HomeMy WebLinkAbout01-23-14 (2) � 1505610140
REV-1500 �` �°,_'°,
OFFICIAL USE ONLY
PA Department of Revenue Coun Code Year File Number
BurBau of Individuai Taxes �Y
Po Box 2soso� INHERITANCE TAX RETURN 2 1 1 3 0 1 0 3 0
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death NMADDYYYY Date of Bi�th MMDDYYYY
0 9 1 0 2 D 1 3 1 0 0 5 1 9 1 6
Deoedent's Last Name Suffix Decedent's First Name MI
J 0 N E S M I L D R E D B
(If Applicable)Enter Surviving Spouse's Infonriation Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Sociai Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
Q 1.Originai Retum � 2.Supplemental Retum � 3.Remainder Retum(date of death
priorto 12-13-82)
� 4.Umited Estate � 4a.Future Interest Compromise(date of � 5.Federal Estate Tax Retum Required
death after 12-12-82)
� 6.Deoedent Died Testate � 7.Deoedent Maintained a Living Trust 8.Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of T�ust)
� 9.Litigation Proceeds Recc�ived � 10.Spousal Poverty Credit(date of death � 11.Eledion 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 CONFIDENTWL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Tele�hone Numberr..,
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Cit�r or Post Offioe State ZIP Code DATE FlLED
C A R L I S L E P A 1 ? 0 1 3
Correspondent's e-mail address:
Under penaltles of perjury,I dedar�e that I have examir�ed this retum,induding accompanying schedules and statements,and�o the best of my kno�wledge and belief,
it is trus,coned snd oompl�6e.Dedatation of prepar�other than the personal representative is based on all infoimation of which preparer has any knowledge.
SIGNAjURE OF P SON RES NSIBLE FO ILING RETURN DATE
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ADDRESS
671 S- MIDDLESEX ROAD CARLISLE PA 1?�15
SIG OF EP R O 1�7 N REPRESENTATIVE
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ADDR
� 60 WES POMFRET STREET �ARLISLE PA 17013
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REV-1500 EX Page 3 File Number
Decedent's Complete Address: 2� 13 0�030
DECEDENTS NAME
MILDRED B. JONES
STREET ADDRESS
671 S. MIDDLESEX ROAD
CITY STATE ZIP
CARLISLE PA 17015
Tax Payments and Credits:
1• Tax Due(Page 2,Line 19) (1) 2,928.92
2. CreditslPayments
A.Prior Payments 2,500.00
B.Discount 125.00
Total Credits(A+B) (2) 2,625.00
3. Interest
(3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 303.92
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; ............................... ❑ X❑
c. retain a reversionary interest;or ................................................................................................ ❑ �
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? ....................................................................................... ❑ �
3. Did decedent own an"in trust for"or payable-upon�feath 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
oontains 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.
For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
ftling 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+(&12)
pennsylvania SCHEDULE B
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
MILDRED B. JONES 21 13 01030
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. 34 SHARES OF METLIFE STOCK 1,687.08
34 SHARES X$49.62 PER SHARE_$1,687.08
...�.
TOTAL(Also enter on Line 2,Recapitulation) s 1 687.08
If more space is needed,insert additional sheets of the same size
REV-1508 EX+(08-12)
pennsylvania SCHEDULE E
DEPARTMENTOFREVENUE CASH, BANK DEPOSITS � MISC.
RESIDENT DECED NTTURN pERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
MILDRED B. JONES 21 13 01030
InGude the proceeds of litigation and the date the proceeds were received by the estate.
All property jointiy owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. CASH ON HAND 4,218.22
2. PESONAL PROPERTY-APPRAISAL ATTACHED 496.00
3. M&T BANK-SAVINGS ACCOUNT#15004208569185 68,477.02
4. M&T BANK-SAVINGS ACCOUNT#25004920096820 1,100.10
• TOTAL(Also enter on Line 5,Recapitulation) S 74 291.34
If more space is needed,use additional sheets of paper of the same size.
REV-1509 EX+(01-10)
pennsylvania SCHEDULE F
DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
MILDRED B. JONES 21 13 01030
If an asset was made jointly owned within one year of the decedenYs date of death,it must be reported on Schedule G.
