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1 � , 1505610143 i C.L REV-1500 EX(02-11) PA Department of Revenue OFFICIAL USE ONLY p Pennsylvania County code Year Fie Number Bureau of Individual Taxes DEPAKMBff OFMWEN'E PO BOx.280601 ' INHERITANCE TAX RETURN 21 14 0580 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 06 09 2014 12 26 1950 Decedents Last Name Suffix Decedents First Name MI NELSON IRA I (If Applicable)Enter Surviving 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 Return2- Supplemental Return 3. Pemarior to d2 582)(Date of Death F] 4. Limited Estate E] 4a.Future Interest Compromise F1 5. Federal Estate Tax Return Required (date of death after 12-12-82) Fx1gDecedent Died Testate Decedent Maintained a Living Trust 0 (Attach Copy of Will) El (Attach Copy or Trust) 8. Total Number of Safe Deposit Boxes 9. Litigation Proceeds Received 10.SbPousal ov Ziit(Dattee�f Death F] 11.Election to tax under Sec.9113(A) t (Attach Schedule O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number RICHARD L WEBBER JR ESQU 717 532 7388 REGISTER OF WILLS USE ONLY First Line of Address 126 EAST RING STREET E Second Line of Address C7 T F D 1-4 City or Post Office State ZIP Code r~ t SHIPPENSBURG PA 17257 ' ,r- n 71 Correspondents e-mail address: rwebbe ei leassociates.com f-j r" M Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my kno tafte a it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which Pieparer has any tMIalkledge. } NGNIMUktE OF PERSON PO�S1 FOR FI DATE Jineene A. Brown :2o ' SS 205 CME,Newville,PA 17241 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ,/f / Richard L.Webber,Jr.,Esquire ADDRESS 126 East King Street,Shippensburg,PA 17257 L 1505610Side 1143 1505610143 J �J 1505610243 REV-1500 EX Decedent's Social Security Number O-ed-rsN-e: Nelson, Ira Irvin 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(Schedule E)............... 5. 62,217. 80 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 7. Inter Vivos Transfers&Miscellaneous NaR Probate Property (Schedule G) u Separate Billing Requested............ 7. 55,037. 74 8. Total Gross Assets(total Lines 1 through 7)........................................................ 8. 117,255. 54 9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 1-2,394 .44 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 6,572. 68 11. Total Deductions(total Lines 9 and 10)................................................................ 11. 18, 967.12 12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 98,288.42 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. 98,288 .42 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 15. 0. 00 16. Amount of Line 14 taxable at lineal rate X .045 98,288 .42 16 4,422. 98 17. Amount of Line 14 taxable at sibling rate X.12 0 . 00 17. 0 . 00 18. Amount of Line 14 taxable at collateral rate X.15 0. 00 18. 0. 00 19. TAX DUE................................................................................................................ 19. 4,422. 98 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 21-14-0580 Decedent's Complete Address: DECEDENT'S NAME Nelson,Ira Irvin STREETADDRESS 165 CME CITY STATE ZIP Newville PA 17241 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 4,422.98 2. Credits/Payments A. Prior Payments B. Discount 0.00 Total Credits(A +B) (2) 0.00 3. Interest (3) 4. If Line 2 is greater than Line 11+Line 3,enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2,Line 20 to request a refund 5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 4,422.98 Make Check Payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN"X"IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;............................................................................... ❑ ❑x b. retain the right to designate who shall use the property transferred or its income;.................................. ❑ ❑x c. retain a reversionary interest;or.............................................................................................................. 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?...................................................... ❑ 0 .............................................................. 3. Did decedent own an"in trust for' or payable upon death bank account or security at his or her death?....... ❑ ❑x 4. Did decedent own an individual retirement account,annuity,or other non-probate property which contains a beneficiary designation?.................................................................................................................. 