HomeMy WebLinkAbout04-02-14 1505610101
REV-1500 °' 9
"' OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania
Bureau of Individual Taxes County Code Year File Number
PO BOX 28o6o1 INHERITANCE TAX RETURN IM
Harrisburg,PA 17128-0601 RESIDENT DECEDENT LL U-1
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
l o06 0 1 3 le)IJ719111 y 1
Decedent's Last Name Suffix Decedent's First Name MI
+ 4 M21 I I I = ICILIA11
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
I® 1. Original Return O 2.Supplemental Return O 3. Remainder Return(date of death
t - . n prior to 12-13-82)
O 4. Limited Estate O 4a. Future Interest Compromise(date of ® 5. Federal Estate Tax Return Required
death after 12-12-82)
A 6.Decedent Died Testate O 7. Decedent Maintained a Living Trust Q 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 Sch.0)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone liUmber
IfIddiz-14 scN - Ff
d1E _R F 11 6-S USE! Y
rrl m rn J Z m N =.v
First line of address Z (J7 ; p T
n
Second line of address o = r m I
a I—'l D -n 1
D
City or Post Office State ZIP Code DATE FILE _
ItAlEldHIA11A 0311310
Correspondent's e-mail address: ck,- c k a.e( P yeA4za i Irlf+
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.
SIGNA_ 7}iRE OF PERSON RESPONSIBLE R FE0 ILING RETURN Ate_ JATE
/vii-l�t.�gti����
ADDRESS
I `7`7 7 ,PA I Fl-
`/ l�
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE I DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610101 1505610101
f
J 1505610105
r
REV-1500 EX , 1
l I rt`- Decedent's Social Security Number
t i r
Decedent's Name:
RECAPITULATION
1. Real Estate(Schedule A). ............... ................ ............. 1.
2. Stocks and Bonds(Schedule B) ....... .................... ........... . 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) .. ... 3.
4. Mortgages and Notes Receivable(Schedule D). ........ ............... ... 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E).. ... .. 5. 1 -55
2 • 6 b
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property
(Schedule G) p Separate Billing Requested........ 7.
8. Total Gross Assets(total Lines 1 through 7)...•.......... .... .... .......... 8.
9. Funeral Expenses and Administrative Costs(Schedule H)............ ....... 9.
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) .....'.. ....... 10.
11. Total Deductions(total Lines 9 and 10). ......... . ... ............ ....... 11, 2710
0
12. Net Value of Estate(Line 8 mihus Line 11) ........ .... .... .............. 12. (e I I
13.Charitable'and Governmental Bequests/Sec 9113 Trusts for which
can election to tax has not been made(Schedule J) ... ........ ............. 13. O . O
r r�
14.- Net Value Subject to Tax(Line 12 minus Line 13) ... ..... .... ........... . 14.
TAX CALCULATION•SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
Jr-. the spousal tax rate,or
_transfers under Sec.9116
ii(a)(1.2)X..O_ •i 15.
16.1 Amounl'of,Line 14 taxable
r at lineal rate X.0' I- v tJ 16. 1 1.100
17. Amount 6f Line 14 taxable
at sibling rate X.12 17.
18. Amount of Line 14 taxable
at collateral rate X.15
19. TAX DUE . ... ....... ....................... ..... ............... ... 19. O
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT .�
Side 2
1505610105 1505610105 J
REI 4600 EX--Page 3 Fite Number
Decedent's Complete Address: Z. 1 — Z 4 13 — U Z
DECEDENTS NAME
STREETA RESS
' '2Pa� -:� VI i la
� �
�1] a rt f c 3 I
CITY STATE zip
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0 O
2. CredilsiPayments
A.Prior Payments
B.Discount
Total Credits(A+B) (2)
3. Interest
(3)
4. If Line 2 is greater than Line 1+Line 3,enter the difference. This is the OVERPAYMENT.
FIN in oval on Page 2,Line 20 to request a refund. (4)
5. if Line 1+Line 3 is greater than tine 2,enter the difference.This is the TAX DUE. (5)
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCK$
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;.......................................................................................... 11 b. retain the right to designate who shall use the property transferred or its income;............................................ n
c. retain a reversionary interest;or......................................................................................................................... ❑
d. receive the promise for life of either payments,benefits or care?...................................................................... 0 IZI
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?.............. ❑ 91
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation? ........................................................................................................................ ❑ V3
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 lax 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)(11)(it)].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(1.2)172 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 172 P.S.§9116(a)(1.3)].A sibling is defined,under
Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-7500 EX`Page 3 File Number
Decedent's Complete Address: l_ j — Z O j 3 -- f J q'L
DECEDENT'S NAME
STREET RESS
_ hccn CL 1 �� soti Lame.
I� tF C- n ti i C 's �? u fT, 122A
CnY STATE 7P
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) :.J J
2. CreditsJPayments
A.Prior Payments
6.Discount
^— Total Credits(A+B) (2) J,�� s, °');}
3. Interest
(3)
4. If line 2 is greater than line 1+Line 3,enter the difference. This is the OVERPAYMENT
Fill In oval on Page 2,Une 20 to request a refund. (4)
5. if line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5)
Make check payable to: REGISTER OF WILLS,AGENT, _
7777=71'7`--
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;............................................
b. retain the right to designate who shaft use the property transferred or its income:............................................ ❑
c. retain a reversionary interest;or..............-..................................—..................................... 21
d. receive the promise for life of either payments,benefits or cue?......
