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04-28-14 (2)
i 1sos61a1©s REV-1500 EX loa-in(Fl) OFFICIAL USE oxLv PA Department of Revenue Pennsylvania Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Number PO BOX 28o6ot Harrisburg,PA 17128-0601 RESIDENT DECEDENT C311 13 SLT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMODYYYY Date of Birth MMODYYYY 07/24/2013 08117/1929 Decedent's Last Name Suffix Decedent's First Name MI CLONTZ JOHN B (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 m 1.Original Return O 2,Supplemental Return C=) 3. Remainder Return(Date of Death Prior to 12-13-82) O 4.Limited Estate O 4a.Future Interest Compromise(date of C= 5. Federal Estate Tax Return Required death after 12-12-82) GIO 6.Decedent Died Testate C=) 7.Decadent Maintained a Living Trust 8, Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) C=D 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death C=) 11. Election to Tax under See.9113(A) Between 12.31-91 and 1-1-95) (Attach Schedule 0) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number o {717)243-66x33 _ m c KATHLEEN K. SMAULIS, ESQ. � C> -b ::o � � CD REGISTER 1I.LL"SE OM :O ED xty. r ry nm Cot �o First Line of Address x" Cri P. O. BOX 1229 e> p B t -TT C-) o T Second Line of Address O r%3 rn --O0 O City or Post Office _ Stale ZIP Coda DATE FILED CARLISLE PA 17013 Correspondent's e-mail address:jrs037carlisle @sprintmail.com Under penalties of perjury,1 declare that I have examined this return,mCluding accompanying schedules and statements,and to the best of my knowledge and belief, It is true,correct and complete.Declaration of pmparer other than the personal representative Is based on all Information of which preparer has any knowledge. F PERS NSIB FO (LING RETURN DATE SIG 04/28/2014 ADDRESS P. O. Box 1229 Carlisle, PA 17013 SIG�tTUR OF PREPA ER T if[R THAy RE R 5ENTATNE DATE 04/28/2014 ADDRESS P.O. Box 1229 Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 J 1505610205 REV-1500 EX(FI) Decedents Social Security Number Decedenrs Nam: JOHN B.CLONTZ RECAPITULATION 1, Real Estate(Schedule A). ...... ......... .............. 11, 2. Stocks and Bonds(Schedule B) ...................._......... _ 2. 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) 3.j L I 4. Mortgages and Notes Receivable((Schedule D)......... 4. 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 74,26517 6. Jointly Owned Property(Schedule F) C= Separate Billing Requested ... & 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) =1 Separate Billing Requested........ 7. t 8, Total Gross Assets(total Lines I through 7)............................. 8. j 100,258.13 9. Funeral Expenses and Administrative Costs(Schedule H) ....... 9. i 21,620.26 10. Debts of Decadent,Mortgage Liabilities and Liens(Scheduled). .......... 10. 2,336-54 11. Total Deductions(total Lima 9 and 10).......... ......... ........ 11. 23,956.80 12. Net Value of Estate(Line 8 minus Lim 11) ....... 12.1 U0 I 11 Charitable and Governmental Sequests/SecgI13 Trusts for which an election to tax has not been made(Schedule J) ........ ....... 14. Net Value Subject to Tiot(Line 12 minus Una 13) ....... --- 14 76,301.331 TAX CALCULATION.SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 F--------- (a)(1.2)X.0_ 15. 0.00 116, Amount of Line 14 taxable at lineal rate X,.0 16. 0.00 i 17. Amount of Lim 14 taxable at sibling rate X.12 f 17. 9,156.16 18, Amount of Line 14 taxable at collateral rate X.16 18. 19, TAX DUE..._... .... ...... ....................... .. ... 19.1 9,156.161, 26. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C=t Side 2 1505610205 1505610205 REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENTS NAME JOHN D. CLONTZ STREET ADDRESS C/O ROBERT STOLIGHT 17 RIDGEWAY DRIVE CITY STATE ZIP CARLISLE PA 17015 Tax Payments and Credits: t. Tax Due(Page 2,Line 19) (1) 9,156.16 2. CrethaPayments., A Prior Payments R Discount Total Credits(A+8) (2) 3. Interest (3) 4. If lire 2 is greater than Line 1+Lure 3,enter the difference. This is the OVERPAYMENT, Fill In oval on Page 2,Line 20 to request a refund. (4) 5. It line 1+Litre 3 is greater than Line 2,enter the differenoe.This Is the TAX DUE. (5) 9,156.16 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: I Yes No a. retain the use or income of the property transferred.......................................................................................... 0 b. retain the right to designate who shall use the properly transferred or its!noon*............................................ ❑ c. retain a reversionary interest..................:.................:..................................._....._............................................ . ❑ . d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ 2. If death after Dec.12,1982,did decedent transfer pmperty 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?.-........... 0 4. Did decedent rnm an individual retirement account,annuity or other rarovobate property,which oix ams 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 172 P.S.§9116(a)(11)(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 172 P.S.§9116(a)(11)(if)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tau return are still applicable even 9 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 decedents 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 decedents 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. REV-*03EX+f8cz) Ql pennsytvania SCHEDULE B 00ARTMMIT OF REV C INHERITANCE TAX RETURN STOCKS $ BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER JOHN E,CL.ONTZ 21-13-0849 All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1' 738 SHARES A T 8 T COMMON STOCK(HIGH$35,50,LOW$34.93,AVERAGE$35,22) 25,992.36 TOTAL(Also enter on Line 2,Recapitulation) $ 25,992.36 If more space is needed,Insert additional sheets of the same size � n REV-1508 Ex+(o&u) ` i pennsytvania SCHEDULE E c DEPARTMENT OF REVENUC CASHr BANK DEPOSITS &"MISC. INHEWANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: JOHN B. CLONTZ 21-13-0849 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 an Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1•: 'ORRSTOWN BANK CHECKING ACCT NO.IOM439- 17,383,77 2 `DBLE WIDE MOBILE HOME ON RENTED LOT,96 COUNTRY VIEW EST,NEWVILLE,PA 45,000.00 3 2009 HYUNDAI SONATA 9,000.00 4' STERLING SILVER FLATWARE 1,525.00, 5 PERSONAL PROPERTYMOUSEHOLD GDS SOLO BY ROWE'S AUCTION 1,357.00- .TOTAL{Also enter on Line 5,Recapitulation} $ 74,285.77 If more space Is needed,use additional sheets of paper of the same size. 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 S. CLONTZ 21-13-0649 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION. AMOUNT A. FUNERAL EXPENSES: i. MYERS-BUDRIG FUNERAL HOME - - 6,431.00.•' a. ADMINISTRATIVE COSTS: 1, Personal Representative Commissions: 4,936.65 Name(s)of Personal Representatives) ROBERT C. STOUGHT Street Address 17 RIDGEWAY DRIVE city CARLISLE State PA Zip 17015 Year(s)Commission Paid: 2014 Z. Attorney Fees: 3,250.00 3, Family Exemption: (If decedent's address is not the same as claimants,attache 0.00 N P explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 356.50 5. Accountant Fees: 6. Tax Return Preparer Fees: 0.00 7. Legal Advertising-Cartfsfe Senitnef and Cumberland Law Journal 232.66 8 Commission-sale of double wide mobile home 3,000.00 9. .Commission-sale of Hyundai Sonata,silverware and tangible personal property,Rowe's Auction 2,308:70! to Filing fee-Pa Inheritance fax return 15.00 s. Filing fee-Account with Cumberland County Register of wills 50.00, TOTAL FROM PAGE TWO(CONTINUATION SHEET) 1,037.73 TOTAL(Also enter on Une 9, Recapitulation) $ 21,620.26 If more space Is needed,use additional sheets of paper of the same size. ESTATE OF JOHN B. CLONTZ FILE NUMBER: 21-13-0849 SCHEDULE H (Continuation page 2) 12. HAULING CHARGE - ROWE'S AUCTION HOUSE 45.00 13. UPS SHIPPING FOR PERSONAL ITEMS TO BENEFICIARIES 174.01 14. GRAHAM MOTOR COMPANY- REPAIRS TO HYUNDAI SONATA 577.26 15. ALLSTATE AUTO INSURANCE - SONATA 147.66 16. SALE (TRADING FEE) OF AT&T STOCK 93.80 TOTAL (THIS SIDE) 1037.73 REV-1512 Ex+(12-12) 117 pennsytvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES &HENS RESIDENT DECEDENT ESTATE OF FIFE NUMBER JOHN B. CLONTZ 21-13-0649 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. REM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ADAM'S ELECTRIC 80.42 2. CHURCH OF GOD HOME-NURSING CARE HAIRCUT 261.95 3. PINNACLE HEALTH EMERGENCY CHARGE 33.31 4; CUMBERLAND GOOD WILL FIRE RESCUS EMS 505.56 5 PINNACLE HEALTH MEDICAL SERVICES 20.54. 6 NEWVILLE COMMUNITY AMBULENCE 641.90 7 ALERT PHARMACY 9155, 6 ADAM'S ELECTRIC COOP 77.70 91 ALLSTATE INS FOR AUTO AND DOUBLE-WIDEMOBILE HOME 164.87 10 CARLISLE PHYSICIANS SERVICES 62.86 it. PINNACLE HEALTH MEd SERVICE 75.14 12; CUMBERLAND GOODWILL AMBULENCE 116.05 13 PINNACLE HEALTH 17.35 14. PINNACLE HEALTH 53.08 15 PINNACLE HEALTH 92.22 TOTAL(Also enter on tine 10,Recapitulation) $ 2,336.54 If more space Is needed,Insert additional sheets of the same size. M-1513 EX+(01-10) pennsytvania SCHEDULE 3 DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN - RESIDENT DECEDENT ESTATE OF: FILE NUMBER: .JOHN 8. OLONTZ 21-13-0849 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).) _ I. borothy Warren,255 Vicksburg Lane Foley,AL 32525 - .sister 50%of net estate 2 Wartha Gibson,115 Jennings Circle,P.O.Box 99,Buffalo,SC 29321 sister 50%of net estate ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH IS OF REV-1S00 COVER SHEET AS APPROPRIATE. tI NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART U—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEEP. $ O If more space Is needed,use additional sheets of paper of the same size. T Historical Prices I AT&T Inc. Stock -Yahoo! Finance Page 1 of 2 Home Mail Neva Sows Finance Weather Games Groups Answers Screen Fhckr Mobile F777777 �Mail Finance Home My PorlfolioMarkel OataBusiness 9 FinancePersonal FinanceYahoo Originals CNBC ((Einar Symed�� Thu,Mar b,2014,11.UAM EST.U S.M WWS cWxa M 4 tee 26MM Dow 0.0%Nasdaq 0.18%. TRADE'.> '�' I.EWX Chic I T -'^v�'J^"�i rsn Jw-ACDF- ® feoaE Zhe caOhbocL s wXarterWe a' j, o M- AT&T,Inc.}c.(T)-Ny5E *Fail. Got the big Picture an all Your Inyeahheat 32.28 0.15(0.48%) 11:34AM EST•Nasdaq Reet T rw Price Sync your Yahoo portfolio now ' Historical Prices Get Historical fail fm:;null �;C Set Date Range 0 Dally Start bate: Jul •', 24 2013 Eg Jae 1,2010 6VJeeMy E+M basa: Jul-:2C 2013 Q Monthly 1{ 8 Dividends Cray t f Get Prices i. i First I Provides I Next I Last Prices 1 It's time to ask: Data Open High Low Clow Volume Pull Close' what are we realy Jut 24,2413 35.39 3550 3493 35.40 30.938.B0o 34A7 r Itwesting for} 'Ckee Price aanstea W dr4daMa and auxts. First I Previous I Next I Last t�iDOmlload to Spreadsheet Currency In USD. I I� oxnm w�vu,..n �de:u Ad TOPICS That Might Interest You... 1.Best Penny Stocks to Buy 5.Stocks to Buy Now I 2.High-Yield Stock Picks 6.Good Stocks to Invest �. 