T°`"`°`"°` County Code Year File Number
PO BOX z8o6o1 INHERITANCE TAX RETURN
Harrisburg,PA i�i28-o6oi RESIDENT DECEDENT � L � �'
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
� ���w � � , Q , O � � � �
DecedenYs Last Name Suffix DecedenYs First Name MI
,, �
0 f� � c� '
(If Applicable)Enter Surviving Spouse's Information Below �n
Spouse's Last Name Suffix Spouse's First Name MI
Q � � _
Spouse's Social Security Number
"' ' ' THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
� � REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
,.� 1. Original Retum p 2. Supplemental Return Q 3. Remainder Retum(date of death
prior to 12-13-82)
p 4. Limited Estate p 4a. Future Interest Compromise(date of Q 5. Federal Estate Tax Return Required
death after 12-12-82)
Q 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)
Q 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(date of death O 11. Election to tax under Sec.9113(A)
between 12-31-91 and 1-1-95) (Attach Sch.O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
� c� OL A L � '� r7 3 ` � [
REGISTER p,€�WILLS USE ONLY
a 7p
c��s � 1'►i
First line of address p �, � �
� o
� � L � S � � -�..; �
Second line of address r' � ��j �
� � � � � �
� �'? �c �'y �
. � � � � �
City or Post Office State ZIP Code � � '"'"� DAT�FlLE�
S /� � U T � I ! "�� O
_ � .,�
�
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.
SIGNATU OF PERSON RESPONSIBLE FOR FILING RETURN DATE
�J
ADDRESS
�o I � f P✓1 �'1 S�--r�.� '. rtic.��c.a r 1�::�. S�]
SIGNATURE F PREPAR OTHER THAN REPRE ENTATIVE ^ D A TE
�` �)
ADDRESS�( I S
� .S�, � �s v P t�a s
PLEASE USE ORIGINAL RM ONLY
Side 1
� 1505610101 1505610101 J
f� '
�
• �' �
� 15�5610105
REV-1500 EX DecedenYs Social Security Number
DecedenYs Name: V t Ci i�i2 ^ .Ci� l � � V�C �6 �-� , � ((J• ; � �l � �''
RECAPITULATION
� ' �
1. Real Estate(Schedule A). . . .. . . .. . . . .. .. .. .. .. .. .. .. .. .. .. .. .. . . . .. .. 1. ; , �; `.� w��.;. :
�_
� � , �`
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). . .. .. .. .. .. .. .. . . .. . .. .. . . � �
q m * <
; �� �� � ����#���� ����
, �(�, �}, 1
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E)... . .. . 5 � "1 7 �� ��
s '� r�`�� ���� . ��,a��:
'.: � y� � c
6. Jointly Owned Property(Schedule F) p Separate Billing Requested . .. .. .. 6. - � ° �
� �
•� ��� � ��'t t����.��s ���:�r� �
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property /�� �'�,�
(Schedule G) p Separate Billing Requested... ... . . 7 = � � � �`������`T��'°� �
�, a�a,-4� '�'' g ��` �s �`� t* >'°'�?°�
� �4 i yk ry
N -: n '�r_ � �.
8. Total Gross Assets(total Lines 1 throu h 7 •• •• •• • • •• • • • 8 � ` �� L �
:
9 ) ��;
. .. . . . . . .. .. .. .. .
` � � r �< < �
9. Funeral Expenses and Administrative Costs(Schedule H). .. .. .. .. .. .... . .. . 9 a � (,� [ � � 8� �� U ., '
�., ;� ����,� ���ks���°:ic��*,�,�,_�i
10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule I) .. . . .. . . .. .. . . 1p � � � � �� ��� �
'��`; �,�.::� s� �'�;�s;.�' °�-`.� �, ����*-r€d. '„
� � ��� � l °� 9
11. Total Deductions(total Lines 9 and 10).. . . .. .. .. .. .. . . .. . .. . . .. .. . . .. .. 11 � �( ) �_
��.��`'o" ..,a`� �����"�n� a"��-��"*� �-�"tl'�
. .. .. .. .. . .. 12
�� � � � �, � � � i
12. Net Value of Estate(Line 8 minus Line 11) .. .. . . . .. . . . . .. .. . � � � W��
.a L£ ,��5",'�ii+�fi 5� `�' �' � � 4 � ��4��
�wv �
13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which � � � � � � � �
an election to tax has not been made(Schedule J) . . . . . . .. . .. . . . . .. . . .. .. 13 ' � �" ,
r=� :� ` ;�_ �s, '� � ':� * ;.
�n�- ` � ky �` �
� . .. .. .. . . .. . 14
14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . .. . i � � ° � , � '� �,� � �'` a� '���
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 �` ��° � � � � � � �* �� � ��` �`° ���
� (y ����� � 15 � ry ''f'`�(.,����Up�rj� � �
(a)(1.2)X.0_ � 3� -f � � � �
.� ��:E� �-��� '������ �, �� � ��
16. Amount of Line 14 taxable � � � " � �� � � 16 � � � � � � � �
at lineal rate X.0_ � � �` � � � a ���
it ; "� �:` �:a � ���,�afi?��+?�'�:; ;�:" �'�;_����'°�°�'`.,,���'��'�a`
��
17. Amount of Line 14 taxable � � � � � � �
at sibling rate X.12 � � �� " � � �� � � �
�;.:.
�s�Y� � ��� .�,;�; � ��, ���. �` �"���� _�:
18. Amount of Line 14 taxable � � � „� � � �
,
a ,
k # � �
at collateral rate X.15 ' � L � 18 � � � - � � � � � �
� �
� . ... ..�.4<r..k,__.�. �.,.��«.w.�.va�a k " �+i�'"� ?x��""�'"y' . �� ��' �
.� . , , � :. .. �'��+ '"��� .." .
t ��
19. TAX DUE .. .. .. ... .. .. ..... .. .. .. .. .. .. .... .. ... .... . . .. .. . . 19.� � �� �U��� �
. .. .. �,�.�,,aa,..�:_���.M�� rm a.�a�°��-s�� ��.sa.,
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
� 15056101�5 1505610105 J
REV-1500 EX� Page 3 File Number /1 G j� r � v �� �y
°� lJ
Decedent's Complete Address:
DECEDENT'S NAME
V � c��. --��r� i c�a Y
- - - - ____ -- __
- - ----- -------- -- - -- --
TREET ADDRESS - —
- - -- -�-�--� �C-v''trt lS���� �' - --
CITY � � l � �� � --- – I STATE ZIP , � - --- -
4 � � � S
Tax P
ayments and Credits:
1. Tax Due(Page 2,Line 19) (1) �
2. Credits/Payments
A.Prior Payments __ _ _
B.Discount
3. Interest Total Credits(A+B) (2)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (3)
Fill in oval on Page 2,Line 20 to request a refund. �4�
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. �5� �
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred:.......................................................................................... � �
b. retain the right to designate who shall use the property transferred or its income:............................................ ❑ ,[��/
c. retain a reversionary interest;or.......................................................................................................................... ❑ LJ
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ [✓]�
2. If death occurred after Dec. 12, 1982,did decedent transfer properry within one year of death ,�/
without receiving adequate consideration?.:............................................................................................................ ❑ L'7
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? ........................................................................................................................ l/� ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent[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 applicable even if the suroiving 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 naturai parent, an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S.§9116(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 decedent's 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.
