HomeMy WebLinkAbout03-26-14 I
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.,._.,l REV���oo E7c tozai)iF4
oF�icia�us�aNGY
PADeperUnentofRevenucs ��y�e y�a� FaeNumber
�s Suroau of Individual Taxes
� Po gOX 2easOt (NHEF2ITANCE TAX RETUF2N 2 1 1 3 1 3 4 4
aHnrrfsbu PA 17128•0601 R�SIDENT D�CE��N7
� @d7ER DECEOENT INFOFtItAATION BEI.OW
Social Sewrity Number Date of Death ►+Sb1DDYYYY Oate ot Sirth th�AODYYYY
� 1 12 � 920 'I 3 1 026 1 924
� Decedent's Last tJame Suftbt Decedent's Ftrst Name MI
� S T � U F � E R . E D I T H D
(OAppifcable)Enter Surviving Spouse's intormatlon Below
�ouse's Last Namo Suffix Spouse's First Ngme MI
�ouso's SOcial Securily Number
THIS RETURN MUST BE FlLED IN DUPl.1CAT�WITH 7HE
RECISTER OF WILLS
FLL fN AAPROPRIAT�OVAl.S BELOW
� 1.Ork,�inal Relurn � 2,Supplempnlal Relum �] 3.Remainder Relvm(Date of Doaih
ptior l012-13�82)
� q.Limiled�state [� 4a.Future Interest Compromise(dale of [] 5.Federal�slale Tex Retum Requlred
dealh aRer 12-12-82y
� g,Oecedent Dled Testate ❑ 7.Dacedent Mainleined a Living Trust ..� 8•Totai Number of Safe Deposit Boxes
(AtEach Copy of Wil� (Attach Copy ofTrust.) .
� 9.Lil'�ga0on Proceeds ReceSved [� 10,Spousal POVerty C�dit(Oate of Death {] �1-Etectbn to Tax undec Sea 9f 13(A)
Setvreon f2-3i•9f and t-t•95) (Atlach Schedute O) � . .,
CORRESPONDENT.TNISS�CTIONMUSTBECOfdPlETED.AL4CORRESPON�EilC&ANDCOI�FfDENT)At,TAXINFORA NS1i0UL�8&DIR�t� �:
Nama paytlme 7elep�ori�lamber W �
E�• . MARK THOMAS � '1 7 � ��a �1 �'c�
R�(31ST6R�j t��S�UBE�N4Y^'
�." � 7C Q '
�3 � � 'T7 YI
C� � 'T� '—�' -'��.
F(rst Lfne of Address r-±
'i 0 1 S OU T M MA RK � 7 ST REET �''
-+a � r�n
b p
Sec4nd bioa ofAddress � . w
Staie ZIP COde �ATEFILB�
Cily or Posl O!f ce �'�����
MEC �-lANi CSBURG PA 'i 70 S5
Correspondenl's e-tna(I address: RMAt�KTHOMASCc�7GMAtL COM _
Utqpr pona�Gea d petjury.t deciare that i h3va Cxomined lhis totum,IndW�ng acoornpanrnD schedufes and atatements,and lo Ihe best ot my knw�iedgo arid berraf,
it is We.cor�ea and compSete.OoGaratlon o(pruDDrerol�er�han Iho pe�sonal reprosen�aiive{s Dosed on a0 tnlvrmaUon e►whkA Proparer bas arry knaMedge,
Si Mg�U_���R ONS F�R FIUNC>RETURN �/"!��€�
1� � �� r r
ADDRESS
5Q4 CAROLINA BE CH AVE SOUTMf CAROLINA BEACH NC 28�28
StG R� E RHPRESENTATNE �A
� r.
"D°n�� MECHANICSBURG PA 17055
101 S. MARKET STREET
PLEASE USE ORIGIMAL FORM ONLY
Side 1
� 1505610190 1.505610�.A0 ,�
� i
� 1505610290
� R�W1500 EX(�1) Decedents Social Secarity Number
lY3
Q
�, o�cecrenr8kame: EDiTH D..STOUFFER � $ $
� R�CAPITULATlON
AO
M 1. Real Estate(Schedule A} �,
� ...................... .................... •
,—
� 2. Stocks and Bonds(Scheduto 8j ...................................... 2• •
�
'�'
'�-' 3, Ctosely Hetd Corporalion,Partnership or Sole•Prop�ielorsbip(Schedute C} ..... 3. •
