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Home My WebLink About04-15-05 +..,., REV-1500 EX (5-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 W I- :.:::$00 00:::0:: wQ.o ;1:00 00::..J Q.1Xl Q. < FILE NUMBER 21 05 INHERITANCE TAX RETURN RESIDENT DECEDENT NUMBER 0124 COUNTY CODE YEAR I- Z W C W (.) W C DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Gabany, Donald W. DATE OF DEATH (MM-DD-YEAR) 01/18/2005 SOCIAL SECURITY NUMBER 234-52-6342 DATE OF BIRTH (MM-DD-YEAR) 02/22/1935 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS u_ (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) N/A SOCIAL SECURITY NUMBER ~ 1. Original Return o 4. Limited Estate ~ 6. Decedent Died Testate (Attach copy 01 Will) o 9. Litigation Proceeds Received o 2. Supplemental Return o 4a. Future Interest Compromise (dale 01 death after 12-12-82) o 7. Decedent Maintained a Living Trust (Allach copy of Trust) o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) o 3. Remainder Return (date 01 death prior to 12-13-82) o 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (Attach Sch 0) I- Z W C Z o Q. 00 w 0:: 0:: o o THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS Andrew.H. Shaw, Esquire Andrew H. Shaw, Esquire FIRM NAME (II Applicable) 61 W. Louther Street Carlisle, PA 17013 TELEPHONE NUMBER (717) 249-1177 z o ~ .J :J !::: Q. <( (.) W c::: 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) (1) (2) (3) (4) (5) 133,600.00 0.00 0.00 0.00 9,991.00 (6) 23,783.54 (7) 0.00 (9) (10) , i U', -; 167,374.54 , - :, ., r',) i'-ii (8) 9,130.00 3,941.46 (11) (12) (13) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) U1 13,071.4S 154,303.08 0.00 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 154,303.08 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o !C( I- :J Q. :E o (.) g 15, Amount of Line 14 taxable at the spousal tax rate, or transfers under See, 9116 (a)(1.2) 0.00 x ,0 Q 154,303.08 x ,0 45 0.00 (15) 0.00 (16) 6,943.64 (17) 0.00 (18) 0.00 (19) 6,943.64 16. Amount of Line 14 taxable at lineal rate 17, Amount of Line 14 taxable at sibling rate x .12 0.00 x .15 18, Amount of Line 14 taxable at collateral rate 19, Tax Due CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 20.0 Decedent's Complete Address: STREET ADDRESS 9 WexfQrc:lCQJ.lJ't CITY Carlisle STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 6,943.64 0.00 0.00 347. 18 3, Interest/Penalty if applicable D. Interest E. Penalty Total Credits ( A + B + C ) (2) 347.18 0.00 0.00 Total Interest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 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) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) 6,596.46 0.00 A. Enter the interest on the tax due. 6,596.46 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;............................................................................."......"... 0 ~ b. retain the right to designate who shall use the property transferred or its income; ...".................................."... 0 ~ c. retain a reversionary interest; or..........................................................."............"......................."........".........." 0 [iJ d. receive the promise for life of either payments, benefits or care? ."..........."..................................."........"...... 0 [iJ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ..............".............."............................"......."....................................,,, 0 ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? "............ 0 ~ 4. Did decedent 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. Under penalties of perjury. I declare that I have examined this retum, 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, DATE L{ "7 .-/ -I) --O..J DATE ....." l( - 1'5 -- 0..5> ADD 61 W. Louther St., Carlisle,~~ 1701_3.__ For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. 99116 (a) (1,1) (i)]. For dates of death on or after January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum 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 twenty-one 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% [72 P.S. 99116(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%, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1 )], The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116(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-1502 EX+ (6-9*, COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF Donald W. Gabany FILE NUMBER 21-05-0124 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is Jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH 9 Wexford Court, Carlisle, PA 133,600.00 TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 133,600.00 REV-1508 EX+ (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Donald W. Gabany FILE NUMBER 21-05-0124 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 NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 . Personal Effects 500.00 2. 