Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
03-14-14
1505611185 •�,••1 REV-1500 EX(02-11)(FI) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Po BOX 280601 INHERITANCE TAX RETURN 21 13 0678 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 06152013 04301928 Decedent's Last Name Suffix Decedent's First Name M I BURGOON JOHN R (if Applicable) Enter Surviving Spouse's information Below Spouse's Last Name Suffix Spouse's First Name M I Spouse's Social Security Number THiS RETURN MUST BE FILED IN DUPLICATE WiTH THE - - REGISTER OF WILLS FILL IN APPROPRIATE BOXES BELOW ® 1.Original Return n 2. Supplemental Return ❑ 3. Remainder Return(Date of Death Prior to 12-13-82) ❑ 4.Limited Estate ❑ 4a. Future Interest Compromise(date of ❑ S. Federal Estate Tax Return Required death after 12-12-82) ® 6. Decedent Died Testate , ❑ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) ff''''�'� ❑ 9. Litigation Proceeds Received ❑ 10.Spousal Poverty Credit(Date of Death LJ 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 INFORMA710M SHOULD BE DIRECTED TO: Name Daytime Telephone Number r4.a MARK E- HALBRUNER, ESQ- 717-731-96t%0 REGISTER OF lSE ONLY' - � C3 rT't First Line of Address •- - 2109 MARKET STREET C--) 7 Second Line of Address © W C:) City or Post Office State ZIP Code DATE FILED CAMP HILL PA 17011 Correspondents a-mail address: M-H A L B R U N E R B H H G L L P-C O M Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, It is true,correct and complete.Declaration of preparer other then the personal representative is based on all information of which prepares has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE SCOTT R . BURGOON, EXR• ADDRESS 1749 KEEL DRIVE ELDERSBURG, M"3-.784 SIGNATURE OF PREP B R OTHER THAN REPRESENTATIVE DATE / t MARK E• HALBRUNER, ESQ. � � ADDRESS 2109 MARKET STREET CAMP HILL, PA 17011 PLEASE USE ORIGINAL FORM ONLY Side 1 1505611185 OM46473,000 1505611],85 ,.,j 1505611285 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: B 0 R G O O N JOHN R RECAPITULATION 1. Real Estate(Schedule A) . . . . , , , , , , , , , , , , , , , , , , , , , 1 $0.00 2. Stocks and Bonds(Schedule B). . . . . . . . . . . . . . . . . . . . . . . . 2 $0.00 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C), , . . , 3 $0.1111 4. Mortgages and Notes Receivable(Schedule D) . _ . . . . . . . . _ 4 $0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E) , , , . . 5. $36,258-76 6. Jointly Owned Property(Schedule F) 7 Separate Billing Requested . . , . 6. $0.013 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) 7 Separate Billing Requested . . . . 7. $341199.05 8. Total Gross Assets(total Lines 1 through 7) , , , , , , , , , , , , , , , , , , 6 $70,457-81 9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . g. $6,607-57 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) , , . . , . . . . 10. $803- 45 11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . 11. $7,411-02 12. Net Value of Estate(Line 8 minus Line 11) , . . . . 12. $631046 -79 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which: an election to tax has not been made(Schedule J), , . . . . . . . . . . . 13 $0.00 14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . , . , 14. $63,046 -79 TAX CALCULATION•SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers un er Sec_9116 (a)(1.2)x.0W $0.00 15. $0.00 16. Amount of Line 14 xable atlineal.a.e...04� $63,046.80 16. $2,837.11 17. Amount of Line 14 taxable at sibling rate X.12 $11-011 17. $0.011 18. Amount of Line 14 taxable at collateral rate X.15 $11-1111 16. 19. TAX DUE , . . . . . . , . , . . , .. . . . . . . 19. $2,837.11 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Q Side 2 1505611285 1505611285 J OM464e 3.000 1505611285 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: B U R 0 0 0 N JOHN R RECAPITULATION 1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 $0 . 00 2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . 2. $0 . 00 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C), , . . . 3. $0 . 00 4. Mortgages and Notes Receivable(Schedule D) . . . . . . . . . . . . . . . . . 4 $0 • 00 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E) . . , , . 5. $361258 .7 6 6. Jointly Owned Property(Schedule F) F-1 Separate Billing Requested , . . . 6, $0 . 00 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested . . . . 7. $341199 . 05 8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . . . 8 $70,457- 81 9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . 9. $6,607• 57 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule 1) , . . . . . , , . 10. $803 • 45 11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . 11. $7,411 - 0 2 12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . 12. $63,046 . 7 9 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J). . . . . . . . . . . . . . . . 13, $0 •00 14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . . . , , . 14. $631046 •7 9 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers un�er Sec.9116 (a)(1.2)x.0- $0 . 00 15. $0 . 00 16. Amount of Line 14 xable at lineal rate x.0 4� $631046 . 