Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
03-18-14
150`5610105 REV-1500 EX(m-ii)(Ft) OFFICIAL USE ONLY PA Department of Revenue pennsytvama Bureau of Individual Taxes °°—°`— County Code Year File Number Po Box 28o6o1 INHERITANCE TAX RETURN �7 Harrisburg,PA 17128-o6oi RESIDENT DECEDENT (_1 13 �� /__ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 'F- 02/27/2013 04/16/1953 Decedent's Last Name Suffix Decedent's First Name MI f HALL JOHN [A](If Applicable)Enter Surviving Spouse's Information Below Spouse's_ Last Name Suffix Spouse's First Name MI HALL r� ^TV BOONCHUAY Spouse's Social Security Number 201 0-44-6624 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW C 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 p 5. Federal Estate Tax Return Required death after 12-12-82) CIM 6.Decedent Died Testate O 7.Decedent Maintained a Living Trust 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 O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number BRENDA A. SORRESSO — f(717)240-0688T f REGISTER OF WILLS USE ONLY First Line of Address LEARVIEW AVENUE Second Line of Address City or Post Office State ZIP Code DATE FILED CARLISLE PA 17013 Correspondent's e-mail address: sorresso @pa.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 preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE 03/18/2014 ADDRESS 4 CLEARVIEW AVENUE, CARLISLE, PA 17013 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 J - �1 1505610205 REV-1500 EX(Fl) Decedent's Social Security Number Decedent's Name: JOHN A. HALL RECAPITULATION 1. Real Estate(Schedule A). ............................................ 1. 0.00 2. Stocks and Bonds Schedule B 2. 0.00 1 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. 2,500.00 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. 63,691.22 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 0.00 8. Total Gross Assets total Lines 1 through 7 8. 66,191.22 9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. 6,348.00 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)......... ...... 10. 203,013.66 11. Total Deductions(total Lines 9 and 10)................................. 11. 209,361.66 12. Net Value of Estate(Line 8 minus Line 11) . ............................. 12. 0.00 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. 0.00 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. 0.00 16. Amount of Line 14 taxable at lineal rate X.0_ 16. 0.00 17. Amount of Line 14 taxable at sibling rate X.12 17. 0.00 18. Amount of Line 14 taxable at collateral rate X.15 18. 0.00 19. TAX DUE ......................................................... 19. 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 J REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENTS NAME JOHN A. HALL STREETADDRESS 2061 RESERVOIR DRIVE CITY STATE ZIP CARLISLE PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 0.00 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 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 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.......................................................................................... ❑ N 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?.............................................................................................................. ❑ 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 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[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and 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. ^ h_3 `+ ►� F:\FILES\DATAFtLE\FstatePiatmmgit1486.LwUL2005 .. ` rn M 'r f7 C"7 C'3 . 11K LAST WILL AND TESTAMENT ° c-, c> o - !:D C= I, JOHN ALLEN HALL, of North Middleton Township,-.Cmkiberland Cuui , Pennsylvania,being of sound and disposing mind and memory,do hereby make,publishaiid declare this to be my Last Will and Testament,hereby revoking any and all former Wills or Codicils made by me. 1. I direct that all my legally enforceable debts, funeral expenses, testamentary expenses and all death taxes(whether such taxes may be payable by my estate or by any recipient of any property) shall be paid from my residuary estate as soon as practicable after my decease and as part of the administration of my estate. My Executrix shall have no duty or obligation to obtain reimbursement for any such tax so paid,even though on proceeds of insurance or other property not passing under this Will. 2. If my wife shall survive me by thirty(30) days, then I give,devise and bequeath all of my estate,both real and personal property, unto my wife,BOONCHUAY HALL,absolutely. 4. I nominate, constitute and appoint my wife, BOONCHUAY HALL, as Executrix of my estate. 5. I direct that my'Executrix shall not be required to file a bond to secure the faithful performance of her duties in any jurisdiction. 