HomeMy WebLinkAbout01-14-14 J 1505610143
REV-1500 Ex(01-10) 1
t�} OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania County Code Year File Number
Bureau of Individual Taxes DEF TMEWQFRVENUE
PO BOX.280601 INHERITANCE TAX RETURN 21 13 6(7q
`T
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
05 09 2013 12 16 1928
Decedent's Last Name Suffix Decedent's First Name MI
HUFFNAGLE SHIRLEY 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
1. Original Return 2. Supplemental Return 3_ Remainder Return(date of death
prior to 12-13-82)
4. Limited Estate 4a Future Interest Compromise 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
6 Decedent Died Testate 7 Decedent Maintmed a Living Trust
(Attach Copy of will) (Attach Copy ofarrust) S. Total Number of Safe Deposit Boxes
g. Litigation Proceeds Received 10.bg'ho eeni?°-al% rediitl(datge of death 11 Election to tax under Sec.9113(A)and (Attach Sch.O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
DIANE G RADCLIFF (717) 737 0100
Rli OF WILLS USE RLY
r _0 Q
6->
TJ
n
First line of address rT1 = n
M
3448 TRINDLE ROAD n z 11 Fc a
Second line of address
City or Post Office State ZIP Code DATE WED 1 rT1
CAMP HILL PA 17011 N
Correspondent's e-mail address: dianeradcliff @comcast.net
Under pe allies 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, rrec nd com lete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNAT RE OF ERSO E IBLE FOR MG RETURN DAT
X Dennis A Huffnagle % /xF Zp/0ii
ACti
1358 Kiner Blvd., 17015
51 E OF P OTHER THAN 7.PRESE TATIVE D TE
Diane G Radcliff / �2QI
= Indle Road, Camp Hill, A
Side 1
L 1505610143 1505610143 J
1505610243
REV-1500 Fit
Decedent's Social Security Number
oeeedem'e Name: Huffnagle, Shirley M
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages&Notes Receivable(Schedule D)........................................................ 4.
5. Cash, Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 64 , 013 . 52
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous N{oq Probate Property
(Schedule G) u Separate Billing Requested............ 7,
8. Total Gross Assets (total Lines 1 through 7)........................................................ 8. 64 , 013 . 52
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 4 , 600 . 20
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1)............................ 10. 2 , 414 . 60
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 7 ,014 . 80
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 56, 998 . 72
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. 56, 998 . 72
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 15 0 . 00
(a)(1.2)X.00
16. Amount of Line 14 taxable
at lineal rate X .045 56, 998 . 72 16. 2 ,564 . 94
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 00 18. 0 . 00
19. TAX DUE................................................................................................................ 19. 2 , 564 . 94
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. rX
Side 2
1505610243 1505610243 J
REV-1500 EX Page 3 File Number 21-13
Decedent's Complete Address:
DECEDENT'S NAME
Huffnagle, Shirley M
STREET ADDRESS
100 Mt.Allen Drive
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 2,564.94
2. Credits/Payments
A. Prior Payments 2,439.77
B. Discount 128.40
Total Credits(A +B) (2) 2,568.17
3. Interest (3)
4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) 3.23
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5)
Make Check Payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;............................................................................... ❑ ❑
b. retain the right to designate who shall use the property transferred or its income;.................................. El lxl
c. retain a reversionary interest;or..................................................................................................I............ x
d. receive the promise for life of either payments,benefits or care?............................................................ x
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receivingadequate consideration?.................................................................................................................... ❑ 0
3. Did decedent own an"in trust for' or payable upon death bank account or security at his or her death?....... ❑ ❑x
4. Did decedent own an individual retirement account,annuity,or other non-probate property which
contains a beneficiary designation?.................................................................................................................. ❑ ❑x
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
.. ..........
jilikiiiiiiiiii .. _ .. .. ...
