HomeMy WebLinkAbout01-27-14 REVA500 EX (06-05) 15056041125 OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 1 0 5 6 9
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
0 4 1 5 2 0 1 1 0 5 1 7 1 9 2 6
Decedent's Last Name Suffix Decedent's First Name MI
V A N C E P A T R I C I A A
(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)
OX 6. Decedent Died Testate F 7. Decedent Maintained a Living Trust 0 B.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 lax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch.0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Day"e Telephonetlltimber
W I L L I A M P D 0 U G L A S 7Mq 0 2 X1`°3 4 P 9 0
w o
Firm Name(If Applicable) ]RRI R OrWIL&6_,xNLY
D 0 U G L A S L A W O F F I C E D A M r j r" f�1
First line of address x O 0
4 3 W S 0 U T H S T `? cz -rt J I
Second line of address rTi
� 'Tt
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:dOuglaslaw(d)_earthlink.net
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 reparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATU OF PERSO SPONSIB R FILING RETURN 1 _ ,DATE _
ADDRESS
43 WEST SOUTH ST CARLISLE PA 17013
SIGNATURE OF PREPARER OTHER THAN PRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056041125 15056041125
J 15056042126
REV-1500 EX
RECAPITULATION
1 0 7 9 0 0 0 0
I. 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) . . . . . . . . I . . . I . . . . . . . . . . . 4.
5. Cash, Bank Deposits&Miscellaneous Personal Property(Schedule E) . . . . . . . 5. 9 9 4 4 2 6 0
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested . . . . . . . 7.
8. Total Gross Assets(total Lines 1-7) . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 2 0 7 3 4 2 6 0
9. Funeral Expenses&Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . 9. 3 9 6 1 9 1 6
10. Debts of Decedent,Mortgage Liabilities,&Liens(Schedule 1) . . . . . . . . . . . . 10.
11. Total Deductions(total Lines 9&10) . . . . . . . . I . . . . . . . . . . . . . . . . . . 11. 3 9 6 1 9 1 6
12.Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . I . . I . I . I . . I . . 12. 1 6 7 7 2 3 4 4
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 1 6 7 7 2 3 4 4
an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . 13.
14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . 14. o 0 0
TAX COMPUTATION-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 _ 0 0 0 15. 0 0 0
16. Amount of Line 14 taxable
at lineal rate X .0 0 0 0 16 0 0 0
17. Amount of Line 14 taxable
at sibling rate X.12 0 0 0 17. 0 0 0
18. Amount of Line 14 taxable
at collateral rate X.15 0 0 0 18 0 0 0
19.Tax Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . I . . . . . . . . 19. 0 0 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Side 2
15056042126 15056042126 J
REV-1500,EX Page', File Number
Decedent's Complete Address: 0569
DECEDENT'S NAME
PATRICIA A. VANCE
STREET ADDRESS
4 ABBEY COURT
CITY STATE ZIP
CARLISLE PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2 Line 19) (1) $0.00
2. Credits/Payments
A,Spousal Poverty Credit
B.Prior Payments
C. Discount
Total Credits(A+B+C) (2) $0.00
3. Interest/Penalty if applicable
D.Interest
E.Penalty
Total InteresUPenalty(D+E) (3) $0.00
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) $0.00
A.Enter the interest on the tax due. (5A)
B.Enter the total of Line 5+5A.This is the BALANCE DUE. (5B) $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; ...................................................................... ❑ El
b. retain the right to designate who shall use the property transferred or its income; ...............................
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? ....................................................................................... El N
3. Did decedent own an'in trust for"or payable upon death bank account or security at his or her death? ......... ❑ 0
4. Did decedent own an Individual Retirement Account,annuity,or other non-probate property which
containsa beneficiary designat ion?.................................................................................................. ❑
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 January 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three(3)percent[72 P.S.§9116(a)(1.1)(1)].
Far dates of death on or after January 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero(0)percent
(72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the 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 twenty-one 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 zero(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 four and one-half(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 twelve(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�X+(6-98;-
SCHEDULE A
COMMONWEALTH OF PENNSYLVANIA REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
PATRICIA A. VANCE 0569
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 atwhich properly would be
exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevantfacts.