3.List of Penny Stocks 7,Fixed Income invostntents 4.Tax•Frae Bonds T S.Top Equity Funds^ _ Feedback aea rd..m•Ator4 ou<aaz•trma-s.em Fed w& Yahoot-ABC News Network http:/J finance.yahoo.com/q/hp?s=T&a=06&b=24&c=2013&d=06&e=24& 2013&g=d 31612014 �3 CaIy \) �w scc s O WN 4� 1-J2IAt zCA)s= , I BANK /Q Isom here For here.For goad. Rc pu vT )RRSTOWN BANK ,7 East King Street 3hippensburg, PA 17257 Account: 50 Int 4401 Time: 1/14/2014 12:10:55 PM M32013 2653 i'2g Check 2653 799.20 M58.05 }6/032013 1 �+ XXSOC SEC SSA TREAS 310 PPU �x%Xr,'r DEQOSCT 1,143.00 �56A132013 1-31 ANN7'YPYMTPRUPPD EC't I *%Ax% 301.26 35/512013 1'3 PENSION BENEFITS PPD "jW--T G T 341.25 5/302013 2651 1.3S PURCHASE WAI MART'STORES CHECKN2651 CARL PA 51.9 35242013 2646 )�� Check 2646 58.67 il5232013 2651 1'� Check 2650 15.00 5 . 95232013 2649 1.3 PURCHASE SAYLOR'S MARKET CHECK#2649 NEWV PA E4ECCE4tSZC, 39.12 5333.69 135232013 2648 '3 PURCHASE WAE•MART STORES CFIECK 02648 CARL PA'EUM'Xi^!,' X ; A*4Vt 39.20 5,372.81 05222013 `30 ELEC PAYMT ADAMS ELECTRIC O PPD E%ALvt v03�- 'TA"Z L0. 43.43 541201 65212003 2645 1-21 Check 2645 52.64 5455.44 05202013 2647 '2$ Check 2647 30.00 550808 65117)2013 2644 1 T PURCHASE WAL-MART STORES CHECK#2644 CARL PA 4.00 5538.08 05/172013 2643 t'2V PURCHASE WAI:MART STORES CHECK92643 CARL PA 18.82 554208 b)t72013 2642 I-1S PURCHASE WAL•MART STORES CHECK42642 CARL Ph 2715 5-W.90 05/172013 2640 1.15 Check 2640 185.75 5,588,15 05/172013 View I= •k3 Depcsit 8.00 5773.90 05/162013 2639 -22 C14ECKPYMT PROPANE SERVICES CHECK#2639 CIAQ* nr "f vtC 221.00 5765.90 bs/15/2013 2641 1.21 Check 2641 3(100 5986.90 05)102013 Viewim J-20 Qcpwit 104.78 6016.90 ,05/092013 2637 1-1 Check 2637 T1R61 37.53 591212 05082013 )-)8 INS PRE TALLSTATE INS CO PPD s 4346 5.949.65 05/08/2013 1'17 INS PREM ALISTATE INS CO PPD �lL'CYCdtJ$l;.. 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"j0.g1JL'F1EG 134.06 5,61& 106110120113 ` INS PPMM ALLSTATE INS CO PPDELES.tNaN'G "TRAcSY>+lrR- 43.46 5,752,8 06A52013 Interest Dcpmit 0.05 i 796.34 06/042013 1'Y 7. 2652 Check 2652 37.53 5 796.29 064142013 1`41 DRAFTS BCBS PREMIUM PPD BG.QX#0bMVr—_r tAa� W\4- 310.39 5$3382 061032013 S�iO PAYMENT AOT Sectni PPD 'UtCSQpNYC _ RWOSVSPU 50.15 b 14421 Total Debim (S24,345.50)1 Total Credits:1 $19.557.111 BANK iom here.For heye.For good, Q )RRSTOWN BANK 7 East King Street ;hippensburg, PA 17257 %ccount: 50 )nt 4001 Time: 1/14/2014 12:36:14 PM il/OV2014 Interest Deposit 12/052013 Interest Deposit 0.01 1405,96 111052013 Interest Deposit 0.02 1,405,95 1 i/Ot20131.98 TCOIDD3311 AT&T INC.PPD 6LCC`T-f'O4M -r(%*kA=M 332.10 1405.43 106252013 1.147 Cha VF4%-%eO-J L1lLT4ZO A=r- %hRtA-%TE\%' 341.25 107183 IO /20i .9(0 REVERSAL BENEFITS PPDY£*.SA,OnwJ-Et_CCTfWAylC S 341.25 1415.08 101012013 I-R5 PENSIONBENEFITSPPD 010AZ'T LO'EtOXrC 341.25 1756.33 )9242013 1-161 REFUND 13CSS PREMIUM PPD SiCC1%4103C -I VlVlWr--Vk 682.86 L415.08 MS/2013 linterest Dc it 0.01 732.22 )9/04/2013 1-g3 JDRAM BOBS PREMIUM PPD ELECTi�1°t'SSO 'T'£A>J.SFC�rL 310.34 732.21 3120 1 3 `QZ. 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ZO H om here.For here.For good. IRS Cocut!TRy Y ZE W 6 SSTA T•�s RRSTOWN BANK N�V.i LL,E� Q� )-72M � 7 East King Street C�U NT / 66064 ti 34 hippensburg, PA 17257 %ccount: 50 Int 0001 Time: 2/6/2014 12:20:02 PM i0l2014 )-I Vim I c CIOXAccn,unt Motiv 03001980 (1745.45 _ .DO W32014 I' TCOiDD1402A &TINC.PPD O-vx CNp "`Qa*,M1y C)c �$T,"r 339.48 17dS.4S 52014 laterest it 0.01 1405. 013 Interest it 0.01 1 .96 1 /052 lnterest De sit 0.02 405.95 1/01801} TCOIDD1311 AT&T INC.PP 332.10 1405.93 b258013 bask 34125 1073.83 01048013 REVERSAL BFNFFITS PPD 341.25 1 415.08 "Inol3 PENSION BENEFITS PPD 115 1 756.33 9242013 REFUND BCBS PREMIUM PPD 682.86 1 415.08 /052011 Irnc= it 0.01 732,22 9/042013 DRAFTS BCBS PREMIUM PPD (31;?9) 73221 Wni)13 YMENTADl'Securi PPD 612 1042.60 +8!302013 P ION BENFFiTS PPD 341.25 1.035.78 !81122013 RECI S PRU PPD 301.26 694.53 18!062013 Cha cbac 1143.00 995.79 i8/052013 Interest i 0.29 2138.79 18/052013 DRAFTS BCBSAkMIUM PPD 310.39 2.1 38.50 Imam xrc•wnmgc Miscell bit 14450.00 448.89 78/72!2013 XXSOC •C SSA TREAS 0 PPD 1,143,00 16 898.89 X81012013 PEN N BFNEPITS PPD 341.25 15 755.89 18/0 1 20 1 3 T 1DD1308AT&TINC.PPD 332.10 15414.64 )MI/2013 ANNTY PYMT PRU PPD 301:26 1508154 )7292013 2671 Check 2671 2 95 14.78 1 A 7292013 7172318960 PHMEDSVCSPROFBIL PPD 2A. 15,063.23 0726/2013 2618 Check 2678 t2.300.00) 15 083.77 6724/2013 26 Chock 2675 (505.5181 17 383.77 07242013 673 Check 2673 33.31 17 889.35 b7f142013 72670 CHECKPYMT PROPANE SERVIjOgS CHECK R2670 221.00 17. 2.66 07242013 View Imam Deposit 38.12 1$143.66 0124nOX SDIOM77 MANULIFE ANC!PPD 13.666-24 18.10S.54 07/2111013 2669 BILL PYMT CenturyUKk CHECK$12669 67.42 439.30 ;0 8013 2672 Chock 2672 65.65 d 72 07822013 ELEC PAY DAMS ELECTRIC D PPD 40.99 4,572.3 7/192013 (259.001 4613.36 071182013 2668 Check 588.93 4,872.3 77112013 2666 2666 57.18 5,461.2 07/112013 View ima a it 85.25 5518.4: 07M92013 2667 X Check 2667 . 4 5433.2: 07/092013 2664 Chock 2664 108.d3 5434.9( 07109/2013 INS PREM ALLSTATE INS CO PPD (I A06) 5154131 07/92013 INS PREM ALLSTATE INS CO PPD 43. 56774 07=2013 665 Check 2665 37.53 5720.9 07/072013 Intent Deposit 0.04 5,758.4 071052013 2638 Check 2638 59.00 5,758.4 071038 3 DRAFTS BCBS PREMIUM PPD 310.39 017.4 07 013 XXSOC SEC SSA TREAS 310 PPD l 143.00 6 .7 /012013 PAYMENTADTSauri PPD 50.15 5184. SI;'I'I'LEMENI' STA TEMENT •'T--Tiatc SELLERS: E'67',4 r� _t^. ,, J,tr»L- t,ist/t BUYERS: n 7 ra Tr _1lskY 7ohll SE . ERS TRANSAC'I'IC)N SALE PRICE: no— LESS Payorr LES Commission LESS LESS LESS LESS LESS LESS` PLUS Proration of Lot Rent /M! .77 PLUS Proration of"Iaxes d'/.,/.o� DUE TO/i^iT.t SFLL?RS jid�4&5"7-YI ........................................................................................... BUYERS TRANSAC°Il()N SALE PRICE,. 8. 7 Title Transfer Fee .So Insurance Yearn P G'•C.. CiosingFees •60 Proration ol'Lolltent 144 77 Proration orl'a=s School ljbm •s'd C'nunty,9riaj, 1•S� ;5-11 tY Other R. r _x' Other Other SUBTOTAL LESS Deposit Received LESS Amount Financed /4-GOe.ed ._TOTAL CREDSTS._-- --".'- DUETO/FROM BUYERS 111M........................................................................................ P,AURSEMGNTS son $pUq Ihi}v . � S? 9 , 13 310-5 �',581o�5�s "i�z5q.ao 259 34 8, 333 3 rR x 2g0 x J3 7� lzYo�tets - Llt,°' -,y i3 x>R s 23 9,6o A 75 S7 CO ROWE'S AUCTION SERVICE (RH 79L) 2505 Ritner Highway • Carlisle,PA 17015 Bill Rowe {AU 153$L1 249.1978 215-1044 574.1048 Dave Rowe {AU 2295I Auction Is Action Call "Rowe" For Satisfaction SELLERS NAME `�` c� cc y _ t o Lt DATE (s ADDRESS LxL� k>Le a 5;;�G '2LLs+r, PHONE -A S�: - a1 'i S OTHER C/O( <'ees u Q Wf W.XC AUCTIONEER I;� r w AUCTION DATEILOCATION CLERK % DESCRIPTION OF MERCHANDISE �`�` `may r 1.��• 4 c_.�'Se,nn_.1..� - Cv..n."�A�..., -r_� c..S �F-f_..a i .at�'I.. — �,9`wr��.a" tow t./. ychat�A- C—L p J / 44-F��ix-,, P,.c L Ly, I Commission the Auctioneers to sell the merchandise to the highest bidder by Public Auction.Merchandise to be sold as is &grouped as necessary to obtain bids. I certify that I am the owner or authorized represen- tative of the merchandise,goods and or property and have good title and the right to sell and that they are free from all incumbrances. I agree to accept all responsibility for providing merchantable title and for delivery of title to the purchaser. I agree to hold harmless the Auctioneers against any claims of the nature referred to in this agreement. ` AU ON SIGNATURE SELLERS IGN TS URE Total Sales (Clerking Tickets Attached) $ 10 S 1 Less Sale Expense: s ' s %Commission Auctioneer $ %Commission Clerks $ OTHER: lk......_ q),- TOTAL SALE EXPENSE DEDUCTED $ 1211-Z SELLERS NET $ ROWE'S AUCTION SERVICE (RH 79L) 2505 Ritner Highway • Carlisle,PA 17015 Bill Rowe (AU 1538L) 249-1978 215.1044 574-1008 Dave Rowe (AU 2295L Auction Is Action Call "Rowe" For Satisfaction SELLERS NAME �1iS°F _ c� ocKfJ fR p Lm�t DATE (S, ADDRESS sui PHONE -A - 61 S / r-r OTHER r. y— V;Lu AUCTIONEER.% AUCTION DATE/LOCATION CLERK % DESCRIPTION OF MERCHANDISE i j 1f1�J�u.r. c_ jhe ht 0.,.�(L,Ly,.1 - Cin.n.o e J��G�u c.S �-t--.a_? Ct.�6-/IJz_— \ : El akr-n �ya., I ezn .v,�r.�.'�'� - -��s 73_ (f-.D LA CA V1 ) / II � flfsJ 'p _ 'T4x7j L'& C z-- C 60 t. Lk-2r_-W3» �J-DNRA l5157 I Commission the Auctioneers to sell the merchandise to the highest bidder by Public Auction. Merchandise I to be sold as is & grouped as necessary to obtain bids. I certify that I am the owner or authorized represen- tative of the merchandise,goods and or property and have good title and the right to sell and that they are free i from all incumbrances. I agree to accept all responsibility for providing merchantable title and for delivery of title to the purchaser. I agree to hold harmless the Auctioneers against any claims of the nature referred to in this agreement. M AU ON SIGNATURE SELLERS SIGNATURE Total Sales (Clerking Tickets Attached) $ L 3 S I Less Sale Expense: q .) S %Commission Auctioneer S 4 S %Commission Clerks $ OTHER: TOTAL SALE EXPENSE DEDUCTED $ SELLERS NET E s 2 7 7, Z", T 7-2 T +n' "JAL' I c i,i e nt "on 3. C'.on.z Estate 243- 95'34 Page:; ��i �ouylv Esq PA 17013 :ten Descripti -,n -At 1 CUM P Si:.an. BL bcjw'. 5 e TT r. 7Jpp— -,'Z;. i vjG .'L r. DIL s I 1,L L V.♦Ji u! 10: 46:32 Rowe' S Auction Service et —A I♦��ylIy���.tQQ ��yy � -j: '•. .�, aTy°'�.1J Yi Pat, i .. :i1JJGhG.f ^r a _ _ �. 14" i� )''t i'11 i y LIA.. rtf}_G^ ;,y dzai- knobs f t cr la4/ry' :,ns frac.es.,bir pr nn nt L v .. _ rr♦ .tJa a eF+ rlM r — r ! ♦ _J iJ Y;'lt a 1'�i1rb J4c;*1"tJ Y'♦ clryy ry♦/Y T}"'G a .♦ ...r .._r. Yt.rt v — — v_ Mts C Lcni ap p- u 1 � .1. a "Y Y •�J• .. - qt A " t - a ��. � ♦ i i .. ..4J x,y r L. ._ ♦.._•�a '*av an Ls-a"Jt' {i(y� `_ • Lai♦ !Th JYG\nwlr�t"r of.;1G u�uaG u♦ �.} G ' ti �� rr. —� rre`t y •e �r'SnS .!1^ _ � r A�f1 ` , J " •_. nfry �.. n v Art l f I E Fast Main Street Walking with Those in Grief-I Mechanicsburg,PA 17055 Robert"Bob"L.Buhrig,.IC,FD,Supervisor eh:www.Myem-Buhrig.com WiBfatn"Bill"L Christopher,FD 1111 irectors@Myers-Buhrig.com Phone:(717)766.3421 . Fax:(717)795.7291 TATEMENT OF FUNERAL GOODS AND SERVICES SELECTED I arges are only for those items that you selected or that are required.If we am required by low or by a cemetery or crematory to use any items,we will explain the reason in writing below. JJyou 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. Eve if you selected arrangements such as a direct cremation or immediate burial.If we charge for embalming,we will explain why below, pr the Service of :,�, },)0_'R , i �t} - I?sle of Death 1-PrtgrtLrC" �,'' S g 1 Irs�Q PA 1-7 D1 N Name .1 Addres O\!.Y ) City State .CHARGES FOR SERVICES SELECTED: C.SPECJALCHARGFS I.PROFF,SSIONALSERVICF,S .............................S Direct Crematfo_ Immediate Burial..............'�."�., .. Basic Services of Funcml Director&Staff n................*..'.:.'.. ...t..... .............................. 5?�L " Etubalming/Clinical Cam.........................................................5 � Anatomical Gift......_..........._.._.._..........................................S—_ Other Preparation of Body........................................................S Forwarding of Remains............................................................. S Dressing&Grooming ................................................$ Receiving of Remains..........................