HomeMy WebLinkAbout07-28-14 J 1505610105
REV-1500 EX(02-ft)(Fq 8 ale
ennTsylllvania OFFICIAL USE ONLY
Bu Department d Revenue PF mE Y
Bureau of Individual Taxes County Code Year File Number
INHERITANCE TAX RETURN !�/T
PO BOX 1
Harrisburg,PA PA 17128-0601 RESIDENT DECEDENT _L
ENTER DECEDENT INFORMATION BELOW
Social Security Number Dale of Death MMDDYYYY Date of Birth MMDDYYYY
Ll_l3� N9S
Decedent's Last Name Suffix Decedent's First Name MI
ICI
(If Applicable)Enter Surviv ng Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
-------_-----------
. ..._.__�, �......�
Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
® 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death
Prior to 12-13-82)
O 4.Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
O 6. Decedent Died Testate O 7.Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT— THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
._ _ --......- ._.. _. .-...-- _._..__.
-Ufn _ ( •.._.-G2/n in{ � 7/7 _ -c>?Q.24 1,
/ REGISTER ORW LLLI USE ONLY—
'T
9i-ll rr 1 C:
ni
First Line of Address
r
l
Second Line of Address
....... _-.... -.._.__. __._.. ...-'
City or Post Office State ZIP AT�FILED
_P Code
6-4,01-o 4_kLo H 17 0 S�S.
Correspondent's e-mail address:
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.
SIGNATUE OE P S ES NSIBLE FOR FILING RETURN DATE
ADDRESS yy��ll f /�(1 / y/�1A
o�U SS 7JPr—�S`71 r2 KU'. P/l UGhnl['s rf /,/—I
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE U DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 1505610105 J
1505610205
REV-1500 EX(FI)
Decedent's Social Security Number
Decedent's Name: j
RECAPITULATION
1. Real Estate(Schedule A). ............................................. 1.
2. Stocks and Bonds(Schedule B) ............. ..... ........ .. ........... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) ..... 3.
4. Mortgages and Notes Receivable(Schedule D).......................... . 4.
mow. ..�......_.._,.._.m.m.
i
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E).. ..... 5.t ,a
6. Jointly Owned Property(Schedule F) O Separate Billing Requested .. ..... 6. ! jIf 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested... ..... 7. ()
8. Total Gross Assets(total Lines 1 through 7). ........ ......... ........... 8. 7f LOS . 1-7
9. Funeral Expenses and Administrative Costs(Schedule H).............. . .... 9.
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)........ ....... 10. j 3 d
11. Total Deductions(total Lines 9 and 10)................. ........ ........ 11.
12. Net Value of Estate(Line 8 minus Line 11) ........... ... ..... ........... 12.
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which y "'
an election to tax has not been made(Schedule J) ..... ........ ........... 13.
14. Net Value Subject to Tax(Line 12 minus Line 13) ..... ................ ... 14.
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 ._......... ........ ......... _.... _.. _... ..........._.....
(a)(1.2)X.0_ 15.'
16.4 Amount of Line 14 taxable _........... ..._... "�""®`�" '�'
at lineal rate X.0 klc_ 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 ........ .... ....... .. ...... .. ... ..... ......... ql
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
L 1505610205 1505610205 J
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
A'k
STREET ADDRESS 5 [�
3 ve li
AqA o&
CITY STATE ZIP Me 0 tesbur 176s
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19)
2. Credits/Payments
A.Prior Payments
B.Discount 0Y-0 . `/ 7
Total Credits(A+g) (2)
3. Interest
(3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4) p —
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5)
Make check payable to: REGISTER OF WILLS, AGENT.
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.......................................................................................... ❑ 14
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑
c. retain a reversionary interest .............................................................................................................................. ❑
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑
2. If death occurred after Dec.12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑ U,
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ [`�]
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation? ........................................................................................................................ ❑ Ell
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)(1)].
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
fling 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(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-ySog IX+(o1-Jo) .
pennsytvania SCHEDULE F
W'
INHERITANCE JOINTLY-OWNED PROPERTY
iNHEiUTAN(E TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
/ //
If an asset became Jointly owned within ofie year of the decedent's date of death,it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A' 61AIDA ze)F ��I_ 'e-
B.
