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HomeMy WebLinkAbout02-25-14 REV-1500 EX(ez-11)(FI) 1505610105�' PA Department Of Revenue pennsylvania OFFICIAL USE ONLY Bureau of Individual Taxes County Cade Year File Number PO BOX 28o6o1 m INHERITANCE TAX RETURN /�I I I� _ Harrisburg,PA 19128-o6ol RESIDENT DECEDENT </ - ENTER DECEDENT INFORMATION BELOW ' Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 11/18/2013 07/05/1922 -_..__..._...."_.... .. ...._".... ......_.......".. :_..._.....__.........-- -............... .: _..___..._...._.._......__......". Decedent's Last Name SuRx Decedent's First Name MI LYONS BEULAH 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 G@D 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death Prior to 12-13.82) O 4.Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-62) CID 6.Decedent Died Testate O 7.Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule 0) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ......... _ _ _ ._. .._."..... ._....._..._."._._._._..__...... _._......_.........._.. ....._.__.. ...._"_..._._. _- _..- . ALLEN W. CARR, EXECUTOR (717) 763-7365 REGISTER OF WILLS USE ONLY First Line of Address 141 LONGENECKER LANE �? __ . . _ .. ..._- �� Second .T --r,- ----- Address m-r' f"rt -7 Czj City or Post On DA7E'FJC£D Cti ce State ZIP Code _..._.__ v 17 l� .__..._"_."._..._._.._.._-_._____""_.__._........_.............._.__.__._. .."._..__ ._..__._.._.".-.."__...""__._.. MIDDLETOWN PA 17057 4CD c % y L fin Correspondent's e-mail address:ACARR @FINANCIALGUIDE.COM — "D Under penalties of pedury,l 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. SIG TL{ PER2 RESPONSIBLE;OR�ILn G RETURN 'A TE ADDRESS 6`•t_//� `/l Ct./Ar/[L rC -I 141 LONGENECKER LANE, MIDDLETOWN, PA 17057 SIGNATU EPARER O F�T-tAN RE✓'/2ESENTATIVE DATE ADDRESS //G/IN ��/i/a y/Vyhy 220 HALDEMAN AVENUE, NEW CUMBERLAND, PA 17070 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 r 1505610205 REV-1500 EX(Fl) Decedent's Social Security Number Decedent's Name: LYONS, BEULAH 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 and Notes Receivable(Schedule D).. ................. ... ... .. 4. 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 44,074.19 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) C= Separate Billing Requested... .... . 7. 8. Total Gross Assets(total Lines 1 through 7).......... . .... ... . .. ........ 8. 44,074.19 - 9. Funeral Expenses and Administrative Costs(Schedule H). ..... .. ...... .... . 9. 7,722.28 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1). ......... . ... . 10. 2,585.69 11. Total Deductions(total Lines 9 and 10).... .......... .. ........ ... ...... 11. 10,307.97 12. Net Value of Estate(Line B minus Line 11) . ...... .......... ............. 12. 33,766.22 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) ..... .. ........... .... .. 13. 2,628.17 14. Net Value Subject to Tax(Line 12 minus Line 13) .. ...................... 14. 31,138.06 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec. 9116 - - - - - -- - - - - - (a)(1.2)X.0- 15. 16. Amount of Line 14 taxable at lineal rate X.0_ 16. 17. Amount of Line 14 taxable at sibling rate X.12 27,395.81 17. 3,287.50 18. Amount of Line 14 taxable at collateral rate x.15 3,742.24 1S 561.34 19. TAX DUE ........ ........... ............... ..... . ....... .......... 19. 3,848.84 20, FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 L 1505610205 1505610205 REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENTS NAME BEULAH M. LYONS STREETADDRESS _ 730 OAK OVAL CITY - STATE ZIP MECHANICSBURG PA 17055 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 3,848.84 2. Credits/Payments A Prior Payments B.Discount _ 192.44 Total Credits(A+8) (2) 192.44 1 Interest (3) 4. If Line 2 is greater than Line 4+Line 3,enter the difference. This is the OVERPAYMENT. Pill 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} 3,656.40 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.........................................................._.............................. ❑ J. retain the right to designate who shall use the property transferred or its income_.._............................