--..................,.............. $--- Casketing or Reporting...._..........................................5 SUB-TOTAL OF SPECIAL CHAROF:S...................................CS Cosmetology&Basic Restoration..............................5 D.CASH ADVANCES Dignity/Sanitary Cam .........--...............................................5�� We charge),nuforourscroiccy in ohrofnerg. r,,, Other Preparation of Body with Dignity/Sanitary Care...........S Greve Opening...................w...........--...................................$ f U Additional Caro for Autopsy and/or Donation.................._.....$___,,,,= Other Cemetery Chnrgcf..,.,....................................................$ Additional Services of Funeral Director/Embalmer ................S Graveside Equipment&Setup..................................................ST. Additional Services of Non.licensrd Attendant(s) ..................$_..._ Clergy,...........................---....................................................S_-.� Sub-Total of Professional Services.............................................A) Deacon/Assistant....................................................................... 5 " 2.USE OF FACHAT1ES,EQUIPMENTAND SERVICES FOR, Altar Scrver_.................r...........................................................$,-,_ . FarewcllViewing .................._............................__............_..S .'"' Sexton......---........................................................................5 ViawingNisitation(Gathering........................................,..........S Organist/Pianist.................................---................................. 5 Funeral Ceremony..................................:..................................S_- "' Soloist/Cantor...........................................................................S_...__` Memorial Service-..................................-..................__.........5 � Instrumentalist........................................................................... $- Grevesideor Committal Service..._...----..........................$__ .�_ Hairdresser....................--.................................---...............S Cremation................................................•�J .y�+y S � Military Honor Guard.......................,.......................................S_ Sheltering and/or Rcfrigcrntian............!!?".!!...K.../..!".`. ........$4?a:! Coroner's Fees..........................................................................S._. p--• Break between Functions.............................._..._.._..._.._.......S ..� Certified Death Certificatas..........................................._..........S Sunday&Holiday Events........................................................S Flowers...................__..................._................._.......................S Other use of Facilities,Equipment and Staff...........................5 _ Reception.....,....................................................................... .....$ Sub-Total of Facilities,Equipment and Services......................A2 S Monument Purchase..................................................................$ 3.AUTOMOTIVE EQUIPMENT i Monument Inscription.....-................. .......................... Care Tmnsport Vehicle&Service to Funeral Home................5 Patriot News.............................................................................$^011.!Sol, L.cad/Clergy Vehicle....................................................-...........$_. " Carlisle Sentinel........................................................................5 _ Hearse/Funcral Coach ..............................................................5__..:�. Newspaper................................................................................ .5. ;._. �- $ j Flower/Stiff/Equipment Vehicle..............................................5 Other...................................... .............. .............. Transfer Vehicle .................. .........................s Other.....—.................—................................—................. Additional Vchicle(s)Time Charge....... ................. Other...,..._....._.....-....................-............... ................. Additional Vehicl4s)Mileage Charge ..................-- SUB-TOTAL OF CASH ADVANCES......_.........—... D S Sub-Tillill of Automotive Equipment.......................................A'S '' " SUB-TOTAL FOR SERVICES SFI,FCI'ED...........................A S ZSUMMARY OFCHARGFS B.CHARGE FOR MERCHANDISE SELECTED: A.TOTAL FOR SERVICES SELECTED................................5 Casket......--.................................................. ...........S B.TOTAL FOR MERCHANDISE SELECTED...................-3 Other Receptacle:A Iterrealive Container(cardboard)...............$ C.TOTAL FOR SPECIAL CHARGES.................................S Cremation Urn(full size)..........................................................S•_jW1 D.TOTAL FOR CASH ADVANCE S.................",................ Outer Burial Container....................--.................. TOTAL OF SECTIONS A+B+C+D.......................—......... ...7�s Keepsake/Jewelry..........—...............................----...........S I Keepsake/Jewelry........... ................................................$ -*—N. Price Guarantee Premium:A,.....................................S Keepsake/Jewelry......... ........--................—...............S —.Y—.N Price Guarantee Premium:B.....................................S--= Keepsake/JcwtAry......... ..............-'-........---.............. Price Guarantee Premium:D........._---......--.......... Memorial Package......... ..............--................................S---= TOTAL OFALL PRICE'GUARANTFE PREMIUMS—......._........S RegisterBook....................................—...................................$ - Memorial Poldiurs(I'myer Cards.................... ............. GRAND TOTAL—........-.................I......11............ ........1—......S Service Bulletins....—...._..,,..,..._............—..................... PAYMENT................--.......—.--.......I.....--............. .......... AcknowledgementCards.,....................................................... BALANCE DUE:.....................................................-................. PrintedObilitarics........--................_..,....................................$ DVDs.............................................—,....... portmils--.—..............—................ —.............. ..........S REASON FOR EMBALMING Flag Case--.................................... ..................................3 ❑Voluntarily Authorimil by Family Temporary Grave Market-.................................. .........:....S 0 Viewing BurialClothing.....—.......--.....................--....................... OtherClothing....-......................---................. ........... Wcbsitc Service...............................—................................... If any law,cemetery or crematory requirements have required the purchase of any c Audio/Visual Use......................................................................$ items listed above,the law or requirement is explained below.At minium, Other.....-........—....---................—...—.......................-......$ 0 the cemetery quires the use of a basic outer burial container/grave Inter S,UB-TOTAL OF MERCHANDISE SELECTED.................x, s ry crematory requires the use of an alternative(cardboard)container. IlWc agree that Itwe have examined the items of good,services and cash advances selected above and found them to be correct and in accordance With the arrangements llwc have remedial. I(We ac- knowledge receipt of a copy of this Stalcoacm Of Federal Goods and Services Selected. Me represent that I/we have mufficiem funds available for payment of the cash price for the good,services and advances selected. )/We also-agree to make payment in Felt within thirty(30)days. DWc agree to bejointly and severely liable with anyone and everyone rise who sips this agreement.A late charge 1.5%per Month Amounting 10 191`6 Per YCW Will be applied to the unpaid boximiec beginning 31 days from the date of this Agreement. I/We will Rise Pay Myers-Bithng funeral HOOM and Crematory,U .11 rotionable costs incurred by Myers-Buhrig Funeral Home and Crematory,Ltd.to collect any amounts Uwe owe under this agreement. j*hme,costs may include but are not Ranked to mlorrev's loss. court casts and all other costs. Any additional services or merchandise ordered or romisted oiler the date andlor signing or this agreement will be considered pro of this agreement and the cost thereof be reflected an the final bill andiror statement and am subject to the payment terms specified horrid. IN WITNESS WHERCOE and kneading to be legally bound,Uwe h ve executed this contract for Firdem)Goods and Services Sctected, (Purchaser)(& (Purchaser) (Purohown) (Purchaser) (Funeral Dircouar):fr�o;t C9z Li While:lugm,=Company,True,or Farrell Home Yellow:Myers-Ruling Fumml Home and Crematory,Ltd Pink:Client Family Rev. 1 THE LAw OFFICES OF KATHLEEN K. SHAUUS, ESQ+ P. O. BOX 1229 1638 WAL>SIuT BOTTOM ROAD CARLISLE, PA 17013 CARLISLE, PA 17015 PHONE(717) 243.6655 - Fax(717) 243-6618 EMAIL: JRS037CARLISLE@SPRINTMAIL.COM Invoice submitted to: Robert Stought, Executor 17 Ridgeway Drive -Carlisle,PA 1 Re: Estate of John B. Ciontz 21-13-0849 Hours Rate Amount 815/13 Preparation of Petition for Appointment/Information by Telephone/Email/Filing petition at Courthouse for Appoinfibent'Of Executors 2.7 hr/$1001hr 270.00 8/26/13 Arrange for advertising 0.4 hr/$100/hr 40.00 8/28/13 Prep. &filing of Notice and Certification Pursuant to Rule 5.6(a) .4 hrl$100/hr 40.00 10/1/13 Sentinel Advertising -� 157.88 --- _-_. 10/12/13 Payment(check no 105) Total due 10/31/13 r _ --� $00.00 YOUR COPY 10)10 ��3 THE LAW OFFICES OF KATHLEEN K. SHAIJUS, ESQ. P. O. BOX 1229 1633 WALNUT BOTTOM ROAD CARLISLE, PA 17013 CARLISLE, PA 17015 PHONE(717) 243.6655 FAx(717) 2436618 EMAIL: JRS037CARUSLE @SPRINTMAIL.COM Invoice submitted to: Robert Stought, Executor 17 Ridgeway Drive Carlisle, PA 17015 Re: Estate of Jahn B. Ctontz 21-13-0849 Hours Rate Amount 03/06/14 Stock certificate transfer with Orrstown Bank 0.7hr/$100.00 70.00 04/09/14 Preparation of decedent's federal, PA Tax retums and Senior Citizen Rebate form 1.1 hr/$100.00 110.00 4/25/13 Preparation, filing of Inheritance Tax Return and Finalizing Estate 27.5 hr/$200/hr 2750.00 Total due 05/01/14 $2900.00 YOUR COPY The Sentinel SHAULIS LAW OFFICE AD NUMBER PAGE NO. www.c v m b e r l l n k.c o m P.O.BOX 1229 424424 1of1 /J CARLISLE,PA 1701 3-1229 BILL DATE _SALESPERSON 717-243-6555 — 09113113 wotfc CAMI&C 9*flLW QG rfLfl C( FiY START DATE STOP DATE 08130/13 09/13/13 AD NUMBER AD DESCRIPTION CLASS I LINES 424424 EXECUTOR'S NOTICE LETTERS TESTAMEN-' —` 10 PUBLIC NOTICES 1 28 " 2 cols Publication Insertions Rate NotAmount Gross Amount 3 THE SENTINEL-LEGAL 3 LGL $148.68 TOTAL AD CHARGE $148.68 3 MOBILE SITE MOB2 $2.00 3 PROOF OF PUBLICATION 01PRF $7.00 Purchase Order Est.John Clontz PAY THIS AMOUNT $157.6L$189.22- 10/08/13 Lee Enterprises no longer accepts credit card payments sent via e-mail. Emaiis containing credit card numbers will be blocked. Please use the coupon below to send credit card payment to our lockbox, THE SENTINEL You may also send the coupon to a secure fax at 319-291-4014. c/o LEE NEWSPAPERS Thank you for advertising with The Sentinel! Deadline for PO BOX 540 in-column legal ads is 4:00 p.m.two business days prior to WATERLOO IA 50704-0540 date of insertion. For questions,call(717)240-7130. Rerum this portion with yourpeyment Legal THE SENTINEL �]Check# ❑Credit Card Ad Number 424424 c/o LEE NEWSPAPERS ❑ ❑ = ❑ ❑ Bitlirtg Date 09M3113 PO BOX 540 WATERLOO IA 50704.0540 Acct M, Amount Due $ 157.68 Exp.Dat-M M . Mn t Name on credit card �.