F�V-�508 DC+(08-�2) .
i : pennsytvama SCNEpYLE E
� ���� CASN, BANK DEPOSITS 8E MISC.
�"�^"¢T'�� PERSONAL PROPERTY
�e+rr ne�srr
ESTATE OF:
�— FILE NUpBER:
��� ���;_ l� �y ( ,�� �..e c: �-G" t.3 t�c�,°7��=.
Ir�ude ti�e prooeeds of 4ft�atiai artd tf�e da#�e tfie pra�oee�v�e reoeived 6qr tl�e estabe.
�P+�P�Y��Y���9���t�be ti'�Sed on Sd�edute F.
� VALI�AT DATE
NUMBfR DESCRIPTION pF p�qTM
1. Ratriot Federaf Credt Union $�1,902.06
2- $2.090.76
Members Fitsf
3.
Per�nal Property,Ford V�.�OOIs
,�' $6,000_OQ_
4.
, -
�s�� d � � � c,rz,�e l��i a�t a�- ��r3-- �0 7�a
� MEMBER'S STATEMEN� OF ACCOUNT;��
.� � �� '
� a�:�ot � • •: � • •
Send Inquiries to: . � � � - , • � , � . •
FEDERAL CREDIT UNION �•o.Box ns �
Catde the Spirit of Financra!Freedom Chambersburg,PA 17201 ��3�
R@ba1�e Up t+D
4.5�ot�
����� Signa#ure'�a�s
t
14354 1 AV 0.360 19708-i4354-36
� �) I 6 1 in � �d r d u) 1 � u i I ��II� `
— I Illlhill � I lin i I Ilill �n I �I i I II I � : , j ` . �' �.�� ry- �� �-_
� VICTOR K TAYLOR � � LitleS Of C�2d`I� "_
'� 619 GLEN STREET N�
'�� SHIPPENSBURG PA 17257-2129 w±
�� —
�
�� r=
�
>� =
o�
<,�-'.-. - �
�. � *�
s
C�,CCUV�-t'� �a� l ��U� '7Cy . . .
www.patriotfcu.org.Patriot Federal Credit Union.717-263-4444.SMARTLine: 717-263-8468
Have a summer vacation, a remodel or other large
purchase?Get the money for what you want nowt
Plus, get a cash rebate up to 1.5%with a Personal
Signature Loan. Make it an amazing summer by
contacting a Patriot lending Center rep today! A
great low rate means a low, affordable payment!All
loans subject to approval.
`'� � � �� � . ��
�
� . .- �: t - .. �. � r. � ..- .
SUMMARY OF YOUR STATEMENT INFORMATION � �
PRIME SHARE ACCOUNT-00 9,718.25 4 YR MONEY MANA(aEMENT-40 15,862.38
DRAFT ACCOUNT-25 7,969.49/ 22 MONTH CERTIFICATE-42 18,351.94
PRIME SHARE ACCOUNT-00
Post Eff Balance
_ _ _Dat�- Dat� Transa.^,tion D2scr tion - - - <_.._ n e New_Balance
06-01 Balance Forward .............................................................................................................. 9,702.62
06-27 Deposit by Check .................................................................••----........................... 12.00 9,714.62
06-30 Deposit Dividend DIVIDEND ................................................................................. 3.63 9,718.25
Annual Percentage Yield Eamed 0.150%from 04/01/13 through 06/30/13
9 718 25
Ending Balance ................................................................................... ,
DRAFT ACCOUNT=25
Post Eff g��
Date Date Transacfion Description � Chanae New Balance
:-
06-01 Balance Forward ..............................................................................:......�...,.............:..... 7,125.49
06-12 Deposit ACH SSA TREAS 310 ..................:.......................................................... . 9S4_00 ° 8,089.49
TYPE:XXSOC SEC CO:SSA TREAS 310 , �
06-15 Withdrawal Transfer .............................................................................................. -120.00 7,969.49
To TAYLOR,VICTOR K XXXXXXXXXX Share 00 �
SHARE AUTOMATIC TRANSFER
DEP PRENOTIFICATION FROM SOC SEC ADMIN
06-30 Ending Balance ................................................................................................................ 7��A�
C.s-f� t-� �-� �, Grrr�- (�c�i rtc�.�l s��. ��r3 —u a��o
M3'�iB�4S 1ST FEDERAL CREDPf UATION.P.O.BOX 40. MEc�xicsBVxc,PENNSYLVANIA 17055 No. 00008 3 1 00b
Acct: XXXXXXX624 Teller: 0635 Date: 07/15/13Time: 11: 02am
------------------------------------------------------------------
See receipt for reference �
------------------------------------------------------------------ .
Check Number: 00 0000831006 � �- �°�-�..,,,,.
Purpo s e : I THDR.AWAL ����°�°
Amount : 2, 090.76 (� �
Pay to : E VICTOR K TAYLOR `�� "1 (p��
C�C C �:.�ti-�'� ��C� ��. ��
,
Victor Kay Taylor 2013-00760
Schedule E
_ _--------
Members 1 st $2,090.76
Patriot Federal $51,902.06
Credit Union
Van Ford 2004 $4,000.00
Clothing, misc. items 2,000.00
-� $59,992.82
, � �a �3 — �p e���4
� , . . � � .
' � �� ��-e c� �- U r c 7v��. �,� ���o dZ
My husband had a 2004 Ford Freestar minivan...the title was in his
name...the title was transferred to my name on September 23, 2013...the
van is valued at $4,000.00--- r
�� pennsylvania SCHEDULE G
DEPARTMENTOFREVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF
�2 G l 3° UU 7�'o C5
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
ITEM INCLUDE 1HE NAME OF 1HE TRANSFEREE,7HEIR RELATIONSHIP TO DECEDENT AND
NUMBER THE DAfE OF TRANSfER. ATfACH A COPY OF THE DEED FOR REAL ESTAiE. VALUE OF ASSE� INTEREST (IF APPLICABLE) VALUE
Mliton Hershey Retirement TIAA �i��,ci�.��
i. jeO�e 1l�'C (a`�',�����-
TOTAL(Also enter on Line 7, Recapitulation) � �� �Cl� � � ,�
If more space is needed,use additional sheets of paper of the same size.