C.
JOINTLY OWNED PROPERTY:
LETTER DATE - DESCRIPTION OF PROPERTY %OF DATE OF DEATH
REM FOR JOINT MADE INCLUDE NAME OF FINANOAL 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 VALUE OF ASSET INTEREST DECEDENTS INTEREST
1. A. 19�(P FA/l�w /(7oo3da4s�c/sS- 19, 3,30-33 _01.1
TOTAL(Also enter on Line 6, Recapitulation) $
If more space Is needed,use additional sheets of paper of the same size.
REV-1511 EX+ (08-13)
pennsylvania SCHEDULE H
'f DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF rr FILE NUMBER
k
Decedenitt debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
r2- dire l c4(on %Se�Or✓I ep,s I o� I tiC �/y9S, dd
g1oO --Z4—w wr 644 (oorll�)L✓rt, ?/" )110/'
i / ✓36 ab
�'�� lI�//w�ou// ,.� y �✓dnepr ' IJ I 1�30. UD
'Pc4noit n�•P,-n-u04P.er I A�IcI�E: 4✓o(r._ .Sa
�w1J�jwn /U�yJf�OGr lYd-Tl C f 17, 1-7 41)
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State_ZIP
Years)Commission Paid:
(( /J •��5,vg
2. Attorney Fees: SJI s �,ie.vl'lVC<k 0i f,,, /35—A/l/.a, J����. Z/A5
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:
5. Accountant Fees:
6. Tax Return Prepaarrer Fees:
7. r�a/1P✓4./1 / V r`/T1%a�l/oY I[✓� fCP�`res k..n�e.w �,�00.U p
�'. Y3•�-1Y•eT�y' .fie-•%esr� / / / ,q / /I �app,c0
�. L rT-P r<3�r wr o,c (�L°n.u�xP,�i �S'2rrr�f��a ti i tie Ytr7"Q' Y r�6nuner�
I S"2a 3 S(7w_-esa•T Fei� �iC , �•Si�
Vkee,l
TOTAL(Also enter on Line 9, Recapitulation) $ 3 �/
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,
INHERTrANU TM RETURN f'MORTGAGE LIABILITIES & LIENS!
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
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. ,Weis P-L'trrtual �os� sryo.SR:�PwP1 Ferly /�V Al
Meal - PA moss
a e re. 7A� s dXy1 e i o� Le^CoZx-e,a�33 C 1041
r moP0-0 't/o
/- 313/
.�. Arar-�7t�x;
lP/U e�l���er
TOTAL(Also enter on Line 10, Recapitulation) $ 333-.;I y
If more space Is needed,Insert additional sheets of the same size.
Crown Classic Banking°
Account number:1000322950455 ■ April 22,2014-May 21,2014 ■ Page 1 of 4
EODCKTDTRU 017362
I"�II�I'IIIsIuILJ"�I�Ilns�isll'Il'I���I'I�'Il'I'Il�"��II" QY@Sti0Y57
FRANCES L SCHMINKY Available byphone 24 hours o day,7 days a week:
CINDA L LEININGER 1-800-TO-WELLS (1-800-869-3557)
335 WESLEY DR APT 606 TTK 1-800-877-4833
MECHANICSBURG PA 17055-3537 Enespanol., 1-877-727-2932
M 1-800-288-2288(6 om to 7 pm PT,M-F)
Online: wellsfargo.com
Write: Wells Fargo Bank,N.A.(345)
P.O.Box 6995
Portland,OR 97228-6995
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You and Wells Fargo Account options
Thank you for being a loyal Wells Fargo customer.We value your trust in our A check mark in the box indicates you hove these s
company and look forward to continuing to serve you with your financial needs. convenient services with youraccoum(s). Goto
wellsfargo.com or toll the number above i/you have z
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questions or ifyou would like to add new services. z
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Online Banking E] Direct Deposit QJ z
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Online Bill Pay Auto Transfer/Payment❑ z
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Online Statements E] Overdraft Protection z
Mobile Banking 0 Debit Card z
My Spending Report E] Overdraft Service E] z
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Considering buying your first or next home?