2002 Buick Regal GS 9,491.00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 9,991.00 REV-1509 EX+ (6-98) SCHEDULE F JOINTLY-OWNED PROPERTY ........ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Donald W. Gabany FILE NUMBER 21-05-0124 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 A. Joyce M. Rider 9 Jenny Drive, Boiling Springs, PA 17007 Daughter B. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VAlUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 01/01/2000 Members 1 st FeU Account # 33864 47,567.07 50 23,783.54 TOTAL (Also enter on line 6, Recapitulation) $ 23,783.54 (If more space is needed, insert additional sheets of the same size) Send Inquires to: 5000 Louise Drive PO Box 40 Mechanicsburg, PA 17055 www.members1st.org l~~J Main Switchboard: (717) 697-1161 or (800) 283-2328 EZ Call: (717) 697-4372 or (800) 283-4372 TOO: (717) 697-5312 or (800) 283-2328 exl. 5312 TeleBranch: (717) 795,6049 or (800) 237-7288 ~qr-f)#J 157 1 AV 0.278 3 -157 1...1111..111...11"11'1111.1",1.1.,1,.11,,1111'111.11,11..11 DONALD W GABANY JOYCE M RIDER CIO JOYCE M RIDER 9 JENNY DRIVE BOILING SPRINGS PA 17007 MEMBERS 1st FEDERAL CREDIT UNION "- .... ~ ~ N- - CXl ~ 0\_ 0- .. Jan 01, 2005 thru Jan 31, 2905"-,, Account Number: 6' _ Account Balances at a Glance: Checking: 268. 17 Savings: 152.22 Certificates: 0 . 00 Loans: 0.00 Money Management: 0.00 Page: 1 of 2 Get your cash fast and direct dep it you RS Tax Refund. See the enclosed insert for more information. CHECKING ACCOUNTS 11 - CHECKING Date Jan 01 Jan 03 Jan 10 Jan 10 Jan 19 Jan 20 Jan 26 Jan 27 Jan 28 Jan 31 Jan 31 Transaction Description Balance Forward Deposit Transfer From Share 00 Check 002697 Tracer 0035906454 Processed Check - DISCOVER ARC TYPE: PAYMENTS ID: 1510020270 DATA: DC ARC DCIDOVARC Check 002698 Tracer 0110040118 Check 002696 Tracer 0119014526 Check 002699 Tracer 0120010712 Check 002701 Tracer 0126016488 Check 002704 Tracer 0127009979 Check 002700 Tracer 0128000500 Check 002702 Tracer 0131013593 Ending Balance CHECK SUMMARY Check # Amount Date 002696 99.00 Jan 19 002697 93.78 Jan 10 002698 196.34 Jan 10 002699 26.00 Jan 20 .. Asterisk next to number indicates skip in number sequence 8 Checks Cleared for 1,142.24 Date Jan 03 M1~Tn1 DEPOSITS AND OTHER CREDITS Amount Description 1,320.10 Deposit Transfer Date - - - Continued on following page - - - Additions Subtractions 1,320.10 93.78- 196.34- 99.00- 26.00- 220.92- 86.20- 400.00- 20.00- Check # 002700 002701 002702 002704* Amount 400.00 220.92 20.00 86.20 Amount Description Balance 90.31 1,410.41 1,316.63 1,120.29 * 1,021.29 995.29 774.37 688 . 17 288 . 17 268. 17 268. 17 Date Jan 28 Jan 26 Jan 31 Jan 27 ) .. N- ~ ~ N_ ~ - <Xl_ 0",_ 0- .. (~l~t MEMBERS I" mtaA.l.CUDlT lIMON 314-157 Jan 01, 2005 thru Jan 31, 2005 Account Number: 33864 Page: 2 of 2 SAVINGS ACCOUNTS 00 - REGULAR SAVINGS Transaction Description Balance Forward Deposit ACH SOC SEC ID: 3031036030 Deposit ACH CIVIL SERV ID: 3121736156 Withdrawal Transfer To Share 11 Withdrawal Deposit ACH SPSBA TYPE: PAYROLL ID: 1236004547 Jan 26 Withdrawal Jan 31 Deposit Dividend 1.000% Annual Percentage Yield Eamed 1. 01(J}6 from 01/01/2005 through 01/31/2005 Jan 31 Ending Balance Date Jan 01 Jan 03 Jan 03 Jan 03 Jan 07 Jan 13 Additions Subtractions 182.00 2,120.10 3,623.10 1,320.10- 2,303.00 2,278.00- 25.00 <Jg 269.72 294.72 142.96- 151.76 0.46 152.22 152.22 05 - MONEY MANAGEMENT Transaction Description Balance Forward Deposit by Check Withdrawal Transfer To RIDER,JOYCE M XXXXXXXXXX Share 00 Jan 26 Deposit Dividend Annual Percentage Yield Eamed 1.4()(J}6 from 01/01/2005 through 01/25/2005 Jan 26 Withdrawal Transfer To RIDER,JOYCE M XXXXXXXXXX Share 05 MONEY MANAGEMENT Closed """717is is the final statement presenting information on this product""" ".... Please retain this final statement for tax reporting purposes ...... Date Jan 01 Jan 07 Jan 26 Additions Subtractions Balance 1,978.00 44,174.06 '* 46,152.06 10,000.00- 36,152.06 43.49 36,195.55 36,195.55- 0.00 LOAN ACCOUNTS 02 - PERSONAL SERVICE LOAN Credit Limit 0.00 Credit Available 0.00 Date Transaction Description Jan 01 Balance Forward Jan 31 Ending Balance Annual Percentage Rate 11.000% Daily Rate .030136% ** Periodic Rate May Vary On This Loan ** Amount Interest Fees Principal Balance 0.00 0.00 YTD SUMMARIES TOTAL DIVIDENDS PAID 00 REGULAR SAVINGS 05 MONEY MANAGEMENT 11 CHECKING 0.46 43 .49 0.00 TOTAL LOAN INTEREST PAID 02 PERSONAL SERVICE LOAN 0.00 Total Year To Date Dividends Paid NOTE: Total includes closed shares 43.95 REV-1511 EX+ (12'99)_ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF Donald W. Gabany FILE NUMBER 21-05-0124 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: Ronan Funeral Home Wayne Noss Flowers Pastor and reception fees 6,960.00 106.00 325.00 2. 3. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 0.00 Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees 1,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 0.00 Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 306.00 5. Accountant's Fees 0.00 6. Tax Return Preparer's Fees 0.00 7. Family Travel Expenses 420.00 8. Mail and postage fees 13.00 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 9,130.00 REV-1512 EX+ (12-03) - SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Donald W. Gabany FILE NUMBER 21-05-0124 Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 1. 2004 Federal income taxes 582.00 2. 2005 County Property Taxes 286.21 3. Moffit Heart & Vascular Group 1.10 4. Good Hope Family Physicians 20.00 5. UGI gas bills 589.94 6. Met-Ed electric bills 121.04 7. Advanced Dermitology and Skin Surg 20.00 8. Central PA Hematology & Oncology 67.37 9. Sprint phone bill 57.93 Visa, account # 4121 4499 9833 8649 142.96 Waste Management refuse bill 46.80 WSO Imaging Center, LP 6.72 Graham Motor Company, Inc. 410.44 Commonwealth of PA (transfer title on automobile) 58.50 AAA (title transfer services) 10.00 Ace Chern Dry (carpet cleaning at residence) 196.69 Boiling Springs Animal Hospital 188.00 Knisely's (pet supplies) Help-U-Sell Real Estate (market analysis and real estate contract) 86.20 995.00 20 Holy Spirit Hospital 54.56 3,941.46 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) . Direct deposit? See page 50 and fill in 45b, 45c, and 45d. Tax, creclits, and paYments ~~ Standard Deduction for-. .' PeoPle who checked any box on line 238 or 23b or who can be claimed as a dependent, . see pagEl 31. . All o~ Single or Married filing separately, $4,850 Married filing jointly or Qualifying widow(er), $9,700 Head of household, $7,150 11\ you have a qualifying child, attach Schedule EtC. Refund Amount you owe lIiJ!tto the beIt.otAbi <~hA .~~~'~;~.;o Daytime phone number (111) ~6~ -lS"'.i" 3- Form 1040A (2004) MESSAGES EXPLAINED. rBELOW 111111. -----,;..------- lJate Service Description Cpt Ox _mmmmlEmmD Line Balance Insurance Charges pending to Prv: Ins Pay/Adj against Ins pending 2630.00 1168.98-1357.49 103.53 12/29/04 1 01/17/05 01/17/05 02/24/05 02124/05 4 OFFICE VISIT EST LEVEL 3 Medicare Payment Accept Assign Adj. HEALTH AMERI Payment HMO/PPO Adj. 99213 428.21 75.00 40.38 0.00 -24.52 -9.00 1. 10* 3\~~\QS 00/00/00 DATE lAST PAID AMOUNT MAKE CHECK. PAYABLE TO: '.:C.. .. _'.." '. :.: "::-:~: .... . ,'",:.,- ;: :.:;'>.:....; ,':"":_,,,:-, ,:':_: ,.,'"_.,, -',__ .c..;.-."....-;.::.;:..;::.,..,.....:.,;...,.-_-........_...:.,:._..,..:......'..........::.,.,...:.,:..:,.:.. . . MOFFI',l''f HEART' & VASCULAR GROUP'. 1000 NORTH FRONT STREET WORMLEYSBURG, PA 17043 PATI! I-DONALD \rf G"ABANt PRVI! 4-FANELLI, CLAUDE, MD ~.. ... .. 1.10* Ph: (717)-731-8315 Acctll: 37160 Date: 03/21/05 Page 1 of 1 '- . ,., #: 89692 Please Pay: $10.00 L..-r Due Date: 04/07/05 DONALD W GABANY ESTATE IDI 19692/ElIZABETH A MILLER CRNP 01/07/2005 OFFICE / OUTPATIENT VISIT ESTABLISHED PATIENT EXP PROBl 01/31/2005 SYSTEM CONTRACTUAL ADJUSTMENT FR~ MEDICARE 01/31/2005 PAYNENT FROM MEDICARE 03/16/2005 PAYMENT FROM HEALTH AMERICA 03/16/2005 PATIENT RESPONSIBILITY - THE BALANCE IS YOUR COPAY WHICH IS NOT COVERED --> BY YOUR INSURANCE. ~~_ij,~~. J~\~1~j jjl:t~ll;~.~j BALANCE TICKET IGHFP011351 65.00 65.00 0.00 -22.21 0.00 -22.93 0.00 -9.79 0.00 -10.00 10.00 .00 10.00 lo{ 3\2/\ .......-......... .. .. ... .-......... ...... - ......., ..... .... - ... ..'... ".-.. ....-....... ..........".... ...... ..... ...........,...-,......... .......... ....-...-........-.............................,.-.--.-..... ....'....-.....---.......---......-.......... ..........i'...i.......'......'i..,......,.,. ...............JM~Q.r.l'~H1":.M~$$.A~~...A$(>:P'TY()Q~.A~~()\.Jrq.... PROMPT PAYMENT WOULD BE GREATLY APPRECIATED. . .....,... ........ -.. ...-..... ......... ... .. ....... ........ ..-....-...........,.,.. ..........-...-........-. ..............,.........,..-...... .-.....-................... ..................................... -.....................-...-... ... ........................ ...........,..,............... .. .... .... ...,.... ..-.......... "..-............-............. ....'.......................'...........,......................... ..ti:~t,~ij~............ ..........,.............,.................,.. .~~~1~lZ!-:It;:.;.. ............-.--.....-........-.,...........::.........,""."':"'."'"'"..,....-:... ..... .......... ..-..... ... .......... 