0 ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1,1994 and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(1)]. 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 percent [72 P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent,or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedents 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 decedents siblings is 12 percent[72 P.S.§9116(a)(1.3)]. A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. Rev-1508 EJC+(1140) SCHEDULE E pennsylvanla CASH, BANK DEPOSITS, & MISC. DEPARTMENT OF REVENUE INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Nelson,Ira Irvin 21-14-0580 Include the proceeds of litigation and the date the proceeds were received by the estate. An property jointly-owned with the right of survivorship mast be disclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 ACNB Bank Account#152811 -Checking Account 1,823.68 Accrued interest on Item 1 through date of death 0.04 2 ACNB Bank Account#9644334-Savings Account 8,861.45 Accrued interest on Item 2 through date of death 0.96 3 ACNB Bank CD#900043206726 25,000.00 Accrued interest on Item 3 through date of death 42.24 4 Minnequa,Legion,Comcast -Refunds 281.43 5 1985 Skyline Mobile Home VIN#22110394L7 4,000.00 6 2004 Ford F150 Super Crew Cab 4WD VIN#1 FTPW145X4KC20622-Mileage 88,267 11,295.00 7 2009 Chevrolet Impala LT VIN#2G1 WT57NX81252431 -Mileage 36,000 10,913.00 TOTAL(Also enter on Line 5.Recapitulation) 62,217.80 (If more space is needed,additional pages of the same size) Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule E(Rev.11-10) Rev-1510 EX+(08 09) SCHEDULE G pennsylvania INTER-VIVOS TRANSFERS AND DEPARTMENT OF REVENUE INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Nelson,Ira Irvin 21-14-0580 This schedule must be completed and filed if the answer to arty of questions 1 through 4 on page three of the REV-1500 is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECO'S EXCLUSION TAXABLE NUMBER THE INCLUDE OF TROAFNSFRERSATSfAC1 A COPY OF TEIR HE DEED FFOHIP TO REREAL STATDE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1 ACNB Bank IRA#455175300002 57,979.61 3,000.00 54,979.61 Accrued income on Item 1 through date of death 58.13 58.13 TOTAL(Also enter on Line 7.Recapitulation) 55,037.74 (If more space is needed,additional pages of the same size) Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule G(Rev.08-09) REV-1511 EX+(10-09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND tWERITANCE TAX RESIDENT DECEDENT RETURN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Nelson,Ira Irvin 21-14-0580 Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: See continuation schedule(s)attached 7,596.19 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zio Year(s)Commission Paid 2. Attorney's Fees Weigle&Associates,P.C. 3,500.00 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation) Claimant Street Address City State ZiD RelationshiD of Claimant to Decedent 4. Probate Fees 228.50 5. Accountanfs Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 1,069.75 See continuation schedule(s)attached TOTAL(Also enter on line 9,Recapitulation) 12,394.44 Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.10-09) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Nelson,Ira Irvin 21-14-0580 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Eby Granite Works-Headstone 475.00 2 Egger Funeral Home 5,921.19 3 Egger Funeral Home-Grave opening 400.00 4 Pastor Kevin Dunlap-Minister 200.00 5 Plainfield First Church of God-Meal after funeral 600.00 H-A 7,596.19 Other Administrative Costs 6 CME-Lot Rent for July 250.00 7 CME-Lot Rent for August 260.00 8 CME -Lot rent for September 255.00 9 Cumberland Law Journal-Advertising 75.00 10 Sailhamer Real Estate-Appraisal of Mobile Home 125.00 11 Valley Times-Star-Advertising 104.75 1-1-67 1,069.75 Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98) Rev-1512 EX*(12-08) SCHEDULE pennsylvania DEBTS OF DECEDENT, DEPARTMENT OF REVENUE INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Nelson,Ira Irvin 21-14-0580 Report debts Incurred by the decedent prior to death that remained unpaid at the date of death,Inctuding unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 ACNB Bank Loan#8837031 3,107.51 2 Adams Electric Cooperative,Inc.