c f
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 orfor the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after January 1,1995,the tax rate imposed on the net value of transfers to orforthe use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
fling 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-0509 EX.(11.10)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Huffnagle,Shirley M 21-13
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-ovmed wiN the night of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 PNC Bank-Acc't No.50-0570-5993 63,584.50
2 PNC Bank Interest 0.48
3 PNC Bank Interest 0.49
4 PNC Bank Interest 0.49
5 PNC Bank Interest 0.45
6 PNC Bank Interest 0.46
7 PNC Bank Interest 0.47
8 PNC Bank Interest 0.46
9 Alert Pharmacy Services 107.89
10 Discover Card/Travelers Refund 88,27
11 Highmark Blue Shield 191.66
12 Verizon 37.90
TOTAL(Also enter on Line 5, Recapitulation) 64,013.52
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule E(Rev. 11-10)
REV-1511 EX.(10-09)
Pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
INHERITANCE TAX RE
ESTATE OF FILE NUMBER
Huffnagle,Shirley M 21-13
Decedent's debts must be reported on Schedule I.
ITEM
NUMBERI DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 2,662.80
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zip
Year(s)Commission Paid
2. Attorney's Fees Diane G Radcliff 912.50
3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State DO
Relationship of Claimant to Decedent
4. Probate Fees 228.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 796.40
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 4,600.20
Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Huffnagle, Shirley M 21-13
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Funeral Luncheon 882.80
2 Rolling Green Cemetery-Grave Opening 1,780.00
H-A 2,662.80
Other Administrative Casts
3 Cumberland Law Journal-Legal Advertisement 75.00
4 Reserve for additional attorney's fees 500.00
5 The Sentinel -Legal Advertisement 221.40
H-B7 796.40
Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6.98)
'Rev-1612 EX4(12.08)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Huffnagle, Shirley M 21-13
Report debts Incuned by the decedent prior to death that remained unpaid at the date of death,Including unmimbumed medical expense..
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Messiah Village-Final Statement 2,414.60
TOTAL(Also enter on Line 10, Recapitulation) 2,414.60
(If more space is needed,additional pages of the same size)
Copyright(c)2008 form software only The Lackner Group,Inc. Form PA-1600 Schedule I(Rev. 12-08)
REV-1513 EX.(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Huffnagle, Shirley M 21-13
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (Words) ($$$)
Do Not List T 't"I'l I. TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
Dennis A Huffnagle Son One-Third
1358 Kiner Blvd residue of estate
Carlisle 17015
Gary B Huffnagle Son One-third
2854 Windside Court residue of estate
Ann Arbor, MI 48103
Michael W Huffnagle Son One-third
1261 Alma Lane residue of estate
Mechanicsburg, PA 17055
Total
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as approp riate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule J(Rev.01-10)
YI
Knot Vill acre Testament
OF
SHIRLEY M.HUFFNAGLE
I, S11IRLEY M. HUFFNAGLE, of Fairview Township, York County, Pennsylvania,
being of sound and disposing mind, memory and understanding, do hereby make, publish and
declare this as and for my Last Will and Testament, hereby revoking and making void any and all
Wills or Codicils at any time heretofore made by me.
ARTICLE I
DEBTS
I direct the payment of all my legal debts, and the expenses of my last illness and funeral
from my Estate as soon after my death as conveniently may be done.
ARTICLE II
TANGIBLE PERSONAL PROPERTY
I give and bequeath my motor vehicle(s), household and personal effects and other tangible
personalty of like nature (not including cash or securities), together with any existing insurance
thereon, unto my husband, CLIFTON W. HUFFNAGLE. In the event my husband CLIFTON
W.HUFFNAGLE predeceases me,I give devise and bequeath the items described in this Article H
unto those of my children who survive me to be divided among them in as nearly equal shares as is
practicable.