80 16. $21837 .11 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. $2,83? - 11 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT X❑ Side 2 1505611285 1505611285 J OM4648 3.000 REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: 21 13 0 6 7 8 DECEDENTS NAME BURGOON JOHN R STREET ADDRESS 5255 WILSON LANE, APT . 225 CUMBERLAND CITY STATE ZIP MECHANICSBURG PA 17055- Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) $2,837 - 11 2. Credits/Payments A.Prior Payments $L100 -00 B. Discount *141 - 86 Total Credits(A+B) (2) *31241 - 86 3. Interest (3) $0 . 00 4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. Fill in box on Page 2,Line 20 to request a refund. (4) $404 -75 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) $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 . . . . . . . . . . . . . . . . . . . . . . . R b. retain the right to designate who shall use the property transferred or its income . . . . . . . . . . ❑ 0 c. retain a reversionary interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. receive the promise for life of either payments,benefits or care? . . . . . . . . . . . . . . . . . . ❑ 2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ® a 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? . 4. Did decedent own an individual retirement account,annuity,or other non-probate property,which contains a 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[72 P.S.§9116(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)(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 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. OM4671 2.000 REV-1508 EX+(0&12) pennsylvania SCHEDULE E DEPARTMENTOFREVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RESIDFNTDECEDENTTURN PERSONAL PROPERTY ESTATE OF: FILE NUMBER: John R. Buraoon 21 13 0678 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. Fulton Bank Checking Acct. No. 3623-51271 $5,912.34 2 2003 Saturn L200 (sale price) $650.00 3 Various Firearms (see attached Inventory) $1,587.00 4 Miscellaneous Personal Property $2,699.73 5 Cash $212.00 6 Bethany Village refund $24,629.53 7 Donegal Insurance refund $34.00 8 Bank of America refunds $61.16 9 United States Treasury 2013 federal income tax refund $473.00 TOTAL(Also enter on line 5,Recapitulation) $ $36,258.76 2w46AD 2.000 If more space is needed,use additional sheets of paper of the same size. REV-1510 EX+(08-09) SCHEDULE G pennsylvania DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC.NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER John R. Burgoon 21 13 0678 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. DESCRIP110N OF PROPERTY ITEM INCLLOET}fNMAEOF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OFDECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IFAPPUCABLE VALUE 1. Ameriprise Financial Co. Brokerage Acct. No. 000640502589133 Beneficiaries: children, Scott R. Burgoon, Deborah A. Donohue and Charles D. Burgoon $20,896.67 100.0000 $0.00 $20,896.67 2 Ameriprise Financial Co. Brokerage Acct. No. 000640507711133 Beneficiaries: children, Scott R. Burgoon, Deborah A. Donohue and Charles D. Burgoon $13,302.38 100.0000 $0.00 $13,302.38 TOTAL(Also enter on line 7,Recapitulation)$ $34,199.05 If more space is needed,use additional sheets of paper of the same size. 9W46AF 2.000 REV-1511 EX+"ao9' _ SCHEDULE H pennsylvania DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER John R. Burgoon 21 130678 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t. Neill Funeral Home funeral goods & services $1,044.51 Total from continuation schedules . . . . . . . . . $670.44 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City State ZIP Year(s)Commission Paid: 2. Attorney Fees: $3,500.00 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: $168.50 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. 1 Miscellaneous expenses incurred during administration, including paper supplies, packing boxes and supplies, etc. $74.31 2 Postage $81.37 Total from continuation schedules . . . . . . . . . $1,068.44 TOTAL(Also enter on Line 9,Recapitulation) $ $6,607.57 9w46AG 2.000 If more space is needed, use additional sheets of paper of the same size. Estate of: John R. Burgoon 21 13 0678 Schedule H Part 1 (Page 2) Item No. Description Amount 2 Bethany Village memorial service luncheon $492.36 3 Royer's Flowers funeral service $178.08 Total (Carry forward to main schedule) $670.44 Estate of: John R. Burgoon 21 13 0678 Schedule H Part 7 (Page 2) 3 Executor's Mileage 2013 rate: $.565/mile 2014 rate: $.56/mile $870.06 4 Cumberland Law Journal publication fee $75.00 5 Patriot-News publication fee $123.38 Total (Carry forward to main schedule) $1,068.44 REV-1512 Ex+(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT OECEDENT_ ESTATE OF FILE NUMBER John R. Burgoon 21 13 0678 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. West Shore Surgery Center medical bill $33.87 2 Bank of America credit card $403.14 3 Omnicare medical bill $24.84 4 Discover Card credit card $149.28 5 Pinnaclehealth Cardiovascular Inst. , Inc. medical bill $11.85 6 Pinnaclehealth Medical Services medical bill $1.38 7 Verizon Wireless phone bill $87.73 8 Holy Spirit Hospital medical bill $85.00 9 Spirit Physician Services, Inc. medical bill $4.29 10 Quantum Imaging & Therapeutic Associates medical bill $2.07 TOTAL(Also enter on Line 10,Recapitulation) $ 803.45 2w46AH 2.000 If more space is needed,insert additional sheets of the same size: REV-1513 EX+(01-10) SCHEDULE J pennsylvania DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: John R. Bur oon 21 130678 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec.9116(a)(1.2).] 