-Electric for month of June 125.00 3 Adams Electric Cooperative,Inc.-Electric for months of July,August 732.84 4 AT&T 76.00 5 Carlisle Regional Medical Center 150.00 6 Nancy Herlt-Lawn Care 200.00 7 Pa Central Credit Union-Credit card 2,120.33 8 Penn State Hershey Medical Center 16.00 9 Walgreens Specialty Pharmacy 45.00 TOTAL(Also enter on Line 10,Recapitulation) 6,572.68 (If more space is needed,additional pages of the same size) Copyright(c)2008 form software only The Lackner Group,Inc. Form PA-1500 Schedule I(Rev.12-08) REV-1513 EX+(Ot-10) pennsylvanla SCHEDULE J DEPARTMENT OF REVENUE INHERrrANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Nelson, Ira Irvin 21-14-0580 NAME AND ADDRESS OF RELATIONSHIP TOSHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (Words) Do Not List Trust s I� TAXABLE DISTRIBUTIONS [include outright spousal distributions,and transfers under Sec.9116(a)(1.2)] Jineene A.Brown Daughter One Hundred 98,288.42 205 CME Percent of Net Newville,PA 17241 Estate Total 98,288.42 Enter dollar amounts for distributions shown above on lines 15 LI H UUY h 18 on Rev 1500 cover sheet,as appropriate. NON-TAXABLE DISTRIBUTIONS: H. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01-10) .. � 4 E 14" LAST WILL AND TESTAMENT I, I. IRVIN NELSON, presently residing at 165 CME, Newville, Lower Mifflin Township, Cumberland County, Pennsylvania 17241, being of sound mind, memory- and disposition, do hereby make, publish and declare this my Last Will and Testament, hereby revoking and making void all Wills by me at any time heretofore made. F RST: PAYMENT OF EXPENSES - I order and direct my personal representative hereinafter named to pay all of my just debts, funeral expenses and expenses involved or connected with the administration of my estate as soon after my death as is reasonably possible. However, my personal representative need not accelerate and pay those unmatured obligations which, in his,her or its opinion, it might be proper and more advantageous to retain or renew and pay as they become due and payable. .If I do not own a burial plot or a grave marker at the time of my death, I authorize my personal representative, in his, her or its sole discretion, to purchase a burial plot and to erect a suitable grave marker at my grave, and to expend sums from my estate for this purpose. SECOND: PERSONAL EFFECTS - I bequeath my household furniture and furnishings and those articles of my personal effects and personal property to my daughter, JINEENE ANN WARNER.. THIRD: RESIDUE OF ESTATE—I give, devise and bequeath all the remainder of my estate, real, personal and mixed, whatsoever and wheresoever situate to my daughter, JINEENE ANN WARNER FOURTH: CONTINGENT BENEFICIARY - In the event that the said JINEENE ANN WARNER should predecease me, I then give, devise and bequeath all of the remainder of my estate to my granddaughter, FELICIA SUZANNE NELSON, subject to paragraph FIFTH below if applicable. FIFTH: TRUST—In the event that my granddaughter,FELICIA SUZANNE NELSON is under the age of twenty-one (21) years, I then direct that her share be placed IN TRUST with LOLA KAY HILLEGAS as TRUSTEE of any property which passes under this Will or otherwise, to invest and re-invest the same until my granddaughter reaches the age of twenty-one (2 1)years,with the following powers in addition to those presently given by law: A. While the beneficiary is a minor, the power to expend the income and, if necessary, the principal towards the health, support and maintenance, and education of the said beneficiary; and WEIGLE & ASSOCIATES, PC. - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG. PA 17257-4397 B. The power and obligation to distribute the remaining balance of the Trust when the said beneficiary reaches the age of twenty-one (21) years, without the necessity of a formal adjudication of the Trustee's Account in the Court of Common Pleas of Cumberland County, upon the receipt of a good and valid release; and C. The principal of the Trust and the income therefrom shall be free from the debts, liabilities. and engagements of those beneficially interested therein, and shall not be subject to assignment by her,nor to attachment or execution under any legal, equitable or other process for the enforcement of judgments or claims of any sort against them, either individually or. collectively. SIXTH: Should my daughter, JINEENE ANN NELSON and my granddaughter, FELICIA