ARTICLE III
REST,RESIDUE AND REMAINDER
I give, devise and bequeath all the rest, residue, and remainder of my Estate, of whatsoever
rh and wheresoever situate unto my husband, CLIFTON W. IiUFFNAGLE. In the event my
nd, CLIFTON W. IIUFFNAGLE, predeceases me, I give and bequeath all the rest, residue
mainder of my Estate, of whatsoever nature and wheresoever situate, unto my then-Iivmg
issue,per stirpes.
ARTICLE W
UNIFORM TRANSFERS TO MINORS
In the event that any beneficiary of my Will shalt not have reached the age of twenty-one
(21) years at the time for distribution of his or her share, distribution of said share may be made in
the discretion of my Personal Representative after considering the age and needs of the beneficiary,
either directly to the beneficiary or to a Custodian under the Pennsylvania Uniform Transfers to
Minors Act,20 Pa. C.S.A § 5301 et seq.,or the applicable Uniform Gifts to Minors Act or Uniform
Transfers to Minors Act in the state of residence of such beneficiary as the case may be. My
Personal Representative may designate as such Custodian any institution or person, including my
Personal Representative, qualified to act as a Custodian for such beneficiary under such Act in
effect at the time such distribution is made. A receipt for any payment or distribution so made shall
be wfull discharge-theiefoi to my Personal Representative,who shall not be responsible to see to,or
be liable for,the application of such proceeds thereafter.
1
2
ARTICLE V
POWERS OF PERSONAL REPRESENTATIVE
My Personal Representative(s) shall have the following powers in addition to those vested
in them by law and by other provisions of my Will applicable to all property, whether principal or
income, including property held for minors, exercisable without court approval and effective until
actual distribution of all property.,
A• To make distribution in cash or in land, or partly in cash and partly in kind, and in
such manner as they may determine.
B• To retain any or all of the assets of my estate, real or personal, without restriction to
investments authorized for Pennsylvania fiduciaries, as they deem proper, without
regard to any principle of diversification or risk.
C. To invest in all forms of property without restriction to investments authorized for
Pennsylvania fiduciaries, as they deem proper, without regard to any principle of
diversification or risk.
D. To sell at public or private sale, to exchange, or to lease for any period of time any
real or personal Property and to give options for sales, exchanges or leases, for such
prices and upon such terms or conditions as they deem proper.
E. To allocate receipts and expenses to principal or income or partly to each as they
from time to time think proper.
F. To compromise any claim or controversy.
3
G. To make such elections, decisions, concessions and settlements in connection with
all income, estate, inheritance, gift, generation skipping or other tax refunds and the
payment of such taxes without obligation to adjust the distributed share of any
person thereby affected.
ARTICLE VI
APPOINTMENT OF PERSONAL REPRESENTATIVE
I name, constitute and appoint my husband, CLIFTON W. HUFFNAGLE, Executor of this my
Last Will and Testament. Should my husband, CLIFTON W. HUFFNAGLE, fail to qualify or
cease to so act, I name, constitute and appoint my son, DENNIS A. HUFFNAGLE, alternate
Executor to complete the administration of my Estate, and if my son, DENNIS A. HUFFNAGLE,
also fails to qualify or ceases to so act, I name, constitute and appoint my son, MICHAEL W.
HUFFNAGLE, alternate Executor to complete the administration of my Estate. I direct that no
fiduciary appointed herein shall be required to post bond for the faithful administration of the duties
required in any jurisdiction.
IN WITNESS WHEREOF,I have hereunto set my hand and seal to this,my Last Will and
Testament,this ,�2Otday of A"tt 0- 2001.
i4 a�-& /h SEAL.�� er�.s�lG (
E- � >
4
Signed, sealed, published and declared by the above-named Testatrix, as and for her Last
Will and Testament, in the presence of us, who at her request, in his presence and in the presence of
each other,have hereunto subscribed our names as witnesses.
5
AFFIDAVIT AND ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA:
: SS
COUNTY OF CUMBERLAND
We, SHIRLEY M. HUFFNAGLE, and
L. u ax.S ' the Testatrix and the witnesses, respectively, whose
names are signed to the attached or 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
purposes therein expressed, and that each of the witnesses, in the presence and hearing of the
Testatrix, signed the Will as witness and that to the best of his/her knowledge the Testatrix was at
that time eighteen years of age or older,of sound mind and under no constraint or undue influence.