[1 Signature Please make chftks payable to: THE SENTINEL t 000x15 THE SENTINEL SHAULIS LAW OFFICE c/o LEE NEWSPAPERS P.O.BOX 1229 PO BOX 742548 CARLISLE,PA 17013-1229 CINCINNATI OH 45274.2548 Idr�Llri;�rLlLrrLh.L,LIJJrrL,iLrfrli,JLddn111 21540200000004244240000000000000001892200000157688 PROOF OF PUBLICATION State of Pennsylvania,County of Cumberland Jackie Cox,Director of Sales,of The Sentinel,of the County and State aforesaid,being duly sworn,deposes and says that THE SENTINEL,a newspaper of general circulation in the Borough of Carlisle,County and State aforesaid,was established December 13th, 1881,since which date THE SENTINEL has been regularly issued in said County,and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following day(s): August 30,September 6,13,2013 COPY OF NOTICE OF PUBLICATION EXECUTOR' NOME t Affiant further deposes that he/she is not ,Letters Testamentarlforthe Estate of JOHN B.CLO%MIafeofCumbenand interested m the subject matter of the } County,Pennsylvania,deceased,have been granted to the undam' nod. aforesaid notice or advertisement,and that rAll persons having claims against th r state of the decedent are requested M all allegations m the foregoing Statement a5 make them known to the undengned and all persons knowing themselves to be Indebted to said Estate will make payment without delay to and those to time,place and Character of publication immediately to the undersigned. fe�Pl� Robert haulis Executor A� "`'ye• cte Kathleen K.Shaule Esquire Carlisle Lew Office ' P.O.Box 7228.Carlisle,PA 74073 Sworn to and subscribed before me this rL Sig fgrn r af�l3 . No Public My commission expires: COMMONWEALTH ON PPNNSYLVANIA Notarial Seal Bethany M.Hoary,Notary Public CBnigle Soto,Cumberland County M cgmmt55ton Expires Sept.26,2015 MEMBER,pENNSYLVANLA ASSOCIATION OF NOTARIES a kAN CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Sete: {717}249-3166 Fax:(717)249-2663 September 20, 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: Kathleen K. Shaulis, Esquire RE: John B. Clontz 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 the following dates: September 6, September 13, and September 20, 2013 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 0 .00 Total Amount Due $ 75.00 Payment received by PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWF_,ALTII 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: September 6, September 13. and September 20,2013 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. ' U sa Marie Coyne, tditor SWORN TO AND SUBSCRIBED before me this 20 day of September,2013 - C Notary Clontn,John B.,dec'd. / Late of Cumberland County, Executor: Robert Stougbt. Attorneys: Kathleen K. Shaulis, .�---- M--^�•-^°-•�^^'""" Esquire,Shaulis Law Office,P.Q. W1 tFksAL Sf AL Box 1229, Carlisie, PA 17013, OE80f AH h COLLINS (717)243-66SS. Notary Public CARLISLE 80ROUGfi,CUMBERLAND CITY hhy Cemr�tissfoa fxpires Apr 28.2014 ORRSTOWN BANK hom hcrc Frnhne FOr ktt¢d. ORRSTOWN SARRT'/Eatt KMp Siroet SMppMHbuY9.PA 17257 View Check Mega Flip Ralpt¢ Realm ,IpIIIV a GAN7L ESTATE _ ° • • • :1.07 OAM14E.PA��t7rr016e: -"-.-�_�2 1I1 6 I� Q . , .W+. . lENDea The UPS Store - 02878 950 Walnut Bottom Rd Suite 15 Carlisle, PA 17015 (717) 241-5554 10/14/13 01:31 PH We are the one stop for all your shipping, postal and business needs. n 1 We can print your next party invitation! u-J n S S� P�-Z (v G Ask us how we can help. Sir?� Il illlllllll(illllllllll(II(UIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIINIII III � f�L c.-r�,�Es 001 001045 (001) TO $ 37.71 Ground Residential Tracking# 1Z74W9130309359313 002 001045 (001) TO $ 22.35 Ground Residential Tracking# 1Z74W9130376027019 003 001045 (001) TO $ 22.71 Ground Residential Tracking# 1Z74W9130309361391 004 001045 (001) TO $ 20.21 Ground Residential Tracking# 1Z74W9130309362434 005 001045 (001) TO $ 24.33 Ground Residential Tracking# 1Z74W9130376030130 006 001045 (001) TO $ 23.07 Ground Residential Tracking# 1Z74W9130309364512 007 001045 (001) rO $ 23.63 Ground Residential Tracking# 1Z74W9130309365557 SubTotal $ 174.01 Total $ 174.01 Check $ 174.01 Receipt ID 83264692644431883472 007 Items CSH: Samantha Tran: 7716 Reg: 001 Visit our website! www.theupsstorelocal.con/2878 Whatever your business and personal needs, we are here to serve you. ENTER FOR A CHANCE TO WIN $1000 We value your feedback To enter please complete the customer satisfaction survey located at: www_theunsstnre.nnm/gnrvev Shipment Receipt : Page #1 of 1 Shipment Receipt : Page #1 of 1 rHm IT NOT A SHIPPING LABEL. PLEASE SAVE FOR YOUR RECORDS, THIS IS NOT A SHIPPING LABEL, PLEASE SAVE FOR YOUR RECORDS. iHIP DATE: SHIPMENT INFORMATION: SHIP DATE: SHIPMENT INFORMATION: loo, Ott 14,-2013 UPS Ground Residential Mon, Oct 14, 2013 UPS Ground Residential 30.80 lbs actual Ni 6.88 Its actual wt 'XPECTED DELIVERY DATE: 31.80 lbs billable at EXPECTED DELIVERY DATE: 6.60 lbs billable wi (ED, OCT 16, 2813 EDO Oies: 18.6042.00x14.00 NEB, OCT 16, 2013 EOD DIas: 5,0007.80x9.88 Declared Value : $100.00 Declared Value = $100.04 )HIP FRON: SHIP FROM: Tobert Siought Robert Ste*i IT Rid My OR 17 Ridges DR Carlisle PA 17O(S Trackitg Nuaber. 1x7499130309359313 Carlisle PN 17015 Tracking Ruwber 1:7499130309361391 (717) 243.9594 Ship Ref 1:D: MMS4HX9527AS5 (717) 243.9594 Shipsen 10: M UNKWX7ft Ship Ref 1: . - SHIP 10: Ship Rot 2: • SHIP T0: Ship Ref 2: - - Gore%y Warren DESCRIPTION OF 60ODS: Dorothy Marren DESCRIPTION OF GOODS: 2255 VICKSBUR6 L8 sw-pictures FOLEY IgCK3653GG 1581 sw-piciures FOLEY AL 36535.15sl Residential esidential SHIPMENT CHARGES: SHIPMENT CHARGES: Ground Residential $29.81 Ground Residential $15.79 Service Options 0.06 Service Opptions 0.00 SHIPPED THROUGH: Fuel Surcharge 45 SHIPPED IMP:P: Fuel Sunhats !.47 THE LEAS STORE #2878 Delivery Area Surcharge 5.25 THE UPS STORE 02878 Delivery Area Surcharge =5.25 CARLISLE,PA 17015.7601 INS Processing Fee IO CARLISLE PA 17i1i5.16D1 CMS Processing Fee SSDD 20 (717) 241-SS54 (717) 24i-5554 g_ Total. 537.71 Total $22.71 uAsi bd3s"Ee °IY�§#4pr§'p'�#^6�uoi+°`. oE:d1:1 L:"sXY".:.'n"!°sR`$Y'or i#xA`nR#i' n§"plR}Tgg}h_orn.tA:RReKixerr:''�g�idrCCxY�r}jisstinr°r:n't.:"sXtnK` n't°sB•ww•• O°x:AnP�#F`- } � (x,#§t�617Y4"E4n .et'§#�PPfio TWWGX .bnv.. YSTOXE RtnMONli'C6eRFMT x K% : �cC icStTtj{ %,nm!)tlif bm%1ncaMint ♦'esTti OirAl% sht T' i T, 2 %nut.tl�p .rM ec�apl T.r i CoM/duns Ln fenrca M 'c1 tilxprOY1G`q 14f \hl i • CCY��T. In IY ..p. .nO 14na ' th-r !hl iK.lxon ,W r11 1°af etltlfiil. C knot' provltlidK>?ir !hi♦-r IM ... ......4an7n ifiY ..p.cb. ignature: ' g Signature: hipaeniID: MMSMUS27AS5 �� ( ���IIU��I� flWNIkI1�It�I���R1101fI1f ShiplemID: MM54HKUXYTRH3 pR.e..tl by 1fh1p(.) The UPS Store �n'L4,n13 �o','3`AM P.Cxilc Tx.. R The UPS Store P..,/RRSD 10:20 RR pacific TtK N Shipment Receipt : Page #1 of 1 Shipment Receipt : Page #1 of 1 THIS IS NOT A SHIPPING LABEL, PLEASE SAVE FOR YOUR RECORDS, THIS IS NOT A SHIPPING LABEL. PLEASE SAVE FOR YOUR RECORDS, SHIP DATE: SNIPNENT IRFORIMITION: SHIP OATS: SHIPNENT INFORMATION: hon, Ott 14,-2813 UPS Ground Residential Mon, Oct 14,1013 UPS Ground Residential 4.68 lbs actual at 2.60 lbs actual at EXPECTED DELIVERY DATE: 5,00 lbs billable at EXPECTED DELIVERY DATE: 3.90 Ibs billable rt WED. OCT 16, 2813 EDO Dias: 9.090.000,00 WED, OCT 16, 2013 EOD Dies: 11.684.000.08 SHIP FROM: Declared Value : 5188.00 Declared Value -. $169.00 Robert Slought SHIP FROM: 17 Rid OR Robert StoughR 37 ftidggaraP OR {erns e A 17015 Aatkingg Nwber: 1014N913031fi027B19 tariisle PA 17015 Tracking Nuaber: 107499130709362434 (717) 243.9594 Shlpaent ]0: 1RI54HXNFFOHJT (7171243-9554 Shiptont I0: MM54HKUNI5878 Ship Net 1: - - Ship Ref 1: . . SHIP TO: Ship Ref 2: - - Ship Ref 2: - - SHIP TO: Dorothy Warren DESCRIPTION OF GOODS: Octal hy Patten DESCRIPTION OF GOODS: 2255 VICKSBURG LN sw-pictures 2255 VICKSBURG LN sr•piciures FOLEY AL 36535-1581 FOLEY AL 36535.1581 Residential Residential SHIPMENT CHARGES: SHIPMENT CHARGES: Ground Residential $16.4S Ground Residential $13.45 SHIPPED THROUGH: Fuel 0 Lions 4.00 Service Opptions .04 Fuel Surcharge 1.45 SHIPPED THROUGH: Fuel Sutc9fee .31 THE UPS STORE 02878 Delivery Area Surcharge 5.25 THE UPS STORE 02878 Delivery Area Surcharge .25 CARLISLE PA 17015.7601 CHS Processing Fee 2O CARLISLE,PA 17815.7601 CMS Processing Fee 11.18 (717) 241.5554 (717) 241.5554 RYp Total $22.35 Total $20.21 Ii�TR "NLii TRACKING. f YTlhl irgtltleuet'1nsXto:.ni°xB`#7'" EX29AQMT' T ORLf YRRC%x114: n! lhl. .dtlrK In b b)u.iir \e et, 1A$fib sl"E; .It'§0tpplg" SRguRR:Lpi..: " a !€t r NSf"@'pt °.<t'§0Tn28.TI1.1bt •nTn, sXP°.:.ni xo Ra IOxan€Nx hipment Receipt : Page 01 of 1 Shipment Receipt : Page #1 Of 1 IS IS NOT P SHIPPING !ABEL. PLEASE SAVE FOR YOUR RECORDS. THIS IS NOT P SHIPPING LABEL. PLEASE SAVE FOR YOUR RECORDS. IP DATE: SHIPMENT 19ORNTION: SNIP DATE: SHIPMENT INFORMATION: I Oct 14,.2013 UPS Ground Residential Mon, Oct 14,•2013 UPS Ground Residential 1810 lbs actual wt 6.60 lbs actual of 3ECTE0 DELIVERY DATE: 11.00 lbs billable wt EXPECTED DELIVERY DATE: 7.00 lbs billable wk 3, OCT 16, 2013 EOO Dias: 12.08w9.88018 Declared Value c $100.00 RED, OCT 16, 2013 EOD Dias: 1d•9e 2.000.00 IP FROM: SNIP FROM: beri Siought Robert $(ought Ridgeway OR Traektngg Nwber: 1:79R9130376030130 17 Ridgeway OR rilele PA 170I5 Shipsen4 ID: MMSMOYFOM Carlisle PA 17015 Tracking Haber; iz7dtl9i3d309364512 17) 243.9599 Ship Rof 1: - (717) 243.9594 Shipsent 1D: MMS4MKMtKHPTF Ship Ref 2: Shp Ref 1: - - Ship Ref 2: IP 10: DESCRIPTION OF GOODS: SHIP TO: rothY Rarren sw.houshold !teas Dorothyy Rarren DESCRIPTION OF GOODS: 35 VICKSBUR6 LN 2255 VICKSEURG LR sw-houshold iteas LEY AL 36535-iS83 FOLEY AL 36535.1591 .sidential Residential SHIPMENT CHARGES: SHIPMENT CHARGES: Ground Residential $1650 Ground Residential $16.12 Service 0pLions jiie5 Service 0 Lions 0.00 1IPPE0 THROUGH: Fuel Surcharge IE UPS STORE 02878 Delivery Area Sutcharge SNIPPED THROUGH: Fuel Surcharge 1.50 tBLTSLE TO 17015-7681 CMS Processing fee 0.20 THE UPS STORE 02878 Delivery Area Sutcharge 5.25 ii7) 291.5554 CARLISLE,PA 17015.7601 CMS Processing Fee 10,20 Total $24.33 (7171241.5559 ``// VVVVp [1 �1[•f {� a pv vv.. yy ♦ Tote! + $+23.0%%1 i IONL] Cont°ctp4«FPP6b'Tn.UU4Niklw✓A.riI1T.i PSK2M.^1N1Or MTtcr «}�Gr«T� C STE ONLInE TOftKIW ppn/�Ir lscpf egdrinttinlAF'zl-Si f4t 5«1 041 hN A�4 Eatl"f"Ean3Ki'IN°1PP�6°f :TOa6Re CKNOY6CDO.6�n16M{' insuGytrgfrli *.I oni,'pPIKTO� ..P.°t l+t 'AWA IA .,N VI' r Hi,ncarvf� p(L'p g dpi �d •p I l.ldueilP Pv1piC'f for t`tl. iNlrp+M1.nl r• c •1Y .. S�Tt m1 alM tl„�8G6Ntirl N�c'W°pk°TKi� Ic;.1{en�iMtcr�f� ri'idi ditiainceniant tnd 14.2 PrPrltl.p (Pr lNb .blpMnt . eCUf MP lO �Y P.e .. gnalure: Signature: ipaentIO: IMS4HKRYFOCR3 11901UMloll min 11 11�11�111r1�M1111111 ShipaentIO: MMS4VIXMIKHPTF III pill Iii[{11 ill1 .IN1111111111 bP.r.tl by LSNiPic} fhe ura $tul l; P°wrttl by ishl.