HomeMy WebLinkAbout01-14-14 REV-1500 EX 10"01 1505610140
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Number
PO BOX 280601 2 1 1 3 0 6 0 7
Harrisburg PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
0 5 1 1 2 0 1 3 1 2 0 1 1 9 2 4
Decedent's Last Name Suffix Decedent's First Name MI
R E I N H E I M E R C L A R A M
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
❑X 1.Original Return 2.Supplemental Return 3. Remainder Return(date of death
prior to 12-13-82)
❑ 4. Limited Estate ❑ 4a. Future Interest Compromise(date of 5.Federal Estate Tax Return Required
death after 12-12-82)
❑ 6.Decedent Died Testate 7. Decedent Maintained a Living Trust 8.Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9.Litigation Proceeds Received 10.Spousal Poverty Credit(date of death 11.Election to tax under Sec.9113(A)
between 12-31-91 and 1-1-95) (Attach Sch.O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMAV9N SHOULD BFNg2ECTFq Tot
Name Daytime Telepl et—ne6umber —" Yn n
M A T T H E W A . M c K N I G H T 7 1 7 ' 2=`'4A 5Z;�xi
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Second line of address -
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6 0 W E S T P 0 M F R E T S T R E E T
City or Post Office State ZIP Code DATE FILED -
C A R L I S L E P A 1 7 0 1 3
Correspondent's 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.
SIGNAATTU�RE�OF PERSON R_ ESPQNSIBLE FOR FILING RETURN DATE /
ADDRESS
A.X A- �L �'"�]S_A)
11 TRISTAN DRIVE APT 309 DILLSBURG PA 17019
SIGNATUR PREP E THAN REPRESENTATIVE DATE
/- 1:3 `4
ADDRESS G /l
60 WEST POMIRET STREET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
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REV-1500 EX Page 3 File Number
Decedent's Complete Address: 21 13 0607
DECEDENTS NAME
CLARA M. REINHEIMER
STREET ADDRESS
1LONGSDORF WAY
CITY STATE LP
CARLISLE PA 17015
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1)
2. Credits/Payments
A.Prior Payments
S.Discount
Total Credits(A+B) (2)
3. Interest
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; ...................................................................... ❑ ❑X
b. retain the right to designate who shall use the property transferred or its income; ............................... ❑ 1x7
c. retain a reversionary interest;or ................................................................................................ ❑ ❑X
d. receive the promise for life of either payments,benefits or care? ....................................................... ❑
2. If death occurred after December 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ❑ X❑
3. Did decedent own an'in trust for'or payable-upon-death bank account or security at his or her death? ......... ❑ Q
4. Did decedent own an Individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation?.................................................................................................. I] ❑
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)(11)(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 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(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.
REV-1503 EX+18-12)
pennsylvania SCHEDULE B
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
CLARA M. REINHEIMER 21 13 0607
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. PRUDENTIAL- PRUCO SECURITIES, LLC 8,763.81
806.238 SHARES OF CIGAX
806.238 X$10.87 PER SHARE = $8,763.81
2. PRUDENTIAL- PRUCO SECURITIES, LLC 134.60
134.600 X$1.00 PER SHARE=$134.60
P
TOTAL(Also enter on Line 2,Recapitulation) $ 8,898.41
If more space is needed,insert additional sheets of the same size
REV-1508 EX+(08-12)
pennsyivania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
CLARA M. REINHEIMER 21 13 0607
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property Jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. UNION CENTRAL-ANNUITY#A00002181 F 5,740.86
BENEFICIARY: THE ESTATE OF CLARA M. REINHEIMER
2. PNC BANK-SAVINGS ACCOUNT#5005693291 73,080.77
3. ORRSTOWN BANK-CHECKING ACCOUNT#106001814 42,857.30
4. CUMBERLAND CROSSINGS- REFUND 5,671.58
5. PA DEPARTMENT OF REVENUE -TAX REFUND 676.82
TOTAL(Also enter on Line 5,Recapitulation) $ 128 027.33
If more space is needed,use additional sheets of paper of the same size.