6. I authorize and empower my Executrix, in her sole and absolute discretion, to purchase or otherwise acquire and retain any investments of which I die seized or any real or personal property of any nature; to sell, lease, pledge, mortgage, transfer, exchange, dispose of or grant options in regard to any or all property of any kind forming a part of my estate for such terms and such prices as she may deem advisable; to borrow money for any purposes connected with the protection and Initials] Page 1 of 3 Pages r preservation of my estate;to mortgage or pledge any real or personal property forming a part of my estate or to join in or secure the partition of same; to compromise any claims or demands of my estate against others or of others against my estate; to make distribution in kind and to cause any share to be composed of cash,property or undivided fractional shares in property different in kind from any other share; to employ agents, attorneys and proxies and to delegate to them such power as my Executrix considers desirable and to pay reasonable compensation for such services as may be rendered by such agents, attorneys and proxies; and to execute and deliver such instruments as may be necessary to carry out any of these powers. In addition,I direct that my Executrix shall have the power to conduct an inventory of any safe deposit box necessary to the administration of my estate. IN WITNESS WHEREOF I have hereunto set my hand and seal this ///J-' day of • ��. (SEAL} ohn Allen Hall SIGNED,SEALED,PUBLISHED AND DECLARED bythe above-named Testator,as and for his Last Will and Testament,in the presence of us,who at his request,have hereunto subscribed our names as witnesses thereto,in the presence of the said Testator and of each other. Page 2 of 3 Pages COMMONWEALTH OF PENNSYLVANIA ) - SS. COUNTY OF CUMBERLAND ) We,John Allen Hall, � t G� rK t C X— and the Testator and the witnesses, respectively,whose names are signed to the oregoing instrument, being first duly sworn,do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his last Will and that the Testator has signed willingly, and that the Testator executed it as his free and voluntary act for the purposes therein expressed,and that each of the witnesses, in the presence and hearing of the Testator,signed the Will as a witness and that to the best of his/her knowledge the Testator was at that time eighteen years of age or older,of sound mind and under no constraint or undue influence. 17 0ohn Allen Hall,Testator Witness Witness Subscribed, sworn to and acknowl ged before me by John Allen Hall, the T tator, and subscribed and sworn to before me by 4,L- >and the witnesses,this /Aday of��6-X4 Notary Public NOTARIAL SEAL VICTORIA L. OTTO, NOTARY PUBJ2006y CARLISLE BORO., CUMBERLAND C MY COMMISSION EXPIRES DEC.2 Page 3 of 3 Pages REV-15o8 EX+(o8d2) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: JOHN A. HALL 2113-0657 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 1. Vehicle- 1999 Pontiac Montana 2,500.00 TOTAL(Also enter on Line 5, Recapitulation) $ 2,500.00 If more space is needed,use additional sheets of paper of the same size. REV-1509 EX+(oi-io) pennsylvania SCHEDULE F ' DEPARTMENT OF REVENUE I JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: JOHN A. HALL 2113-0657 If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. Boonchuay Hall 2061 Reservoir Drive, Carlisle, PA 17013 Widow B. C. JOINTLY OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH REM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 12112184 Members 1st Federal Credit Union - Account#12073 12,382.44 50% 6,191.22 B. 09/30/99 Real Estate Property - 2061 Reservoir Drive, Carlisle,PA 17013 115,000.00 50% 57,500.00 I TOTAL(Also enter on Line 6, Recapitulation) $ 63,691.22 If more space is needed,use additional sheets of paper of the same size. Send Inquires to: Statement of Accounts St 5000 Louise Drive PO Box 40 Mechanicsburg,PA 17055 Feb 01 , 2013 thru Mar 24, 2013 www.memberslst.org Main Switchboard: (717)697-1161 or(800)283-2328 EZ Call: (717)697-4372 or(800)283-4372 Account Number: 12073 ® TDD: (717)697-5312 or(800)283-2328 ext.5312 TeleBranch: (717)795-6049 or(800)237-7288 MEMBERS 1st Balances at a Glance: FEDERAL CREDIT UNION Checking: 0.00 Savings: 1,115.00 Certificates: 6,813.53 JOHN A HALL Loans: 0.00 BOONCHUAY HALL Money Management: 0.00 C/O BOONCHUAY HALL 2061 RESERVOIR DRIVE Swipe 5 YTD Reward: 0.40 CARLISLE PA 17013-1057 Page: 1 of 3 Your current Member Loyalty Rewards level is Titanium. We're looking for the"Best of Show-Dog" and "Best of Show-Cat"I Enter our Pet Photo Contest today. See the enclosed insert for more details. CHECKING ACCOUNTS 0011 - CHECKING Date Transaction Description Additions Subtractions Balance Feb 01 Balance Forward 2,479.83 Feb 02 Withdrawal Debit Card CHECK CARD 14.99- 2,464.84 02/02 717-218-0282 GOLD'S GYM CARLISLE PAUSO4490 Feb 03 Withdrawal POS#550596 25.70- 2,439.14 BYS WHOLESALE C 460 Stat CAMP HILL PA Feb 05 Withdrawal Debit Card CHECK CARD 29.95- 2,409.19 02/04 818-7007000 LIFE ALERT EMERGENCY#1 CAUS440 Feb 05 Withdrawal Debit Card CHECK CARD 40.17- 2,369.02 02/05 800-2303833 HCG*HARRIET CARTER PAUS2924700 Feb 14 Withdrawal Debit Card CHECK CARD I 18.90- 2,350.12 02/13 FUEL ON CARLISLE CARLISLE PA Feb 18 Withdrawal Debit Card CHECK CARD 14.91- 2,335.21 02/17 TURKEY HILL#294 MECHANICSBURG PA_ Feb 21 Check 003394 Tracer 0000409664 17.95- 2,317.26 Feb 26 Deposit by Check �' 3,944.16 6,261.42 Feb 26 Withdrawal 800.00- 5,461.42 Feb 28 Deposit Dividend 0.050% 0.10 5,461.52 Annual Percentage Yield Earned 0.050%from 02/01/2013 through 02/28/2013 ( Based on Average Daily Balance of 2,697. 