Whether you're just in the planning stage or you've already started looking for a home,give us a call at 1-866-582-1253 and we'll help o
guide you through the process.
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Activity summary Account number: 1000322950455
Beginning balance on 4/22 $1,753.49 FRANCES L SCHMINKY
Deposits/Additions 18,537.31 CINDA L LEININGER
Withdrawals/Subtractions - 2,815.40 Pennsylvania account terms and conditions apply
Ending balance on 5121 $17,475.40 For Direct Deposit use
Routing Number(RTN): 031000503
Overdraft Protection
This account is not currently covered by Overdraft Protection. If you would like more information regarding Overdraft Protection and eligibility requirements
please tail the number listed on your statement or visit your Wells Fargo store.
Account number:1000322950455 N April 22,2014-May 21,2014 ■ Page 2 of 4
intarest summary
Interest paid this statement $0.07
Average collected balance $9,027.73
Annual percentage yield earned 0.01%
Interest earned this statement period $0.07
Interest paid this year $0.13
Transaction history
Check Deposits/ Withdrawals/ Ending daily
Date Number Description Additions Subtractions balance
4/28 2354 Check ......._ 50.00„ 7,703.49
VI_ . _ .........._ _. __...__. .__...... _._..,. _, .. .._-__.__ ..... .e ._...... ....._..____.... _ .._.. .._ ..
5/1 2357 Check _ 4.90_ 7,698.59
5/2 SSA Treas 310 Xxsm Sec 050214 zxxxx931013 5SA Frances L 1,000.00 2,698.59
2359 Check �_....._.._�..__._.....___._
223.00
5/5 2355 Check � 88.54 2,387.05
2358 Check 32.06 �.. 1,354.97
5/8 2391 Check _ 500.00 ' 1,854.97
5/9 Edeposit IN Branch/Store 05/09/1403:40:57 Pm 6416 Carlisle 17,537.24
Pike Mechanicsburg PA 0455 _
519 a2360 Venzon Finanaa Payments 14050802360941287238110002 61 88 19,330.3
................�._._ .._... _. .....__"__.__ .._.. .... ..._.._...... ... ....._.... . ......._. ......_._....
5/14 2392 Check 1,855.00 17,475.33
�,s._ ____. ...._... ..._........ ,_.__ ...,..
5/21 Interest Payment _ 0.07 17,475.40
Ending balance on 5/21 17,475.40
Totals $18,537.31 $2,815.40
The Ending Daily Balance does not reflect any pending withdrawals orholds on depositedfunds that may have been outstanding on yauraccount when your
transactions posted. If you had insulficientavailable funds when a transaction posted,fees may have been assessed.
^ Convertedchedc:Check converted to an electronic format byyourpayee or designatedrepresentative. Checks converted to electronic format cannot be
returned,copiedor imaged.
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m
Summary of checks written(checks listed are also displayed in the preceding Transaction history) N
Number Date Amount Number Date Amount Number Date Amount
2354 4/28 50.00 2358 5/6 32.08 2391” 5/8 500.00
2355 5/5 88.54 2359 5/5 223.00 2392 5/14 1,855.00
2357" 5/1 4.90 2360 5/9 61.88
"Gap in check sequence.
Monthly service fee summary
For a complete list of fees and detailed account information,please see the Wells Fargo Fee and Information Schedule and Account Agreement applicable to
your account or talk to a banker.Go to wellsfargo.com/feefaq to find answers to common questions about the monthly service fee on your account. yyy111{VV��
Fee period 04/22/2014-05/21/2014 Standard monthly service fee$20.00 You paid$0.00
The bank has waived the fee for this fee period.
How to avoid the monthly service fee Minimum required This fee period
Have any ONE of the following account requirements
Monthly automatic loan payment toa Wells Fargo mortgage 1 0 ❑
Combined balances in linked accounts,which may include $7,000.00 $0.00 ❑
Average daily balance in time accounts and FDIC-insured retirement accounts
Csp ION SgR`,C�� AUER CREMATION SERVICES OF PENNSYLVANIA, INC.