(r) TI16 UPS Store 8//413011 10102 An Ptculc Tl.a N l8/ikli011 28,31 Nn P.clll. Ti. N ;hipment Receipt : Page #1 Of 1 HIS IS NOT R SHIPPING LABEL. PLEASE SAVE FOR YOUR RECORDS. iIP DATE: SHIPMENT INFORMATION: In, Oct 142 2013 UPS Ground Residential 8.05 lbs actual wt tPECTED DELIVERY DATE: 9.00 lbs billable at E0. OCT 16, 2813 EDO Declared Value $100.00 HIP FROM oberl Stough( 7 Ridggewe; DR Tracking Nuaber: 1t7dR9138 9365551 717isle PA 11815 Shipaent ID: MMS41IXN000MIU 111) 243.9594 Ship Raf 11 - - Ship Ref 2: - - HIP TD: DESCRIPTION OF GOODS: 255 VI Warren sw.houshold !teas 255 YTCKSBiMtG LN OLEY RL 36535-iS81 esidential SHIPMENT CHAMS: Ground Residential $16.65 Service Options 1.57 AIPPEO THROUGH: Fuel Surcharge NE UPS STORE 112070 Delivery Area Surcharge 5.25 .'ARLISLE,PA 17815.7601 CMS Processing Fee 0 26 ,717) 241-5554 Total p}. _523,63 XPL TC OMLIIIE ,kPCk3N0 t i-1. .ddr`.. in b Rrlll 'e 8«13GE«T G :kit°:. nt., P EK4 .nt I ESTICNSr G nt.ct ENI OxnsT'OwN BANK ' rrom hmsrorhererer�rood. ORRVOWN BAW 77 Eeft MV Street 6ttlpPmR ".PA 17257 View CMtk knob Flip Rotate Return JOHN BCLONTZF$TATE 8 " 503 17 RIDOMAY OR ' CARUtLE PA 170M, i �Mt J 0 4 { iq � t3 LEMOEfl i CUSTOMER #: 2439594 160487 Graham Motor Company, Inc. *INVOICE* 1402 Holly Pike DEBORAH KAY STOUGHT Carlisle,Pennsylvania 17015 17 RIDGEWAY DR Tel.(717)243-3066 � (800)992.4743 • Fax(717)249.7998 CARLISLE, PA 17015-7614 PAGE 1 Web Site:http://www.grahammotors.com HOME: 717-243-9594 CONT: 717-243-9594 E-mail:servlcefgrahammotors.com BUS : CELL: SERVICE ADVISOR: 112 KAREN MCBETH ' COLOR YEAR _}-' MAKEIMODEL , VIN ILICENSE!AEG,#1 MILEAGE IN OUT TAG 09 HYUNDAI SONATA SNPET46C79H534196 HGE8154 44386 44366 196 DEL."DATE ' . PROMISED.; - Po No' RATE PAYMENT INV. DATE 25DEC09 I 25DEC09 D 16:30 12SEP13 27 111 CASH 16SEP13 R.O.OPENED READY OPTIONS: DLR:GRAHAM ENG:2.4 Liter 13 : 06 12SEP13 15: 33 16SEP13 LINE OPCODE TECH TYPE HOURS LIST NET TOTAL A GRINDING IN RIGHT FRONT WHEEL AREA. CHECK ALL BRAKES. 58A REPLACE REAR .BRAKE PADS & TURN ROTORS 117 CCM 100..00 100 . 00 1 954DI313 BRAKE PAD 71. 00 71. 00 71. 00 125 :REPLACE RIGHT REAR BRAKE 'CALIPER' AND BLEEa BRAKES 127 CCM 71. 36 71.36 1 1161983412A CALIPER S 180 . 00 186. 00 180. 00 CARTS, 251 ',00 LABOR: 171 , 36 OTH R1 2xt�. 0 dpi 6TAL LINE A � 422,.36, *•wrw*+**wwtwwwwwwwwwwww v�.w*** wwwwwwww,rwwwww+rwwww 40, OIL, & FILTER CHANGED, LUBE" "LU9-K_". 117 .. CBM IT. 21 17.21 . . 1 21334 OIL FILTER 7. 52 7. 52 7 . 52 5 12345615 OIL 2 81 2 81 14 . 06 PARTS: 21. 57 LABOR: 17,21 OTHER: 0.40 TOTAL LINE B: 38 .78 .. �:*wa�w'ww,kwwwww w�RaY w:vrw+ww ww C CHECK BELTS, FLUIDS, HOSES. TIRE PRESSURES i 2�. 39B ALL-,YTEMS CHEC£;,OKAY" �:� 999 ,. CCC 0 .00 0 .00 PARTS: D:OO ..LABOR. (�THERa_ 4..tl0 - TOTAL:�I,INE C: 0. 00 ww*www*wwww***ww*ww'tww*www*wwwwwwwww*ww -'*:wwwww,+wwww D CHECK BALI-iNCE OF' FRONT TIRES., - ECK ALIGNMENT.- I'E'TS J..EI,OF,TS WFIII;E' DRIVING j .6 31 BALANCE TWO 'TIRES '.- .... .. - 117 CCM 18.00 18. 00 4$ .4 .WHEEL AIFIGNMENT . , 167 CCM 65.45 65 .45 BAITS . ;:,, 0''. 00 ' ,Ix"OR, . ' ` '$3 :4'5 :OTH 0 00.: . `:, SOtAI LINE,D: $3.45- �ww,rwwwwwwwwwwwwwwwwww wwwwwwwww wwwwwwwwwwwwwww N WARRANTY DISCLAIMER: ALL PARTS AND ACCESSORIES ARE SOLD AND ALL REPAIRS ARE DESCRIPTION TOTALS - PROVIi1E0"SP'TRE"VVWSMP ASaS. THE DEALERSHIP HEREBY EXPRESSLY DISCLAIMS ALL WARRANTIES, EXPRESS AND -W(PUED, INCLUDING ANY IMPLIED WARRANTIES OF Thank LABOR AMOUNT 272 . 02 MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE, AND NEITHER ASSUMES NOR AUTHORIZES ANY OTHER PERSON TO ASSUME FOR IT ANY UABIUTY IN CONNECTION WITH THE YOU PARTS AMOUNT !-- 2'7 2_57 SALE OF PARTS OR PRODUCTS OR THE REPAIR. THE ONLY WARRANTIES ON PARTS AND ACCESSORIES OR REPAIRS ARE THOSE WHICH MAY BE OFFERED BY THE MANUFACTURER OR THE Or GAS,OIL,LURE 0�. dd d ORIGINAL PARTS DISTRIBUTOR AND ONLY SUCH MANUFACTURER OR DISTRISUTOR SHALL BE Your --�- LIABLE FOR PERFORMANCE UNDER SUCH WARRANTIES.CUSTOMER SHALL NOT BE ENTITLED TO Business! SUBLET AMOUNT 0. 00 DAMAGES S FOR LOSS OFAUSE DEALERSHIP TIME, LOSS OF PROFIT ON NCOME,SOROANYO OTHER MISC.CHARGES " INCIDENTAL DAMAGES. 4.44 By signing below, you acknowledge that you were notified of and authorized the ALL PARTS ARE NEW TOTAL CHARGES 544 . 59 Dealership to perform the serdcestrepairs ftemized in this Invoice and that You received UNLESS OTHERVWBE LESS INSURANCE 0 . 00 (or had the opportunity to inspecU any replaced parts as requested by you.Tha vahltla INDICATED. SALES TAX is being returned to you in exchange for our payment of the Amount Due. 32 .67 DATE CUSTOMER SIGNATURE AUTHORIZED DEALERSHIP REPRESENTATIVE SIGNATURE PLEASE PAY THIS AMOUNT F577.26 ,,/',�� C-t'R1E�S TG AIR- CL.sOre s ALTO 6 FO CC .PuLsLiC Au.CT 00 D91w,m Drops ADP 101091 SERVICE INVOICE TYNE 2.292C••ASIS'-PEN1rEYIYAH(A."It"I.nvrp onlov #4ucv policy out 12,EMir D��i ; . 124 Ea st Main 5f You're in good hands. Polmyro,PA 17078 i r r IIr r r L i r m d r l r i Information as of September 23,2013 ndl ! I! bll u!! Idldl t!1 u! t6 i 11 GCU ! 1 1 Policyholder Page t of 2 JOHN B CLONTZ John 8 clontz C/O ROBERT C STOUGHT C/0 Robert C Stought 17 RIDGEWAY DR Policy number CARLISLE PA 17015-7614 978591286 Your policy provided by All st Ir-2n d casualty insurance Co Covered vehicle 2009 Hyundai sonata To pay in full $576.64 O'cy peso Effective August 13,2013 through .Minimum premium amount due 144.16 February 13,201412:01 a.m.standard time Installment fee —' '" 3.50 Your Allstate agency is Minimum amount due by October 13,2013 $147.66 Timothy Fritz (717)838.8112 You may pay the minimum,or any amount up to the remaining$576.64 premium amount.if you pay less than$S76.64,we will charge the$3.50 installment fee. You will be charged $3.S0 installment fee each time you pay the minimum amount due or any amount between the minimum amount due and the pay in full amount. You can avoid paying installment fees if you pay the pay in full amount to that case,you will not be sent a bill until your policy renewal,unless you make a change in coverage resulting in additional premiums.Please see the back of this bill for payment schedule and history. Stay ahead of bad weather Ways to pay with free Mobile Weather Alerts Phone and on-line self service options are available at from Allstate. (1.800-901-1732)or www.allstate.com C. at offstate.com/afetts Go Paperlessi View and pay your bill on-line.You can apply for a-8111 by visiting My Account at alistate.com/ebiil or go to MyCheckfree.com.Access your bill easily and lower the chances of � # } fraud or identity theft.We'll send you an email letting you know when it's time to view and pay your bill. ! Sign up for an automatic payment plan and have your payments 7 i automatically deducted from your bank account,credit,or debit card. (continued) Detach bottom portion here !a�LN 113 IS Page 1 of 2 SO\fl SatR�E.S- Dt:Qos`�.TEt� 2rSOOt,84 �_� � �omputershare + j ^+�+ Computershare Trust Company,N.A. at&t �. PO Box 43078 Providence,RI 02940-3078 Within USA,US territories&Canada 800 351 7221 Outside USA,US territories&Canada 781 5754729 www.00mputershanscomlatt s 000255 'II'lllllll'IIIIIIII'I'I'lllllatll'Il'Il'Illrrllll'IIIIIlI1lallla ROBERT C STOUGHT EX EST JOHN B CLONTZ 17 RIDGEWAY DR CARLISLE PA 17015 Holder Account Number C1003563959 FID I IIIIIII IIII VIII VIII IIII)VIII VIII VIII VIII VIII VIII IIII IIII -Ticker Symbol T CUSIP 00206RI02 AT&T Inc:-= SalesAdvtce Trade Date: 20 Mar 2014 15:14(Time) Settlement Date: 25 Mar 2014 Cost Basis Method: FIFO Shares/Units Price per Gross Amount Trading Bankingwre Backup Otherl Net Amoun Sold Share/Unit(USD) of Sale(USD) Fees(USD) Fees(USD)Oitholding(USD) Fees(USD) of Sale(USD 738.000000 34.005000 25,095.69 93.80 0.00 0.00 0.00 25,001.81 Covered Transaction Total: 0.000000 Noncovered Transaction Total: 738.000000 Covered Shares/Units Covered Cost I Covered Short Term Covered Long Term Overall Coverer Sold Basis(USD) GainfLoss(USD) Gain/Loss(USD) Gain/Loss(USD 0.000000 NIA NIA - NIA NN PLEASE SEE REVERSE SIDE FOR IMPORTANT DISCLOSURES AND DEFINITIONS 1 L T R A T T + ODICD70003 us.ur.e.4dy..•al.rl_49951(wn2ssm00255r IMPORTANT INFORMATION—RETAIN FOR YOUR RECORDS. fhs adJ,a is your retard of the share taraaubn in your account on to beaks of the Company as W of fie Direct Regisfrmon Syame.This advice is amber a negotiable bodement nor a security,and delivery of it does net of LLSNt Wader any didde bg redisera bshould bekeplwthWNWalmtdootmen are doll ourawra potfieashmes.Noadionmyourparlisrequred. The IRS requires that vier repod-g sl bas's of curtain chars ecuuretl aOer Jemuery 1,2011.If tour shares rare Wwsredby NeleOiaatm antl you havesold a banslened tw shares mdrequeAed a spetltc Wsl basist C1.edi-E d F.Ms as have processadmmquesled Ilya did rSpevtya dai basisalodation mated,wa lave detautted toeireertie win.first ant(FlFO)fa egmetyissuse,orforarbon dosedend f4ntls,avenge mstbass meNOd. Passe notetlat ClWed�End Fa('rts mdbr Registered thvesbmixri Canpames ere pat reqused fi repod Wsl basis untl Japery 1,2012.Plena vast er websib a Wreull yalr lax ativaer Hyou need addtoai intwmafia aboN Wsl pasis, upon request,fie Company wit furom to any shareholder,Mlhoul charge,a MI statement W the designations,rights(includng rights under any Canpan)'s Right Agreement,rany),preferences and limitations of the shares of each tlass ant series autherized to be Issued,and the annority of the Board of Directors b divide the shares into series and to delemme and change rights,preferences and Inner..A my tlass cur series. Assets are not dapoets of care miume and are out insured by the Fedeml Deposh insurance Caporetie,fie Semites Investor ftedion Capaatlon,a any order useare erstale ageo/. M you do nom keep in barred with us or do not have my activity in your accegM M the Our periods epedged by state Im.yap properly court become subject to stale unclaimed property laws and transferred to rib appropdete state. 4 0 U D R A T T 001r%001 d nni,050448 4553/0247221()2831 2,2.2 ORRSTOWN BANK Fwm hem.FM pr ,Car good. ORRRTOWN RANK 77 East OV Re"t 6abpee%aLn.PA 17257 View CiK*Msoe V:-p FIIR Rotate Retum m �s 17 A IT CLpNT2 E 102 STATE 1q i�' 4CAAAUSl- •AOITJt6 W+,1s,.a- /� ZQ� r• ,y ^er�,,of.Q�otism?t - tkEe 4L3p �+� l $ 8<) LMTTOWNHANK .q,oA,rAle.a� _ -��7sQ'A•4.. `.