1. Scott R. Burgoon 1749 Keel Drive Eldersburg, M 21784 One Third of Residue: $21,015. 60 Son $21,015.60 2 Deborah A. Donohue 246 Naugatuck Drive Greensburg, PA 15601 One Third of Residue: $21,015.60 Daughter $21,015.60 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.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ $0.00 9W46AI 2.000 If more space is needed,use additional sheets of paper of the same size. Estate of: John R. Burgoon 21 13 0678 Schedule J Part 1 (Page 2) Item No. Description Relation Amount 3 Charles D. Burgoon PO Box 1345 Montague, NJ 07827 One Third of Residue: $21,015.60 Son $21,015.60 DEATH CERTIFICATE LAST WILL AND TESTAMENT LAST WILL AND TESTAMENT OF JOHN R. BURGOON I,JOHN R.BURGOON,now of Camp Hill,Cumberland County,Pennsylvania,do publish and declare this to be my Last Will and Testament,hereby revoking all other prior wills and codicils made by me. FIRST: Family Background and Appointment of Executor. (A) Family and Background Information. I am not married. I have three children, SCOTT R.BURGOON,DEBORAH A.DONOHUE and CHARLES D.BURGOON, and they are referred to as "my children"throughout this Will. (B) Appointment of Executor and Trustee. I appoint my son,SCOTT R.BURGOON, to act as my Executor,and ifhe predeceases me,resigns,becomes incapacitated or does not complete the duties of my Executor, then I appoint my daughter, DEBORAH A.DONOHUE, to act as my Successor Executor. The aforenamed persons are all hereinafter referred to as "Executor" or "Executors", and they shall serve without bond and without being required to account to any court. The Executor shall also serve as Trustee of any trusts created hereunder. SECOND: Funeral and Last Illness Expenses; Taxes. (A) Expenses of Funeral and Last Illness. I direct my Executor to pay my funeral expenses and the expenses of my last illness from my estate. (B) Taxes. I direct my Executor to pay any and all estate,inheritance,succession,legacy, transfer and other death taxes or duties,by whatever name called,including any and all interest and penalties thereon, imposed under the laws of any jurisdiction by reason of my death, upon or with respect to any and all property included in my gross estate for the purpose of such taxes, whether such property passes under or outside of this Will,out of my residuary estate,without being prorated or apportioned among or charged against the respective devisees,legatees,beneficiaries,transferees or other recipients of any such property or charged against any property passing or which may have passed to any of them. The Executor shall not be entitled to reimbursement for any portion of any such taxes from any such person. THIRD: Tangible Personal Property. Except for those items expressly excluded in this Will and those items enumerated in the Letter of Instruction, I bequeath all my tangible personal property,including but not limited to clothing,jewelry,furniture,household furnishings,household goods,motor vehicles,personal effects and all other similar articles which I own, and the insurance thereon, to my children, SCOTT R. BURGOON, DEBORAH A. DONOHUE and CHARLES COPY LAST WILL AND TESTAMENT OF JOHN R. BURGOON PAGE 2 D.BURGOON,and the then-living natural issue of any predeceased children,to be divided among them as they may select in as nearly equal shares, per stirpes, as is practical. Tangible personal property shall not include: (1) any and all property used by me in any business, (2) cash on hand or on deposit in banks,(3)stock or securities,(4)any type of evidence of indebtedness and(5)any life, health or accident insurance policies. If there is any disagreement as to distribution,I direct my Executor to make such distribution, and the decision of my Executor shall be final and binding. Any items not selected or any items which my Executor considers unsuitable for my beneficiaries may be distributed or sold in the sole discretion of my Executor, and if sold, the net proceeds therefrom shall be added to the residue of my estate. Any such article allocated to a minor may, as my Executor deems advisable, either be delivered to the minor or to any person to safeguard on behalf of the minor. The reasonable costs of protecting, appraising, packing, storing, shipping, cleaning, delivering and insuring all items distributed in this Article THIRD shall be paid as expenses of administering my estate. Notwithstanding any other provisions in this Article THIRD, I may leave a separate, dated and unsigned Letter of Instruction,which I shall place with this Will,containing directions as to the ultimate disposition of certain of the property bequeathed under this Article THIRD,and such Letter of Instruction shall determine the distribution of such items. \. FOURTH: [This article has been intentionally left blank]. FIFTH: Residuary Estate. (A) I give,devise and bequeath all the rest,residue and remainder of my estate,of every kind and character, real, personal and mixed, tangible and intangible, and wherever situated, including any lapsed or renounced legacies, devises or residuary bequests and any property over which I may have a power of appointment,in equal shares to my children, SCOTT R.BURGOON, DEBORAH A.DONOHUE and CHARLES D.BURGOON,provided that the share of any child who does not survive me shall be distributed to his/her then-living natural issue in equal shares,per stirpes. (B) Prior to final distribution of my estate,the Executor,in the Executor's discretion,may make partial distributions to one or more beneficiaries or trusts. As a consequence,the executorship and any trusts created under this Will may exist contemporaneously. A distribution may be made subject to any indebtedness or liability of my estate. 