Real property which is'oinll -owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. 4 ABBEY COURT $107,900.00
CARLISLE, PA 17015- Sale
TOTAL(Also enter on line 1,Recapitulation) $ 107 900.00
(If more space is needed,insert additional sheets of the same size)
REV-1508 EX+(6-98}
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
PATRICIA A. VANCE 0569
Include the proceeds of litigation and the dale 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. PRE-PAID FUNERAL EXPENSES FROM SECURCHOICE $2,693.74
2. Personal Property $344.59
Erb Auction
3. M&T Bank- Checking Account $76,851.41
950224340
4. M&T Bank Savings Account $7,458:38
87214768
5. 2005 Chevy Cobalt/sale price $6,000.00
6. Refund of Mayapple Home Owners Association Fees $115.00
7. United Church of Christ Home $4,057.25
Refund for overpayment
8. Hoffman Roth Funeral Home $200.00
Refund for overpayment
9. K R MacDonald Inc $524.00
Refund Home Owners Insruance Policy
10. Centurytel, Inc. $42.09
11. Ohio Casualty/J. Rodney Fickel Insurance Agency $245.00
Refund on Car Insurance Premium
12. Tax proration received on real estate sale $911.14
TOTAL(Also enter on line 5,Recapitulation) $ 99 442.60
(If more space is needed,insert additional sheets of the same size)
REV-1511 EX+(12-99)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF - FILE NUMBER
PATRICIA A. VANCE 0569
Debts of decedent must be reported on Schedule 1.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERALEXPENSES:
1. HOFFMAN ROTH FUNERAL HOME $3,585.00
B. ADMINISTRATIVE COSTS:
1, Personal Representative's Commissions
Name of Personal Representative(s) WILLIAM P. DOUGLAS $10,367.13
Social Security Number(s)IEIN Number of Personal Representatives)
Street Address
City State Zip
Year(s)Commission Paid:
2. Anomey Fees DOUGLAS LAW OFFICE $10,367.13
3, Family Exemption:(If decedents address is notthe same as claimants,attach explanation)
Claimant
Street Address
city State Zip
Relationship of Claimant to Decedent
4. Probate Fees GRANT OF LETTERS TESTAMENTARY $128.50
6 Accountant's Fees
6. Tax Return Preparers Fees
See Attachment Page(s)
TOTAL(Also enter on line 9,Recapitulation) $ 39 619.16
(If more space is needed,insert additional sheets of the same size)
REV-1513 EX-(9-00)
a" SCHEDULEJ
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
PATRICIA A. VANCE 0569
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 oulright spousal distributions,and transfers under
Sec.9116(a)(1.2)]
1.
Collateral
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18,AS APPROPRIATE,ON REV-1500 COVER SHEET
]]. NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
See Attachment Page(s)
TOTAL OF PART II- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 167 723.44
(If more space is needed,insert additional sheets of the same size)
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
PATRICIA A.VANCE _ 21 11 0569
Decedent's Name Page 1 File Number
Schedule H -Funeral Expenses &Administrative Costs -B7.