SUZANNE NELSON, both predecease me or die on or before the thirtieth day following my death so that distribution could not be made under the foregoing Paragraph TIIIRD or FOURTH, I give, devise and bequeath the remainder of*my estate to my sister, LOLA KAY HILLEGAS. SEVENTH: PERSONAL REPRESENTATIVE - I nominate, constitute and appoint my daughter, JINEENE ANN NELSON,to be the Executrix of this my Last Will and Testament_ In the event that she be unable to fulfill the duties of Executrix, I then nominate, constitute and- appoint my granddaughter, FELICIA SUZANNE NELSON as Executrix of this my Last Will and Testament, if she has attained the age of twenty-one (21) at the time of my death. In the further event that my granddaughter has not attained the age of 21 at the time of my death or is unable to serve, I nominate, constitute and appoint my sister, LOLA KAY HILLEGAS, as Executrix. EIGHTH: WAIVER OF BOND - I direct that my personal representative(s), Guardians, and-Trustees shall not be required to give bond for the faithful performance of their duties in any jurisdiction. NINTH: NO PROVISION FOR EDIBERLY DAWN NELSON- I have made no provision in this Will for my adopted daughter, IUZBERLY DAWN NELSON, for reasons which are well known to her. TENTH: TAXES - I hereby direct that all federal, state and other death taxes payable because of my death, with respect to the property forming my gross estate for tax purposes, whether or not passing under this Will, including any interest or penalty imposed in connection with such taxes, shall be considered a part of the expense of administration of my estate and that such be paid out of the rest and residue of my estate. WEIGLE & ASSOCIATES. P.C. - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG. PA 17257-1397 1 IN WITNESS WHEREOF, I, I. IRVIN NELSON have hereunto set my hand and seal to this my East Will and Testament, the first two (2) pages signed.for identification only, this day of 2009. Aem"� (SEAL) I. NELSON This instrument-was by the Testator, on the date hereof, signed, published- and declared by I. IRVIN NELSON to be his Last Will and Testament, in our presence, who at his request and in the presence of each other,we believing him to be of sound and disposing mind and memory,have hereunto subscribed our names as witnesses. WEIGLE Sc ASSOCIATES. P.C. — ATTORNEYS AT LAW — 126 EAST KING STREET — SHiPPENSBURG. PA 17257-1397 COnVONWEALTH OF PENNSYLVANIA Ss COUNTY OF CUMBERLAND 1, L IRVIN NELSON, the person whose name is signed to the foregoing instrument,having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument I as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. NELSb- f-4 Sworn or affirmed to and acknowledged before me by 1.IRVIN NELSON,the Testator, this day of 2009. /Z Notary Public NOTARIAL SIAL RICHARD L.MEBBER JR.,NOTARY PUBLIC SHIPPENSBUPG BOPO.CUMBERLAND COUNTY My COMMMI ON EXPIKES JULY 15,2010 WEIGLE & ASSOCIATES, P.C. - ATTORNEVS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND We, .. and ) tir( Cc A e the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law,-do depose and say that we were present and saw L IRVIN NELSON, the Testator, sign and execute the instrument as his Last Will;that he signed willingly and that he.executed it as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of-the Testator, signed the Will as witnesses; and that to the best of our knowledge the Testator was at the time eighteen (18) or more years of age and of sound mind and under no constraint or undue influence. Sworp,ormffirmed to-and subscribed before me Vz by rt I C witnesses this day of 2009. Notary Public NOTA M-11 SEAL RICHARD L.VVEBBER JR.,NOTARY PUBLIC SHIPPENSBURG BON-0,CUMBESLAND COUNTY Ply COQ MISSSION EXPIRES JULY jr),2olo WEIGLE & ASSOCIATES. P.C. - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG. PA 17257-1397 ACNB BANK July 3,2014 Richard L. Webber,Jr., Esquire Weigle&Associates,P.C. Attorneys at Lav 126 East King Street Shippensburg,PA 17257-1.397 Re: Estate of Ira Irvin Nelson Dear Mr. Webber: The following information is being provided as per your request: Acct.Type Account No. Account Accrued Ownership Date Date Opened Principal on Interest to Joint D.O.D. D.O.D. Checking 152811 $ 1,823.68 $.04 Individual N/A 2/17/1989 Savings 9644334 $ 8,861.45 $.96 Individual N/A 6/30/1983 CD 900043206726 $25,000.00 $42.24 Individual N/A 3/24/2014 IRA 455175300002 $57,979.61 $58.13 Individual- N/A 