REV-1510 EX+(08-09)
pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
CLARA M. REINHEIMER 21 13 0607
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
ITEM INCLUDETIE NAMEOFTTE TRANSFEREE,THEIR RELATIONSHIPTODECEDEMM7D DATE OF DEATH % DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE VALUE OF ASSET INTEREST OF rmK�q VALUE
1. ORRSTOWN BANK- BURIAL FUND 3,410.72 100.00 3,410.72
ACCOUNT#4000014661
RONAN FUNERAL HOME
2. ORRSTOWN BANK-IRREVOCABLE BURIAL FUND 2,738.29 100.00 2,738.29
ACCOUNT#5060062514
RONAN FUNERAL HOME
TOTAL Also enter on Line 7,Reca tulation $ 6.149.01
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
RESIDENT DE ED RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
CLARA M. REINHEIMER 21 13 0607
Decedent's debts must be reported on schedule 1.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. RONAN FUNERAL HOME PAID FROM 6,149.01
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representauve(s) NEALA R. YLER 6,500.00
Street Address 11 TRISTAN DRIVE APT 309
City DILLSBURG state PA ZIP 17019
Years)Commission Paid:
2, Attorney Fees: IRWIN &McKNIGHT, P.C. 7,250.00
3. Family Exemption:(If decedents address is not the same as claimants,attach explanation.)
Claimant
Sheet Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: REGISTER OF WILLS 293.50
5 Accountant Fees:
6. Tax Return Preparer Fees: PATRICIA A. ROSENDALE, CPA 375.00
FINAL FIDUCIARY TAX RETURN
7. CUMBERLAND LAW JOURNAL- ESTATE NOTICE 75.00
8. THE SENTINEL- ESTATE NOTICE 189.54
9. REGISTER OF WILLS -SHORT CERTIFICATES 15.00
10. NOTARY 25.00
TOTAL(Also enter on Line 9,Recapitulation) $ 20 872.05
If more space is needed,use additional sheets of paper of the same size.
REV-1512 FCC+(12-12)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES&LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
CLARA M. REINHEIMER 21 13 0607
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. ORRSTOWN BANK-OUTSTANDING CHECK#1062 136.00
2. ORRSTOWN BANK-OUTSTANDING CHECK#1064 8,932.00
3. ORRSTOWN BANK-OUTSTANDING CHECK#1063 10.00
4. PHILHAVEN -MEDICAL 10.00
5. THREE SPRINGS FAMILY PRACTICE-MEDICAL 8.46
6. OMNICARE KING OF PRUSSIA- MEDICAL 65.93
TOTAL(Also enter on Line 10,Recapitulation) $ 9,162.39
If more space is needed,insert additional sheets of the same size.
REV 4513 EX.(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
CLARA M. REINHEIMER 21 13 0607
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include ou1116(a)l1.2)]htspousal distributions and transfers under
Sec.9
1.
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
It NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1. GIRL SCOUTS HEMLOCK COUNCIL (25%) 28,260.07
350 HALE AVENUE
HARRISBURG, PENNSYLVANIA
2, YOUTH FOR CHRIST(25%) 28,260.08
EISENHOWER BLVD.
MIDDLETOWN, PENNSYLVANIA
3. ST. JOHNS LUTHERAN CHURCH (25%) 28,260.08
111 WALNUT STREET
BOILING SPRINGS, PENNSYLVANIA
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 130F REV-1500 COVER SHEET. $ 113 040.31
If more space is needed,use additional sheets of paper of the same size.