..,.. , '
, �..�.,.°',� , � � , � � c�t�l� �
TtAA �:�i L�,,�y�5���`��- � �
� CREF;.� ` � _ J —1 � '� 0'
8500 Andrew Camegie Blvd �/V� July 18, 2013
�aHCUU.s�v�s cr�arione.ivc 2szsz-ssoo . - - C�� ,��Q�-+�--�,5 �:o i(�. �
, �
0030012013�71723595926358170000015/S ,�i S�+��� � i � ,�f 3 — �� 7�O�
t ,
CAROLE MAY TAYLOR `
619 GLENN STREET Questions?
SHiPPENSBURG, PA 17257 ` Log onto your account
i ' ' tiaa-cref.org
Ca11800 842-2252
M-F 8 a.m. to 10 p.m. (ET)
` � Sat 9 a.m.to 6 p.m. (ET)
_�— -,".�_.. —_ _ . __ -,�,�
n,�',,
�� ' -.,
— --�-----__ _ _
___ --- --____ _� _ _ _ _- _ _ ._____ _ _ _ _ __ ---- _. _ .-_ . ___— ___. - -
a'r CONFIRMATION STATEMEN7 __,,.--w°`
� f,...�,,.-.__,.;
_ :zz-��.-�.� a
— This statement confirms a transaction(s)made to your acxount. Please review your statement and let us know
_ promptly in writing, of any inaccuracies. Unless we receive written notification within 60 days after you receive
— your quarterly statement,we will assume this information is correct. If you have any questions please calt us.
�
�
�
,� Account Information
..�
= Plan_ M(LTON HERSHEY SCHOOL GR�UP SUPPLEMENTAL RETIRE ANNUITY PLAN
�
�
,. _ - : � _
;� '� �Tr�sfer of Funtls#o New Savings 8 tnvesfinent Plan Contracts "
�
� Effective Date: July 17,2013 Processing Date:July 17, 2013
_� Total Amount:$61,557.44
� The amouMs beiow have been moved to your Savings 8lnvestment Plan cantracts,which will be sent to you
� under separate cover.
�
��
FROM ORIGINATING CONTRACTS: -
TIAA Number. K86516J-0 CREF Number:J86516J-2
_... . ___
UNIT/SHARE NUMBER OF
INVESTMENT(FROM) AMOUNT PR10E UNITS/SHARES �
TIAA TRADITIONAL SRA MDO -$61,557.44 N/A N/A
TO NEW SAVINGS�INVESTMENT PLAN CONTRACTS:
TIAA Number: L9908JM-0 CREf Number: M9908JM-8
UNIT/SHARE NUMBER OF
INVESTMENT O AMOUNT PRICE UNITS/SHARES
TIAA TRADITIONAL SRA MDO ' $61,557. N/A N/A
�__
��
TIAA-CREF Individual �Institutionat Services, LLC
�..+.. v �- U i C��'` \C°..���.il$��1951b1
CRE� r.o.sog 12si �
NC 28201 �-S �
� ��cu►�s�wc� Charlotte� �Q f� � (�O �J�o G
. ��seeat�.6awus �,,,
� „'� �
��� ��
OLE TAYL�R (�'U
pay�ment for: CAK -
TIAA,: K86
5163� C�F= Jg6516J2 � ,�
Check Date: 07l17/13 Effecl3ve Date. 07/1b113
PaY�nts
p�duct i°ns ,_------
�
� t Info�'�t7on SUmma�Y fi"� 2,646.7$
� pay� - � ,.�"
� `� � 529.36`�
""�'� Account�S) Total � -� �
t
� T�X@S � \ , .' l�,i. �--...�._._
_..--_ `.
T ` ~'
_.--
---
� �
_.__--
��
� ' 2.646.?8
_...—" 529.36
�_
� Gross Totals $2,117•42
�
� Net Total ,
.�.--
.� .
,..�_- .
�, _
V° tiaa-cref.org or call our Automated .
; : ' -�9,atix�i.� go to www• seven daYs a week.
: For. ya�'.c���`. ;�g��252, .24 hours a day. ear in
���1�. �. ���g) ` ents to the IRS fo� the Y
Telep2lp� �poTts all taxable payt° consultant
Pleas� note,that '�;���•�have questions, you can sPeak With a TI�9��. to 6 P•�• _
whiCh they. are made- � � � g a.m. to 10 p.m. ET and Saturday__�.-.----- _�_
to Friday -----
at (800) 842-2252 M��Y . .�.--,-------------
_ ._-_
__..... _:...
` . � � �� a ent rias been sent to your financial institution as direct •
Your P � � ��LE TAYLOR A/C **�*'�**"3475
�. .
;;. .
.� .
- CAROLFs- TAYLOR
619 GLENN STREET .
SHIPPENSBURG PA 17257
�-
� .
�
October 18,2013
Carole Taylor �v� 3 � �v_��o
Estate of Victor Taylor
532-3166
Notes for Mliton Hershey School Retirement Account
Victor was employed at Mllton Hershey School and had a retirement
account set up that you must withdraw from when you are 70-1/2, which he
had set up.
Paper work attached-
Minimum distribution was paid for the year 2013 on--July 16, 2013
Amount $2,646.78 taxes were deducted $529.36
Balance remaining $61 .557.44
$64,204.22 at the time of death in account
I called TIAA---1-800-842-2262
There are no taxes to report on this account and it is NOT set up as an
annuity. Taxes are paid at the time of the withdraw for minimum distribution
yearly at 20%.
"This was not set up for a life time income. This is a retirement fund he set
up through his employer, he was receiving minimum distribution up the age
of 70-1/2 upon his passing he had not taken all of his minimum distribution.
This account is not authorized under retirement based off of withdraws."
; pennsylvania SCHEDULE H
� DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF
�t G7�� �� �- cs�. �-U�,� - 6a�(�U
Deced nt's debts must be reported on Schedule I.
NUM ER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. $5,069.80
Comeluis&Kelso,Obituary,death cdertificates,memofi/book
Parklawns Cemetery,grave marker flag pole,grave markers $3,625.50
Preacher,flowers,Memory Cards,Memory Luncheon,Memory donation CVAS,VFW Service Post#1599 $1,012.00
Masonic Lodge Service Lodge#143
g, ADMINISTRATIVE COSTS:
1, Personal Representative Commissions:
Name(s)of Personal Representative(s)______-- ---------
Street Address ___ _. _---------- ---- -------
City----------------- State--ZIP. --
Year(s)Commission Paid:____. _—--------- ---------
2. Attorney Fees: � � l.tsSG C�C1��S � ' �S O�
1;�1 �.��, �:.
r� ��
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.)
�
,�(��
Claimant ---------—
Street Address______ ------
Cit State ZIP ___
Y---------- -- -
Relationship of Claimant to Decedent - --- ---
4. Probate Fees: $228.00
5. Accountant Fees:
6. Tax Return Preparer Fees:
7.
TOTAL(Also enter on Line 9, Recapitulation) $ � (� l ` C,3 D
If more space is needed, use additional sheets of paper oP the same size.
�
... q� .- V �. p o N V V I I i o J N cQ N�y.TT. � �N � {a m i
� , E 33 3aEim3 y m ��a � � I �CW7yin�a@Yc? �C � �C v , i.