2/19/2008 Beneficiary Jineene A.Warner-Nelson Inquiries concerning ACNB Corporation stock information should be directed to the Registrar--^d Transfer Company at 1-800-368-5948. If you need any additional information,please contact me at(717)339-5116. Sincerely, Lois A Kime Deposit Services Supervisor acnb.com a acnbbusiness.com o PO.Box 3124,Gettysburg,PA 17325 Phone 717.334.3161 =fall Free 1.888.334.E CNB(2262) AD-Avtometic Deposit•AP-AL4ormlic Payment•ATIA-Cash mukawat•DC-Dfid 60d+FT-FwA-.TTmmfes•SC-Senice Charge•M Tax DeducfiZtte CD8 .. .. • . - - -- :PAYMEAQ;k�,- - _.:17�IT- GUEE.. .ik,'i'E - �v4Mat iOt V D 110Pi. - ..Yfl'►i-MWAt. aiEW(4) '[t 4 i4: '-t�11�1 Qt 1" tSr 10 y - a to`7 "�?7 c,_r i(.5�e orb t M ISLi 7 C I. Cts 't rte} • - - Kelley Blue Book Pae 1 of 2 " Kellet Blue Book The Trusted Resource i. �r rkfvatis°m:strt Y{�,�, 2004 Ford F150 SuperCrew Cab Sell To Private Party Pricing Report G*0d CEx,aticn $1'f,295 $10,420 $4#:,570 g 'Style:XLT FMJQ p 4D 51/2 it CoexlRiws Mileage:ss,267 '.$11.970 :.r Vehicle Highlights .,..r Fuel Economy: Max Seating:6 Private Party Values valid for your area through 7/2/2014 city 14Mwy 18/Comb 16 MPG Doors:4 Engine.VB,4.6 Liter Drivetrain:2wD Transmission:Automatic EPA Class:Standard Pickup Trucks Body Style:Styleside Pickup Country of Origin:United States Country of Assembly:United States Your Configured Options { Our options,basal oni typical equipment for this car. 1 Options that you added while configuring this car. Engine ! Braking and Traction i Entertainment and Instrumentation t VS,4.6 Liter ABS(4-whew i AM/FM Stereo r Transmission f Comfort and Convenience t CD(Single Disc) Automatic Air Conditioning safety and Severity Drivetrain Pourer Windows Dual Air Bags 2\WD Power Door Locks I wheels and Tires Cruise Control Alloy wheels !! Steering i Power Steering i t Tilt wheel f s i 2 , Glossary of Terms Kelley Blue Book@ Trade-in Value-This Is the amountTi p you can eared to receive villein you trvrJa in your car to a dealer.This value is deiecmined based on the style,cwxfdiw,mileage and options Its crucial to know your car's i"dimted' true condition when you sell it, Trade-In Range-The Trade-In Range Is Kelley Blue Books estimate of what you can reasonably egred so that you can price it to receive this week based on the stye,oocnditior,mileage and options of your veNde when you trade It appropriately.Consider having In to a dealer.Hasew.r,every dealer is different and values are not guaranteed. your mechanic give you an objective report. Kelley Blue Book@ Private Party Value-This is the starting point for negotiation of a used-car sale between a private buyer and seller.This is an'as bf value that does not include any warranties.The finial price depends an the car's actual conditiorr and local market factors. http://wtuNnv.kbb.com/ford/fl50-supercrew-cab/2004-ford-fl 50-supercretu-cablxit-pickup-4d... 7!2/2014 Kelley Blue Book Page 2 of 2 Private Party ttange-The Private Party Range is Kelley Blue Book's estimate of what you can reasonably expect to receive this week for a vehide with stated mileage in the selected condition and configured with your selected options,exdudng taxes,title and fees when selling to a private party. Excellent Condition-3%of all cars we value.This car bola new and is In exceGenit mechan9cal condition.R has never had paint or bodywork and has an interior and body free of wear and visible defects.The car is rust-free and does not need recd ndidontng.Its dean engine compartrnent Is free of fluid leaks.R also has a dean We history,has complete and verifiable service records and will pass safety and smog inspection. Very Good Condition-23%of all cars vie value.This car has mhwr wear or visible defects on the body and interior but is in excellent mechanical condition,requiring only minimal reconditioning.It has little to no paint and bodywork and Is free of rust Its dean ergine cornpartmee nt is free of fluid leaks.The tires match and have 75%or more of tread.R also has a dean We tdstnry,with most service records available,and wig pass safety and smog hispedion. Good Condition-54%of all cars we value This car is free of major mec anical problerns but may need some reconditioning.Rs paint and bodywork may require minor touch-ups,with repairable cosmetic defects,and its englie compartment may have minor leaks.There are minor body sadtdies or dings and minor interior blemishes,but no rust.The tires match aid have 56%or more of tread.R also has a dean We history,with some service records available,and will puss safety and snag Inspection. Fair Condition-18%of all res we value.This car has some inednaruml or cosmetic defects and needs servicing,but is still in safe running condition and has a dean title history.The paint,body arid/or interior may reed professional servicing.The tires may need replacing and there tray be some repairable rust damage. 