10.00 .00 10.00 Make Checks Payable To: GOOD HOPE FAMIL PHYSICIANS For Billing Questions Call (717)-732-8877 PLEASE DO NOT SEND CASH THROUGH THE MAIL EG1521-32 PAGE 1 OF 1 81 428 t '#: 89692 Please Pay: $10.00 Due Date: 02/03/05; .'.,. .'.~... ... . .".0_" ....... ._. ._.'.. ..........-..-.........--..,.....-. .,............-...........,....,..... ..,. . ~4 .'. .'. ._._ .'... U"_ ._. .'... ..........._..u...._......h_.._. .............n_.............__......., :~..:::~~m~.:;;...:1~:r:m~]~i.. .......,...............-........ ............'.........'.'........04.. DONALD W GABANY IDI 19692/"ICHAEL R GAWLAS DO 11/09/2004 OFFICE 1 OUTPATIENT VISIT ESTABLISHED PATIENT DETAILED 12/06/2004 SYSTEM CONTRACTUAL ADJUSTMENT FR~ MEDICARE 12/06/2004 PAYMENT FROM MEDICARE 01/12/2005 PAY"ENT FROM HEALTH AMERICA 01/12/2005 PATIENT RESPONSIBILITY - HAM IPT HAS .10 COPAY. 95.00 BALANCE TICKET .GHFPOOS143 m:m:jtmm:m:ml::::::j%mt.:tFm#jmm::m~M~t~kiH,i$."Aq'tl.i.J.Qill'2tOQ8.mA~ijp'ijKtjm:%mtjmm1tj~mmt:wmt.....n::mr :tl~:.i.::~~::::~:j:P~:. PROMPT PAYMENT WOULD BE GREATLY APPRECIATED. }............... .....:.:.,.. ':.........................'.. ]f!. ~,' c" ,~_ '","'. . ,'.". -.';- " .' . '. '... " .'_ .' ".""'--." ". .....,. ~ '. ".- ~:::b~h~~~S GOOD HOPE FAMIL PHYSICIANS Dr- G o..u) \ a. 6 PLEASE DO NOT SEND CASH THROUGH THE MAl L For Billing Questiol1sCil (717)-732-8877 EG1521-32 PAGE 1 OF 1 D1 t-# Bllllnll Summary for Service to: DONALl) W GABANV 9 WEXFORD CT CARLISLE PA 17013 Rate Classification: Residential Heating Billing Period: 01/1412005 to 02/14/2005 (31 days) Company Read Questions? Ca\l1-800-276-2722 or write to UGI at PO BOX 13009 Reading, fA 19612-3009 . Your current UGI charges include State taxes totaling $ 7.06. CPT 2137721928281 t;~t!m' Bllllnll Summary for Service to: DONALl) W GABANV 9 WEXFORD CT CARLISLE PA 17013 Rate Classification: Residential Heating Billing Period: 12/15/2004 to 01/14/2005 (30 days) Estimated Read Questions? Call 1-800-276-2722 or write to UGI at PO BOX 13009 Reading, PA 19612-3009 * Your current UGI charges include State taxes totaling $ 5.70. CPT 2137721928281 Past BlJllnformatlon - UGI Utility The account balance on your last bill was ..-...-....... Thank: you for your payment of ..................................... Your balance as of 02116/2005 ................................... $ 176.95 -176.95 0.00 i> Current Bill Information - UGI Utility Customer Charge ..._......................................................... 8.55 Commodity Charge ( 172 CCF at $0.89215) ............ 153.45 Distribution Charges (First 50 CCF at $0.38000) ... 19.00 Distribution Charges (Next 122 CCF atSO.31541) . 38.48 fA State Tax Surcharge ............................_......_............ -0.33 Total Current Charges - UGI Utility ................_........_ 219.15 UGI UtlI eha es CIWIld this bill ............._................................................................... Total Amount Due, Please Pay by Due Date (03/10/2005) ........-.........................; $'219. j ",-~~/ ;J-:-J ( - 0) Past Bill Information - UGI Utility The account balance on your last bill was ................ Thank you for your ~yment of ..................._................ Your balance as of 1/18/2005 ................................... $ 133.23 -133.23 0.00 Current Bill Information - UGI Utility Customer Charge .............................................................. 8.55 C~m~o~ity Charge ( 137 CCF at $0.89219) ............ 122.23 D!st~but!on Charges (First 50 CCF at SO.38000) ... 19.00 DlstnbutrDn Charges (Next 87 CCF at $0.31540) 27.44 fA State Tax Surcharge ..............................................:::: -0.27 Total Current Charges - UGI Utili~ ............................... 176.95 UGI Utili cha es owed this b \I .................................................................................. Total Amount Due, Please Pay by Due Date (02/08/2005) ..................................... c2ld-( () S- (.J tth V1Dt~ t-# GAS SE.VICE B\I\lnll Summary for Service to: DONAIJl W GABANV 9 WEXFORD CT CARLISLE PA 17013 Past Bill Information - UGI Utility . The accDunt balance on your last bill was ............. Thank: you for your payment of .................................. YDur balance as of 03/18/2005 ................................ $ 219.15 -219.15 0.00 Rate Classlflcat~on: Residential Heating BIlling Period: .. 02/14/2005 to 03/16/2005 (30 days) Estimated Read Questions? 'te t UGI at Call 1-800-276-2722 or wn D PO BOX 13009 Reading, PA 19612-3009 * YDur current UGI charges include State taxes totaling $ 6.24. CPT 2137721928281 Current Bill Information - UGI Utility 8.55 custo':~~'Ch~~~Ti"51""cCF'a'i'Sii:B9219i"::::::::: 134.72 gisTJbut!~n Charges ((NFiextrst1581C~tFa~~~o3:~~~~i ~~:~g DistributlDn Charges . -0.29 PA State Tax Surcharge ............:.:........................."