SHIRLEVk HUFFMAZLE a
f,44-d 12
Witness
Witness
Subscribed, sworn to and acknowledged before me by SHIRLEY M. HUFFNAGLE,{
Testatrix, and subscribed and sworn to before me by -r-(wh4 ��i,-y11 Qar.P and
Ks �-• TutnS witnesses, 's ( da of
y 2001.
Notww Saes Notary Public
Daft 0. c�i" "d Cot
My eannMssbn E�ires CIeC,Mamw �
6
total Banking Statement
For the period 05/18/2013 to 06/10/2013
For 24-hour information,sign onto PNC Bank Online Banking SHIRLEY M HUFFNAGLE DECO
on pnc.com. Primary account number:50-0570-5993
Account number.50-0570-5993-continued Page 2 of 4
transaction Summary
Checks paid/ Check Card FOS Check Card/Bankcard
Withdrawals signed transactions POS PIN transactions
3 0 0
Total ATM PNC Bank Other Bank
transactions ATM transactions ATM transactions
0 0 0
aterest Summary As of 06119,a total of$2.53 in interest was
Annual Percentage Number of days Average collected interest Paid paid this year.
Yield Earned (APYE) in interest period balance for APYE this period
0.007 11 66,15 7.60 .00
lverdralt and Returned Item Fee Summary
Total for this Period Total Year to Date
oud Overdraft Fees .00 25.00
activity Detail
hecks and Substitute Checks
ieck Date Reference Check Date Reference
mber Amount paid number number Amount paid number
f29 49.80 05/22 M254007 1531 4,221.70 05/24 086448289
30 693.68 05/22 085437912
Sap in checksequence There were 3 checks listed totaling
Hier Deductions Therewere2 Other Deductions totaling
to Amount Description $63,584.50,
/29 .00 Outstanding Item Close
/29 63,584.50 Debit Memo Reference No. 521511322
ally Balance Detail
:e Balance Date Balance Date Balance Date Balance
/18 68,549.68 05/22 67,806.20 05/24 63,58450 05/29 .00
�F
FORra166R-0111
Jo Jo's Pizza B Pasta
107 West Main Street
Mechanicsburg, Pa 17055
(717) 766-8292
Server: Admin Station: 3
- --- — - ---- -----
Order #: 106767 Here
-------------------------------- -----
25 Parties 0 610.00
5 Parties `Z x 102.00
Bar Subtotal: K. I I 0
Food Subtotal:. .00.00
Tax 1: _ 42.72
ORDER TOTAL: 754.72
18% TIPS: , now
128.16
TOTAL: $BB2.8B
Cash Tendered: .200.00
Balance: $682.88
» Ticket #: 93 «
5/16/2013 5:18:05 PM
THANK You!
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1G). PNCT3ANK
040
UPPER ALLEN (112)
127 KIM ACRES DRIVE
MECHANICSBURG PA 17055
Cashbdx 14 AM
* Deposit Multi/Mix
12:00 JUL 17 2013
Account Number XXXXXX6018
Tran Amount $337.45
Cash Amount $0.00
W/S ID WWS0109B Sequence Number 00035
Batch 301
This deposit or Payment is accepted subject to
verification and to the rules and regulations of
this bank. Deposits may not be available for
immediate withdrawal. Receipt should be held
until verified with your statenent.
ALERT PHARMACY SERVICES, INC.