01495-2614 Kelley Blue Bonk Co.`,Inc M rights reserved. 2014 Kefky err-Book Ca..Inc.A9 rights testi ved.612 712014-71212014 EdiUm for PennsyMand]7207.The sp-drx rnf—ffm regv9ed m deremfne Me r kv for M60artla/ar VeWe>'ras Supp(M by Uie Pers-,7—erathrg Mh rrp*,t VOW'vahratlorrs are opbrvns and n. y vary horn vehkie tm vehida/gyral-krafbns w01 vary based rmm market ain&Uoris,spedfnalloris,veMde ourdnton x other parffnear drvtmstarmrs perttn_nt to M s partnadar vehicle m Me rransa.dbn or Me par Ws m Me transadhn.rhts rryort h Wended row the hrdhddual-e of Me pens-gen Ug Mk r V*rt—y and shall lilt be sold or tr—ftted to—Mer Fedy.KdL-y 8hr--0aot assumes no resp.-kRy f-e .m or..*wore.ft.14070) http://www.kbb.com/ford/fl 50-supercrew-cab/2004-ford-fl50-supererew-cab/Xlt-pickup-4d... 7/2/2014 Kelley Blue Book Page 1 of 2 Kelley Blue Book The Trusted Resource r Advvtkencd Wby ads? Silt To Private Party 2009 Chevrolet impala Pricing Report Goad Fair CIM.&6M Very Good $1x,277 C.Qt. S10,352 $11.577 Style:LT sedan 4D '► CondA,a Y Mileage:36,000 r a $12,002 .,r F � Vehicle Highlights Fuel Economy: Max Seating:6 Private Party Values valid for your area through 7/2/2014 City 17/Hwy 27/Comb 21 MPG Doors:4 Engine:V6,Flex Fuel,3.9 Liter Drivetrain:FWD Transmission:Automatic,4-Spd w/Overdrive EPA Class:Large Cars Body Style:Sedan Country of Origin:United States Country of Assembly.Canada Your Configured Options Our pre-seledffi options,he on typical equipment for this car. , Options that you added while configuring this car. 4` Engine Comfort and Convenience Seats V6,flex Fuel,3.9 Liter Air Conditioning Power Seat i Transmission Power Windows wheels and Tires I Automatic,4-Spd w/Overdrive Power Door Lodes Alloy Wheels Drivetrain ! Cruise Control !!i FWD t Steering Bratdng and Traction Power Steering Traction Control Tilt Wheel j StabilTrak Entertainment and Instrumentation ABS(4-Wheel) AM/FM Stereo MP3(Single Disc) I OnStar i Safety and Security Dual Air Bags F&R Side Air Bags Glossary of Terms Tip: Kelley Blue Book®Trade-in Value-This is the amount you can expect to reoeive when you bade in your car to a dealer.This value is detennti,ed based on the style,mndtim,mileage and options It's crucial to know your car's irdcatEd. true condition when you set(it, Trade-In Range-The Trade-In Range is Kelley Blue Book's estimate of what you mn reasonably egmd so that you can price it to remlwe this wee based on the style,oonndibon,mileage and options of your veWe when you trade It appropriately.Consider having in to a dealer.However,every dealer is different and values are not guaranteed. h4://xv-%vNv.kbb.coin/chevrolet/impala/2009-chevrolet-impala/It-sedan-4d/?condition--fair&... 7/2/2014 Kelley Blue Book Page 2 of 2 Kelley Blue Book®Private Party Value-This is the starting point for negottatlon of a used-or sale your mechanic give you an between a private buyer and seller.This is an'as ie value that dos not Include any warranties.The final objective report. price depends on the car's actual oondfion and local market factors. Private Party Range-The Private Party Ramie is Kelley Blue BoWs estimate of what you can reasonably opect to receive tics week for a vehicle with stated mileage in the selected condition and configured with your selected options,eWU[fing taxes,title and fees when selling to a private party. Excellent Condition-3%of all cars vie value.This car looks new and is in excellent mechanical condiftri.It has never had paint or bodywork and has an interior and body free of wear and visible detects.The car is cast-free and does not need reconditioning.Its don engine compartment is free of fluid leaks.It also has a dean We history,has complete and verifiable sesviee records and will pass safety and smog Irnspec ian. Very Good Condition-23%of a0 ors vie value.This car has minor view or visible defects on the body and Interior but is in excelient mechanical condition,requiring only minimal reconditioning.It has little to no paint aril bodywo k and