4. Morigages artd Notes Receivable(Schedule D) .......................... A. .
S. Cash,8ank Deposits and Misceilanoous Personal Propertyr(Schedults�)....... 5. 2 � 9 7 8• 3 7
6. Jofntly pwnad Properly(Sct�adule F� ❑ Soparate BtllEng Requested....... 6. ' .
7. Inter•V'rvos Tranafers&Misoellaneaus�Probate Ptoperly
(Schedule G) Separate BIlltng Requested.,...., r. 3 0 2 9 2, 8 0
8, 7otat Qross Assets(total Unes S through 7) ........................... a. 5 2 1 9 1 . 1 7
9. Fune�al Expensos and Admfnislrative Costs(SChedule H) .................. 9. 6 '� a �J. 5 Q
10. Debts of Decedent,Mortgage Liabililies,and Lians(Schedule I) .............10, 3 1 9 7. 3 5
», 7otaS peducttons(totat Llnes 9 and 10) ............................... i�. 9 3 0 2. 8 5
12. Not Value of Estafe(I.tne 8 minus Line 11) ............................ �z. 4 2 8 8 8. 3 2
13. Charitable and Govemmenlal8equoslsiSec 9113 Trusls for wbich
an election to tax has not beert made(Schaduie J) ...................... 13. .
14. Hot Valae SubJoct to 7ax(Llne 12 minus Ltne 13) .................,....14. 4 2 $ $ $. 3 2
TAX CALCUlATION-SEE INSTRUCTIONS�OR APPLiCABLH RA7E5
15. Amount of I.ioe i4 taxable
at Iha spousai tex rate,or
Ifensfers under Sec.91 S6
(a)t�.2)x.o� 0 . 0 Q ts. Q. 0 0
16. Amount of lina 14 taxebla
at linaat ralo X.045 4 2 8 8 8 . 3 2 �s, 1 9 2 9. 9 7
17, Amount of I.ine 14 taxable •
pt sibling rate X.12 � . � 0 17. 0. � 0
18. Amount of 4ies 14 taxabla
at coltakeral�ata X.'15 � • � Q 18. d. � �
�s. YAx ouE ......................................................�a. 1 9 2 9. 9 7
20. FII.l.IN TH�OVAI.lf YOU ARH REQU�STING A REFUND OF AN OVERPAY1VtENT �
&Ide 2
� 150561Q290 1505610290 �
`RE1/-i600�CX(PI}Page 3 Fllo Number
Decedent's Comptete Address: 21 1$ 1s44
o�c�aeNrsNn►,+E �
EDITH 0.S70U�FE�2 ,, ��
STRF@TADDRESS � ""-"-'�'
�
N
P
•��� STATE �IP
�
.-,
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Ta�ayments and Credits:
1. �iu Oue(Page 2,ilne 19) (i) 1.929.97
2. 6�editslPaymenls 1,929,87
A.Pdor Paymenls
B.Disoount 96,50
To�al Credits(A+s) �z) 2,026.47
3. fnlerest — -
a. !t line 2(s greater Ihan Une 1�+Line 3,enter tMe d'Qterenoe,Ti►is Is!he OVERPAYMENT, (3}
Fili tn ova)on Pa9Q 2,Ltne 20 to request a rafund. (9) 96.5U
5. 1(Uoe 1*line 3 is greate�Ihan Une 2,enter the d;ftetence.This is tha TAX DUE. (5} 0.00
Make check payable to: R�GfSTER OF WILLS,AGENT
PLEAS�ANSW�R THE FOLLOWING QU�STIONS BY pLACING AN"X"lN TH�APP�OPRIATE BLOCKS
1. pid decedent make a Iransier and: Yes No
a. retain the use or inoome of lhe prope�tY Iransfened ..................................................................... ❑ �
b. relain!he right to designate who shall use lhe p�operly Uanstened or ils f�come ............................... ❑
c. retain a reversionary intecest ..................................................................................................... ❑ �
d. cecetve Iha ptomise for lite ot eil�er pajrmeats,benafits ot care? ....................................................... ❑ �J
2. If dealh ocqrrred after Recembet 12,f 982,d'xl decedent transfe�property wil�fn one year of daalh
vn1houl recefving adequate consideraiion? ....................................................................................... ❑ �
3. Did deoedent a�vn an'in wst fo�'a payabte-upon�dealh bank aocoUnt wsecurily at hfs a her deal�? ........, ❑ �
A. Did decedent awn an lndividual reUremenl aocounl,annuily or oiher non�grobale propeAy,whtch
oonlainsabeneficlarydesignailon?.................................................................................................. � ❑ �
IF TH�ANSWEit 70 ANY OF 7iiE ABOVE QUESTIONS IS Y�S,YOU(NUST COMPLET�SCF#EDUL�G AND FII.E 1T AS pARF OF THE R�TUR�1,
For dates of death on or aEter Ju�y 1,9984,and beiore Jan.1,1995.iha Eax rale itnposed on Ihe neE value of�ransfers to or for fhe use of the suiviving spouse i;
is 3 percent�72 P.s.§9116(a�(1.���iy�.
