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Home My WebLink About12-03-13 1505610105 REV-1500°`(02-1=)(Fn OFFICIAL USE ONLY Bu Department of Revenue Pennsylvania Bureau of Individual Code Year File Number duat Taxes PO BOX28o6ot INHERITANCE TAX RETURN �� t ;L14 Harrisburg,PA i7u8-o6o1 RESIDENT DECEDENT i ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 191-26-6550 12/02/2010 12/22/1926 Decedent's Last Name Suffix Decedent's First Name MI Swigert Mary J (N Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Ml Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW OD 1.Original Return C=:) 2.Supplemental Return p 3. Remainder Return(Date of Death Prior to 12-13-82) O 4.Limited Estate p 4a.Future Interest Compromise(date of C=) S. Federal Estate Tax Return Required death after 12.12-82) OD 6.Decedent Died Testate C=:) 7.Decedent Maintained a Living Trust 2 S.Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9.Litigation Proceeds Received 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A) Between 12-31.91 and 1-1-96) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATMN SHOULD BE DIRECTED TO: Name Daytime Telephone Number William S Daniels, Esq (717)243-3831 REOTER OF WILLW' SE ONLY rn rn First Line of Address pu :z, 7-1 G7 n 1 W High St,Ste 205 u' Z7 2. r1 Mca a x n w nT rn Second Line of Address Cn ;7 ;ru C7 C'? .t: C) C'3 n L..a Ti 'i7 'rt City or Post Office State ZIP Code t CDA*RL� -<- Carlisle PA 17013 ~ r--- m k cr1 CO O + . ->I Correspondent's e-mail address: Under penalties of penury,I declare that I have examl6ed 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. SIGNATUR ERE�BPO B R FILING RETURN DATE ADDRESS I 206 Oak Dr, Mount Holly Spri A 17065 SIG-� EBARER OT ESENTATIVE . DATE / ADDRESS , 1 W High St, Ste 205, Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 '�, 1505610105 1505610105 J 1505610205 . REV-1500 EX(Fl) - Decedent's Social Security Number Decedent's Name: Mary J. Swigert 191-26$550 RECAPITULATION - 1. Real Estate(Schedule A). . . ... ..........................I.......... 1. 152,900.00 2. Stocks and Bonds(Schedule B) . .. . . . . ... ............................. 2. 344,459.26 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) .. ... 3. 4. Mortgages and Notes Receivable(Schedule D). ... ....................... 4. -� 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 67,9$7.67 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. I 135,848.33 8. Total Gross Assets(total Lines 1 through 7). . . . . . . .... .. . ......... . . . ... 8.k 701,195.26 9. Funeral Expenses and Administrative Costs(Schedule H)...... t ............. 9. 1 14,075.74 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1)... . . ...... ... . 10. - 8,104.18 11. Total Deductions(total Lines 9 and 10).. .... ... ...... .................. 11. 22,179.92 12. Net Value of Estate(Line 8 minus Line 11) .......... .. ... .. . . . .......... 12. - 679,015.34 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) ........ . .. .. .... ....... 13. 14. Net Value Subject to Tax(Line 12 minus Line 13) . .. .. . . . .. . . . . .. . ..... .. 14. i 679,015.34-1 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.0_ 15. 16. Amount of Line 14 taxable at lineal rate X.0 45 679,015.34 16. 30,555.69 17. Amount of Line 14 taxable -at sibling rate X '2 17 18. Amount of Line 14 taxable at collateral rate X A 5 18, 19. TAX DUE . ... .. ............ .. . ........ . ...... ..................... 19.1 30,555.69 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT - p Side 2 L 1505610205 1505610205 J REV-1500 EX(FI) Page 3 He Number Decedent's Complete Address: DECEDENT'S NAME Mary Jane Swigert STREET ADDRESS 1 Longsdorf Way#12 CITY STATE Z1P Carffsie PA 17015 Tax Payments and Credits: 1. Tax Due(Page 2,Une 19) (1) 30,555.69 2. CredWPayments A.Prior Payments 29,634.81 B.Discount 1,052.63 Total Credits(A+B) (2) 30,687.44 3. Interest (3) 131.75 4. If Une 2 is greater than Une 1+Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,Une 20 to request a refund. (4) 0.00 5. if Une 1 +Line 3 is greater than Une 2,enter the difference.This is the 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 income of the property transferred.......................................................................................... ❑ 0 b. retain the right to designate who shall use the property transferred or Its income......................................_.... ❑ N c. retain a reversionary interest.............................................................................................................................. ❑ 0 d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 0 2, if death occurred after Dec.12,1982,did decedent transfer property within one year of death without receiving adequate consideration?............................................................................................................. ❑ ■ 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 no"robate properly,which contains a beneficiary designation? ........._......................................... ❑ .................................................................... 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 out 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)(n)I.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 surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in(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. REV-1502 EX+(11-08) pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER Mary Jane Swigert All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts. Real property that is jointtyrowned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet If the property has been sold. ITEM Include a copy of the deed showing decedents interest if owned as tenant in Common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. 229 W.Pomfret Street,Borough of Carlisle,Cumberland County,Pennsylvania 152,900.00 TOTAL(Also enter on Line 1, Recapitulation.) $ 152,900.00 If more space is needed,insert additional sheets of the same size. REV-1503 EX+(8-98) SCHEDULE B COMMONLTH OF PEN INHERITANCE TAX REN RNANIA STOCKS & BONDS RESIDENT DECEDENT ESTATE OF Mary Jane Swigert FILE NUMBER All property jointly-owned with right of survivorship must he disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE Of DEATH t fAlcatel 770 shares @$28.55 164,733.50 2. Van Kampen US Mtg-664.6 shares @$13.05 8,673.03 3. ucent -304 shares @$2.84 863.36 4. Comcast Corp-104 shares @$20.72 21,631.68 5. Fairpoint-20 shares @$.017 0.51 6. Frontier Communication-391 shares @$9.39 3,671.49 7. LSI Corp-88 shares @$5.92 520.96 8. NCR Corp-200 shares @$14.59 2,918.00 9. Qwest Communication-641 Shares @$7.08 4,538.28 10. Teradata Corp-200 Shares @$41.27 8,254.00 11. Verizon Communication-1632 shares @$32.74 53,431.68 12. Vodafone Group-791 shares @$25.91 20,494.81 13. Savings Bonds-various(See attached) 54,727.96 TOTAL(Also enter online 2,Recapitutation) $ 344,459.26 (If more space is needed,insert additional streets of Ore same size) REV-1508 EX+(11-1o) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. RESIDENT DE EDENTTURN PERSONAL PROPERTY RESIDEM DECEDENT ESTATE OF: Mary Jane Swigert FILE NUMBER: Include the proceeds of litigation and the date the proceeds were received by the estate. All property Jointly owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER VALUE AT DATE DESCRIPTION OF DEATH 1-rFederated cking Account 8,499.44 2. l Account 15,091.89 3. MMKT 17,294.00 4. Alcatel-Lucent replac ement check 744.81 5. M&T Bank checking account 24,047.53 6. Social Security Check 1,117.00 7 Personal Property(see attached appraisal) 1,120.00 8. Cash in Sale Deposit Box 73.00 TOTAL(Also enter on Line 5, Recapitulation) $ 67,987.67 If more space is needed, use additional sheets of paper of the same size. REV-1510 EX+(08-09) pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND RESIDENT MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Mary Jane Swigert 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. ITEM DESCRIPTION OF PROPERTY NUMBER INDUCE THE NAME OF THE TRw4EREE THEIR ReAVONSRPTo DECZflert aro DATE OF DEATH % DECD'S EXCLUSION TAXABLE TIEDOEOFTRF1El9t ATawACO%DE T[EO®Fw aFA��n,Te VALUE OF ASSET INTEREST nn� VALUE I, Western National Life Insurance Company Kurry W.Swtgert,son,February 10,2011 20,729.03 100 20,729.03 Western-Southern Life Assurance Company 2. Kuny W.Swigert,son,February 16,2011 28,864.26 100 28,864.26 Western-Southern L'ffe Assurance Company 3. Kuny W.SMgert,son,February 16,2011 73,610.89 100 73,610.89 Aurora National Life Insurance Company 4. Kuny W.Swigert,son,February 15,2011 12644.15 100 12644.15 TOTAL(Also enter on Line 7, Recapitulation) $ 135,848.33 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX4 (10-09) Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND RESIDENT ED RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF Mary Jane Swigert FILE NUMBER Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Hoffman Roth Funeral Home 3,527.15 2. Westminster Cemetary 5,095.00 3. Reception 193.59 8. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) None Street Address city State ZIP Yeags)Commission Paid: 2. Attorney Fees: 3,500.00 3. Family Exemption:(If decedent's address is not the same as daimant's,attach explanation.) Claimant N/A Street Address city State_ZIP Relationship of Claimant to Decedent 4. Probate Fees: 595.00 5. Amountant Fees: 6. Tax Return Preparer Fees: 7. Advertising: Sentinel,Cumberland Law Journal 325.00 a. Registrar,filing fees 30.00 s. Appraisal Fee 60.00 to. Reserve for setting Estate 750.00 TOTAL(Also enter on Line 9, Recapitulation) $ 14,075.74 If more space is needed,use additional sheets of paper of the same size. REV-152 EX+(12-08) j pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, RESIDENT DE TAX RETURN MORTGAGE LIABILITIES & LIENS RES[DENr DECEDENT ESTATE OF Mary Jane Swigert FILE NUMBER Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. Cumberland Crossings 23.70 2. EMS 281.24 3. Care Rx 275.57 4. Cumberland Goodwill EMS 147.24 5. Carlisle Regional Medical Center 490.23 6. Cumberland Crossings 1,812.61 7. Pinker Associates 799 8. Holy Spirit Hospital 74.80 9. Carlisle Regional Medical Center 10.66 10. Midway Self Storage 638.58 11. Continuing Care Rx 385.32 12. American Modem Select Insurance Company 640.00 13. Real Estate Property Taxes 2,491.24 14. CW Fritz and Company 113.00 15. PA Income Taxes 457.00 16. Tax Return Preparation-Kevin B.Benton,CPA 255.00 TOTAL(Also enter on Line 10, Recapitulation) $ 8,104.18 If more space is needed,insert additional sheets of the same size. REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESrDENT DECEDENT ESTATE OF: FILE NUMBER: Ma Jane Swi ert NUMBER NAME AND ADDRESS OF PERSONS RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE ( ) Do Not List Trustees) OF ESTATE I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec.9116(a)(1.2).J 1• Kuny W.Swigert,206 Oak Drive,Mount Holly Springs,PA 17013 son 100% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size. I, MARY JANE SWICERT, of the Borough of Carlisle, Cumberland County, Pennsylvania, declare this to be my last will and testament, and revoke all wills and codicils which I have previously made. I - I give and bequeath all of my tangible personal property, including automobiles, to my husband, Wayne K. Swigert, if he shall survive me. I1 - All the rest, residue and remainder of my estate, real and personal, I give, devise and bequeath to my husband, Wayne K. Swigert, if he shall survive me. III - If my husband, Wayne K. Swigert, shall not survive me, I give, devil and bequeath q my entire estate, real and personal, to my son, Kurry N. Swigert, absolutely and in fee simple, if living, otherwise to his surviving issue, per stirpes. IV - Any share of my estate which shall become distributable to a minor may be held in a savings account, certificate of deposit or similar security, in a federally insured banking or savings institution in the name of the minor and marked not to be withdrawn until the minor attains the age of 18 years or on order of a court of competent ,jurisdiction. V - I appoint as Executor of this will, my husband, Wayne K. Swigert, and if for any reason he should fail to qualify or cease to act as such during the administration of my estate, I appoint my son, Kurry W. Swigert, as Executor of this will and if he should fail to qualify or cease to act as ouch during the administration of my estate, I appoint Farmera Trust Company of Carlisle, Pennsylvania, as alternate Executor of this will. IN WITNESS WHEREOF, I have hereunto act my hand and seal this ,�day of September, 1486. (SEAL) Signed,Signed, sealed, published and declared by Mary Jane Swigert, testatrix above named, as and for her last will and testament, written on one sheet of paper, in our presence, who in her presence, at her request, and in the presence of each a' other have hereunto subscribed our may, names as attesting witnesses: 9 n . ��CQCI r7✓i .ana+v nwun a+maw nuy.n aoiwu.wNc.i rv..ww.w.wy .u—ur...-....�.. .................... Detailed Results for Parcel 04-21-0320-111. in the 2010 Tax Assessment DistrictNo 04 Database Parcel—ID 04-21-0320-111. MapSuffix !VHouseNo 229 W PO MFRET STREET SWIGERT, WAYNE K&MARY JANE ----- -- -------- PropType R PropDesc -- LivArea 1725 CurLandVal 20000 CurlmpVal 132900 CurTotVal 152900 CurPrefVal ! - Acreage .06 CIGmStat ----------- TaxEx 1 SaleAmt SaleMo ! SaleDa SaleCe SaleYr ! !HF_Approval—status edBkPage 0015A-00039 arBlt 1900 Fle_Date 10/25/2004 A 1 of 1 7/4/2011 8:26 AM ORRSTOWN FINANCIAL ADVISORS A Tradition of Excellence December 23,2010 Kung W. Swigert 206 Oak Drive Mt Holly Springs,PA 17065 RE: Estate of Mary J. Swigert Dear Mr. Swigert, As per your request,following are the date of death values for the security holdings in your Mother's Brokerage Account 4N2-604342. Name of Holding Symbol Number of Share Price 12/02/2010 Share Value Shares 12/02/2010 AT&T T 5770 $28.55 $164,733.50 Invesco Van VKMGX 664.60 $ 13.05 $ 8,673.03 Kampen US Mtg Alcatel Lucent ALU 304 S 2.84 $ 863136 Comcast Corp CMCSA 1044 $2032 $ 21 631.68 Fairpoint FRCMO 30 $ .017 $ .51 Communications Frontier FTR 391 $ 939 $ 3,671.49 Communication LSI Co LSI 88 $ 5.92 $ 520.96 NCR Corp NCR 200 $14.59 $ 2,918,00 Qwest Q 641 $ 7.08 $ 4,53818 Communication Teradata Corp TDC 200 $41.27 Verizon VZ 1632 $32.74 $ 53,431.68 , Communication Vodafone Group VOD 791 $25.91 S 20,494.81 Federate Cap Res FCR 17,294 $ 1.00 $ 17,294.00 MMKT(cash) Total Acet Value as $307,025.30 of 12/02/2010 J Sincerely, AtL+1+tCSL73 �LYtt ° ALisa "ggleman / Registered Representative Securities and other investment products offered though Financial Network Investment Corporation,Member SIPC.The Onstown Bank and Orrstown Financial Advisors arc not affiliated with Financial Network, NOT A DEPOSIT-NOT FDIC INSURED-NO BANK GUARANTEE � o� �-_.r-3--' ..F,_.�4-- F•r —F,j t-T—F. 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N ° D y m v D D N '° N � n dg Sm^ N N O N H C O S a° SL IZ H nv- m Calculated Value of Your Paper Savings Bond(s) http://www.treasurydirect.gov/BC/SBCPrice Calculated Value of Your Paper Savings Bond(s) Calculator Results for Redemption Date 12/2010 Total Price Total Value Total Interest YTD Interest 20,550.00 $54,727.96 $34,177.96 $2,122.72 Bonds: 1-31 of 31 Serial # Series Denom Issue Next Final Issue Price Interest Interest Value Note Date Accrual Maturity Rate 31978031 EE $100 10/1981 04/2011 10/2011 $50.00 $232.36 4.00% $282.36 31987030 EE $190. 10/1981 04/2011 10/2011 $50.00 $232.36_ 4.00% $282.36 29125435 EE $100 09/1981 03/2011 04/2011 $50.00 $232.36 7 4.00% $282.36 29114627 EE $100 08/1981 02/2011.08/2011" $50.00 $232.36, 4.001/0 $282.36. 29114671 EE $i00 10/1981 04/2011 10/2011 _ $50.00 $232.36: 4.00% $282.36 27926247 EE $100 07/1981'0112011' 07/2011 $50.00 $232.36 4.00% $282.36 27914976 EE $100 06/1981 06/2011:06/2011' $50.00 ,_ $238.04 4.00% $288.04 27914975 EE $100 06/1981'06/2011 06/2011 $So.00 $238.04 4.00% $288.04" 25990670 EE $100 05/1981 05/2011 05/2011 $50.00 $238.04 4.00% $288.04 25983276 EE $100 04/1981 04/2011 0412011 $50.00. $250.84 4.00% $300.84 c25983275ee EE _ $100 04/1981 04/2011 04/2011. _ $50.00 $250.84 4.00% $300.84 m5486511lee EE $1,000 10/1992.04/2011 10/2022 $500.00 $789.20 4.00% $1,289.20 m45865110ee EE $1,000 10/1992 04/2011 10/2022 $500.00 $789.20 4.00% $1,289.20_ m45865109ee EE _$1,000 10/1992 0412011: 1012022 $500.00 $789.20 4.00% $1,289.20. m45865108ee EE $1,000 10/1992.04/2011 10/2022_ _ $500.00-_ _$789.20 4.00% $1,289.20 m45865107ee EE $1,000 10/1992 04/2011 10/2022 $500.00 $789.20 4.00% $1,289.20 m45865106ee EE $1,000 10/1992 04/2011 10/2022 $500.00 $789.20; 4.00% $1,289.20 m45865105ee EE $1,000 10/1992 04/2011 10/2022; _ _$500.00_ $789.20 4.00% $1,289.20: m45865104ee EE $1,000 10/1992 04/2011 10/2022 $500.00„ $789.20' 4.00% $1,289.20 m45865103ee EE $1,000 10/1992 04/2011" 10/2022 $500.00 $789.20 4.00% $1,289.20 m45865102ee EE $1,000 10/1992 04/2011 10/2022 $500.00 $789.20 4.00% $1,289.20 m45762584ee EE $1,000 08/1992 02/2011 08/2022 _ __$500.00 $789,20 4.00% $1,289.20 m45762579ee EE $1,000 08/1992 02/2011 08/2022 $500.00 $789.20 4.00% $1,289.20 m45762578ee EE $1,00008/199202/2011 08/2022 $500.00 $789.20 4.00% $1,289.20 m45762577rr EE $1,000 08/1992 02/2011.08/2022 _ $500.00" $789.20 4.00% $1,289.20 m45762576ee EE $1,000 08/1992 02/2011.08/2022_ $500.00 _ $789.20 4.00% $1,289.20 _ v2353705ee EE $5,000.08/1992 02/2011" 08/2022 $2,500.00_ $3,946.00 4.00% _$6,446.00 v239031ee EE $5,000 07/1992.01/2011 07/2422 _$2,500.00" $3,946.00. $6,446.00: _ v2349030ee EE $5,000 07/1992 01/2011'07/2022 $2,500.00. $3,946.00 4.00% $6,446.00 v2349029ee EE $5,000 07/1992 01/2011 07/2022 $2,500.00 $3,946,00 4.00% $6,446.00 v2349028ee EE $5,000 .07_/1992 01/2011 07/2022- $2,500.00 $3,946.00, 4.00% $6,446.00 Totals for 31 Bonds.$20,950.00 $34,177.96 $54,727.96 Notes NI Not Issued _ NE Not eligible for payment PS _ Includes 3 month interest penalty MA Matured and not earning interest 1 of 1 10/1/2013 3:00 PM ORRSTOWNBANK A Tradition of Excellence ORRS P.O.Box 250 Shippensburg,PA 17257 Temp-Return service Requested Date 1/05/11 Page 1 Primary Account 106005553 Enclosures 000317 0.8080 AV 0.335 TR00003 Mary Jane Swigert 1 Longsdor£ Way #12 Carlisle PA 17015-7623 C H E C K I N G A C C O U N T S Account Title Mary Jane Swigert 50+ Interest Checking Check Safekeeping Account Number 106005553 Statement Dates 12/06/10 thru 1/05/11 Previous Balance 8,452.42 Days In The Statement Period 31 1 Deposits/Credits 47.00 Average Ledger 2,467.57 1 Checks/Debits 8,499.44 Average Collected 2,467.57 -- -- - ` Se.cvice..F.ee _ -__ _ __._-_.__ 00 _Interest_ __ ----- .Eaxn,ed ._._ ..__. Interest Paid .02 Annual Percentage Yield Earned 0.01$ Current Balance .00 Deposits and Additions Date Description Amount c 12/06 Deposit 97.00 12/15 Credit to Cloed Account .02 r M O O 0 o Electronic Debits and Withdrawals Date Description Amount 12/15 Close Account 8,499,44_ °o 0 0 Daily Balance information o.. Date Balance Date Balance c M 12/06 8,499.42 12/15 .00 N N O to O n N N C O Kt\ O Interest Rate Summary 12/05 0.010000$ TOTAL CONTROL ACCOUNT FEB 9, 2011 E, C10 BNY Melton Meftife ramii of Com anies P.O. BOX 8906 Pape 1 OP 1 Y P WILMINGTON, DE 19899 Fund Number: 01 Account Number: 4058806903 66114 TCAIPC01 THE ESTATE OF MARY JANE SWIGERT KURRY SWIGERT EXECUTRIX 206 OAK DRIVE MOUNT HOLLY PA 17065 ; 0 C TOTAL CONTROL A,CCOUNT 60.182/433 I i { REDEMPTION CHECK ::;01934705 . ACCOUNY NUMBER .DATE _ 3 0000114 4656866903 'r':FEBRUARY09,2011 AMOUNT• ' i PAY TO THE ORDER OF: $"'^`«""' 15 091.89 1 THE ESTATE OF MARY JANE SWIGERT voto AFrtR 180 DAYS KURRY SWIG£RT EXECUTRIX a 266 OAK DRIVE MOUNT HOLLY PA*17665 PNC B hii, N.A. 001 - 'Jeannette, PA A T4;D S ATURE 4 i I e ao a n• c c -o e Il'03934405lI' 1:0433016274 100834335cilia z =O m?im �'�t 002013 t �>o 0 0 s�JOZ � D 31 t .>ru TT m z0i ❑ on xDD� Az No ZDz0 f 1 w e m Z O Ny z ami < ram b y Z - zi'am R g a mm(n/1 l • •ow n{ 0" \ 1 N � m f O A O O.DZ 41 4�\;I!r\<�!till•%/r fy�l hilVLliri o ❑ OOOK b W 9 ii>`ri it i�%ill=f\ pY"l!%��lyf In I-7C3:c Oo > Otn to 0, `O U W O, _>mWX O G7 N 11 N -0 $h all, <N I\t lyi7•i1"��ilf\-Q>11�:j O O r - s c' '�:5�i1-,1<,1p="1'nn I/I\.\_\//i(i(o^t0?t�✓:.I1�.1=I�.I 11 t�41�11(��I!I l�%�i,a/rC,=_1%�L��'�ip.0,Ir.,a1 I`!.I�olT,r��I1i\ I i:`i�/i I,1IU:•1-i\�n ltv rl;h•_� 7 ym e ems a r Oa- \`°n 0 \;d--- N W w,pol u-39 e a �-• �r � last �:F_k mw �-]fl"I. =: pi ."cl) .Y.;:,_ila�,�\ii%�il ,li-i1,- gg _ _ . k;= h•d Zm ° Vimzo INJ 055 'o r,. 3� 6aio D �J W ZymvO O _ KD ]IT a� 0 ( 1..vrr L• > 30 IF YOUR ADDRESS IS NOT CORRECT PLEASE PRINT THE CORRECT STATE STREET. ADDRESS ON THE BACK OF THIS STUB AND RETURN IT TO THE RETIREE SERVICES ADDRESS ABOVE. P.O. BOX 24989 JACKSONVILLE FL 32241-4989 ESTATE OF MARY J SWIGERT 1 LONGSDORF WAY #12 CARLISLE, PA 17015-7623 ACCOUNT ID: LUCENT Q MGMTBENE Plau Name: eLUGENTITEGHNOI:OGIE$ikC ` « ... � ..... , ... 