� 3 wo�° �_ L � ' NCm � !Q N _-. ya ! ' c z �
CI m vi °' �.1°a � Z N m Y I i = o�:,-w c 3 � cc �:
tJ{ � E � awm n LCU Em�j � i �U 000 �= `°� e Ol, � � � i
I �' m`� m° � 3 c G c m�� j u�'�c� �61 � m ; �.�� � i
n' � L� Nc N > " N m W cny.� � � �+ Eti �a�a � � f I
� Uf �' � �t� 3 3 � W/� �-O� � � � � o mad= `�� '� j t m '\
� �4. y » m � 0 b ii 01 C �N � � R i� d� � m¢ m ' t�.
� � � W Uj � � c�omE ma � � E °o� I � { Ia m=y�� �a a
u, � u� �� Cba� >a a „ m � !�W �- �_ � G � � - ���
� Q � Z a2` �F �ma cs � o-___ I cC: mmc �'�.._ � � �
3Z � � �!1 �� 'mj � � �� Q mda` � Im���-° "o'to= � �sj
} j OD � LL L!J N� � ��o a�id Z �du°im� � Icw�� o �N '� '� I ° � �
Q JCO �j � �� � � mFmo� m"' t a o,� rna�i� � ��¢ ''°'@m mo .�'.� ' � v-� ,
�j Y N p_, ' 0 .' �.° a� N= �� F ° ��C7a � Iaa o.m N� ��a i #! 1 � m
� Z � � 2 Z � r �; �� 0 3 m E� Z t L m� c c m Q m� m�n.cLi oi ti�t � i : m� .�
Q Z c�I F- LJ.� u� E �'a�i E°�; °Q � 'm m N m@ t 3 z m`rn� m`�°L °.s c �a j j `O1"'
�p � W N a� u� � �m�y mm LHO� o m.oQm �Q,�oE,ay ! .� � ;�
dl� � � m '° c tao � U? mo � m� � mU � n`"aiLO�>.=r � � Em 4�
� z (jjP� � t!J � oa= m° a°_m W � 3 � � � om`-° o ��U ��_9-y ` i n� � � �
J Q U F� Q � 0 3 m m m ro � °' °=° LLI �`°� �m' m c° ° m °' �a��� 3 L �� i z ��� �
Ge N � Z a U� 0 3� �=o a = � m� J �a a s � c a�? E n m��-=w o � Z! ( Q A" :i
�O! (OO � F � C3 = am UEaE N E Em . � °�wr0 E m_ � °_mm � m °cmo � � Q. � ��
�, ¢ �� mnm � > > o Q m � `_-' � � momr a a�ia°.� � 000� o �' ' {3.1 m >
- vi( ~ W � m�' m m o o � o m � ca m o �... F ca m?t a-o c 4 tn� � U `a�
i� � 0 � �� N �qo V c my �C nd�ma � aa inn�� �c'myo '1mid� !� wt i
� mvc c� w ° >.: mv!P3 '6 � .acm�- c a���o' V -
�r (n p rnm�m �- 3 N c V c o; � - m y...a E _ >.-- irn : � �
-re w � a °,m E m� m `6 � Q L��x °' u'_- '�a E m m v',?'E c°� .pu7 ini Iin � �= o m
P+ U Umm ��S� oa � ¢ � a � f-
flf J '�� . .'y
: a � ,'� a� ! V I� I ! "� � ' � j'��� � :a I ` I
� � � � � � � 3+ � .�S! \� � .
+ 1 ,` { , `i� �
� ( � � � � ��: ! �
� I � ,� , J � �, � � � � ,��I�;� �� � ' �t� ".
O � ',, � : � m � I i � �I (���� '�
Yr � � F • - ' i � i��� '\\ a ' � ;`i �.
� r j }i.
� � : '1 D v ' 1 i
tn ! c ; I I ; �'
^, Q i �, ; C� � � � �, � i i �, .��`1�? ;`��
� � z j � � �„ �, � � � �= �
� l ° � � --�\� u � `Y���i�
� c� � .
� d i ,i
� z> a � � � � �' ` � -�' ! 1 �; �'�I a
� t -
� � � d� � ` '� ` If = I ! `..�'' : ' .�\'�� "'S i !+.•��j�� I�
� a Z � t�ll . � t/� ' E o '. y R � I � n 4 i v� . '.�� : �� 'i f ;' 1 v
i '�'� � 3l
� �
ti
� Z N � �! � = u m ' °' � � � ' � � ����i,
m : c : , . :—J_
� Q d�R N W ���{ 'z m � w ¢ � � � : n i i � ��. � <n is, ^ .tj� �
LY VtY I�` Z � �" � LL lL Q y N � V : O � ( � : . .. ,. fli� � 1J �
f1 li O � Z . ` GI Q tp � : G � f N N f� ' .
l � � I �, ` a � o �` � " .4
� � r � � f � � � � ' Z m d � U �m ' ( U �. ^ E Z � y -.;i
� � � Z � w m S o O c Q o o. , � ¢ m i m _ a � a C\` `y V
r L'1 W � a m c J 'o > o � Z ( � ° � i � o -' ' � � �� �\`4'.��,.•� �
[� � � � Q .0 > E c_'�6 R o Q v� � m � n � = o ' ( � -� 1� F a a y N l� �� ;
� � w F Y = u� m m m' `° z v° a o I n Q aTi � � � d m m � H a.�� � _ � +�
T � W O cn (� � � o, � m m � � = U �i Z, 3 � U rn � � m w e f� ° � m � I �P
LL LL Q , C tp LL "O V' m m � m I � LL :n cr c3 z N� C`% � ' 't�
(� Q O O � �. � � > 'a U � ° � m � a d � Q � � = m � ti Q .y m = :
w [u ut � 'v `° m m ` F �n Q �� I m E :� t � O ° � I o 'o '-° o ¢ a \D � p . I
w a a v `� n°. ¢ E .o o � U ci 1 � c� a o � �-- 3 I i tn � ��,.m � c:
0 0 0 � - F-
� � I .` 9 1 ! . >" ' i ' I i i ''� {i
� �� � � i � � � � � �t 'i
� � - �
( i � �r.� � � ! � ,d")t:
` d '� .l� � ;✓� I j � I�.
U �; � L -� �� � � ! � i I � � !
! !��
� �'�. �: �i � , , i 'i , �� i i 1�
� '
w i i
I -] 1:�
' ' I I . � . ! . , .
y � 4 I � ; a ' ( � +el� . � � ' �
;i I � �,�'� � ( � v � 1 �
�
s� �°� � � �'� , ' `� � � j . � �
,.
�c �,4 I � '� � � � I � . . . vJ � 4 ' � � � . � '.