17 Feb 28 Deposit Swipe 5 Rebate 0.25 5,461.77 f Mar 02 Withdrawal Debit Card CHECK CARD _ t 14.99- 5,446.78 03/02 717-218-0282 GOLD'S GYM CARLISLE.PAUSO4490 j Mar 04 Withdrawal `` 630.00• 4,816.78 Mar 04 Withdrawal 4,786.83- 29.95 Mar 04 Check 003395 Tracer 000029-8'58-6; 164.88- 134.93- Mar 04 Withdrawal Courtesy Pay fee 35.00- 169.93- Mar 05 Withdrawal Debit Card CHECK CARD 29.95- 199.88- 03/04 818-7007000 LIFE ALERT EMERGENCY#1 CAUS440 Mar 05 Check 003396 Tracer 0000408697 72.17- 272.05- j Mar 05 Withdrawal Courtesy Pay fee 35.00- 307.05- Mar 06 Check 003397 Tracer 0019253594 259.08- 566.13- Processed Check- HARTFORD FIRE IN TYPE:CHECKPYMT ID:2060383750 DATA:01-HARTF783- I --- Continued on following page--- Send Inquires to: Main Switchboard: (717)697-1161 or(800)283-2328 5000 Louis Nt PO Box 40 a Drive EZ Call: (717)697-4372 or(800)283-4372 Feb 01,2013 thru Mar 24,2013 Mechanicsburg,PA 17055 TDD: (717)697-5312 or(800)283-2328 ext.5312 Account Number: 12073 EMBE�RS�1• TeleBranch: (717)795-6049 or(800)237-7288 www.memberstst.org Page: 2 of 3 Date Transaction Description Additions Subtractions Balance Mar 06 Withdrawal Courtesy Pay fee 35.00- 601.13- Mar 08 Check 003398 Tracer 3611509875 18.97- 620.10- Processed Check- CAPITAL ONE ARC TYPE:CHECK PYMT ID:95417190BA Mar 08 Withdrawal Courtesy Pay fee 35.00- 655.10- Mar 09 Deposit REFUND CP FEE 140.00 515.10- RETURN 4 COURTESY PAY FEE Mar 09 Deposit Transfer 515.10 0.00 From HALL,BOONCHUAY XXXXXXXXXX Share 0011 Mar 24 Ending Balance 0.00 Total for Total this period year-to-date Total Overdraft Fees 140.00 140.00 Total NSF Fees 0.00 0.00 CHECK SUMMARY Check# Amount Date Check# Amount Date 003394 17.95 Feb 21 003397 259.08 Mar 06 003395 164.88 Mar 04 003398 18.97 Mar 08 003396 72. 17 Mar 05 5 Checks Cleared for 533.05 SAVINGS ACCOUNTS 0000- REGULAR SAVINGS Date Transaction Description Additions Subtractions Balance Feb 01 Balance Forward 107.47 Feb 28 Deposit Dividend 0.200% 0.02 107.49 Annual Percentage Yield Earned 0.240%from 0210112013 through 02/28/2013 Mar 04 Withdrawal 102.49- 5.00 Mar 21 Deposit 1,110.00 1,115.00 VISA CREDIT Mar 24 Ending Balance 1,115.00 0010- IRA SAVINGS i Date Transaction Description F ` Additions Subtractions Balance Feb 01 Balance Forward 0.00 Mar 24 Ending Balance j 0.00 CERTIFICATE ACCOUNTS 0017- 11 MONTH IRA CERT Maturity Date- Aug 01, 2013 Date Transaction Description + / ' Additions Subtractions Balance Feb 01 Balance Forward � 4 6,809.61 Feb 28 Deposit Dividend 0.750% 3.92 6,813.53 Annual Percentage Yield Earned 0. 750%from 02101/2013 through 0212812013 Mar 24 Ending Balance 6,813.53 YTD SUMMARIES TOTAL DIVIDENDS PAID 0000 REGULAR SAVINGS 0.04 0010 IRA SAVINGS 0.00 ... Continued on reverse side... st Send Inquires Main Switchboard: (717)697-1161 or(800)283-2328 ��. 5000 Louise Drive EZ Call: (717)697-4372 or(800)283-4372 Po Box ao Feb 01,2013 thru Mar 24,2013 Mechanicsburg,PA 17055 TDD: (717)697-5312 or(800)283-2328 ext.5312 Account Number: 12073 MEMBERS° TeleBranch: (717)795-6049 or(800)237-7288 www.memberslst.org Page: 3 Of 3 0011 CHECKING 0.21 0017 11 MONTH IRA CERT 8.25 Total Previous Year IRA Contributions 0.00 Total Current Year IRA Contributions 0.00 Total Year To Date Dividends Paid 0.25 NOTE:Total includes closed shares Total Year To Date Nontaxable Dividends 8.25 Don't forget about our new Member Loyalty Rewards Program. The more products you have with us, the more benefits you'll receive. Ask an associate for details or visit our website at www.memberslst.org for details. G i t I I . i s k i i Page 1 of 3 d Book Number. NAME Tax lean or so, Sec Ho. I • C -6 JIM name) (first name) (mWdLe name or initia v P"dence 4r�P.O:Address Z City C.HR Li S L. L-. state }•) zip /..6 r3 ate.of Birth pccupation 1 lC?f' 1L Tel 2:y r 3 l GGroup a Affiliation CU Branch 1 hereby.'Make application for membershiipp in the credit.unioh named below. an agree to conform toots- Iri laws and amendments:thereof copies of whkh have been made avaiiable tome;and to subscribe for.at least onet:(1)share.It Life Savings.insurance is carried in conneciton with my actaunt l.agree.in consideration of the. credit-union carrying such insurance,that arty designatton or change°of benefigaty m &by'me shall only.be binding.upon the credit union,if)have filed with-the credit union:priorto mi&ath.such designation orchange of beneficiary.in wdtiitg,signed by me,on the foim suppUed fly the credit union;and tnthe absence of so filing s designation or change of beneficsary,l agree on behalf of myself: heirs.etc;to indemnify and save harmless the credit union from all Mss or damage by reason o!the payment of the proceeds of.such insurance to such`per: son as the:credit uunsonpcords show to.be en. dihereto. SIGNATURE CL ,- Dater :( DAFCU Vense iActivuies Federal Credil Vnion) ' This: 4 cation-approved he'Board;Executive Committee;ar Membership:Officer .Q Date: Signed. Secret w.. Executive, - mittee Member. Membership Officer. c Goss cut 2 designations:itr each of the two Tuies above not:applicable: J JOINT SHARE ACCOUNT AGREEMENT -DAFCU (Defense Acttvities Federal Credit Union). is hereby authorized to recognize any of the. signatures:subscribed hereto.in the payment of funds or.the transa< ion of any business for this accourit :The joint owners of this account;:hereby agree.wkh each other and wifb.said Credit Union that jig sums now p.aid 41% on-shares.or heretofore or hereafter-paidin on shares by any or all'of said�oini o�rners:to their.eri dit as.surh jolm owners-with all accumulations ihereon..are-and shalt be owned by thern.jointly.with-right of survivorship: and be subject:to the withdrawal or receipt of any of:therik and;paymentto,any.of them or.-the`survivouor our. vivors.shall be°valid and discharge said Credit Union from any liability for such payment Any oraaof said join;owners may pledge all or any part of the shares in this account as collateral security to a loan or,.loans. The right or-authority of the credit union under this.agr"Fnent s W not be.changed pr termin:iled by. said:-awn4rs.