For dates of dsalli on or atter Jan.1,1995,lhe!ax raie imposed on lha nel value of transfers to or for the use of!he surv(vfng spouse is 0 percent
(72 P,S.§91 i${a)(1.1){i!j).7he sfalute doas not exemp!a Uansier to a survivEng spouse from tax,and Ihe statutory requlrements tor dlsdosure of assets and
f!(ng�a tax return are sliil applfcable even if the surviving spouse is the only banefidary,
For dates of death on or aiter July 1,2400:
• The iax rafe imposed on the net vafue of UansFecs from a deceased child 21.years of age or younger aldealh io or for l�e use of a nalurat parent,an
adoplive parent ot a stepparent ot ihe drild is U percent[72 P.S.§9116(a)(1.2)J,
• l'he tax rate imposed on lhe net value oE trans(ers lo or for ihe use of Ihe decedenrs Ifneal beneficiaries is 4.6 percent,excepi as noted in p2 a.S§9116(aK4}�
• 7he iax rate imposed on Ihe aet value of Eransters to or for the use of•the decedent's sib3ings Is 12 percent(72 P.S.§9116(a�(1,3)j.A sibling ls deSned,
under SecEton 9102,as an indtvkival who has at least one parent in common wi�h l�e decedeni,M�hefher by blood or adopGon.
• REV•1�p8 E7C+f08•12)
� � pennsylvania SCHEDUL� �
nePnRr►��rno�a�rau� CASH, BA[�tK D�F��S1TS&MISC.
���rar�c������ P��ZSONAI.PROA�I2TY
Es �oF: �r��Hunss��:
Ep�H D.STOUF�ER 21 13 1344
T d lnclude Ihs proceads oi litigatlon and the date tho pro�eeds were receEved by lhe estale.
� All property Jvintly owned with right of surv(vorship musE be dlsclosed on Schedulo a,
� VALUE AT DATE
N B�R DESCR{P7lON OF DFATH
� PNC BANK 20,418.56
.7. CHECKING ACCOUN7'#5140074143
� 1NCtUDES 9.ar4 lNTERES7'
2. PNC BANK 'I,S58.81
MONEY MARKEf ACCOUNT#5006132197
!lVCLUDES.02/NTEREST
TQTAL(Also eoteron Line 5,Recapitutation) S 21 878.37
IF more space fs needad,use additional sheots of paper of the same size.
+ ft�V•1�10 @X*(08•09J
pennsylvanja • SCHEDUL� G
D[PARTRtEfITQ�REVENU$ (�T�1�•ViVOS i'RANSF�RS AND
INNEPoTARCETNCRETURN MISC.NON-PR08AT�PRQP�RTY
�s�o�rrrbECaoe��r
ES �OF F11.F NUhfB�R
EC�H D STOUFF�R 21 13 1344
� ThSs sd�edule must 6e compteted and fited'dihe anssver lo any of ques6ons 1 Uuough 4 on page lhree of tho R�V-150U is yes.
� D�SCR�PTION OF PROPERTY
ITF� ���,p�h�{vy,�oFne�twvu�.�Et►�xrta,►norrs►eptooEtE�+rk,v DATEOFp�A7H °�iOFDHCD'S FXCLUSION TAXABIH
NUM R n+EOAreoFtwwsr�x.er►�CaeoopraFn+6o�arataeuESrerE VALUEOFA33ET INTEREST �� 4AlU�
t.� NATIONWIDE LIFE AND ANNUITY 01-6145330 25,929.19 100.Q0 25,129.11
r-
2 iVA7tONWlD��IFE AND ANNUITY 01-6180892 5,083.69 100.00 5,083.69
TOTAL Alsoenleron llne7,Reca 'tulation $ 30 292.80
If moraspaea 3s needed,use additionaf sheetsoipaperof U�e same s�za.