......
........................
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
contains a beneficiary designation? ........................................................................................................................ ❑ V1
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. 1,1M,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent 172 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995, the tau rate imposed on the not value of transfers to or for Ste use of the surviving sparse is 0 percent
172 P.S.§9116(a)(1.1)(b)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
Ming a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after Jury 1,2400:
• 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 172 P.S.§9116(a)(1.2)).
• The tax rate imposed on the net value of transfers to or for the use of the decedents lineal beneficiaries is 4.5 percent, except as noted in
72 P.S.§9116(1.2)T72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblinrggs is 12 percent 172 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,wfiether by Wood or adoption.
REV-1508 Ex+(v-10)
pennsyivania SCHEDULE E
OEPARTNDYT OF REVENUE CASHr BANK DEPOSITS It N=
FWWRtFNlrf TAX REnM - PERSONAL PROPERTY
RESIDENT DELEDW
ESTATE OF: FILE NUMBER:
JAA( V 4 ki 7-1 - `Z-a 13 10 Z
Include the pmoedds of 1'digation and the date the proceeds were received by the estate.
At property jointly owned with right of survivors hlp must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
ckC-C,Kin {� ac c rJ.wn -7 -T { 7
{ GC C -jA7 '1") ° 1 `Y 0 7--- 1
{ � i
23 Ck rik
o ' 20x (c�.j9
P A'i - (rc�h i -PA its 7-3�f-3
a'CC oo-oo o 41 .3 �
tJ ;l.tJr� I1iYtEl4 li7r'! 5l_ iiiCji'7Cti-,
lv li l7i� er � �f fr M y-
i
+`.,..ri..-s L.. f.iC c C?i•-s r"'1- T— �)�•Z`^�, o
TOTAL(Also enter on Line 5, Recapitulation) j J ZC io to
if more space is needed,use additional sheets of paper of tit same size.
Performance Checking Statement
For the pMiod 09/113/3013 to 10/101"13
For 24-hour information,sign onto PNC Bank Online Banking CLAIRE C MCVITTY
on pnc.00m. Primary account number 50-7004-1502
Account number.50-7009-1502-continued Page 2 of 4
Acdv1tV 1/OW
Depesits and Otbw Adififtme There were 7 Deposits and Other Additions
Date Amount Description totaling$7.988.10.
09/17 4,000.00 Direct Deposit-Qvdit Aeis XXXXXXXXX0351
09/18 625.91 Direct Deposit-AMP Payout
Ameriptise Fine XXXXXXX7913
09/18 431.60 D vect Deposit-AMP Payout
Arneripsise Fine XXXXXXX9598
09/30 980.11 Direct Deposit-Annuitant
PA Treasury Dept XXXXXXXXXXX1477
10/0) 738.40 Direct Deposit-Alahl;
Ing Fin Ser 754 XXXXXX8578
10/03- .. 1x17.001 DrectDeposit-XxsocSec .
SSA Treas S 10 XXXXX0661A
10/10 .08 Interest Payment
Checks and Substitute Checks
Check Date Renitence Check Date Reference
number Amount paid number number Amount paid number
7658 50:00 09/18 084440190 7667 430.94 10/09 08x718790
7666* 50.00 10/03 08x68xY.'19
*Gap in check sequence There were 3 checks listed totaling
$530.94.
Daly Babowe D91WH
Data Batas Date Balance Date balance Date Balance
09/13 5,24941 09/18 10,256.52 10/0I 11,970.03 10/09 2 706.09
09/I7 9,249.01 09/30 11,236.63 10/03 13,137.03 10/10 12,
• �M1r
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`Myers uhrtg
Funeral Homj Crematory ,.
October 21,2013
Karen Schaeffer
1777 Winterhaven Drive
Mechanicsburg,PA 17055
Dear Karen:
Thank you for allowing us the privilege of serving you and your family. We know that financial
statements can be confusing, so below is a summary of your account.
Statement of Goods&Services $ 11,142.00
Less: Contract Addendums 237.42)
Less: Payment from Insurance (9,224.00) ,�.,,,._:,__
Subtotal: Invoice#10442 $ 1,680.58
Less:Terms Discount (822.00)
Your Balance Due by November 6,2013 $858.58 F--
We have enclosed a complete invoice for your records. /O.. jttt(
Please call us at any time that we may be of service. 7tC y f/
With Warn Regards,
Michelle L.Buhrig
Treasurer
Enclosure
Walking with Those in Grief
Robert"Bob"L.Buhrig,Jr.,ro,sum,i r•'willlam"Bill"L.Christopher,rD
Phone: (717)7663421 • Fax: (717)745.7291 • 37 East Main Street • Mechanicsburg,PA 17055 • imrntMyers-Buhrig.com Directon@,Mycm-Buhrig.com
"- - EiEV4511 EX+(10-0ej -
SCHEDULE A
O MAMONWE&TH OF PENNSYLVANIA RMERAL EVENSES$
INHERMANCE TAIL RETURN ADMINISTRAMCOM
RESIDENT DECEDENT _ v
ESTATE OF FflE NUMBER
71 •- 2-6 i 5 - IQaa
� peon of decedent must be reported cn Sdreetlk L
nEm
NUMBER DESCRIPfiON AMOUNT
A. FUNERAL FJCPENSES: , f 1 J 4Z U U
' I y es P3-LA t I r
B. ADMINISTRATIVE COSTS:
1. Personal RepesonraWs Comm"as
e
Niff m of Personal ReprasenWwKs) ---LL_—...•.. __.____�._�....__._.