is free of rust.Its dean engine compartment is free of fluid leaks.The tires matdT and have 75%or more of tread.It also has a dean title history,with most service records available,and will pass safety and smog Inspection. Good Condition-54%of all cars vie value.This car is free of major mechanical problems but may need some recDr4tioning.Its paint and bodywork may require minor touch-ups,with repairable cosmetic defects,and its engine compartment may have minor leaks.There are mirror body Mdid es or dings and minor Interior blemishes,but no hist The tires matdn and have 50%or more of tread.R also has a dean Me history,with some service records availatie and rill pass safety and smog inspection. Fair Condition-18%of all cars we value.This car has some mechanical or otic defects and needs servidng,but is still in safe running condtion and has a dean title history.The pakrt,body and/or Interior may read professional servicing.The tires may need replacing and there may be some repairable rust damage. ®1495.2014 KeDeyy Blue Boole Co.',Inc Ata rights rese wed. ®2014 Kdiey Blue Book Co.,Ina AD dghs reserved.612712014-71212014 EdVon for Pennsylvania 17201.The sped1k Infbmition required to delermine the value for this parrfadar vehrde v.'as supplied by the peso.gme.MV thB report Vehtde vahiatiom are opinion and may vary from-ehlde to-hide.Adual vak»Bmm mg vary based upon market cmndNora,speatliratfans,vehlde canddfan or other paNkvlar cft—tances pertinent to lift partiadar vehide or do transadlon or the paras to the tma cBDn.This repwt res kdended for the 1ndh4dua1 use of the person generatfig th6 report only and she➢ not be-td or trans.Wted to—therperty.Kelley Slue Book asems rro respo-Maty for errors or omHSMns.(-.14070) h4://wNvA v.kbb.com/chevrolet/impala/2009-che-vrolet-impala/lt-sedan-4d/?condition=fair&... 7/2/2014 .. . . , , , , , - . . .. �:_,��� . : . , . . . , . . : . :. .�°�C). 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J .. take full responsib�laty far#Fie accuracy COM _ aK --- of the ab1.ove speilmgs:and:dates . :..'.., I W. , B&,1 ;.,;: :: : Check How to Luer Letter Its wa © oslte Y pP ty fxh�R Y sy' .Unit Price:$=- xJ -� "x Flower Vase $ ;.Corner host $ l llsc :`$ t.; . • --$` Total $ k , Deposit$' t, t .` ._ B j : ': E' $ 5 r `^' . {:agree that said.memorial,with title thereto and right of possession thereof,"shall rema' ,,your personal p' erty until l have pa;d fior'it in: full.In default of any payment hereunder,1 license'you to.repossess'and remove the said memona! without.guilt or-trespass or other wrong,. -}and authorize and.empower you,in my name and on my behalf,to apply toEthe management o€ysajd cemetery or other:premises€ora permit - ...'for its,.rerrio4al-and to.ake a v o e o - FUNERAL,PURCHASE CONTRACT EGhGER FUNEIM ROME, INC. (STATEMENT OF FUNERAL.GOODS AND SERVICES SELECTED) R CHARLES EGG$R,Supervisor Icherves are only for these Items that aro used,if we are required by law to use any Items, FRANK C. ES ER,Funeral Director we will explain the reasons In writing below.) 16 pig Spring EGGAvenEa a unerale,re or �rrr+++ Section 13,204 of the Rules and Regulations of the Fbnnsyivanip Stale Board of Funeral Directors requires this Phonc{717)776.3414 � �, y p p agntract to be signed by the person or persona arranging for the funeral sorvice and by the funeral director + "i �t (A) OUR SERVICE: *"''' "� BASIC SERVICES OF FUNERAL DIRECTOR&STAFF ,..,..S Full name of deceased - --rte r et- N e 6 ) Age s EMBALMING ., ..... .... ....., $ _y s t ) R INT Name) If you selected a funeral which requires embalming such Date of Death JUA 'ter 2p.L_L.Deceased is � �� of parson arranging services, as a lunarel with viewing, you may have to pay for � (01"Relationship)embalming.You do not have to pay for embalming you did nctepprovetfyouselectodarrangementesuch asadirect (0) CASH ADVANCE ITEMS: Total(A)Forward $ cremation or Immediate burial, If we charged you for embalming,we will explain why below. Cemetery Opening ' X g REASON FOR EMBALMING; tl Certified Copies of Death : $=E0 --" — Offering for Church and/or Clergy,,,,,,,,,,,,,,,,,,,,,,,,,,$ OTHER PREPARATION OF THE BODY....................$_.._. Hairdrosser..............................................USE . i OF FACILITIES&EQUIPMENT: Out of Town Newspaper ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6 For Funeral Ceremony,Inc,staff(runpN v4m,chmah a oaho..,.,.