-or any of them except by written notice to said credit union which shall not affect tr"sactions theretofore-maide. (the signature on first fine should be.same as•signed-oa ont of car(l) Dated 1~C. - 191 f✓) �'�'�"-- G( !7 Joint Account No 2l Q 7-3 CC 3 -Owners 3/17/2014 Page 3 of 3 JOINT SHARE ACCOUNT AGREEMENT The C•r!dit Union is hereby authorized to recognize any of the signatures subscribed hereto in the payment of fund's or the transaction of any business for this account. The joint owners of this account. hereby agrer with teach other and with said Credit Union that all sums now paid in on-shares. or heretofore or herrafter paid in on.dhares by any or all of said joint owners to their credit as such joint owners with all arr••eulations thereon,.are:aod shall be owned by theta Jointly, with right of survivorship and be subject to-die with- drawal or receipt of any of them. and payment to any of them or the survivor or survivors shall be valid and discharge said Credit Union from any liability for such payment. Any or all of said joint owners may pledge all or any part of the shares is this account as collateral security-to a loan or loans. 'The right or authority of the credit union under this agreement shall not be changed or termi- nated by-said owvm. or any of them e:rept by written notice to said credit union which shall not affect transactions theretofore made. (the signature on first line (t/) should be same as signed. on fiont of card) [?aced: April f m w joint rUxount N4. Owners Form me--i23 PA Rev. 7/62 r ~Wan W _n.......�....'....,.v. •- � 3/17/2014 TAX PARCEL NO.:�� � � DEED co Z � -� . W 4, b IG :2: rr7 --d n C> ti Z F"rl rn This Indenture, Made the 30 day of 4QA ,in the yegof Cn One Thousand'Tine Hundred and Ninety-nine(1999) b� Between: JEFFREY L. HEISHMAN and DEBORAH A. HEISHMAN, single persons, of North Middleton Township,Cumberland County,PA (hereinafter called the Grantor(s),of the.one part, and •tc C d . HALL and BOONCHUAY HALL, his wife,of York,York County,PA cu L r w (hereinafter called the Grantee(s), of the second 0— U.) IaNgS�SETH,that the said rantor(s), for and in consideration of the sum of Eighty-seven oM c4h , Kundred($87100.00) Dollars,lawful money of the United States of America, thfi well and truly paid by the Grantee(s), at or before the sealing and delivery hereof,the reftipt whereof is hereby acknowledged,have granted,bargained and sold,released and confirmed, and by these presents,grant,bargain and sell,release-and confirm-unto,the said Grantee(s),their heirs and assigns: ALL THAT CERTAIN tract of land and improvements,thereon erected, situate in North Middleton Township,Cumberland County,Pennsylvania,bounded and described in accordance with a survey and plan thereof made by D. P. Raffensperger,R.S.,dated January 1, 1961,as follows: BEGINNING at a point in the center of Township Road T-504,known as Reservoir Drive, said point being opposite the southern line of George Street(Rellim Street);thence extending along the southern line of George Street(Rellim Street) South eighty-six(86)degrees ten(10)minutes East one hundred forty-five(145)feet to a corner of land now or formerly of Carl L. Crone; thence along said land South three(3)degrees fifty(50)minutes West one hundred forty(140) feet to a point in the northerly line of the Lake View Heights Tract;thence extending along Lots No. 11 and 12 on Plan No. 3 Lake View Heights,recorded in Plan Book 9,at page 50,North eighty-six(86)degrees ten(10)minutes West one hundred twenty-three and twenty-four one- hundredths(123.24) feet to a point in the center of Reservoir Drive aforesaid;thence along the center line thereof North five(5) degrees West one hundred forty-one and sixty-eight one- hundredths(141.68)feet to the point and Place of BEGINNING. Having thereon erected a one story frame dwelling known as No. 2061 Reservoir Drive (Southeast corner George Street(Rellim Street)). UNDER AND SUBJECT to the restrictions of record. It is understood and agreed however,that the recital of the within mentioned restrictions shall not be construed as a.revival thereof in the event they have expired by limitation,violation or for any other reason.. IT BEING the same premises which Roger L.maker and Vicki L.B?ker,his wife, and Joyce H. Mumper,widow,by their deed of June 14, 1985, and recorded in Cumberland County Records in Deed Book 31 H at page 829, granted and conveyed unto Jeffrey L.Heishman and Deborah A. Heishman,his wife,Grantors herein. AND the said grantor/grantors do hereby SPECIALLY WARRANT the property hereby conveyed. IN WITNESS WHEREOF, I/We set our hands and seals the day and year first above written. Sealed and Delivered in the presence of SEAL) .` ;ISi:aVIAN y DEBORAH A. HEIS ITMAN BOOT( FACE 971 CERTIFICATE OF RESIDENCE: I hereby certify the precise residence of the Grantee(s)herein is as follows: �i l,7 o-f3 ATTORNEY/AGENT FOR G EE(S) COMMONWEALTH OF PENNSYLVANIA ss COUNTY OF Cv.rnoPrlc.►u9 On this the day of Selik I9_;before me, a Notary Public;the undersigned offcer,;personally appeared: JEFFREY L. HEISBMAN and DEBORAH A.HEISHMAN, single persons; known to me,or satisfactorily proven to be the person(s)whose Name(s)is/are subscribed to the within instrunient,and acknowledged that they executed the same for the purposes therein coutam*ed. 'IN WITNESS WHEREOF,I have hereunto set my hand and notarial seal NOT Li c7 NOT XP ARIAL SEAL COMMISSION EIRES, „E - --1tlCENY�.IfUYYEBT,lIOTARY:PUBLIC CRY OF CARU ERLAND NY COYYISSION EXPIREB.JIUQUST 11 Y009. Office for the recording of Deeds, in-and for Cumberland County,Pennsylvania,Recorders".. Certificate: m==m:m m . 