7 x hA : P PAMNT DATE CHECK PAYEE SOC. 01/10 11 10134846 . PAYMEi N�T $7".81 z _° .. `= y "=P,AY;MEN�,?pETATI ? w fi rx ' H's .� r..;?°a,.��.: ...,:•, :'.cal;: 4 744.81 TOTAL: 744.81 TOTAL: Rh,REPLA CE CHECK/! 10132720 s sis = •• s`REPLSt�CH'GHCK DAF'I'$ �OI/b4/11`` _. `' u�£iFCcei pREPLACE�CFIEGK AMOUNT ;�574h 81 Diu Pagel of 2 P SAMUEL O'BRTEN-Re:prod-Date of Death Request From: DATE OF DEATH REQUESTS To: O'BRIEN,P SAMUEL Date: 1/4/2011 2:36 PM Subject: Re:prod-Date of Death Request Per you request,please find below the date of death values for Mary Jane Swigert,SS#191-26-6550. aACCOUNT NUMBER BALANCE ACCRUED INTEREST TOTAL n 9830135357 24,047.46 .07 24,047.53 There is also a Safe Deposit Box at the High Street Carlisle Branch,Box#4052 Let me know if there's anything else you need :) Thanks, Tammy Spencer Records Management/DOD Unit M&T Bank- "Understanding what's important." >>><psobrien mtb.com> 12/18/2010 9:58 AM>>> Account Information Date of death: 12/02/2010 Account Number: 9$30135357 Product Type: Deposit Account Request Details Deliver to: Requestor Delivery Options: E-mail Delivery Details: ebm801 file://C:\Documents and Settings\EBRN80L\Local Settings\TempWgrpwise\4D233053R... 1/18/2011 3 - - -� r --- -- -- -- - -- ----- -- - � f � n `�� loo io Ool O- x J �- ---------- 477-00+ 596-00+ k--107-00+ 1,120° WESTERN J NAT[ONAL L'I f e I n s u r a n c e C o-m p 6 n P.O.Box 871 Amarillo.lens 791 05-087 1 FEBRUARY 10, 2011 1.800A24A990 KURRY W SWIGERT ' 206 OAK DR MOUNT HOLLY, PA 17065 RE: Contract VV217214 Dear KURRY W SWIGERT: We are pleased to advise you that we completed processing your claim for annuity benefits on February 10, 2011. In order to provide you with the benefit of flexibility in disbursing your funds, we have opened a WNL Bridge Account for you. The total amount of your claim proceeds is $20,729.03. The beginning balance of your WNL Annuity Bridge Account is $20,729.03, as described below: Non-Taxable Amount $14,000.00 Taxable Amount $6,729.03 Federal Tax Withheld $0.00 State Tax Withheld $0.00 $20,729.03 The taxable portion will be reported on Internal Revenue Service Form 1099-R. Your account will earn a competitive rate of interest and provide immediate access to your funds with no monthly service charge. Interest earnings on your WNL Bridge Account will be reported as required by the Internal Revenue _ --'--Service— State Street Bank and Trust will mail your new account kit shortly. The kit will include your personalized checks and a detailed explanation of your WNL Bridge Account. If you should have any questions, please call 1-800-331-4631. Sincerely, ( �//�'6 , • e,'� B. M. Graves Manager Annuity Claims WESTERN-SOUTHERN LIFE ASSURANCE COMPANY C CINCINNATI OHIO OU STATEMENT OF DEATH CLAIM SETTLEMENT INFORCE DEPT MARY JANE SWIGERfi 2-16-2011 (MAIL TO 980 5157 MARY JANE SWIGERT PAYEE W002062778BG CHECK #OC 07151717 HAS BEEN ISSUED FOR $26,869.26 THE CLAIM ON THE ANNUITY LISTED ABOVE HAS BEEN APPROVED AND A CHECK FOR m YOUR SETTLEMENT AMOUNT IS ATTACHED BELOW. WESTERN-SOUTHERN LIFE WILL NOTIFY THE IRS THAT THE TAXABLE AMOUNT OF THIS PAYMENT IS $8,869.26 FOR THE 2011 TAX YEAR. IF YOU HAVE ANY QUESTIONS, CALL A WESTERN-SOUTHERN LIFE REPRESENTATIVE AT (800) 926-1702. e AMOUNT OF CONTRACT $28,869.26 t� TOTAL PAYABLE THIS CONTRACT $28,869.26 AMOUNT OF THIS CHECK $28,869.26 r Detach the check below. •,cowoovrz• ,ro9 x _T.HE-FACE-OF THIS •• • •- • : R e a WESTERN SOUTHERN LIFE ASS1 E PANY SANNOFAMERICA 61dIry19' ® ' •,,, -.•• r 'j r.r,' '� � WINDSOR CT t N Fw. Y .. CONTRACT ID 's %1•DIST 231x6-21 �, OtU7151717 ,WO020627788G •• ;980 -h 49 r J„' "6 2 .r.. a vovto tleo bar of �S.tf EXACTLY *****28 864* �DOLsT�ARS SAND f)26CENTS ( ' !' pmot o ckt, 7C) Li„ r.f ,{/. ,, µ,>1 T� Y% ..x:• `�{ Y ri r*frt '*32i: ]lc:i... �•. ( ..s ! tro i' kJ .� a K:a�- rv- :;Q°'Y,,' ``. � • • 4...��r a : XURRY".W SWI E- . 206-OAK DR V.I i ,MOUNT HOLLY PA 17065 0 � . M,t' /7/\y�J'1�fi5 'V .�Qg . U . t•:Y.Rlf.�n•!:aaII1'.t"Y.:.:::e s,'.'A.`L,fn C..1.��:tlY-0.'.l'ti' rc,Ni�VRYO}%•R{vyJft'a.:'a'y�L s!(✓'1'1ti).•:`:':/:�!':.:•:: .. �. .' i a:r'i? II'07 Ls i7 L711' 1:0 L L90b445t: 6808311' ® WESTERN-SOUTHERN LIFE ASSURANCE COMPANY CINCINNATI OHIO STATEMENT OF DEATH CLAIM SETTLEMENT INFORCE DEPT 2-16-2011 MAIL TO 980 5199 SWIGERT MARY PAYEE W0020603580 CHECK #OC 07151957 HAS BEEN ISSUED FOR $73,610.89 THE CLAIM ON THE ANNUITY LISTED ABOVE HAS BEEN APPROVED AND A CHECK FOR YOUR SETTLEMENT AMOUNT IS ATTACHED BELOW. WESTERN-SOUTHERN LIFE WILL NOTIFY THE IRS THAT THE TAXABLE AMOUNT OF THIS PAYMENT IS $23,610.89 —_ FOR THE 2011 TAX YEAR. c IF YOU HAVE ANY QUESTIONS, CALL A WESTERN-SOUTHERN LIFE REPRESENTATIVE AT (800) 926-1702. B e AMOUNT OF CONTRACT $73,007.59 ° TOTAL PAYABLE THIS CONTRACT, $73,007.59 INTEREST $603.30 AMOUNT OF THIS CHECK $73,610.89 Detach the check below. `1CN30DOC• „ WESTERN SOUTHERN LIFE ASSURANCEf CO IPANY BWKOFAMERICA 51-44n+s;, dY.° t tL`A .�4ut,V y „ t WINDBOE,OT CONTRACT ID ''. .DIST 216 2bS Ot ? 07151957 W0020603580 980 v ✓ t a r '2, rL � y Nd 4 } �t d T tY Payee the enter ol4 ' t 1� EXACTLY ,t yyf , l a 3 h`+ QA p ounfal Check , n t" ' ��• n4 i fi KURRY Yl SWIGERTI? r x at PrfC0n $06 OAK DRIVE.* HOLLY 'PA 17065 awak c MOUNT - 11.07 15195711' 1:01L9001,451: 6808311' Li Aurora National Life Assurance Company P. O. Box 4490 Hartford,CT 06147-4490 Phone 800-265-2652 http://www.auroralife.com February 15,2011 Estate of Mary J.Swigert Kurry W:Swigert,Executor . 206 Oak Drive Mount Holly,PA 17065 Re:Contract#C03024692D , Insured: Wayne K.Swigert Dear Executor: Our check representing full and final settlement of this claim is being forwarded under separate cover. The net proceeds have been determined in the following manner: BENEFIT AMOUNT: $12,305.33 ANNUITY PRINCIPAL:$5,075.52 ANNUITY GAIN: $7,229.81 ADDITIONS: DEDUCTIONS: Death Claim Interest $338.82 Loan $ Post Mortem Dividends $ Loan Interest $ Dividend Deposits $ Premium Due '$ Interest on Dividend.Deposits $ Benefits Assigned $ Paid-Up Additions $ Federal Withholding $ Premium Refund $ State Withholding $ NET PROCEEDS:$12,644.15 YOUR PERCENTAGE OF THE DEATH BENEFIT: 100% YOUR AMOUNT OF THE DEATH BENEFIT:$12,644.15 Death Claim Interest Rate:2.5 Period from 01/10/2010 through 02/15/2011 . If you have any questions,please call our office at 800-265-2652,Monday through Friday from 7:30 AM to 4:30 PM Central Standard Time. / Sincerely %��/Q 219 North Hanover Street Carlisle,Pennsylvania 17013 717.243.4511. toll free 1.866.451.4511 Q it l�E' fox 717.243.3723 v .hoffmorroth.com FUNERAL HOME- & CREMATORY, INC. inforalwtfmarroth.com December 20, 2010 Kurry Swigert 206 Oak Drive Mount Holly Springs, PA 17065 Statement of Funeral Expenses for: Mary.Jane Swigert- - - Date of Death: December 2, 2010 Account Id:.16095-271 PACKAGE: Immediate Cremation, Memorial Service at Funeral Home ' OPTION 3-Cremation $ 2,290.00 FACILITIES AND PROFESSIONAL SERVICES: Sub Total: $ 2,290.00 Equipment and Staff for Graveside Service $ 190.00 Sub Total: $ 190.00 MERCHANDISE: Urn: Companion Urn $ 250.00 Register Book $ 25.00 Memorial Folders $ 25.00 Acknowledgement Cards $ 20.00 Sub Total: $ 320.00 TOTAL FUNERAL HOME CHARGES: $ 2,800.00 CASH ADVANCES: 24 Certified Death Certificates at$6.00 each $ 144.00 Newspaper Notice-Sentinel $ 160.68 Newspaper Notice-Patriot $ 297.47 Clergy .$ 100.00 Coroner's Fee --- - - $ 25.00 Sub Total: $ 727.15 Total Funeral Expense: $ 3,527.15 Total Payments Made: $ 3,527.15 Payments Made: Debra Swigert Check 133 Dec 10,2010' 727.15 Kurry Swigert Check 1001 Dec 20,2010 2,800.00 Balance: Please return this portion with your Remittance. $ Amount Enclosed Mary Jane Swigert SERVING OUR COMMUNITY SINCE 1907 PRESIDENT • • OWNER ROBERT rci Qcality,Selection,Savings,Every Day. Visit us on the Internet www.GlantFood$tores.com - My soai is to ensure your satisfaction every time you shop with us. If there is anyfhlns more I can do to Improve your experience please call or write. Chad Hach, Store Manaser - -Giant Food Stare # 112 255 S. Sprin' Barden 'St reef ; Carlisle, PA 17013 Store Telephone: (717) 249-2323 Pharmacy Telephone: (717) 249-8836 12/06/10 6:33PH - THANK YOU 48005142866.; . MED RELISH TRAY 22.99 F: SPIRAL HALF HAM BC 38.57 F' SC BONUSBUY SAVINGS 7.73-F Price you pay 30.84 - LAUGHING COW 6Z BC -- 2.29. F SC BONUSBUY SAVINGS .10-F Price you pay 2.19 APPLE DUMPLINGS 2.69 F - COOK.LVR VARIETY 17.99 F' SNRCKERS DELITE -29.99 F TOTAL BEFORE SAVINGS 1.14 52 'YOUR TOTAL SAVINGS- 7.83- -S-TOTAL AFTER SAVINGS 106 69 -. TAX PAID 00 - ****TOTAL ..106 69'' VF CREDIT CARD - 106 69.' r rrrrrxp:r rrrrrrrr a.i ere*rt'fxi*>t.��tk*3x GIANT Walmart :;:.. Save money.Live better. --- - Walmart MANAGER.SCOTT COCHRAN ( 717 ) 258 - 1250 CARLISLE, PENNSYLVANIA ST# 2574 OP# 00004096 TE# 16 TR# 03931 - ROLL 007518500003 F 2.87 N - ROLLS 007101035560 F 1.97 N ROLL 007518500003 F 2.87 N ROLL 007618500003 F 2.87 N GV FF MLK 007874235203 F 1.66 N GV HF HF 060538818716 F 1.73 N GV HF HF 060538818716 F 1.73 N GV HF HF 060538818716 F 1.73 N CELERY SL 003338365325 F 1.78 N CHICKEN BRTH 005100012114 F 1.98 N CHICKEN BRTH 005100012114 F 1.98 N CORN 002880029263 F 3,00 N MCC/SCG PAPR 005210000448 F 1 .98 N FORKS 007874211675 2.50 X SPOONS 007874211679 2.50 X GV CLEAR CUP 068113192552 1.94 X CHINET PLATE 003770032226 4.24 X CHINET PLATE 003770032226 4.24 X TABLECLOTHS 004704203052 11.00 X TABLECLOTH 002833248078 10.00 X DAMASK TC 076668696185 9.00 X KITCHEN MAT 008609328481 10.00 X SUBTOTAL 83.57 TAX 1 6.000 % 3.33 TOTAL 86.90 MCARD TEND 86.90 - ACCOUNT # 9993 APPROVAL # 02215Z PAYMENT SERVICE - A CHANGE DUE 0.00 # ITEMS SOLD 22 TC# 1044 1592 5519 0062 8387 Illllllllllllllllllnlll IIIII UI IIII Illllllllllllilllllilllllllllllllllllllllllll We sladly accept valid manufacturer 8 Internet coupons. 12/06/10 10:24:17 ***CUSTOMER COPY*** . E j S ❑ O N H`H 1 N H H H H H T �4 � M 6� U' u U p -°. S e y 0 - � •L 0. [-...1 A4 � ❑ VhHHHHH H. HH H QCU U u��4 g A °° O T•- 'h � 1 --C �. O� ❑V .e. U � C � U � : V N v : m - E E=a T . @ ❑ t aa' 2 - a j -. �R O -O 6 UUU 5_ S �d F •5 '9 U : " 'S g C3 N C ��r o CF¢. r�,°,F ❑�•�• ''d'E U 0 wmz w W J,w °= 6 n O >4 0 .2 :=L_X a Q O y 6o a Est5 < � � 'eg—6 ta€ o �°c :'v�, 3 F n O ' ❑❑ CL Ho �E o .•_�4r Gd �i'� N O +.Z:�«_.-.-- - -�'.'..