•OpC'• 4100 Jonestown Road • Harrisburg,PA 17109 • 1-800-720-8221 • Fax 717-541-9943 • Shawn E.Carper,Supervisor
SYLYANIN,
140483 SVP5
May 11 , 2014
Mrs . Cinda Lelninger
308 Berkshire Road
Mechanicsburg, PA 17055
Frances L. Schminky - Deceased
SPECIAL CHARGES
X Direct Cremation $1 , 795.00
Nationwide Guarantee Program
Worldwide Travel Protection
TOTAL SPECIAL CHARGES $1 ,795 .00
PROFESSIONAL SERVICES
X Services of Funeral Director & Staff Included
Other Preparation of the Body
Facilities & Staff for Memorial Service
Staff & Equipment for Memorial Service
Witnessing the Cremation
Private Family Viewing
Packaging/Forwarding of Cremated Remains
Personal Delivery of Cremated Remains
Scattering of Cremated Remains
TOTAL PROFESSIONAL SERVICES $0.00
AUTOMOTIVE EQUIPMENT
X Removal Vehicle Included
Lead Car/Clergy Car
Family Car
Service Vehicle
TOTAL AUTOMOTIVE EQUIPMENT $0.00
MERCHANDISE
Register Book
Memorial Cards
Thank You Cards
Remembrance Package
Alternative Container
X Cardboard Container
Burial Vault
Veterans Flag Case
Grave/Memorial Marker
X Precious Memories Jewelry
TOTAL MERCHANDISE
CASH ADVANCED ITEMS
Grave Opening
Cemetery Equipment
X Patriot Newspaper Notice $212 .37
X Lewistown Newspaper Notice $106.30
Vault Service Charge
Clergy
Church/Organist/Soloist
Flowers
X Crematory Charge Included
X Dauphin County Coroner Fee $30.00
X 5 Certified Copies of Death Certificate $30.00
TOTAL CASH ADVANCED ITEMS $378. 67
SUMMARY OF CHARGES._
Special Charges $1,795.00
Professional Services $0.00
Automotive Equipment $0.00
Merchandise $0.00
Cash Advanced Items $378 .67
SUB TOTAL $2, 173.67
CREDITS $0.00
AMOUNT PREPAID Date $0.00
TOTAL $2 , 173 . 67
AMOUNT PAID Date May 20, 2014 -$2, 173. 67
BALANCE DUE $0.00
THIS STATEMENT MAY NOT REFLECT ALL NEWSPAPER CHARGES
Law Offices of
Saidis, Sullivan & Rogers _
A PROFESSIONAL CORPORATION
635 NORTH 12TH STREET, SUITE 400
CARLISLE OFFICE LEMOYNE, PA 17043
26 WEST HIGH STREET TELEPHONE: (717) 612-5800 - FACSIMILE: (717) 612-5805
CARLISLE, PA 17013 EMAIL: attorney@ssr-atiorneys.com
TELEPHONE: (717) 243-6222 www.ssr-attorneys.com
FACSIMILE: (717) 243-6486 REPLY TO LEMOYNE
June 2, 2014
Cinda Leininger Our file# 12962 142405
308 Berkshire Road Invoice# 16292
Mechanicsburg, PA 17055
EIN: 27-2700453
RE: Estate of Frances Schminky
Payments received since last invoice $0.00
Accounts receivable balance carried forward $0.00
DATE DESCRIPTION HOURS AMOUNT LAWYER
05/15/2014 Meeting with C. Leininger 1.00 $225.00 ABH
TOTALS 1.00 $225.00
Billing Summary a I�
3�b
Total professional services $225.00
Total of new charges for this invoice $225.00
Total balance now due $225.00
** Trust account remaining balance is $0.00
PRIVACY POLICY: During this firms representation of you,we may receive nonpublic,personal information from you or
from sources about you. It is our policy and practice that our attorneys and staff do not at any time reveal information relating
to our representation of you unless you consent after consultation,except for disclosures that are impliedly authorized to carry
out the representation,and except for disclosures required or authorized by the Pennsylvania Rules of Professional Conduct.