``� � � � , I i � � _.\� !� � � i
a�,s +
� ; �, ,,
�' ! i i
€� � � � '�; , ;
�n V : �,,; � ,I , , ,
tt; ' o > � _ � �; � i �
� = a o c� ; W� _ ,; i ; � r
N � u
,I @ N Ma•. '�^'�' CG O N � � \ ' : U JI � . )� _ 1-
V
� � R > U ` a � E y v w rL s� � i , . �,.1 . . c�
� � s � o �
� _ � � � � �\ �
o . e� � � '� ' _ �� U it;�.,, n _ �,
�, y y � C = G :� �. � �� W � �; , ; 2 ;-� w
� m � > ti � o o - c l4 - i+% � a'r `c I I i . . - . .. _ �. :n
6L � W � � � C O w � . LL � � � � � N ,%! j ` �: ' : _ �. O ' '�� �. _ Z
o '' � m Q = ' `c m in � -° °-' 49 � � �. a`'-�� � ! d �. i j � � � . � T
(/) 3 a 7 t: U; a: �L x d c t LC�I � > I� a'� 1 I ti � - � . C:
� � � a' °¢ 't °a o a`, . E �: > a� � � � ' � ' � �. v. . . � ¢
.°� � y � � _ 6 W _ C i ¢ : _ � sc `!1 p� � ' � U ' � ° .- - � - . �
G �. , O ' y __ ` O . . : _ � LL li O z - � ` Z ."�., ti. ' - C . L
' �y m � d _ � � � c tv .J W o m � ' � C�� O � � ° i � �' e� 3 s � � ti . .� ¢
E a - o a 'o � _ �' o � -> w.,,� . � i F m o m �v `� � rn ' � w - � •~.
� �-� n d V� e e� R � 9 � � � p �J n Z � U - 2 � �: � m .. . �
� ti E � � � y `^ F- r= _ � tn w a � v O a _ � :� ci -
ti m w O . tl � � > > >
CV � �
��� � � --- ' "/..� � ���- �
` �. �r�- �� .����
PRENEED COUNSELOR SALES RECEIPT
_R. ___:.�-
PARKLAWIV�ER�ORi�tl G�4RQENS AtVD i1�AUSULEUiUi �1 No.�4
32'f 8 PFIIL�tpELpHtA AVE
CHAMBERSBURG, PA i 7201
717-253�125
oarE �� ��
R�cavE�r� �
h��
'n�e an�ou�r �,O� �
�t
AS:DOWN pAyMENT ❑ REGULAR PAYMENT�
C� � CRED(T CARD CHARGE ❑
cHECK Z�t'Z— -
°r. CARD7YPE.❑
_ FOR THE PURCHASE OF INTERMENT WGHTS AND/OR MERCHANDtSE AND SER1/�CES�THE ABOVf NAMED CEIYIETERY.
RECBYED BY CEMETERY
��C ElOR
DAT6 BY
NANE
- GEN 8002(fi�)
�
Q
`� � ��rr�- I�, `��-���'�- ���3 --�c����t�
' ' Service Corporation International
PRINT SiNGLE CASH RECEIPT u�" �013
Page 1�1
Batch#: 99298973 Batch da�e: 9/6J2013
#of Trans: 1 Batch Am� �100.U0
Location: 0601-Parlclawns Memorial Gardens&Mausoleum f,�sh ReoeipR da0a: 9/6/20131:27:00 PM
Address: 3218 Philadelphia Ave CeSh Reoeipt#: 060114108536
. Chambersbur PA 17201 Cash�tAmt 100•00
9 -
Pey� D'iscover ��, pay�er; Carole Taylor Ref�:
Type: .
-. --;,- _ ; .. -.-�. _ .-.
r'�' �
��� ' __ -, .._ � ,. . .__.-. _ . . .,e _ , _. .�... _.. _ _ ._
����� _' _ , - ". .� ,-_. .. �.1 .,.^�,� . ._..�_ _� - �
Misc Mdse Sales True AN �t �Q`e 100.00
� ��� Tptak 100"00
�t� �Y�'r
Trans ID -
�
s
�G�'�<-� �i,l��Il�
��
�r�-��, �� -.�-���� �I3 �- �c��loo
� � l.� � �:_��.:.r:.
✓,/` Service Corporation International
PRINT SINGLE CASH RECEIPT Datie 10/312013
Page 1 of 1
Batch#: 99597639 Batch date: 10/3/2013
#of Trans: 1 Batch Amt: $870.00
Locafion: 0601-Parklawns Memorial Gardens&Mausoleum Cash Receipt date: 10/3/2013 8:44:00 AM
Address: 3218 Philadelphia Ave Cash Receipt#. 060114108571
Chambersbur PA 17201 Cash ReoeiptAmt 870.00
9
Payment Discover Payer: Carole M.Taylor Ref#:
Type:
Cor�rad# Pnrchaser �
060100105972
s�o.00 �lc'�1�-
GL A,ocount Ue,scxip�ion �
Total: 870.00
Trar�ID -
�
. , ��ti°_1 ��6_:�,�~l�'�, � � .'r � _- � �� -- - '�, �
�� ��
`� � t � .- s - s ,k i - _
_ �
r�-,-�c� c�����
.
. v ��� r������. _
, : �
���. ` ���.,�,. � ^�+i�s �a����`.�'''.�.�. '�`_r�'�.p�'''""'�.�� ���'"�`�'���_�`a*�,+-�
�'��� . ' � ' � � :��� ���
-: - , . � ��`�. ��¢
�. *
�ME'TERy IPf7C]GRMENT RIGI�TS,MERCHANDISE AND SERVICES PURCHASE/�ECURITY�1GREE1t�iENT = .
. THIS AGREEMENT PROVIDES FOR END4WMENT CARE
RETAIL INSTALLMENT`CONTRACT � - ` � _-_ -, :
���
This Agreement is made this day of ,20 ,by and betw rsigned"Seller"
and ' '`�F ` �_.,- hereinafter sall�ihe"Purchase�"
Addcess � ; .:: .`, #
ResidenceTelephogeNb.( .` � . ,.� : . � i�ayTelephoneNo•( ) � -
WI'i'Id��SETH THAT: T�e Seller agrees to seli and Purchaser agrees to buy the following describe�Interment Rights,Merohandise and Services:
❑Deve{aped Q PretleveIoped ❑Lot ❑Lawn Crypt ❑Mausoleum �Niche ❑Other .
Description of In�erment Rights'
:No. ` _ ` R�'ERMENT RIGHTS;MERCI-IANDISE AND SERVICES '. • : .
�
[nterment Rights{iric:$ EGF) S Less:
; Memosia[i�zation-TYP� .; ' ' . ° . Down PaymentCash............ .......... . .. ....... _ (S - )
�r�_.
'S� ��� Gredit For f )
Memoriat Base - Type _ "
$ize Color �)TotalI?ownPayrr►ent..... .-•- •••••---• -•-.. .;:. .._.. fS .- "� -' 3
>Memoniallnstaltation/Igspection Fee_..... ---- (c) Unpaid Balance of Cash Price(Amount Financed) H: ` '"`"-
1Vlertia�rial.Mainteaance....:.... :...... ...... ................:... (d)Service Gharge(Finance Charge) ._.:, '
Casicet-Descnpnon - V.
Matecial+:Vltou�UNietat( Gauge (e)Time Balance(Total of Payments} ::__.