Strad Adder .
cfty Stile nA
Yeaqs)Comrftslan Pain T_.--
2. Attorney Fees
3. Family Exempdan:{!i derEderBs address is not dlesame as t{aimards,apach explmration}
Cldmant _ A
SVed Aft=
,�
City State Zfp .
Retacorr"of Claimant to Decedent
4. Probate Fees Z f
S. Aomrmtanrs Fees
6. Tax Rdum Prepames Fees
7. ��rPi'7tit £� ' IY14'f•e-i t�t'tY'1C-c'- �"t-t?C �Oj: U o
i .
TOTAL{Also enter an fore 9,Recap{uliftn) S 1 t lc ,&0
iN mad space's needed,btmrt adfflftW sheets of dre dame size}
37 East Main Street Walking with Those in Grief
Mechanicsburg,PA 17055 Robert`Bob'L.Buhrig,Jr.FD,Supervisor
Web:www,Myers-Buhrig.com William"BID"L.Christopher,FD
Directors Gi Myers-Buhrig.com Phone:(717)7663421
Fax:(717)795.7291
STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED
Charges are only for those items that you selected or that are required.if we are required by low or by a cemetery or crematory to use any items,we will explain the reason in writing below.
If you selected a funeral that may require embalming,such as a funeral with viewing,you may have to pay for embalming.You do not have to pay for embalming you did not ap-
prove if you selected arian ements such as a direct cremation or immediate burial.If we charge for embalming,we will explain why below.
For the Service of �+ A t E. _(-- e``v r,_. , of _ Date M Death t Preaeed I U . - 2 O t ,3
Charge m: e..'W ,fi:Kt� � C:...�.... �-t . �,x..tr r� k+s... '1`+tt �'a{rt�t..'<•»�•.) , �'!'. iir47Vr-
Name Address City State
A.CHARGES FOR SERVICES SELECTED: C.SPECIAL CHARGES
1.PROFESSIONAL SERVICES immediate Burial...._.................".............,.........................._...,5
Basic Services of Funeral Director&Staff.............................$ a � Direct Cremation................., ..................._......$
..........................
-Fmbalming/Clinical Care............................ ............-...... Anatomical Gift..............___..........._....._....,.......
...._._......_.$_, --
Other Preparation of Body........................................................$ "' Forwarding of Remains...............................:...........__.............
.$
Dressing&Grooming .... _ Receiving of Remains.............................................................
.$ —.
Casketing or Reposing..........................I.....................$_= SUB-TOTAL OF SPECIAL CHARGES......___..._.....»....»»..0 S
Cosmetology&Basic Restoration.............................,$ '^ y D.CASH ADVANCES
Dignity7Sanitary Cara ..................._.......................................$r{ We chmge}rorrfor our services in obtaining..
Other Preparation of Body with Dignity/Sanitary Care-..__...$ "" Grave Opening-_ .........,.................$
Additional Care for Autopsy and/or Donation........................ Other Cemetery Charges.._.......................................................5
Additional Services of Funeral Director/Embalmer ................$ Graveside Equipment&Setup........,....................,....................5
Additional Services of Non-licensed Attendant(s) ..................$ �. Cie ' fit:f..`.. .._............,...................._.....................S_
rgy.hk*s.. _._.._
Sub-Total of Professional Sendees..»._.».....„.,........._».............A7--$� "�� Dcaconiftssi&tk'HL.........._............__....._..._..........._........._......5
2.USE OF FACILITIES,EQUIPMENTAND SERVICES FOR: Attar Server..........._...__.._._........_."._....................................$ .
FarewellViewing......._.._.....____..._....._.............................$ Sexton......................................................................................S
Viewing/Visitation/Gathering..................._..........................,...$ Organist/Pianist..............................,....................,....................5
Funeral Ceremony...........-......................... $ Soloist/Cam or................_..........._...........................................5
Memorial Service..................................._.!?......._............_.... Instrumentalist.............................................._.........................
.5
Graveside or Committal Service.............................................. Hairdresmr.............................__......_..._ _
............................. „S _
Cremation.............................................................................„...$ � Military Honor Guard................................................,........
.....5
Sheltering and/or Refrigeration................................................5_ —' Coroner's Fees................._......._....._..-
Break between Functions........................_..__._.................,....5_ �. Certified Death Certificates....__...,.._�..........................._..S_- -
Sunday&Holiday Events......................__...__.........__..._......$_.-- Flowers_... ..........................