_........ ❑ c. retain a reversionary interest.............................................___........................................................................ ❑ J. receive the promise for life of either payments,benefits or care?...................................................................... ❑ ■ 2. if death occurred after Dec.12,1992,did decedent transfer property within one year of death without receiving adequate consideration?................_........_................................................................................ ❑ O 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 designation? .............................................................................._...._.............___.............. ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death 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 172 P.S.§9115(a)(1.1)(1)], 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)(t2)]. • 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(x)(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. h , REV-1508 EX+(o8-12) R a pennsytvania SCHEDULE E DEPARTMENT OFREVENuE CASH, BANK DEPOSITS & MISC. INHERITANCE DECEDENT URN PERSONAL PROPERTY RESIDEM DECEDENT ESTATE OF: FILE NUMBER: LYONS, BEULAH M. 21-13-1315 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 1t127 ECKING ACCOUNT-PNC BANK A/C 50-7009-8835 1,296.13 KIM ACRES DRIVE,MECHANICSBURG,PA 17055 2, MONEY MARKET ACCOUNT-PNC BANK A/C 50-0205-5841 6,215.27 127 KIM ACRES DRIVE,MECHANICSBURG,PA 17055 3. CASH ON HAND 103.34 4. ANNUITY-ING RELIASTAR LIFE INSURANCE COMPANY CONTRACT#SFUA005891 15,235.73 909 LOCUST STREET, DES MOINES, IA 50309 5, ANNUITY-ING RELIASTAR LIFE INSURANCE COMPANY CONTRACT#SFUA012276 13,430.04 909 LOCUST STREET, DES MOINES,IA 50309 6. REFUNDABLE ENTRANCE FEE-MESSIAH LIFEWAYS 7,484.48 100 MT.ALLEN DRIVE,MECHANICSBURG,PA 17055 7. CASH BALANCE ACCOUNT-ING RELIASTAR LIFE INSURANCE COMPANY A/C#81304382039780 6.10 P.O.BOX 535405,PITTSBURGH,PA 15253-5405 8, GERBER LIFE-REFUND OF INSURANCE PREMIUM 303.10 TOTAL(Also enter on Line 5, Recapitulation) $ 44,074.19 If more space is needed, use additional sheets of paper of the same size. REV-1511 Ex+ (08-13) R. pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE DECEDENT RETURN ADMINISTRATIVE COSTS RESIDENT DKEDEM ESTATE OF FILE NUMBER LYONS, BEULAH M. 21-13-1315 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' S.GERALD WEAVER FUNERAL HOME 5,611.40 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 1,000+00 Name(s)of Personal Representative(s) ALLEN W. CARR Street Address 141 LONGENECKER LANE City MIDDLETOWN State PA ZIP 17057 Year(s)Commission Paid: 2014 Z. Attorney Fees: 302.38 3. Family Exemption: (If decedents address is not the same as clalmant's,attach explanation.) Claimant Street Address city State_ZIP Relationship of Claimant to Decedent 4. Probate Fees: 158.50 5. Accountant Fees: 650.00 B• Tax Return Preparer Fees: 7. TOTAL(Also enter on Line 9, Recapitulation) $ 7,722.28 If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(12-12) ffpennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, RESIDENT DECEDENT RN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT - - ESTATE OF LYONS, BEULAH. M. FILE NUMBER 21-13-1315 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. rPPL AH LIFEWAYS-NURSING HOME CHARGES-ROOM 2,163.42 ' 2. AH LIFEWAYS-HOME CARE ASSISTANT CHARGES 330.00 3. ECTRIC UTILI TIES 37.02 4. VERIZON TELEPHONE 55.25 TOTAL(Also enter on Line 10, Recapitulation). $ 2,585.69 ;. IT more space is needed,insert additional sheets of the same size. REV-1513 EX+(01-10) j 'pennsytvania SCHEDULE J 3 DEPARTMENT OF REVENUE BENEFICIARIES INMERTTANCE TAX RETURN RESIDENT DECEDENT - ESTATE OF: FILE NUMBER: LYONS, BEULAH M, 21-13-1315 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 outright spousal distributions and transfers under Sec.9116(a)(1.2).) 