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
CLARA M. REINHEIMER 21 13 0607
Decedenfs Name Page 1 File Number
Schedule J - Beneficiaries -2B
II. B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
4. CHILD EVANGELISM FELLOWSHIP (25%) 28,260.08
150 FAIRVIEW DRIVE
CARLISLE, PENNSYLVANIA
SUBTOTAL SCHEDULE J-28 28,260.08
LAST WILL AND TESTAMENT
I, CLARA M. REIN MBMR, of South Middleton Township, Cumberland County,
Pennsylvania, being of sound mind, disposing memory and full legal age, do hereby make,
publish and declare this to be my Last Will and Testament, hereby revoking all Wills and
Codicils heretofore made by me.
1. I direct my Executrix to pay all of my debts, funeral and administrative expenses as
soon as convenient after my decease. Furthermore, I direct that all state,inheritance,suasion
and other death taxes imposed or payable by reason of my death and interest and penalties
k
thereon with respect to all property composing of my gross estate for death tax purposes,whether
or not such property passes under this Will,shall be paid by the Executrix of my estate.
2. My Executrix may, at her discretion, compromise claims, borrow money, retain
property for such length of time as she may deem proper; lease and sell property for such prices,
on such terns, at public or private sales, as she may deem proper; and invest estate property and
income without restriction to legal investments unless otherwise provided hereunder.
3. I authorize and empower my Executrix to sell any realty and/or personalty owned by
me at my death and not specifically devised or bequeathed herein, at public or private sale or
sales and to give good and sufficient deeds and/or bills of sale therefore, in fee simple, as I could
do if living. My Executrix is authorized and empowered to engage in any business in which.I
may be engaged at my death, for such period of time after my death as seems expedient to said
Executrix.
76
4. I give, devise and bequeath all of my estate of whatever nature and wherever situate as
follows:
a. Twenty-Five Percent(25%)to Girl Scouts Hemlock Council,
350 Hale Avenue,Harrisburg,Pennsylvania;
b. Twenty-Five Percent(25%)to Youth For Christ, Eisenhower
Boulevard,Middletown,Pennsylvania;
c. Twenty-Five Percent(25 1/6)to St. Johns Lutheran Church,
Boiling Springs,Pennsylvania;and
d. Twenty-Five Percent(25%)to Child Evangelism Fellowship,
150 Fairview Drive, Carlisle,Pennsylvania.
6. I nominate and appoint NEALA R. EYLER to be the Executrix of this my Last Will
and Testament. In the event she has predeceased me, failed to qualify or is not able or does not
serve for whatever reason, I then appoint ANNETTE M. McALISTER to be the Substitute
Executrix of this my Last Will and Testament, whereby the said Substitute Executrix shall have
the same powers as are given to the original Executrix hereunder.
7. No Executrix acting hereunder shall be required to post bond or enter security in this
or any other jurisdiction.
2
-166
8. I hereby suggest that my personal representative retain the services of Irwin &
McKnight as attorneys in the settlement of my estate.
IN WITNESS WHEREOF,I have hereunto set my hand and seal this 26a'day of March,
2007.
(SEAL) -
CLARA M REINHEBIER
Signed, sealed,published and declared by the above-named Testatrix, as and for her Last
Will and Testament, in our presence, who, at her request, in her presence and in the presence of !
each other have hereunto set our names as subscribing witnesses.
3
, f
ACKNOWLEDGMENT AND AFFWAVIT
WE,CLARA M.REINHEnm,KAREN S.NOEL and SHARON L.SCHWALM,
the Testatrix and witnesses respectively, whose names are signed to the foregoing instrument,
being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed
and executed the instrument as her Last Will and that she had signed willingly, and that she -
executed it as her free and voluntary act for the purpose herein expressed, and that each of the
witnesses, in the presence and hearing of the Testatrix, signed the Will as a witness and that to
the best of their knowledge the Testatrix was, at that time, eighteen years of age or older, of
sound mind and under no constraint or undue influence.
�LARA M.REIlVHE R
_ / l
S.NO
SHARON L.SCHWALM
COMMONWEALTH OF PENNSYLVANIA :
: SS:
COUNTY OF CUMBERLAND
Subscribed, sworn to and acknowledged before me by CLARA M. REINHEIMER,the
Testatrix herein, and subscribed and sworn to before me by KAREN S. NOEL and SHARON
L.SCHWALM,witnesses,this 2e day of March,2047.