Other use of Facilities,Equipment and Staff..........................$���",,, „ ... Reception.............................:...................................................5_ W
Sub-Total of Facilities,Equipment and Services........_._......».A2$ ,v v*. ,� Monument Purchase.-.......................................................
3.AUTOMOTIVE EQUIPMENT Monument Inscription...................................................»_..._.'S
Care Transport Vehicle&Service to Funcmi Home................5 T Patriot News__._...................... ....ST =
Lead/Clergy Vehicle.-............................................................5 ' Carlisle Sentinel......._............................_...............................
5;✓
Hearse/Funeral Coach..........................................._................s-7 = Newspaper.....,....,............., _S
,
...............................................
Limousine ..................................".............................................5 Newspaper................................................................____.......5
Flower/Staff/Equipment Vehicle...............__.........................5„�_ Other...._..._...........,.............____._._...........:......_................5
TransferVehicle ..............................._......................____....5 "' Other.........................................................................................$ �^-
Additional Vehicles)Time Charge........t.t_,{...........................5 _ Other.................................................._.................................."..5--^- -�;
Additional Vehicles)Mileage Charge...i,_.`. ........................5 O l t* SUB TOTALOFCASH ADVANCES.._...-.«.,.............._...."...,D S+'x ' 3
Sub-Total of Automotive Equipment..................__.--".._"..A3$
SUB-TOTAL FOR SERVICES SELECTED.._».__.._..,_._.».A S SUMMARY OF CHARGES g-Z j —
R.CHARGE FOR MERCHANDISE SELECTED: A.TOTAL FOR SERVICES SELECTED_..............................5
Casket..._...................................... .................................$ .,_ B.TOTAL FOR MERCHANDISE SELECTED..._.................5�_
............
Other Receptacle:Alternative Container(cardboard)...............5 C.TOTAL FOR SPECIAL CHARGES........_.....___........
_..S -
Cremation Um(full size)....................... ....__SZs4 D.TOTAL FOR CASH ADVANCES......................................S�e'` `Li"_4
Outer Burial Container_,........._.................... .........................5�•^,_. TOTAL OF SECTIONS A+B+C+D.................. c
Keepsake/Je veiry._....._........._.............._...........,...................
5—„-....
Keepsake/Jewelry...............................................,,......,............5 Y N Price Guammee Premium:A....__,.........._...._,.....,.,,,5
Keepsake/Jewelry................................................_......,..........,5 Y N Price Guarantee Premium:B..._...................................5
Keepsake/Jewelry......_............_................._............._.............5 ”' Y N Price Guarantee Premium:D............................,......,...$
Memorial Package.._........................_..._...............................5 TOTAL OF ALL PRICE GUARANTEE PREMIUMS........__.._...$ �-
Register Book........................
Memorial Folders/Prayer Cards................................................5 S "" GRAND TOTAL.._...........«. S h
Service Bullet ins................_........__.............................,....__S _
—+�. PAYMENT..._....................».._».............,«.......«..».......,_..»$
Acknou'ICdgement Cards......_.._........_..,.._............._.._......_..$ '>'Ll
Printed Obituaries..................._.............._.........__...................$ TS_ BALANCE DUE:........»...........................................................$TI-1
DV Ds................................................................................._....$
Portraits....___................_............_..........,.....____.........._....$ REASON FOR EMBALMING
Flag Case..........._..................................................___............$^a p Voluntarily Authorized by Family
Temporary Grave Marker............................._........................5_,i,_ ❑Viewing
ri.uxb,a. .._._................................................................$ �' {]Other.
RECEIPT FOR PAYMENT
GLENDA EARNER STRASBAUGH Receipt Date: 10/15/2013
Cumberland County - Register Of Wills Receipt Time: 09:55 :47
One Courthouse Square Receipt No. : 1075884
Carlisle, PA 17613
MCVITTY CLAIRE CRESSMAN
- Estate File No. : 2013-01092
Paid By Remarks: WILLIAM MCVITTY 1(, I I to 15, ('a
------------------------ Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 210 . 00 CUMBERLAND COUNTY GENERAL FUN
WILL 15.00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23 .50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5. 00 CUMBERLAND COUNTY GENERAL FUN
INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN
INVENTORY 15.00 CUMBERLAND COUNTY GENERAL FUN
---------------
Cash $288.50
Total Received. . . . . . . . . 5288 50
COMMONWEALTH OF PENNSYLVANIA REV-1162 EX01-96)
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT.280601
HARRISBURG,PA 17128-0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 018412
SCHAEFFER KAREN M
1777 WINTERHAVEN DRIVE
MECHANICSBURG, PA 17055
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
13504945 $205.00
ESTATE INFORMATION: SSN:
FILE NUMBER: 2113-1092
DECEDENT NAME: MCVITTY CLAIRE CRESSMAN 1
DATE OF PAYMENT: 11/18/2013
POSTMARK DATE: 11/15/2013
COUNTY: CUMBERLAND
DATE OF DEATH: 10/06/2013
TOTAL AMOUNT PAID: $205.00
REMARKS: KAREN SCHAEFFER
CHECK#6596
INITIALS: WZ
SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
TAXPAYER
REV-I612 E)(+(12-08)
sA
-W� va
n SCHEDULE
vapeinnla
MAl"IEWOFAMME DEBTS OF DECEDENT,
MHERnAKE TAX RERM MORTGAGE LIABILITIES&LIENS
RESIDEW DECEDW
MATE OF // NUMBER
, 2;.Qi3 - j0Q7—
Iteport detda MOMW by ft decedent PW to bedin*d MMIIMW unpaid at tM daft of destb,fidWk*winialImbMW MKftM OW6AM&
n'EM VAUX AT DATE
NUMM DESMWnDN OF DEM
1. cjLc
?3 z Dr
L9clot3 -Kd .