" g�vtsi��xf(oaas>
pennsytvania SCHEDUL� I-�
DEPARThI&NTUF REVENllfi FUNERAL.EXPENS�S AND
n+ft��ranc�raxr�uru� ApMfNlSTRATlVE COSTS
� tt�s��rrroscEOe»r
ES Q�OF FILE NU�ABER
ED�H D.STOUFF�R 21 13 1344
0
� Decedent's debts musl bo roported on ScAedulo I.
. M
N BER DESCi2�P7(dN AM4UNT
A. d FUNERALEXPENSES:
�,. Musselman Funeral Home 4,a17A0
B, AOMINISTR/tiTIVECOSTS:
1. Perso�ai ReptesentaGve Cornmisslons:
Name(s)of Pe�sonal RvpresenqOlre(s)
SUeCtAddrass
CAy State 2!P
Year(s}Commssion Paid:
2, Attomoy Focs: 1,410.00
3, Fam�'y Exempfion:(It dea:denfs addrass is not Ihe same as cJaSmanCs,atlach explanation.}
Cta�mant
SU�eelAddrecs
�i�y Sble Z3P
Reiatansbip ot Cialmantto Dccadmd
a. p„����: 168.60
5, pcpountantFees: •
6. 7ax Rerom PreparerFees: Morrow'Tax Association 100.00
7. ADDITIONAI.ShiORT CEi2'f1FiCATES 10.Q0
TOTAL(Also enler on line 9,Recapilulaation) $ • g�05.50
If mora spacc I�needed,uso additia�al sheets of pnper of lhe sairie s'rce.
` ,REV•i���rx•(rx•tz)
p�nnsylvania SCF3EDULE 1
osanxm�rrrog��HUe DE�TS 0�D�CEDENT,
i�+�ror�r�xr�tuwr MORTGAGE LIABILITIES&LIEIVS
� s�s�oFr�roECEO�rr
EST �0� FIL�F�UMBER
ED�M D STOUFF�R 21 13 73d4
� � Repod debts incurred by the decedant prior ta deafh that remained unpaid at fhe date oi death,Including unreimbursed medtcal expenses.
:�EM VALUE A7 DATE
�Mg�R UESCf21PTI0N OF QF.A7H
1� HOSPIC�OF CENTRAL PA 3,Q00.00
INV.5309-PA 1/10/14
2. ZL070�F,GIl.BERT'&GOI.D 94.OQ�
1NV12/9$l93 CO-INSURANCE PAID CK 8615 9/40/14
3. l�1NhlACLE HEAI.TH EMERGENCY PAIq 2-24-14 33.39
CH�CK#8793
4. ADb1710NAL MEDICAI EXPENSES 150.00
T07AL(A3so enter on Une 10,RecapitulaGoo) S 3 197.35
i(moro space ts needed,insurt oddiGona!sheels of lhe sama size.
r Rev�i5i3e�.�onw)
penns�►lvania SCHEDULE J
o�P�uern+ei+roF R�erue ���JEFIC1A121ES
nmearnr�rnxaErvRr+
� r�S+�r�oEC�c�+cr
fS �OF: PILE NU1dBER:
E I•i D.STOLIFF�R 2'i 13 1344
� RElAT10iJSHIP TO pEC£UENT AMOUNT OR Sf�ARE
h!Ul�R NAlAE ANO ADDR�SS OF P�RSON(S)REC�IVIPtG PROP�RTY Do Not LtstTnistee(s) OF ESTAT�
Y� 1'AXA9LEOISTRIBUYIONS P�S�8tifi(a (1.2).j���sand�a�ufersu�er
�. GEORGE D.STOUFFER Lineal 100.00
'a' SO4 GAROLINA BEACH AVE SOUTH
r CAf20LINA BEAChI; NC 28�i28
ENT�R DOLIAft Ald0U1JrS FOR DISTRISUTIOMS SHOWN ABOVE ON lINES 15 7HROUGH 18 OF REV 1b00 COV�R SHEET,AS APPROPR�A7�.
jj, �10N TAXABL�DISTRIBUilOi�lS:
A.SPOUSAL DIS3RIBUTIONS UNQER S£CrtON 9113 FOR VYHICH AN�L&CFION TO TAX IS NOi'7AKEN:
1.
�
8.CHARiTABl.�AND GOV�t2NhiENTAI qlSTR16UTIOVS:
1.