SURVNING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A.CURTIS B. SMITZ 671 S. MIDDLESEX ROAD SON
CARLISLE, PA 17015
B.ANN C. SMITZ-DAVIS 1742 E. MAYLAND STREET DAUGHTER
PHILADELPHIA, PA 19138
c.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM F�2 JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST
1. A. 09/1967 M&T BANK 4,694.27 50. 2,347.14
CHECKING ACCOUNT#2670014097
2. B. 04/1973 MEMBERS 1ST FEDERAL CREDIT UNION 1,471.73 50. 735.87
SAVINGS ACCOUNT#70502-00
TOTAL(Also enter on Line 6,Recapitulation) � 3 083.01
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
MILDRED B. JONES 21 13 01030
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 in�uoE r�wv�oF n��aNS��,THEIR RELATIONSHIP TO�CEDENT AND DATE OF DEATH X OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TR/WSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST �F a�.�c�� VALUE
1. SERIES E SAVINGS BONDS-INVENTORY ATTACHED 3,751.88 100.00 3,751.88
TOTAL Also enter on Line 7,Recapitulation) a 3 751.88
If more space is needed,use additional sheels of paper of the sarr�e size.
REV-1511 EX+(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
MILDRED B.JONES 21 13 01030
Decedent's deb�s must ba reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. RONAN FUNERAL HOME 6,667.48
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
SVeet Address
City State ZIP
Year(s)Commission Paid:
2. Attomey Fees: IRWIN&M�KNIGHT, P.C. 4,500.00
3. Family Exemption:(If decedenYs add�ess is not the same as daimanYs,attach explanation.) 3,500.00
Claimant CURTIS B. SMITZ
StreetAdd�ess 671 S. MIDDLESEX ROAD �
�ity CARLISLE state PA z�P 17015
Relationship of Claimant to Decedent SON
4. pro(��F�: REGISTER OF WILLS 173.50
5 Accountant Fees:
6. Tax Retum Prepa�er Fees: PATRICIA A. ROSENDALE, CPA 375.00
FINAL FIDUCIARY TAX RETURN
7. ROY D. GOTTSHALL-APPRAISAL ON PERSONAL PROPERTY 55.00
8. ANGELA M. SMITZ-WOOD-HOUSE CLEANUP 550.00
9. CARPET REPLACEMENT 700.00
TOTAL(Also enter on Line 9,Recapitulation) S 16 520.98
If more space is needed,use additional sheets of paper of the same size.
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
MILDRED B. JONES 21 13 01030
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 pndude outriight spousal distributions and transfers under
Sec.9116(a)(1.2�.]
1. CURTIS B. SMITZ Lineal 65,087.20
671 S. MIDDLESEX ROAD 1/4TH REMAINDER
CARLISLE, PA 17015 JT. ACCOUNT
2. ALBA CORNISH Lineal
10314 ARRAN CT. 1/4TH REMAINDER
HUNTERSVILLE, NC 28078-7120
3. WAYNE C. SMITZ Lineal
720 NORTH 67TH 1/4TH REMAINDER
HARRISBURG, PA 17111
4. ANN C. SMITZ-DAVIS Lineal
1742 E. MAYLAND STREET 1/4TH REMAINDER
PHILADELPHIA, PA 19138 JT. ACCOUNT
5. WILLIAM W. CAREY, II Lineal
1125 SGATT STREET SAVINGS BONDS
BRONX, NY 10460
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 TAX IS NOT TAKEN:
1.
B.CHARfTABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S
If more space is needed,use additional sheets of paper of the same size.
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LAST WILL AND TESTAMENT
I, 1VIIL.DRED B. SMITZ JONES, of South Middleton Township, Cumberland County,
Pennsylvania, declare this insttument to be my last will and testament, hereby expressly revoking
all wills and codicils heretofore made by me.
1. I direct my executor to pay all of my debts, funeral and administrative expenses as soon
as may be done conveniently after my decease.
2. I authorize and empower my executor to sell any realty owned by me at my death and
not specifically devised herein, at either public or private sa1e, and to give good and sufficient
deeds therefor, in fee simple, as I could do if living.
3. I give, devise and bequeath all of my estate of every nature and wherever situate to my
four children, share and share alike, the child or children of any deceased child tal�ng the share
their parent would have taken if living.
4. I nominaxe and appoint Curtis B. Smitz to be the executor of tlus my last will and
testament; he is to serve as such without bond. Should he die before my death, renounce or
refuse to serve for any reason, or die leaving any of my estate unadministered, I nominate and
appoint Ann C. Davis, as substitute executrix, also to serve as such without bond, with the same
powers as are given herein to my executor.
�
. , ,
: • • ^ ,
5. I hereby suggest that my personal representative retain the services of Irwin, Irwin &
McKnight, as attorneys in the s�tttlement of my estate.