Estate of Shirley Huffnagle 1529
Date 7/3/2013
Type Reference .Original Amt. Balance Due . Discount
6/24/2013 Bill Refund 107.89 107.89 Payment
107.89
Check Amount 107.89
I \ ;
\ l
J
-Orrstown Checking Refund
107.89
II
II
Val Z OA VERIZON CRG VERIZON PA
,,, 6 BOWDOIN SQUARE BOOR B BOSTON, MA 02114-2911 000608037;
Account Number Description
.I 7176918284708 CREDIT BALANCE REFUND
ii DATE ACCOUNT NUMBER TOTAL REFUND
ii 06/19/13 7176918284708 $37.90 -
il
II
I
II
it
I
II
II
II
II
II
LI
PNC BANK
040
UPPER ALLEN (112)
127 KIM ACRES DRIVE
MECHANICSBURG .PA 17055
Cashbox 13 AM
* Deposit Multi/Mix
12;11 JUN 24 2013
Account Number XXXXXX6018
Tran Amount $88.27
Cash Amount $0.00
W/S ID D1WS01098 Sequence Number 00186
Batch 302
This deposit or pargent is accepted sublect to
verification and to the rules and regulations of
this bank. Deposits nay not be available for
isaediete uithdroual. Receipt should be held
until verified with Your statenent.
THE ATTACHED CHECK IS AN OVERPAYMENT REFUND ON YOUR
DISCOVER CARD ACCOUNT NUMBER
THANK YOU FOR SHOPPING WITH DISCOVER CARD.
-_ IIu11uH 111IP1111141111Id4d11hrlludnPh111
1182718
HUFFNAGLE,SHIRLEY M
0 1261 ALMA LN
MECHANICSBURG PA 17055-9710
O117E 17E0 ce1 111 1, CHECK AMOUNT ACCOUNT NO.
05/191 13 1182718 ts 17: :j 02311814446
2488
TRAVELERSJ
ONE TOWER SQUARE - 0000 PBPZA
HARTFORD, CT 06183
2{88
ESTATE OF SHIRLEY HUFFNAGLE
C/O MICHAEL HUFFNEGLE
1261 ALMA LN
MECHANICSBURG PA 170559710
DATE: 06/12/13
CHECK NUMBER: 883I 31712445
AMOUNT: 71."00?**;}
OFFICE: 818 AGENT: OJA291
ACCOUNT: 978829653
REFUND DUE TO CANCELLATION 978829653
NAMED INSURED ESTATE OF SHIRLEY HUFFNAGLE pS�"
AND ADDRESS C/O MICHAEL HUFFNEGLE
e
1261 ALMA LN O9
MECHANICSBURG PA 170559710
** IF YOU HAVE ANY QUESTIONS, PLEASE CALL (717) 657-3141 *
ALAN HOSTETLER AGTS
HESSIAN 1
For PB-0i
Ufewa s'
at MESSIAH VILLAGE Y
100 MT.ALLEN DRIVE,MECHANICSBURG,PA 17055 RESIDENT# UNIT I STMT. DATE
110510 _ 090W 1 05/31/2013
RESIDENT(S)
MICHAEL HUFFNAGLE Mrs. SHIRLEY M. HUFFNAGLE
1261 ALMA LANE
MECHANICSBURG,PA 17055 TOTAL AMOUNT DUE $21414.60
DATE DUE 06/30/2013
DATE DESCRIPTION RATE Days/Units CHARGES CREDITS BALANCE
Balance Forward 4,221.70
05/23/2013 PAYMENT RECEIVED - THANK YOU!!! 4,221.70 0.00
***Nursing Care ***
05/08/2013 RM/BRD-NURSING- SEMI-PVT 05101-05101 295.00 8,00 2,360.00 2,360.00
05/08/2013 PREVAIL BRIEF 1.40 39.00 54.60 2,414.60
RZ
Dsts
t� cttcT.
RESIDENT# CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE
110510 2,41, 0.00 0.00 0.00 0.00 $2,414.60
RESIDENT NAME Mrs.SHIRLEY M.HUFFNAGLE Fo X01
WA
Please make check payable to Messiah Lifeways at Messiah Village.
A 1%finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you!
If you have any questions or concerns about your bill,please address them directly to Fiscal Services at 790-8220. Thank You!