�Ji . A ) 113 !c fl LENaEq . ATEBILLED METER N LIK B_ _ACCCUNT_NUM8ER Adams Electric Cooperative,Inc. 09/04/2013 93107508 2051339301 1338 Biglerville Road ACCOUNT SUMMARY I-� P.O.Box 3605 fprav!ton!nBalance: 77,70 _07 Gettysburg, PA 17325-0605 Payments Received: -77,70 'Balance Forward: 0.00 Total Basic and Non-Basic Charges: $0.42 888232-6732 ATcuthanr*F=rg? perurivcKtK 1ACCOUNT BALANCE 80.42 adamsec.coop ".V it 93 COUNTRY MEW EST Cycle 01 n gmgg, 'jg 262 1 Av 0.360 4 262 [AUG 12 668 1s 74 JOHN 8 CLONTZ EST C-1 P-1 17 RIDGEWAY DR CARLISLE PA 17015-7614 JUL13 524 17 77 fill 11111,11 AUG 13 t 1 4 A METER If jelPtes Rdg It I am a, Rate Classification _Vnit4_ I 1 563 ; --93107508- 107/31—-26234 �GSMI —26781 .000 I BILLING DETAIL BASIC CHARGES NON-BASIC CHARGES Energy Supply prices and charges are set by your electric generation supplier.Your current price to compare is$0.0729. Adams Electric Cooperative Inc. 888t232.6732 I W, 1338 BiglervIle Road A Gettysburg,PA 17325-1055 ENERGY SUPPLY: Energy charge 553kwh@ .07290 40,31 TOTAL ENERGY SUPPLY 40.31 Liz DISTRIBUTION: Access Charge 28.50 Distribution charge 553kwhg .02100 11.61 TOTAL DISTRIBUTION 40.11 TOTAL BASIC CHARGES 80.42 x _ 82 URRSTOWN BANK Fran WTF.11.r Fagad. MRSTO MNK P Eex Kbq 6bx1 WVP-n q-PA 17251 view Cbec mue Flip RPteta Ratum .JOHN 6CLONTZ Tolls 2671 W COWMY VIEW FSTAM' NCA"AUF-PA tr.At pAn IR �Jl3 � Mf. d C �� ,.t )i �J2� ) 13 Q IENPEa V CHURCH OF GOD HOME i �y � i �� J,LL Form PsA, 801 N. HANOVER STREET CARLISLE, PA 17013 RESIDENT# I UNIT I STMT. DATE ROBERT STOUGHT 803275 H2OlB 06/30/2013 17 RIDGEWAY DRIVE RESIDENT(b) CARLISLE,PA 17015 John B. Clontz TOTAL AMOUNT DUE $281.95 DATE DESCRIPTION DaYsI CHARGES CREDITS BALANCE Units Balance Forward 0.00 06/03/2013 Male Hair Cut 1 1195 11.95 06/19/2013 Nursing Care-Private Pay 06/19-06/1.9 4 1 270.00 281.95 2,81 9 RESIDENT# CURRENT OV OV ER 30 ER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE 803275 281.95 0.00 0.00 0.00 0.00 $281.95 Fm P"I RESIDENT NAME Mr.John B.Clontz c�m7lR QRRSl'OWN s,•NK MRST01AY1 RANK»Feat Iorp 6eeet SEIDW4 ep.PA 172V WOW Checw hnepo FBp Rotate Return _..__jOHK 8 CIANf2 .. _..._..2673 -- "COV74TRY WOV VRA'M Vll4Nll1,J��y1'A IZl1 �} ��t��.. Q 1(t '1Iw1� PAr_m_ �Yw Li7VU4.._y'vy"':z j?F. : � -_—•._.r.._.. IlnrNO ORRS�TOW BANK (JA c -'d,&- �.r J ��(�j t pGrA LENDER i+4!PrV7x". i�G � IrVV1' 04114113 23 ERIC KRtEG DO 486 OOM ADMITTED TO HOSPITAL .00 05/22/13 23 FRANKOITRAGUAMD 285.9 00999 ADMITTED TO HOSPITAL .W OWi9113 23 ELEANOR F OUNHAMMO 285.9 00999 ADMITTED TO HOSPITAL .00 03/21/13 23 AMANDA BROOKS PA 564.00 99284 EMER DEPT HI SEVERITY&URG 304.00 04/17/13 PYMT-MEDICARE ASSIGNED .00 4522113 23 FRANKDITRAOLIAMD 285.9 99285 EMER DEPT HIGH SEVERITY&T 461.00 OW26l13 PYMT-MEDICARE ASSIGNED DO 06W13 PYMT-MEDICARE ASSIGNED 130.58• PR2 COINSURANCE AMOUNT 06/20/13 WIOFF MEDICARE ASSIGNED 294.47- 0612W13 WJOFF MCR 2%RDCT PYMT AMT 2.66- 06/19/13 23 ELEANOR F DUNHAM MD 285.9 99265 E RflEfTMiQhf3ExE11TY&T 461.00 CY.� 3 33� 71 \R W5 PLACE OF SERVICE:21.INPA T 22 OUTPATIENT 23.EMERGENCY ROOM "'NOTE"' Your insurance has been billed as noted below. Any unpaid balance is due before 08/30/13 , and is your responsibility. STMT DATE 0.30 DAYS 3150 DAYS 81.96 DAYS OVER 90 DAYS PRIMARY INSURANCE ONDARY INSURANCE 07101H 3 33.31 .00 .00 .00 MEDICARE-ELECTRONIC PATIENTS NAME LOCATION OF SERVICE ACCOUNT NUMBER S ON JOHN 8 CLONTZ HARRISBURG HOSPITAL PHI 1022363 - • $33.31 PLEASE VISIT US AT:www.MyMedAccount.com CUSTOMER SERVICE PHONE:1 (877)846.7929 PERSONAL BALANCE: $33.31 CUSTOMER SERVICE HOURS:9:04-8:00 Mon-Fri Eastem INSURANCE BALANCE: $765.00 PLEASE PAY YOUR PERSONAL BALANCE WORKERS COMP.BALANCE: $.00 PINNACLE HEALTH EMERGEN DEPARTMENT SERVICES,LLC PO BOX 850055168 PHILADELPHIA,PA 1917x5168 STATEMENT SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION page 1 of 1 94390.40 ORRSTOWN BANK ORRSTOWN MRX 77 EM KhV BUeel&*Ww0n-PA 17257 View Chock 00000 Flip RotalO Net= JOHN B CLONTZ 2675 93COUNTRY VtEW MTATM _4E JL I CAFIN�' CLLS PTA. 7j 2y 113 IFFDM ccnocA .nit Payment TO; _ .`.. _... _ ...... . . - -• • i t timberland Goodwill Fire Rescue EMS 13-172386 6127!2013 $389.70 Billing Office PO Box 726 New Cumberland, PA 17070-0726 QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Esparto+:866.724-4114 Fax: 717-214-6020 Email:Infoaambulanmbilitngoffice.com Date of Service: 6/2'V2013 19:27 Please visit our website to provide Insurance or make payment, and for additional payment options and frequently asked questions: Patient Name: C40NTZ, JOHN From: PinnacleHealth Hospitals www.ambulancebillingoffice.com To: CHURCH OF GOD HOME IMPORTANT MESSAGE: This type of service is not covered by ambulance memberships, Medfcare� Medicaid and most secondary insurances. Payment is your responsibility. 6121113 Wheelchair Van One-Way Trans A0130 1.0 48.00 48.00 6121113 Mileage A0425 25.5 13.40 341.70 Total 389.70 0.00 0.00 DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT. ..- {I aNnn... ....-.. ----..-..-- 'STATEMENT OF MEDICAL SERVICES LAST STATEMENT DATE: 02/25/11 �p �y NEW CHARGES: 61630.02 PI:S,1MCLEHEALTH NEW FAYMENTS: 6752.30 PtOVGTI NEW ADJUSTMENTS: 6585.64 INSURANCE BALANCEt 61626.33 YOUR BALANCE: 620.54 If Any Questions, Please Contact: PHNS AT 717-231-6960 OR 1-800-565-6229 - JOHN B CLONTZ ACCOUNT: 2783 07/02/13 FED TAX XO 8 251709054 INSURANCE YOUR CHARGE PAYMENTS AD.Af5TNMM BALANCE BALANCE >>> PATIENT: JOHN S CLONTZ 21`c -25 OP RECUR HER ,LV PERFORMED AT: FAMILY CARE OF OIL PERFORMED BY: PNFC OF DILLSBURG *04/26/12 OFFICE VISIT EST PT LVL 4 130.00 49.25- 30.75- 0.00 PROCEDURE: 99214 DIAGNOSIS: 414.00 it04r2sfI2 ONE RX,E-PRSCR SOO SENT 0.01 0.01- 0.00- PROCEDURE: 88555 DIAGNOSIS: 414.00 *06/12/12- OFFICE YISIT EST FT LVL 4 130.00 99.25- 30.75- 0.00 PROCEDURE: 99214 DIAGNOSIS: 401.1 ■06/12/12 ONE RX,E-PRSCR GENR SENT 0.01 0.01- 0.00 PROCEDURE: 68553 DIAGNOSIS: 401.1 z Wwlz OFFICE VISIT EST PT LVL 4 201.00 99.25- 101.75- 0100 PROCEDURE: 99214 DSASMOSISt 414.00 *10/09/12 OFFICE VISIT EST PT LVL 4 201.00 99.25- 101.75- 0.00 PROCEDURE: 99214 DIAGNOSIS: 414.00 .+10/09/12 ME RX,E-PRSCR GENR SENT 0.00 0.00 PAGE 2 OF 4 7) zq J ► ,tc� z��y PAGE 3 OF JONN B GLONTZ ACCOUNT: 2783 07/, I INSURANCE i CWIR6E PAYMENTS ADJUSTMENTS BALANCE BA ' PROCEDURE: 08553 DIAGNOSIS: 414.00 %01/16/13 IANUN PNEUMOCOCCAL 75.00 65,77- 9.23- PROCEDURE: 90732 .DIAGNOSIS: V03.82 %01/16/13 ADMIN PMEUNOCOCCAL/MEDI 34.00 24.18- 9.82- PROCEDURE: 60009 DIAGNOSIS: V03.82 %01/16/13 OFFICE VISIT EST PT LVL 4 - 201.00 102.69- 98.31- PROCEAURE: 99214 DIAGNOSIS: 434.91 %01/16/13 ONE RM,E-PRSCR OENR SENT 0.00 PROCEDURE: 68553 DIAGNOSIS. 434.91 , %03/11/13 PF SCREENED-FOR FUTURE FA' --"" "' __"` ""-0':00""- ....r....: PROCEDURE: )DOO(X DIAGNOSIS: V15.88 %03/11/13 FALLS NO POC DOCUMENTED 0.00 PROCEDURE: XXX70I DIAGNOSIS: V15.88 %03/IL13 OFFICE VISIT EST PT LVl 4 20L00 8235- 98.32- 2 PitDCEDURE: 99214.25 DIAGNOSIS: 414.pb %05/22/13 OFFICE VISIT EST PT LVL 4 206.00 80.51- 104.95^ 20.54 PROCEDURE: 99214 DIAGNOSIS: 698.9 PERFORMED AT: HARRISBURG HOSPITAL .PERFORMED BY: HOSPITALIST AT CGOH %06/19/13 INIT OBSERVATION CARE NOD 259.00 259.00 PROCEDURE: 99229 DIAGNOSIS: 284.19 BALANCE: JOHN B CLONTZ % INDICATES MEN FINANCIAL ACTIVITY SINCE LAST BILL. PAGE 2 OF PAGE 4 Of OxxsTOWN BANK From km An here ft good. -- MRST RANK 77 Pass KkQ Snaet SMppensdee.PA 17257 VIOW Check t111lpe POP Rotate Return .,:.�.:f..Y. s+-s�3 o°�snao ..nw1P Cmrese.QJ S °' yGYJJ U VCAIT-� 70: g � 3 ) V3 a Faic Q LEMOER ' rNEWVILLE COMM. AMBULANCE C/O PROMED SERVICES, INC. 4 W. MAIN STREET SHIREMANSTOWN, PA 17411 1-866-678-6855 Patient Bill Page: 1 Printed: 07125/13 06:05 JOHN B CLONTZ ID: Newv-1999 93 COUNTRY VIEW ESTATES NEWVILLE, PA 17241 DOB: 08/17/1929 Une Date Range Prov Procedure DxRef POS Patient: JOHN B CLONTZ ID: 1999 DOB: 0811711929 Claim Number: 47130439)ia nosis 1) 799.9 Ins: 1)MC/Non 251446721A 2)KS/Non ZCN058535470369 0105/22-05/22(13 010 A0429RHGY 1 A 750.00 1 750.00 0.00 415.00 335.00 335.00 Procedure: BLS EMERGENCY SERVICE 02 0522-05/22/13 010 A0425RHGY 1 A 511.50 34 511.50 0.00 204.60 306.90 306.90 Procedure: MILEAGE MEMBER REDUCED RATE 07-26-13 MEDICARE DENIED. NON COVERED CHARGES. PAYMENT IS NOW DUE FROM YOU AT THE MEMBER REDUCED RATE Patient Totals: 1261.50 1261.50 0.00 0.00 619.60 641.90 641.90 Total Amount Due By Guarantor. 641.90 Cis � CSb'? �� 1G �\a zoy ORRSTOWN BANK Fmm hucFartert.idr Shod. ORRS (Wl RAW 77 Fssl Keg SItPo1 ShWO""C PA 17M View Check dope 0 FIIR Route Return No, 603 ela sn= ORRSioaRHdlRr .p L__ ora Q._CIL'lJ'2 LENDER 1 .w, r nz vn'. MT HOLLY SPQR. PA 17065 t � `* ACTIVITY FOR CLONTZ, JOHN -CLONJ - -803275 `07/1871'3 - 9-095712 -5 "--ATROPINE 1� EYE--5 '- Ol -- I '18.BO -'8 03 18.80c 107/18/13 9095713 10 ONDANSETRON 4MG 01 14.21 07/18/13 2051173 30 MORPHINE SULFATE 0100 14 .21 107/18/13 9095710 2 ESCITALOPRAM 10MG 01 1.42 •00 5.64c 107/20/13 4134651 10 LORAZEPAM PLO GEL 01 34.68 .00 1.42c 07/22/13 .00 34.68 1 Payment-Thank You 65.65-#2672 .00 65.65- 07/24/13 9096416 5 ATROPINE 1% EYE 5 01 18.80 .00 18.80c ' q 3SS 93 . 55 . 00 LEGEND rorwl rwx 'us oalanoe Cha es thw month Finance Char p O-�` � H raai aa�m a aoana i AMOUNT DUE 5 . 65 + . 93 . 55 + . 00 = 159. 20 65 . 65 - 93 . 55 iLL PHARMACY RELATED INQUIRES PLEASE CALL Alert Pharmacy Services, Inc at 1-800-266-9954 Statement Terminology on reverse k ORRSTOWN BANK ham haerwt=m F.,Far rpod. MRSTMN BANK 77 Eesl King StNoR SH .IslG ry PA 1)]51 View Cheek"age Flip Route Return .101103 .. ao..or��A•ukr:h.ic 4M,jxnet'rx.�nG: �$ '77 �, _ • o n .I'G4AV 'g.Cm-rT2` �Q•eu wCi. .�¢w...' ..'� vo�.ane ®S� Onaslw.R.�z _ �°e.=s,.�r�_ _•--.•.•_. _ Boni`: 0. CtA;Anz kinpia V +oslsaasm _DATE BILLED—METER NUMBER. .ACCGUNT NUMBER-1 08/01/2013 93107508 2051339301 Adams Electric Cooperative,inc. 13338�%leO,le Road ACCOUNT SUMMARY Ge:lysburg,PA 17325.0045 Previous Balance: 40.99 Payments Received: -40.99 Balance Forward: 0.00 Total Basic and Non-Basic Charges: 77.70 888232-6732 A Ta->:l a Em:%1aCocp= m l ACCOUNT BALANCE 77.70 adams=c.coop - 93 COUNTRY VIEW EST Cyclo O7 KWH USE HISTORY M52417 VG 7 MP 59 1141 1 AV 0.360 4 1141 79 JOHN B CLONTZ C-4 P-10 93 COUNTRY VIEW EST a NEWVILLE PA 17241-8760 2 14 J A s o N D J F M A M J J METER 9 Date/Prev Rdg Date/Pros Rdg Mult KWH Dom Rdg D_em Billed P.P. Rate Rate Classification 93107508 . 66/30 24710 07/31 262341 1 6241 .000 .000' 0 ; RE501- Residential T BILLING DETAIL BASIC CHARGES NON-BASIC CHARGES Energy Supply prices and charges are set by your electric generation supplier.Your current price to compare is$0.0729. Adams Electric Cooperative Inc. 888232-6732 ! 1338 Biglerville Road Gettysburg.PA 17325.1055 ENERGY SUPPLY: Energy charge 524 kwh @ .07290 38.20 TOTAL ENERGY SUPPLY 3820 n DISTRIBUTION: Access Charge 28.50 c — Distribution charge 524 kwh @ .02100 11.00 1 8�;- S_ F—A) TCM_F TOTAL DISTRIBUTION 39.50 TOTAL BASIC CHARGES 77.70 -7 -7.L Detach here IMPORTANT INFORMATION FOR YOU �JOHN B CLONITZ Are these the correct phone numbers you will use to contact us? DATE BILLED METER NUMBER ACCOUNT NUMBER Primary correction:717-776-0190 Correction 08/012013 93107508 2051339301 Business/Work:(000)400-0.0o Correction AUTO BANK DRAFT 77 70 Mobile/Coll:(000)-004"0 Correction ON 08/21/2013 __ Addl work: (000)4004-00 Correction Ponam/on out--tand;ng balances will�-9 apphgd after H•+due dots Addl coil:(000)00-000-Correction r 'c 400252051339301000000000000000000080120134 zap ORRSTOWN BANK IMRSTO BARK 77 Fsst 16p 6MeM BRppaMWp,PA 17257 View ChOCkM A00, 0 FRO RBtetO Retum inane �..(20D.iw.t:_ .. -'• . .•f S /8'1.8 ''':: Oa�BADx - QL�luI S6NN �C�NT2 �•� _ RIB 87 _ p�..t C. qt8 svl7ea•, . e$..iC '�Aa:,Y.+. kE -,renewal auto policy declarations WA l estate s Your policy effective date is August 13,2013 n"i.. Gow $t.n .d V'° Pla' You're in good hands. Page 1 of 3 Information as of July 11,2013 Total Premium for the Policy Period Please review your insured vehicle and verify its VIN is correct. Summary Vehicle covered identification Number(ViN) Premium Namedinsured(s) 2009 Hyundai Sonata 5NPET46C79H534196 82739 John B Clontz If you pay in installments* $827.39 Mailing address ....................................... ....... 