4 LAST WILL AND TESTAMENT OF JOHN R. BURGOON PAGE 3 SIXTH: Spendthrift Provision. No beneficiary shall have the power to anticipate, encumber or transfer his interest in the estate in any manner other than by the valid exercise of a power of appointment. No part of the estate shall be liable for or charged with any debts, contracts, liabilities or torts of a beneficiary or subject to seizure or other process by any creditor of a beneficiary. SEVENTH: Powers of Executor. In addition to such powers and duties as may have been granted elsewhere in this Will or by law,but subject to any limitations stated elsewhere in this Will, the Executor shall have and exercise exclusive management and control of the estate and shall be vested with the following specific powers and discretion: (A) In the management, care and disposition of the estate, the Executor shall have the power to do all things and to execute such instruments as may be deemed necessary or proper, including the following powers, all of which may be exercised without order of or report to any court: (1) To sell, exchange or otherwise dispose of any property at any time held or acquired hereunder, at public or private sale, for cash or on terms, without advertisement. (2) To invest all monies in such stocks,bonds, securities,mortgages,notes, choses in action, real estate or improvements thereon, and any other property as the Executor may deem best, without regard to any law now or hereafter enforced limiting investments of fiduciaries. (3) To retain for investment any property deposited with the Executor. (4) To vote in person or by proxy any corporate stock or other security and to agree to or take any other action in regard to any reorganization,merger,consolidation,liquidation, bankruptcy or other procedure or proceedings affecting any stock, bond, note or other security. (5) To use attorneys, real estate brokers, accountants and other agents if such employment is deemed necessary or desirable,and to pay reasonable compensation for their services. � r r 1 LAST WILL AND TESTAMENT OF JOHN R. BURGOON PAGE 4 (6) To compromise,settle or,adjust any claim or demand by or against the estate and to agree to any rescission or modification of any contract or.agreement affecting the estate. (7) To renew any indebtedness; as well as to borrow money,and to secure the same by mortgaging, pledging or conveying any property of the estate, including the power to borrow from the Executor at.a reasonable asonable rate of interest. (B) Except as otherwise provided herein,whenever the Executor is directed to distribute any estate assets in fee simple to a beneficiary who is then under.twenty-five(25) years of age, the Executor shall be authorized to hold such property in trust for the beneficiary until he becomes twenty-five(25)years of age,and in the meantime shall use such part of the income and the principal of the estate or trusts as the Executor may deem necessary to provide for the proper health, maintenance, support and education of the beneficiary. If the beneficiary should die before becoming twenty-five(25)years of age, the property then remaining in trust shall be distributed to the personal representative of the beneficiary's estate. When acting as Trustee; the Executor shall have such powers as are otherwise granted under this Will to the Executor. (C) In making distributions from the estate to or for the benefit of any minor or other person under a legal disability,the Executor need not require the appointment of a guardian but shall be authorized to pay or deliver the same to the custodian of such person,to pay or deliver the same to such person without the intervention of a guardian,to pay or deliver the same to a legal guardian of such person if one has already been appointed, or to use the same for the benefit of such person. (D) In the disbursement of the estate and any division into separate shares,the Executor shall be authorized to make the distribution and division in money or in kind,or both,regardless of the basis for income tax purposes of any property distributed or divided in kind,and the distribution and division made and the values established by the Executor shall be binding and conclusive on all persons taking hereunder. (E) The Executor shall be authorized to lend or borrow, including the right to lend to or borrow from my estate at an adequate rate of interest and with adequate security, and upon such terms and conditions