ITEM
NUMBER DESCRIPTION AMOUNT
7. S.W. BARRETT APPRAISAL FEE FOR HOUSE $350.00
8. THE SENTINEL TO ADVERTISE $221.40
9. THE CUMBERLAND LAW JOURNAL TO ADVERTISE $75.00
10. CARLISLE BOROUGH TAX ACCOUNT PERSONAL TAXES $4.90
11. K. R. MACDONALD INC - HOMEOWNERS INS $534.00
12. COMCAST $133.70
13. SOUTH MIDDLETON TWP MUNICIPAL AUTH $119.13
14. CENTURY LINK $42.91
15. M&T BANK SAFE DEPOSIT BOX RENTAL $68.00
16. MILLENNIUM PHARMACY PRESCRIPTIONS $68.58
17. The Villas (Homeowner Assoc Fees& Maintenance) $345.00
18. AT&T $80.26
19. Jean Salinger-Cleaning Services $40.00
20. Rick Mentzer- Repairs to Home $145.00
21. Pre-Death legal services (trips to nursing home, residence, review contracts, etc. ) $3,000.00
22. Met Ed $179.86
23. Cumberland Goodwill (Ambulance) $88.40
24. J. Rodney Fickel Ins $272:00
25. Midas (Car Inspection) $149.45
26. The Sentinel (Advertise Car) $31.49
27. Peerless Ins. (Auto Ins.) $277.00
28. Douglas Law Office (Reimburse for payment on Car Registration) $36.00
29. Real Estate Commission to Prudental & ERA $6,474.00
30. Broker Fee to ERA for sale of real estate $195.00
31. Real Estate Transfer Tax- 1 percent $1,079.00
32. South Middleton Township Municipal Authority-final water reading $23.97
33. 2012 School Real Estate Taxes $862.35
35. Reserved for filing first and final account $275.00
SUBTOTAL SCHEDULE H•B7 $15,171.40
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
PATRICIA A. VANCE 21 11 0569
Decedent's Name Page 2 File Number
Schedule J -Beneficiaries -2B
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1. Helen O. Krause/Animal Foundation, Inc. $33,544.68
PO Box 311
Mechanicsburg, PA 17055-0311
2. The Humane Society of Harrisburg Area, Inc. $33,544.69
7790 Grayson Road
Harrisburg, PA 17111
3. Carlise Chapter of The American Red Cross $33,544.69
79 East Pomfret St.
Carlisle, PA 17013
4. The Salvation Army/Carlisle Citadel $33,544.69
125 S. Hanover St.
Carlisle, PA 17013
5. PAWS $33,544.69
PO Box 855
Camp Hill, PA 17001
SUBTOTAL SCHEDULE J-28 $167,723.44
LAST WILL AND TESTAMENT
I, Patricia A. Vance, single person, of 4 Abbey Court, South Middleton
Township, Cumberland County, Pennsylvania, being of sound and disposing
mind, memory and understanding, declare the following to be my last will and
testament, hereby revoking any and all wills heretofore made by me.
Item I. I direct that my funeral be held by Hoffman-Roth Funeral
Home as per my agreement with them.
Item II. I direct my executor hereinafter named to pay all my debts
and funeral expenses.
Item III. I direct that all my possessions be sold at public auction and
the proceeds be distributed in equal shares to the following
charitable entities;
Pet Adoption Center, c/o Nancy Baker, Box 442, Boiling Springs,
Q�a PA.
b. Paws Association, Camp Hill, PA.
c. Helen Krause Animal Foundation, Mechanicsburg,PA.
d. West Shore Humane Society, Sinclair/Eppley Roads,
Mechanicsburg, PA.
e. Carlisle Chapter of the American Red Cross, 95 Alexander Spring
Road, Carlisle, PA.
I. The Salvation Army, Carlisle Citadel, 125 South Hanover Street,
Carlisle, PA.
In the event any of the aforesaid cease to exist then said share shall lapse and be
divided among the remaining entities in equal shares.
Item IV. I nominate, constitute and appoint William P. Douglas, Esq.,
as my executor and attorney for my Estate and direct that he
shall serve without bond.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this
2151 day of February, 2007.
Patricia A. Vance
Signed, sealed, published and declared by the above named testatrix, as and for
her last will and testament, who at her request, in her presence, in our presence,
and in the presence of each other have hereunto subscribed our names as .
attesting witnesses:
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
I, Patricia A. Vance, whose name is signed to the attached or foregoing
instrument, having been duly qualified according to law, do hereby
acknowledge that I signed and executed the instrument as my last will, that I
signed it willingly; and that I signed it as my free and voluntary act for the
purposes therein expressed. /j
T at kia A. Vance
Sworn to and subscribed before
m this�215`day of Febru , 2007.