� --
flt�ter€3urial Gontainer-Type (f} Time Sale-Price(Totai Sa1e Price)...-••-- -••._....._._.. S �-- �:�
_ Inbermei4[,�ndi�eeordingFee --••••....:...... ...............
_ : :
� PtnCe3sing�Ce....„ .... ,.. ....� -....: --° . � ;:
Remarks
-OEher. :- . �
'"f ianspc�rtation and Rela�tion Protection Plan(see below}
g� `Saies�Tax . .. .. . .. ..... ...
.... ._� . .---..•-••• . ..
: (a)TotafiC;ash Price(including Sates Tax)......_. .._.._ $ .. --,. , _
'�ie 7'ra�csp,�r�ir�m�il i{elncatinn Pmtectivn Plan being putchased hereunder is a product provided by a third party;no�by the ce�isetery ide��'�ifified in
:tt�is p�gteect��nt..The#hu�d pazi}+provider is riot owned by or af�iliated�v'iYh the cemetery,and�he cemetery is not responsible forthe gerfoimance ofthe
�rv�ces;assaeiated witk�ihe Tra»sponation cnrd Relocation Protection Plan. The Pucchaser will be required to enter into a separate contract with ti��thud
p�Ry pFFOVider . tng to�'rairsportation and Relocation Protection Plan. That plan has been referenced in this Agreement and incltided in it��retiase:'
r�ce ab�ve sc��r tlte r�tivexiience of tfie Purchaser i�matcin ' ents. � `.
. _TI'E1�If2ATI�Afi:QF.�I�fU�TNT FINANCED of $ . $ sha11 be eredited to yai�r aceount wittt"Se.�l�r.
A�'ioutit:paid to'ot�te�s an yaur behaif$ _ 'to public officiais,$ -. to Medical Air Services Associatian;Inc:�we�na�y
be tetgining�portio�of this amount). _
A�l�u�ii; �+"INANCE Amount Finaaced Total of Paymentc ToCaI S�le F�ice
gBlt(:Ei�!'1't�GE CHARGE The amount of credit The amoutrt you wilL have The tofia�cos�of�tur p�s
R�►"E`E' . '�e doliar amount the provided to you or paid after you have made aIl ehase on cre.dit;ntcludi�g
- '�e cost of your cnedit ' credit will cost you. on your behaif. payments as scbeduledy ouur down�yrnent vf.
as a y�'Fate. : , $ - °>. - ; �):
�fo- ��)$ ._ (��$ (��� __ (a-r-ci}$ _ -
�our-p�ysnenE�chedeie wiIl be:
Nt�mbcr`ofPayments Amount of Paymenis V1�hen Payments Are Due �
_ � Beginniag ' _ _
�paymen� IEyou,pay v#�eatly,you wiII be entitled to a rebate of all orpart vf the Finance Gharge.
5ecunty You;are giving a security interest in the goods and property being purchased. -
I.ate C�arges; �f futl payment is.not made wittsin 15 days after it is due,you will be chazged SS.tl(?or 5°!0 of such payment,whiehever is(ess. ..
Oti��rProv►sions:5ee t1�isAgreement for any additional information about nonpayment,defauit,az►y required repayment in fuFl(excivsitve Qfuneai�d finance
charges).lrefore th�sc�iednlet!daie,and prepayment rebates and penalties.
lf accepted�y�eller,,the patties�ereto agreexo fihe following terms and cot►ditions: , ' - - :
1.AgreementtaPay.Hawingfirst been quoted both a Total Cash Price and a Total Sale Price for the items described above,and fQrvaluejreceived,ti��ndersigned
Furchaser,joiutlyand��raltq,if more than one,promises topay to tfie order of Seller,at its addnessshown below,the amount identified aboveasdieTatat ofPayments
in aecutdanee with the paymeet schedule dates set out above. - ` _
2.�'iNe. SetlerwiU i+etaii+tit�e La said Intetment Rights and Merchandise until the Total Saie Price has'been paid by Purchaser to Selter. --
3.Ceme#ery Bi�es st►d Regedafions. Pnci�6aser agrees that aII rights conveyed under this Ag`eetnent are subject to,and P'urchaser,ag�ees.taat�ll tit�ies cc�giy
�vidi,thep�eseitt€a�ui ag ina�be�fter adoptect,amended or altered)Rules,Regulations and Bylaws of Seller,which are avaitable forexam�natio�t itt Seite�'s office.
�.�'�J�!���I�P�'��Y�t in full,whether voluntanly or upon acceleration by reason v€Purc6asei's defauit and payment in futi or jut7gmentfiPing en�ted
against Pitt!chaserfor�unpaid batance,Pur�haser shall receive a rebate of any unearned F'mance C6azge computed in ace.ordance with tI�Actuarial mettwcl.'7�(i)
fheneedfor�ntermentalc�c�yri't�rin 720daysofthedateotthisAgreementandtheAgreementispaidinfiilior('u)thisAgreementprnndeseuigfuct�epat7e�e
of ine�riar�a�r,�iun and i�msfallation and ispaid in fall within 120 days of t6e dafe of this Agreement,Purchaser wat be entitled toaful!rie�a�eofaH�"ioance
� ���� �������
� � �
� �c� — U�7�oc7
u\ �
� �
� _
� -
r., _._
..�' -a g � � � �'�
� Q .� .� � `��
� ? . � � � --
� :n -� �- � �:
r-. ;, � �:�
. � o u
? z '� - t� � fs ' �
� J � � � ^ . _ � M � �: n �
.�� '�Y�J N ` � � . � �
/ 9 �� Qf }
� \ — � ���� � `� � �, '} il Q �
�
.. ,��:�N r'� , _vj . �i � ^
.�c, x�7 V1 {(,� � ,� j '— V
'�/�,�� {
tJr W Z r � V, � Y~ � ,�� U '�`�"
��� � � Q� .° � ,,�
. y � p � M a�r _Y .._ i .
�C �� ��, p —L7 ��nn 1
. �- " x __ � a ;r. 7 �!
��] � y! � V 7 � � µ.��.�1
..t. . x � � �` � 'L Q ��"�.G.' .
{_
L C �� �
� � • _��,��—�
. [
_ t
�, �,-��., �� ���,��i�� � 7 � �
�
� ---
�, � �, _--- ----
. � O .-i � M Qj O� � �y .�_ C_� � -------------__'.___..
�D M
I 1 O � t� Svmj 0 O� p� fJ �__ � C.7 � O
� � `-� � cl .��. ° o � � � r.�j � O
o X �_ t�� � t�'-�-
�� X t�1 �
�� �C ���-; Lu o o � _ _..�. a`� '� .
� ,.�� �.0 � r.1 a X l_-' .�� �
. � > ¢ � � { .. � _j _=-'s �
�l .� � 2 ��1 � � x _ �~ !� �
Q � � :., � � Q � _ t;� � ` � J �
� � � �. V � . _' � i : fi--
� � � � � � � a ' � � , '� � .
.Y � Ln 0 Q � �.