as the Executor shall deem fair and equitable. EIGHTH: Rights and Liabilities of Executor. No bond or other security shall be required of any Executor. This instrument shall always be construed in favor of the validity of any act or omission by the Executor, and the Executor shall not be liable for any act or omission except in the COMMONWEALTH OF PENNSYLVANIA SHORT CERTIFICATE COUNTY OF CUMBERLAND I, GLENDA FARNER STRA SBA UGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 20th day of June, Two Thousand and Thirteen (D Letters TESTAMENTARY in common form were granted by the Register of said County, on the estate of JOHN R BURGOON late of LOWER ALLEN TOWNSHIP (First,Middle,Last) in said county, deceased, to SCOTT R BURGOON (First,Middle,Last) and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 20th day of June Two Thousand and Thirteen. File No. 2013- 00678 PA File No. 21- 13- 0678 Date of Death 611512013 S.S. # Registe� t/s (' Puty NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL PA REV-1500 SCHEDULE E CASH, BANK DEPOSITS & MISCELLANEOUS PERSONAL PROPERTY � ,Q1(�1 1057 0022 r TL--._ P.O. Box 4887 �� Rd=B Lancaster,PA 17604 LISTENING IS JUST THE BEGINNING! fultonbank.com / STATEMENT OF ACCOUNTS I,I 3623-51271 X Temp-Return Service Requested STATEMENT PERIOD j FROM THROUGH 5-28-13 6-25-13 0 PAGE 1 OF 2 111'1'I'I��'1' 't�l�ll��� I'1111,IIrl�lllrrll 0 ENCLOSURES TR00051 013761 0.6500 .AT 0.384 0 70,HN R .SURGOON . 522.5 WILSON LN APT 225 U- MECHANICSBURG PA 17055-6663 LL ACCOUNT: 3623-51271 PRIME LIFE INTEREST CHECKING SERVICE ENDING DEPOSITS/ . CHECKS/ 10 FEES BALANCE PREVIOUS S DEBITS 5,912.43 STATEMENT BALANCE CREDITS 6,023.67 6,136.88 6,025.64, ACCOUNT/INTEREST INFORMATION INTEREST PAID THIS YEAR DEPOSITS/" CHECKS/ - - BALANCE - _-f CREDITS DEBITS DATE ACTIVITY DESCRIPTION REFERENCE 6,025.64 OS-28 BEGINNING BALANCE 2.07 05-28 CHECK 1334 00313202020 43.25 5,959.64 05-28 CHECK 1335 00315402120 20.68 05-28 CHECK 1336 00316707380 1 800.00 05-29 AEIS CREDIT 130528 00077900000 17 21 7,742 ,43 0300640507711 1333 00328804850 61.78 05-29 CHECK 1337 00301304800 200.00 7,480.65 05-30 CHECK `" 05-30 CHECK 1339 00304509740 1,269.00 05-31 US TREASURY 310 00077900000 XXVA BENEF 053113 5,518.00 3,231.65 XXXXXO159 00 101338 00308909485 05-31 CHECK 00077900000 1,293.58 06-03 GLAXOSMITHKLINE C,j I'D PAYMENT 130601 GSKREMACADIAABS 00077900000 1,661.00 06-03 Xxs�RSEC 060313 - 6,186.23 XcXKX0159A SSA 30.70 06-04 AGIA800-235-6943 00077900000 o LITINSPG 060313 43.19 0000SBUR743028A 06-04 VERIZON.WIRELESS 00077900000 6,112.34 o 10 PAYMENTS 130604 5,912.34 . � 051949086400001 04975207310 200.00 5,912 .43 lt�CD 06-10 WITHDRAWAL 09 5,912 .43 U-� 06-25 INTEREST CREDIT 06-25 ENDING BALANCE CHECK SUMMARY * INDICATES SKIP IN CHECK NUMBERS AMOUNT AMOUNT CHECK NO 43.25 CHECK NO 17.21 1335 20.68 1333 2.07 1336 i 1334 I PETERSBURG PA 17520; 1-800-800 INQUIRIES: PO BOX 504' EAST , NOTICE:SEE REVERSE SIDE FOR IMPORTANT INFORMATIC CHECK REQUEST FORM AJUVitl a Q 0 ASBURY SERVICES,INC.&AFFILIATES 201 RUSSELL AVENUE GAITHERSBURG,MD 20877 PAY TO: SEND CHECK TO: Estate of John Burgoon c/o Scott Burgoon,POA ❑ PAYEE 1749 Keel Drive OTHER(SPECIFY BELOW) Eldersburg,MD 21784 __ _ _ _ ----------------------- Send check to Beth Merkel at Bethany Village.Please provide check copy to Stefanie Harris. EXPLANATION: Entrance Fee Refund Date Check Required 187ul.13 Check Total $ 24,629.53 ENT FAC DEPT ACCT DESCRIPTION $AMOUNT 810 00 00 2800 Standard Entrance Fee $ 28,846.53 810 00 00 1206 Resident Refund $ (4,217.00) TOTAL: $ 24,629.53 BV Marketing S. Harris ORIGINATED BY DATE APPROVED BY DATE 3-4 BURGOON JOHN R C/O SCOTT R BURGOON 1749 KEEL DRIVE ELDERSBURG MD 21784 AGENT NUMBER: 0004278 ISSUE DATE: 08/20/2013 MCO = 05; MOD = 20 PLEASE FOLO AT PERFORATION BEFORE SEPARATING CHECK THE BANK OF NEW.VORK MELLON %r70'- PA �/' IS.SUED'BY: DONE. -N UAL INS. CO. M t�NCE GROLIl' GA RETURNED. PREMIUM :"•: DATE:, AUGUST 20, 2013 ' G 1022485:'INSURED: BI7RGOON JOHN R :f:Y '`.CHECK NO.. 2237215 I k. : + BURGOON ,JOHN R- PAVTO PAY S-;�r�;;;,":;;,��;;4,': THE,ORDER C/,0-SCOTT. R BURGOON 34.00 OF. 1749 KEEL DR:IV,E i CHECK IS VOID OVER'$5,000.00 WITHOUT TWO SIGNATURES SBURGMD T RESEATE6 WITNfN 6 MONTHS ISSUE DATE 1 .H MP u■ 22372LSilo 1:043301GO0: 0L4111079111' BankofAmerica 13 October 15, 2013 \ V Dear John R Burgoon Estate, Enclosed you will find a check which represents a credit balance refund from your Bank of America account. Remember that all credit balance refunds are subject to final audit. Any adjustments will be posted to your account. If you have further questions, please contact our Customer Satisfaction Department at 1-800-441-9977. We appreciate this opportunity to be of service to you. THE FACE OF THIS DOCUMENT HAS A MULTICOLORED BACKGROUND ON BANK OF AMERICA--NA - 503 02-57 AZ9 ZZrJ�42 DEPT : .7 1825 E BUCKEYE RD PHOENIX AZ 85034-421:6,: 91=170/1221.' . • -,.October 161'�2013'.. PAY TO THE :ORDER OF $25.62 rgoon :state° .:. :•,�,�*** twenty." iv e and--`62/160' • Mot Vai'id After 120 Days DOLLARS BM10151301-02098 :4.264 29'6!