� �,--� J R/ -. n i �.:,r� ._ �!.:Y'--•F r Z 4 z' CAC qh�- o yy � � �. CF C � 6h h ❑ c y i o V'U m'c dQ z u ggx a � O 7a 04 t o� mow. •o a ? _ ? fo X F' x �X x _2 N Z: .. z ' s E e o Z o ° SfYn xxq^ E'' > ai 00 U RESIDENT STATEMENT FROM j CUMBERLAND CROSSINGS Statement Date Due Date ACCOUNT NUMBER 1 LONGSDORF WAY CARLISLE, PA 17015 01/31/2011 2/23/2011 20630179 717-245-9941 1 $0.00 AMOUNT PAID $ Please make check payable to CUMBERLAND CROSSINGS MARY J SWIGERT Remit To: c/o KURRY SWIGERT 206 OAK DRIVE Diakon Lutheran Social Ministries P.O. Box 8500-1131 MOUNT HOLLY SPRINGS, PA 17065 Philadelphia, PA 19178.1131 Comments D"escriptioF' iDaysl FCFia`es/ § P, -y;nents ^Balance ; r.•.. . -.,,m..:� �.Units :.. •(Credit) �i,f.•rr 7 `yic> {:^S Balance Forward $23.70 $23.70 01/13/11 -01/13/11 Payment Check#1012 $23.70 $0.00 TOTAL BALANCE DUE: $0.00 FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CUMBERLAND CROSSINGS MARY J SWIGERT 20630179 CONTINUING CARE RX 28 S SECOND ST NEWPORT PA 17074 \2�lab # t S T A T E M E N T Statement Date: 11/30/10 Page: i Account #: 100056571 DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT STRETCHER One Way Transport T2005 1.0 108.75 OXYGEN ADMINSTRATION A0g22 1 0 108.75 WAITING TIME-112 HOUR 65.01 85.01 A0999 1.0 28.94 28.94 Transport Van Mileage S0209 21.0 3.74 78.54 Total Charges 261,24 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT -- ---- -- _. _ _ Total Credits 0.00 PLEASE PAY THIS AMOUNT—INVOICE DUE UPON RECEIPT --� RETURNED CHECK FEE—$31.00 $281.24/" PATIENT NAME: SWIGERT,MARY J CALL NUMBER: 211102W AMOUNT PAID: 2 12102/2010 IMPORTANT MESSAGES: THIS SERVICE IS NOT COVERED BY MEDICARE OR MEDICAL ASSISTANCE. 00-2 l WEST SHORE EMS -BLS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011 Name: MARY JANE SWIULHI MARY SWIGE.RT i LONGSDORF WAY CARLISLE, PA 1701S Please Remit Payment To: - Number Cumberland Goodwill Fire Rescue EMS Billing Office 10-162660 1212112010 $79.93 P.O. Box 726 New Cumberland, PA 17070 QUESTIONS ABOUT THIS BILL? Phone:877-214.6018 Espanol: 866-724-4114 Fax:717-214.6020 Email: info@ambulancebillingofflm.com Date of Service: 1'V24f2010 14:57 please visit our website to provide insurance or make payment, and Patient Name: SWIGERT,MARY J. for additional payment options and frequently asked questions: From: CUMBERLAND CROSSINGS To: Carlisle Regional Medical Center www.ambulancebillingoffice.com I Medicare has paid their poriion of these chargis- The balance duo is youFr responsib?li_ry. Ifyou fiavesupp/emental insurance which covers this co-pay amounx please complete the back ofthe invoice_or.eontacaoar bitting offzce Thank you " z r - 1/24/10 ALS Emergency Transport-Lei A0427 1 1,335.00 1,335.00 1/24/10 Mileage A0425 2 11.50 23.00 1/24110 Adjustment-Insurance -944.60 2121/10 Adjustment-Insurance 7.08 2/21/10 Payment -340.55 Total 1,358.00 -937.52 -340.55 C12c�c X09 Jtir { 47,2 {�+ _r_.} ....,.w.._.- .......,. R_,4-..M1 DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT. Please Remit Payment To: Invoice AC -Inyowe Date., count Balance Cumberland Goodwill Fire;Rescue FMS Billing Office 10-162699 12121/2010 $67.31 P.O. Box 726 New Cumberland, PA 17070 QUESTIONS ABOUT THIS BILL? Phone:877-214-6018 Espanol:866-724-4114 Fax: 717-214-6020 Email:info @ambulaneebillingoffice.com Date of Service: 1 V2612010 11:13 Please visit our website to provide insurance or make payment, and Patient Name. SWIGERT, MARY J. for additional payment options and frequently asked questions: From: CUMBERLAND CROSSINGS o www.ambulancebillin ffice.com To: Holy Spirit Hospital 8 E e Medicare has paid them portion of These charges xThe balance due ie your re potrszbzlzty Lfyou have suppCementdl insurance whicJa covers tlslc0 pay amour p�"ease con3ptete the back of the mvazce or,6antaet our btlJing office hankyou rt Fn` nil m ii M- r > t ,F t: u r ,.. zd '�'+ x�� p_ 1/26110 BLS Emergency Transport A0429 1 600.DO 600.00 1/26110 Mileage A0425 22 11.50 253.00 1/26!10 Adjustment-Insurance -365.31 2121110 Adjustment-Insurance 60.53 2/21/10 Payment -480.91 Total 853.00 304.78 -480.91 DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT. rnncm nnmc rnncni nmwuum nu. unit ur acnvwc i,rc ur ocnvroc Mary J Swigert 9481667 11/24/2010 INPATIENT DATE DESCRIPTION PAYMENT/ADJUSTMENTS 12/16/10 ADJUSTMENT 9,201.80- 12/16/10 INSURANCE PAYMENT 1,960.90- PAYMENTS AND CHAROEE RECEIVED AFTER THE,STATEMENT DATE WILL BE REFLECTED ON THE NEXT STATEMENT, t t $490723 The amount shown on this statement is outstanding at FOR BILLING QUESTIONS,PLEASE CALL: this time. Your prompt payment will be greatly (717)960-1680 appreciated. Bills can be paid online at our hospital internet web site www.carlislermc.com ' V � � it UPON RECEIPT RESIDENT STATEMENT FROM CUMBERLAND CROSSINGS Statement Date Due Date ACCOUNT NUMBER 1 LONGSDORF WAY CARLISLE, PA 17015 11/30/2010 12/23/2010 20630179 717-245-9941 NILOIIFTJQS + + �$1,264.32 AMOUNT PAID $ Please make check payable to CUMBERLAND CROSSINGS MARY J SWIGERT Remit To: c/o KURRY SWIGERT Diakon Lutheran Social Ministries 206 OAK DRIVE P.O.Box 8500-1131 MOUNT HOLLY SPRINGS,PA 17065 Philadelphia,PA 19178-1131 Comments >,4. `Y'yDdtC�l �¢ ,re'y"' ,.a' a "DeSCflptlOn� wl""Y�`y UmhY RDa„y$1'�1.`In�a7S° Fd �i,-Cffaf CS 1 P8yf11aOtS� ` I .BalanCea�sFi si, +ro I"" ., �' .,- , ,... �. ... .,. /G $ „�„E` n. 11,,.. d= � r _ 5 ti VnItB Cifeft�, � 'h 11/27110-11130110 R&B Private Pay 4 $980.00 $980.00 11/27/10-11/30/10 Oxygen concentrator 4 $16.92 $996.92 11/30/10-11/30110 Incontinence Charge 8 $22.40 $1,019.32 12/01/10-12/31110 R&B Private Pay 31 $7,595.00 $8,614.32 12/02/10- 12/31/10 R&B Private Pay (30) $(7,350.00) $1,264.32 TOTAL BALANCE DUE: $1,264.32 DO NOT DETACH THIS VOUCHER PAT, IS MENED AND THE-ENDORSED No. I (DOG MEN °"" 12�27'l0 50-5033 ""`°°` DATE 313 rR PAY To,. °a..o --__—.___— TOTHE UMf3E2L.A-ND CROSSwJ& •�I or IN,+a...,°, ORDER OF ff �tGHTEV4 IJND/tED�W`ELVCN LL"SANb �00 DOLLARS A ... _ ..°.,or A-A-S ORRSTOWN`13ANK t G E tLT ...M,..°. IGN HERE_ M' __ / '�• L=1(1�Cu TOR �' a:°.x°°nee e.c.Or c°ec. .. m.—�,a—.„.,,—,� r:03L3150361: 1103 0087341' FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CUMBERLAND CROSSINGS MARYJ SWIGERT 20630179 RESIDENT STATEMENT FROM CUMBERLAND CROSSINGS Statement Date Due Date ACCOUNT NUMBER 1 LONGSDORF WAY CARLISLE, PA 17015 11130/2010 12/23/2010 207301179 717-245-9941 Illifflelf-A $5,054.80 AMOUNT PAID $ Please make check payable to CUMBERLAND CROSSINGS MARY JANE SWIGERT Remit To: c/o MARY JANE SWIGERT Diakon Lutheran Social Ministries 1 LONGSDORF WAY P.O. Box 8500-1131 ASSISTED LIVING Philadelphia, PA 19178-1131 CARLISLE, PA 17015 Comments _ . I.4rRjr+hsyi'a,y�'.`-71� �I:DE8CIiptlOn'`u�1.<.iii rs<•Z�;yj!5.:,i7_.?DB /`,:c3';Firx+e�',.<h `." C �i`.. �3a'y"•,y '' 4 ye r'? s,4 rlf� y>i,� HH r r i tl�rQBS/ gYlPBylile�t6 ,� rL:Balancer',+ Ffct..s.L� n (C►edlta;r}t Balance Forward $4,978.00 $4,978.00 1123110-11/23110 Payment Check 9 4610 $4,976.00 $0.00 11/03/10-11103/10 Barber/Beauty Chargeable 1 $14.00 $14.00 11/10/10-11/10/10 Barber/Beauty Chargeable 1 $21.00 $35.00 11/18/10-11/18/10 Barber/Beauty Chargeable 1 $23.00 $58.00 11/24/10-11/24/10 Meal Credit 1 $(16.24) $41.76 11/30/10-11/30110 Meal Credit 4 $(64.96) $(23.20) 11/30/10-11/30/10 Sales Tax-Phone-Basic 1 $1.42 $(21.78) 11/30/10-11/30/10 Phone-Monthly 1 $23.56 $1.80 12/01/10-12/31/10 R&B Private Pay Monthly 31 $51068-.99 $5,054.80 TOTAL BALANCE DUE: lo5a $5,054.80 - fbS .51 FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CUMBERLAND CROSSINGS MARY JANE SWIGERT 207301179 6r€�wwn,wu ,won wrwvnu evuEur-GEre-IgTir"��i�il�F,iGvnu crown c6ielme—n—ts Balance Forward $4,978.00 $4,978.00 11/23110-11123/10 Payment Check#4610 $4,978.00 WOO 11/03!10-11103/10 Barber/Beauty Chargeable 1 $14.00 $14.00 11/1 0/1 0-1111011 0 Barber/Beauty Chargeable 1 $21.00 $35.00 11118110-11/18/10 BarberiBeauty,Chargeable 1 $23.00 $58.00 11/24/10-1 1124110 Meal Credit 1 $(16.24) $41.76 11130/10-11130/10 Meal Credit 4 $(64.96) $(23.20) 11130/10-11/30/10 Sales Tax-Phone-Basic 1 $1.42 $(21.78) 11/30/10-11/30/10 Phone-Monthly 1 $23.58 $1.80 12/01/10- 12/31110 R&B Private Pay Monthly 31 $579g3.gt} $5,054.80 TOTAL BALANCE DUE: $5,054.80 IDS FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CUMBERLAND CROSSINGS 1 JANE�SWIGERT- 207301179 PLEAS PORTION ,YOUR PAYMENT,RETAIN BQTr09 PORTION YOU H RE O5 r , iP1Date "'Descr ptitin #Days�! Charges ! Payments' lance'° ' +�: - � �'" I' cUnits'E'' Credit 11/21110-11130110 R&B Private Pay 4 $980.00 $980.00 11/27/10-11/30/10 Oxygen concentrator 4 $16.92 $996.92 11/30/10-11/30110 Incontinence Charge 8 $22.40 $1,019.32 12/01/10-12/31/10 R&B Private Pay 31 $7,595.00 $8,614.32 12102/10-12131110 R&B Private Pay (30) $(7,350.00) $1,264.32 TOTAL BALANCE DUE: $1,264.32 FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CUMBERLAND CROSSINGS MARYJSWIGERT 20630179 PLEASE RETURN TOP PORTION Wn!YOUR PAYMENT.RETAIN BOTTOM PORTION FOR YOUR RECORDS PINKER & ASSOCIATES PODIATRIC MEDICINE AND FOOT SURGERY MARK E. PINKER, D.P.M., F.A.C.F.A.S. MARK GOLEC, D.P.M. ELISE J. NELSEN, D.P.M. 47 BROOKWOOD AVENUE CARLISLE, PA 17015 (717)243-2236 12/21/10 MARY JANE SWIGERT CUMBERLAND CROSSINGS 1 LONGSDORF WAY 11935.0 ( 1 ) CARLISLE PA 17015 DESCfflFTION MARY JANE SWIGERT (11935-0) 11/04/10 DEBRIDE MYCOTIC NAILS 60 . 00 12/06/10 Ins Pmt-SECURE HORIZONS DIRECT 31. 94 12/06/10 - Adjustment 20.07 TOTAL FOR MARY JANE SWIGERT l v FOR YOUR CONVENIENCE WE ACCEPT MAJOR CREDIT CARDS, CASH OR CHECK. IF YOU HAVE A QUESTION OR CONCERN ABOUT TOTAL DUE CURRENT 1 31 -60 DAYS 1 61 -90 DAYS 191 -120 DAYS JOVER 120 DAYS 7 . 99 7.99 0.00 0.00 0.00 0.00 sz ESTATE OF MARY JANE SWIGERT W-ta3 102 KURRY W.SWIGERT, EXECUTOR 206 OAK DRNEy MT HOLLY,PA 57085 a1.'.z�.4 l HOLY + 4"t explanation of benefits dof OLYSPIRI H05,PITAL ✓c�l $ 714 So )mpany(s)and have " �- /� rF—^ �I penis and/or adjusunenis SEVcr,T470uP, Ni.4AA5FkNA GG,14T tEwrS . , ;e make payment for the R take advantage of a discount and remit$74.80 C3RRSTOWNE N% 1. A PmdtRad g"Evall..... / 2 41)rd loft„ lent ways to make 4:0313L50361: t03 00873411' 010 Vice at 717-763-2138 - --- to make payment by credit card. 1 � If cke d �iX.wa— 1 2--il1 r 2. Mail tear-off coupon below with payment using the enclosed self-addressed envelope. Account � Patient Name: Swigert ,Mary Jane Previous Balance: 5.00 Statement Date: 01/14/11 Total New Charges: 93,461.90 Service Date(s): 11/26/10 Payments/Adjustments: $3,373.90- Account Balance: $88.00 Account Number: 38547501 Please Pay This Amount: $88.00 OR Medical Record Number. 