93 Country View Estates If you pay in full(includes FullPaya Discount) $775.83 Newville PA 17241-8760 policy number "If you pay less than the Pay in Full amount you will be charged an installment fee(s). 418 591286 Your policy provided by Discounts (included in your total premium) Allstate Fire and Casualty Insurance Allstate Easy Pay $32.32 Prior Insurance $18.98 Company Plan Carrier olic rind Safe Driving Club $173.72 Passive Restraint $89.35 Beginning August 13,2013 through February 13,2014 at 12:01 a.m.standard Multiple Policy $155.37 Antilock Brakes $59.83 time Responsible Payer$33.91 Electronic Stability $51.26 Your Allstate agency is Control Timothy Fritz Homeowner $48.14 124 East Main St Total discounts $662.881 Palmyra PA 17078 k (717)838-8112 TimothyFritz@allstate.com Policy discounts $462.44 IN ACCORDANCE WITH SECTION 1725 OF Allstate Easy Pay $32.32 Responsible Payer $33.91 THE MOTOR VEHICLE FINANCIAL Plan RESPONSIBILITY LAW,THIS IS TO Safe Driving Club $173.72 Homeowner $48.14 INFORM YOU THAT COLLISION DAMAGE Multiple Policy $155.37 Prior Insurance $18.98 TOA RENTAL VEHICLE WILL BE COVERED Carrier IF:1)THE RENTAL VEHICLE IS A FOUR WHEEL PRIVATE PASSENGER 2004 Hyundai Sonata discounts $200.44 AUTOMOBILE OR A UTILITY AUTOMOBILE,AND 2)AT LEAST ONE Passive Restraint $89.35 Antilock Brakes $59.83 PREMIUM FOR AUTO COLLISION Electronic Stability $51.26 COVERAGE APPEARS ON YOUR POLICY Control DECLARATIONS.COVERAGE WILL BE SUBJECT TO DEDUCTIBLES AND TO POLICY TERMS AND CONDITIONS, Listed driver an your policy INCLUDING ANY APPLICABLE John Clontz-Widower male driver,age 83,Safe Driving Club ENDORSEMENTS. Excluded drivers from your policy A None 817. 39 =- - 13-7. l�Su,�� ..��- m 02077 t -&C—v -s Z Allstate Indemnity Company Allstate. You re in good halls. AMENDED Manufactured Home Policy Declarations Summary NAMED INSURED(S) YOUR ALLSTATE AGENT IS: CONTACT YOUR AGENT AT: John Clontz Timothy Fritz (717)838-8112 C/O Robert C Stought 124 East Main St 17 Ridgeway Dr Palmyra PA 17078 Carlisle PA 17015-7614 POLICY NUMBER POLICY PERIOD PREMIUM PERIOD 9 18 591287 08/03 Begins on Aug. 3,2013 Aug. 3, 2013 to Aug. 3, 2014 at 12:01 A.M.standard time, at 12:01 A.M.standard lime with no fixed date of expiration LOCATION OF PROPERTY INSURED 93 Country View Estate, NwMlle, PA 17241-8760 INSURED MANUFACTURED HOME MANUFACTURER-COMMODORE SERIAL NO. -DF01985AB YEAR-2007 Total Premium for the Premium Period (your bill will be mailed separately) Premium for Property Insured $540.09 TOTAL $540.09 Your pollen ehonpe(s)am effeetlre as of Aug. 3,2013 �) S , b\ C===r 1-7 -'A say E4T -7 s2 MOP '010=713NUN0E0'6'uuIA5I3flq00INW402' InnNd NCD21-3 Page zoo 05STOWN BANK hom acye-For tweeF rgaod. ORRSTOIAIN BANK 77 East Kiy Shwi%ippe,eWD,PA 172" View Gtleck koape �yy flip Rotate Retom CIA eL...tC ...ty MY p• . YO 1113.: . ltv ml. ®R LENDER �D D l PAYMENTS M'D Account No: CPS9537117 Medical billing.Technology-drNen. Numero De Cuenta: Summary of Charges .Page Number: 2 of 2 Emergency Grand Total: $10.15 PAYMENTS/ DATE PROVIDER DESCRIPTION OF SERVICE CHARGES ADJUSTMENTS PATIENT BALANCE 10/16/12 Lupold Emergency Dept Visit- Dr $486.00 11/08/12 Payment- Insurance $40.59 11/08/12 Contractual Adjustment $435.26 $10.15 05/08/13 Payment- Insurance $.00 Duplicate Claim/service. 06/26/13 Transfers $.00 _. — Pymt Made To-Pi/insured '— -- '-- Resp Party. . C�� bbd G�)3 ?lease be aware that each time you receive services from Carlisle Physician Services, a separate account is created. The insurance companies listed on the front of your statement will be billed as a service to you. The actual benefits will depend on your insurance policy and !emaining deductible due. The amount not covered by insurance is the responsibility of the guarantor. If you are unable to pay the amount ;hown, please contact Patient Financial Services at 877-358-0145 for payment aoangments between the hours of Sam-8pm Monday through Thursday and Sam-6pm Friday EST. )uring the care you received at Carlisle Physician Services,you may have received services from a separate contracted Physician Affiliate. fou will receive separate bills from these physicians groups for services rendered. Examples of some of these types of bills are laboratory, ialhology, radiology,or other services. Should you have any questions concerning their bill, please contact them directly. 1111tS�du 3691-APOLLOSTM-1782072-1474613170-P;7661477.1-505;33522206-1;2 C .' 3 � 6 2-g g t V D I PAYMENTS TV0 Account No: CPS9544675 . Medical bililog.Technalogy driven. Numero De Cuenta: Summary of Charges Page Number: 2 of 2 Emergency Grand Total: $19.35 PAYMENTS/ DATE PROVIDER DESCRIPTION OF SERVICE CHARGES ADJUSTMENTS PATIENT BALANCE 01/26/13 Lupoid Emergency Dept Visit-Or $726.00 . 02121/13 Payment-Insurance $77.41 02/21/13 Contractual Adjustment $629.24 $19.35 05108113 - Payment-Insurance $.00 Duplicate Claim/service. 07/11113 Transfers $.00 Pymt Mails To Ptllnsuied Resp Party. Please be aware that each time you receive services from Carlisle Physician Services,a separate account is created. The insurance !companies listed on the front of your statement will be billed as a service to you. The actual benefits will depend on your insurance policy and i remaining deductible due. The amount not covered by insurance is the responsibility of the guarantor. If you are unable to pay the amount .shown,please contact Patient Financial Services at 877-358-0145 for payment arrangments between the hours of Sam-8pm Monday through Thursday and Sam-6pm Friday EST. During the care you received at Carl€sle Physician Services,you may have received services from a separate contracted Physician Affiliate. You will receive separate bills from these physicians groups for services rendered. Examples of some of these types of bills are laboratory, pathology, radiology,or other services. Should you have any questions concerning their bill, please contact them directly. 369i-APpLIO$TM-1782072-1474613172-P•768'1477.1-506'33522206-5 7,,, A4D IPAnaNTSMD Account No: CPS9530901 Medical billing.Technology-drivon. Numbro De Cuenta: Summary of Charges Page Number: 2 of 2 Emergency PAYMENTS/ Grand Total: $33.38 DATE PROVIDER DESCRIPTION OF SERVICE CHARGES ADJUSTMENTS PATIENT BALANCE 07/30112 Coachi Emergency Dept Visit-Dr $1,082.00 08/13/12 Payment- Insurance $.00 Prov Not Cert To Be Paid On This Dos 10/09/12 Payment- Insurance $133.53 10/09/12 Contractual Adjustment $915.09 $33.38 04/24/13 _. Payment-.Insurance _ ,. _ $.00, ! Duplicate Claim/service. 06/26/13 Transfers $.00 Pymt Made To Ptlinsured Resp Party. Please be aware that each time you receive services from Carlisle Physician Services, a separate account is created. The insurance companies listed on the front of your statement will be billed as a service to you. The actual benefits will depend on your insurance policy and remaining deductible due. The amount not covered by insurance is the responsibility of the guarantor. If you are unable to pay the amount shown, please contact Patient Financial Services at 877-358-0145 for payment arrangments between the hours of Barn-8pm Monday through 'Thursday and 8am-6pm Friday EST. During the care you received at Carlisle Physician Services,you may have received services from a separate contracted Physician Affiliate. You will receive separate bills from these physicians groups for services rendered. Examples of some of these types of bills are laboratory, pathology, radiology,or other services. Should you have any questions concerning their bill,please contact them directly. 11MM-Will 3691-APOLLOSTM-1782072-1474613167-P•7661477-1-504'33522208-1:2 zaa ORRSMWN BANK F.hnr For Mre fargood. ORRR (Mhl RANK 12 Emt Kep RNeet&ftwdbn.PA 172V View CRea tmepe Flip Rotate Return iw is, ....V�/'��� SGMV B,`l JR r0'1�" tYEbt < ,e �.q[mpo[c7,(CLY47� In tm g ' �9 1 13 --- al .. � r MEN 9 'MEDICAL SERVICES EY TEMENT DATE: 07/02/13 Clio I ] ES: $809.00 -NNACLEHEALTH J ENTS: 4366.07 _ ProveTL "� S t�- STMENTS: 0608.54 E BALANCE: 41594.69 NCE: 575.14 f Any (kaectlons, Please !: PFpS AT 71 - -8960 OR I-800-565-6229 OHN 8 CLONTZ ACCOUNT: 2783 07/23/13 FED TAX ID { 251709054 INSURANCE YOUR CHARGE PAYMENTS ADJUSTMENTS BALANCE BALANCE >> PATIENT: JOHN B CLONM OP RECUR "ED PERFORMED AT: FAMILY CARE OF DILLSBURB PERFORMED BY: PHFC OF DILLSBURB 43/11/13 OFFICE VISIT EST PT LYL 4 201.00 82.15- 98.31- 20.54 PROCEDURE: 99214.25 DIAGNOSIS: 414.00 05/22/13 OFFICE VISIT EST PT LVL 4 206.00 80.51- lOk.95- 20.54 PROCEDURE: 99214 DIAGNOSIS; 698.9 PERFORMED AT: HARRISBURG HOSPITAL PERFORMED BY: HDSPITALIST AT COOH 06/19/13 INIT OBSERVATION CARE NOD 259.00 86.04- 151.01- 21.95 PROCEDURE: 99219 DIAGNOSIS: 284.19 INPT 041513 041813 (4/15/13 TO 04/18/13 PERFORMED AT: HARRISBURG HOSPITAL PERFORMED BY: IOSPITALIST AT C60H 04/15/13 INITIAL HOSPITAL CAR LVLI 196.00 76.SB- 99.89- 19.53 PROCEDURE: 99221.A2 DIAGNOSIS; 786.50 04!15/13 SUBSEQUENT HOSP CARE LVL3 199.00 65.99- 116.17- 16.84 PROCEDURE: 99233 DIAGNOSIS: 466 PAGE IOF 2 Pf a.couch and artom w th yow ptymM 05STOWN BANK -� W Free,1wri i-;=.Wgd. C)RRG7 MNK 77 E"RmD preel WW—burg,P*17257 View clwk"we Flip Rotate Return No. VMS qr�.6m& s I jl�� VI co-ft C�V.NUAA- d-4-— s0iIA-CUNLI-� IFNDER Please Remit Payment To: =13-182800��ti Cumberland Goodwill Fire Rescue EMS Bitting Office 7/23/2013 $116.05 PO Box 726 New Cumberland, PA 17070-0726 QUESTIONS ABOUT THIS BILt.7 Phone: 877-224-6018 Espaftl: 866-724-4114 Fax: 7i7.214-6020 EmaiC infoCambulancebitiingoffice.com Please visit our website to provide Insurance or make payment, and Date of Service: 7118+:2013 15:27 for additional payment options and frequently asked questions: Patient Name: CIONTZ,JOHN www.ambulancebillingoffice.com From: PinnacleHealth Hospitals To: CHURCH OF GOD HOME IMPORTANT This type of service is not covered by ambulance memberships, Medicare, Medicaid and most secondary insurances Payment is yoiir responsibility. 7/18/13 Stretcher Van One-Way Transpo A0130 1.0 80.00 80.00 7/18/13 Mileage S0209 20.6, 36.05 Total �—�.. 6.05 0.00 0.00 t 6120 t3 �- Gbh DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT. STATEMENT OF MEDICAL SERVICES ��-eC'1LQ� LAST STATEMENT DATE: 08/13/13 PINNACLEHFALTH / V� �1�6L NEW CHARGES: 4470.00 NEW PAYMENTS: 0171.76 Proven HER ADJUSTMENTS: $254.43 INSURANCE BALANCE: 4171.45- YOUR BALANCE: $17.35 If Any Qtustionc, Please Contact: PHNS AT 717-231-8960 OR 1-800-565-6229 JOHN 8 CLONTZ ACCOUNT: 2783 12/18/13 FED TAX 10 R 2517090 INSURANCE YOUR CHARGE PAYMENTS ADJUSTMENTS BALANCE BALM+ >>> PATIENT: JOHN 8 CLONTZ INPT 061913 062013 06/19/13 TO 06/20/13 PERFORMED AT: HARRISBURG HOSPITAL PERFORMED BY: FOSPITALIST AT CGOH ■06/19/13 INITIAL HOSPITAL CAR LVL2 265.00 103.73- 134.81- 26.46 PROCEDURE: 99222.AI DIAGNOSIS: 284.19 *06/20/13 NOSP DSCH DAY "GMT >30MIN 205.00 68.03- 119.62- 17._ PROCEDURE: 99239 DIAGNOSIS: 284.19 BALANCE: JOHN B CLONTZ S17. A INDICATES HEN FINANCIAL ACTIVITY SINCE LAST BILL. ( 'T OTHER CHARGES BILLED TO INSURANCE 197.91- I) rj fI y V W �7 PAYMENTS OF 71.44 APPLIED TO YOUR CHARGES NOT INCLUDED ON THIS BILL. - FULL PAYMENT ON YOUR ACCOUNT BALANCE IS DUE. IF THIS BILL DO NOT REFLECT THE CORRECT INSURANCE INFORMATION, PLEASE CONTACT OUR OFFICE. IF PAYING BY CHARGE CARD PLEASE INCLUDE THE THREE DIGIT SECURITY > CODE LOCATED ON THE BACK OF YOUR CARD. - D A a a� PAGE_ 1 O Pau.de h SW. w1th Your MMM For Olio tin Ooy A®.