. � .
IN VVITNESS V�i��REOF, I have hereunto set my hand and seal this �'0� day of Apnl,
1993. .
� .
��,,�:�j`� • ����o• (SEAL)
1VIILDRED B. S Z]O
Sigaed, sealed, published and declared by MIL,DRED B. SMITZ 70NES, the testatrix
above named, as and for her last will and testament, in the presence of us, who at her request, in
her presence and in the presence of each other have subscribed our names as witnesses hereto.
2
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. ��.
. .. • •
. ►. .
ACgNOWLEDGMENT AND AFFlDAVIT �
WE, IVIILDRED B. SMITZ JONES, BETZI A. MORRISON and KATHLEEN M.
KENNEY, the testatrix and witnesses respectively, whose names are signed to the foregoing
instrument, being first duly sworn, do hereby declare to the undersigaed authority that the
testatrix si$ned aad executed the instrument as her last will and testament that she had signed
vvillingly, and tha.t she executed it as her free and voluntary act for the purpose herein
expressed,and tha.t each of the witnesses, in the presence and hearing of the testatrix, sigaed the
will as a witness and tha.t 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.
., ,.
,
MII.DRED . S S
.�
A.M ON
KATHLEEN M.
COMMONWEALTS OF PENNSYLVANIA :
: ss:
COUNTY OF CUMBERLAND :
Subscribed, sworn to and acknowledged before me by MII.DRED B. SMITZ JONES,
the testatrix, and subscribed and swom to before me by BETZI A. MORRISON and
KA1'�EEN M.KENNEY,witnesses,this �3 A day of April, 1993.
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MILDRED B JONES
671 S MIDDLESEX RD
CARLISLE PA 17013-9224
The�S nq�t�es that w�nport the a�t bub af t�tfain Nisns
acquind sPoer Jsnuary �� Z011 aed tMn wld. 8h�ns
trsn�fernd out of sn acoowR wUl b�don�u�iig our d�lt aoat
basis cakulNion of first M�fl�st aut(FIFO)uNas otl�rlM
ir�rucbd. PNsn vbit our r►�bsib.t�ri�w 1h��ncload FA4
or consult rour�x adviaor�you ne�d addl�onsl bdonna8on
sbout ca�st bssis.
Dear Holder:
Re: MILDRED B JONES
Compe�ny Name:MetUfe,Ir�. Aocount Number:0027133380
DRS book-entry shares:0 Cer'�icated Share�:0
Policytblder TNSt book-entry shares:34
As requested,endosed are the forms and instructions needed to transfer the decedent's stodc to a new a000unt or another hdder.We hav�e�so enc�osed
answei�to FrBquently Aslced Questions(FAQs)bo assist�u with canpleting fhe fam and fio answer transfer relafied questia�s you may have.You can find
additional helpful inforrnation in the`Help'secfion of our website,www.computershare.condinvesfior.
To rBquest the transfer,yau will need to c�anplete fhe following steps:
Step 1: Transfer Request form—Complete the endosed form.AII surviving regis�ered holder�(if applicable)or a legally authorized representafire rrwst sign
tt�e"Authotized Sigr�turesa se�ion(section 1�,with a Medallion Signature Guaranbee for eac�s�nature.An individ�l signing on b�alf of ihe cun+ent
registered holder must indicate his or her capaciiy next to the signature on the�am�e.g.John Smith,Execx�tor or John Smifh�Cus�ian).See fhe
endosed FAQ docx�ment for a�ditia�al irrformation. .
If the deoedent held any oertficated shares,you must mdude fhe aiginal stock oerdficate(s)along with the Transfier Reque.st form.If a aertifica�is
lost,please oon�ct us at the customer s�rvioe number lis�ed on the�op right oomer of this letter fio fi�d out the oost and prooess�or requesting a
certficate replaoement Lost certificates must be replaoed prior to transfenir�g the shares.
Sfiep 2: Form W 9,tax certification—The new hdder should s�n and dafie se�tia�9 of the enc�osed Transfer Request form.If the r�ew hokler is urrable to
pravide tax oertification at this fime,we v�l send him or her a Form W�J(Request for Tax�yer I�ntification Number�d Certification)orx,e the
transfer request is processed.Canputershare will be required to withtmld taxes on arry div�dends or other cash distributia�s unt�tax oeraficafion is
� reoeived by us.