684419 Discounted Amount of$74.80 if paid on or before 02/13/2011 Insurance .information Contact Us Ins. 1: SECURE HORIZO Please call Customer Service at 717-763-2138 Ins.2: to add or make corrections to your insurance Ins. 3: information, or to make arrangements for a Ins.4: payment plan. If you are unable to make payment, please contact the Financial Counselor's Office at(717)763-2885 to discuss financial assistance options. Please Note., Your physicians will bill separately for professional services. Make Checks Payabte To: Holy Spirit Hospital A¢ 5N 0T m °r Dam Pay only m°4 8$.00 38547501 $74.80 MARY JANE±SWIGERT If aldbyg02/13/2011. 383 N 21ST STREET ❑ M3 ❑ ❑ � ❑ " CAMP tm.LPA I7011 Cart Nvmker. CVV2 No:" Em.A,e: +gym.nm, ADDRESS SERVICE REQUESTED si°ruarc Mwn<,HM: 71 •SU Ch<ck lox Hynm•ddr•<,m hez • n bt <mp•d, mean mnt <hn'..n bat. 'The CW2 No.is requhod to procoss your payment R is the last 3 digits on the back of your crodd card,by your signature. For Am"card holdom,it is the 4-digit number on the front of Yom card,above the cart)number. 00006083 001 0.53 38547501 MARY JANE SWIGERT 1 LONGSDORF WAY HOLY SPIRIT HOSPITAL CARLISLE PA 17015-7623 P.O. BOX 822183 PHILADELPHIA,PA 19182-2183 0000385475010010000000880000100735000000017,300000132000000074&00213207,14 05HOLY Previous balance:Total New Charges: 53,461.90 Payments/Adjustments: *3,373.90- Account Balance: $88.00 H C) S P t T A L Please Pay This Amount: $88.00 OR The Spirit of Caring Discounted Amount of$74.80 if paid on or before 02113/2011 Charq- ] , s Trans. ate Description Amount 11/26/10 3 PORT PUMP SET 28.70 11/26/10 ZOFRAN IMF 4MG12.OML 5.20 11/26/10 NACL 0.9 1000 82.50 11/26/10 NACL 0.9 1000 82.50 11/26/10 VENIPUNCTURE 19.00 11/26/10 METABOLIC PANEL,C 169.00 11126110 CARDIAC ORDER SET no 11/26/10 CPK (CREAT. PHOS) 68.00 11/26110 CKMB 66.00 11/26/10 URIN, (NO MICRO.) 37.00 11/26/10 MICROSCOPIC, URIN 35.08 11/26/10 CBC,AUTO DIFF 115.00 11/26/10 URINE CULTURE 99.00 11/26/10 BLOOD CULTURE 314.00 11/26/10 BLOOD CULTURE 314.00 11/26110 TROPONIN T 97.00 11/26/10 CHEST 2V 380.00 11/26/10 IV PUSH 209.00 11/26/10 LEVEL IV 1-4 MRS INTER 1,119.00 11/26/10 EKG 184.00 11/26110 EKG PC-INTERPRETATION 8 RPT 38.00 12/16/10 MEDI HMO Q47 SECURE HORIZ0 362.28- 12/16/10 MED HMO OUT/AREA C/A Q47 SECURE HORIZO 2,976.62- 12/16/10 MED HMO OUT/AREA C/A Q47 SECURE HORIZO 35.00- 01/13/11 MEET HMO Q47 SECURE HORIZO .00 01/13/11 MED HMO OUT/AREA C/A Q47 SECURE HORIZO .00 r r l:t.�se e,r Otis�;tcce t<;tuakr ctq;,;n;7,x'S En;yctt :v1ar�< ai in nr.etste;nfararttits�. N:uS;e: .. ........... .. ..__.....__. ...__. .._... _. ..... _....,_ ._. ACnuutll i•.n: ......,. _ ...__.._....._. ..._Piva:m:_. r`.tidre+sc i?nsta�•� I'h nr ..... _....... P:nq+I n'dr - . tin;p;rt '_r:idkii ss: !nenra uce Cm qt nry•:Atidrt'. i'Nunu^ .. is<ur.ntcr°olic,-m too>tt;cct No: .__.. _ ,_y.._ {it 6ti)S Nw_. . .__.._........._...__-_.._ poji.T hinh9er':;N:11n+c: P,_s 'lio!d..r`s Date.of I?t Yh Po @o}Hoider'x(tanner' [1N E j! noit lk Id,i 5<rrial Seen itr'N z ns,ie, ,Rci:iu)11s1ttp pt lg0;ueti' 4 tf 7 Spouse Child . . JOLY We have received the explanation benefits from your insurance company(s)and have applied whatever payments and/or adjustments St are appropriate. Please make payment for the PP I T A L balance due$88.00 OR take advantage of a The Spirit of Caring 15%prompt payment discount and remit$74.80 on or before 02H 3/2011, 38547501 Here are two convenient ways to make MARY JANE SWIGERT payment: 1LONGSDORF WAY CARLISLE PA 17015-7623 1. Call Customer Service at 717-763-2138 to make payment by credit card. 2. Mail tear-off coupon below with payment using the enclosed self-addressed e nv_e e..,._.._ _�......_. . . Patient Name: Swigerl ,Mary Jane Previous Balance: $.00 Statement Date: 01/14111 Total New Charges: $3,461.90 ServiceDate(s): 11/26/10 Payments/Adjustments: $3,373.90- Account Balance: $88.00 Account Number.. 38547501 Please Pay This Amount: $88.00 OR Medical Record Number. 684419 Discounted Amount of$74.80 if paid on or before 02/13/2011 Ins. 1: SECURE HORIZO Please call Customer Service at 717-763-2138 Ins.2: to add or make corrections to your insurance Ins. 3: information,orto make arrangements fora Ins. 4: payment plan. If you are unable to make payment, please contact the Financial Counselor's Office at(717)763-2885 to discuss financial assistance options. Please Note: Your physicians will bill separately for professional services. rAlltnl nnmt rAlltnl AG6UUnl NU. UAlt Ur 5tnVIUt 1Trt Ur UKV1Ut Mary J Swigert 1066395 11/22/2010 OUTPATIENT DATE I DESCRIPTION PAYMENT/ADJUSTMENTS INDUSTRIAL/CLIENT ACCOUNT 12/29/10 ADJUSTMENT 12/29/10 INSURANCE PAYMENT 181.59- 21.65- c \Lo �( �IIs�'( PAYMENTS AND CHARGES RECEIVED AFTER THE STATEMENT DATE WILL BE REFLECTED ON THE NEXT STATEM MESSAGES ENT. lly $5.41 ' The amount shown on this statement is outstanding at FOR BILLING QUESTIONS,PLEASE CALL: this time. Your prompt payment will be greatly (717)960-1680 appreciated. . Bills can be paid online at our hospital internet web site www.carlislermc.com l PON RECEIPT �� IIYIILIYI IYn111L IIYI ILYI IYVVV VI\1 IY V. Y/IIL VI VLIIYIV 111 L VI VLII YIVL Mary J Swigert 1068452 11/29/2010 L OUTPATIENT DATE DESCRIPTION PAYMENT/ADJUSTMENTS INDUSTRIAL/CLIENT ACCOUNT 12/21/10 ADJUSTMENT. 148:68- 12121110 INSURANCE PAYMENT . 21:01- . PAYMENTS AND CHARGES RECEIVED AFTER THE STATEMENT DATE WILL BE REFLECTED ON THE NEXT STATEMENT. , 65.25 MESSAGES The amount shown on this statement is outstanding at FOR BILLING QUESTIONS, PLEASE CALL: this time. Your prompt payment will be greatly (717)960-1680 appreciated. Bills can be paid online at our hospital internet web site www.carlislermc.com Y ry u PON RECEIPT Receipt 30809 Created: 12/04/2010, 11:13:56AM MIDWAY SELF STORAGE 1545 HOLLY PIKE CARLISLE, PA 17015 (717)258-9000 Kurry Swigert 206 Oak Drive Mt Holly Springs,PA 17065 Payment Type Check#/Comments Item Amount Applied To Master Card $10.00 Setup Fee Prorated $34.00 Rent Prorated $2.04 Sales Tax Prorated $34.00 Rent Prorated $2.04 Sales Tax Total Payment: $82.08 Unit(s)Rented Balance $0.00 Unit# Next Billing Date Paid To Date 0776 1/1/11 1/1/11 0777 1/1 111 111/11 Signature Cardholder acknowledges receipt of goods and or services in the amount of the total shown XXXXXXXXXXXX9525 hereon and agrees to preform the obligations set forth in the cardholder's agreement. CAsmswVteceipLry[ ' „STATEMENT'# 32814 MIDWAY SELF STORAGE 1545 HOLLY PIKE CARLISLE,PA 17015 12/17/2010 F07776,0777 KURRY SWIGERT 206 OAK DRIVE AMOUNT ENCLOSED NIT HOLLY SPRINGS PA 17065 For billing questions,please call(7l 7j 258-9000 PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT --------------- ----------- --------- ------- .......--------------1------------------------- ----------- 0776,0777 $0.00 Starting balance 0777 12/4/2010 $10.00 $10.00 Setup Fee 0777 12W2010 1/1/2011 $34,00 $44,00 Rent/ Prorated 0777 12/4/2010 1/1/2011 $2.04 $46.04 Sales Tax/ Prorated 0776 12/4/2010 1/1/2011 $34.00 $80.04 Rent/ Prorated 0776 12/4/2010 1/1/2011 $2.04 $92.08 Sales Taxt Prorated 0776,0777 12/4/2010 $82.0$ $0.00 0776 1/1/2011 2/1/2011 $37.50 $37.50 Rent 0776 1/1/2011 2/1/2011 $2.25 $39.75 Sales Tax 0777 1/112011 21112011 $37.50 $77.25 Rent 0777 1/1/2011 2/1/2011 $2.25 $79.50 Sales Tax Ending Balance AMQtINT DUE ( $79.50 ,) For billing questions,please call (717)258-9000 Please notify the office of any address changes and/or phone number changes.Rent is due on the I st of the month. . 60 0 40 1<11�"t MIDWAY SELF STORAGE „rST ATEIVIENT # . 36042 MIDWAY SELF STORAGE 1545 HOLLY PIKE CARLISLE,PA 17015 7/18/2011 0776,0777 KURRY SWIGERT $ 206 OAK DRIVE AMOUNT ENCLOSED MT HOLLY SPRINGS PA 17065 For billing questions,please call(717)258-9000 PLEASE DETACH AND RETURN THIS PORTION V111M YOUR PAYMENT ____________________________________________________________________________________________________ sp vcaA�la�by�y f��-^^r t s..•m.cA x..susecY au. w..srw .ue:asaar •n'',E'��'s'_..a. � ._!"<ents+i .%..CS''=z�t:. �.. 0776,0777 $79.50 Starting balance 0776,0777 7/1/2011 $79.50 $0.00 0776 8/1/2011 9/1/2011 $3750 $37.50 Pent 0776 81112011 9/1/2011 $2.25 $39.75 Sales Tax 0777 8/1/2011 9/1/1011 $37.50 577.25 Rent 0777 8/1/2011 9/1/2011 $2.25 $79.50 Sales Tax Ending Balance � DUUE $79.50 For bitting questions,please call (717)258-9000 Please notify office if credit card has been changed. Please notify the office of any address changes and/or phone number changes.Rent is due on the 1 st of the month. MIDWAY SELF STORAGE C:wnsM1Stxtema�.nx . ST TnEME';� 34717 MIDWAY SELF STORAGE 1545 HOLLY PIKE CARLISLE,PA 17015 4 KURRYSWIGERT $ 206 OAK DRIVE AMOUNT ENCLOSED WHOLLY SPRINGS PA 17065 For billing questions,please call(717)258-9000 PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT ................................................................................................................................................... _.......... ............... 0776,0777 $79.50 Starting balance 0776,0777 4/12/2011 $79.50 $0.00 0776 5/1/2011 6/1/2011 $37.50 $37.50 Rent 0776 5/1/2011 6/1/2011 $2.25 $39.75 Sales Tax 0777 5/1/2011 6/1/1011 $37.50 $77.25 Rent 0777 5/1/2011 6/1/2011 $2.25 $79.50 Sales Tax Ending Balance trONT.DUE' $79.50 For billing questions,please call (717)258-9000 Please notify the office of any address changes and/or phone number changes.Rent is due on the 1 st of the month. MIDWAY SELF STORAGE Cdtmsv�SmtemnLryt S LA FWAT,,"# ' 35102 MIDWAY SELF STORAGE 1.545 HOLLY PIKE CARLISLE,PA 17015 5/17/2011 0776,0777 i KURRYSWIGERT $ 206 OAK DRIVE AMOUNT ENCLOSED MT HOLLY SPRINGS PA 17065 For billing questions,please call(717)258-9000 PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT ;,r". ,,i�P ta �w.i dd .,, ," mSM'�u` tm �t��0 „ ', Pa {e s Ba1a�.sS il<S�§�ea�xu�.�° FS`��'".a° �i S"h.%M*``'..I AN MET 0776,0777 $79.50 Starting balance 0776,0777 5!2/241 I $79.50 $0.00 0776 6/1/2411 7/12011 $3250 $37.50 Rent 0776 6/1/2011 7/12011 $2.25 $39.75 Sales Tax 0777 6/1/2011 7/1/2011 $37.50 $77.25 Rent 0777 6!1/2011 7/12011 $125 $79.50 Sales Tax Ending Balance ANO'UNTalII�E $79.50 For billing questions,please call (717)258-9000 Please notify the office of any address changes and/or phone number changes.Rent is due on the 1 st of the month. MIDWAY SELF STORAGE C:lsmsw�Statemntpt i ::STATEMENT# ; 36509 MIDWAY SELF STORAGE 1545 HOLLY PHU CARLISLE,PA 17015 8 KURRYSWIGERT $ 206 OAK DRIVE AMOUNTENCLOSED MT HOLLY SPRINGS PA 17065 For billing questions,please call(717)258-9000 PLEASE DETACH AND RETURN THIS PORTION KITH YOUR PAYMENT -___________________________________________________________________________________________________ Untt s • "D -T t -To x. a f BeIled K Payments Balance Category <<"'V .A.Ri._i'....,. �...Y......r. . .