...... 193.83 Total Current Charges - UGI hUltlhbtvll............................ .............................. UGI Utili cha es owed t s ~II .................................................. PI Pa by Due Date (04/11/2005) ................................... Total Amount Due, ease y 3[~}11 O~ February 09, 2005 IAccount Number: 1000199740 6 0 I !:& Page 1 of 4 M67 Billing Period: Jan 12 to Feb 08, 2005 for 28 days Next Reading Date: On or about Mar 10, 2005 Bill Based On: Actual Meter Reading Bill for: DONALD W GABANY 9 WEXFORD CT CARLISLE PA 17013 Residential To avoid a 1.500/. Late Payment Charge being added to your bill, please pay by the due date. ~- J( -Cb ttMa Met-Ed A FntEnstru em;;:- March 11, 2005 .~'~:;;;;~~';~~~~iJ~r. 1_ NlITIler: 10 00 19 9740 60 I Page 1 ~~ I Bill for: DONALD W GABANY 9 WEXFORD CT CARLISLE PA 17013 Billing Period: Feb 09 to Mar 10, 2005 for 30 days Next Reading Date: On or about ~ 11, 2005 Bill Baled On: Actual Meter Reading To avoid a 1.50% Late Payment Charge being added to your bill, please pay by the due date. l Met-Ed A FntErwgy ear;;::- January 12, 2005 I Account Number: 1000 19 9740 6 0 I Page10f4 i M67 Billing Period: Dee 10 to Jan 11, 2005 for 33 days Next Reading Date: On or about Feb 08, 2005 Bill Based On: Actual Meter Reading Prorated Bill Bill for: DONALD W GABANY 9 WEXFORD CT CARLISLE PA 17013 .~&:~ To avoid a 1.50% Late Payment Charge being added to your bill, PI~ase pay by the due date. Keep this portion for your records Date Patient Patient 10 Description Amount Starting Balance -0.00 04/21/04 Donald Gabany 108 Office consultation, moderate 151.00 04/21/04 Donald Gabany 108 Remove lesion, trunk/arm/leg 157.00 05/10/04 Donald Gabany 108 Medicare Ins PaymentlMCRlCK -189.56 05/10/04 Donald Gabany 108 ~edTcare PPS Adj ./MCR -71.06 05/19/04 Donald Gabany 108 Office/outpatient visit, est, 66.00 06/01/04 Donald Gabany 108 Insurance PaymentlHA/g$ -27.38 06/07/04 Donald Gabany 108 Medicare Ins PaymentlMCRlCK -40.38 06/07/04 Donald Gabany 108 M~dicare PPS Adi.7MCS. -15.52 06/10/04 Donald Gabany 108 Patient PaymentlCK #.22j 4 -40.00 09/23/04 Donald Gabany 108 Patient Refund 9.90 - 10/28/04 Donald Gabany 108 Office/outpatient visit, est, 103.00 10/28/04 Donald Gabany 108 Biopsy of skin lesion 98.00 10/28/04 Donald Gabany 108 Biopsy of external ear 120.00 11/19/04 Donald Gabany 108 Medicare Ins PaymentlMCRlCK -167.01 11/19/04 Donald Gabany 108 Medicare PPS Adj./MCR -112.25 12/20/04 Donald Gabany 108 Insurance PaymentlHA/CK -21.74 Ending Balance 20.00 I j:JE: /O~ Current 0.00 31-60 0.00 61-90 91-120 20.00 0.00 121+ Unapplied 0.00 0.00 Total 20.00 Due Now $ 20.00 vanced Oerm and Skin Surg For billing inquiries call: 717-766-0500 Insurance Last Billed on Nov 19, 2004 Monthly paymebts must be made on this balance. --------------------------_._--~----------- ~19/04 DONALD OFC VISIT, EST LEVEL 4 110.00 63.18 .00 .00 15.79 PATIENT COINSURANCE 2/17/04 DONALD OFC VISIT, EST LEVEL 4 110.00 63.18 .00 .00 15.79 PATIENT COINSURANCE /" ~ ~ l~\ ~ ~n+V-aJ M.e.d 1 caJ P A- H-e 6V1CO{ 9Y +- cla...f.e SPECIAL COMMENT: atient balance is due upon receipt! (*) indicates insurance due monies. We abate insurance due for 45 days, then you re responsible for payment in full. If you must pay insurance due monies, please notify your employer and insurance arrier. 31.58 .00 .00 .00 .00 31.58 498.18 '.:::..:111::111111[".:1.:.11 :!:::'II~II:IIIII: 1:":!I~l~i.ll.1111 11::.1111:.1:;11'11:.....::"111: :).....~:~lT'IIII:::::.!1 :1..IIII...:j.I!:ili~.lif.'jii:i:::.1 ['[lli;tlllllilli:!!::\ . ., .. . ... . * BALANCE IS DUE UPON RECEIPT * THANK YOU * ~ DONALD 01/12/05 DONALD CONSULT OFFICE LEVEL 5 PATIENT COINSURANCE OFC VISIT, EST LEVEL 4 PATIENT COINSURANCE CANCELATION OF APPOINT 255.00 170.18 22.55 .00 DONALD 110.00 63.18 .00 .00 .00 .00 .00 .00 '0\-1 Icj } 0er1iYaJ PA Pr5SOCl CA.J-es Onco logy --- SPECIAL COMMENT: atient balance is due upon receipt! (*) indicates insurance due monies. We abate insurance due for 45 days, then you re responsible for payment in full. If you must pay insurance due monies, please notify your employer and insurance arrier. 35.79 .00 35.79 35.79 .:.:.I...I:,':11111111!111:l:jIIIII111111Il..II:.I~I~~1.:11.111.jll...::II.lrl.tll:!::i:'jl:I':'II;;iil~lIf.1111'11'1" 111Iiillll'll.:j:.:il.1:.I::li:li..r.'II:II::I::': . .00 .00 .00 2322.48 * BALANCE IS DUE UPON RECEIPT * THANK YOU * ..... .... . Sprlnt@ Monthly statement: January 1, 2005 10f 7 ~ 'I !: Customer service 1-800-829-8009 Internet address sprint.com/local i. Customer number . ! . 717-258-4017-469 I I \ i I, I i i i I ! local Long Distance Total Monthlv Service Charges 11.54 .00 11.54 Discounts and Promotions -3.00 -3.00 Other Charges and Usage .07 28.77 28.84 Taxes and Surcharges 6.13 3.50 9.63 Previous charges Payment December 16 - Thank you! 1 ;. Balanc~ . 