No r Public
C4 MQN 7ti QF PENNSYLVANIA
Notarial Seat
Roger 8.Irwin,Nolary Public
Carlisle 13 CumbeHand County
tNt+Camm sston E�ires Uct.3,2808
M mber,Pennsylvania Association Of Notaries
08/26/2013 09:56 7176971451 ROBERTYOCKIN PAGE 01
PrudentiM PraoO$eeurlttas,LLC t441�
COMMAND aeMm Center
Phi Box 70196
Philadelphia,PA 10176 /�
(600)296-7637 / / v e-r/'j
%Wprudenael.cam
August 15, 8013
Robert P, Yockin
The Prudential Insurance Company of America
150 Corporate Center Drive, Suite 105
Camp Hill, PA 17011
Re. XXXX-1094
Clara M. Reinheimer IRA
Deer Mr. Xockin:
Per your request, we are confirming the balance on the above-referenced Pruco Securities Account, Our
records indicate that as of 05/11/2013, the value of this account was:
Irlvestmle
Shares rice
CIGAX Money Market 806.238 $1� $8,783.80
134.800 $1.00 $134.60
Total Portfolio Value $8,898.40
If you have any questions or need additional Information, please contact the COMMAND Service Center
at (800) 235-7637, Customer Service Ropresentativas are available to assist you between 8:30 a.m. and
7:00 p.m. ET. Monday through Friday.
Sincere) ,
Philip W ds
Registe d Principal
Pruco Command Operations
Pruco Securities, LLC aaII�
ejh
Registered Principal of Pruco Securities, LLC (Pruco).
Securities products and services are offered through Pruco. The Prudential Insurance
Company of America, Newark, NJ and Pruco are Prudential Financial companies. 1-
800-201-6690
— s., REED
Individual Division
Claims Service Office pp'� n
P.O.Box 40888/Cincinnati,OH 45240-0888 JUN 2.7 2013
Toll Free 800-319-6302
IRWIN&McKNIGHT
June 21, 2013 LAW OFFICES
NEALA R EYLER EXECUTRIX Re: A00002181F
ESTATE OF CLARA M REINHEIMER Clara M. Reinheimer
60 WEST POMFRET ST
CARLISLE PA 17013
Dear Executrix:
Enclosed is our check for$5,740.86 representing the proceeds of the certificate listed by number at the
beginning of this letter. This check includes interest on claims in the amount of$12.87, calculated at a
rate of 2.0% from the date of death to the date of payment.
This deferred annuity policy was designed to provide annuity income benefits upon election; however,
the annuitant died prior to this election and, as a result, the value of the contract is now payable in a
lump sum. Under the current Internal Revenue code, that portion of the value of the contract which
exceeds the cost of the contract-the net premiums paid -is taxable to the recipient as ordinary income.
We calculated this excess or profit as$0.
If you have any questions concerning this contract, please do not hesitate to contact me. Our toll-free
number is 1-800-319-6302.
spectfu�
Earl Ray, FLHC MI, ACS
Senior Claim Oakliner
Individual Li Clai s
Enclosures:
ecr
cc: Agency 347 Michael J. Garofalo
�l
Variable products issued by Union Central Life Insurance and underwritten by Ameritas Investment Corp. (AIC)member FINRAISIPC
Jun. 18. 1013 11 :36AM PNC Bank No. /2/8 P. 1/1
. C.
rune 18, 2013
Roger B Irwin Esq.
Irwin&McKnight P.C.