1. ALICE HEISEY,112 TIMBER VILLA,ELIZABETHTOWN,PA 17022 NONE 1247.42 2. LOIS SMITH, 1791 LISBURN ROAD,CARLISLE,PA 17015 NONE 1247.41 I BEULAH CHARLES,2151 ALTADENA DRIVE,ALTADENA,CA 91001 NONE 1247.41 4- LOA LYONS BUCKWALTER,1512 34TH CIRCLE SE, SISTER 5479.17 RIO RANCHO,NM 87124 5. ELVA LYONS BULGRIEN,1700 N.SHELDON ROAD SISTER 5479,16 SANDUSKY,MI 48471 6. CLARE J.LYONS,4472 W.SIMPSON ROAD,OWOSSO,MI 48867 BROTHER 5479.16 7. ROZELLA LYONS,1464 N.M-52,APT.30,OWOSSO,MI 48867 SISTER 5479.16 B. VERNON LYONS,1431 OVERBROOK ROAD,ENGLEWOOD,FL 34223 BROTHER 5479.16 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH IB OF REVAS00 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. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. JACOB ENGLE FOUNDATION,431 GRANTHAM ROAD,MECHANICSBURG,PA 17055 2628.17 TOTAL OF PART IT -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ONLINE 13 OF REV-1500 COVER SHEET. $ 2628.17 If more space is needed,use additional sheets of paper of the same size. ,kP »1 RECORDED OFF.V+C OF REGISTER OF W I_LS oi3 Ot L -17 S ib WILL CLERK OF ORPHANS' COUR of CUMBERLAtO CO., P. BEULAH M. LYONS I, BEULAH M.LYONS, currently of Upper Allen Township, Cumberland County, Pennsylvania, realizing the uncertainty of this life, but with confidence in God and trust in His Son, my Lord and Savior, 7esus Christ, who died for my sins upon the cross and rose again to redeem me and give me eternal life, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking any and all prior Wills and Codicils made by me. I. I direct that all my just debts and funeral expenses be paid from the assets of my estate as soon as practicable after my demise. H. I direct that all estate and inheritance taxes that may be assessed in consequence of my death, shall be paid out of the principal of my general estate to the same effect as if said taxes were expenses of administration and all property includable in my taxable estate whether or not passing under this Will shall be free and clear thereof. III, I bequeath unto Elizabeth L. Kanode all my household furnishings. If she predeceases me or has no need of those items at the time of my death, they shall be distributed according to the separate instructions I intend to keep with my Will. IV Any,equity that I may have in our cottage at Messiah Village shall remain with the ;{ r VilAi6l tbrihi b neft of Hhzab—h L, Kar.ode. I she predeceases me or if there is any eqi gjefe..af:ihe time of her death, said equity shall be divided as follows: A. Fifty percent(50%)to be divided equally among my then surviving brothers and sisters; B. Fifty percent(50%)to be divided equally among the then surviving brothers and sisters of Elizabeth Kanode. V. All the rest, residue and remainder of my estate I devise and bequeath as follows: n � 1 A. Ten percent (10°/a) unto The Jacob Engle Foundation, Inc., Grantham, Pennsylvania, to be used for the charitable purposes I intend to outline to it by way of separate instructions. B. Ninety percent(90%)to be divided equally among my brothers and sisters who survive me. VI. I appoint Allen W. Carr, Sr., Executor of this my Will. In the event that he fails to qualify or ceases to act as Executor, I appoint A. Wesley Carr, Jr., Executor in his place. VII. I direct that no bond be required of my fiduciaries for the faithful performance of their duties in any jurisdiction. IN WITNESS WHEREOF,I, BEULAH M. LYONS, herewith set my hand to this my Last Will, typewritten on two (2) sheets of paper including the attestation clause and signatures of witnesses, this 2 3 r4day of January, 1996. 