24.58 -24.58 .00 ....... ,.............-.......... ." _-'......... '.....H.....' "..-.-........."............,....... . ...."........................ ..........-................ 2oo$'t: :T~tal..Dlje:..;." ...,.....,........,...-...,......-...,............. ,D~ii'Due;W \ I 7 , u u / 1/ IO~ I L @ Please recycle NNNNNV~ 1'.' ~ Sprint~ / Monthly statement: February 1, 2005 10f 5 Customer service 1-800-829-8009 Internet address sprint.com/local Customer number 717-258-4017-469 Summary of Current Charges Local Long Distance Total Monthly Service Charges .92 .00 .92 Discounts and Promotions -3.00 -3.00 Partial Month Charges -2.47 .00 -2.47 Other Charges and Usage .00 14.10 14.10 Taxes and Surcharges -.05 1.42 1.37 Previous charges Payment Januat\' 25 - Thank you! Balance ~/l3!O~ * Please recycle MMMNNNYY 5 II -~ ~ ;"5:t:.:f-~~~ Account Number: . 4121 449998338649 Closing Date: 02123/05 Credit Limit: $9,500.00 Available Credit: $0.00 ......- , :'"0" .,. Ac:couQt SUIMlCilI'Y..;' ..... ,.' Previous Balance. S Purchases Cash Credits PaymentS Insurance other Debits finance Charges NEW BALANCE VISA- cAG~~~m! .1~q~jii~~~J~~~:.:ofl' iilA Customer Service: ... (717) 795-6032 ~(\:~;:~;,~:_:;J~G ~~,"-; -,':"'.' '. '-',...t:',',";_.'."" ;: ,>:":~;"';;;~*-':~-i_ ~~.~.- I~ ~::~n~,:~yment Due ;3J~~:" Mall payments to: VISA POBOX IT044 MADISON WI 53707-1044 .:jt1iIi(jJtirjj .~~W * tHE TOTAL FINANCE CHARGE PAID ON YOUR ACCOUNT DURING THE PAST YEAR . * WASu.$ 0.00 * ...\"....&.......l...~..J.....&,.....A.,U,A......"'........,....."".......L"'.......Lll.................J..L"......A.......~.........* . . TO REPORT A LOST OR STOLEN CARD PLEASE CALL: 800-325-3678 LST STLN AFTER HRS 717-795-6032 MEMBERS 1STF.C.U. TO OBTAIN ACCOUNT INFORMA TlON 24 HOURS A DA Y CALL: 800-299-9842 "~': '::' ;; _co, ;.,.-___~-.~,"". ";"';-~.'-':-_."'::''- ;;-- 01f26 01/27 6010 $ 14296- ~05h - il~eJl1 cecl( -fo Page 1 of 1 U6 L ~, /) 5 Customer: Cec.n G ( DONALD GABANY ~ ':::'j Account Number: e. ~11-0074758-0061-6 INVOICE Invoice Date: 03/01/2005 Invoice Number: 2683618-0061-1 Due Date: Due Upon Receipt WM ezPay Account 10: 00006-34135-02004 fj. . E MANAGEMENT ANAGEMENT r:\ALPA JSTRIAL PARK RD .L PA 17011 '()878 .8850 .9153 FAX 3'-1 S- -cJ 5- ~ "d"a,:.", "',",,',' :."_._;.;'.: .,_..,.-.;,.., <'~. ....:.j: _. ._::.,. <:: .,.,.:...-;.,;',.": >'__ .., :..:';>,_'.,:i,:.' It !;-..mmary n Amount Balance 46.26 3dits and Adjustments 0.00 yments Received 46.26- Tent Charges 46.80 Total Amount Due 46.80 Total Amount Past Due 0.00 e P,"Od:',':M4R4~PR:rMY2O(fS:;:;+:T~~;i~\~iti;~,o::i,;.~.ifit,~*,~;S!&:2~1:~,?i7L{:8'~l~:(~~ e t.o,iatiQrl;~t17'l:.~$8;i;~l:iapj./QQii~t~fW'eXfQrg:~~;::';::ilji:fS!~;0~:j\~;~;~ Description Qty Amount 5 Tags rei rs 18 tags Total Current Charges 0{I~OS- ~ ~ Current Invoice Amount Total Amount Due ',,1 46.80 Please pay total amount due. Thank you for your business. WE CAN NO LONGER ACCEPT PAYMENTS AT OFFICE LOCATIONS. PLEASE USE REMIT TO ADDRESS ON PAYMENT COUPON. Want to pay this bill by phone? Please call 1-888-824- n 44 to make a convenient, secure payment. Available 24 hours a day, 7 days a week. Check ou1 Matt Kenseth racing the #17 WM Ford Taurus in the NASCAR@ Busch Series Want to pay this bill on-line? Go to www.wm.com to leam more about WMezPay and make a convenient, secure payment. WSO IMAGING CENTER, LP BILLING OFFICE 1 A92 2527 CRANBERRY HIGHWAY WAREHAM MA 02571-5010 800.299.9170 OR 508.295-5556 Office hours are: 8:30AM - 4:30PM Eastern Time 7:30AM - 3:30PM Central Time If you have an HMO please reply promptly EIN 13-4269349 P0103TOO110337 DONALD GABANY A92*123547 9 WEXFORD COURT CARLISLE PA 17013-7612 1111111.. .111'1'11111..11.111.1.111'11.11..1.111'111.1111111.1 PAGE 1 ,.@? ~C1f1J R ~ct. ~ 1fo~ ~.. -- !!!!!!!!!! iiiiiiiiiiii - -- - 8- o~ ~- O~ .- iiiiiiiiiiii - -- = -- !!!!!!!!!! .... ... ..... l;::.: ':: . ..., . ........,... .. ... ...........' . . , . . ...... '" Graham Motor Company, Inc. 1402 Holly Pike Carlisle, Pennsylvania 17013 Tel. (717) 243-3066.(800) 641-2221. Fax (717) 249-7998 Web Site: http://www.grahammotors.com E-Mail: graham_saleS@kns.net SERVICE ADVISOR: 119 GUS FRIDENVALDS ':'.IN.: ' .~!.~, '...' :ltl;i\~E!NrQ:QT .... 