93 Cr un ro ro c cna • �sw=3C r— a=74::': Ln ra CA "'rf tom”! �• - .fi:. t7-. 'rY - - . .. .... ."-. ` Fes-••,iD _ .. .F7 to-�'t-..a-+•F-+ -d3 W •"� �. , CA CA, �BOOK. IG�� .PAGE 2 ui REV-1510 EX+(08-09) I ' s , pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER JOHN A. HALL 2113-0657 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. ITEM TRANSFEREE,OF PROPERTY DATE OF DEATH %OF DECO S EXCLUSION TAXABLE INCLUDE THE NAME OF THE TRANSFER ,THEIR RELATIONSHIP TO DECEDENT AND NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST IF APPLICABLE VALUE 1. IRA(Sun Life Financial): Boonchuay Hall(Beneficiary),Widow of 76,580.99 100 0.00 John A.Hall. Date of Transfer10102l2013 TOTAL(Also enter on Line 7, Recapitulation) $ 0.00 If more space is needed,use additional sheets of paper of the same size. Sun Life Assurance Co.of Canada(US) im/ P.O. Box 9133 Wellesley Hills INIA 02481-9133 Sun `+s�� Life Financial Prepared for. Sun Life Financial Keyport Value Syr 1125 Anniversary Statement John A Hall February 18,2013 206I Reservoir Dr Carlisle PA 17013-1057 Account Value: $76,580.99 IIII'MIN'�����II�'11111111 'I��III,116�,116,16,IIIII�Ir1�,1 Contract: : KA13133285-01 Date Issued: ` . 2/18/2009 . Initial Investment: $801664.72 _Contract information _. __ _ _-- _ interest-Rafe _ -- Owner(s) John A Hall From February 18,2013 to February 18, Annuitant John A Hall 2014 your new interest rate (Effective Qualification Type Individual Retirement Account Annual Yield) is 5,05%. Bonus Rate Tiers Contract Activity Summary The interest rate is determined by the Value as of February 18, 2012 $81,309A I.: contract accumulated value,and may change Payments $0.00, with each additional payment,each.monthly Interest Earned $3,642.53 anniversar3l of the issue date or and Withdrawals $8,370.65. withdrawals. Value as of February 18, 2013 $76,580.99 Value of contract Additional Rate Surrender Value as of February 18, 2013 $75,671.20 on date of payment for each payment 49,999.99 and louver +0% 50;000.00 or greater + .15% Contact Us Visit our website ww-w-sunlife-usa.com For automated service 800-367-36.54 For all questions 800-367-3653 '= Includes all applicable surrender charges and market value adjustment. YOUR INVESTMENT ADVISOR r— MEI�SSA`GEI Craig A Nissley For a secure way of accessing your contract, Invest Fin Corp Ins Agency INC and trackingyour investment you can log on 1166 Walnut Bottom Rd to wvtw.sunlifc-usa.com.CustomerLink Carlisle PA 17013-9160 offers on-line access to your annuity 24 hours a day. Manage your contract, review current values,and download forms all at your fingertips. Sun Life Assurance Co.of Canada(US)is a member of the Sun Life Financial group of companies. 20130219 1125 Page 1 of l Contract InformationPrint Title Page 1 of 1 Sun Life Financial Contract Number:KA13133285-01 As Of:08/09/2009 Product: Sun Life Financial Keyport Value 5yr Annuitant:JOHN A HALL Contract KA13133285-01 Annuitant: JOHN A HALL Number: Account Status: INFORCE Product: SUN LIFE FINANCIAL KEYPORT Financial NISSLEY,CRAIG A VALUE 5YR 1166 WALNUT BOTTOM RD JOHN A.HALL Advisor: CARLISLE,PA 17013-9160 Owner: 2061 RESERVOIR DR Advisor Number: 2323784 CARLISLE,PA 17013 BOONCHUAY-HALL- 6192 Beneficiary: Four SSN: Tax ID Number: XXX-XX-6811 Advisor Status: ACTIVE Issue Date: 02/1812009 Account Type: INDIVIDUAL RETIREMENT ACCOUNT Next 02/18/2010 Premiums $80,664.72 Anniversary: Received Income Date: 05/01/2048 As Of Current Interest 3.45% 08/09/2009: Rate: Contract Value Interest Earned: $1,299.65 As Of $81,964.37 Premiums Paid: $80.664.72 08/09/2009: Bonus: $0.00 Optional Total $0.00 Programs: Withdrawals: Telephone NOT ELECTED Transfers: https://accounts.sunlife-usa.com/fpl/yourbusiness/accountlist/annuitycontracfnfo/index.cf... 8/10/2009 Page 1 of 1 Sun Life Financial Contract Detail for KA13133285-01 as of 10/0212013 Product Sun Life Financial Keyport Description 5 Year Contract Status Irdorce Value Syr CDSC Annuitant Boonchuay Hall Contract Type Individual Issue Date 02/18/2009 Retirement Account Owner Name Financial advisor Ncssiey,Craig A Boonchuay Hall XXX-XX-6624 Advisor last four SSN XXX-XX-6192 Contract values Total contract value $71,057.75 Total cash surrender value $69,328.70 Death benefit value $71,067.34 Withdrawals since Issue Date $24,996.40 Balance Detail Investment Options Units Unit Value(or Balance %of Total Interest rate) 5YR MVA FIXED ACCOUNT 0 5.05 $71,057.75 100.00% 5YR MVA FIXED ACCOUNT 0 5.05 $71,057.75 100.00% 5YR MVA FIXED ACCOUNT 0 5.05 $71,057.75 100.00% 5YR MVA FIXED ACCOUNT 0 5.05 $71,057.75 100.00% 5YR MVA FIXED ACCOUNT 0 5.05 $71,057.75 100.00% Total $71,057.75 10/3/2013 REV-1511 EX+ (08-13) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER JOHN A. HALL 2113-0657 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Joseph H.Brown Funeral Home, Baltimore,MD - Cremation 895.00 Cumberland Valley Memorial Gardens, Carlisle,PA - Burial and Marker 5,000.00 Rev.Lynn Schultz, Officiant 100.00 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. 