HomeMy WebLinkAbout03-04-14 (2) 1505610140
REV-1500 Ex m-10'
PA Department of Revenue 'tlsE tMtLY
Bureau of Individual Tama INHERITANCE TAX RETURN
�Y Cade Year Fife Nuke
PO BOX 28MI 2 1 1 3 0 5 8 9
_ Hanisbum,PA 11126.0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Data of Death MMDOym Date Of Sith NMODYM
0 5 1 9 2 0 1 3 1 2 1 2 1 9 2 4
Do edent's Last Name Suffix Dooedu M'S First Name MI
C 0 6 6 I N S W A D E T
(If Appiic")Enter SurAvMg Spouse's Info notion Babes
Spouse's Last Name Suffa Spxwae'a First Name Ml
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
®
1.Original Rehm ❑ 2.Suipplamental Return ❑ a Remainder Return(data of&a&
prior to 12-13-M
❑ 4.Limited Estate ❑ .)a.Funds interest Compromise(date of ❑ 5,Federal Estella Tax Rahn Requited
death after 12.12.02)
® 6.Decedent Died Testate ❑ 7.Decedent Maintained a Luting Trust a.Total Number Of Sate Deposit Boors
(ARach Copy of Will) (Attach Copy of Trusq
❑ 9.U WdOn Pmatads Received ❑ 10.SPOUSsi Poverty Credit(date of death ❑ 11.Election to tax under sec 9113(A)
•• between 12-31-91 end 1-1.65) (Attach Sch.0)
CORRESPONDENT-THIS KC ION MUST BECOWLETEA ALL CORRESPONDENCE AND CONFAENTUH.TAX WORL T M6MLDBEORWMT*
Name Daytime Telephone Number
D 0 U 6 L A S 6 M I L L E R 7 1 7 2 4 9 2 3 5 3
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First fete of address
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Second line of addresss� ��+
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.City or Post Office State 21P CodeT8
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S TU PONSIBLE fOR fIlJNO RETURN DATE .-
ADDRESS v .�
3864 CORIff T BOZEMAN MT 59718
SCM11JAP Of EPgRE�g7t�1'N�EPRFSENTATNE �D /d
ADDRESS
60 WEST POMFRET STREET CARLISLE PA 17013
PLEASE USE OR**"FORM ONLY
Side 1
1505610140 1505610140
J 1505610240
REV-1500 EX
Decedents Social Security Number
De edienrs Name: WADE T. COGGINS
RECAPITULATION
1. Real Estate(Schedule A) . . . . . . . . . . .. .. .. . . . . . .. . . . . . . . . . . . .. . . . . . . . 1.
2. Stocks and Bonds(Schedule 8) . . . .. .. . . . . . . . .. .. . .. . . . . . . . . . . . . . .. . . 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) . . . . . 3.
4. Mortgages and Notes Receivable(Schedule D) 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E).. . . . . . 5. 9 7 2 8 3 . 0 4
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. 1 7 1 1 . 1 9
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested . . . . .. . 7. 1 5 4 0 8 1 . 7 3
8. Total Gross Assets(total Lines 1 through 7) 8. 2 5 3 0 7 5 . 9 6
9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . .. . . . . . . . . . . . 9. 2 0 2 3 3 . 5 4
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) . . . . . . . . . . . . . 10. 1 7 0 . 8 0
11. Total Deductions(total Lines 9 and 10) . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . 11. 2 0 4 0 4 . 3 4
12. Net Value of Estate(Line 8 minus Line 11) . . .. .. . . . . . . . .. . . . . . . . . . . . .. 12. 2 3 2 6 7 1 . 6 2
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . .. . . 13.
14. Net Value Subject to Tax(Line 12 minus Line 13) .. . . .. . .. . . . . . . . . . . . . . 14. 2 3 2 6 7 1 . 6 2
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X _ 0 . 0 0 15. 0 . 0 0
16. Amount of Line 14 taxable
at lineal rate X.045 2 3 2 6 7 1 . 6 2 16. 1 0 4 7 0 . 2 2
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 0 0 17. 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 0 0 18. 0 . 0 0
19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . .. . . . . . . . 19. 1 0 4 7 0 . 2 2
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Side 2
L 1505610240 1505610240 J
REV-1500 EX Page 3 File Number
Decedent's Complete Address: 21 13 0589
DECEDENT'S NAME
WADE T. COGGINS
STREET ADDRESS
770 S. HANOVER STREET
CITY STATE ZIP
CARLISLE PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 10,470.22
2. Credits/Payments
A.Prior Payments 5,000.00
B.Discount 250.00
Total Credits(A+B) (2) 5,250.00
3. Interest
4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. (3)
Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 5,220.22
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ...................................................................... ❑ ❑X
b. retain the right to designate who shall use the property transferred or its income; ............................... ❑ 0
c. retain a reversionary interest;or ................................................................................................ ❑ I]
d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ ❑X
2. If death occurred after December 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ❑ ❑X
3. Did decedent own an'in trust for"or payable-upon-death bank account or security at his or her death? ......... ❑ ❑X
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation?.................................................................................................. 0 ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in
72 P.S.§9116(1.2)[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined,under
Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-1508 EX+(0812)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS Fr MISC.
RETM PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
WADE T. COGGINS 21 13 0589
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. THE ALLIANCE DEVELOPMENT FUND, INC. 21,198.40
ACCOUNT#15637
2. THE ALLIANCE DEVELOPMENT FUND, INC. 50,241.32
ACCOUNT#15638
3. PNC BANK-CHECKING ACCOUNT#5003961184 25,843.32
TOTAL(Also enter on Line 5,Recapitulation) $ 97 283.04
If more space is needed,use additional sheets of paper of the same size.
REV-1509 EX-(01.10)
pennsyivania SCHEDULE F
DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY ,
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
WADE T. COGGINS 21 13 0589
If an asset was made jointly owned within one year of the decedent's date of death,it must be reported on Schedule G.
SURVWiNG JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A. ROBERT C. COGGINS 3864 CORWIN STREET SON
BOZEMAN, MT 59718
B.
C.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTIONOFPROPERTY %OF DATE OF DEATH
REM FOR JOINT MAOE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENTS VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUEOFASSET INTEREST DECEDENT51NTEREST
1. A. 12/2011 STOCKMAN BANK 3,422.37 50. 1,711.19
DEMAND DEPOSIT ACCOUNT#1812006454
TOTAL(Also enter on Line 6,Recapitulation) E 1,711.19
a more space is needed,use additional sheets of paperof the same size.
REVA 510 EX+(08-09) —
pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER•VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
WADE T. COGGINS 21 13 0589
This schedule must be completed and filed If the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
REM DESCRIPTION OF PROPERTY
MCLUOE THE NAME OF THE TRANSFEREE.THEIR REATIONSHlPTO DECEDENTAND DATE OF DEATH % DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER.ATTACH A COPY OF THE DEED FOR REAL ESTATE.- VALUE OF ASSET INTEREST QFAPItN/81.4 VALUE
1. MUTUAL OF AMERICA IRA ANNUITY#81-246532-7 35,031.07 100.00 35,031.07
2. FRANKLIN TEMPLETON INVESTMENTS 51,802.10 100.00 51,802.10
FRANKLIN GROWTH FUND- CLASS A
ACCOUNT#106-60171100753
3. FRANKLIN TEMPLETON INVESTMENTS 47,719.97 100.00 47,719.97
FRANKLIN UTILITIES FUND-CLASS A
ACCOUNT#107-70183181404
4. FRANKLIN TEMPLETON INVESTMENTS 19,528.59 100.00 19,528.59
FRANKLIN U.S. GOVERNMENT SECURITIES FUND CLS A
ACCOUNT#110-10166314350
TOTAL (Also enter on Line 7,Recapitulation) 154 081.73
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
WADE T. COGGINS 21 13 0589
Decedents debts must be reported on Schedule t.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERALEXPENSES:
1. HOFFMAN-ROTH FUNERAL HOME 8,793.00
2. FUNERAL LUNCHEON 308.31
3. GEORGE'S FLOWERS 99.64
4. PASTOR 250.00
5. ORGANIST 50.00
6. SHARED HISTORY 50.00
R ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Years)Commission Paid:
2. Attorney Fees: IRWIN & McKNIGHT, P.C. 7,000.00
3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: REGISTER OF WILLS 143.50
6 Accountant Fees: SMITH ELLIOTT KEARNS & CO. 340.00
2013 INCOME TAX RETURN
6. Tax Return Preparer Fees: PATRICIA A. ROSEN DALE, CPA 375.00
FINAL FIDUCIARY TAX RETURN
7. REGISTER OF WILLS- SHORT CERTIFICATE 5.00
8. THE UPS STORE-SHIPPING 158.43
9. TRAVEL EXPENSE-GAS 61.79
10. TRAVEL EXPENSE-FLIGHTS 964.50
11. TRAVEL EXPENSE-CAR RENTAL 521.23
12. TRAVEL EXPENSE-SLEEP INN 977.96
13. TRAVEL EXPENSE-MEALS 135.18
TOTAL(Also enter on Line 9,Recapitulation) $ 20 233.54
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES&LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
WADE T. COGGINS 21 13 0589
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. CHAPEL POINTE- NURSING/PHARMACY 170.80
TOTAL(Also enter on Line 10,Recapitulation) $ 170.80
If more space is needed, insert additional sheets of the same size.
REV-0513 EX+{01-10)
pennsylvania SCHEDULE J
DEPARTMENT Of REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
WADE T. COGGINS 21 13 0589
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 ouNht spousal distributions and transfers under
1. ROBERT C. COGGINS Lineal 232,671.62
3864 CORWIN STREET REMAINDER
BOZEMAN, MT 59718
ENTER COLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size.
LAST WILL AND TESTAMENT
I, WADE T. COGGINS, presently of the Borough of Carlisle, Cumberland County,
Pennsylvania, being of sound mind, disposing memory and full legal age, do hereby make,
publish and declare this to be my .Last Will and Testament, hereby revoking all Wills and
Codicils heretofore made by me.
ONE. I direct my Executor or Executrix, as the case may be, to pay all of my
debts, fimeral and administrative expenses as soon as convenient after my decease. Furthermore,
I direct that all state, inheritance, succession and other death taxes imposed or payable by reason 4
of my death and interest and penalties therm with respect to all property composing of my gross
estate for death tax purposes, whether or not such property passes under this Will, shall be paid
by the Executor or Executrix of my estate.
TWO- My Executor or Executrix may, at his or her discretion, compromise
claims, borrow money, retain property for such length of time as he or she may deem proper;
lease and sell property for such prices,on such tomes,at public or private sales, as he or she may
deem proper; and invest estate property and income without restriction to legal investments
unless otherwise provided hereunder. I authorize and empower my Executor or Executrix to sell
any realty and/or personalty owned by me at my death and not specifically devised or bequeathed
herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale
therefor, in fee simple, as I could do if living. My Executor or Executrix is authorized and
empowered to engage in any business in which I may be engaged at my death, for such period of
time after my death as seems expedient to said Executor or Executrix.
InWaI W'Z"4--
THREE. I give, devise and bequeath all of my estate of whatever nature and
wherever situate to my spouse,JANE M. COGGINS.
FOUR. If my spouse,JANE M. COGGINS, does not survive me by a period of at
least sixty (60) days, then I give, devise and bequeath all of my estate of whatever nature and
wherever situate to my son, ROBERT C. COGGINS, absolute. In the event that both my spouse
and my son predecease me, then I give, devise and bequeath all of my estate of whatever nature
and wherever situate as follows:
A. Provided that she has not separated herself from my son and that no
divorce action had been filed prior to his decease, 50% to my son's spouse, BEVERLY
A. COGGINS,per stirpes; and
B. 50% in equal shares to my grandchildren. In the event that any of my
grandchildren predecease me,then I give, devise and bequeath their share to their spouse,
if any, provided that their spouse has not separated from my grandchild and that no
divorce action had been filed prior to their decease. Otherwise, I give, devise and
bequeath their respective share to their children, if any, per stirpes, which provides that
the child or children of any deceased beneficiary shall take the share their parent would
have taken if living.
FIVE. In the event of a common disaster causing the death of myself, my spouse
and all of my beneficiaries provided above, without surviving issue, all within a period of sixty
(60) days, then I give, devise and bequeath the rest, residue and remainder of my estate as
follows:
InWa1WJ 2
A. 500%to THE CHRISTIAN AND RRISSIONARY ALLIANCE,a non-profit
organization principally located at 8595 Explorer Drive, Colorado Springs, Colorado, or
its successors or assigns,for its general religious or charitable purposes;and
B. 50% to CHAPEL POWE OF CARLISLE, a non-profit organization
principally located at 770 South Hanover Street, Carlisle, Pennsylvania 17013, or its _
successors or assigns,for its general religious or charitable purposes.
SIX. If, under any of the provisions of this Will, any principal becomes vested
in a minor,my Executor or Executrix,as the case may be,including any administrator c.t.a.,shall
have the discretion either to pay over such principal or any part thereof to any parent of such
f
minor, any guardian of the person or estate of such minor,or any person with whom such minor
resides, or to retain the same as trustee of a power in trust for the benefit of such minor during his
or her minority. Any of the principal thus retained, and any of the income therefrom, including
the whole thereof, may be paid to or applied for the benefit of such minor from time to time in
the discretion of the trustee of such power. When such minor reaches majority,the funds so held
shall be paid over to such person, or, if he or she shall sooner die, to his or her legal
representatives. In so holding any principal or income for any minor, the trustee of such power
shall have all the rights,powers,duties and discretion conferred or imposed upon my fiduciaries
acting under this Will. I further direct that no bond shall be required from any person receiving a
payment hereunder and receipt from such person shall be a fall discharge to the trustee of such
power who shall not be bound to see to the application or use of such payment. The trustee of
such power shall be entitled to commissions at the rates and in the manner payable to a
testamentary trustee.
InitiatIV 3
SEVEN. I nominate and appoint my son, ROBERT C. COGGINS, to be the
Executor of this my Last Will and Testament. In the event he has predeceased me, failed to
qualify or is not able or does not serve for whatever reason, I then appoint my son's spouse,
BEVERLY A. COGGINS, to be the Substitute Executrix of this my Last Will and Testament,
provided that she has not separated herself from my son and that no divorce action has been filed.
In the event that she has predeceased me, failed to qualify or is not able or does not serve for
whatever reason, I then appoint my granddaughter, COMFORT C. PRICE, to be the Substitute
Executrix of this my Last Will and Testament, whereby the said substitute personal
representatives shall have the same powers as are given to the original Executor hereunder.
EIGHT. No person(s) shall benefit hereunder unless such beneficiary shall survive
me by sixty(60) days.
NINE. No Executrix or Executor acting hereunder shall be required to post bond
or enter security in this or any other jurisdiction.
TEN. No beneficiary may assign, anticipate or pledge his or her interest in any
income or principal held or distributable hereunder, and no beneficiary's creditors may levy,
attach or otherwise reach any such interest.
ELEVEN. If any person or institution entitled to share in any distribution under the
terms of this my Last Will and Testament becomes an adverse party in any proceeding to contest
the probate of this Last Will and Testament, such person or institution shall forfeit his, her or its
entire interest inherited hereunder and all provisions in favor of such person or institution shall
be declared void and of no effect. The share of such person or institution so forfeited shall be
distributed as part of the residue pursuant to Paragraph Four hereof except that if such person or
InitiaflW7 G 4
institution is entitled to share in the said residue, that interest shall be distributed proportionately
to the other residuary distributees.
TWELVE. It is my wish and desire that my heirs and beneficiaries, in accordance
with Biblical scripture and principals, would tithe a portion of those funds received by them
under this my Last Will and Testament. This provision is not mandatory for my heirs and _
beneficiaries,but an expression only of my wishes and intentions.
[THE REMAINDER OF THIS PAGE HAS BEEN INTENTIONALLY LEFT BLANK]
InitiaC&':I - 5
ACKNOWLEDGMENT AND AFFIDAVIT
WE, WADE T. COGGINS, TRACI D. SMITH and CHERYL L. CLELAND, the
testator and witnesses respectively, whose names are signed to the foregoing instrument, being
first duly sworn, do hereby declare to the undersigned authority that the testator signed and
executed the instrument as his last will and that he had signed willingly, and that he executed it
as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in
the presence and hearing of the testator, signed the will as a witness and that to the best of their
knowledge the testator was, at that time, eighteen years of age or older,of sound mind and under
no constraint or undue influence.
r=
WADE COG S y1f,"
f.
TP4CI D.SMITH
e .
C YL L.CLELAND
COMMONWEALTH OF PENNSYLVANIA :
. SS:
COUNTY OF CUMBERLAND
Subscribed, sworn to and acknowledged before me by WADE T. COGGINS, the
testator herein, and subscribed sworn to before me by TRAC D.SMITH and CHERYL L.
CLELAND,witnesses,this ay of August,2003.
t Public
COM 10 WEALTH OF PENNSY V IA
Nofarlal Seal
JaoquellneLDrOVZ h,NotaryjrCad1*BMCUMbeftrdChy
4Oo mmis ME)VMSAug,14DD7
Member,Penm*anla Asmdalon ofNNadae
THE RECEIVED
ALLIANCE JUi� 03 2(I'i
DEVELOPMENT FUND,INC.
IRWIN&MCKNINN3
LAW OFFICES
May 29, 2013
Irwin & McKnight, P.C.
60 West Pomfret St.
Carlisle, PA 17013
Dear Douglas G Miller,
This letter is in response to the letter received on May 29, 2013 regarding the Estate of Wade T.
Coggings. The answers to each of your questions are below. Please contact us if you need any
further information.
1. The registered owner or owners (exact title of account).
a. All accounts are titled under the ownership of
Wade T. Coggins as Sole Owner
2. The date on which the account was established.
a. For the two accounts which remain open (15637, 15638), both accounts were
opened on November 1, 1997.
3. If there was a change in ownership or registration of the account within one year prior to the
date of death, please provide the date of such change and the title of the account prior to
the change.
a. No changes in ownership or registration have occurred within one year prior to the
date of death on any accounts held by Wade T. Coggins.
4. If there were any accounts closed within one year prior to the date of death, please provide
the date, title and balance of the account closed.
a. Account 15434 was closed on March 6, 2013, titled in the name of Wade T. Coggins
and the closing balance withdrawn was $10,021.66.
5. Any interest accrued to date of death for the calendar year.
a. Accrued interest on account 15637- $161.73
b. Accrued interest on account 15638 - $241.32
6. The date of death balance (principal plus accrued interest, if any).
a. DOD balance on account 15637- $21,198.40
b. DOD balance on account 15638- $50,241.32
PO Box 63419, Colorado Springs, CO 80962-3419
Main 719.268.2250 Toll Free 888.878.3060 Fax 719.268.2259 Email adf @adf-inc.com Website www.adf-inc.com
A Supporting Organization of The Christian and Missionary Alliance
THE
ALLIANCE
DEVELOPMENT FUND,INC.
Please contact us if you have any further questions.
Blessings,
� i
Zachary Gray
Manager for Investment Services
The Alliance Development Fund, Inc.
gravz(cDadf-inc.com
PO Box 63419,Colorado Springs, CO 80962-3419
Main 719.268.2250 Toll Free 888.878.3060 Fax 719.268.2259 Email adf @adf-inc.com Website www.adf-inc.com
A Supporting Organization of The Christian and Missionary Alliance
nuJ. G/. GV I / .IJY'IIYI IIYV 00.110.
IYV. JV/J G/ J
May 29, 2013
Irwin&McKnight
Attorneys at Law
Attn: Douglas Miller
60 West Pomfret St
Carlisle PA 17013
RE: Wade T Coggins
SSN: 243-281281
DOD: 05/19/2013
Dear Sir/Madam:
In response to your request for Date of Death (DOD)balances for the customer noted above,our
records show the following:
Checking Account
Account.#5003961184 Established: 07/01/2002
WADE T COGGINS
DOD balance: $25,843.13 +0.19 accrued interest
Please note that this office provides date of death balances for deposit accounts(IRAs;CDs, Checking and
Savings). We do not process any financial transactions or provide statements. Sf you need assistance with
any of these items,please call 1-888-PNC-BANK(1-888-762-2265)or stop by your local PNC Bank branch
office.
Sincerely,
National Financial Services Center
PNC Bank,N.A.
Member FDIC
pace; 1 of 9.
Stochman Banh
1433 North 19th Avenue• PO Box 11448 •Bozeman,MT 59719
406556.4130 Fax 406556.4141
May 29, 2013
Douglas G. Miller
60 West Pomfret Street
Carlisle, PA 17013
Dear Mr. Miller:
have enclosed a copy of the only signature card on the account for Mr.
Wade T Coggins along with the most current statement which shows his balance
on his date of death. If you need anything else from me, please let me know.
Thha�n�k yyoou,
p
l.Jt.x4."' "�, UQ, ,
Stephanie Saunders
Customer Service Supervisor
Bozeman Oak
406-556-4135
stsaunders(a)stockmanban k.com
R
R
LENDER
Member FDIC
Account Agreement Date: 12/06/2011 .
institution Natne & Address Internal Use
Stockman Bank Account Title &
P'0 Box 11448 WADE T COGGINS ,
ROBERT C GOGGINS
Bozeman MT 59719-1448,
1519 BLUEBIRD LANE
BOZEMAN, MT 59715-9293
Ownership of
The specified ownership will remain the same for all accounts.
IMPORTANT ACCOUNT OPENING INFORMATION: Federal law requires (For consumer accounts, select and Initial.)
us to obtain sufficient Information to verify your Identity. You may be
asked several questions and to provide one or more forms of ❑ Single-Party Account 29 MuIU le-Part y Account
identification to fulfill this requirement. In some Instances we may use
outside sources to confirm the Information.The information you provide ❑ Corporation-For Profit ❑ Corporation-Nonprofit
is protected by our privacy policy and federal law. ❑ Partnership ❑ Sole Proprietorship
Enter Non-Individual Owner Information on page 2. There is additional ❑ Limited Liability Company `-
OwnedSigner Information space on page 2.
- ❑ Trust-Separate Agreement Dated:
Nmne WADE T COGGINS •_ -
laielhnmlp OWN@R
(GYleck appropriate ownership strove-select and initial below.)
Add1°`• ❑ Single-Party Account
p'mp Atlteesa 1519 BLUEBIRD IgNE BOZEMAN, MT 59715-9293 ❑ Single-Party Account with Pay-On-Death(POD)
Ma
or dins int) Multiple-Party Account with Right of Survivorship
Fbme Ma>e ❑ Multiple-Party Account with Flight of Survtvorship and POD
wort Plume ❑ Multiple-Party Account without Flight of Survivorship
WHO Mons ❑
6MSp
alrth Dole 12/12/1924 (Check appropriate beneficiary designation above.)
ssxmW 243.28-1287
GoV t Issued Rroto ID
(Type.NuIrbn-.Stee
feels Osle,8P,Dale$ E.DEF71Y CUSTOMER ID EXPIRED SEE BACK
Dlher to // ❑ If checked, this is a temporary account agreement.
(Deunpllon.Detdlst
ED Number of signatures required for withdrawal: One
Tsnpl.Yer RETIR
ous
The undersigned authorize the financial
rep Institution to Investigate credit
• e - e . ertd emptoy on t em as and obtain reports from consumer reporting
Nome egenoy(Ies) u them each h of e u Except as otherwise provided a law
ROBERT C C.OGGINS withdrawals other documents,each of the undersigned is authorized
quired nu to make
aetolronudp OWNER withdrawals from the aae is s ),Drovid h the required number 11 of
signatures indicated above is satlstied. The undersigned personally and
Address as or on behalf of,the account owners)agree to a terms of and
as receipt of copy(ies)of, th s document and the tolfowing:
29 Terms and Conditions 29 Privacy
Pr aV?e�Oee 1519 BLUEBIRD LAND BOZEMAN, MT 59715-9293 99 Electronic Fund Transfers eD Truth in Savings
Nunn Mom ❑ Substitute Checks 29 Funds Availability
330-703-5728 Q9 Common Features ❑ 1812006454
Moen.Mom rl Agency Designation (See Owner/Signer Information for Agency
ran TPeesignation(s).)
Agency designation(select and initial): ❑ Survives OR
aft one 09123/1950
❑ Terminates on disability or Incapacity of parties.
sswnN 217-48-2022 r.-
GrToV a lswee Mwo 10 0905619504123 MT 1 F A r(/I 'J ]
l.M OR!".EXP. mej IIINNNADE T COGGINS t/V
10/18/2011 09/23/2019
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(Desaipaon,Dslells)
BERT C COGGINS
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r Mae,P+P 0M 8 ATM •❑ Debit/Check Cards(No. Requested: )
Olha 1D // ❑ ❑
menevom Miles) ❑ ❑
eno-in, Changing Terms Of Account
Backip Withholding Certifications (Select and Initial Wow,)
In(if not a 'U.S. Person,'certify foreign status separately.) Single Part rty VFf js Farms may be Changed by a
Single Pant __f!'.�`
TIN:243-28-1287 ❑ Multiple-Party Account's Terms may be Changed Only by
99 Taxpayer I.D. Number (TIN) -The number shown above is my Agreement of All Parties
correct taxpayer Identification number. R�!f��1!1
29 Backup Withholding -1 am not subject to backup withholding • - - IGilInfo �
either because I have not been notified that I am subject to backup
withholding as a result of a failure to report all Interest or dividends, Laura Lee
or the internal Revenue Service has notified me that i am no longer NEW PRIMARY CUSTOMERt MERE EXISTING CUSTOMER
subject to backup withholding. OR V87S LICENSE EXPIRED VERIFIED OTHER INFORMATION FOR ID
❑ Exempt Recipients - I am an exempt recipient under the Internal SS CARD INVESTMENT STATEMENT, INSURANCE CARD.
Revenue Service Regulations.
I certify, under penalties of perjury the statements checked in
this sac and that I am a U.S, person(including a U.S.
resident dllen).
X (Date)
WADE T COGGINS
Sigmun Cad-MT MiWPIAZMT 51212007
aMR9y in
wdtas a F;"SWAM 02003,2008 t as. Pepe 2 0l 2
Print Page 1 of 1
ELITE 50 CHECKING 1812006454 Stockman Bank 5/29/2013 9:03:00 AM
Printed by: Stephanie Saunders Reporting Institution: 0
Demand Deposit 1812006454 - WADE T COGGINS
Relationship Date of Phone Number Tax Identification
Birth
,^ WADE T COGGINS NP Owner/Signer *** ** ********** SSN
IB ROBERT C COGGINS Owner/Signer *** ** ********** SSN
3864 CORWIN ST
BOZEMAN MT 59718
Additional Relationships
Tax Name: WADE T COGGINS
Current Cycle
Description Debits Credits Date Balance
Balance Forward: May 08, 2013 $6,148.37
Check#1015 $726.00 May 20, 2013 $5,422.37
Check#1016 $2,000.00 May 20, 2013 $3,422.37
Balance This Statement: May 28, 2013 $3;422.37
http://l 72.24.13.223/DDA_DDA 1151/DDA 1151.AS PX?Action=QUICKPRINT&XMLGu... 5/29/2013
MUTUAL OF AMERICA
MUTUAL OF AMERICA
LIFE INSURANCE COMPANY
320 PARK AVENUE
NEWYORKNY 10022-6839
877 302 9104
212 224 2512 FAX
LIFE&DISABILITY CLAIMS
June 6,2013
Mr.Robert Coggin
3864 Corwin Street
Bozeman MT 59718 � („ �, Ala lk�.-
Re: Wade Coggin (l
Claim#: 91221
Dear Mr. Coggins:
We are sorry to hear that Mr. Wade Coggin has passed away. On behalf of Mutual of America,
please accept our deepest sympathy.
Mr. Coggin participated in an Individual Retirement Annuity (IRA) plan with Mutual of
America. Mr. Coggin designated his spouse, Ms. Jane Coggin, as the primary beneficiary
under this plan. It is our understanding that Ms. Jane Coggins predeceased Mr. Coggin. If this
information is accurate, as the secondary beneficiary of this plan, you are entitled to a benefit in
the current lump sum amount of$35,073.65 as detailed on the Benefieiary's Election of a Death
Benefit Option form which is enclosed for your completion.
Please note that although the benefit from the IRA is fully taxable to you, it is not subject to the
20%federal tax withholding requirement.
Before we can disburse this benefit, we require substantial proof that Ms. Jane Coggin
predeceased Mr. Wade Coggin. Please do so by providing us with a copy of Ms. Jane Coggin's
death certificate.
Any taxable distribution that is not directly rolled over is taxable to you in the year of
distribution. Federal tax law permits you to roll over such taxable distribution to an Inherited
IRA (If available in your state), i.e., an IRA established in your name as the beneficiary of Mr.
Wade Coggins. Please note that there are special requirements that apply to an Inherited IRA.
Enclosed is an Inherited IRA brochure about the savings and investment option that are
available to you. If this is an option that interests you and you would like to learn more, please
call 866-939-7655 to speak with one of our Rollover Specialists. They can be reached Monday
through Friday from 9:00 am. to 8:00 p.m. Eastern Time.
Please note that upon attainment of age 70 ''/z, Mr. Coggin was required to begin receiving
Minimum Distribution payments each year from this plan.
Franklin Templeton Investor
c Services,LLC
"- 100 Fountain Parkway
• St.Petersburg,ft 33716-1205
FRANKLIN TEMPLETON let (800)632-2350
INVESTMENTS franklintempleton.com
June 6,2013
Robert Coggin ��``p � � �IQ��
PIS
3864 Corwin Street �1 1
Bozeman,MT 59718-6193 V
.ubject: Franklin Growth Fund-Class A
Account#106-60171.100753 J v
Franklin Utilities Fund-Class A -7
Account#107-70183181404 - ° ► 7/ �'
Franklin U.S. Government Securities Fund-Class A
Account#110-10166314350 1
�q/
FTB&T CUST For The Rollover IRA Of J
Wade T Coggin
Dear Mr. Coggins:
We were recently notified of the deaths of Wade T. Coggin,who maintained a retirement plan
with Franklin Templeton Bank& Trust, and his primary beneficiary,Jane Coggin. Please
accept our sincere condolences.
For the protection of the shares,we will place a hold on any monetary transaction until we
obtain the necessary documentation and authorization from the beneficiary.
It has been determined that Jane Coggin pre-deceased Wade T. Coggins;therefore,the assets in
the referenced accourits shall be.m.&tlts,«ortingent beneficiary.
For the protection of the shares,we will place a hold on any monetary transaction until we
obtain the necessary documentation and authorization. To transfer shares held in the plan to you
as the beneficiary,we require the following:
❑ The enclosed Retirement Plan Beneficiary Distribution Request form, completed in its
entirety and signed by the appropriate individual(s).
■ The Method of Distribution and Distribution Instruction station must be completed.
■ The signature(s) must be guaranteed by an"eligible guarantor institution,"as specified in
the Signature Guarantee Information instructions. A notary is not acceptable. The
individual(s) signing the form may wish to contact a financial advisor or financial
institution for their specific requirements prior to obtaining a signature guarantee.
❑ A photocopy of the death certificate of Jane Coggin.
A postage paid envelope is enclosed for your convenience.
LHII(GES- fi• n•I(;i
SUPER BUFFET 101-199 0 �I.
OS 48 NOBLE BLVD CARLISLE, PA"17913
CARLISLE. PA 19813
(71792493883
4N236693883
TERMINAL I.D.: 66938831 late: 05/22/2013
'TOP: 03:56:54 PM Terminal: 2
Session: 2905
UISA
XXXXXXXXXXXX4223
SALE
BATCH: 060450 INU: 14 Order Number: 227559
HV E: 12:5401 HUT NO: 54157B
BASE $258.31 its Poscription Price
�O—m IUNERAL MACHE W/ 2 DZ RED ROSES $ 9Q On
TIP --- q
TOTAL _____ ��_'�1 Sub Total: $ 90.00
Delivery Charges: $ 4.00
ROBERT C COMING Sales Tax $ 5.6a
I AGREE TO PAV ABODE TOTAL AMOUNT Total Amount Due: $ 99.Eli
ACCORDING TO CARD ISSUER AGREEMENT CC Tendered: $ X99.64
(MERCHANT AGREEMENT IF CREDIT UOUCHER)
Change Due: $ 0.00
***CUSTOMER COPY***
Thank You For Your Business!
Tint [)its: 05/22/2013
Tint Time: 03:56:54 PM
ORIGINAL-Payee C^���
DUPLICATE-FF.D.oIA. ACCT NO.
m1PLICATE-Ftmere1 Hama
P®EF1AIEC! LASTBALANCE $ 7 500
❑ INTEREST
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❑CHECKa LESS PAYMENT 7 Cil/
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18699
The UPS Store - #2878
950 Walnut Bottom Rd
1 Suite 15
Carlisle, PA 17015
(717) 241-5554
05/22/13 12:02 PM
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II Iliillllillllllllllllilllllilllllllllllllll�� ilillllllilllllll VIII
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25x25x25 box
002 020548 (009) ****S* 0 $ 18.50
25x25x25 Mat Gust
003 030548 (016) ****S J $ 11 .00
25x25x25 Sery Cust
004 001045 (001) TO $ 116.42
Ground Residenti
Tracking# 1Z74W: :,,0369911817
So lotal $ 156.67
SALESIAX (T1) $ 1 .76
Total $ 156.43
VIA $ 158.43
nL,L,UUNI NUMBER
o .
AIRPORT SHELL
BALTIMOREATMDN211240
(410) A50-8997
N Baltimore Ave SALES RECI I
a
17B66y Springs SHELL2 187;u .
7"t.7) 486-4439 1001 AVIAI .
_
BALTIMORE .!f) 21240
eaded $3 .439/1
. p No : 8i'' DATE 05/21 5:34PM
@ ;
ume: 7, 885 Ga ' INVOICE# 334"U1
AUTH# l,n2u4q
Total : $27 , 1;., VISA
$27 . 11 XACCOUN ! H93
15811.;: COGGINS/ Ruki
Visa PUMP PRODUCT $/G
4XXXXXXXXXX 3 8 9 3 03 UNLD $3.599
!!4/2813 12: 36: 23 GA9. 632 FUEL TOTAL
$ 34.67
TOTAL SALE.. $ 34.67
Now thru 8/5/13 each
time you swipe an
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For more details
visit
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COME ABACK OSOON
www,�orrbiM.com-Booking confirmation-printer version https:/Iwww.orbitz.comf book/bookingeonfrmalion?locators_,..
Print
Booldog color nation Thank you for booking on Orbits!
Flight:Harrisburg Sun, May 19,2013
We'll send a confirmation e-mail to rotxKcoggins50fgmail.com with your reservation
details.
Cost and billing summary
Flight Billing information
Ahline Mdwgi) $444.80 Card troubles name:
Rober=oggins
(nwa 1) Card Will
Total time at looking $444.80$444.80 ysa
Taxesand teas hidudea Card number,
4223
Additional baggage fees may apply. Billing Address:
3864 Corwin St
This reservation was made on Sat,May 18,2013 9:03 PM WT. Bozeman,MT 59718
US
Air policies and additional billing information
e Changes to this fidketwill roar change fees.
Price Assurance
Tracking Details Good news:You currently have our lowest Price
What Is Pro,Aseuianos?
Te a condNons
Traveler Information
Threader 1: ROBERT COGGINS
Gender: Male
Date of bbm: 923150
Airline Ticket Number. 03771916470092 1 Electronic
Prins ryphone number. 4065515149
Mealf(favailable): Standard
-The TSA requires each travelers first,middle and Iasi names,gender and date of birth.dthe Information above is not correct,please make changes.
Confirmation Numbers
Orblla record locator:PBORB5300322544
US Airways record location BKOBNC
Flight information
vmvdmodiy Seas I Terms and conditions I Fare miss
Seats are unassigned an one at all ofyoura(ghts.The airline will assign your seats atcheck•la.
®Bles Right details
Leave Sur Mayla Total time:9hr 19min
Depart Bozeman,MT,United States - USA,wys 7999
1:34 PM Ganalm Field(BZN) - Economy
Stop 1 Denver,CO,United States 523 mi I thr 38min
3:12 PM Denver Irha rational Airport(DEN)
Iof2 51181138:06 PM
Comment/Complaint? Add to Address Book?
17 k ' 10
r if
YOUR ITINERARY AND RECEIPT
To access your boarding pass at the airport, print email now and scan at a Delta
self-service kiosk.
Please review this information before your trip. If you need to contact Delta or
check your flight information, go to delta.com or call 1-800-221-1212. For a complete
list of world wide phone numbers, please visit www.delta.com/contact us.
You can exchange, reissue and refund eligible electronic tickets at delta.com. Take
control and make changes to your itineraries at delta.com/itineraries.
You can check in for your flight up to 24 hours prior to departure time. Check in online
by clicking the link below or download the Fly Delta app h=. You can also use the app
to change seats, track your bag, view your flight status and so much more.
Thanks for choosing Delta.
Flight Confirmation #: GAUBQY ( Ticket #: 00623317092753
***Visit delta.com or use the Fly Delta app to view, select or change your seat
Receipt Information
Billing Details
Passenger:
ROBERT CHARLES COGGINS
Payment Method:
Vl************4223
Ticket Number:
00623317092753
FARE:
459.53 USD
Taxes/Carrier-imposed Fees:
60.17
Total-
519.70 USD
V
RA 623626332 BI I 0
Rental 19-MAY-2013 1162 PM
HARRISBURG INTL ARPT
Return 26-NAV-2013 07:07 PM
BALT WASHINGTON INTL APT
ROBERT COGGINS
Vehicle i 004869
Model 200
Class Driven SCAR Class Charged ICAR
License# JM1283 State/Province PA
MIKms Driven 768
MIKms Out 2981.
MIKms In 3749
Charges No Unit Price Amount
IOW 7 Days 22.99 160.93"
SPPL LBLTY 7 Days 12.95 90.66
T &M 1 Week 153.54 153.54"
UNLIN MIKM 0 MIKms 40.01"
AIRPORT USE FEE
TRANS ASSISTANCE TAX 26.25"
CFC 3,751DAY
VEH RENTAL TAX 62.000 X 7.71
SALES TAX 66.000 X 23,14
Total Charges USD 621.23
Deposit Visa 4223
Amount Due USO 521.23
Taxable Items
Subject to Audit
Customer Service Number 1.800-468-3334
17552876
Account: 284927350
Steep Inn (PA055) Date: 5123113
5 East Garland Drive Room: 202 LcxaP
Carlisle,PA 17013 Arrival Date: 5/19/13
$ (717)249.8863 Departure Date: 5/23/13
x r coo I C E HOTELS GM.PA055@choicehotels.com Check In Time: 51201131:01 AM
Check Out Time:
Rewards Program ID:
coggins,robert You were checked out by:
3864 corwin street You were checked in by: Jmefad.pa055
Bozeman,MT 59718 Total Balance Due: 348.76
5/19/13 Room Charge #202 coggins,robert 79.99
5/19/13 State Tax 4.80
5119/13 Occupancy Tax 2.40
5/20113 Room Charge #202 coggins,mbert 79.99
5/20113 State Tax 4.80
5/20/13 Occupancy Tax 2.40
5/21113 Room Charge #202 Goggins,robert 79.99
5/21/13 State Tax 4.80
5/21/13 Occupancy Tax 2.40
5!22113 Room Charge #202 coggins,robert 79.99
5/22113 State Tax 4.80
5/22/13 Occupancy Tax 2.40
5/23113 Visa Payment (348.76)
XXXXXXXXXXXX4223
Room Charge 319.96
State Tax 1920
Occupancy Tax 9.60
Visa Payment (348.76)
Balance Due: 0.00
This rate is not eligibie for partner rewards.
For your convenience,we have prepared this zero-balance folio indicating a 0.00 balance on your account. Please be
advised that any charges not reflected on this folio will be charged to the credit card on file with the hotel. While this folio
reflects a 0.00 balance,your credit card may not be charged until after your departure. You are ultimately responsible for
paying all of your folio charges in full.
x
CHOICEPrtYlIBg25',,,„
0)
Thank you for booking with Expedia! Your
booking is confirmed.
You can manage your reservation or review your itineraU online for the most up-to-date
information.
(try
t"`l1.
BOOKED
Your reservation is booked. No need to call us to reconfirm this reservation.
View hotel details
890 Ejkr*dgti,Landhg Road t fnthic im Heights MD. 21090-United States of America
Tel: 1 (410) 853-8400, Fax: 1 (410) 869-8060
Checking In
• CheckAn time starts at 3 PM
• Your room wilt be guaranteed for late arrival
Important Hotel Information
Although Expedia does not charge a fee to change or cancel your booking, DoubleTree
Hotel Baltimore - BWl Airport may still charge a fee in accordance with its own rules &
regulations.
• Cancellations or changes made after 3:00 PM (Eastern Daylight Time (US &
Canada))on May 22, 2013 are subject to a hotel fee equal to the first night's rate
plus taxes and fees.
• Cancellations or changes made after check-in on May 23, 2013 are subject to a
hotel fee equal to 100%of the total amount paid for the reservation.
•
View your online itinerary for additional rules and restrictions.
Award points and airline mileage may not be awarded when booking an Expedia
Special Rate hotel.
Room
King bed
Includes: Free High-Speed Internet
Reserved for
Robert Coggins
2 adults
Requests
One King Bed, non-smoking room
Price Summary
Total
$629.20
Collected by Expedia
Room Price
$629.20
4 nights
$139.00/night
Taxes & Fees
$73.20
All prices quoted in USD.
Additional Hotel Services
The following fees and deposits are charged by the property at time of service, check-in,
or check-out.
• A pet fee will be charged per stay
The above list may not be comprehensive. Fees and deposits may not include tax and
are subject to change.
kuby Tuesday 04894
11160 Veirs Mill Road
** ** YOU MAY BE A WINNER ****** Wheaton. MD 20902
To complete,,a Guest Survey & * (301) 962-4270
* enter a monthly drawing for * 11 7 lashma B --------------- ---- --
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* PHONE or ONLINE * ---- ------------------ -------
k 1-800-651-6565 or * 3 WATER 2.49
k crackerbarrel-survey.com * 1 COFFEE DECAL 13.49
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ACCESS CODE: 431-142-701-538 1 DOUBLE CHOC CAKE 40,00
Enter access code above to * Cash 26.96
take survey. Access Code * Sub Total 1.62
Tax Collect 28.58
expires 7 days from today. * Payment 11.42
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D"I
IIIII�IIIII IhII IIII
Cracker Barrel Store #4;1
Carlisle, PA
379512 VALARIE S 2 I+JAI -
TBL 245/1 7015 GST 1 dPpVI
MAY22'13 4:20PM
--------------------------------
1 WATER 0.00
1 FF CKN & DUMPLIN 8,69 TLUllli LEADER H ILT11`IYIG r-8-3ZALD'S
1 COFFEE 1.99 E.E:AEIlCH H:VDFS.. 1.5 I-$3
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166898 PA,
1 LINDOR BALL 0,59 ET4fl
166898 q 1 ! T Ul F. YOU i ! !
1 LINDOR BALL 0.59
166898 Il Lit 7 1T 7qi 9i H Storc;A 16316
1 LINDOR BALL 0.59
Subtotal 12.45 %'E'l:i (S C' r:144
State&Local Tax 0.65
Total 13 . 10 3 Y KV` :'ae• cf:
REF:154823
AUTHCODE:00670B l-`,i 111TAL
XXXXXXXXXXXX4223 u:n.hle Chzesz4ar. er 1 .2`
VISA 13.10
--398038 CLOSED MAY22 4:52PM-- ':r:l \ 1 `K
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N01"u -t a free cookip., CJ F0 MCIF iffr
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P, Mac
I I IdEl r c c N 20.01"
13'
11110M. All I IR DOWN;
If:['.11 Ij-(I-I I c, i Ma r a g P.r: P'Ioi Da ma $116316
I?(C R'll:1 ADE DEW Cal I ma oil qriv ammEurts,
I' !Idly
I VI 1 1 1
T10 301-112E-1. ?1 B I tctre# 7845
i.2: '13 'hu) 12:29
H N 1ANM
If r 311E 2 10• K 11237 NEW HAMPSHIRE AVE
SILVER SPRING, No 20904
(301) 681-5360
I TOTAL MID 8aIB'903246?5
31.11:1 1 E! 1 .00 P�: h.ot ID: 088290324675
ID: I eer
':;Iji It?t:I 1 .00 Sale
t 1881 1 .00 'MA Entry Method: Swiped
Amount: 8 99,00
1.18';8 'IC101 Ed 1 .10 Tip:
ITIV In 3E) 0.04 Total: --------
----------------
WIN I H i-I--I: flx)b c,nIfite 0928Q3 19;99:19
I-I1IW.HI':A 3,/7 845 InVII: 000008 Appr Code: HIM
Apprvd: Online Batchg: 000313
...........—
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Doutaletree BWI
890 11kridge Landing Road J'
linthicum Heights, MD 21090
Panera Bread
SUN MAY 26,2013 Cafe 3761
(;HEC,K #261555-- I Silver Spring, MD 20904
TABIF #22, Phone: 301-680-7940
4 FUN BIIFFLI $39.8o '/26/2013 1:27:22 PM
TAX C -eck Number: 305.,17 Lashior: Ryan
oUfi
S IOIAL $2.$42.19 39 3 Strwb Poppy Chx Sal 26,07
GRATUITY •1 $7,16 3 No Meal Upgrade
10TA L $49 . 35 3 xxxBAG/ROLL
3 Bottled Water 5.67
TIP:__(?- . 05-, SubTotal 31.74
Tax 1.91
35 Total 33.65
Visa 33.65
RiIOM #; Acct:XXXNXXXX4223
AuthCode:86588B
PRINT NAML. 1�s Trans#:6911
SIGNATURE:—
Join us for r e :fast Ip
buffer everyday in the HMSHOST
restaurant! DTW PRESS A20
lime; 09:18 O CUSTOMERS DETROIT INTERNATIONAL AIRPORT
283971 Ciarra
- 1610---- --------------------
YOU HAVE BEEN SERVED C 11 K 1610
BY Amina (SRV) MAY27 ' 13 8 ; 04AM
012000001598
AOUAFINA 20OZ 2 . 39
036232060741
1 HICKORY MIKEY ' S 3 . 99
040000004325
1 M & M PEANUT KIN 2 . 19
012000005312
1 PEPSI-COLA 20OZ 2 .09
SUBTOTAL 10 .66
AMOUNT PAID 1 O . 6 6
CASH 21 .00
CHANGE 10 . 3.4
1.83971 Closed MAY27 08 :04AM- - -
iHANK YOU FOR YOUR BUSINESS!
TELL US ABOUT YOUR EXPERIENCE
TOM DI DID
734-626-6094
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