• . ..-t 0776,0777 $79.50 Starting balance_... - 0776,0777 811/2011 $79.50 $0.00 0776 9/1/2011 10/1/2011 $3250 $3750 Rent 0776 9/1/2011 10/1/2011 $2.25 $39.75 Sales Tax 0777 9/1/2011 10/12011 $37.50' $77.25 Rent 0777 9/1/2011 10/12011 $2.25 $7950 Sales Tax Ending Balance s AMCIl11VT,DIJE n $79.50 For billing questions,please call (717)258-9000 Please notify office if credit card has been changed. Please notify the office of any address changes and/or phone number changes.Rent is due on the I st of the month. MIDWAY SELF STORAGE C:=vMSua mm.ryt STA—MEN! s# 36988 MIDWAY SELF STORAGE 1545 HOLLY PIKE CARLISLE,PA 17015 9/16/2011 F0776,0777 KURRY SWIGERT $ 206 OAK DRIVE AMOUNT ENCLOSED MT HOLLY SPRINGS PA 17065 For billing questions,please call(717)258-9000 PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT ____________________________________________________________________________________________________ Y v'� IIn�t br D Y ro 1 ' Billed Pay_m nits Balance �G'stego IC :n ar �: : -ten 0776,0777 $79.50 Starting balance 0776,0777 9/1/2011 579.50 $0.00 0776 10112011 11/112011 $37.50 $37.50 Rent 0776 10/1/2011 11/1/2011 $2.25 $39.75 Sales Tax 0777 10/1/2011 I1/1/2011 $37.50 $77.25 Rent 0777 10/12011 11/1/2011 $2.25 $79.50 Sales Tax Ending Balance Iffl ��, $79.50 For billing questions,please call (717)258-9000 Please notify office if credit card has been changed. Please notify the office of any address changes and/or phone number changes.Rent is due on the I st of the month. MIDWAY SELF STORAGE CONTINUING CARE RX 28 S SECOND ST NEWPORT PA 17074 * * STATEMENT * * Statement Date: 12/31/10 Page; 1 Account #: 100056571 CC MARY JANE SWI8ERT MARY RWIGERT 1 LONGSDDRF NAY CARLISLE/ PA 17015 Date Description Qty Amount -------- ---------`-----------------`---------------- ---------- Previous Balance 27S. 57 12/2i/10 DOC#99289G35 PAYMENT ~ THANK YOU 27S. 57-12/O1/1O RX# 8041084 MORPHINE SULF 20M8/ML SOL 1 1Q� OO COPAY 12/01/iO RX# 8041307 ACETAMINOPHEN 65OMQ SUPP 12 77. 63 3 i2/0t/10 RX# 8042412 DSW 1/2NSS W/20ME0 KCL 10 4000 1131 12/01/10 RX# e042421 IV—TUBING^MCT857OG—SET N/ 3 13� R3 12/01/10 RX# 8046959 mORPHINE SUi-F 5M8 GYR~PYX 1 2. 10 12/01/10 RX# 8092741 IV—INSERTION — PERIPHERAL 1 15D� OO 12/0i/10 RX# 8092755 IV~C/�TH 22QX1 `' 4UTOQAURQ 1 @� 11 12/01/10 RX# 8092758 IV—START KIT W/CHLRPRP LT 1 1.� 38 12/0j/10 RX# 9092763 IV—CLAVE MICRO W/EXT SET 1 2� 16 12/01/10 RX# 8092766 SODIUM CHL 9% 10ML/12ML 1 1 110 ** continued on next page ** ^` CONTINUING CARE RX Statement date: 12/31/10 28 S SECOND ST NEWPORT PA 17074 Account #: 100O56571 CC Name: MARY JANE 8WIQERT MARY SWIAERT 1 LDNgSDORF WAY CARLISLE/ PA 17015 � � � CONTINUING CARE RX 28 S SECOND ST NEWPORT PA 17074 * * S T A T E M E N T # # Statement Date: 12/31/10 Page: 2 Account #: 100056571 CC MARY JANE SWIGERT MARY SWIGERT 1 LONGSDORF WAY CARLISLE, PA 17015 Da-t.e- ----Descripti-on._.-. _, _Oty----Amount--- -- .. - - -------- -------------------------------------------- ---------- 12/02/10 RX# 8048015 ACETAMINOPHEN 650MG SUPP. 2 2. 95 12/03/10 RX# 8050354 IV-PUMP-BAXTER 6201 RENTA 2 24. 00 11/30/10 RX# 8064213 IV-INSERTION - PERIPHERAL 1 150. 00 11/30/10 RX# 8064219 IV-CATH 22GX1 " AUTOGAURD 1 2. 11 11/30/10 RX# 8064226 IV-START KIT W/CHLRPRP LT 1 1. 38 11/30/10 RX# 8064232 IV-CLAVE MICRO W/EXT SET 1 2. 16 11/30/10 RX# 8064237 SODIUM CHL 9% 10ML/12ML 1 1 1. 10 Ending balance - Pay this amount ---------> 385. 32 Past Due Past Due Past Due Current 31-60 days 61-90 days 90+ days ----------- ----------- ----------- ----------- 385. 32 . 00 . 00 . 00 QUESTIONS PLEASE CALL 1-800-675-2279 EXT: 1304 CONTINUING CARE RX 28 S SECOND ST NEWPORT PA 17074 * * STATEM5NT * * Statement Date: 12/31/10 Page: 2 Account #: 100O56571 CC MARY JANE SWTgEOT MARY 8WIQERT 1 LONQSDORF WAY CARLISLE, PA 17015 Date Description GtU Amount .---�—`.— ---------------------------------------------- ----------- 12/02/10 RX# 8048015 ACETAMINOPHEN 65OMG SUPP 2 2. 95 ~ -- ' . —., ."~"~,^ ,.. 1. 1�1 n^v�rn L",o, mc^/rA o oil nn No. | 6�1S D33 | | � 3Q 313 DATE DOLLARS °,^,",, `~^=`"^°..^`=ANm woEoc_---`a�=a��s�=a�--�� 1:O3 L 3 1S0 3 r3«: 103 O08 ?3411" / QUESTIONS PLEASE CALL 1-800-675-2279 EKT: 1304 ----------------- ------------------------ -------------------------------------------- Please cot here and remit this portion with payment Remit to: CONTINUING CARE RX Statement date: 12/31/10 5775 ALLENTOWN BLVD SUITE 101 HARRISBURG, PA 17112 Account #: 100056571 CC Ending balance: 385. 32 � -2°/c/6^-37` Name: MARY JANE gAI8ERT Amount enclosed: MARY SWIGERT 1 i.ONgSDORr WAY CARLISLE/ PA 17015 Email Us Exit 0iaST0WNBXN- A Tradition of Excellence bank0home Bill Pay e-NotTirations Options Accounts Transactions Transfers Stop Payments Statements Current Ttansections Download Saamh ORRSTOWN BANK 77 East King Street Shippensburg, PA 17257 View Check Image 1 iV K TRY W.SWIGL•RT i '—, 2# 656 DEBRA L.SWIGERT w+TS SSty�E1 2M OAiCD UNIS Pit 7i7-4W1186 AMT IIOf.LYSPIiW�GS,PA 17P65 /y - }#�tBit�t+trll"tODERaIJ<�EbT Soft ttl: tim+tfPA Y 1 $ 040. 0o rd PAY'l�OTtCEO)�gF � StSL�uNL+R,ED�1a.;?• +Ll�r n.�Aasl`,_3�!DIVa �rS ..�'t..Y-�-. . n d ?tMl9!' OiR—STMNIJANK R W.W7 gfFS� t.rst tts Ogg 004 43T 317 Cd � r ♦ r.-fil� caw ,$ Ali��2Stie�9a7F +4HRl•.�b �. }^� C��SS%W�`m:'.'a�,.k'+��^'...: MC:G�Y.A1!v.vl3�?: s LENDER 1 of 1 916/20119:23 PM TAX PAYER COPY Bill N0: Avne�ETO Control NO 004-000155 ;ARLISLE BOROUGH TAX ACCOUNT 2011 statement of Real Estate Taxes Bill Date: 7101!2011 'O BOX 100,53 WEST SOUTH STREET Total :ARLISLE PA 17013 Assessed Land Improvement Miner l 152 900 Values 20 000 132 900 30 492- Homestead &xclusion Discount Face Penal )MAIPTIGN CARLISLE AREA S.D. .10% ASSESS.NO- 04000155 Rates 12.26060 12.26060 12.26060 22 1 874.65 SCHOOL R/E 128.64- MAP NO: FRET STREET Homestead Credit 229 AC W POMFRET STREET ACRES .060 DEE 0015A/00039 A r-,�--�i MOUNT DUE—> $1,711.08 $1,746.01 $1,920.61 �: S t LAND LESS THAN I ACRE pa id On or After 7/01/2011 9/01/2011 11/01/2011 Residentiai(Under 10 Acres) L paid On or tere 8 31/2011 10131/2033 12/31120111 RESIDENTIAL A11 PAYER AUG A (7 2, 9 F NO PAID BY 12!31111 THIS BILL WILL BE RETURNED TO TAX SWIGERT,WAYNE K&MA YJAN 229 WEST POMFRET STR ET O $�1 BUREAU BILL FEET COLLECTION. CARLISLE PA 17013-2823 (/ -E OFFIGEHOURS -- i PD-ROAT-FRIDAY 7:30AM-4:30PM PHONE(717)249-4422 CLOSED SAT,SUN&HOLIDAYS CASH ONLY AFTER 12/15/11 NOTICE OF PROPERTY TAX RELIEF Your enclosed ax bill includes a tax reduction for your homestead Yni nd/oufhava re received property. As an eligible homestead and/or farmstead property, tax relief through a homestead en Relief rAct ea law passed by the�P nnsylvaniaiG General under Assembly designed t is duce y taxes-designed to reduce your property Ii ' Email Us Exit ®RRSTOWNB!N- ATradition of Excellence bank®home Oil Pay a-Notfii ations Options Accounts Transactions Transfers Stop Payments Statements Current Transactions Download Search ORRSTOWN BANK 77 East King Street Shippensburg, PA 17257 V'N Check Image 97-1973 1eGrro P�tqPae�'f 3u— JA B 1$3 .306'(lrr/i h'/IYr/O totm5'7}at a r 5 to fh<� s .: er D 1 ,tom— -730 Rd •,`p."a✓ - 1 CX:d/r D O L L A R S i! 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W °O FLW'm as mz{ y¢y�� ans � � �v�©�� (7 "� 6❑z� z ❑ V Q W (7Oz K I IwaaF .C7 c.' w ¢. �i¢ e0 211000¢ 2 ¢ = a O I 6y3 O $ w � o ¢= ¢ 5m a , m� >� . o � r� �o zaW JW xz�'G d �Q opt°z�><Q ¢ a 5 a `> agW'SwW a'hle-p- .� ❑�¢ L) may= at� dw¢ � 4.$$w w .�==a = 'N .'.s L' � NOw�a�osyi� a❑OO❑.= asLL❑ ❑❑ _R0a ❑❑❑0❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑❑ 0 31 " { lkllwlgODD &7'd❑ ❑❑❑ - ❑❑ ❑❑ .❑ ❑`❑ 1000118171 s PA-40 — 2010 Pennsylvania Income Tax Return ENTER ONE LETTER OR NUMBER IN EACH BOX. Do Not Use Your Preprinted Label 191184475 N Extension. SWIGERT N Amended Return. WAYNE K Occupation RETIRED R Residency Status. PA Resident/Nonresident/Part-Year Resident Occupation from to D Single/Married, Filing Jointly/Married, Filing Separately/Final Return/Deceased Date of death 11010 206 OAK DRIVE N Farmers. MT. HOLLY SPRINGS PA 17065 school District Name SOUTH NIDDLET 21830 1 a Gross Compensation, Do not include exempt income,such as combat 1 a 0 zone pay and qualifying retirement benefits. See the instructions. 1 to Unreimbursed Employee Business Expenses. 1 b ❑ 1c Net Compensation. Subtract Line 1b from Line 1a. 1C 0 2 Interest Income. Complete PA Schedule A if required. 2 ❑ 3 Dividend and Capital Gains Distributions Income.Complete PA Schedule B if required. 3 3513 4 Net Income or Loss from the Operation of a Business, Profession or Farm. 4 0 5 Net Gain or Loss from the Sale, Exchange or Disposition of Property. 5 ❑ 6 Net Income or Loss from Rents, Royalties,Patents or Copyrights. 6 ❑ 7 Estate or Trust Income. Complete and submit PA Schedule J. 7 ❑ 8 Gambling and Lottery Winnings. Complete and submit PA Schedule T. 8 ❑ 9 Total PA Taxable Income.Add only the positive income amounts from Lines 1c, 9 3513 2,3,4,5, 6,7 and 8. DO NOT ADD any losses reported on Lines 4, 5 or 6. 10 Other Deductions.Enter the appropriate code for the type of deduction. N 10 0 See the instructions for additional information. 11 Adjusted PA Taxable Income.Subtract Line 10 from Line 9. 11 3513 PAIA0412L nrzsno EC Page 1 of 2 FC 1000118171 m m 1000118171 J PA•40 — 2010 1000218187 Social Security Number ? 191184475 Name(s) SWIGERT, WAYNE K. 12 PA Tax Liability.Multiply Line 11 by 3.07 percent(0.0307). 12 108 13 Total PA Tax Withheld.See the instructions. 13 0 14 Credit from your 2009 PA Income Tax return. 14 ❑ 15 2070 Estimated Installment Payments. 15 ❑ 16 2010 Extension Payment. 16 0 17 Nonresident Tax Withheld from your PA Schedule(s)NRK-1.(Nonresidents only) 17 0 18 Total Estimated Payments and Credits.Add Lines 14, 15, 16 and 17. 18 0 Tax Forgiveness Credit.Submit PA Schedule SP. 19a Filing Status: Ol Unmarried or Separated 02 Married 03 Deceased 1 9 a 00 19b Dependents, Part B, Line 2,PA Schedule SP 19b 00 20 Total Eligibility Income from Part C,Line 11, PA Schedule SP. 20 0 21 Tax Forgiveness Credit from Part D, Line 16, PA Schedule SP. 21 0 22 Resident Credit. Submit your PA Schedule(s)G-R with your PA Schedule(s)G-S,G-L and/or RK-1. 22 0 23 Total Other Credits. Submit your PA Schedule OC. 23 0 24 TOTAL PAYMENTS and CREDITS.Add Lines 13, 18,21,22 and 23. 