West Pomfret Professional Bldg
60 W Pomfret St
Carlisle,PA 17013-3222
RE: Clara Mae Reinheimer
SSN: 195-32-0029
DOD: 05-11-2013
Dear Mr. Irwin:
In response to your request for Date of Death(DOD)balances for the customer noted above,our
records show the following:
Savings Account
Account#5005693291 Established: 07-21-2008
CLARA MAE REINMIMER
DOD balance: $ 73,080.05 +0.72 accrued interest
Interest paid 01-01-2013 thru 05-11-2013 $42.37 'YTD
Please note that this office provides date of death balances for deposit accounts(IRAs,CDs,Checking and
Savings). We do not process any financial transactions or provide statements. If you need assistance with
any of these items,please call 1-888-PNC-BANK(1-888-762-2265)or stop by your local PNC Bank branch
office.
Sincerely,
National Financial.Services Center
PNC Bank,NA,
Member FDIC
This message is intended for the use of the individual or entity to which it is addressed and may
contain information that is privileged confidential and exempt from disclosure under applicable law.
If the reader of this message is not the intended recipient or the employee or agent responsible for
delivering this message to the intended recipient, you are hereby notified that any dissemination,
distribution or copying of this communications is strictly prohibited. If you have received this
communication in error,please notify me immediately by reply or by telephone at 800-762-1775 and
immediately destroy this faxed document.
Pace 1 of 1
®6/20/13 Deposit Inquiry Page 01 of 15 12 : 29: 46
Clara M Reinheimer CIF number: R000206
% Neala Eyler Phone: (H) (717) 432-2821 Birth date:
11 Tristan Dr Apt 309 (B) (000) 000-0000 12/01/1924
Dillsburg PA 17019 Tax ID number: 195-32-0029 Br# : 006
Account type : 50+ Interest Check
Account number: -106001814;
Closed Messages l of 'l
Available Balance: . 00 Date last active: 5729/13
Collected balance: . 00 Last Dep: 5/03/13 1, 078 . 00
Current balance: . 00 Date last overdrawn: 0/00/00
Yesterday' s bal : . 00
Last stmt balance: . 00 UaUe ZiL sLaTlement : 10 1
Avg collected bal: . 00 Date last contact : 12/12/0 qRVM"GEMRANM Avg led a ance: 0 0;• 1
0 +. ccrue . 00
m Service chg/Int cycle: 10 Service charge: Yes
Automatic NSF fee: Yes SC Waive expiration: 0/00/00
Statement/passbook code: Not coded Service charge code: 11
More. . .
F1=Addl functions F2=Image F3=Exit F4=Sweep Inquiry
F5=History F6=Messages F8=Maintenance F24=More Keys
C h0bt Acme
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� 6/20/13 Time Deposit Inquiry Page 1 of 5 12: 58 : 33
Mara M Reinheimer CIF number: R000206
Irrevocable Burial Fund Phone: (H) (717) 432-2821 Birth date:
Ronan Funeral Home (B) (000) 000-0000 12/01/1924
11 Tristan Dr Apt 309 Tax ID number: 195-32-0029
D_I burg PA 17019 C/D type: 13 120 Month Growth
Account number: 4000014661
deemed Due tooth/Disability Has messages 1 of 1
Cur e: 00 Certifica't`e*no � —
Accrued interest : . 00
Penalty amount: . 00
Current cash value: . 00
riginal balance:- 21616. 00 Hol amount: .00
M-T-D interest : . 00000 Y T-: t Uiinteres 64 .
M-T-D Agg Days : _ Per diem: . 00000
T Next payment date: 6/12/13
Last renewal date: 1/12/07 Next pay amount: . 00
Last renewal balance: 2, 616. 00 Value after next pmt : . 00
Renewable: Yes
Ihterest pmt freq: 1 M Deposit Acct/Type:
Interest disposition: Add to balance More. . .