`( E �
Notary
Notarial Seal
Anne M.Cox,Notary Public
Cadise Borough,Cumberland County
My Commission Expires June 3,200
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
T
We,'QVLC� q�/ ��.� ane���`Cv� t�"Lt/��--� �-n&hose names are
--�
signed to the attached or foEi-egoing instrument, being duly qualified according to
law, do depose and say that we were present and saw testatrix sign and execute
the instrument as her last will, and that she signed willingly and that she
executed it as her free and voluntary act for the purposes therein contained, that
each of us in the hearing and sight of the testatrix signed the will as witnesses;
and that to the best of our knowledge, the testatrix was at that time 18 or more
years of age, of sound mind and under no constraint or undue influence.
U
Sworn to and subscribed before'
me this 215`day of February, 2007.
i
i
Notarial Seal
Anne M.Cox,Notary Public
Cadise Borough,Cumberland County
My Commission Expires June 3,2009
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FRB AUCTION C' .
620 North Hanover St,
Carlisle, Pa. 17013
FINAL SETTLEMENT
SELLER NAME Estate of Partricia A. Vance DATE OF SALE 21-Jul-1 i
ADDRESS 4 Abbey Court
CITY Carlisle State Pa Zip 17013
PHONE �~
LOCATION OF SALE 4 Abbey Court, Carlisle Pa,
AUCTIONEER Tammy Erb(Erb Auction Co.}
DESCRIPTION EXPENSES RECEIPTS
Total receipts checks & cash) $985.00
Auctioneer fee @ 20% $197.00
Advertising F Communications&Sign a Rama $123.41
Labor @$10.00hr. $280.00
No sale items removed $40.00
TOTAL EXPENSES1 $640.41
TOTAL RECEIPTS $985.00
LESS TOTAL EXPENSES $640.41
NET PROCEEDS PAYABLE TO SELLER 4344:59'
i (or we),the se ler,acc of this settlement and acknowledge receipt of the above specified net proceeds
fro e oti n of m goods and property sold on the above date. I accept all responsibility for
prove in er ha itle to all goods, and property sold, and for delivery of title to the purchaser.
Auc tine r Sig ature Seller's Signature
Date 7 7 It Date
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Carlisle,°ennsylvania 170',3
717-243.451 1
toll free 1.866.451.4511
fax 717.243.3723
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FUNERAL HOME & CREMATORY, INC. InfoC4iofhrarvoth.com
June 13, 2011
Attorney William Douglas
43 West South Street
Carlisle, PA 17013
Statement of Funeral Expenses for: Patricia A. Vance
Date of Death: April 15, 2011 Account Id: 16227-098
PACKAGE:
Immediate Cremation
OPTION 5 - Cremation $ 1,890.00
Sub Total: $ 1,890.00
MERCHANDISE:
Urn: Centurian (without Lip) Roman $ 180.00
Sub Total: $ 180.00
TOTAL FUNERAL HOME CHARGES: $ 2,070.00
CASH ADVANCES:
Westminster Cemetery $ 1,230.00
10 Certified Death Certificates at$ 6.00 each $ 60.00
Monument Lettering @ Westminster $ 200.00
Coroner's Fee $ 25.00
Sub Total: $ 1,515.00
Total Funeral Expense: $ 3,585.00
Total Payments Made: $ 3,585.00
Payments Made:
SecurChoice Check 63287 May 4, 2011 2,693.74
Fraternal Order Of Eagles Check 556393 Jun 13, 2011 200.00
Douglas Law Office Check 2298 Jun 13, 2011 891.26
Reimbursement H/R ck Jun 13, 2011 (200.00)
Balance: $ 0.00
Please return this portion with your Remittance.