24 0 25 TAX DUE.If Line 12 is more than Line 24, enter the difference here. 25 108 26 Penalties and Interest. See the instructions. Enter code: 26 0 If including form REV-1630/REV-1630A, mark the box. N 27 TOTAL PAYMENT DUE.See the instructions. 27 108 28 OVERPAYMENT.If Line 24 is more than the total of Line 12 and Line 26,enter 28 ❑ the difference here. The total of Lines 29 through 35 must equal Line 28. 29 Refund—Amount of Line 28 you want as a check mailed to you. Refund 29 0 30 Credit—Amount of Line 28 you want as a credit to your 2011 estimated account. 3❑ ❑ 31 Amount of Line 28 you want to donate to the Wild Resource Conservation Fund. 31 0 32 Amount of Line 28 you want to donate to the Military Family Relief Assistance Program. 32 ❑ 33 Amount of Line 28 you want to donate to the Governor Robert P.Casey Memorial 33 ❑ Organ and Tissue Donation Awareness Trust Fund. 34 Amount of Line 28 you want to donate to the Juvenile(Type 1)Diabetes Cure 34 ❑ Research Fund. 35 Amount of Line 28 you want to donate to the PA Breast Cancer Coalition's Breast 35 ❑ and Cervical Cancer Research Fund. Signature(a).Under penanies of perjury,I(we)declare that I(we)have examined this return.Including all accompanying schedules and statements,and to the best of my(our)belief,they are true,correct,and complete. Your Signature Spouse's Signature,if filing jointly Efile Opt Out Preparer's Name and Telephone Number (717) 256-4900 1 Dat��eJ1 Kevin Benton -f I �� FIRM FIN 232928418 Kevin B. Benton, CPA l��Tyn� 401 East Louther Street, Su e 0 Carlisle, PA 17013-2647 PreparersssN/PTIN P00193887 L 1000218187 A e2of2 PAIR a M 2/I 5111 1000218187 J 1000118171 / PA-40 — 2010 Pennsylvania Income Tax Return ENTER ONE LETTER OR NUMBER IN EACH BOX. Do Not Use Your Preprinted Label 191266550 N Extension. SWIGERT N Amended Return. MARY J Occupation RETIRED R Residency Status. PA Resident/NonresidenUPart-Year Resident Occupation from to D Single/Married, Filing Jointly/Married, Filing Separately/Final Return/Deceased Date of death 120210 206 OAK DRIVE N Farmers. MT. HOLLY SPRINGS PA 17065 School District Name SOUTH MIDDLET 21830 1 a Gross Compensation. Do not include exempt income,such as combat 1a 0 zone pay and qualifying retirement benefits. See the instructions. 16 Unreimbursed Employee Business Expenses. 1b 0 1 Net Compensation. Subtract Line lb from Line la. 1C 0 2 Interest Income. Complete PA Schedule A if required. 2 70 3 Dividend and Capital Gains Distributions Income,Complete PA Schedule B it required. 3 11052 4 Net Income or Loss from the Operation of a Business, Profession or Farm. 4 0 5 Net Gain or Loss from the Sale, Exchange or Disposition of Property. 5 5 6 Net Income or Loss from Rents, Royalties, Patents or Copyrights. 6 0 7 Estate or Trust Income. Complete and submit PA Schedule J. 7 0 8 Gambling and Lottery Winnings. Complete and submit PA Schedule T. 8 0 9 Total PA Taxable Income.Add only the positive income amounts from Lines Ic, 9 1112? 2,3,4,5,6,7 and 8. DO NOT ADD any losses reported on Lines 4,5 or 6. 10 Other Deductions.Enter the appropriate code for the type of deduction. N 10 0 See the instructions for additional information. 11 Adjusted PA Taxable Income.Subtract Line 10 from Line 9. 11 11127 PAIA0412L 11/23110 EC Page 1 of 2 FC 1000118171 m m 1000118171 J J PA-40 — 2010 1000218187 Social Security Number ? 191266550 Name(s) SWIGERT, MARY J . 12 PA Tax Liability.Multiply Line 11 by 3.07 percent(0.03071 12 342 13 Total PA Tax Withheld.See the instructions. 13 ,❑ 14 Credit from your 2009 PA Income Tax return. 14 0 15 2010 Estimated Installment Payments. 15 ❑ 16 2010 Extension Payment. 16 0 17 Nonresident Tax Withheld from your PA Schedule(s)Ni(Nonresidents only) 17 0 18 Total Estimated Payments and Credits.Add Lines 14, 15, 16 and 17. 18 ❑ Tax Forgiveness Credit.Submit PA Schedule SP. 19a Filing Status: 01 Unmarried or Separated 02 Married 03 Deceased 19a 00 19b Dependents, Part B, Line 2,PA Schedule SP 19b 0❑ 20 Total Eligibility Income from Part C,Line 11,PA Schedule SP. 20 0 21 Tax Forgiveness Credit from Part D,Line 16, PA Schedule SP. 21 0 22 Resident Credit. Submit your PA Schedule(s)G-R with your PA Schedule(s)G-S,G-L and/or RK-1. 22 0 23 Total Other Credits. Submit your PA Schedule OC. 23 0 24 TOTAL PAYMENTS and CREDITS.Add Lines 13, 18,21, 22 and 23. 24 ❑ 25 TAX DUE. If Line 12 is more than Line 24, enter the difference here. 25 342 26 Penalties and Interest. See the instructions. Enter code: E 26 7 If including form REV-16301REV-1630A,mark the box. Y 27 TOTAL PAYMENT DUE.See the instructions. 27 349 28 OVERPAYMENT.If Line 24 is more than the total of Line 12 and Line 26, enter 28 0 the difference here. The total of Lines 29 through 35 must equal Line 28. 29 Refund—Amount of Line 28 you want as a check mailed to you. Refund 29 0 30 Credit—Amount of Line 28 you want as a credit to your 2011 estimated account. 3❑ ❑ 31 Amount of Line 28 you want to donate to the Wild Resource Conservation Fund. 31 0 32 Amount of Line 28 you want to donate to the Military Family Relief Assistance Program. 32 0 33 Amount of Line 28 you want to donate to the Governor Robert P.Casey Memorial 33 0 Organ and Tissue Donation Awareness Trust Fund. 34 Amount of Line 28 you want to donate to the Juvenile(Type 1)Diabetes Cure 34 0 Research Fund. 35 Amount of Line 28 you want to donate to the PA Breast Cancer Coalition's Breast 35 0 and Cervical Cancer Research Fund. Signatumi Under penalties of perjury,I(we)declare that I(we)have examined this return.Including all accompanying schedules and statements,and to the best of my(our)belief,they are true,correct,and complete. Your Signature Spouse's Signature,if filing jointly E-File Opt Out Preparer's Name and Telephone Number ( 7) 258-4900 Oate Kevin Renton )`n n^ I fl FIRM FIN 232928418 Kevin B. Renton, CPA 401 East Louther Street, to 2 0 Carlisle, PA 17 013-2 6 4 7 Preparefs55NIPTIN P00193887 1000218187 Page2of2 1000218187 J PAIAO 2L 2115111 Kevin B. Benton, CPA Client 4475SWI 401 East Louther Street, Suite 220 April 1,2011 Carlisle, PA 17013-2647 (717)258-4900 Estate of Wayne K. and Mary J. Swigert C/O Kurry Swigert 206 Oak Drive Mt. Holly Springs, PA 17065 Home: (717)486-3186 FEDERAL FORMS Form 1040 2010 U.S. Individual Income Tax Return Schedule B Interest and Dividend Income Schedule D Capital Gains and Losses Form 8853 Medical Savings Account Deduction PENNSYLVANIA FORMS Form PA-40 2010 Pennsylvania Income Tax Return Form PA-V Pennsylvania Payment Voucher Schedule A/B Taxable Interest and Dividends Form PA-40 Sps 2010 Pennsylvania Income Tax Return Form PA-V Sps Pennsylvania Payment Voucher Schedule A/B Sps Taxable Interest and Dividends Schedule D Sps Sale, Exchange or Disposition of Property Form REV-1630 Sps Underpayment of Estimated Tax FEE SUMMARY Preparation Fee $ 255.00 Amount Due 255.00 pot y_y�/ i J 48500041046 REV-485 EX(08-04) SAFE DEPOSIT BOXINVENTORY PA Department of Revenue PLEASE USE ORIGINAL FORM ONLY Social Se nty or De th Certificate Number Date of Death County Code Year File Number rub _ . Decedent's Last Name - Suffix First Name MI DS E©ADDRESS O�Fp/D�/GRE,Vi �f//pGR G✓/f' //7�/gGXISG� STATE /Ips. d�F T 9 DEPOSIT NAME// 'l-.PEN �"I/y! LN OF �G� V.L/�' NAM STREET A[jDRiSS;� C .0 (/v S7` 3e.S f- - --------- - � NAME,ADDRESS AND RELATIONSHIP(IF ANY)TO DECEDENT,OF PERSONS)PRESENT AT THE BOX OPENING a. NAreJE RELATIONSHIP: ^ -_. ._ STR T AD p J�5 II E: ✓ RELATIONSHIP; STREETADDRESS: CITY: - STATE. ZIP CODE: C. NAME: RELATIONSHIP: STREETADDRESS: CITY: STATE ZIP CODE: NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED yED STRf q ADDRES : CITY: TE: ZIP C E: /— l � ----- - / l� Lj NAME OF PERSO M KIN ST ENTRY DATE AND TIME OF LAST ENTRY . LiINt�J f u 16 b'.lS DATE OF CO GG(RANT BOX NUMBEjiPUB X 1 ,TITLE WHICH BOX IS R UESTED LU NAME AND ADDRESS OF PERSON(S)HAVING ACCESS TO BOX I/1Vnl K. a. NAME: b. NAME: STREETADDRESS: STREETADDRESS: ............_......---- ___ CITY: STATE: ZIP CODE: CITY: STATE: ZIP CODE: In NAME AND TITLE OF EMPLOYEE TAKING THE THE INVENTORY WAS A WILL IN THE BOX? [I YES ipl NO If yea, a. Dale of will: b. Name and address of personal representative,If named In the will NAME: STREETADDRESS: CITY: STATE: ZIP CODE: _----------- ..—_—_ c. Name and,oddr as of attorney,If a NAM �j _..... �STRfET A9DRE / _ . ... -. - 1... � E ZIP� ar CODE 48500041046 48500041046 REV-485 EX SAFE DEPOSIT BOX INVENTORY Page__ Df INSTRUCTIONS (1) ash:Report total only. (2) Stocks: List in detail every common or preferred certificate,warrant or other rights found in box.Stocks are to be designated by name of company,certificate number,date of certificate,name in which stock is registered,and number of shares and Gass of stock. (3) Obligations of U.S.Government:Number of Items,date of Issue,face value,names in which registered and type of ownership, i.e.,jointly held,payable on death,etc. (4) ,donds:Designate by name,amount,serial number,or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks:State name of depositor, number of book,last date appearing in book,name of bank and branch,and balance. (6) Jewelry, dr,Coins,Stamps,Manus pts,etc:List and describe as fully as possible. (7) Reeds,Mortgages,Current I urance Policies or of r evidences of Indebtedness:List and describe as fully as possible. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION // G / ✓�� DEPT.280801 HARRISBURG,PA 17128-0601 ITEM ITEM DESCRIPTION NO. Go - �' `P _a _S rig r G°C P-2_ 3 Z19G�� --- 8 ..._ .�-5_�✓�/�r��-.,, .cJ /Ge'G was-vv�e t�2'_��/�l. �=-�_�Z--�2?�G'��_ _ s�—�.---E�`�i-`- ---- /y... - P - Al- r6c-l r -- �, I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS PERSON RECEIVING COPY OF CORRECT ANQCOMPUETF T)GkTHE BE OF MY KNO EDGE AND BELIEF. SAFE DEPOSIT OOX INVENTORY: SI ATUR SIGNATURE ...._._.____._.__ — ______ .___.__�_eX _RI E� �� PRINT NAME AND CH KAPPROPRW: PRINT TITLE DA/TE� x CHE A TEB ewtatmti dlrix) ❑Ad AeminlaVeWdMx) n f+��N A' `�' - Eatnb ftepreronlaWS ❑Jdnt o"nar of sere Eepoall bw NOT/E::Attach additional 811," x 11" sheet(s)if necessary or use duplicates of this page of form. The Department is authorized by law,42 U.S.C.