. V Z 2 t.�: tY � ., �s ,^.�- . � d
u: O `� " v = '`�, T.i �"° Z
LiJ `7' � ��� ` ' 1; : L �:.J
� � h � . .)�� : 4-1 "-Z�
�" a L:a
V J v � � �� � � � . � .
`�� Gl .� �?S �Q
1 ` � � .. T i . -' �, , J ; v ` . .
+--� .� ' f� _ �� � "`'�-.,-_-�'
O = � U r �
� � !TS � C�'1 �.Y'F; :.J � LY j .a' ' ".^X. . .
1 � i 6 � � � � '� y � '• .i�•r- J x.
� � Q.! d � � i � �_u � i.�i ,.
'G.= i_ � � Z +II tu L2 � . �! 'i }—°
.. � cf� � iu �. ."+� �� C� .
t� r._ �
O ,-a ap �`�-. -.-a r-� .
� � rn o � ° � n� � � .
L? p Op M rJ p � �! Q'— � �� �j ;
� � o Y p Q � fl � ���
O k -��j-.
6 �
O X:
"J o ?� i
; w �
'' Q � � � • � ' +[. ,
� � X
Q � � J � ± .
� ,.. � U � i �
"� � m � j V
�n p � z
-' _C � w t�.�
� Z m � � �
;� o � O
�
`� v,
_? � y[ r� v
i� � �-_
�
�
rn � p � �.� -c� � � -
� � � ; � .
o � o � � d
w
i � � p _ � t� *a � `c g � Q
� 'v `v '�' � � L � ��� =.tJ `�
� � t- � �L� ra ,� � � � GL 1--
� tn US r �u � Cl.. � �
� �,,
, ,, . a`�l � -- �c�-7�j v
. �;
_. __ _�. ,
' °" `�
;
° � �.1�-�..--_-w-- �
� , a �,�;�.�_�"��_--�--. �r_.. ,
,, �""'"���t� :.:3������sr� ���1�:..�_ '�� '. '�° _.�____._ _�.�.�...._�,w_.�___._.__.�._
� ' � ���re�.. __�-- __._. ..�
,� _�_.__...�.,_________�.�.�..�___ �
_ --°-�–_--------�---°--------m°�
� p
"' y a� � ����.,•,F,a�i`•'� � �,t �:�' �.: ,�,��',�°"'�,,�,7'_�-...�.-.-.- 4.'.�i i�3�.a '. ..��j� !� .
� �¢a� �d�.e..Y.�`.a�e.�,,,..i. �.,,e .,....,• �� � .
Z Z'C3. � J"`' �} rl i C . �" �i . ..e.�e.... -
� Q>>� €-4C. �'��.,?�.Li"� �L_��r`- �+�:"�g �_�#�'v;��,�':�_�,.�_ __.....�_ _..g.-�v.,_ ,.�-� ___._.._._
�u�m n . ...._ .m._._�. .....-.___....._._m.._ . .
N � 0 N� • .� , � ..-.�.s,....��...a.....e. . .. ..
c} U � —,,,.s.-�....�...�n,-.�.........a.....��- a... ....e,.s.--«.,e �
� � � h R �3" .� � � ..C,. � { � ¢ ����p,����� 1_
� W� � ��...�-�.-�..-1�-a.-�...�._, � __�_.��'_,�-�••.-.,} ���ti.Y>° �
� U � � � ��� _ �...._.{ �...--�:'�5�4`1����'c'�����'� �'�c.4 1��.-. �
��,c� � , � ; j�y �._�___ ..�'�: �� ,
� > ; t � z - .�._���
��
, ^_____—.-_.______
--- --
� __ ._____—
---
C � Y /
F � ,a
f`�,✓ ""��' v � lY_(��
�
� - *�.� _� .�i.o-.
�s
v �'��s s
?�� � �.{q�
� �
, ��...
r �t
,.�3%•�.>�
� .,��t's!a -.
ti:,
�-�7'.JI�i� C�� V i �t-i�- K. �c,c,,,�1 c�+r �-e`i� � U o`7�C�
� -, - �.--� _�� ��'IGI�� & ASSOCIATES, P.C.
Attorne�:•s-at-Lmv
�.-__:.�- ��_asr��s��r
-- ._ : �'-4'°�T �rnr�sBZ�z�,PEt'\SIZ�"atZa 17257-139 i
-- ._�'������R.'R
T'ELEPHO��E(?l�532-7388
�s��r��:�4 FAX(71'�53�5289
:�'?'m�_�5�SRIGHT
R$�:�.�.sxo�-sE October 31, 2013
���rs_ Garole YVi. Tavlor
fs�9 C��e�n S��i
k�"�'�R13.�^!�y.y"4�� _ ��� r�?�^ . . . . .
. gOR PI2t?�S�IC3��I. SER�-I�� �ZEE�+�E�I9: ;`._.�-� -- --- - -- — _ '
Review of estate documents, asset verifications, and debts
of decedent;two (2)office conferences with spouse to
review preparation and organization of Pennsylvania ,, � `t�(��
i n heri tance t a��re t u r n prepare d an d being f i le d by spouse 1 7 5.0 0 �'
PLEASE MAKE CHEC%S PAYABLE TO "WEIGLE&ASSOCIATES,P.C."
A billing fee of ten dollars per monthly statement will be charged after 30 days
�' -- ' �s-F��' � �F U f ���- 1� . ��.y l�Y �.�
�, �o „ �� ,��
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH Receipt Date : 7/10/2013
Cumberland County - Register Of Wills Receipt Time : 13 : 01 : 19
One Courthouse S quare Receipt No. : 1074804
Carlisle, PA 17613
TAYLOR VICTOR RAY
Estate File No. : 2013-00760
Paid By Remarks : CAROLE TAYLOR
CJ
------------------------ Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 135 . 00 CUMBERLAND COUNTY GENERAL FUN
WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 10 . 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN
INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN
----------------
Check# 515 , $218 . 50
Total Received. . . . . . . . . $218 . 50
� �
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH Receipt Date: 7/24/2013
Cumberland County - Register Of Wills Receipt Time: 14 :45 :44
One Courthouse Square Receipt No. : 1074984
Carlisle, PA 17613
TAYLOR VICTOR KAY
Estate File No. : 2013-00760
Paid B�r Remarks: CAR.OLE TAYLOR
BAJ
-----------------------�- Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
SHORT CERTIFICATE 10 . 00 CUMBERLAND COUNTY GENERAL FUN
� ----------------
Check# 522 , $10 . 00
Total Received. . . . . . . . . $10 . 00
; .