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: 353.00 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL(Also enter on Line 9, Recapitulation) $ 6,348.00 If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER JOHN A. HALL 2113-0657 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. Mortgage Liability-Wells Fargo Bank NA -Property at 2061 Reservoir Drive, Carlisle,PA 17013 43,831.61 2. Carlisle Regional Medical Center- Treatment from 02/19/13 thru 07/25113 125,633.29 3. The Johns Hopkins University Clinical Practice Association - Treatment from 02125/13 thru 02/27/13 18,128.76 4. Center for Emergency Medicine(STAT MedEvac) - Emergency airlift 02/25/13 15,420.00 TOTAL(Also enter on Line 10, Recapitulation) $ 203,013.66 If more space is needed,insert additional sheets of the same size. =1 Return Mail Operations Statement date 03/13/13 PO Box 14411 # Des Moines,IA 50306-3411 Loan number 0619771686 Property address 2061 RESERVOIR DR CARLISLE PA 17013 Customer Service online Fax wellsfargo.com 1-866-278-1179 no Telephone 1-800-222-0238 1AB 24508/017480/024508 0068 1 ACQOW U 936 Correspondence PO Box 10335 Hours of operation Mon-Fri 6 a.m. p.m. JOHN A HALL Des Moines,IA 50306 Sat 8 a.m.-2 p.- CT 2061 RESERVOIR DR - Payments CARLISLE,PA 17013-1057 PO Box 11758 Purchase or refinance Newark NJ 07101 1-800-443-3429 We accept telecommunications relay service calls. Important messages DISASTER PREPARATION Summary Our disaster assistance team is here Payment(principal and/or interest,escrow) $666.98 Unpaid principal balance $43,831.61 to help if you are ever affected by a Optional product(s)2 $7 68 (Contact Cusr—SeMce f-yoarpayoffb/ance) disaster such as a fire,flood,or storm. p Interest rate 5.875% If needed please contact a customer service Escrow balance Total payment due 04/01/13 $674.66 Interest paid ceare $1,633.59 to-date $433.82 representative at the number above. Refinance now while mortgage rates are still low You may be able to refinance your mortgage and reduce your monthly mortgage payment The sooner you call,the sooner you could begin to enjoy the program benefits.Call 1-866-810-2596 Activity since your last statement or visit your local branch Date Description Total _Principal Interest Escrow Other 03/13 Payment $674.66 $269.35 $21613 $18150 Opt product$7.68 Read b Ready to u q your next home? 03/13 Principal payment $45.34 $45.34 Were here to help you understand your options, 'Credit Plus $7.68 so you can make informed home buying decisions. Learn about our low down payment programs, flexible financing options,and how we can help make buying your next home a rewarding experience.Call 1-866-418-3476,stop by your local branch,or visit wellsfargo.com/newhome. Mention Code DMR7ABL 0174 8 010 24 5 0 8ACQ0WUS1-Er-M1-coos 124 Please detach and return withyaurpsyment. - Loan number 0619771686 hlclrtid"payment -- payment r,lrt ams Current monthl y due $674.66 Y Total payment due 04/01/13 $674.66 uV- After 04/16/13 a late charge may apply $24.27 prnwipal Check here and see JOHN A HALL reverse foraddress COtn?CtiOn 24 508/0174 80/024 50 8 0068 IACQOWU936 i Z _':l:l�iiu�:'-�.lid:iT• Other WELLS FARGO HOME MORTGAGE h r_ a PO BOX 11758 - NEWARK NJ 07101-4758 cicitir>tlat w Total nmoun•t enclosed (Please do not send cash) 936 0619771686 2 10000067466006989300674660000000 000000010637336570 5 REGCARUSLE IONAL -' MLDtCAL CENTER YOUR • • Oka YOUR OPTIONS Patient Name John A Hall a Online at wrww.carlislermc.com Account Number 9546365 (available 2417) Date of Service February 19, 2013 Service Type Inpatient Services By phone-717-960-1680 Insurance Name Freedom Life ins 62324 Name of Insured John A Hall ®By credit card-complete section below and return Policy Number 656694206 Arnntun+Dris Frei^n You $125,6?3.2e,' CO By check-return section below with check YOUR • ® YOUR OF Amount due from you is$125,633.29 as of 05/05/2013 for The charges listed below do not reflect the discount that Inpatient Services performed on February 19,2013. you and your insurance company received. Nursing 2,213.64 Total Charges $125,633.29 Pharmacy 14,602.23 Discounts/Adjustments Given $0.00 Supplies 11,169.77 Insurance Payments Received $0.00 Radiology 1,873.55 Amount You Paid $0.00 Cat Scan 11;708.02 Ultrasound 782:03 Lab 9,357.96 Cardiovascular Study 1,376.26 Pharmacy 8,990.62 Amount Due F c,,T You IV Solutions 18,480.86 Emergency Room 9,396.89 s ICU 5,740.80 Cardiology 4,166.91 © A MESSAGE • • YOU... KIR� 3269-HMASTMT-1683059-1414963060-P;7363633-1-2;33267075-2;1 Your insurance has been filed as a courtesy.To date,we have received no payment from your insurance carrier.We,therefore,expect you to pay this bill.Please contact. your insurance carrier if you have any questions. FOR CREDIT CARD PAYMENT,PLEASE FILL OUT BELOW... EI MASTERCARD oec�ver Dt COVER VISA ...vJ71 O EX 6 S1E 361 Alexander Spring Rd. CARD NUMBER EXP. REGIONAL Carlisle,PA 17015 SIGNATURE SECURITY CODE PATIENT NAME STATEMENT DATE DATE DUE John A Hall 05/05/2013 UPON RECEIPT Patient Financial Services: ACCOUNT NUMBER AMOUNT DUE AMOUNT PAYING 717-960-1680 9546365 $125,633.29 n Check box it address below is incorrect or changed and indicate change(s)on back. 5540498(PC2) REMIT THIS PAYMENT STUB TO: 00"10 0202 JOHN A HALL CARLISLE REGIONAL MEDICAL CENTER 2061 RESERVOIR DR PO BOX 281442 CARLISLE, PA 17013-1057 Atlanta, GA 30384-1442 00000954636500012563329JOHNAHALL 1 0 CARLISLE REGIONAL `f I.DiCAI. CLNTER © YOUR INFORMATION I f•1 YOUR OPTIONS Patient Name John A Hall �J a Online at www.cariislermc.com Account Number 9546365 (available 24/7) Date of Service February 19, 2013 Service Type Inpatient Services By phone-T17-960-1680 Insurance Name Freedom Life Ins 62324 Name of Insured John A Hall ®By credit card-complete section below and return Policy Number 656694206 Amount Due From You $125,633.29 ®By check-return section below with check Q • • • OF Amount due from you is$125,633.29 as of 05105/2013 for Respiratory _ _ 14,359.26 Inpatient Services performed on February 19, 2013. Processing fee for blood 4,499.21 Dialysis 6,915.28 