Auen, a vv in PA
P-r -T (I-x C,'j tf C�0-r - f VA, CC-y*i
PA
TOTAL(Also enter on tine 10,Recapitulation)
if more space is needed,insert addidonal sheets of the same sire.
1%SBURY
��T,TTT T �( ► ', STATEMENT Page: 1 of 4
VILLAGE ' Imrpice# _ -'' Account Date
581210 23405 091092013
Anticipate More � � ' �.� t?1
325 Wesley Driver_
Mechanicsburg,PA 17055
Due Date Amount Due Amount Paid
0911742013 $23,765.52
Karen Schaeffer, / C7
C Resident Name
1777 Scha ffer, Dr. _
Mechanicsburg,PA 17055 McVdty,Claire C
PLEASE DETACH AND RETURN UPPER PORTION WITH YOUR REMITTANCE
McVitty,Claire C Bethany Village-The Oaks 091092013
Peswption Units Unit Ne Balance:..:
T ou Cost C s red
RESIDENT R PO BIL
71312013 Balance orward V $11,878.69
9/012013 9/302013 Room and Board 30.00 Day 346. 10,380. $22,258.69
81012013 8/012013 Ancillary Supplies 1.00 Each 7.7 $22,266.44
8/012013 8/012013 Incontinence Care-ModlHeavy 1.00 Day 120 12.0 $22,278.44
12013 12013 Nebutizer Treatment 1.00 Day 8. 8.2 $22,286.69
8/012013 8/312013 Nutritional Supplements 66.00 Each 5.1 342.8 $22,629.54
8/022013 8/022013 Ancillary Supplies 1.00 Each 7.7 7.7 $22,63729
8/022013 81022013 Incontinence Care Mod/Heavy 1.00 Day 12. 12. $22,649.29
8/022013 2)2013 Nebulizer Treatment 1.00 Day 8.2 8.2 $22,657.54
8!032013 /032013 Ancillary Supplies 1.00 Each 7.7 7.7 $22,665.29
8/032013 8/032013 Incontinence Care-Mod/Heavy 1.00 Day 12. 12. $22,67729
8/132013 8/032013 Nebulizer Treatment 1.00 Day 82 8.2 $22,685.54
8/042013 042013 Ancillary Supplies 1.00 Each 7.7 7.7 $22,693.29
8/0412013 8/042013 Incontinence Care-ModtHeavy 1.00 Day 12.0 i2. $22,705.29
8/042013 8/042013 Nebutiizer Treatment 1.00 Day 8.2 8 $22,713.54
013 2013 Ancillary Supplies 1.00 Each 7.7 7.7 $22,72129
8/052013 8/052013 Incontinence Care-Mod/Heavy 1.00 Day 12.0 12. $22,733.29
8/052013 /752013 Beauty/Barber shampoolset 1.00 Each 18.7 18.7 $22,752.04
2013 8/052013 Nebulizer Treatment 1.00 Day 8.2 8.2 $22,76029
013 013 Ancillary Supplies 7.00 Each 4.1 28.91 $22,789.20
8/062013 062013 Incontinence Care-ModMeavy 1.00 Day 12.0 12. $22,801.20
&W2013 81062013 Nebulizer Treatment 1.00 Day 8.2 8.2 $22,809.45
72013 72013 Ancillary Supplies 1.00 Each 7.7 7.7 $22,81720
8/072013 8!072013 Incontinence Care-Mod/Heavy 1.00 Day 12. 12. $22,82920
072013 8/072013 Nebulizer Treatment 1.00 Day 8.2 8. $22,837.45
8/072013 8/072013 Massage Services 1.0D Each 40,OC 40. $22,877.45
13 82013 Ancillary Supplies 1.00 Each 7.7 7.7 $22,885.20
8/082013 082013 Incontinence Care-Mod/Heavy 1.00 Day 12. 12. $22,897.20
82013 82013 Nebulizer Treatment 1.00 Day 82 8. $22,905.45
PLEASE DETACH AND RETURN UPPER PORTION WITH YOUR REMITTANCE--
Bethany Village-The Oaks 11/07/2013
a .t ;:.. escrt t EJnits nd 's alahr�.
p;wn.