+ � ......., ,�^-'��"'�`� -w. \.-__,�
. � � i °
Estate of Victor K. Taylor — �� �3 �407�O
Carole Taylor 532-3166
Funeral Expenses
,�,�.,-
Corneluis & Kelso funeral expense $4612.40
obituary, death certificates ck #507 $397.40�'
memory book ck #509 60.0(�
Total-$5,069.80
Parklawns Cemetery $2655.50
Flag pole grave marker Discover Card $100.00'°��
Grave markers Discover Card $870.00�"
Total-$3,625.50
Preacher cash $100.00�
Flowers Discover card $106.00-�
Memory cards ck #508 $76.06
Luncheon Discover Card $230.0(��
Memory donation CVAS ck #1450 $300.00�
VFW Chambersburg post #1599 ck # 1460 $100.00
Masonic Lodge #143 ck # 1461 $100.00
total-$1012.06
Total Expenses $9707.36
, � s--���. v � U c c�� /�� �a-��a r �t� - O v 7� G
Schedule H Probate Fees
Courthouse filing $218.00 Check #515
two more short slips 10.00 Check #522
�� � 7s. ���
� _�--j-� � N e � I`- ��5 t,.�c��
f1 K-
U
i pennsylvania SCHEDULE I
� DEPAHTMENTOfREVENUE DEBTS OF DECEDENT, '
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
�s ���� U � � � c 7v2- �ou.� Tcc� (G�2 010 l3 -- UO 7<o G
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT OATE
NUMBER DESCRIPTION OF DEATH
1.
Ambulance fee $87.04
2. Health Port ��2�7g
TOTAL{Also enter on Line 10, Recapitulation) $ $169.$3
If more space is needed,insert 3dditionat sheets of the same size.
���-F�. � � V � C:`1�v 1(� �<, C�� �C.�.�.� � CH'Z. `�v�`� -a�-�r°U
a�►,3 _ �v,6v�
. WEST SHORE EMS - BLS ��-��
. 205 GRANDVlEW AVE SUITE 211 � � ���~'�
CAMP HILL, PA 97011-1708 oa R�sE s�ne
�'�'I'S��� Phone#: (800)3b7-0512 Federai Ta�c ID: 23-2463002
�FIOLY$DtR iffJ117H SYSIFM - .
PAn�rtT r�a�nE viCTOR TAYLOR ���� NOViTAS SOLUTIONS,INC. REJ
HIGHMARK-FREEDOM BLU NONE
CALL NUAABER: DATE OF GALL: 05128J2013
244268W
FppM; HERSHEY MEDICAL CENTER
TO: 619 GLENN ST
�►CCfli3N�'SUN11�11�RY �
VICTOR TAYLOR , _ 295.03 ::,
619 GLENN ST TOTAL CHARGES:
P O BOX 181 P1►YMENTS/ADJi1STMENTS: 2�7.99
SHIPPENSBURG,PA 17257 �Py►Y THt3 AMOUM: 87.04
:�
t�T'ACNALONG PERFnRATLON AND RETlJRAI STUB WtTH PAYA9ENT
. .<DESC131l�ffC�t OF CNARGE._._. ._:Qt1ANTiTY,_ _: UNtT PftiCE _ AAAUt1NT?
Stretcher One Way Trans Member T2005 1.0 96.06 �:06 '
Transport Van Mileage S0209 53.2 3.74 198.97
_ r �
� �
_ ` ��� `
._ � �� a �� ��
� � �f Y �
i . � ;
To#al Charges 295.03
:.D�tOAtl�F PAYMBd'1' - RECEIP'i '` FAYME�!"E'D/tTE: i411A(kINT
Denied by Insurance-TRfCARE FOR LIFE 09i20/2013 0_00
Medicare Assignmerrt Adjustmerrt 08h 8/2013 63.31
Payment Medicare HMO 16078840 06N8/2013 144_S8
- --
Total Credits 207.99 _
`r� _ .a�.�ar�r���� �^���a Pncae .,.''��''� `'"e .�` . �, � .---'�
� . _ $87.04
. �7� -� �� _ �ya�R -
�.9isw't =$= xe�� >.��a4w`13oi..-r�
PA3'1EM'F NJ�M�- =7AY}..OR,VIGTOk� �- CAti NUMBEFt. ?Z��Z�$�MI '" - AN(OtiNT RAID: .
f�9/23/�Q13 -
P �`� A claim for this invoice amount was DENIED by your insurance
F�rp�nr,^c: �?T�^R,
E �. . __ ,..
carrle�.The balance!s your rasponsibil'rty-pfea.se remit
payment to our office.
WEST SHORE EMS-BLS 205 GRANDVIEW AVE SURE 211 CAMP HILL,PA 17011-9T08
� . . ._ � -. �.,� .._..._'
, ,
- �.S�--G �e � �r U � c rr�e K°'`'� T� �CM�.
� , � r 3 - CUC7 7(� ('j -
_ �'�
�'�
�
1 pg s� U00156
"""�""`AUTO'*MiXED AADC 300 �
000000156 01 RAB 0.405 -�'�'
,_ ATTN:C�ole Taybr °o�
0
Caro�TaYbr ��
$
SHIPPENSBURG PA 17257-2i 29 .��
ap..��.r�l�.6��.r,n�,���,trllt�r�l��Ii�ift.�.rN,r�r�n��.. X�
s
. �
� �
�
_ _ �
. �
. .. .. . . � ��
. . . . . . �. . . . �. � . . � � �
��
�
� Dete:Sep 13,�13
Dear Csrole Taylor,
Your request f�medical records from PENN STA7'E HERSHEY M was completed and delivered as you requested,hawever,
,paymcnt t�s not been received It has been_more than 35�and die enclosed invoice for $a2.19 remains unpaid. It is important
'that t6is obligaiion 6e seuled as our�ya�nt terais are aet 30 days. � _�
Onliue Psvmeat-to�t payrmajt ailu�e please go to wwr�.hr.althu�rt�v.rom and.make sure you have ycwr invoice mimber and amount for security
purposes as well as major credit c�+d. HealthPort afloepis Visa.MasterCard,Amai�E�cpress aad D'tscover.
T�nne Pav�ent-to reanit PaY�bY P���g a ciedit c�nd ple�e c�ntacx a PaYment�c�xati�at 1,888-768 9369
C�ck Pavmeat—to�nii payment by check or creclit c�nd please i�lude the bottom pc�tion of this page to�re payment is P�Y aPPlied.
Please contact us at 1 88-9 or via email at CollcxtiunsC N�altfiPonco,n. 'I3�ank yon for your prnmpt atienti�to this valid and owiag debL
� Invoice Number Invoice Date Balance Ih�e
. - tt732a647a6 O�i�12073 �82.79
- � � ��
Charge My: ❑Visa�MasteaCand�Discover�Ame�iEap - ��~�
EASE MAKE CHECKS PAYA�:-�
. HealthPort
Card no. �P• i P.O.Box 449900
� Atlants,GA 30384-9900
scceet Address _ : � f l)
�� Check Nnmber: ( T�
G�ly Srate - Zip Code �� Pay�nt Amoank �o�.��
S
Card Holder Name �
In Nwaber Tnvoice Date Bulance Dae
Sig�une M 6 �13 �-79
. r- �..5 �a � c� � U � G i�r2 k c�.�—C�"a..t,�l o r2
�, v t3 — o0 7 �Oo
Schedule I
Ambulance fees
West Shores EMS $87.04 Check # 1452
Penn State Healthport $82.79 Check #1446