84007 2585373 RIDER JOYCE RIDER 9 JERRY DRIVE BOILING SPRINGS, PA 17007 HOME: 717-258-5373 BUS: 717-772-5807 *INVOlCE* PAGE 2 LIST NET TOTAL .:, . ~ .. ,', ....:.... ON BEHALF OF SERVICING DEALER, I HEREBY CERTIFY THAT THE INFORMATION CONTAINED HEREON IS ACCURATE UNLESS OTHERWISE SHOWN. SERVICES DESCRIBED WERE PERFORMED AT NO CHARGE TO OWNER. THERE WAS NO INDICATION FROM THE APPEARANCE OF THE VEHICLE OR OTHERWISE, THAT ANY PART REPAIRED OR REPLACED UNDER THIS CLAIM HAD BEEN CONNECTED IN ANY WAY WITH ANY ACCIDENT, NEGLIGENCE OR MISUSE. RECORDS SUPPORTING THIS CLAIM ARE AVAILABLE FOR (1) YEAR FROM THE DATE OF PAYMENT NOTIFICATION AT THE SERVICING DEALER FOR INSPECTION BY MANUFACTURER'S REPRESENTATIVE. TATEMENT OF DISCLAIMER The factory warranty constitutes ell of the warranties with respect to the sale of this item~tems. The Seller hereby expressly disclaims all warranties either express or implied. including any implied warranty of merchantability or fitness for a particular purpose. Seller neither assumes nor euthorizes any other person to assume for it eny liability In connection with the sale of this item/items. (SIGNED) DEALER, GENERAL MANAGER DR AUTHORIZED PERSON (DATE) CUSTOMER SIGNATURE PLEASE PAY THIS AMOUNT CUSTOMER COPY Members 1st Federal Credit Union Online - My Accounts - Check Images Page lof 1 ~lL.\lBLR~ 1~( Ol\LI~E Accounts Home View Account Details Order Statement Withdraw by Check Export Account Information Transaction Search VISA History Loan Application Mortgage Application Online Services Planning Tools Personal Profile Privacy Policy Security Terms & Conditions Site Map Transfer Funds Contact Us Help Cb.eckJmages The images you requested may take a few minutes to download. If the ima~ not appear within several minutes, please contact the Call Center at (SOD) 8 Representatives are available to assist you Monday through Friday, from 7al 7pm,and Saturday Sam to lpm. Click on the image to view a larger version. Back to History Front of Check: JOYCE M..IODER ..)IIiI!IiNY.... IIl.J1'N5MlIn 1lOUl\lCSI'lIllNGS.... UIlI7 ....,... 115 - ~n~-Ql'-OS IS 10.00 IMnoAAA .~III' i II AI. n .-.d... I l\rf.l- !m!e C III i8 ll.. &C IX) J tO~ . IntA1s. m ,,- CNv . Back of Check: - ... 1i'~~n~ I I;.l>i~i"~ t!t\~u. fi~Q 1~ ii4;.~~ ~: 'L):~~7 i~~~:l~ ~......~-..;:: &~"'\...~ Back to History Savings federally insured by NeUA. Accounts Home Transfer Funds Equal Opportunity Lender. Contact Us Help https:fJol1line,members 1 storglservletftpservlet?transactiontype=sessionProfileActionBean", 4illJ'2D05 Members 1st Federal Credit Union Online - My Accounts - Check hl1ages Page 1 of 1 l\lL.\lBLR~ l~t 01\:LI:\"E Accounts Home View Account Details Order Statement Withdraw by Check Export Account Information Transaction Search VISA History Loan Application Mortgage Application Online Services Planning Tools Personal Profile Privacy Policy Security Terms & Conditions Site Map Transfer Funds Contact Us Help Cb.eckJmages The images you requested may take a few minutes to download. If the ima~ not appear within several minutes, please contact the Call Center at {BOO) 8 Representatives are available to assist you Monday through Friday, from 7al 7pm, and Saturday Sam to lpm. Click on the image to view a larger version. Back to History Front of Check: r........- J()YCEM.IUDER 9~ IH.~ .......SftfiGS.I'A DlIIIW 1.1.8 .....,.... - ~_ e1 -bl'l .M'" I rr~e;;::z;;~~~_ I $:.:..I.~~ l-~~---~:_~. ':lJ;'J8li..lC lWUsar.S'''. . a fIlOOOOD1'ifar.ra.... Back of Check: . 04 J 7942''*98 O3OJ2tlO6 03J0Cll:l040 Fr.l'B~Alll.A bf'la SPaS.. 'nlC= U?3.? PfC-08 - 'Q N C;j;,o ~ -:... 'fan ". o:~~ 0 t..~:; ~~"'~l t" ~~.....:. .:.....~" .. ,,:) E:-;~:3 ::j~~:: ~,i~t~ - t.~ ... ;':~ . gO ..... '::t ~ 0> 0> - ~"l ~ I c.....qc<";,Qtn~ .J.;:;i..:'_ot~-I-",:~4. Back to History Savings federally insured by NeUA. Accounts Home Transfer Funds Equal Opportunity Lender. Contact Us Help https:#online,menibers1storg!servletltpservlef?transactiontype=sessionProfileActionBeal1", 4/11/2005 1/28/2005 BOILING SPRINGS ANIMAL HOSPITAL 550 PARK DRIVE BOILING SPRINGS, PA 17007 (717) 258-4575 Page 1 /1 Mr. & Mrs. Glenn & Joyce Rider 9 Jenny Drive Boiling Springs, PA 17007 Client 10: 756 Invoice #: 180602 Patient 10: 15242 Patient Name: Nicki Species: CANINE Breed: POODLE, MINIATURE Weight: 8.10 pounds Birthday: 01/28/1991 Sex: Female 1/28/2005 1/28/2005 1/28/2005 1/28/2005 1/28/2005 DescrlDtion Deramaxx 25 mg Chewable Tablet OFFICE CALUEXAMINATION LEVEL I EXAMINATION AFTER HOURS FEE YOUR VET WAS DR. PITTELlI THANK YOU JILL - RECEPTIONIST Staff Name Karen J. Pittelli, DVM Quantitv 5.00 1.00 1.00 1.00 1.00 Patient Subtotal: Total $8.00 $25.00 $11.00 $0.00 $0.00 $44.00 Instructions Please inform our office of any changes to your address or home phone number. Invoice Total: Total: Balance Due: Previous Balance: Balance Due: Check Check Number 3089: Less Payment: Balance Due: $44.00 $44.00 $44.00 $0.00 $44.00 ($44.00) ($44.00) $0.00 Please inform our office if the address or telephone number on your pet's record has changed since your last visit. " I . AD-Automatic Deposit . AP-Automatic Payment . ATM-Teller Machine . DC-Debit Card . T-Tax Deductible . TT-Telephone Transfer NUMBER OR DATE TRANSACTION DESCRIPTION PAYMENT ,/ FEE DEPOSIT $ 'S'1L/ ~:S7 CODE AMOUNT AMOUNT ~ 10 J.