Step 3: Sales Instructlons—If the new owr�r wishe.s to sell the shares as a result of this transfer andlor from an exisfing aoo�nt�tl�e New Aocount Owner's
Sale lnstruc6ons in Se�tion 10 must be c�mpleted and signed.
Step 4: Additional tax documentation—Obtain either{a)or(b),as applicable:
(a) If the decedent nesided in a sfiate in whict�an inheritanoe tax wa"mer is required,an Inheritar�oe Tax Waiv�form.
(b) If the deoedent d�i not reside in a state in which an inheritanoe tax waiver is required,eitl�er(i)a Notarized Affidavit of Dorrncile(blank form
endosed),or(ii)an Inheritance Tax Wai�r stamp affixed next to the signafiure on the Transfer Req�st form.
See the last page of the enclosed FAQ document for additional information on these items and how to obtain them.
Step 4:� Send all required documents outlined above to:
Regular mail: Ovemightic�rtifiedlregistered delivery:
pp 6� Com ershare
oX 43��6� 250 Royan Street
Providence,RI 02940-3�6 Canton,MA 02021
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499 Mitchell Road,MiUsboro,DE 19966 Adjustment Services
Phone 888-502-4349
F ax (302)934-2955
October 2,2013
Law Offices
Irwin&McKnight,P.C. ���iEI�E�
West Pomfret Professional Building
60 West Pamfret Street Q�T o 4 2��3
Carlisle,PA 17013-3222
��WlN i�McFfNiGH�
�aw o�ic�s
Re: Estate of Mildred B. Smithz-Jones
Social Securit��165-26-5483
Date of Death: September 10,2013
Dear Sir or Madam:
Per your inquiry on September 27,2013,please be advised that at the time of death,the above-named decedent
had on deposit with this bank the following:
1. 7j�pe of Account Checking Accourrt
' Account Number 2670014097 �
1
Ownership(Ncunes o� Mildred B.Jones ��
Curtis B.Smitz
Opening Date 09/Ol/1967
\
Balance on Date of Death � $ 4,694.26 �
Accrued Interest $ .01
----------------------______---------------------------
Total $4,694.27
� 2. Type ofAccount Savirigs Account ,
Accm�nt Number 15004208569185
Ownership(Names o� Mildred B.Jones
Cw�is B.Smitz(POA)
Opening Date 03/OS/1990
Balance on Date ofDeath $ 68,476.08
Accrued Interest $ .94
._..___..__..__..__..__....__......___.._..___----------....__---_________.
T�� $68,477.02
.
Y 3. Type of Accaunt Savings Account
, .
AccauntNumber 15004200928090 ,�
\
Ownership(Names o,� Mildred B.Jones(Signat �
Shiloh Ba�tist Cyaa�ch(Organizazion) e ��
� '�
Ruby Clements(SiSrurta') �
Ruth�Hodge(Si or) � �
� ` �
Opening Date 10/Ol/1977 C1x a,
c �
Bulcmce on Date of Death $ 715.17
Accrued Interest $ .02
Total $715.19 ------------------------------------------------
4. Type ofAccount Savings Account
AccotmtNumber 25004920096820
Ownership(Names o� Mildred B..Io»es
Cw�tis B.Smitz(POA)
Opening Date I1/12l1991
Bala�ce o�Date of Death $ 1,100.OS
� Accrued Interest $ .OS
Total $1,100.10---------------------------------___--------
For any addilional infocmation on the above accounts,including ownership and any c6anges,ctosures and/or reimbursemmt of fnnde,
q��u tne�n sa«r c��at n�2�o�as�.
We were unable to locate any safe deposit boz for the above-mentioned decedent
11�ia ktber daa not indude�ury Aawunts in w6ich the daxased may 6a�+e been listed as P�ver of Attio�vey,Caabodi�n d Uaifarm�, .
Repnsentnliv�e Paya,or Trusbee under a Writben Agreement
S1t1061��,
Valarie Memer
Adjustment Services
St
��C�����
.
MEMBERS 1� OCT 0 2 2013
FEDERAL CRIDiT tJNION
�R�fIN Y�McKNiGH�'
iAW OFFICES
PRIMARY OWNER: Mildred B Jones
REGULAR SAVINGS ACCOUNT:
Account Number/Suffix 70502-00
Date Account Established 04/13/1973
Principal Balance at Date of Death $1,471.68
Accrued Interest to Date of Death $0.05
Total Principal and Accrued Interest $1,471.73
Name of Joint Owner Ann Smitz
Date Joint Added 04/13/1973
MEMBERS 1ST FEDERAL CREDIT UNION
�.Q�
Tessa L Klugh
Lending Insurance Support Specialist
September 30, 2013
Estate of: MILDRED B SMITZ-JONES
Date of Death: 09I10/2013
Social Security Number: 165-26-5483
5000 Louise Drive • P.O.Box 40 � Mechanicsburg,Pennsylvania 17055 • (800) 283-2328 • wwwmembersl st.org
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,
Ronan Funeral Home .