Total Charges $125,633.29 TOTAL CHARGES $125,633.29 Discounts/Adjustments Given $0.00 Insurance Payments Received $0.00 Amount You Paid $0.00 Arneent Due r-rorn You $125,633.29 A MESSAGE • • 3269-HMASTMT-9683059-1414963060-P;7363633-1-2;33267075-2;2 Your insurance has been filed as a courtesy.To date,we have received no payment from your insurance carrier.We,therefore,expect you to pay this bill. Please contact L your insurance carrier if you have any questions. r FOR CREDIT CARD PAYMENT,PLEASE FILL OUT BELOW... –� MASTERCARD ® DISCOVER Y I SM D —11111 AMEX 361 Alexander Spring Rd. CARD"UMBER EXP. fig REC1pNAl Carlisle,PA 17015 re SIGNATURE SECURITY CODE PATIENT NAME STATEMENT DATE DATE DUE John A Hall 05/05/2013 UPON RECEIPT Patient Financial Services: ACCOUNT NUMBER AMOUNT DUE AMOUNT PAYING 717-960-1680 9546365 $125,633.29 KJAYM F-1 Check box if address below is incorrect or changed and indicate change(s)on back. — &54M EM 9B THIS PAYMENTS TUB TO: es(P�) MWSMF )04410 0102 JOHN A HALL CARLISLE REGIONAL MEDICAL CENTER 2061 RESERVOIR DR PO BOX 281442 CARLISLE, PA 17013-1057 Atlanta, GA 30384-1442 gill 11111111111 1111 Jill 1ln Jill I 0 0000954636500012563329JOHNAHALL 1 THE JOHNS HOPKINS UNIVERSITY moo�r�� o r �`���, YfE CLINICAL PRACTICE ASSOCIATION � ' Y- ;:.. STATEMENT DATE: 05/01/13 CHECK NUMBER: Billing Inquiries: Call(410)933-1200 or 1-800-657-0066 or ❑ o� 3 OR 4 DIGIT p ❑ J ❑ wsc SECURITY contact us via e-mail at jhupbs @jhmi.edu (please include ❑ t5a� CREDIT CARD NUMBER account number,patient name,address,and phone number) EXPIRATION DATE Office Hours:Monday-Friday,9am-4pm SIGNATURE: m/ PAYMENT DUE DATE ACCOUNT PAY THIS AMOUNT AMOUNT ENCLOSED PATIENT: JOHN HALL NOW 30-495142A MAKE CHECK PAYABLE.AND MAIL TO: JOHN 'i�l�i'1�1"'1111'III'Il"II11'IIII't'll'lllll'll' THE JOHNS HOPKINS UNIVERSITY JOHN HALL 15243 1 AB 0.381 AMECH CLINICAL PRACTICE ASSOCIATION 2061 RESERVOIR DR PO BOX 64896 CARLISLE, PA 17013-1057 BALTIMORE, MD 21264-4896, ❑ CHECK BOX IF YOUR ADDRESS/INSURANCE HAS CHANGED (SEE REVERSE SIDE). 304094189050120130105178848963 PLEASE DETACH AND RETURN THE TOP PORTION WITH YOUR PAYMENT. STATEMENT OF PHYSICIAN SERVICES (AS OF MAY 1, 2013) ACCOUNT NUMBER: 30-4951428 PAGE PATIENT NAME: JOHN HALL THE FOLLOWING INVOICES DESCRIBE OUTSTANDING CHARGES FOR SERVICES PROVIDED BY PHYSICIANS AT THE JOHNS HOPKINS UNIVERSITY. THE LEFT SIDE DESCRIBES THE SERVICES PROVIDED AND THE CHARGES FOR EACH SERVICE. THE RIGHT SIDE DESCRIBES ACCOUNT ACTIVITY AND THE AMOUNT YOU ONE. PLEASE NOTE THAT THIS IS A PHYSICIAN BILL AND NOT A HOSPITAL BILL. CALL (443) 997-0100 OR 1-800-757-1700 FOR QUESTIONS CONCERNING YOUR JOHNS HOPKINS HOSPITAL BILL. CALL (443) 997-0100 OR 1-800-757-1700 FOR QUESTIONS CONCERNING YOUR BAYVIEW HOSPITAL BILL. CALL (443) 997-0200 OR 1-877-361-8702 FOR QUESTIONS CONCERNING YOUR JOHNS HOPKINS BAYVIEW MEDICAL CENTER BILL. CALL (443) 997-0300 OR 1-866-323-4615 FOR QUESTIONS CONCERNING YOUR HOWARD COUNTY GENERAL HOSPITAL BILL. Wt INVOICE NUMBER: 30-62526201 �" s CHARGES PAYMEN7�ACTIVI71ft `„ s ^, re � ^` �' �PROVIDER: MARGARET MARY FYNES MD 00 s JHU RADIOLOGY N07E 'tVO4�INSUKANCECLATM<1JASIi ED>FtlRTHiiSEitVICE x .... $42.00 TF�VOt} HAVELI ($URANE 4t1fAF# 01� 02/25113 71010/26-RADEX CH 1 VIEW FRNT ................... fRS� fHIS $fV10E, IES `TOTAL•. $42.00 GONTI4CT�OUR OF�ICEi1Ts(�F1t1JNJ33`1OOzORf BO0 $57<I3066`�� r xq S1r``f^�✓.r�'dt�'s�,, � �''�S-L¢4,"S?jr7 04 �{"} o�'.z'�' �S' t pro'�n�E''�A• • _ ➢t�aU 1Y+* 'k 4.1t V a. '3R tk�.f �,7kr* � ,�.° ,�Y, S�FIKAL�NOTIC)� S�fVD pAY1dENfi TODRY x„m. ,�,{ .; r� t'ttl ..ea4 ftw °ix•a. � �Ax � 3c-y t "'+rx `£ L� dam; INVOICE NUMBER: 30-62526202h ' �tRx' � q „ ! y � , CHARGES #'AYMENT ACTIVITaItv�r` ub ' � �X z r� PROVIDER: MARGARET MARY FYNES MD UNfsDUE�1VON �, rt '� $90 00 e JHU RADIOLOGY � °� x ; aryL ";¢ns (d4T FNO``INSURANCf CIIM SSERVICE 02/25/13 74000/26-RADEX ABD 1 ANTEROPOST VIEW 2 UNITS) .....: $90.00 TF`YOl1�iiAVEJINSURANCETHAf C'I}V�£RS1TflIS� £ftYICE, 'P,LEASk TOTAL: $90.00 GONT�ACT O1R{SFFIC pfs �41fl1 X33 120Q Oi( 00 65J 0065 n — �A�✓.tr�7� 5 Jy��;L .1a.+r l•rs S"+�e a,k�� .esa�x'�,, ` x u , 5 '�����3�•*�FlfitAL'ENO'[YCIr�'�5D�PA1fMENTr�ODAY.�' *������*'�" - �F.s y,tar?`.ir£.'x Er3+..yzt..k':."!n4,-.;,�a c..3�'t`'- �.rn.=:'•'�� ;.lsr �"�`h,..._ �s 7 �"�'. � INVOICE NUMBER: 30-62526203 ' CHARGES PAYMENT ACTIV TY" # N V ' y'x- `IMF d6FC:t'.`.".�' ��'4d�+�.�,�Nn�jZ y 1 c�3,. '�.. �a'r � '`^*'e 7vr PROVIDER: MARGARET MARY FYNES MD AIIUNT�Oj1E NbW" � ��x t $45 00 , JHU RADIOLOGY4 ` NOT£;NO�INSURANCE GLAIM�T+fAS'frfl 1U�fOAMI,S SERVILE � k4 02/26/13 74000/26-RADEX ABD 1 ANTEROPOST VIEW ................ $45.00 .If"YQIf +IAVf IjVSURANCf�TiiAf�OVfItS�THIS� ERVICf; LfI#SE;F TOTAL: $45.00 CONTAC7�URaOFfIGE A7'{41A) X333 12fI0 OR Z $006,�57 006b ,r: 61 '"-,* �+,;• ' a8 K o.,`A a�'x ar, •a` a 'Y�+L '.T"y, ;s p5,z .: v �� ;�!�.:s=s7i. -.k"�1 q..- ^emu-�..aF,z..;•9}:r 'a4�- ti:^i� ..9�:r. Y; IHE JOHNS HOPKINS UNIVERSITY CLINICAL PRACTICE ASSOCIATION PO BOX 64896, BALTIMORE, MD 21264-4896 (410) 933-1200 1-800-657-0066 mg-Rda mi nm STATEMENT Of PHYSICIAN SERVICES (AS OF MAY 1, 2013) ACCOUNT NUMBER: 30-4951428 PAGE PATIENT NAME: JOHN HALL Nfr, '4 INVOICE NUMBER: 30-62599600 CHARGES pAYMEHT ACTIViTyi Es aXx i f ; oa9] "`ed-�.,�,�^L�'• '2 �hv c t�•h�,R c��'�`,�C��',.•7,.. �•�'k*vY'SZ i 'e'^t�+ �,. PROVIDER: HUGH G CALKINS MD 1AM0�U1�TilUE10 h $30 00 x, JHU CARDIOLOGY OTf {�OS {dSUANCLAINt iJAS-FiLfO}FOR'sfHi$ f{i�VICE' 2 ° x.fj� J h✓ s S 9 y3 4 Ys ,> TL 02/25/13 93010-ECG ROUTINE ECG W/LEAST 12 LDS I&R ONLY ....... $30 00 rIF�YOU11U �iNSRANCIiTCOVtS THI$�SE72Vi�CE; �LfA$ � TOTAL: $30.00 CONTACT UUR;OFFiCE (430) 33 1200 Ox1Od 657-0065 ,' W.