'v.,tAt k M, (SEAL) BEULAH M. LYONS Signed by BEULAH M. LYONS, by her declared to be her Will in our presence, who have hereunto subscribed our names as witnesses in her presence and at her request, this 2 3,,-( day of January,A4 a __residing at residing at__ rea u z -2- "qM ccsrnz(iNWEALTH OF PENNSYLVANIA COUNTY OF ' BEULAHM. LYONS the testatrix and the GERALD J. BRINSER foregointnesses, respectively, whose names are signed to the attached or g instrument being Brst dul authority that the testatrix signed and executed th udio hereby declare to the undersigned signed`u'hmgly(ar°wil nglY directed another to sign for herent as her Last Will free and voluntary act fox the ), and that she executed it as her the presence and hearing pteposes therein expressed, and that each Of the witnesses, in Out"knowledge the testatrix as at at time signed i the Will as witnesses and under no constraint and that to the best of aunt ar undue " ghteen years of age or alder, of sound mind influence. BEULAH M. LYON'S' - i WITNESS Subscribed, swam or LYONS, the testatrix, o affirmed and acknowledged before this x 3--,day of Janu S'I`D J. BRINSER andFr:.,zp me by BEULAH M Y> 1996. asTf' L,K 4 No n witnesses, SE 1 NOTARY PUBL (± Notate;veal Coma Sue GPmarth mh o �xcv s�`��u Y Permsye✓an a-�s � NOL,-ries -3- 44, a r r REGISTER OF WILLS CERTIF ---- ICATE O&F F CUMBERLAND COUNTY GRANT OF LETTERS PENNSYLVANIA No. 2013- 01315 PA No. 21- 13- 1315 Estate Of: BEULAHMLYONS /Firs(,Middle,Las,) Late Of: UPPER ALLEN TOWNSHIP CUMBERLAND COUNTY 0 Deceased Social Security No: WHEREAS, on the 17th day of December 2013 an instrument dated January 23rd 1996 was admitted to probate as the last will of BEULAH M L YONS /R'v,Middle,LasU late of UPPERALLEN TOWNSHIP, CUMBERLAND County, who died on the 18th day of November 2013 and WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA FARNER STRASBAUGH Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARYto: ALLEN W CARR who has duly qualified as EXECUTOR(R)X) and has agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYLVAN IA. 71V TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my Office on the 17th day of December 2013. Reglster - _ puty **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) BEEF= Total Ranling-StAtement, ....... ................... ....... .......... .......... .............. PNC I Bank E)-PNCRAN'K ............... ..........I....... ....................... ............................................ ................ ...... ......... ..... .... Primary amount number:50.7009-8835 Page I of 4 For the period 10/22/201a to 11/20/2013 Number of enclosures:0 002095 0 For 24-hour banking,and transaction or BEULAH M LYONS interest rate information,sign on to 730 OAK OVAL PNC Bank Online Ranking at pric.com. MECHANICSBURG PA 17055-8408 Foroustomerservice call 1-888-PNC-BANK Monday-Friday:7 AM-10 PM ET Saturday&Sunday: 8 AM-5 PM Er Pam servicio an espaRoL 1-866-HOLA-PNC Moving? Please contact us at 1-888-PNC-SANK DiD Write to:CustomerServioe PO Sole 609 Pittsburgh PA 15230-9738 Visit us at PNC.com TI)Dterminal:1-800-531-1648 For hearing impaired clients only Relationship Overview Bank Deposit Accounts Description A=dvnt Number Deposit Balance Free Checking 50.70048835 _ 1,296.13 Premium Money Market 50-0205.5841 6,215.27 Total Deposits 7,511.40 F= Checking Account Summary 13sufah M Lyons* Account number. 