Interest at 1 1/2% per month on unpaid balance after 30 days.
Saidis Sullivan & Rogers is excited to be able to offer you the opportunity to receive your
statements via email. To sign up or for more information email billing @ssr-attorneys.com.
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a,
5223 Simpson Ferry Road
Mechanicsburg, PA 17055
(717) 6248846
Cinda Leininger
308 Berkshire Road _ _
Mechanicsburg, PA 17035 IN ♦`�OICE__ -
Scott contact=(717)421-5722
5/20/14 Engraving on marker
for Frances L $222.50 $222.50
Steve of Romberger Memorials
to handle this work
Payment due upon receipt
Please make payable to
Lasered Granite Art
Balance Due $222.50
Thank you very much
for your order
www.laseredgraniteartandmonuments.com
laseredgraniteart@pipeline.com
Page: 1
M E D I C A L E X P E N S E S
SCHMFRI
Patient : SCHMINKY, FRANCES Pharmacy: WEIS PHARMACY #058
RespPty: 5140 SIMPSON FERRY ROAD
335 WESLEY DR APT 606 MECHANICSBURG PA 17055
RPh: WALTER, MIKE
MECHANICSBURG PA 17055 3537
Birth: 10/29/1925
Prescriptions : Date: 04/01/2014 TO 05/31/2014
LastFill RX # Drug Name Qty Physician Name T/P Price
04/03/14 7072094 ANUCORT-HC 25MG 12 Dr.LUCKENBAUGH RUB PAC 6 . 00
04/11/14 7069268 ADVAIR DISKU 250/50 60 Dr.LUCKENBAUGH RUB PAC 9 . 00
04/11/14 7076253 VENTOLIN HFA 54 Dr.LUCKENBAUGH RUB PAC 9. 00
04/12/14 8726354 A+D OINTMENT 226 Dr.OTC 8. 98
04/15/14 7076394 HYDROCHLOROT 25MG 180 Dr.LUCKENBAUGH RUB WEIS 19. 98
04/15/14 8726354 A+D OINTMENT 226 Dr.OTC 8 . 98
04/16/14 8726354 A+D OINTMENT 226 Dr.OTC 8 . 98
04/28/14 . 8726894 TOPCARE HAND SANITI 295 Dr.OTC 4 . 95 _
05/01/14 7076253 VENTOLIN HFA 54 Dr.LUCKENBAUGH RUB PAC 9 . 00
05/01/14 8726928 TOP CARE MENTHOL CO 30 Dr.OTC 1. 29
Report Date: 06/06/2014 $86 . 16
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41 a�
Weis Fharmacy+#58
.5140 Simpson terry Read
Meehanksburg,FA 17055
Care Plus Oxygen of Lemoyne
Returned Mail Only-No Correspondence Send Payments to:
PO Box 13150 Care Plus Oxygen of Lemoyne
Overland Park,KS 6628p2�-2141 2233 East Main Street
IIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII I�IIIIIII IIII Montrose, CO 81401-3831
May 06, 2014
Account p: Dates of Service Balance
156370 02/02/2014 $32.08
Patient Name:
77M7955 Frances Schminky
,. FRANCES SCHMINKY
335 WESLEY DRS
APT 606 dd
MECHANICSBURG,PA 17055-3537 For Billing Questions, Call
(855)4488283 1`
Monday-Friday
9:00 sm -4:00 pm
Pay Online:
LATE FEE $15.00
www.AeroCareUSA.com • 547.08
Dear FRANCES SCHMINKY:
Your account remains seriously delinquent. We have not received payment for the balance shown. If payment is not
received within 10 days, we will review the account to determine whether to engage a collection agency or attorney to
pursue this debt.
Please send payment immediately. If there is a concern with your account,please contact us at(855)446-8283. Thank you
for allowing us to be of service to you.
Sincerely,
Care Plus Oxygen of Lemoyne
PLEASE RETURN BOTTOM PORTION WITH YOUR PAYMENT(ALLOW 740 DAYS FOR POSTAL DELIVERY)
..............................................................................................................................
rI
I
S
SAM HEFFELFINGER
610 E KELLER ST
MECHANICSBURG, PA 17055
717-697-6108
Cleaning services for Frances Schminky's:apartment 5/19/14 $200.00.