•&329 XXXX John R Burgoon Estate 1749 Keel Dr Bank ofAmerica Eldersburg, MD 21784 1150022584209115 1: 1 2210L7061: L89003L33115 Bank of Americ dwd�� d� October 15, 2013 Dear John R Burgoon Estate, Enclosed you will find a check which represents a credit balance refund from your Bank of America account. Remember that all credit balance refunds are subject to final audit.Any adjustments will be posted to your account. If you have further questions, please contact our Customer Satisfaction Department at 1-800-441-9977. We appreciate this opportunity to be of service to you. THE FACE OF THIS DOCUMENT HAS A MULTICOLORED BACKGROUND O BANK OF RICA`NA DEPT AZ9-503-02-57 :' :' 22552�9,�< 1825 E BUCKEYE RD PHOENIX AZ 85034-4216- - PAY TO THE John:R RDER OF :Bur oanEsta#e *tax $35.54 Thiif: Five:ald 54/100::. Not Valid After Days '� � � - '> `°' >` DOLLARS BMI0151301-00487 "`''5490 9946'6535 XXXX y John R Burgoon Estate 1749 Keel Dr BankofAmenka - Eldersburg, MD 21784 O!s�� ` n■00 2 2 58 2 5 9811' 1: 1 2 2 LO L 706 : 18900 3 L 3 3110 PA REV-1500 SCHEDULE G INTER-VIVOS TRANSFERS and MISCELLANEOUS NON-PROBATE PROPERTY T EU FILES I �W pa d ife_vPrF cotnmun ceti95C9 t' To Kenneth L Rapp/Reld/AMPF ••er/GO -F r_ •.., ; erY;by cc Samarth•R 0owar/CMN1AMPF r•_; b 06%20/201310:06.AM. S l ct 19510945 9 001 JO R BU RGOON DEATH SETTLEMENT UIREMENTS-PLEASE DO NOT _ t•, DELET RiverSource life Insurance Company Ameriprise Financial Company 70100 Ameriprise Financial Center Minneapolis,MN 55474 w a a s� June 20,2013 ca c� G>� KENNETH LEE RAPP 25 S 35TH ST CAMP HILL,PA 17011-4409 19510945 9 001 Dear I ENkWM LEE RAPP: We have received notification of JOHN R BURGOON's death. The deceased's name appears on the following accounts. Account values as of 06/15/2013 are listed below. At the end of this letter, you will find a list of beneficiaries shown in our initial review of the accounts Account Information Basic Brokerage Account Number Ownership 00064050258 9 133 IRA-beneficiary designated Basic Brokerage with ONE Account Number Ownership 000640507711 133 Individual-TOD Basic Brokerage Account Number Total Value 00064050258 9 133 $20,896.67 Basic Brokerage with ONE Account Number Total Value 000640507711133 tl3,302.38 � 'age 3 of 6) In order to take appropriate steps to settle the accounts we will need these documents: Estate Settlement Form(3248) (For accounts:000640502589 133,00064050771 1 133) To process a settlement on a Beta account,each claimant must complete an Estate Settlement Form(Form 3248). This form includes separate sections for qualified and non-qualified accounts as well as sections at the end of the form to be signed and dated by all new account holders for all accounts. The account level suitability information requested on the form is required if you intend to retain the investments you receive through this process. If suitability information is incomplete we will not delay settlement;however,activity allowed on any accounts created through settlement will be limited to liquidation only. We will not contact you to complete the suitability information. Instructions for completion of the Estate Settlement Form are available as Form 3248-INST. Both forms are available through an Ameriprise Financial Advisor or online at http://ww%v.airieriprise.com/amp/global/customer-service/account-service.asp under the Iist heading "Estate Q Settlement". ol An Obituary or Statement listing all children of the decedent (For accounts:00064050258 9 133,00064050771 1 133) Because the beneficiary designation is living lawful children or children per stirpes,we require either an obituary or a statement signed by either the advisor or an adult child, listing all children of the decedent (both living and deceased).If a child is deceased,we require a certified copy of his or her death certificate. In addition to this, other requirements may be needed. Additional Account Features Form 15028 version AD(01/10)-Important Notice for ONE Financial Accounts and SPS Advantage Accounts with ONE Features-Potential Loss of Features (For account:00064050771 1 133) ONE Financial Account features include the following: Check Writing, ATM Card, Credit Card, On-Line Bill Payment, Over Draft Protection,High-Yield Savings.The estate settlement process may impact the availability of the features associated with a deceased client's Ameriprise ONE Financial Account or SPS Advantage Account with ONE features. The account features will still be accessible to a surviving joint owner or trustee(s),currently listed on the account, until we have received all requirements to complete settlement. To ensure the continuation of features for the new account registration please submit a completed Additional Account Features Form 15028, as well as a signed and completed W-9 for any new fiduciary that will be on the new account registration. If these forms have not been received in our office at the time of settlement,features may be'removed during the settlement process. Please contact our office at 1-800-862-7919,Option 2 ask for Estate Settlements. Request for Waiver or Notice of Transfer(Possible)(PA)Form REV-516 EX (For accounts:00064050258 9 133,00064050771 1 133) This document verifies that the state tax bureau is consenting to the transfer of the assets. Form REV-516 should be completed by the beneficiary and mailed to the Pennsylvania Department of Revenue. A waiver will be sent