.- 255 York Road
Cariisle, PA 17013
•�Tel: 717-258-9863 Fax: 717-241-4041
Lynn A. Ronan, Funeral Director .
Friday,September 20,2013
Mr. Curtis B. Smitz
671 S.Middlesex Road
Carlisle,Pennsylvania 17015
Dear Mr.Smitz,
Thank you for selecting our funeral home to pmvide services for your family during your time of bereavement I hope that you
found our services,so far,to be of the highest staudards that we always try to achieve. The following is a summary of the
service charges as previously explained and provided in written form on the services for:
� � NIILDRED�B.JONES . . .
PROFESSIONAL SERVICES
Basic service of funeral director and staff $ 2215.00
Embalmiag � 770.00
Dressing, Casketi�g, and Cosmetology 295.00
Total Funeral Service Selected
TOTAL PROFESSIONAL SERVICES $3,280.00
FAC'I]Ll[7�STAFF AND EQ_UIPMENT
Use of Fa ''ties&Staff for Visitation 455.00
Use of Facilities&Staff for Ceremony at Funeral Home 540.00
Use of Staff 8c Equipment for Graveside Service 285.00
+ FACII�ITIES,STAFF AND EQUIPMENT $1,280.00 .
AUTOM4TIVE E(�TJIPMENT �
Transfer of Remains to Funeral Home � 475.00 �
Hearse/Funeral Coach $ 380.00
Flower Velucle $ 90.40
Flower/Lead Car � 90.00
TOTAL AUTOMOTIVE EQITIPMENT $1,035.00
OTHF1t MERCAANDISE SELEGTED
Memorial Package(Bridge of Faith) $ 215.00
. . . . TOTtiL,�THER MERCHANDTSE SELEGTED $215.00
CASA ADVANGCS
Certified Copies of Death Certificate � 96.00
Clergy Honorarium � 100.00
Organist 100.00 �
Newspaper Notice Carlisle Sentinel 3�9.48
Flowers 212.00
CASH ADVANCE TOTAL 5857.48
TOTAL OF SERVICES 56,667.48
BALANCE DUE $6,667.48
If there are any questions or concerns that remain unanswered,please call me. „
Sin ly,
��
L A. onan
Funeral Director
�
. � We have received the expianation of bene�fits
. j� from your insurance company(s)and have
L appiied whatever payments and/or adjustments -
are appropriate. Please make paymerrt for the
� PITAL
balance due of$1,184.00�R take advar�tage of _
The Sp��c of Cari�g a 159G prompt payment discount and remit
$1,006.40 on or before 11/28/2013. -
46101739 Here are 3 convenient ways to pay:
NiI1LDRED S JONES 1. Make paymerrt oniine at www.hsh,or�g.
671 S MIDDLESEX RD 2. Mail te�ar-o#�coupon below with payment
GARLISLE PA�17015-9224 in the enciosed envelope.
3. C�lii Customer Service below to make
payment by phone.
• .
Patient Neme:� Jones,Mitdred S Previous Balance: �1�,395.65
Sta#emerrt Dat�: 10/29/13 Total New Charges: �3,722.91
Service Date(s): 09/08/13-09110/13 PaymentsJAdjustmer�ts: #16,934.56-
Accourrt Balance: #1,184.0 0
Account Number: 46101739 p���pay This,qmount: ;1,154.00 �R
Medical Record Number: 707061 piscounted Amount+af i1,Q�� �_�i#p�id��t
ar before 11i28/Ztf13
. - a . �
t
Please call Customer Senrice at 717-763�2138
Ins. 1: MEDICARE I/P to add or make co�ions to your insurence
Ins.2: UNITED AMERIC information, or to make arrangements for a
Ins.3: paymer�t plan. if you are unabie to make
Ins.4: payment, please contact the Patierrt Financial
Advocate's Office at(71�763-2885 to discuss
� financial assistance options.
�
.
P/ease Note: Your physic�ians will biil separately fnr p,rofie�ssionai servK.�es.
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