70TA1.OF PART I I-ENTER T07'Al NON-TAXA9LE DISTRIBUTIONS 0�`J UNE 13 OF REY•i500 COV�R SfiE�T. S
if more spaca is needed,use addilionat sheets of papa of Ihe same size.
� � �'� REV-'i5�0 Discount, Interesfi and Penatty Wo�ksheet
Dts�ount Ca[culation
rs
To1�AmounE Paid within three calendar months of the decedent's date of death:. ,. 1_,�2,�,.9,�
a
Dis�unt; 96.50
m
, �
�-
� �
Inte�st Tab1e
�Ysar Days Delinquent Balance Due interest
this time period th(s year this period
Before 1981 _
1982
1983
'f 984
1985
1986
1887 _..,..,._____� --
1888 throu h 1991
1992
'1983 throu h'1994 ,_�
1935 throuc�h 1588 ��
1999_, _ _._
200R
2001 �
2002,,,, _
2Q03
zooa
2005�
2006_ _ , _____._,�...�....
2007
20Q8
2009_
2010 .,
2091 throu h 2014 � ,
�,.. . .____�_._,�.�.�.�.�.. �......— _..._.�..... �.__.
�,~~ �f'OTALS ,,,_�_ �^�
Penalty Calculation
If the decedent's date of death�vas on or before March 31, 1993,lnsert the appl3cable amount;
'fotal salance Oue on January 17,1996:,�.�....�__._�......_.._.._
Pena�ry: � ,�,. �-_._.....,_r
COMMOlAVFALTfiOf PENNSYLY/W�A f1EV-1182 QX(1�•89)
OEPARTMET�T OF REVFNU6
BUPFAV OF It10NJ0llAL7hXES
OEPS,t80601
HARRISSpRO,Pq t7128�0697
pENNSYIVANIA
REC�VE�.FROM:. INHER{TANCE AND ES1'ATE'TAX
�. OFF1CIAl fiECEIPT
� NO. CD 018905
a
�
m
m
�HOMAS R MARK
�01 S MARKET STREET
�ECHANICSBURG, PA 17055-3851
�
ACN
ASS�SSMENT AMOUNT
CONTROi�
NUMBER
....... ,,,, _�.---•.. ,_.,,.
101 ( $1,929.97
ESTATE lNFORMA710N: ss►v: �
� FILE NUMBER: 2113-1344 (
pECEDENT NAME: STOUFFER EDITH D �
DATE OF AAYM�NT; 03/19/2014 �
PASTMARK DATE: Q3I19/2014 f
CQUNTY: CUMBERI.AND � -
DA'f� 0� DEA7fi: 12/19/2013 �
�
TOTAL AMOUNT PAiD:. S1,929.97
REMARKS: RCAT TO ATTY
CMECK�t 3316
INi'TlAl.S: DB1
s�A�. RECEtVED BY;. LISA M: GRAYSON, ESQ.
REGISTER OF WE[.l,S
TAXPAY�R
.
�Ja�s. 'li. lU}4 1:24P�� P�YC 8ank � • . Na. 3943 P. V2
� � �.����i� � . . �
Q ';i��t�tt�"�Fl��ky .
0
� .. .
M Jant�uy21,20X4 '
J
� RIVIark Thomas Esq. `
� 101 S N,Farkst SE
Mechanicsburg,P.A. �7055 .
lt�: BdichD Stouffer
SSN': I 85-20•6674
nOD' 12-I9�2Q13
Dear Mr.xhorrxas:.
Tn response fo your requese for Date of neath(DOD}balances for tha customer noted a�ove,aur
records show the foilowing:
C�eckrug Accuunt
' Accounf�5140074143 , Established:0�-Ol»I97$
�D�T�T�S'�O�UFFBR .
DaD balance: � 1,559,79-+-0.02 accraed mterest �
Interest paid 41-0I-2013 thru 12-I9-20�3�0,18 'YTn
Savings A.ccount
Accaunt#540b132197 �stablished: l1-05-2010
EDITH D STOUFfiFR -
ppD balance� $20,417.02+1,5�1 accrued interest
Iaterest�aid Ol•O l-2013 thru I2-]9-20 t 3�22,18 'Y'xn .
P[case note Wat t(us oi�ice providrs date of death balances for deposit accounts([RAs,CAs,Checking aud
' Savings). '9�'e do not process any tinancial transactiobs or provide statements, lf you need assistance 1viW
an�of thess items,plcasc call 1-888-PNC-�ANI�(I-888 762-22bS)or skop by your local PNG Banlc branch
o�ca. - .
Sincerel�,
Nationai Fir�a�cial Sexv�ces Ce�ztez
T'NC Bank,N.A.
Mem6cr��TC
Page I of 2 -
,
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aa�.v7�
�
� �,. February 3,.2014
-o art Your Sfde9
�
M
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� R.�vlark�'homas
Y
101 South Market St
Meahanicsbu,rg;,PA 17055
Dear Mr. Thomas:
Thank you for your correspondence regarding Edith.b. Stouf�er, Contract num6ers
O1-6145530 and 01-f>1$0812.
As req�ested,the date o�'death vaiue fox comtract 01-6145330 is$25,129.1 I. The
date o�death value.for contract 0�.-6180812 is�5,083.69.
IF we can prov:ide further service,please do not hesitate to call us tou free at 1-800-
634-5222.. 4ur customex service representatives aze ava;lable Monday -�Thursday
8;00 am--4:30 pm EST and Friday 8am-12 noon EST.
SincerelY,
Tr�tcome Products Sernice Center
lks
One Natlonwide Plaza Nationwide tnsurance �
Coitunbus 0�43215 22?A Nationwi@e rinancial
,
�
�������a� �`�����.� �o�� ��� ��°��a���� �����c��
324 Hctmmef Avenue
� Lemoyne,PA 97043 '
a ?el:717-763-7�40 �ax:717-73Q-9798
� Brlan C.Musselman,Supervisor
° Cllfford D.Fores#er Sr.Funerat Dfrector
c
v
m
� Monday,December 23,20I3
Y
� O
� Mr.. Oeorgc D.S#out�'er
50�Cazolina Beaeh Avene►e$outu Saads II Unit 1K �
South CaroEina Beach,NC 2&128
Dear George�
Thank you for selccting ovc funcral)soine to provsdc services fo�your farnily during you�time of bcreavcment. [hopa that you found
ovr servtces,so tar�to be ofihe blgliest standards that we alevays try to achieve. Tt�e following is a susnmary of lhe servica ciiarges as
previously explained and provldcd in writtcn form on the servlces for:
�DZ`X'H D.STOUr'T�E�
PROPESSXOI`!AL SL�RVTC�S
S Includec!
Embalming S Inc[udccl
' OdierPreparalionofBody S.Included
7'raditiona[Funeral Packages B S 5495.00
�otai Funcral Service Sclectcd
TQ'I'AY.Y�LOFES.SIONAC.SL�ILVICFS 55,495.OQ
Use ofFacilit(es&Statf for Visitaiion S Inaluded
Usa of Facilitics&Staff for Cerernony at funcral f#ome S Inciuded
Use of Staff&&c�uipment for Graveside Servico S Included
1Ya»sfer of R«nams to Funem!Home S Inctuded
Hearse�/Furteral Goach S lnciuded
Ox��i 11',iGRCIiANpIS�S�GECxL�D
Rolling Gteen
Rolling Greert
, Clothing Budnl Qo�m $110.00
Acknowlodgcment Cards 3 Inciudod
Regis{crBook S fncluded
Memorial Poldcrs S Inciuded
'X'01i1L 01'I1GIt ML�RCHANDxS�S�X.�GTED $110.00
CASit AAVANCES
Certif►ed Cop�es of Death CextlGaete S Includal
Ctergy Honorarium S 200.00
�fewspaperNolsea HactisburgPafriotNaws S2�I6.00
Flowcrs-Caskct Spray S 225.OU
CASH AriVANCETOTAL S671.U0
L�SS: Crcdits grantcd S1,859.00
Pro-PaidAmount S1,859.00 •
TOT�U,OI�SLRVICT;S S4�4X7.00
T3AX,ANG�AUE S4,4I7.00
If tlecre are any quostions or coneerns tba s�emeirt unanswerec),please call me.
Siucere(y,
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late eharge ou any a unt unpaid past Uie due @ate. ,
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,� 217 Souih Car2isle Streei •p.0.Box 302
Q - � New Btoomticld,PA 17068
a ��°.,s.:. 717-582•2211 • Fax 717-582•7724
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'Z'ax Preparation Pox Year L'�U t 3
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Accounting Services For Year r_______
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Hospice oF Cen�ra3. Pennsy.�vania �������
1320 Linglestown Rodd
fiarr3sburg, PA. 17120 Invoice Nurnber:
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�. � Invoice Date,
�Oj 71?-'732-7.000
�aX� 717-234-036h � 12/31/13
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Tidith stou��er f�g�,l`�,�, .