F1=Addl functions F2=Image F3=Exit F4=Sweep Inquiry
F5=History F6=Messages F8=Maintenance F24=More Keys
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6/20/13 a Deposit Inquiry Page 1 of 5 13: 23: 40
C°±aT�°M Reinheimer CIF number: R000206
Irrevocable Burial Fund Phone: (H) (717) 432-2821 Birth date:
11 Tristan Dr Apt 309 (B) (000) 000-0000 12/01/1924
Dillsburg PA 17019 Tax ID number: 195-32-0029
C/D type: 13 120 Month Growth
Account number: 5060062514
Redeems ue o Death/Disability Has messages 1 of 1
Current balance: . 00 Certificate no: -• -5060062514—
Accrued interest: . 00
Penalty amount: . 00 A
Current cash value: . 00
Original balance: 1, 500. 00 Hold amount: p
M-T-D interest : 00000 Y-T-D .interest: •40. 53'
M-T-D Agg Days: Per diem: . 00000
Last payment date: 5/29/13 Next payment date: 6/21/13
Last renewal date: 12/21/08 Next pay amount: . 00
Last renewal balance: 2, 350. 48 Value after next pmt: . 00
Renewable: Yes
nterest pmt freq: 1 M Deposit Acct/Type:
Interest disposition: Add to balance More. . .
F1=Addl functions F2=Image F3=Exit F4=Sweep Inquiry
F5=History F6=Messages F8=Maintenance F24=More Keys
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10 J02j12 1 2 SUB NURSING EVAL/MANAG 2 99307 459.81 45.00
10/31J12 Medicare Payment 33. 10
10/31/12 Acceppt Assiggn Adj.- 3.62
11/15/12 HOP ADMINIST Pa ent 0.00
12/10/12 Check-Personal Payment 8.28 0.00
11/12/12 1 2 SUB NURSING EVAL/MANAG 2 99307 459.81 45.00
12/04/12 Medicare Payment 33.10
12/04/12 Acceppt Assiggn Adj. -3.62
12/16/12 HOP ADMINIST Payment 0.00
01/10/13 Check-Personal Payment 8.28 0.00
11/28/12 1 2 SUB NURSING EVAL/MAN AG 2 99307 692.9 45.00
12/26112 Medicare Payment 33.10
12/26/12 Acceppt Assi gn Adj . -3.62
01/01/13 HOP ADMINIST Payment 0.00
02/07/13 Check-Personal Payment 8.28 0.00
01/05113 1 2 SUB NURSING CARE EVAL/MAN 99308 459.81 65.00
01/29/13 Medic DEDUCT Payment 0.00
02/04/13 HOP ADMINIST Payment 55.00
03/12/13 Check-Personal Payment 10.00 0.00
02/07/13 1 2 SUB NURSING EVAL/MANAG 2 99307 459.81 45.00
03/05/13 Accept Assign Adj. -2.70
03/05/13 Medicare Payment 33.84
03/11/13 HOP ADMINISTmPayment 0.00
04/10/13 Check-Personal Payment 8.46 0.00
03/11/13 1 2 SUB NURSING CARE EVAL/MAN 99308 459.81 75.00
04/03/13 Accept Assign Adj. -9.25
04/03/13 Medicare Payment 52.60
DATE LAST PAID AMOUNT • - r SIMI, 1"V1 • r -
05/08/13 10.00
TAKE THREE SPRINGS FAMILY PRACTICE e
HECK 303 NORTH BALTIMORE AVE
AYABLE TO: MT. HOLLY SPRINGS, PA 17065 Continued
Ph: (717)-486-8550
PATJ/ I-CLARA M REINHEIMER PRV# 2-DELL, DAVID A, M.D. Acct#: 948
Date: 06/28/13
Page I of 2
L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make payment.
DATE LAST PAID AMOUNT • • •. OWN,
05/08/13 10.00 8.46 0.00 0.00 0.00 0.00 0.00 0.00 8.46
THREE SPRINGS FAMILY PRACTICE T46*
HECK 303 NORTH BALTIMORE AVE arABLETO: MT. HOLLY SPRINGS, PA 17065 Payment Due Upon Receip
Ph: (717)-486-8550
PAT# I-CLARA M REINHEIMER PRV# 2-DELL, DAVID A, M.D. Acct#: 948
Date: 06/28/13
Page 2 of 2
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