50-7009-8835 Overdraft protection Provided By: XXXXXX5941 Overdraft Coverage-Your account is currently Opted-Out. You or yourjoint owner may revoke your opt-in or opt-out tholes at any time. To learn more about PNC Overdraft Solutions visit us online at p= rrVoverdmtucIvsIons. Call 1-97)-5863005,visit any branch,or Sign on to PNC Online Banking,and select the'Overdraft Solutions•link under the Account Services section re,manage both your Overdraft Coverage and Overdraft Protection settings. Balance Summary Beginning Deposits and Checks and other Ending balance other additions deductions balance 1,38057 692.00 776,44 199613 Average monthly Charges balance and fees 1,427.80 .00 Transaction Summary Checks.pald/ Check Card POS Check Caftysts.keard wflhdraveals signed transactions Fos PIN transactions Total ATM PNC Bank Other Bank transactions ATM transactions ATM transactions 0 0 0 PNDMLT01-JOB97761-N40-NNNNNN-002-004116 it Page 1 of 6 "' Annual Statement As of 11/14/2013 ReliaStar Life Insurance Company 909 Locust St Des Moines,IA 50309- Phone:(800)369-5303 Fax:(515)698.2001 Internet:w,w,ingannuities.com BEULAH M LYONS 730 Oak Oval Mechanicsburg PA 17055-8408 Contract Information Contract(dumber. SFUA005891 Owner(s): BEULAH M LYONS Product: RL USLICO FPDA Annuity Annuitant(s): BEULAH-M LYONS Effective Date: 11114/1994 Tax Status: Non-Qualified Total Premium: $15,000.00 Contract Performance Summary Most Recent Contract Year 11/14/2012-11114/2013 Beginning Accumulation Value $14,649.74 Interest/Credits $585.99 Partial Surrender!Withdrawals ($0.00) . Account Value Adjustment $0.00 Ending Accumulation Value $15,235.73 Beginning Cash Surrender Value $14,649.74 Ending Cash Surrender Value $15,235.73 Additional Information As of 1111412013 Accumulation Value $15,235.73 Surrender Charge ($0.00) Cash Surrender Value $15,23533 Surrender Charge-The charge applicable upon full surrender.Please refer to your contract for a&tlonal information. Cash Surrender Value-Equals the greater of the Minimum Guaranteed Contract Value or the Accumulation Value,adjusted for Market Value Adjustment(where applicable)less surrender charges and other applicable charges. Interest Rate Information Current Dollar Current Rate Current Rate Guaranteed Amount Effective Date Interest Rate Through $15,235.73 11/14/2013 4.00% 11/14/2014 003057 00001 00006 000300057901000 - tarr, Al From: Michele Maglich Brown [MBrown @MessiahLifeways.org] Sent: Monday, January 27, 2014 3:05 PM To: Carr,At Cc: Rebecca Rose Subject: Request to Transfer Refundable Entrance Fee Attachments: Transfer Form.docx Hi Alan. Per our conversation earlier, please find attached the form to request that the balance of refundable entrance fee be applied to the cost of care in Nursing or Enhanced Living. Please complete this and return to me and we will apply the amount of the refundable entrance fee to the outstanding balance owed on Beulah's account. The amount available is$7,484.48. Michele "4 ME551A1Uifewaxfc- fi**4L6c 5mbm d° y Michele Maglich Brown Director of Financial Operations 100 Mt. Allen Drive Mechanicsburg PA 17055 Direct: 717.591.7204 1 Fax: 717.795.5556 m brown @messiahlifeways.ore I Messiahlifeways.org The information transmitted is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. Any review,retransmission,dissemination or other use of, or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this in error,please contact the sender and delete the material from any computer, MLDISC20131003 t INIGAw� ReliaStar Li fe Jusm ante Company PO Box 535405 Pittsburgh, PA 15353-5405 BEULAH M LYONS 863 0228_ ALLEN W CARR ADMIN OF ESTATE 5-5—MAAD MIDDLETOWNECpAR17057-3060 PAGE: 1 �hi�L�lulPillr:::I�urhdl�ri4lr�h�ri��hrl:ulli�q:uw PAYMENT SUMMARY VENDOR NO: 81304382039780 VOUCHER NO: 0000114028 VOUCHER DATE: REF.DOC. 01/31/14 REFERENCE NUMBER REF.DATE DOCUMENT DISCOUNT/ADJ AMOUNT AMOUNT NET AMOUNT .................................. ............................................................................ ..(Uetech Here) ... ........... IN lF Reli9Star.Life,Tn$manceCompany ... 60-160/433 Pp Box 535405':.': '. Pi4tsbur h'PA 15253-5405 .. 'C1'>EE'K:DATe .:CHECK NOIdBEp< t 1 01/31/2014 0000114028 TO VALID FOR 90 DAYS THE BEULAH M LYONS ORDER ALLEN W CARR ADMIN OF ESTATE OF: 141 LONGENECKER LN MIDDLETOWN, PA 17057-3060 THE BANK OF NEW YORK MELLON PITTSBURGH, PENNSYLVANIA 11'❑❑00 1 140 2Bn' 1.0t, 3 30 160 it: ❑ 14,,,0 19 311'