$ Amount Enclosed
Patricia A. Vance
Service ID#: 16227-098
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Cited Church of Christ Homes
Wirth 31st Street, Camp Hill, PA 17011-
MEMO 2913 DATE CHECK NO. C--rnTFIVIF(uT
IMBURSEMENT VOICE oarE 06/15/2011 AMOUNT
INVOICE NUMBER 66798 4,057.25*++ 066799
RAH RSE HOME 0511212011 AMOUNT
rRICIA VANCE 702253 DISCOUNT
4,057,25 NET
4,057.25
$
PRO a �
Balance B/F 4dilt
- 7,741.24„
04/13/11 DOUGLAS,WILLIAM
04/14/11 Personal Laundry Services 1 30.00 30.00 7,741 24 30.00
04/14/11 Cable Televis!on 1 24.75 --- 24.75 -- --^-- 54.75
4/01/11 - 04/14/11 Room&Board-Semi-Private �� 14 257.00 3,598.00 3,652.75
4/01/11 - 04/30/11 Room&Board-Semi-Private 30 257.00 -7,710.00 -4,057.25
Current 1-30 Days 31-60 Days 61-90 Days Over 90 Days Amount Due
Frs
.00 -4,057.25 .00 .00 .00q�QS�y25,
NOTE: ***** PAYMENT IS DUE UPON RECEIPT***** BUT NO LATER
THE 25TH OF THE MONTH ***** Please remit the LAST AMOUNT
your statement.Include the ACCT# from the statement on the MEMO Statement Date:05/12/2011
of your check. Payments after 5/9/11 do not reflect on statement.
NOTE: ** LATE PAYMENTS ARE SUB3ECi TO A 1,25%LATE CHARGE PER - Due Date:05/25/2011
A$10.00 FEE WILL BE CHARGED for RETURNED CHECKS**
Patricia Vance - Account #: 102253
Sarah ATodd Memorial Home
1000 West South Street
Carlisle, PA 17013
Telephone: (717) 245-2187
K R MacDonald Incorporated
Paid TO ESTATE OF PATRICIA A VANCE c/o WILLIAM P DOUGLAS 26371
Memo H.O. P06CY Cancellation Date 08/12/2()I1
Account
ACCOUNTS '-E—C"V—A'LE
$524.00
PNC CHECKING
(Ck 26371,Ref 50619)--- -$524.00
K R MacDonald Incorporated PNC BANK,
4900 Derry Street, P.O. Box 4500 60,1273/313
Harrisburg,PA 1 71 1 1-0500
(717)564-4221 0811212011
YTOTHE
DER OF — ESTATE OF PATRICIA A VANCE c/o WILLIAM P DOUGLAS 524100
Five Hundred Twe nty Four And NOtIQ --- A S
Q
Two Signatures Required
ESTATE OF PATRICIA A VANCE c/o WILLIAM P DOUGLAS
43 W SOUTH STREET
CARLISLE, PA 17013
H.O. Policy Cancellation
(Ck 26371,Ref 50619)
oo 2 P3 3 7 lit, 1:0 3 13 12 7 3al: 511355072211'
K R MacDonald incorporated 26371
Paid To ESTATE OF PATRICIA A VANCE c/o WILLIAM P DOUGLAS Date 08/12/2011
Memo H.O Policy Cancellation
Account Amount
ACCOUNTS RECEIVABLE $524.00
PNC CHECKING -$524.00
(Ck 26371,Ref 50619)
CENTURYTEL, INC. Document / Date
ATTN: Controller' s Group 2000780418 / 09/15/2011
P.O. BOX 4065
MONROE, I,A 71211 Your vendor nimber
e
1.-877-386-7151 500000
l�eiliUiy�.a
Document Invoice Date Gross Amount Deductions Net Amount
Text
Payment is made on behalf of EQ United Tel-PA, T856 .
1900038220 3140993750 09/14/2011 42 . 09 0 . 00 42 . 09
Refund Questions? Call 1 888 723 8010
Sum total 42 . 09 0 . 00 42 . 09
Payment rdocuntent Ciie�k number Gate CuYtency Payment a ilount
24.00780418 04034903821 09{152011 USD ** ****i*****42 . 09*
CENTURYTEL, INC. Check Number
ATTN: Controller's Group
P.O. BOX 4065 0003490382
JPMORGAN CHASE BANK,
-a DALLAS
MODL40E, LA 71211
oe S� 1-877-386-7151 se-e¢/iiza
CenturyLink
Void after 50 days 0911512011
**= FORTY-TWO USD and 09;100 ***
USD
Pay to the urc,r of
u ABBEY C?' ..Lj/ l
CARLISLE PA 17015-4065
Protected by poolsitiiv'e pay
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