h C st d'
9/3012013 Balance Forward RESIDENT RESPONSIB L1TY $23,635.79
Received(10/21/2013) -10,380.00 $13,255.79
10/01/2013 10/3112013 Room and Board -8,996.00 $4,259.79
10/012013 0/012013 Ancillary Supplies 1.00 Each 7.7f 7,7f $4,267.54
10/012013 10/0112013 Incontinence Care-Mod/Heavy 1.00 Day 12. 12.00 $4,279.54
10/022013 10/022013 Ancillary Supplies 1.00 Each 7.79 7.7E $4,287.29
10/022013 10/0211013 Incontinence Care-Mod/Heavy 1.00 Day 12.0 12. $4,299.29
10/022013 0/022013 Massage Services30 minutes 1.00 Each 40.0 40. $4,33929
10/032013 10/032013 Ancillary Supplies 1.00 Each 7.79 7.7 $4,347.04
10/03/1013 10/03/2013 Incontinence Care-Mod/Heavy 1.00 Day 12. 12. $4,359.04
10/04/2013 101042013 Ancillary Supplies 1.00 Each 7.7 7.7 $4,366.79
10/042013 10/042013 Incontinence Care-Mod/Heavy 1.00 Day 12. 12. $4,378.79
101O52013 10/052013 Ancillary Supplies 1.00 Each 7.7 7.7 $4,386.54
10/05/1013 10/052013 Incontinence Care-Mod/Heavy 1.00 Day 12.0 12.0 $4,398.54
10/062013 10/06/2013 Ancillary Supplies 1.00 Each 7.7 7.7 $4,406.29
10/06/2013 10/062013 Incontinence Care-Mod/Heavy 1.00 Day 12.0 12. $4,418.29
1 /t
K
,r
4
Please welcome Dana Renaut to Bethany Village as the new Facility Billing Counselor.Please contact Dana at 717-591-8029 with billing
questions.Thank you!
TOTAL
TOTAL RESIDENT RESPONSIBILITY $4,418.2
\�1 A STATEMENT OF ACCOUNT
OMNICAREKINGOFPRUSSUI'`• Ce(
69908 SNOWDRIFT RD f t r�- - 3 PAGE: 1 of 2
ALLENTOWN,PA 18106 (t
� tP �Q
ACCOUNT NO: 70037
RETURN SERVICE REQUESTED '`•� 34285 INVOICE NO: PH1077171
St. ___,.. DX NO: KOPDX
INVOICE DATE: 09130/13
007786 0202 Phone:877-670-6323 FACILITY: 7003 BETHANY VILLAGE THE OAK
PATIENT NO: 47
You may also view/pay your bills at: PATIENT NAME: MCVITTY,CLAIRE
hnps:llmyomniview,ornnicare.com AMOUNT DUE: 271.58
t 111thtutnkl ttrit�ltttt/hgrtrt•irrllrllrsrrdtltilttPltll TAX: 0.00
CLAIRE MCVITTY
KAREN SCHAEFFER DUE DATE: 10/25/2013
1777 WINTERHAVEN DR
MECHANICSBURG, PA 17055-5192 AMOUNT DUE: 271.5$
34285•TWA17OZgPO07932
3WA17Y7SX:1.2
KEEP TOP PORTION FOR YOUR RECORDS-RETURN BOTTO;]STUB WITH PAYMENT IMMIMM1010MIIMMMMMMM
MCVITTY, CLAIRE 7003 BETHANY VILLAGE THE OAKS
ACCOUNTNUMSER INVOICE DATE
7003.47 09/30/13
DATE RX NO. TRANS DESCRIPTION PHYSICIAN NDC NO. QUANT AMOUNT TYPE
Medicare D Plan: URC/HARP/EVERCARE/SECURE
H./SIERRA/UNISO
09/05/13 7663 LOCK PAYMENT - THANK YOU - Lockbox 20130905074504 -261.98
000108037
08/14/13 R700115U CHARGE VALACYCLOVIR WINING TABLET (COPAY) HALDIPUR 16714-0697-01 8 7.00 RX
09/13/13 R22131072 CHARGE METAMUCIL SMODTH TEXTURE, S/F POWDER Claim is not HALDIPUR 37000-0741-17 660 18.08 OTC
related to Hospice diagnosis and is therefore
non-covered
09/16/13 R22140064 CHARGE POLYETHYLENE GLYCOL 17GM/1ROSE POWDER (COPAY) HALDIPUR 00574-0412-02 255 7.00 RX
09/16/13 R22139324 CHARGE FOLSIC 2-2.5.25KG TABLET (RP:FOLTX NEW STRENGTH) HALDIPUR 51991-0384-90 30 27.35 RX
Claim is not related to Hospice diagnosis and Is
therefore non-covered
Messages
Finance Charges may be assessed at a MONTHLY PERIOD RATE OF
1.50%(ANNUAL RATE OF 18W%)based upon an urmaid balance
outstandkV 30 days or more.