to Ameriprise Financial stating that the assets can be released. Copy of Certified Death Certificate (For accounts:00064050258 9 133,000640507711 133) The death certificate can be a photocopy of the original document that bears certification from the health department or local registrar and includes the cause of death. In order to be compliant with fair claims practices of many states we will be immediately corresponding with the beneficiaries listed for any Life and Annuity accounts held by the deceased client. Similarly we will be corresponding with the beneficiaries or claimants of all accounts held by the decedent within a minimum of six months of the date of this letter. Please contact us if you wish to see a copy ofthese correspondences. We also request any information you may have that may facilitate our efforts to contact other beneficiaries on the accounts involving the deceased. i u 4 Beneficiary Information We have the following beneficiaries on record for the deceased's accounts. Account Number: 00064050258 9 133 Designation: PRIMARY BENEFICIARY LIVING,LAWFUL CHILDREN IN EQUAL SHARES 100.00% IF A CHILD IS DECEASED,HIS OR HER SHARE TO BE PAID TO HIS OR HER LIVING,LAWFUL CHILDREN IN EQUAL SHARES I Account Number: 00064050771 1 133 Designation: PRIMARY BENEFICIARY 0 LIVING,LAWFUL CHILDREN IN EQUAL SHARES 100.00% t.M IF A CHILD IS DECEASED,HIS OR HER SHARE TO BE PAID TO HIS OR HER LIVING,LAWFUL CHILDREN IN EQUAL SHARES PA REV-1500 SCHEDULE H FUNERAL EXPENSES and ADMINISTRATIVE COSTS Service Corporation International ° ❑ PRINT SINGLE CASH RECEIPT Data 71182013 Page 1 of 1 Batch#: 98764170 Batch date: 7/18/2013 #of Trans: 1 Batch Amt: $1,044.51 Location: 7411 -Neill Funeral Home,Inc. Cash Receipt date: 7/18/201311:56:00 AM Address: 3401 Market Street Cash Receipt#- 741113967827 Camp Hill PA 170114428 Cash Receipt Amt: 1044.51 Payment Check Payer. Scott Burgoon Ref# Check#1001 Type: Contract# Ptirduaser Amt 741101000419 Burgoon,Scott R. 1044.51 GL Account Description Amt Total: 1044.51 Trans ID - Neill Funeral Home,Inc. 3401 Market Street ,\ Camp Hill,PA 170114428 (717)737-8726 �� ti Supervisor:Kevin J.Shillabeer 7 f The following is a detailed bill for the professional services andlor merchandise arranged for John R.Burgoon Date of Service:June 29,2013 Scott R.Burgoon Statement Date July 03,2013 1749 Keel Dr Contract Number 741101000419 Eldersburg,MD 21784-6577 Arranger Name Kevin J Shillabeer Initial Selection Final Selection Difference Funeral Director and Staff Services Basic Professional Service Fee $870.00 $870.00 -- Total Funeral Director and Staff Services $870.00 $870.00 -- Care and Preparation of Remains Refrigeration $400.00 $400.00 -- Total Care and Preparation of Remains $400.00 $400.00 — Use of Facilities and Related Services Supervision for Memorial Service at Funeral Home $395.00 $395.00 -- Total Use of Facilities and Related Services $395.00 $395.00 — Transportation Transfer of Remains to Funeral Home $495.00 $495.00 Transfer to or From Crematory $195.00 $195.00 -- Service Vehicle $195.00 $195.00 -- Total Transportation $885.00 $885.00 — Other Goods and Services Cremation Fee $395.00 $395.00 – Compassion Helplines $225.00 $225.00 -- US Aftercare Planner $225.00 $225.00 --- VFW Flag Case $175.00 $175.00 — Memorial Package $85.00 $85.00 -- Total Other Goods and Services $1,105.00 $1,105.00 — Merchandise r 21 A tv BETHANY VILLAGE t 325 Wesley Drive Mechanicsburg, PA 17055 ico5 SERVICE/MATERIAL INVOICE 3482 Bethany Village Provided by Scott Bu[goon 7/10/13 Provided To Billing Date Debbie Barris 3482 Prepared By Invoice Number Date Service Performed/Material Used Rate/Price Total Catering Charges 6/29/13 Memorial $468.73 Sales Tax 23.63 Total $492.36 **Please return one of the copies with payment. Thank you.** �RRSSOCV�`° CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717)249-3166 Fax:(717)249-2663 July 26, 2013 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Mark E. Halbruner, Esquire RE: John R. Burgoon Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: July 12, July 19, and July 26, 2013 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVANIA : ss. COUNTY OF CUMBERLAND Lisa Marie Coyne,Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, viz: July 12, July 19, and July 26, 2013 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time,place and character of publication are true. 'sa Marie Coyne, ditor J� SWORN TO AND SUBSCRIBED before me this 26 day of July, 2013 Notary Burgoon,John R,dec'd. Late of Lower Allen Township. Executor: Scott R. Burgoon c/o Mark E.Halbruner,Esquire,Gates, Halbruner, Hatch & Guise, P.C., _ 1013 Mumma Road, Suite 100, FN TAARIAL SEAL Lemoyne,PA 17043. RAH A COLLINS Attorneys: Mark E. Halbruner, Notary Public Esquire, Gates, Halbruner, Hatch CARLISLE BOROUGH,CUMBERLAND COUNTY &Guise,P.C.,1013 Mumma Road, Suite 100,Lemoyne,PA 17043. on Expires Apr 28,2014 The Patriot-News Co. *2020 Technology Pkwy Patti*� Suite 300 Mechanicsburg, PA 17050 Now you know Inquiries - 717-255-8213 GATES, HALBRUNER & HATCH, P.C. ATTN: TRACI HILFERDING 1013 MUMMA ROAD SUITE 100 LEMOYNE PA 17043 THE PATRIOT NEWS THE SUNDAY PATRIOT NEWS Proof of Publication Under Act No. 587, Approved May 16, 1929 Commonwealth