- Ilz S- f-J.dUQ .,5(. ; ~ $ 20 f:o $ 3~j 37 hc-e V), Vl'YI Q100 l/z.'') Good Mop e.. COfXJ-Y fD )0 3 t..fi- 37 . ~]P.~ 1\1]~f j.{V\ tSt?] ,,'~ ..$f'. <itb. "0 ~bg l7 ." . '. . I - I t ,:':-;:'^ .. ,- -- . >7 ---.. . '" ... ..-:-- '. .....{ . .... i. '.' ..... .. Ii ..... ...... '.. ....... . .... ....../ '.' ........ /. >. '.' ......... .. ...... .......... ..... '. >.. '.. I .... .. I ~ '. . ......... .... ..... ." .' ~ ...... , ; ~ . <. - .' .... ..' < .' / < , .. I......... ...... ". .. ~ I.. . '. . ...... ........ . '.' 0 .......... > ......... ........... .... i > I. .... ..... I '.' , .... .... ./ '. .... < . .... I> .. ........... .......i .,./ <.1. .............. ..i/..< ..... >. .. . ....... ... .. ,~=-.~.- I . ....'1 '.' ~-.'r~ . .... i .... .. PROTECT YOUR ACCOUNT _ KEEP CHECKS IH A SAfE PlACE. If THEY ARE LOll OR llOlEH. HOTlfY YOUR flHAHCIAllHlTlYUTlOH IMMEDIATELY. =- r[ '..'...~- .....T{-.~ .._-.b-,.'"""_....'W~--'"""'...~"~,.."lh',..,"'~ntt'";;C'"""f"".',,,,,.,~".._ ,.'-v ,,,,.,.~,,~,~, ,,,,-'~'c-'?""'"""",,,",,,:.,,,.; 7""'''''',",JF.~?1;"'7 .i i ./ I I r I i I I I I I ! -.. ( , ) ( - iiiiiiiiiii ;;;;;;; - _w _II: _m -0 -I- _Ill -., !!!!!!!!! - - HOLY SPIRIT HOSPITAL ~ 503 NORTH 21 ST STREET CAMP Hill, PA 17011-2288 11111111111111111 ~1II11111111111111111111 11I1I 1111111111 11111 ~IIIIIIIII~IIIII MAR 29 2005 Patient Name: Account Number: Patient Responsibility: , Date of Service: 09/25/04 DONALD W GABANY 24053811 :l:'l':~~~illj:!!~iiiilii:~~:i:i:::::.::::l~'i:::::::::~~~:: Lf (to lor:::- 1,11" 1,11" 1,11" 11.111.11.1'111.11.1..1..."" 11.1.1..1'11" 16800 AT 0.292 DONALD W GABANY TRDDDD7 9 JENNY DR BOILING SPRINGS, PA 17007-9541 Dear Patient/Guarantor: Thank you. for choosingHOL Y SPIRIT HOSPITAL for your health care needs. Your account has a balance of $54.56. If you are unable to pay this amount in full, or have any questions, please contact our Patient Financial Services by calling (Toll Free) 1-877-254-9239. If you have insurance coverage, please contact us immediately so that we can bill your insurance for you. If you have already paid the balance, thank you, and please disregard this letter. Sincerely, Patient Financial Services If you have multiple accounts, please indicate the account numbers and the amount applied to each on your check. Payments received without an account number may be applied to the oldest account. -------_________y!~~~~~b~~t~~~~~~~~~~~~~~~tty________________ PI FASF RETURN THIS PORTION WITH vnUR PAVMFNT LAST WILL AND TEST AMENT OF DONALD W. GABANY Know all men by these presents, that I, Donald W. Gabany, the undersigned of 9 Wexford Court, Carlisle, South Middleton Township, Cumberland County, Commonwealth of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all former wills by me at any time heretofore made. 1. I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can be conveniently done. Note: see my burial arrangements at Rolling Green Cemetery, Camp Hill, P A. 2. All the rest, residue and remainder of my estate, real, personal and mixed, of whatsoever nature and wheresoever the same may be situate, I give, devise and bequeath to my daughter, Joyce M. Rider, absolutely and unconditionally. 3. In the event my daughter should predecease me or die within thirty (30) days of my death, then I give, devise and bequeath my entire estate to my grandchildren, Sarah M. Kingsborough and Stephanie D. Kingsborough in equal shares. 4. Lastly, I nominate, constitute and appoint my daughter, Joyce M. Rider, Executrix of this, my Last Will and Testament, and in the event she should be unable or unwilling for any reason to serve in such capacity, I nominate, constitute and appoint my son-in-law, Glenn H. Rider II, executrix of this, my Last Will and Testament. Dated: August 9, 2000 V~~i~je1J COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND 5S: On this, the 9th day of August, 2000, before me, a Notary Public, personally appeared Donald W. Gabany, known to me (or satisfactorily proved) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto setroy hand ~ seal. & ~liC Notarial Seal Maryann Ellis, Notary Public Wormleysburg Bora, Cumberland County My Commission Expires Nov. 21, 2003 Member, Pennsylvama Association ot Notaries COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT RIDER JOYCE M 9 JENNY DRIVE BOILING SPRINGS, PA 17007 ___nn_ fold ESTATE INFORMATION: SSN: 234-52-6342 FILE NUMBER: 2105-0124 DECEDENT NAME: GABANY DONALD W DA TE OF PAYMENT: 04/15/2005 POSTMARK DATE: 04/15/2005 COUNTY: CUMBERLAND DATE OF DEATH: 01/18/2005 NO. CD 005209 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $6,596.46 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: J M RIDER CHECK#148 SEAL INITIALS: VZ RECEIVED BY: REGISTER OF WILLS $6,596.46 GLENDA FARNER STRASBAUGH REGISTER OF WILLS