PREVIOUS BALANCE CHARGES FINANCE CHARGE TOTAL CHARGES PAYMENTS & CREDITS AMOUNT DUE
430.94 102.62 0.00 533.56 -261.98 271.58
STATEMENT OF ACCOUNT
i ONINICARE KING OF PRUSSIA J l^
ALLEN SNOWDRIFT 10 PAGE: 1 Of 1
6990B SNOWDRIFT RD tt4 yyr
RETURN SERVICE REQUESTED F-13 5 ACCOUNT STATEMENT
INVOICE NO:O: 7
KOPDX
a DX NO: KOPDX
INVOICE DATE: 11/30/13
001993 0101 Phone: 877-670-6323 FACILITY: 7003 BETHANY VILLAGE THE OAK
PATIENT NO: 47
You may also view/pay your bills at: PATIENT NAME: MCVITTY,CLAIRE
hops://myomnMew.omnicare.com AMOUNT DUE: 308.18
TAX: 0.00
�111nlI"16r�11�11"!�"I191�n111"1+u'�I�1�'�1'�III'1��'�'11��1
CLAIRE MCVITTY
KAREN SCHAEFFER DUE DATE: 12!2512013
1777 WINTERHAVEN DR
MECHANICSBURG, PA 17055-5192 AMaUNTOUE: 308.18
34285-TXZOSSKJY007964
3XZOA3TO9:1.1
KEEP TOP PORTION FOR YOUR RECORDS-RETURN BOTTOM STUN WITH PAYMENT INIIMEN11110 1rH®W
MCVITTY, CLAIRE 7003 BETHANY VILLAGE THE OAKS
ACCOUNTNUMBER
.•
7003-47 11/30/13
DATE RX NO. TRANS DESCRIPTION PHYSICIAN HOC NO. QUANT AMOUNT - TYPE
Medicare D Plan: UHC/AARP/EVERCARE/SECURE
H./SIERRA/UNISO
11/27/13 - REFUND REFUND ON CREDIT BALANCE
Messages
Finance Charges may be assessed at a MONTHLY PERIOD RATE OF
1.50%(ANNUAL RATE OF 18.00%)based upon an unpaid balance
outstanding 30 days or more.
PREVIOUS BALANCE CHARGES FINANCE CHARGE TOTAL CHARGES PAYMENTS & CREDITS AMOUNT DUE
-122.76 0.00 0.00 -122.76 430.94 305.18
BONNIE K. MILLER, TAX COLLECTOR
2233 GETTYSBURG ROAD
CAMP HILL PA 17011-7302
(717) 737-5671
RETURN SERVICE REQUESTED
PER CAPITA DELINQUENT NOTICE FOR
ID # 001920 flax bill number 095613
Billing date 7/01/2013
Balance due at net
Pay penalty amount Q11,0001
YOUR PER CAPITA TAXES HAVE NOT BEEN PAID ON TIME AND IS NOW DUE AT THE
PENALTY AMOUNT. IF NOT PAID BY DECEMBER 31, 2013 YOUR PER CAPITA TAXES
WILL BE SENT TO STATEWIDE TAX RECOVERY. IF YOU HAVE ANY QUESTIONS
PLEASE CONTACT BONNIE MILLER BY MAIL OR TELEPHONE (717) 737-5671.
NO PERSONAL CHECKS WILL BE ACCEPTED AFTER DECEMBER 12, 2013.
ONLY MONEY ORDERS, CASHIER CHECKS OR CERTIFIED CHECKS WILL BE ACCEPTED
NO LARGE BILLS WILL BE ACCEPTED DUE TO COUNTERFEIT BILLS.
MONDAY, TUESDAY & THURSDAY 9:OOAM-2:45PM OR BY APPOINTMENT
CLOSED: NOV 25-DEC 2, DEC 23-JAN 1 ALL MAJOR HOLIDAYS & ELECTION DAYS
CLAIRE MCVITTY
5225 WILSON LANE #46 J J
#46
MECHANICSBURG, PA 17055 �,� � AAfQ
REV-1513 EX+(01-10)
s pennsytvama SCHEDULE
` aEFARTMENTOFAP&NUS BENEFICIARIES INHOU IA.NCE TAX RETURN
Restom DEmom
ESTATE OF: FILE NUMBER:
RELATIONSHIP TO DECEDENT AMOUNT OR RE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustees) OF ESTATE
. 1 TAXABLE D)SnuBUT[ONS(Include outright spousal distributions and transfers under
Sec 9116(a)(1.2).)
�-i . `their-.-(fi e. ' c Q.i.�c�h�-�. `r- 4.7 W: L4
byRn4-o4-ickw-n Dr.
Z i � (,,CZk1te ��tari r-
j\/ke c•kut-,* a� Ltr .y �f9A
ENTER DOLLAR AMOUNTS FOR DISUUBUTLONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,A5 APPROPRIATE.
EL NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL.DISTRIBUTIONS UNDER SECTION 4113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1 N'j e_.c,h a ti i e �( i r( �i t? � C`�R� t 0.h L"'4`� L -i-t-D e.� `7
TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. 455) . {;j
If more space is needed,use additml sheets of paper of the same size.
LAST WILL AND TESTAMENT
I, CLAIRE C. McVITTY, of the Township of Upper Allen,
County of Cumberland and Commonwealth of Pennsylvania, being of
sound and disposing mind, memory and understanding, do make ,
publish and declare this as and for my Last Will and Testament,
hereby revoking and making void all former wills and codicils by
me at any time heretofore made.