[NumMr. Amount Due: 2783 $1.7.- HI2 REP: PRPY Gavru.mr m-. ----Due Hyr PINNACLE HEALTH MED SVCS JOHN B CLONTZ 01/08/_ PO BOX 1286 11 .vise HARRISBURG PA 17108-1286 HC: I2H0 Numhmv cw core: Ham.wai ADDRESS SERVICE REQUESTED rdWd rN.me A"°°°ltW& ❑ Check box and enter any address or wmmem c mm sio..n� 1-7.35 Insurance corrections on back 35 _ Make Check Payable To PINNACLE HEALTH MED SVCS 00001133 01 PIT+-III nih^6 ••HUUdN 111hdn•1d1 u p Hy ��` JOHN B CLONTZ PINNACLE HEALTH NED SVCS 93 COUNTRY VIEW EST PO BOX 1286 NEWVILLE PA 17241-8760 HARRISBURG PA 17108-1286 � ) » �VA STATEMENT OF MEDICAL SERVICES d - - 2 L4 1 LAST STATE rT DATE: -12/li/13 NEW CJNRGES 01807.00 'INNACLEHEALTH NEW PAYMENTS: 0675.70 PXDVOTl MEW ADJUSTMENTS: 01030.90 INSURANCE BALANCE; 0224.53- YOUR BALANCE: 070.45 It Any 4mationa, Pleese Comma#; PHNS AT 717-231-8960 OR 1-800-565-6229 - IJOHN B CLONTZ ACCOUNT: 2783 01/0$/14 FED TAX ID i 251709054 1NSU3AttE YOUR CHARGE PAYMENTS ADJUSTMENTS BALANCE BALANCE >>> PATIENrn JOHN B CLONTZ INPT 661913 062013 06/19/13 TO 06/20113 PERFORMED AT: HARRISBURG HOSPITAL PERFORMED BY: HOSPITALIST AT CGON 06/19/13 INITIAL HOSPITAL CAR LVL2 265.00 103.73- 134.81- 26.46 PROCEDURE; 99222.AI DIAGNOSIS: 284.19 06/20/13 MOSP OSCH DAY NW >301IIN 205.00 68.03- 119.62- PROCEDURE; 99239 DIAGNOSIS: 284.19 �} `-"`I-,�"•-~"� IMPT 071213 071813 07/1?J13 TO 07/18/13 15 ,`y4!p, j l'> PERFORMED AT: MARRISSURRG HOSPITAL PERFORMED BY: HOSPITALIST AT COOK 3107/12/13 INITIAL HOSPITAL CAR LVL2 26x.00 103.73- 134.81- 26.46 PROCEDURE; 99222.AI DIAGNOSIS; 284.19 ;107/13/13 SUBSEQUENT HOSP CARE LVL2 138.00 45.77- 80.55- 11.68 PROCEDURE: 99232 DIAGNOSIS: 284.19 "-.`.'��'"''"�� ■07/14/13 SUBSEQUENT HOSP CARE LVL2 138.00 45.77- '80., 5- 11.68 PROCEDURE: 99232 DIAGNOSIS: M. 9 PERFORMED BY: PALLIATIVE CARE c>& I1(7 I ! AGE .1 OF 4 fft� 4pch•M eNUrn wMr Year aeym.m �2d t`� AM B CLONTZ ACCOUNT: 2783 01/08/14 INSURANCE YOU! CHARGE PAYMENTS ADJUSTMENTS BALANCE GALA! *07/15/13 INITIAL INPT CONSULT LVL5 392.00 152.31- 200.83- 38.86 PROCEDURE: 99255 DIAGNOSIS: 783.7 j PERFORMED BY: IDSPITALIST AT CGOH 111 *07/15/13 SUBSEQUENT HOSP CARE LVL2 138.00 45.77- 80.55- ji PROCEDURE: 99232 DIAGNOSIS: 284.19 Ii x07/16/13 SUBSEQUENT HOSP CARE LVL2 138.00 45.77- 80.55- I1. PROCEDURE: 99232 . DIAGNOSIS: 284.19 PERFORMED BY: PALLIATIVE CARE *07/16/13 SUBSEQUENT HOSP CARE LVL3 199.00 65.99- 116.17- 16.84 PROCEDURE; 99233 DIAGNOSIS: 783.7 PERFORMED.BY:_HDSPITALIST._AT.000H ....-._. _.._ . .-- -. - - "-. -`--° *07/17/13 SUBSEQUENT HDSP CARE LVLI 75.00 24.92- 43.72- 6�, PROCEDURE; 99231 DIAGNOSIS: 284.19 PERFORMED BY: PALLIATIVE CARE *07/18/13 SUBSEQUENT HOSP CARE LVL3 199.00 77.64- 101.55- 19.81 PROCEDURE: 99233 DIAGNOSIS: 783.7 PERFORMED BY: HOSPITALIST AT CGOH *07/18/13 NDSP OSCH DAY MGNT >30HIN 205.00 68.03- 119.62- 17.35 PROCEDURE: 99239 DIAGNOSIS: 284.19 BALANCE: JOHN B CLONTZ 670 i * INDICATES NEW FINANCIAL ACTIVITY SINCE LAST BILL. OTHER CHARGES BILLED TO INSURANCE 370.31- PAGE 2 OF my �Infwma0on___.____�____-____ �SSEaGE1D.1EakE FR�CM•MMIS_m 1I01A_IIdQl1`SS�.-_- ORRSTOWN RANK ' Fmm hMC F«hem Fm�Wd. , ORR6TOMtJ DANK 1i Ent Kip Skeet ShWwud V,PA 11251 view Check IIRace Flip Rotate Realm /oNN O CLOFIR ESTATE °a-8 �• 11'4 17FUDGF�PA 1M 7GK_LG I l _-_- .rap' •</�.re^ -c -.. -- — .Dkrr/r'o � c= OARSTOWNHM r UP vy) a3��y Y� Q LENDER I . �T 1 STATEMENT DP MEDICAL SERVICES / LAST STATEMENT DATE: 02/19/14 NEW CHARGES: 60.00 YtNNAt:tE:f�FJtil.f t1 NEN PAYMENTS: 80.00 _ l�b'0'e2: MR ADJUSTMENTS: 60.00 INSURANCE BALANCE: $236.25 YOUR BALANCE: 592.22 _ If Any Questions, Phase Contact: PH KS AT 717-231-8960 OR 1-800-565-6229 iJOHN B CLONTZ ACCOUNT: 2783 03/12/14 « FEB TAR ID 0 251709054 INSURANCE YOM C ADJUSTMENTS BALANCE)�`l CHARGE PAYMENTS ADJUSTMEN BALANCE >>> PATIENT. JOHN B CLONTZ gg OP RECUR ME0 PERFORMED AT: FAMILY CARE OF DILLSBURG PERFORMED BY: PHFC OF OILLSBUR6 �'2- 05/22/13 OFFICE VISIT EST Pr LVL 4 206.00 80.51- 104.95- 20.54 PROCEDURE: 99214 DIAGNOSIS: 696.9 PERFORMED AT: HARRISBURG HOSPITAL PERFORMED BY: MOSPITALIST AT CGOH 06/19/13 INIr OBSERVATION CARE MoD ?59.00 86.04-• 151.01- 21.95 PROCEDURE. 99219 DIAGNOSIS: 28¢.19 VW 061913 062013 06/19/13 TO 06/20/13 PERFORMED AT: HARRISBURG HOSPITAL PERFORMED BY: HOSPITALIST AT CGDH 06/19/13 INITIAL HOSPITAL CAR LVL2 265.00 103.73- 134.81- 26.46 PROCEDURE: 99222.A2 DIA0140615: 284.19 INP'T 071213 071813 07/12/13 TO 07/18/13 PERFORMED AT: HARRISBURG HOSPITAL PERFORMED BY: MOSPITALIST AT CGOH 07/12/13 INITIAL HOSPITAL CAR LVL2 265.00 103.73- 134.81- 26.46 PROCEDURE: 99222.AI DIAGNOSIS: 284.19 PAGE OF 2 Pim dM hard.Mum MW Your pmy"m Pow 0IRM Un OnH Aammx Nomikm Amw 15-=: HI2 REP: PRPY r c783 onoa�592.22 PINNACLE.HEALTH MED SVCS JOHN B CLONTZ � 04IO2/14 H Fag HARRISBURG 17108-/286 HC: 12HO Card ea: ry cndc em.D= ADDRESS SERVICE REQUESTED Ca hdgcrName AmMmr,me: YY ) -{Check box and enter any address or l�Odmum Prymcoc Siputmr: ,Z,,<.-c.� ._.t Insurance Correctlons on back Make Check Payable To PINNACLE HEALTH MED SVCS 00001060 01 1hM 1r1R!•«H11M••1R'••MNHrIR 411IN1H•i,u•e11ip•Nh•• , JOHN B CLONTZ PINNACLE HEALTH TIED SVCS 17 RIDGEWAY DR PO BOX 1286 CARLISLE PA 17015-7614 HARRISBURG PA 17108-1286 I I i I LAST WILL AND TESTAMENT OF i F;,, `4 JOHN B. CLONTZ I I. JohnBvClontz, of Cumberland County, Pennsylvania, being of sound mind, : .:- �I CU emory and understanding, do hereby make, publish and declare this as and for my I jLast Will and Testament, hereby revoking all other wills and codicils heretofore made i by me. i i! I FIRST I' I direct the payment of my debts and the expenses of my last illness and funeral �i from my estate as soon after my death as conveniently may be done. I wish to be cremated and my ashes to be disposed of by my personal representative as he shall determine appropriate. I direct the payment of all inheritance I ' and other taxes by my estate. � I SECOND I give, devise and bequeath the following specific property to the respective heirs as indicated: to Robert Stought, my neighbor, truck and trailer; to Martha Gibson, any ! .'� and all stocks, except any A T & T stock, bonds or mutual funds owned by me at my death but this specific bequest shall not include any annuities owned by me at my death; to Joe McCarson, any shares in A T & T. Then, I give, devise and bequeath the I I sum of ten thousand ($10,000.00) dollars to each of the following individuals: Dorothy i Warren, per capita and Martha Gibson, per stirpes. Then, I give, devise and bequeath fI the rest, residue and remainder of my estate to my sisters, Dorothy Warren and Martha Gibson, in equal shares. In the event Martha Gibson predeceases or fails to survive (I � G i �I� I 'i or fails to survive me, I give devise and bequeath her share of my estate to Robert Gibson, Henry Gibson, Leslie Gibson and Ann Cody, in equal shares, per stirpes. II THIRD I direct that no executor, guardian or other fiduciary named, nominated, or I appointed by this my Last Will and Testament shall be required to post any bond or give any security of any type for any purpose whatsoever, any law or rule of the court of the i, I� Commonwealth of Pennsylvania or any other jurisdiction to the contrary I� notwithstanding. I direct that the law of the Commonwealth of Pennsylvania shall apply I I I� to any interpretation or application of the validity of this instrument. FOURTH it My executor shall have the following powers in addition to those vested in them I by law and by other provisions of this will, applicable to all property, real, personal or I I j mixed and wheresoever situate, including property held for minors, whether principal or income, exercisable without court approval, and effective, with respect to each item of u i said property until actual distribution thereof. i A) To retain, as investments of my estate or trust, any or all assets of my i estate, real, personal, or mixed, without regard to any principal of diversification, and to purchase and acquire real or personal property and to hold any or all of such real and I it personal property retained or acquired without making the same productive of income. B) To pay all taxes, charges and expenses of maintenance, upkeep, j improvements, development, protection, preservation and investment of any retained or acquired real or personal property, such payments to be made from either principal or i I income as my executor shall determine. (I i i 'I i I it i Ij Signed, sealed, published and declared by the above named testator, John B. l Clontz, as and for his Last Will and Testament, in the presence of us, who, at his II i I request, in his sight and presence, and in the sight and presence of each other, have reun ubscri tou r names as witnesses. v'neu n ubs C ADDRESS � r n ADDRESS �rJ 1GQC \j") )L l�iP4Vl'I�tl, �� �73F � �i I COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND We, John B. Clontz, >Q;y iL L & Y1C-, and A-) dAL'ZC�-- 4 n�1LS I the testator and the witnesses, respectively, whose names are signed to the attached or j foregoing instrument, being first duly sworn, do hereby declare to the undersigned I authority that the testator signed and executed the instrument of his Last Will and Testament, and that he signed willingly and that he executed as his free and voluntary �I act for the purposes therein expressed, and that each of the witnesses, in the presence i l and hearing of the testator, signed the Will as witnesses, and that to the best of their knowledge, the testator was at the time eighteen (18) years of age or older, of sound if mind and under no constraint or undue influence. i I Sworn to and subscribed before me this 8th day of March, 2012. U UT i COMMONWEALTH OF PENNSYLVANIA j Notanal Seal Jennifer S.Lindsay,Notary :bCarlisle Born,Cumberland MY Commissbn Explres Nov.29,2015 MEMBER,PENNSYLVAry[A AS�TTON OF NOTARIES ,�,j i C M yy � � '9C G f/j rr lT' w . v. > z st= n p �7 Ape Vi a do nYn000 0Zp Z S Hx Cx-7 I i I ' 1 REGISTER OF WILLS CERTIFICATE OF CUMBERLAND COUNTY GRANT OF LETTERS PENNSYLVANIA y No. 2013- 00849 PA No. 21- 13- 0849 Estate Of: JOHNBCLONTZ (First,Middle,Gast) a/k/a: JOHN CLONTZ JOHN BOLICK CLONTZ Late Of: NORTH MIDDLETON TOWNSHIP CUMBERLAND COUNTY 0 Deceased Social Security No: WHEREAS, on the 5th day of August 2013 an instrument dated March Sth 2012 was admitted to probate as the last will of JOHN B CLONTZ /First,Middle,last a/k/a JOHN CLONTZ JOHN BOLICK CLONTZ late of NORTH MIDDLETON TOWNSHIP, CUMBERLAND County, who died on the 24th day of July 2013 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA FARNER STRASBA UGH , Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: ROBERT C STOUGHT who has duly qualified as EXECUTOR(RIX) and has agreed to administer the estate according to law, all of which fully .appears of record in my office at CUMBERLAND COUNTY COURTHOUSE, CARLISLE, PENNSYLVANIA. IN TESTIMONY WHEREOF,- I have hereunto set my hand and affixed the seal of my office on the 5th day of August 2013. F -gister 1/s P i **NOTE*'*' ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST)