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HomeMy WebLinkAbout06-12-14 .J REV-1500 EX(02.11) 1505610143 OFFICIAL USE ONLY Iff PA Department of Revenue Pennsylvania coanty code Year Fla Numaer Bureau of Individual Taxes ..Rr" OF ate PO BOX.280601 INHERITANCE TAX RETURN 2 1 14 00332 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 09 15 2013 06 03 1953 Decedent's Last Name Suffix Decedent's First Name MI TAGG JANET M (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffer Spouse's First Name MI TAGG STEPHEN M Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® 1. Original Return ❑ 2. Supplemental Return ❑ 3.RReomrainder Return r (Date of Death to ❑ 4. Limited Estate ❑ 4a,Fmure Interest comprerMse ❑ 5. Federal Estate Tax Return Required (date at death after 12-12-82) ❑ B, Decedent Died Testate ❑ Detedant MRinw1ned a LMng Trest 8. Total Number of Safe Deposit Boxes (Adach copy of w�0) (Attach Copy of Test) po ❑ 9. Litigation Proceeds Received ❑ 1o.Spousal Poverty Credit(Date of Death ❑ 11,Election to tax under Sec.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 MICHAEL C GIORDANO 717 745 4160 REGISTER OF WILL% SE ONL; a, -�-.- O r�7 L7 1 i First Line of Address c n Q' 221 W MAIN STREET fr' _ —' o° r*1 m !� Second Line of Address " : �. ;;p 6 h T T I C7 O On Z3 1 City or Post Office State ZIP Code o 5 z-TE FIL r n MECHANICSBURG PA 17055 o u' o Correspondent's e-mail address: mgiordano Cgiordanolaw.COm Under penalties of perjury,I declare that I have examined this return,Including accompanying schedules and statements,and to the best of my knowledge and belief, it Is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE O ERSOf RESPONSIBLE FOR FILING RETURN DAT�/�//� -T� — Stephen M.Tagg ADDRESS 1210 McCormick Road Mechanicsburg, PA 17055 THER THAN E DATE Michael C Giordano 6 �p I ao( y ADIFRESS If Michael C. Giordano,Attorney& Counselor at Law 221 W. Main Street, Mechanicsburg, PA 17055 Side 1 1505610143 1505610143 J J 1505610243 REV-1500 EX Decedent's Social Security Number Decedent's Name: TAGG, JANET M RECAPITULATION 1. Real Estate(Schedule A).......................................................................................... 1. 2. Stocks and Bonds(Schedule B)............................................................................... 2. 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C).......... 3. 4. Mortgages&Notes Receivable(Schedule D).......................................................... 4. 5. Cash,Bank Deposits&Miscellaneous Personal Property 14 433 . 61 P p rty(Schedule E)................ 5. r 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6. 73 , 745 . 53 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested............. 7. 79 , 537 . 00 8. Total Gross Assets(total Lines 1 through 7).......................................................... 8. 167 716 14 9. Funeral Expenses and Administrative Costs(Schedule H)..................................... 9. 14 , 705 . 50 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................. 10. 6 , 428 . 35 11. Total Deductions(total Lines 9 and 10).................................................................. 11. 21 , 133 . 85 12. Net Value of Estate(Line 8 minus Line 11)............................................................. 12. 146 , 582 . 29 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. 146 , 582 . 29 TAX COMPUTATION-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.00 146 , 582 . 29 15. 0 . 00 16. Amount of Line 14 taxable at lineal rate X .045 0 . 00 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE................................................................................................................... 19. 0 . 00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑ Side 2 1505610243 1505610243 J REV-1500 EX Page 3 File Number 21 - 14 - 00332 Decedent's Complete Address: DECEDENT'S NAME Tagg, Janet M STREET ADDRESS 1210 McCormick Road CITY STATE ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A. Prior Payments B. Discount Total Credits(A +B) (2) 0.00 3. Interest (3) 0.00 4. if Line 2 is greater than Line 1+Line 3,enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2,Line 20 to request a refund S. If Line i +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 0.00 I Make Check Payable to: REGISTER OF WILLS, AGENT. w . �. 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;.............. z c. retain a reversionary interest;or.................................................................._....................._....................... x d. receive the promise for life of either payments,benefits or care?.............................................................. x 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?....................................................................................................................... ❑ n 3. Did decedent own an*in trust for' or payable upon death bank account or security at his or her death?......... Q 4. Did decedent own an individual retirement account,annuity,or other non-probate property which contains a beneficiary designation?.........-.......................................................................................................... n ❑ 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 JuN 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 Januarryy 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 relturn 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 C72 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.$g9116((a)(1.3). A sibling is defined under Section 9102,as an individual who has at least one parent in common with the decedent,wfiether by bloo�or adoption, JIt 7 Pennsylvania SCHEDULE E iii DEPARTMENT OF REVENUE ETURN CASH BANK DEPOSITS AND MISC. INHERRANCE TAX RETURN f RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF Tagg, Janet M FILE NUMBER 21 - 14-00332 Include the proceeds of litigation and the date the proceeds were received by the estate.All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE OF NUMBER DESCRIPTION DEATH 1 PSECU Account#....5722 5,783.83 2 Members 1st Account#...1409 180.64 3 TD Ameritrade Account# ... 12441 1,469.14 1995 Holiday Rambler 5th Wheel Travel Trailer 7,000.00 VID# 1KB381R39SW013196 TOTAL(Also enter on Line 5, Recapitulation) 14,433.61 REV-16N E%s(01-10) 10 pennsylvania DEPARTMENT OF REVENUE SCHEDULE F INHERITANCE TAX RETURN JOINTLY-OWNED PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Tagg, Janet M 21 -14-00332 If an asset was made joint within one year of the decedent's date of death,it must be reported on schedule G. SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT Stephen M. Tagg 1210 McCormick Road Husband A Mechanicsburg, PA 17055 JOINTLY OWNED PROPERTY: ITEM LETTER DATE Include name o Inanc,al ins I u,on ancFban account numbs DATE OF DEATH %OF DATE of DEATH NUMBER FOR JOINT MADE r similar identifying number.Attach deed for jointly-held real VALUE OF ASSET DECP'S DECEDEWS INTEREST TENANT JOINT estate. INTEREST 1 A 01/01/2002 TD Ameritrade Account# ... 001651 147,491.06 50% 73,745.53 TOTAL(Also enter on line 6,Recapitulation) 73,745.53 REV-1610 EX+(00.o8) ij Pennsylvania ' DEPARTMENT OF REVENUE SCHEDULE G INHERITANCETAX RETURN INTER-VIVOS TRANSFERS & RESIDENT DECEDENT MISC. NON-PROBATE PROPERTY IIII1i ESTATE OF Tagg, Janet M I FILE NUMBER 21 - 14-00332 This schedule must be completed and filed If the answer to any of questions 1 through 4 on page 2 is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH % EXCLUSION TAXABLE VALUE NUMBER IntluVe ma moms of the transferee,(heir relationship to deC` Mt VALUE OF ASSET DECO'S (IF APPLICABLE) and the date of transfer. Atteeh a copy of the deed for Mal 080818. INTEREST 1 Sun Life Regatta Variable Annuity Account#...6850 47,342.55 47,342.55 2 Members 1st IRA Account#...1409 32,194.45 32,194.45 I TOTAL(Also enter on line 7,Recapitulation) 79,537.00 REV-1511 Ex+(10-09) pennsylvania SCHEDUL.EH DEPARTMENT OF REVENUE RMBRALE)GUISMAM INHERITANCE RETURN RESIDENT DECED ENT MMNW M7WE COSM FILE NUMBER ESTATE OF Tagg, Janet M 21 - 14-00332 Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER FUNERAL EXPENSES: A. 1 Myers Buhrig Funeral Home 5,782.00 37 E. Main Street, Mechanicsburg, PA 17055 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Represeniative(s) Street Address city State Zip Year(s)Commission Paid 2. Attorneys Fees Michael C. Giordano, Attorney& Counselor at Law 5,000.00 3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation) Claimant Stephen M.Tagg 3,500,00 Street Address 1210 McCormick Road city Mechanicsburg state PA zip 17055 Relationship of Claimant to Decedent Spouse 4. Probate Fees Petition 260.00 JCS(23.50),Automation(5.00), Short certificates(20.00) 48.50 Inventory(15.00), Inn. tax return (15.00), Renunciation(10.00) 40.00 5, Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1 See attached 75.00 TOTAL(Also enter on line 9,Recapitulation) 14,705.50 Schedule H COMMONWEALTH OF PENNSYLVANIA Funeral EVerrses& INHERITANCE TAX RETURN Administrative Costs continued RESIDENT DECEDENT ESTATE OF Tagg, Janet M FILE NUMBER 21 - 14 -00332 2 Estate Notice in Cumberland Law Journalq 75.00 Page 2 of Schedule H IVpennsylvania SCHEDULE 1 DEPARTMENT E REVENUE DEBTS OF DECEDENT MORTGAGE INHERITANCE ANCE TAX RETURN � RESIDENT DECEDENT LIABILITIES & LIENS FILE NUMBER ESTATE OF Tagg, Janet M 21 - 14-00332 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION AMOUNT Pinnacle Health($1,981.85 and $744.50) 2,726.35 Credit Card: PSECU Visa AfC#... 5701 1,498.00 Credit Card: Chase Card A/C ... 1293 981.00 Credit Card: Chase Card A/C#...4795 1,223.00 TOTAL(Also enter on Line 10,Recapitulation) 6,428.35 r - f J C L W 8 POseca com28 Statement Period:Number.id: 08/01/ 13 to 08/31!13 Direct Inquirles regarding preauthorized electronic transfer or account enors to the above address. Page Number: Regular 1 of 3 Account Balances at a Glance Total Shares: $6,218.36 Total Certificates: $0.00 JANET TAGG Total Loans: $0.00 1210 MCCORMICK RD MECHANICSBURG,PA 17055-5973 gee& 1,276.46 N°n'JM� ,2'11.51 __IIyt�l FREE Security Software for Your PC bya`s• "'a OA Download Rapport at psecu.com/security/softwarez, v � Trustees K if not en am we aw"p W PSEcu.P u b m tetpamlbte fa fhe d,b ,torten,a,er&m avadated WM fhe Rapport»ftw a by 1.§, r. YEAR TO DATE INFORMATION Description Amount Total Dividends Year to Date $3.88 SHARES Posting Effective Transaction New Date Date Transaction Description Amount Balance REGULAR SHARES ID 01 08/01 Beginning Balance 1,276.30 08/31 Payment: Dividend 0.150% 0.16 1,276.46 Annual Percentage Yield Earned 0.150%from 08/01113 through 08/31/13 Based on Average Daily Balance of 1,276.30 08/31 Ending Balance 1,276.46 Dividend YTD: Year to Date 0.68 VACATION SHARES ID 02 08/01 Beginning Balance 271.48 08/31 Payment: Dividend 0.150% 0.03 271.51 Annual Percentage Yield Earned 0.130%from 08/01/13 through 08/31/13 Based on Average Daily Balance of 271.48 08!31 Ending Balance 271.51 Dividend YTD: Year to Date 0.24 CHRISTMAS SHARES ID 03 08/01 Beginning Balance 0.00 08/31 Ending Balance 0.00 Dividend YTD: Year to Dale 0.00 CHECKING ID 04 08/01 Beginning Balance 3,605.30 D8/02 Payment:Direct Deposit TO AMERITRADE 8,000.00 11,605.30 v, PSEClUmi Pennsylvania State Employees Credit Union JANET TAGG 3.. P.O. Box 67013 Harrisburg, PA 1 71 06-701 3 ? _;, 800.237.7328 Member Number: 0178""'*` '44_ psecu.com Statement Period: 08/01/13 to 08/31/13 Page Number: Regular 2 of 3 Posting Effective Transaction New Date Date Transaction Description Amount Balance 08/02 TYPE: ACH OUT ID:5470533629 08102 CO:TD AMERITRADE 08/02 Withdrawal Direct Deposit DISCOVER -1,961.95 9,643.35 08/02 TYPE: E-PAYMENT ID: 2510020270 08/02 DATA: DC PYMNTS DCIINTNET CO: DISCOVER 08/07 Withdrawal via Home Banking Transfer To Loan 09 -973.54 8,669.81 08107 Withdrawal via Home Banking Transfer -1,000.00 7,669.81 08/07 To TAGG,VANESSA M XXXXXXXXXX Share 01 08/12 Withdrawal Direct Deposit DISCOVER -1,483.61 6,186.20 08112 TYPE: E-PAYMENT ID: 2510020270 08/12 DATA: DC PYMNTS DCIINTNET CO: DISCOVER 08/12 Withdrawal at ATM#00007844/W43006 -100.00 6,086.20 08/12 ATM MEMBERS 1ST FC 4 MARKET PLAZA WAY 08/12 MECHANICSBURG PA 08/12 Withdrawal via Home Banking Transfer -1,000.00 5,086.20 08/12 To TAGG,VANESSA M XXXXXXXXXX Share 01 08/14 Payment: Direct Deposit SSA TREAS 310 1,125.30 6,211.50 08/14 TYPE: XXSOC SEC ID: 9031036030 08/14 CO: SSA TREAS 310 08/19 Check 003342 -1,000.00 5,211.50 08/26 Withdrawal Direct Deposit TD AMERITRADE -400.00 4,811.50 08/26 TYPE:ACH IN ID: 3470533629 08/26 CO: TD AMERITRADE 08/27 Check 003343 -1,000.00 3,811.50 08/30 Payment: Direct Deposit PA TREASURY DEPT 831.09 4,642.59 08/30 TYPE:ANNUITANT ID: 1236003133 08/30 DATA:A7208131347230011 08/30 CO: PA TREASURY DEPT 08/31 Payment: Dividend 0.100% 0.53 4,643.12 Annual Percentage Yield Earned 0.100%from 08/01/13 through 08/31/13 Based on Averaae Daily Balance of 6,239.12 08/31 Ending Balance 4,6433.12, - Dividend YTD: Year to Date 1.56 CLEARED DRAFT RECAP Draft# Date Amount Draft# Date Amount Draft# Date Amount 3342 08/19 1,000.00 3343 08/27 1,000.00 *Indicates a break in check sequence. MONEY MARKET ID 07 08/01 Beginning Balance - 27.27 08/31 Ending Balance 27.27 Dividend YTD: .Year to Date 1.40 **The balance used to compute interest is the unpaid balance each day after payments and credits to that balance have been subtracted and any additions to the balance have been made. ......*** FEES******".* TOTAL FEES FOR THIS PERIOD $0.00 .*****...INTEREST CHARGED TOTAL INTEREST FOR THIS PERIOD $0.00 Page i o: rSt VI MEMBERS 11t •FEDERAL CREDIT UNION Account At a Glance Account Number: 0000021409 Name: JANET TAG( ALRLevel: Gold Member Since: 10101/197. dLR Primary: NO E-Mail: JANETTAGG@COMCAST.NE1 MODUCTS ns e Balance bb Rata Maturity DaG %EGLILAR SAVINGS $180.66 `g0 BRA .150% RA SAVINGS SAVINGS $5,136.28 1a��5 .150% —/—!- 12 MONTH IRA CERT $27,058.17 / 400% 3/1411, PRODUCTS BALANCE: $32,375.11 TOTAL BALANCE: $32,375.11 SERVICES :STATE M E NTS/E N OT I C E S TOME BANKINGIEZ CALL AVERAGE MONTHLY BALANCE 4on4RA Shares Aug 2013 Jul 2013 Jun 2013 May 2013 Apr 201: tEGIJLAR SAVINGS $180.64 $180.62 $ 180.60 $180.58 $180.5( RA Shares Aug 2013 Jul 2013 Jun 2013 May 2013 Apr 2013 Mar 2013 Feb 2013 Jan 2013 Dec 2012 Nov 2012 Oct 2012 Sep 201: RA SAVINGS $ $ $ $ $ $ $ $ $ $ $ ! 5,_135.65 5,135.00 5,134.37 5,133.72 5,133.09 5,132.22 5,131.43 5,130.56 5,129.27 5,128.01 -5,126.70 5,125.4, 12 MONTH IRA $ $ $ $ $ $ $ $ $ $ $ :ERT 27,049.27 27,040.08 27,031.19 27,022.01 27,013.13 27,006.06 26,995.67 26,986.50 26,977.34 26,968.47 26,959.31 26;950.4! 9/23/20 . . . } . 2 | r 2 ! , \ / & \ IP , - ka ` 71 ! a ! 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DEALER PREP 1 DEALER PREP 1 0 1 $50.00 $50.00 ALL PRO PROW Total City Ordered: 5 0 5 Percent Unfilled: 100 Deposit History Subtotal: $594.75 Cashier: Date R t# Amount a ment Local Sales Ta) 6%Tax +$O.00 'THERRON 2/8/2014 70967 $374.7 Check TOTAL: $594.75 TPArD �� Deposit Balance: $374.75 6a.y Pr+rn —� Balance Due: $220.00 Customer Signature: L f-7�10'z� Thank you for your orderl TIMOTHY D.HERRON ALL PRO WEST TRUCK AND t • r TRAILER ACC,INC. DIN#£3597-'3 r Matt Haak, Sales Phww 717.S91.1200 .��2 Fu 717.591.12t2 I `Wy, V7ii, Ct11:717.554.6t95 1 .— `'' �t�uFQt1C�,tom t� � &O\x Ani�go Y . .. I GE ,TIFICATEP;OFTITLE FOR A VE .ICLE`� � :i__���' .1�..::.^..':.p 5!�I.z_._:..:•:'•_._�-"'1:�.^..-^,.�^..•:. �.:�:�::Y=_._....�....'.._::�:_•C: ". - 19CA377�SwS33F33L9QN1 $�4T1I3 }. 3ilb9II�.3A b VEFpCLE LDEN1tF"MINDER i" �Y --A�ff OF V_ ,! Ay •A'LL�'1�REjlD1M�BE"-q�i fir''w"a 1y '� -- ✓ .._� Y,....._ �...� ��•SrC_L x{. �• Jw ':..... T 1`w'T... ...1Y�..-x01.1-. BODV TYPE) Y QUPI t 6EA AP T C L*PR �•� . DATE PA T o I DATE Of 1550E UNUOEN WEiDM pNYP �^'OLVIP "- •� TrtLE 8rUN08 —� _ t !7\ s5 `< , ''� f A r• t. '! £. P bptFAt€ ee4��.,,r v E FHP mpM aSLLOLAE ODOMETER DISLLOS_URE ERAL CAH RE-06TE 2'9 W 15i � BW.xDb� . �1c;NETAG/G � 12] Ot MC, RMT CK RD NFws Rtl0noN�° y �; NE{FIAN[GSBUR-G PA�1705 °"" "" L .LCWWJ YLWLL! P ISWAlA PIX1LC YpN`AE !` � . 4� �F"•'' �-- I 4 •xy�iNEmY�,m�EO°,TI�oP�>re1�.CR�`��` . 1 • • • a I t ( . '-< ,� VF'NiarNN*AWn.PE�u�uG�OVw�+ ' F q$i LIEN FAVOR OF J I L2 ,�M r i - E D�l1EN FA y % 6N(AL AE{ •\.`\`A.o\ i a • wL%aw x,axa(�,, °aRa a u+ x PST IIEN RELEASED � '�" \«t' Y SpPp4Y brm Yq l•\ i • V. k• 'Y�4[il' ye. �ka�TE.Y L'rP .f iri <..�. BY SECOND LIEN RELEASED AV1110NSf0R RESEMATIVE �= DALE .' W&M AODnW • •929210 AUINpP�OREPPESEMATNE . JANET M TAGG ' ` 1 1210 NCCDRMICK' RD — S MECHANICSBURG PA 17955 PNrI a a m• Y LIP Paaa..ma.a w PIP1.111.M D•P•nP.. 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' sc �« §! , _ 0 2m §° ! k 7 | ■ E ® a « ■mb§22 | # a . \ � @o { kk � � ° $ . \ )<WM a £ \ ( # i # 7 # # ) ! ! k) ) ) k ( ( f ! \ r ® _ MFS Regatta Variable Annuity Sun Quarterly Statement July 1, 2013 through September 30, 2013 Life Financial 0034077 Oi ATO.381 ^MTO 90011017055.597310 COI- 141054 JANET IM TAGG Contract number 38.5800-006850 1210 MCCORMICK RD MECHANICSBURG PA 17055-5973 Product Regatta Variable Annuity Owners) IAIJEr M TAGG 111111111 11111111"'161I11111IIII11111I'I I 111111''11111'111111" Annuitants) JANET M TAGG Plan type IRA Summary of values Year to date This quarter Issue date March 19,1990 Account activity Beginning Account Value $43.278.34 $45,430.93 Withdrawals and fees -$30.00 — Earnings(gain/loss) 54,094.21 $1,911.62 Ending Account Value..........................................................................................$47,342.55 Surrender Value — $47,312.55 Personal rate of return 9.39% 4.20% Beneficiary protection Death benefit value..................................................................................... ...$47,342.55 m 4 "s $ When reviewing this statement,please keep in mind that the values are current as of the statement date and may fluctuate. Please refer to the current $ prospectus for more detailed information. ° issued by:wn Gfe Assurance Company of Canada(U.S.).P.O.Box 9133,Wellesley Hills.MA 02481.9133, Sun Life Assurance Company of Canada(U.S.)is a member OF the Delaware life group of comparres The Sun Lire names and marks are used under license. Sun Life Assurance Company of Canada(U.S.)provides this confirmation on belialf of the broker/dealer listed in the-Contact information' section,who is acting as an agent of Sun Life Assurance Company of Canada(U.S.). 00www.sunlife.com O 24-hour automated service 800-752-7218 0-1 Customer Service 800-752-7216 M4 8:30 a.m.-6 p.m.ET 1 of 4 9wYers Jquhrig Ff u it,eraI Horu� .v Crematory ,., custdmer. O N O C E ..Stephen Tag9 1210 McCormick Road Mechanicsburg,PA 17055 Invoice Number: 10925 Invoice Date: Sep 15,2013 Page: 1 -Name of Deceased Data of Death payment Terms Funeral Director,: Janet T.Tagg September 15, 2013 Net 30 Day's William L.Christopher item Humber. Quantity ' Description - Unit Price ! Amount. - SSO Special Charges $ 4,320.00 M Merchandise $ 160.00 M Merchandise Adjustment $ 772.00 CA Cash Advances $ 890.00 CA Cash Advances Adjustments ($ 160.00) ank you for allowing us to serve you and vour famii . Subtotal $ 5,782.00 We gladly accept the following forms of payment: Shipping $ 0.00 Cash, Check, Visa,MasterCard,Discover,American Express Sales Tax $ 0.00 Kindly make your check payable W: Total Invoice Amount $ 5,782.00 Myers-Buhrig Funeral Home and Crematory Payment/Credit Applied $ 5,782.00 Past due accounts are subject to interest charges of 1.5%per month. TOTAL DUE 0.00 Walking with Thosv in Grief IN RuLJ� nnhert"Bob'L.Buhrig,dr., William"Bill"[_Christopher,m Phone: (717)766.3421 • Fax: fnA 795.7291. • 37 Ensl Win Street • Mechnnicsbwg.PA 17055 • sww:Myen-Buhrill.conn DlMTlors a Mycrs-Iruhrig.conn RECEIPT FOR PAYMENT LISA M. GRAYSON, ESQ. Receipt Date : 4/10/2014 Cumberland County - Register Of Wills Receipt Time : 10.: 51 : 17 One Courthouse Square Receipt No. : 1077589 Carlisle, PA 17613 TAGG JANET M Estate File No. : 2014-00332 Paid By Remarks : STEPHEN M TAGG DB1 ----------- Receipt Distribution - ---- ------------ ---- --- Fee/Tax Description Payment Amount Payee Name PETITION LTRS ADM 260 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D SHORT CERTIFICATE 20 . 00 CUMBERLAND COUNTY GENERAL FUN AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN RENUNCIATION 10 . 00 CUMBERLAND COUNTY GENERAL FUN Check# 4546 $348 . 50 Total Received. . . . . . . . . $348 . 50 �e��nrvD co CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717)249-3188 Fax:(717)249-2883 May 9, 2014 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: Michael C. Giordano, Esquire RE: Janet M. Tagg 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 following dates: April 25, May 2, and May 9, 2014 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 ------------- Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH 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: April 25, May 2, and May 9, 2014 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. -- Lisa Marie Coy e, Editor SWORN TO AND SUBSCRIBED before me this 9 day of May, 2014 e� Notary Tagg,Janet M., dec'd. Late of upper Allen Township. Administrator: Stephen M. Tagg, 1210 McCormick Road, Mechan- COMMONWEALTH OF PENNSYLYANIA icsburg, pA 17055. Attorney: Michael C. Giordano, NOTARIAL SEAL Esquire,Attorney&Cotlnse]or at DEBORAH A COLLINS Law,221 W.Main Street,Mechan- Notary Public icsburg, PA 17055. CARLISLE BORO..CUMBERLAND CNTY My Commission Expires Apr 28,2018 b. YT03 CMAJRi4W :T .CHtil]Ja IHA3 8iC£,83 IqA zarivi [� STATEMENT OF MEDICAL SERVICES LAST STATEMENT DATE: 01/13/14 NEW CHARGES: 0339.00 PiNN,ACLEHEALT14 NEW PAYMENTS: 815.57 Provem NEW ADJUSTMENTS: 01189.46 INSURANCE BALANCE: 074.56 YOUR BALANCE: 01981.85 If Any Questions, Please Contact: PHNS AT 717-231-8960 OR 1-800-565-6229 *;JANET M TACO, ACCOUNT: 13051026 02/19/14 FED TAX ID # 251709054 INSURANCE YOUR CHARGE PAYMENTS ADJUSTMENTS BALANCE BALANCE >>> PATIENT: JANET M TAGG OP SPEC PERFORMED AT: PH WOMEN'S CANCER CENTER PERFORMED BY. PH WOMEN'S CANCER CENTER 03/29/13 ABDOM PARACOMESIS O4VTHE 339.60 _ 36.40- 302.60 PROCEOURE: 49082 DIAGNOSIS: 789.51 04/05/13 AS" PARACENTESIS OX/THE 339.00 76.40- 262.60 PROCEOURE: 49082 DIAGNOSIS: 789.51 04/12/13 OFFICE VISIT EST PT LVL 2 84.00 49.57- 34.43 PROCEDURE: 99212.25 DIAGNOSIS: 789.51 04/12/13 AS" PARACENTESIS IOVTHE 339.00 36.41- 302.59 PROCEDURE: 49082 DIAGNOSIS: 789.51 05/03/13 ABOOM PARACENTESIS DN/THE 339.00 76.41- 262.59 PROCEDURE: 49082 DIAGNOSIS: 789.51 06/07/13 ABOOM PARACENTESZS ON/THE 339.00 76.40- 262.60 PROCEDURE: 49082 DIAGNOSIS: 789.51 u7 N 07/19/13 ARBOM PARACENFESIS OX/TME 339.60 76.40- 262.60 ro zr_ PAGE IOF 4 For Oaiu Vn Ortiy Acm.o.s"ssmem Amwnc Sync 1112 13057026 l_ $1981.85 REP: PRPY c.. } nn:w We wear.----- PINNACLE 11F,AU111 NiEO SVCS JANET M TAGG I 03/12/14 110 BOX 1286 (- _ ]HARRISBURG PA '17108-1286 0 `-,,,,1 0 El 0 HC: 12HD wnM.mee 'CO6r. um mm: ADDRESS SERVICE REQUESTED C.meaaer+.cma ❑Creek box and enter any address or mwm.m mymety stsulw .. Insurance corradlons on back $1981.85- Make COeck Payable To PINNACLE HEALTH MEO SVCS 00001046 02 i4Piriti niir Ir ilttyiN•ll16Nhri n.ai.p.NNN1,,.. JANET N TAGG PINNACLE HEALTH MED SVCS 1210 NCORMICk RD PO BOX 1286 MECHANICSBURG PA 17055-5973 HARRISBURG PA 17108-1286 4■ ri+r JANET M TAGG ACCOUNT: 13057026 02/19/14 INSURANCE YOUR CHARGE PAYMENTS ADJUSTMENTS BALANCE BALANCt PROCEDURE: 49082 DIAGNOSIS: 789.51 *08/07113 ABDOM PARACENTESIS DX/THE 339.00 15.57- 172.46- 250.97 PROCEDURE: 49082 DIAGNOSIS: 789.51 08/02/13 ARBON PARACENTESIS DX/THE 339.00 76.41- 76.41- PROCEDURE: 49082 DIAGNOSIS: 789.51 *08/02/13 CHARGE REVERSAL 339.00^ INPT 050813 051313 05/08/13 TO 05/13/13 PERFORMED AT: .HARRISBURG HOSPITAL PERFORMED BY: PH WOMEN'S CANCER CENTER 05/08/13 INITIAL HOSPITAL CAR LVL2 265.00 154.36- 110.6+ PROCEDURE: 99222 DIAGNOSIS: 338.3 PERFORMED BY: PALLIATIVE CARE *05/09/13 INITIAL INPT CONSULT LVLS 392.00 392.00- O.Ot PROCEDURE: 99255 DIAGNOSIS: 783.7 *05/09/13 PROLONGED PHYS INPT I HR 176.00 176.00- 0,0( PROCEDURE: 99356 DIAGNOSIS: 783.7 *05/09/13 PROLONGED PHYS INPT 30 M 175.00 175.00- 0.9( PROCEDURE: 99357 DIAGNOSIS: 783.7 PERFORMED BY: PH WOMEN'S CANCER CENTER 05/09/13 4 SUBSEQUENT HOSP CARE LVL1 $00.00 176.56- 123.44 PROCEDURE: 99231 DIAGNOSIS: 336.3 PERFORMED BY: PALLIATIVE CARE *05/10/13 SUBSEQUENT HOSP CARE LVLS 199.00 199.00- 0.0( PROCEDURE: 99233 DIAGNOSIS: 783.7 *05/12/13 SUBSEQUENT HDSP CARE LVL1 75.00 75.00- 0.0( w t n ry PAGE 2 OF _ . ___ . . _ - .Wease usaetdsspaca toms*ec0erett{ons.toyan->_vMressnr.easwa!we infomraMme 4udnmor Nvrtn: Plwve: Gwmmor Address: City: Since: Zip: Relatiormaip n Ifsumd: RehtionaNip n Irvvumd: PRIMARY ❑ SELF ❑ SPOOSE SECONDARY ❑ SE ❑ spouse INSURANCE COVERAGE ❑ CHILL ❑ WHEW INSURANCE COVERAGE ❑ c»tta ❑ CTHe IrtaumMe COmpmry Name: PNO.: inadnnce COmpony Ndrrc: Fvw faaumsra Compedy Addmsa: ietsomae Com�ny A.dd•eaa: Poliq Holdara Wine: Dsce of Birth: Polley Holders Name: Dan of 3;nL Pots/E Gmup>F %IH,Erfmt Lsn Pocky A Gnvp 4: Ppi"Effami (kIw Employer*Name: P1 w Emplpyera W..; plwre: Emplges Addmda: EmpIo e.Addme STATEMENT OF MEDICAL SERVICES ry PINNACL EHEAUM Proven' If Any Qu itims, Plo m Cdntwt: PHHS AT 717-231-8960 OR 1-600-565-6229 -(` +JANET M TAGG Y ACCOUNT 13057026 02/19/14 INSURANCE YOUR CHARGE .PAYMENTS ADJUSTMENTS BALANCE BALANCE PROCEDURE: 99231 DIAGNOSIS: 783.7 PERFORMED BY: PH,NOMEN'S CANCER CENTER 85/13!13 HOSP OSCH DAY HBTTX3OMrM 138.00 80.24- 57.76 PROCEDURE: 99238 DIAGNOSIS: 338.3 BALANCE: JANET-M .TAGG Si981.65 ■ INDICATES NEM.FIWINCIAL ACTIVITY SINCE LAST BILL. FULL PAYMENT ON YOUR•ACCOUlT BALANCE IS ONE. IF THIS BILL DOES NOT REFLECT THE CORRECT INSUIUHCE-INFORHATION, PLEASE.CQITACT .OUR OFFICE: IF PAYING BY CHARGE CARD PLEASE INCLUDE THE THREE DIGIT SECURITY CODE LOCATED ON.THE BACK OF YOUR CARD. . THANK YOU•FOR CHOOSING PINNACLE HEALTH MEDICAL SERVICES. OUR OFFICE HOURS ARE 8:ODAM TO 4:30PM, MONDAY, MEONESDAY, FRIDAY AND B:DOAM TO 6:00PM TUESDAY AND TURSOAY THIS BILL REFLECTS CHARGES FOR PHYSICIAN SERVICES PROVIDED PINNACLE HEALTH MEDICAL SERVICES. ,PLEASE NOTE, ANY LAB 0RI DIAGNOSTIC SERVICE HILL BE BILLED SEPARATELY THROUGH PINNACLE a' HEALTH HOSPITALS OR AN INDEPENDENT LAB. N J Y PAGE 3 OF 4 rr•;\i ,Pot send correspondence to this address. •-+ ONAMSY01 - ; ` • ' PO Box 1022 � PiNNACLEHEALTH Wixom MI 