FIRST. I order and direct that all my just debts and
funeral expenses be paid by my Executor , Executors or Executrix,
as the case may be, hereinafter named, as soon as conveniently
may be done after my decease .
v
ti
~ SECOND. I give , devise and bequeath all the rest, residue
and remainder of my Estate, real , personal and mixed, whatsoever
and wheresoever situated, unto my husband, LAWRENCE F . . McVITTY,
absolutely and in fee simple if he survives me by as many as
sixty ( 60 ) days .
THIRD. If my husband, LAWRENCE F . MCVITTY, does not
survive me by as many as sixty ( 60 ) days , then and in that
event, I give, devise and bequeath all the rest, residue and
remainder of my Estate, real , personal and mixed , whatsoever and
wheresoever situated, in equal shares unto my two children,
namely, KAREN M. SCHAEFFER and WILLIAM J. McVITTY , share and
share alike, absolutely and in fee simple .
If either of my said children should predecease me , I
order and direct that the foregoing residuary share of such
deceased child shall be distributed unto her or his issue per
stirpes by representation and not per capita, but subject,
LAW OFFICES
SNELSAKER, however , to the protective provisions In Item Fourth hereinbelow
CKER & SILVER
with respect to any beneficiary who has not attained the age of
twenty-three (23 ) years at the time of my death.
FOURTH. I order and direct that the distributive share
under Item Third hereinabove of any beneficiary who has not
attained the age of twenty-three ( 23) years at the time of my
death shall be delivered unto THE FIRST BANK AND TRUST COMPANY
OF MECHANICSBURG, PA. , as my testamentary trustee, IN TRUST,
NEVERTHELESS, to hold, manage, invest and reinvest for the
r^
ultimate use of such beneficiary and until said beneficiary
attains the age of twenty-three ( 23 ) years , at which time said
h j Trust shall be terminated and the remaining net balance thereof
�v and accumulated interest thereon shall be distributed and paid
over unto the beneficiary absolutely.
During the existence of any such protective trust, I
authorize and empower my said Trustee to use, consume and apply
from time to time such amounts of income and principal as my
said Trustee in the sole exercise of its discretion shall deem
to be necessary and proper for the beneficiary's education,
taking into consideration the primary obligation of the
beneficiary' s surviving parent to provide for such education.
The term "education" shall be deemed to mean college or other
post-highschool training which is intended to enhance the
beneficiary's productivity as an adult or to improve his or her
quality of life.
LASTLY. I nominate, constitute and appoint my husband,
LAWRENCE F. MCVITTY, to be the Executor of this, my Last Will
and Testament, but if for any reason he should fail to qualify
L W OFFICES as such Executor or cease so to serve, the n and in that event,
SNELSAKER,
FLICKER & SILVER nominate, constitute and appoint my two Children, namely, KARE
M. SCHAEFFER and WILLIAM J. MCVITTY (or either of them in the
event that one should fail to qualify or cease so to serve) , to
be the Executors hereof , each and all to serve without bond or
other security as a condition of qualification hereunder .
IN WITNESS WHEREOF, I, CLAIRE C. MCVITTY, have hereunto
set my hand and seal to this , my Last Will and Testament which
consists of three (3) typewritten pages to each of which I have
affixed my signature this �,g rci day of )9p r I 1 , A.D . ,
One Thousand Nine Hundred Eighty- even (1987 M.
{ ,^
° 1SEAL )
The preceding instrument, consisti of this and two ( 2 )
other typewritten pages , each identified by the signature of the
Testatrix, was on the date thereof signed, sealed, published and
declared by CLAIRE C. MCVITTY, the Testatrix therein named, as
and for her Last Will and Testament, in the presence of us, who,
at her request, in her presence, and in the presence of each
other, have subscribed our names as ,witn sses hereto.
I f
nr �lix:xn c. MCVITTY, RICHARD C. SNELBAKER and JANET M.
FORRY, the Testatrix and the witnesses, respectively, whose
names are signed to the attached or foregoing instrument, being
first duly sworn, do hereby declare to the undersigned authority
that the Testatrix signed and executed the instrument as her
Last will and Testament and that she had signed willingly, and
that she executed it as her free and voluntary act for the
purposes therein expressed, and that each of the witnesses, in
the presence and hearing of the Testatrix, signed the will as
witness and that to the best of his or her knowledge the
Testatrix was at that time eighteen years of age or older, of
sound mind and under no constraint or undue influence .
i
tri
INN
witness
'AM DIV
witness
Subscribed, sworn to and acknowledged before me by CLAIRE C.
MCVITTY, the Testatrix, and subscribed and sworn to before me by
RICHARD C. SNELBAKER and JANET FORRY, witnesses,
this .?3 tea' day of , 1987.
ww*FFICES �7
SNELBAKER, ary Public
CKER & SILVER Gl,TYANIlIK E. RCU.SUW,
NcckRricsauRC
• r or o c s oraaY RU RIC
MY CCM � roUri
n,
Mtmber, ° ffSSl4W EXPIRES FE82j1894
As AniaYirn at f;gf3t%es