�'�} �.� 1; .r •o-b .-x>,a.°r 5.' s '.r•'Sx—.- F?'�; �• i\c,a, °o INVOICE NUMBER: 30-62616256 � $ � `� t CHARGES #�AYh1EH1 jICTiVITY � ]r �Fyr PROVIDER: JOSEPH E MARINE MD AMOUNT DUE NOW $30 00 JHU CARDIOLOGY N(STf zNOzINSURANCf £LAI1AS, ILEDFOR�TiIISE1fVICE 02/26/13 93010-ECG ROUTINE ECG W/LEAST 12 LDS I&R ONLY ....... $30.00 if Y4U HAVE`INSURI{NCf T�IAT COYfRSTlfiS� Fi1VICf,i�LEASf ; TOTAL: .$30.00 CONTACT OUR�OFFICE7 (41n)h933h200 OR1-$00 657 0066 __ INVOICE NUMBER: 30-629669034 CHARGES PAYMENT ACTIVIT)( x w Z, � * g.'rxt.Ka�'a��xt-� '4'•��'F"��7� t�� AMOUNTfDUE SNOW �U; c �frjr PROVIDER: CHRISTOPHER L WOLFGANG MD $7610 88 JHU DEPT OF SURGERY N4T �NO�`iNUkANEE C ?MfY1AS= ILEbFi3 '111IS�SERVICE� ' 02126/13 48105-RESECJ/DBRDMT PANCREAS NECROTIZING PANCREATITIS $761 0.88 IfEYUU HAl E'IfdSURAf VCfT1ATk£41tERSTa#T,S;fftSyCf° i'LEA$E� b TOTAL: $7610.88 CONtACT:OtlR©FFiGf A7�(4�8)�933s200.OR?1 800r65T {►06b : �'�....�s?�`T.u+?r....�{±.nT, kn.: •t:-s �cr Y..�`'eiq:.a.:''".c..;�:,!.;:, a2;KS,:.s,Jon..c+` . IMPORTANT: 1 1 1 1 A COLLECTION FROM 1 1 PATIENT PAYMENTS RECEIVED SINCE 04/01/13... $0.00 INSURANCE PAYMENTS RECEIVED SINCE 04/01/13. $0.00 ACCOUNT'BALANCE I INSURANCE PENDING r-7ATIENT OWES $10517.88 $0.00 $10517.88 THANK YOU FOR CHOOSING THE JOHNS HOPKINS UNIVERSITY CLINICAL PRACTICE ASSOCIATION! 0 THE JOHNS HOPKINS UNIVERSITY CLINICAL PRACTICE ASSOCIATION PO BOX 64896, 8ALTIMORE, MD 21264-4896 (410)933-1200 1-800-657-0066 015243 002 002 THE JOHNS HOPKINS UNIVERSITY "�.��� � �� �7 on CLINICAL PRACTICE ASSQCIA110N STATEMENT DATE: 06/01/13 CHECK NUMBER: Billing Inquiries: Call(410)933-1200 or 1-800-657-0066 or 3 OR 4 DIGIT Y(Sa. D r o ❑ osr-;eet ❑ ,�] SECURITY contact us via e-mail at jhupbs @jhmi.edu(please include CREDIT CARD NUMBER account number,patient name,address,and phone number) E%PIRA7IDN DATE Office Hours:Monday-Friday,9am-4pm SIGNATURE: m/ PAYMENT DUE OATE ACCOUNT 6 PAY THIS AMOUNT 6ANOUNT ENCLOSED PATIENT: JOHN HALL - MAKE CHECK PAYABLE AND MAIL TO: ��il��ilill��ll�llllll�lliilllllllll��l�nl�l�llurl liiml�lrl THE JOHNS NAPKINS UNIVERSITY JOHN HALL 15101 1 AB 0.381 AMECH CLINICAL PRACTICE ASSOCIATION 2061 RESERVOIR DR PO BOX CARLISLE, PA 17013-1057 BALTIMORERE,, MD 21264-4896 ❑ CHECK BOX IF YOUR ADDRESS/INSURANCE HAS CHANGED (SEE REVERSE SIDE). 304094189060120130076108848964 PLEASE DETACH AND RETURN THE TOP PORTION WITH YOUR PAYMENT. STATEMENT OF PHYSICIAN SERVICES (AS OF JUNE 1, 2013) ACCOUNT NUMBER: 30-4951428 PAGE 1 PATIENT NAME: JOHN HALL THE FOLLOWING INVOICES DESCRIBE OUTSTANDING CHARGES FOR SERVICES PROVIDED BY PHYSICIANS AT THE JOHNS HOPKINS UNIVERSITY. THE LEFT SIDE DESCRIBES THE SERVICES PROVIDED AND THE CHARGES FOR EACH SERVICE. THE RIGHT SIDE DESCRIBES ACCOUNT ACTIVITY AND THE AMOUNT YOU OWE. PLEASE NOTE THAT THIS IS A PHYSICIAN BILL AND NOT A HOSPITAL BILL. CALL (443) 997-0100 OR 1-800-757-1700 FOR QUESTIONS CONCERNING YOUR JOHNS HOPKINS HOSPITAL BILL. CALL (443) 997-0100 OR 1-800-757-1700 FOR QUESTIONS CONCERNING YOUR BAYVIEW HOSPITAL BILL. CALL (443) 997-0200 OR 1-877-361-8702 FOR QUESTIONS CONCERNING YOUR JOHNS HOPKINS BAYVIEW MEDICAL CENTER BILL. CALL (443) 997-0300 OR 1-866-323-4615 FOR QUESTIONS CONCERNING YOUR HOWARD COUNTY GENERAL HOSPITAL BILL. INVOICE NUMBER: 30-62966903 CHARGES PAYMENT �ICTI�11 i Y x c; f "' xt w PROVIDER: CHRISTOPHER L WOLFGANG MD ;AMOUNT'iUE ttOpl .:bra � :�.� ' � $7610 88 JHU DEPT OF SURGERY r� �* a N0�'� � TtFSUIiANCI:CLAIM WAS 1'IiEb FOR THiS' SERVTI�E 02/26/13 48105-RESECJ/DBRDMT PANCREAS NECROTIZING PANCREATITIS $7610.88 ;IF YOU NAVE ISURAi�CE JiIAT�Cfi?VERS' IISIRI�E, CEASE TOTAL: $7610.88 (ANTAC7'fllR OFFrCI A7 �41{I) 333 1200 OR 1 $OO 657 {f066 z� TO AVOID FURTHER COLLECTION ACTION, PLEASE PAY NOWII s= PATIENT PAYMENTS RECEIVED SINCE 05/01/13... $0.00 INSURANCE PAYMENTS RECEIVED SINCE 05/01/13. $0.00 ACCOUNT BALANCE I INSURANCE PENDINGI PATIENT OWES $7610.88 1 $0.00 ��E� THANK YOU FOR CHOOSING THE JOHNS HOPKINS UNIVERSITY CLINICAL PRACTICE ASSOCIATION! rHE JOHNS HOPKINS UNIVERSITY CLINICAL PRACTICE ASSOCIATION PO BOX 64896, BALTIMORE, MD 21264-4896 (410) 933-1200 1-800-657-0066 ois+ol 001 001 INVOICE CENTER FOR EMERGENCY MEDICINE PO BOX 223016 PITTSBURGH,PA 15251-2016 INVOICE#: 21113021428 TOLL FREE:866-539-0038 DATE: ST ATMedEVac 06/20/2013 Pay online at:https;l/paybill.upmc.com PRIOR PATIENT PYMTS: 0.00 BILL TO: AMOUNT DUE: 15420.00 Hall, John 2061 Reservoir Dr PATIENT: Hall,John 2061 Reservoir Dr Carlisle, PA 17013 Carlisle, PA 17013 ACCOUNT#: PAT-121261 TRIP#: 21113021428 DATE OF SERVICE: 02/25/2013 - PLEASE RETURN TOP PORTION WITH PAYMENT POLICY NAME: INS.M INS.#: PATIENT PICKED UP: HOSPITAL, Carlisle Reg. Med. Ctr. PATIENT TAKEN TO: HOSPITAL, Johns Hopkins Hospital DESCRIPTION OF ILLNESS/INJURY: OTHER INSURANCE INSURANCE DESCRIPTION • • 13 BASE 10100.00 1 15420.00 0.00 0.00 0.00 15420.00 13 MILEAGE 76.00 70 Please Remit This Amt Due:15420.00 Special Notes: PLEASE CALL WITH OR SEND YOUR INSURANCE INFO. 1-866-539-0038 EXT 2 THANK YOUI STAT MedEvac is a direct Air Carrier EJIMA774L UPMC-2063 Rev.(08111) REV-1513 EX+(01-10) i pennsylvania SCHEDULE ] DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: JOHN A. HALL 2113-0657 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. Boonchuay Hall, 2061 Reservoir Drive, Carlisle,PA 17013 Widow 100% 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. $ If more space is needed,use additional sheets of paper of the same size.