of Pennsylvania, County of Dauphin) ss Marianne Miller, being duly sworn according to law, deposes and says: That she is a Staff Accountant of The Patriot News Co., a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, with its principal office and place of business at 2020 Technology Pkwy, Suite 300, in the Township of Hampden, County of Cumberland, State of Pennsylvania, owner and publisher of The Patriot-News and The Sunday Patriot-News newspapers of general circulation, printed and published at 1900 Patriot Drive, in the City, County and State aforesaid; that The Patriot-News and The Sunday Patriot-News were established March 4th, 1854, and September 18th, 1949, respectively, and all have been continuously published ever since; That the printed notice or publication which is securely attached hereto is exactly as printed and published in their regular daily and/or Sunday/Community Weekly editions which appeared on the date(s) indicated below. That neither she nor said Company is interested in the subject matter of said printed notice or advertising, and that all of the allegations of this statement as to the time, place and character of publication are true; and That she has personal knowledge of the facts aforesaid and is duly authorized and empowered to verify this statement on behalf of The Patriot-News Co. aforesaid by virtue and pursuant to a resolution unanimously passed and adopted severally by the stockholders and board of directors of the said Company and subsequently duly recorded in the office for the Recording of Deeds in and for said County of Dauphin in Miscellaneous Book"M", Volume 14, Page 317. PUBLICATION COPY This ad# 0002266117 ran on the dates shown below: July 09, 2013 July 16, 2013 '°- July 23, 2013 < .i�� . . . . . . . . . . . . . . . . . . . . and subscribed bef m, is 31 day of July, 2013 A.D. o ary Public (T_ MMO EALTH OF PENNSYLVANIA Notarial Seal Holly Lynn Warfel,Notary public Washington Twp.,Dauphin County My Commission Expires Dec.12,2016 i MEMBER,PENNSYLVANIA ASSOCIATION OF NOTARIES LETTERS TESTAMENTARY for the Estate of John R.Burgoon,deceased, late of Lower Allen Township, Cumberland County,Pennsylvania, having been granted to the executor named below,all persons Indebted to the Estate are requested to make Immediate payment and those having claims against the Estate are requested to present them for settlement without delay to: Scott R.Burgoon,Executor c/o Mark E.Halbruner,Esquire GATES,HALBRUNER, HATCH&GUISE,P.C. 1013 Mumma Road,Suite 100 Lemoyne,PA 17043 PA REV-1500 SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES and LIENS nkof America JOHN R BURGOON Account Number:5490 9946 6535 9766 May 12-June 13,2013 Account Information: K•ww.bankofamerica,com Payment Information Account Mail billing Inquiries to: New Balance Total........................................................................$403.14 Previous Balance...........................$492.24 Bank of America Current Payment Due......................................................................$15.00 Payments and Other Credits..............—200.00 P.O.Box 982235 Purchases and Adjustments................105.31 El Paso,TX 79998.2235 Total Minimum Payment Due............................... ..................$15.00 Fees Charged.................................................... ........... 0.00 Mail payments to: Payment Due Date.............. ............7/10/13 Interest Charged ................................5.59 Bank of America P.O.Box 1.5019 Late Payment Warning:If we do not receive your Total Minimum Payment by New Balance Total.................... .....$403.14 Wilmington,DE 19886-5019 the date listed above,you may have to pay a late fee of up to$35.00 and — Customer Service: your APRs may be increased up to the Penalty APR of 29.99%. Total Credit Line..........................$21,600.00 1.800.789.6701 Total Minimum Payment Warning:If you make only the Total Minimum Total Credit Available...................$21.196.86 Payment each period,you will pay more in interest and it will take you longer Cash Credit Line...........................$4,400.00 (1.800.3463178'I-FY) to pay off your balance. For example: Portion of Credit Available for Cash.......................................$4,400.00 it you niake You VVIII fxlyoff Atid Statement Closing Date....................6/13/13 adiditional c4argvs the balance up paying ary esUrneited Days in Billing Cycle..................................33 using this card shown,on this o of land each,• • • about Only the Total 3 years $499.78 Minimum Payment If you would like information about credit counseling services,call 1-866.300-5238. Transaction Posting Reference Account Date Clete DescrJption Number Number Amount Total Payments and Other Credits 05/29 PAYMENT-THANK YOU 9590 —200.00 —$200.00 Purchases and Adjustments 06/08 06/10 NICK'S 114 CAFE NEW CUMBERLANPA 0113 9766 27.03 06/10 06/11 AUTOCAMP CAMP HILL PA 0019 9766 78.28 $105.31 Interest Charged 06/13 06/13 Interest Charged on Purchases 5.59 continued on next page... Enclosure(s) 20130619192753001920 AO 0622 302 000 1 01264 #002 8P 0.364 JOHN R BURGOON c/o scott burgoon 1749 KEEL DR ELDERSBURG, MD 21784 i-iin•I•�jlll�lllihnih1ll11hl1•I Rill IIIIIIIN1n 1111