C/p George SCOUgfer 1 11 w'�I
509 Carolina B�Gh Ave South
Cazolina BeaCh, NC 28428
ResidentID:StouEferFdi�h
�'ayment Terms Aue}Jate
NeC 15 Aays ,���5��,q
Description Amount
esidential Care - DeCember �.2-19, 2013 3,OQ0.00
�Iease note ouz• zzewv o�'�ce addxess-- �320 I:zng�esto��vn X2.oad,FIarz•isbua•
�,� x7xxo
Total.I,nvoice Axnoun 3,o00.o0
Check/CxediC.Memo No PaymenUCredit Appliec
P�tl� 1�-to-t4 ToT.�x. 3,000_00
Thanlc you foY choosing.�ospzce of Centt•a�Z'enr�sylvania.
� 1 1 Any t+ayments Vr C:narges Huer i oa noove n�nu►g vaie vwu Mppea,vn�ou�nvti��,d,�„�r+,,, �
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� Pati.enk:. E. STOUE'FER
Doctor:- SUSAN J ROSSO
t1713/13 99202 OFFICE OUT@T NE41 20 MINUTES 9b.00 90.Oi
� �X: ].�.0:1 DERMATOBHYTOSIS OF NAIL
3¢/13J13 ADUYTxONAY. DIAGNOS�S , O,.OU 90,q�
N DX: 729.5 PAIN IN SOET Tx55l3ES O� L
1�02/13 PMT 'fCtAVE�,ERS MEDICRR� cfl 2057091 55.05- 34,9:
1 02/1.3 W/0 �REIVET,ERS t•fEDI c� 205704� 20.91- ].4:0•
1 16/l.3 C�LONIAL/kT RESPONSIBTLITY c# 2057042 0.00 14.0�
1�16/13 Co-a.ns i4.09
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PLACE OF SERV.CODI
ZT,OTOF�', GI�,FERT & GOLD
� 5108 E TRXNDT,E RQ #1,00 �� �108
12 Patlenl'aHome
ChartNumber 61937 MECHAtJICSBURG QA 1705Q 21 InpaGentHOSp�at
22 Oulpatieeltiospilai
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PlaceofServicrt TRYNDL� OE'E'XCE 24 AmDuWlorySurgkolCcnl
31 Sb'Aed(�hrrsing Fatilily
Phone ?J.? 767, 3162 ReterriagPhystcian SCHS�TARTZ 32 NurstngFaar,ry
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ANSI COb� AESCRIPTXON:
3 ^ CO-PAYMENT AHOUNx. AHOUNT D�IE LESS THAN OR EQUAL '�0 CO-PAYML�NT.
TE' YOU B�LIEVE THAT YOUR CI.AIM HAS BEL'N 1��RONGFULLY DENIEil OR REJECTED, WS W�T,L B� GLAD TO COtVSZUEP
ANY ADDI�IONI►L FACTS Y0I1 MAY WISH �0 SUBMIT. IP YOU D�SAGR�L' WZTii OUC� D�CISYON, YOU ARL �NTITLLD
TO A IiANAGEHEiV7' R�VY6W OF THE CLAIM. k'I.EASE F�RS��A1tD YOUEi KLQUE3T POR A MANAGBtiENT RBVIE{�1 Ta THL
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� R. .MAltl'f T1�1'OMAS'
� Attor.uey at Lmv
o X 0,1 Soutlt Market Street
mMecl:arcicsbrrrg,.Pen�tsylvafifa X7055
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:r Tele,�fioi:e: (717) 796-2100 �'fiX; (717) 796-3600
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� March�12,20.14
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George D,Stouffer,Executor
SO4 Carolina Beach Avc,.South
Sands 11,U`nit 1T�
Carolina Beach,NC 28�28
Re:Estate o�Edith D..Stouffer
Dear George:
�nclosed is a complete capy o�ihe Tnheritance Tax Rehun far your recards, Aiso
enctoscd are hvo pa�es for your signature. •Please sign and returri just ttie two signature pages to
my offtce,
Very truIy youxs,
R:Mark Thomas,Esquire
Rlv1Tljkr
Enclosures