§405(c)(2)(C)(I),to require disdcxsure of Social Secudty numbers in mnnedon with administering state tax laws.The Department uses the Social Security number to Identify the decedent and personal representatives of the estate.The Commonwealth may also use the inlamadon in exchange of tax Information agreements with Federal and local taxing authorities.The state law mhibi s the Commonmam's personnel I=disclosing mnfidendal tax Information ex t for official purposes. — --- REV-485 EX SAFE DEPOSIT BOX INVENTORY Page----of INSTRUCTIONS (1) Cash:Report total only. (2) Stocks:List In detail every common or preferred Certificate,warrant or other rights found in box.Stocks are to be designated by name of Company,certificate number,date of certificate,name In which stock is registered,and number of shares and Gass of stock. (3) Obligations of U.S.Government:Number of Items,date of Issue,face value,names in which registered and type of ownership, i.e.,Jointly held,payable on death,etc. (4).Aronds:Designate by name,amount,serial number,or other designation.(Bearer Bonds) (5) Bank and Savings and Loan Passbooks:State name of depositor,number of book,last date appearing in book,name of bank and branch,and balance. (6) Jewelry,Sons,Stamps,Manuscripts,etc:List and describe as fully as possible. (7) A , Mortgages,Current Insycance Policies or other evidences of Indebtedness: List and describe as fully as possible. (8) II other contents. ✓ (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION /DEPT. 1 ITEM HARRISBURG.PA 17128-0801 N0: ITEM DESCRIPTION - his �w s t /GcG �f Vic` A9 yf "6 31 tt7 --- �.....__S ✓C'�y/L�s71' /�<""' /C�J �ht r c%' - - ------------------------- - - �-- �-7 - I CERTIFY UNDER PENALTY OF PERJ AT THE ABOVE RECORD IS PERSON RECENIN I COPY OF CORRECT AND COMPLETE TO EST F MY KNOWLEDGE AND BELIEF. SAFE DEPOSIT B X INVENTORY: SIGNATURE SIGNATURE /� PRI INA j� PRINT NAME AND CNECK PROPRIATE % ELOW: �././�9_?�S' DATE CHECK APPROPRIATE 80X: 0-5'_ 4Ex tMtflxl ❑Adm ini."torw xl 4: " ❑Jdm m,, W d ssfe d .It C . N , *'dAy ry plicates of this page of form. The Department is authorized by law,42 U.S.C.§405(c)(2)(C)(i),to require disclosure of Social Security numbers in Connection with administering state tax laws.The Department uses the Social Security number to identlly the decedent and personal representatives of the estate.The Commonwealth may Also use tlhe InMnrlatlm In exchange of tax information agreements with Federal and local taxing authorities.The state law prohibits the Comaronwealth's personnel from disclosing cenBdental tax infonnetlon exce t for official s. REV-485 EX SAFE DEPOSIT BOX INVENTORY Page-of INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List In detail every common or preferred certificate,warrant or other rights found in box, Stocks are to be designated by name of company,certificate number,date of certificate,name in which stock is registered,and number of shares and Gass of stock. (3) Obligations of U.S.Government:Number of items,date of Issue,face value, names in which registered and type of ownership, i.e.,jointly held,payable on death,etc. (4) Bonds:Designate by name,amount,sedal number,or other designation.(Bearer Bonds) (5) Bank and Savings and Loan Passbooks:State name of depositor,number of book, last date appearing in book,name of bank and branch,and balance. (6) Jewelry, Coins,Stamps,Manuscripts,etc: List and describe as fully as possible. (7) Deeds,Mortgages,Current Insurance Policies or other evidences of Indebtedness:Llst and describe as fully as possible. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 80 1 71 PA 17 HARRISBURG, 12 3-0801 ITEM ITEM DESCRIPTION NO.J el"__ --- ---- --- -- I CERTIFY UNDER PENALTY OF PERJU T THE ABOVE RECORD IS PERSON RECEIVING COPY OF CORRECT AND COMPLETE TO THE B T OF KNOVILEDGE AND BELIEF. SAFE DEPOSIT BOX INVENTORY: SIGNA E . SIGNATURE PRINT NAME� y7 ^x PRINT NAME AND CHqCK APPROPRI E BOX BELOW: ►<_uRY W. sw (GC2T - ------------ - — PRINT TI/i%L-E �! / DATE ��/ CHEGKAPPROPRIATE BOX : "7� v /G Q5-'! z 'VExecutw(ft) ❑AEminlelrerorlNx) _ �' y ❑Esleb RePreee^have ❑Jdnl caner of set delxxlt Eoz rNOTE:Attach additional 8'la"x 11" sheet(s) if necessary or use duplicates of this page of form. Department is authorized by low,42 U.S.C.§405(c)(2)(CV),to require disclosure of Social Searity numbers In connection with administering state tax laws.The Department uses the al Seadty number to identify the decedent and personal representatives of the estate.The Commonwealth may piso use the Inbrmalion In exchange of tax Information agreements Federal and local taxing authodbes,The state law Inks the Commonwealth's personnel tom disclosing confidZiB tsx Inbrmadon except br official s. i �J REV-48S EX(05-04) 48500041046 SAFE DEPOSIT BOXINVENTORY PA Department of Revenue PLEASE USE ORIGINAL FORM ONLY Sodal Sewrfty or Death CerBfieale Number pate of Death County Coda Year File Number _ Decedents Last Name SuHi% First Name ML \.1 . ©AD RESSQF £ SE'E'T_: c_ ( . �"`__._ ,__...._._. ._,,.... NAME AN A/R RB'O,N' ESTIING THE OPENINO OE THE SAFE DEPOSIT BOX STRE ((//ADDR S5: > � G/ p f?�r6c S , _s't 1 � 1 y NAME.ADDRESS AND RELATIONSHIP(IF ANY)70 DECEDENT,OF PERSON(S)PRESENT AT THE BO%OPENIN A. NAME: RELATIONSHIP: I $TREE/j ADDRESS: ....., C11Y: JJj TATE COD b. NAME....—.(/_�!.. '-day-I..✓ �_..__...._. .RELATIONSMI � ..._� _.._/... ..1 - .._.�.._ ....... ._._..._...__—._. ......._.____...._..... _........_____.�.______...____.._.. ...._.._.-__ . STREET ADDRESS: CITY: STATE: ZIP CODE: .. . .._ .. ._._ ...... .... . ........_._................ ..._................__.»...._._—_..__............—_....,.____......__-__ _....,..__ c. NAME; RELATIONSHIP: , ___.....___._...._.._.......,__...._. --------- --------------- -----_---_...___.______ 5TREE7ADORESS: CITY; STATE: ZIP CODE: ' NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME- - —.___ _..__—_..T_—___— STREETADDRESS: try. STATE: ZIP CODE: 1 a 7013 NA OF PERSO ING LAST ENTRY DATE AND TIME OF LAST ENTRY f 4 (tit DATE OF CO TRACT TO NT BO% NUMBER OF Sox I fTLE UNDER WHICH BOX IS REOUE,TED Nt). t\ aoi aO511 F_ Lotnt or o X" NAME AND ADDRESS OF PERSONS(HAVING ACCESS TO BOX a NAME: b. NAME: STREET ADDRESS: STREETADURESS: CITY: STATE: ZIP CODE: CRY: STATE: ZIP CODE: NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY ja WAS A WILL IN THE BOX? O YES NO if yea, e.Date of Will: __ ._T___.____......_._...__.—__...__.__.... .... ......... . It. Noma and edtlrose of personal roprosentottve,if nemod In the wni NAME: STREETADORESS: CITY: STATE: ZIP CODE: c. Name and address of attomoy.H any NAME: _—_.. STREET ADDRESS_. CITY. ZIP CODE: `AT-_`'a�—'�� 48500041046 48500041046 REV-485 EX SAFE DEPOSIT BOX INVENTORY PBgB_ of INSTRUCTIONS (1) Cash:Report total only. (2) Stocks:List in detail every common or preferred certificate,warrant or other rights found In box.Stocks are to be designated by name of company,cerdfidale number,date of certificate,name In which stock Is registered,and number of shares and Gass of stock. (3) Obligations of U.S.Government:Number of Items,date of Issue,face value,names In which registered and type of ownership, i.e.,Jointly held,payable on death,etc. (4) Bonds:Designate by name,amount,serial number,or other designation.(Bearer Bonds) (5) Bank and Savings and Loan Passbooks:State name otceposltor,number of book,last dale appearing in book,name of bank and branch,and balance, (S) Jewelry,Coin&,Stamps,Manuscripts,etc:List and describe as tufty as possible. (7) Deeds,Mortgages,Current insurance Policies or other evidences of indebtedness:List and describe as fully as possible. (B) All other contents. (S) Return completed form to: DEPARTMENT OF REVENUE INHERRANCE TAX DIVISION DEPT.280801 HARRISBURG,PA 17128-0801 ITEM p0, ITEM DESCRIPTION I 1 CERTIFY UNDER PENALTY OF PERJU AF E ABOVE RECORD IS PERSON RECEIVING COPY OF CORRECT AND COMPLETE TO THE B;27 OF KNOWLEDGE AND BELIEF SAFE DEPOSIT PDX INVENTORY: SIGNATU SIGNATURE �j PftiNT NAME LL� — -- PRINT NAtoWs KAPPR08 E O EIGW: ---- --T /� l�_ .�l ...� __—_.__ _t—kxS ,.4 pfti Tilt DATE CNECKA0% '-- W - i �y� /c:--5—M. W8xewmogmx) ❑Adnflil. arm(Wx) �,rys�a�.. � ✓ u �" � 3C ❑Eabce Repnwnwaxa pJdm om,ar oreera d+voxn lwx NOTE:Attach additional x x 11"sheet(s)If necessary or use duplicates of this page of form. The Department is suftrized by law,42 U.S.C.§405(c)(2)(C)(1),to require dlsdosure Di Social Seardfynumbem in wrinactlm with administering state tax laws.The Department uses the Social Searcy number to identify the decadent and personal mpresentatves of the estate.The Commonwealth may also use are Infrmation In exchange of tax Information agreements will Federal and local taxing autmodl es.The state law Prohibits the Commonwealth's personnel from disdos ti oonfidental tax Infamutlon except for ofidal s. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE REV-1162 EX(11-96( BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG,PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 014070 SWIGERT KURRY W 206 OAK DRIVE MT HOLLY SPRINGS, PA 17065 ACN ASSESSMENT AMOUNT CONTROL -------- Nld NUMBER 101 $20,000.00 ESTATE INFORMATION: SSN: 191-26-6550 FILE NUMBER: 2110-1224 DECEDENT NAME: SWIGERT MARY JANE DATE OF PAYMENT: 02/28/2011 POSTMARK DATE: 03/02/2011 COUNTY: CUMBERLAND DATE OF DEATH: 12/02/2010 TOTAL AMOUNT PAID: $20,000.00 REMARKS: CHECK# 104 INITIALS: HMW SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS TAXPAYER COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE REV-1162 EX)11-96) BUREAU OF INDIVIDUAL TAXES DEPT,200601 HARRISBURG,PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 014943 SWIGERT KURRY W 206 OAK DRIVE MT HOLLY SPRINGS, PA 17065 ACN ASSESSMENT AMOUNT CONTROL e NUMBER --------- -------- 101 $7,400.00 ESTATE INFORMATION: SSN: 191-26-6550 FILE NUMBER: 2110-1224 DECEDENT NAME: SWIGERT MARY JANE DATE OF PAYMENT: 09/09/2011 POSTMARK DATE: 09/09/2011 COUNTY: CUMBERLAND DATE OF DEATH: 12/02/2010 TOTAL AMOUNT PAID: $7,400.00 REMARKS: CHECK# 172 INITIALS: HMW SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS TAXPAYER COMMONWEALTH OF PENNSYLVANIA REVA 162 EX{11-96} DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT.260601 HARRISBURG.PA 17128-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT No. co 018206 SWIGERT DEBRA 206 OAK DRIVE MT HOLLY SPGS, PA 17065 ACN ASSESSMENT AMOUNT CONTROL NUMBER •--- Wd 101 ( $2,234.81 ESTATE INFORMATION: SSN: 191-26-6550 FILE NUMBER: 2110-1224 DECEDENT NAME: SWIGERT MARY JANE DATE OF PAYMENT: 10/04/2013 POSTMARK DATE: 10/04/2013 COUNTY: CUMBERLAND DATE OF DEATH: 12/02/2010 TOTAL AMOUNT PAID: $2,234.81 REMARKS: CHECK##414 INITIALS: DMB SEAL RECEIVED BY: GLENDA FARMER STRASBAUGH REGISTER OF WILLS TAXPAYER