3`�
LAST WILL a mcl TESTAMENT . 7
Unmarried Person
I, ri�nn �s . SGi�wti n ICu o � %o'5efng of sound mind
and memory and over the age of ghteen years, do hereby ake, declare, and publish this to be my Last Will
and Testament, hereby revoking all Wills and Codicils heretofore made by me. ,
First. I am not married and have: (chock one) ❑ No Children [Adult Children
Second. I direct that my just debts, funeral expenses, expenses of administration, and any Inheritance
and succession taxes, state or federal,shall be paid only as required by law.
Third. I give all my estate to L. lea;;r cub provided that he/she shall survive me for-
sic{6}awgl#rs, and failing to so survive me, I.give all my estate to
Fourth. I designate �w as Independent Executor/Executrix of this Last Will
and Testament. In the event that r shall predecease me or fails to serve as
independent Executor/Executrix, then I designate: as Independent . Executor/
Executrix of this my Last Will and Testament. I further direct that no appointee hereunder shall.ye required to
give any bond for the faithful performance of his/her duties.
Fifth. I hereby grant to my Independent Executor/Executrix all the powers, rights, discretions, and duties
conferred upon fiduciaries by law with full power to sell, lease, mortgage, invest, reinvest, or otherwise
dispose of the assets of my estate.
In Testimony Hereof, I•have sign mIy name to this Last Wi I and Testament in the presence of Chit
I� sJ , and my witnesses, who at my request
and in my resence and in the presence of each othe , have"signed names hereto as attesting witnesses
this the „10`w day of 20J , at 33�SiJ�s-/p,. ��. 4.o�tcdlo J7C�a�. � 70
� Cr
(Sign here)Testators tri x "
Wes/ of 70S60 kw.i� 7'r ( 7QTS
Witness Sin a (Street) (City) State) (Zip)
(Social Security Number)
(2) `�? 2dP `C� - of 102 FarwK Dr PA 1-1055
Witness Signature ,{Street) (City) (State) (Zip)
(Social Security"Number).
4w IX5 '
i Sigma��uure (Str r - (City) (State) (Zip)
(Social Security Number) `
Acknowledgment Of Notary
STATE OF „
COUNTY OF CU P&( l C
�
^�. REFORM ME, the undersigned authorgi on, ' this day personally appeared
t Q41CAC t h „r,1z 4 £iestatorfrastatrixq,. ' a1 i,bl v �a� p9 and
r ric7 �ca _(Witnesses), known to me to be the todTestatrix and-the witnesses
(respectively),whosh`names are subscnbed to the foregoing instrument in their respective capacffies,and
All of said persons being by me duly swo'm; the said the Testator/testatrix,
declared`to me and to the said"witnesses in my presence that sald'instrutne" is histber,l ast Will and
Testament; and that he/she had wittingly made and executed it as his/her free act and deed for the
purposes therein expressed;and the said witnesses,each on their oath,stated to me in the presence and
hearing of the said Teatatorfrestatrix and the said Testator/Testatrix had declared to them that said
instrumentis hi"er Last Wiliattd Testament andthat he/she oxecutedithe same as such and wontodeach
-of them to sign if'es a witnes ,aryd upon theiroath,eachvitness stated further that theydtd sittnthe'sam
as a witness u4 in the presence-ot said TestatorlTestatrix and-at tiis/her request,artd''diat he/she was at
that time over the age Oteighteen(18}ybars and was c f sound mindAnd that each of sa dwitnesses was'
then at least eighteen (18)years of age.
. T1s�staibrrl'"estatrix � .
Witness
the
SUBS9111$EU ANQ ACKNQfl LOGED BEFORE ME by the said the
Testator/Testatiix, and SUBSCRIaED AND SWORN TO BEFORE ME by the said
(' T 1 and -$aC ,A9t%vf e S:( witnesses, this the { day dt
20:IH,..,
Notary-public, $tWIN
COMMONWEALTN FOP �M 1iANUi.
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