4839}1022 Hospitals ADDRESS SERVICE REQUESTED (717)221-1294 (888)467-2563 November 6,2013 Representatives Available: Mon—Thu 8'OOAM-8:OOPM 56517818-1000 171508699 Fri 8:00 AM—5:00 PM , ')LdIJIIIIII11iL�h�lidlilhi111�1"'�'I'll�ll)'�II'll��ll" Janet Tagg --' 1210 Mccormick Rd Mechanicsburg PA 17055-5973 's Bill#: 130460741 Patient Name: Janet Tagg D�ate oT$ervicTO113 Location,of-Service: Pinnacle Health Balance Due:_5744.5 our records indicate the balance on your account is now due in full. Please pay this immediately using the enclosed envelope.You may also pay by credit card_by using the form below. if you need to make payment arrangements, please call us as soon as possible. Financial assistance is available for the,uninsured or underinsured who apply and qualify. For more information, please call or see our website at www.pinn6clehealth.org/bilipay. You may also pay online at https.1/billpav oinnaclehealth.oig Sincerely, Pinnacle Health Hospitals Patient Accounts Department SEE REVERSE SIDE FOR BILLING DETAILS AND OTHER IMPORTANT INFO RMATIONN'o umsron000 m cn,m roc ooncco nocnt ncrnnu nun ern mu nu,co nno+.na,.,.uc cun,ncrn un m..nnc.w «n.n..evn, mi V,r x, Do not send correspondence to this address. . ONAMSYO+ r PO BaX+o2 P�NNACLEHEALTH Wixom MI 48393.7022 - .:ADDRESS SERVICE REQUESTED Hospitals (717)221-1294 (888)467-2563 November 6,2013 Representatives Available: Mon–Thu '8:00 AM 8:00 PM . 5651781.8=1000 17+508699 Fri 8:00 AM=5:00 PM - ��LrIfd111�1111�G�II�jnllilln111�Ln�gill�lll'lll'Il��ll" JanetTa99 1210 Mccormick Rd. Mechanicsburg PA 17055-5973 Bill#:130460741 Patient Name: Janet Tagg _ Date of Service:06/10/13 :Location of Service: Pinnacle Health Balance Due: $744.50 Our records indicate the balance on your account is now due in full. Please pay this immediately using the enclosed envelope. You may also pay.by credit card by using the form below. If you need to make payment arrangements, please call us as soon as possible. Financial assistance is available for the uninsured or underinsured who apply,and quality. For'more information, please'call or see our website at www Dinnaclehealth.orgibillbay. You may also pay online at httos.Ilbill,6av pinnaclehealth ora Sincerely, Pinnacle Health Hospitals Patient Accounts Department SEE REVERSE SIDE FOR'BILLING DETAILS AND OTHER IMPORTANT INFORMATION W70NAMSY011000 T TO ENSURE PROPER CREDIT.DETACHAND RETURN LOWER PORTION IN THE ENCLOSED ENVELOPE T IF PATIKG BY MASIE RD OISFAVE VISA"MMUN UMBS RU,WTBELOW _ ❑ ❑ VISA SA ❑ �+–� ❑. • —.., bftos.'llbilloav oinnacleheallh.oro CARD NUMBER MUST INCLUDE 3 DIGIT E%P.OATE AMOUNT SECURMY LODE FROM BACKOF FARO MAKE CHECK PAYABLE TO: SIGNATURE PATIENTNAME BILL NUMBER Janet Tagg +30460741 PAYTMISAMOUNT SHOW AMOUNT Q Pinnacle Health Hospitals 5744.50 PAID HERE V PO Box 2353 - Harrisburg PA 17105-2353. IIr111111ilIrIIIIIrIl11111rI111111111111� IIIl1111111111I11111 _ STATEMENT The amount shown below represents To discuss payment,Call: your finaniiat obligation to: PiNNACLEHEALTH Pinnacle Health Hospitals Hospitals (717)221-1294 PO Box 2353 (668)467-2563 For all other inquiries: Harrisburg, PA 17105 (717)221-1294 MESSAGE: Thank you for choosing Pinnacle Health Hospitals,The balance on your account is due.If you need assistance or have insurance coverage,please call our customer service department.if you need to make arrangements for payment,we have representatives available to assist you. Financial assistance is available for the uninsured or underinsured who apply and qualify.For more'information, please call or see our website at www.DinnaGehealth.ordlbillpa, _ You may also pay online at httosl/Oilloay.pinnaGehoallh.orq HOSPITAL SERVICE DATE PATIENT NAME BILL NUMBER 06/71/13 JANET TAGG 130445859 FOR YOUR HOSPITAL SERVICES: Hisc $1931.OD Oriqinal Billed Amount 51931.00 Total Payments and Adjustments $-1708.50 Patient Responsibility $222.50 • $222.50 __ -•- -- - aD�NAMSmaoGT' , V PLEASE DETACH AND RETURN LOWER PORTION WITH YOUR PAYMENT V Do not send correspondence to this address. IF PA'4XGBYWSTERCARD USEOWIL x WARERroiNExFRESII�Rttovrenow CARD NUMBER EXP.DATE 'd ONAMSY01 PO BOX 1022 UST THREE DIGITS FROM BACK OF CARD AMOUNT S Wixom}ell 4$393-1022 CARDROLOER'S STREET ADDRESS CARDNQtIIER'SZIP GORE ADDRESS SERVICE REQUESTED SIGNATURE BILL NUMBER STATEMENT DATE 130445859 NOVEMBER 5.2013 PATIENT: JANET TAGG AMODUrrovowE s PLEASE INCLUDE BILL NUMBER ON CHECK,MAKE PAYABLE TO: 57397001-1001 170474436 I $,III11111-111111-it'1111 Pinnacle Health Hospitals Janet Tagg PO Box 2353 1210 McCormick Rd Harrisburg PA 17105.2353 Mechanicsburg PA 170555973 IellfitrTTfr.IUfirrrlfdTllirf;,IIIIiTirTJIITiTflr,it,d:f,f https:/lbillpay..pinnactehealth.ora STATEMENT The amount shown below represents To discuss payment, call: your financial obligation to: 4 (717)221-1264 Pinnacle Health Hospitals Hospitals (888)467-2563 For all other inquiries: PO Box 2353 (7.17)221-1294 Harrisburg, PA 17105 MESSAGE: Thank you for choosing Pinnacle Health Hospitals.The balance on your account is due.If you need assistance or have insurance coverage.please call our customer service department. If you need to make arrangements for payment,we have representatives available to assist you. Financial assistance is available for the uninsured or underinsured who apply and qualify. For more information, please call or see our website at www binnaclehealth.oralbilio9v. You may also pay online at htipsYlbillpav Dinnacleheal orq HOSPITAL SERVICE DATE PATIENT NAME BILL NUMBER' 06107/13 JANET TAGG 451169607 FOR YOUR HOSPITAL SERVICES: $111.00 Lab/Blood Original Billed Amount 5111.00 Total Payments and Adjustments $-31.08 Patient Responsibility $79.92 • ,$ $79.92 8MNMASYO11001 T PLEASE DETACH AND RETURN LOWER PORTION WITH YOUR PAYMENT T Do not send correspondence to this address. F PAYING BY MASrrRCARD.OSCOVE ViSAMAMEAIG1N ExPRES fiLI OIIT BELDYI CARD NUMBER EXq DATE Li ONAMSY01 LAST THREE DIGITS FROM BACK OF CARD PO Box 1022 EGvW $ Wixom Ml 48393-1022 CARDHOLDER'S STREET'ADDRESS CARONOLOER'S ZIP OODE ADDRESS SERVICE REQUESTED SIGNATURE BILL NUMBER STATEMENT DATE 451169607 - OCTOBER 8 2013 PATIENT: JANETTAGG AMOUNT YOUOwE _ • • $ 579.92 - • . PLEASE INCLUDE BILL NUMBER ON CHECK,MAKE PAYABLE TO: 567235531001 150321138 IIIIIIIIIIIIIIIIIII"I"II'I'IIIIII"I'IIIII"11'IIIIIIIIIIII"II Pinnacle Health Hospitals JanetTagg PO Box 2353 1210 McCormick Rd Harrisburg PA 17105-2353 Mechanicsburg PA 17055.5973 11111111111111111111111111111!1111 lllllllll lllllllllrlllrl htfps.Ilbillpay,ginnaaletrealth oEg STATEMENT The amount shown below represents To discuss payment, Call: your financial obligation to: PINNACLEHEALTH Pinnacle Health Hospitals Hospitals (717)221-1294 For all other inquiries: (868)467-2563 PO Box 2353 (717)221-1294 Harrisburg, PA 17105 MESSAGE: Thank icall nacle Health Hospitals.The balance on your account is due. If you need assistance or have inlease call our customer service department. If you need to make arrangements for paymetatives available to assist you. Financilable for the uninsured or underinsured who apply and qualify. For more information, please ite at www oihnac Aehealth org/bilipay. You may also pay online at https//bilipav pinnaclehealth oro HOSPITAL SERVICE DATE PATIENT NAME BILL NUMBER 06/10113 JANET TAGG 130460741 FOR YOUR HOSPITAL SERVICES: $445.00 Lab/Blood $188.00 x-ray(NUCmed $633.00 Original Billed Amount Total Payments and Adjustments $ $442.92.08 Patient Responsibility $442 $ $442.06 605ONAMSYDI 1001 T PLEASE DETACH AND RETURN LOWER PORTION WITH YQURPAYMEtn - „-__ DO not Send Correspondence to this address. IF PAYING BYMASTERCARD V SDOOER VISAm AMERICAN EXPRESS,FILL OUT BELOW CARD NUMBER E%P-DATE Ell ONAMSY01 LAST THREE DIGITS FROM BACK OF CARD PO Box 1022 AMOUNT $ Wixom MI 48393-1022 CARDHOLDER'S STREET ADDRESS CARDHOLDER'S ZIP COOS ADDRESS SERVICE REQUESTED SIGNATURE BILL NUMBER STATEMENT DATE 130460741 SEPTEMBER 30 2013 AMOUNTYOU OWE PATIENT: JANET TAGG $442.08 -• • PLEASE INCLUDE BILL NUMBER ON CHECK,MAKE PAYABLE TO: 56517818-1001 143932467 fill IIII Jill,IIIIII III 11111 111111111111811111,,1111 Pinnacle Health Hospitals PO Box 2353 Janet Tagg Harrisburg PA 17105-2353 1210 McCormick Rd Mechanicsburg PA 17055-5973 IIIr11111J11JII111,Jd 1,Jd,dL11,1,,,II,11,I,111LIL111 https-//billpav pinnaclehealth.org R . ` . F , m « ! @f\! { # ) $ § \ �p c \ 72lE !) \} \ . „ a© OFFICE OF REGISTER OFmGa 00 \ /±N 12 jq % � Q . D g G C /o# RT /- §E�§ g \A0 �� o _p .\ \ _ ) § % j § § ■ § § S #U) 3 � - LD § 2 ƒ e s \ f ƒ \ K � ,e 2& a® _ 2 »§ _ ! .0'} & ] $ ` m §A n a _ . � O Ra;] in (L) Q m = � � 6.60 8 o kk\\ k § k i § \ } B to .A | . k � 1 ~ 777 , ■ . Kx OR . � ? Any amount¥__material may f��-long_the envelope,not__and the contents are entirely , 1 i '. .. � . . ._e .. � r; � :...e l..... ' y - `