$_...,. Out of Town Funeral Homes .................... For Visitation or Viewing,Incl,staff Ir.w*i m*church ar o1w ,,,$ Transportation(Air/Train),,.., Properetlon Room ..:...................................e Other Use olFacilities.....................•.,,,...,.,.. .�:._ �lr'+•t�1' ... (Administrative Areas,Reeapt)on Areas Parking ___. .,.,.. Faell ties,Shelter of Remains,✓k all other mist, rtO4 tt $ � furnishings&equipment within the Funeral Nome,) �✓ ..,,...,. TRANSFER OF REMAINS TO FUNERAL HOME........,.., { Miles Transported) Total(B) S AUTOMOTIVE EQUIPMENT; (C) ADDITIONAL ITEMS ORDERED LATER: Total(A)&(B) Casket Coach(Hearse)...............................s_....� _ ,,,,,,6 'Flower Car................................. s -�- Funeral Sedan ..............1,,,,,,.......,,,,,,,,,$ OTHER SERVICES/FACILITIES/EQUIPMENT; It Is agreed any additional Items ordered later shall become a Total(C) S $____ ___ part of this contract and shall be inserted herein, C .,..,.....8Tose)Amount to , MISCELLANEOUS MERCHANDISE LEGAL,CEMETERY,CREMATORY OR OTHER REQUIREMENTS COMPELLING THE PURCHASE OF ANY ITEMS LISTED w Acknowledgment Cards .........(?Q)................a Visitors Register.................. ...... ..... ABOVE: Memorial Folders(ISO) ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,$ The undersigned purchasers)hereby attest to the followin :(1)I/We authorized embalming of the above named deceased. Temporary Grave Marker............................$ (2)I/We were shown a Casket Price List and an Outer Sural Container Price List before the showing of caskets and outer burial containers.(3)I/We were given/offered for retention a General Price List upon the beginning of a discussion of - CASKET $ funeral arrangements and/or selection of services and merchandise. TERMS— OUTER BURIAL CONTAINER(As Selected) $ OTHER MERCHANDISE:' Receptacle(other than casket) $ 1,or we,homing read the abovo,accept and approve same,and Jointly and severally promise to make full payment therofor. 6 Reeel t'61&cop„o. thla contract Js.acknpwledged. Wearing Apparel 6 M. J MIS w r. 0 _ __ . m r o S fu f Putchaasr'e d r Sreet Address ' a S.a,No. ` S--h state Ip Code FORWARDING OF REMAINS TO ANOTHER FUNERAL HOME...................... $ RECEIVING OF REMAINS FROM ANOTHER FUNERAL HOME...................... $ _r ignstura of sssw or Ca. star dtmet Address Cky ana state tip Co e DIRECT CREMATION lAs Selected)..................................... ...... $. Signature of Purohassr or Co• urahaaar 6treet Address sty and rata Zip Code IMMEDIATE BURIAL(Aa Selected) .....,....,. $ We agrao to render the service and furnish the Tota)(A) $ „i' . 9,t mere andise Indicated above. Egger Funeral Home, Inc. By � ��.zr _t»� r CONODOGUINET MOBILE ESTATES Lease agreement "Renewal" This agreement,made and entered into in duplicate on this day September 1, 2013 by and between CONODOGUINET MOBILE ESTATES herein after call the Management (Leaser) and herein after called Resident(Leasee). WITNESSETH: That the Management(Leaser) does hereby rent (Lease) to the Resident(Leasee)the following described premises, to wit: Lot# ` =.;_. for the term of ONE YEAR commencing on September 1, 2013 and ending on August 31, 2014, for the following monthly sum: Basic site rental Additional residents Pets Storage fees Others Total monthly rent 5 This tenancy is not transferable. ;. r DOB f� -/S Signed, SS,,�-��.��1:,:'�`-- SS No �:�� ;�; �;� ��; �_.. Signed SS NO DOB Signed SS No DOB Signed SS No DOB Date .m ` , p' Phone No In the presence of Management !' .!` r; f' ° ;:'z"L-, (Manageinent) RECEIPT FOR PAYMENT ------------------- ------------------- LISA M. GRAYSON, ESQ. Receipt Date: 6/19/2014 Cumberland County - Register of wills Receipt Time: 09:48 :20 One Courthouse Smiare Receipt No. : 1078337 Carlisle, PA 17dl-3 _ NELSON IRA IRVIN Estate File No. : 2014-00580 Paid By Remarks : JINEENE A BROWN DMB ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 135.00 CUMBERLAND COUNTY GENERAL FUN WILL 15 .00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 20 .00 CUMBERLAND COUNTY .GENERAL FUN INVENTORY 15.00 CUMBERLAND COUNTY GENERAL FUN INH TAX RETURN 15.00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23 .50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5. 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check# 241228 . 50 Total Received. . . . . . . . . H28 .50 I y i •0955` ACNB BANK PROMISSORY NOTE AND DISCLOSURE Principal Loan Date Maturity Loan No call I Coll Account Officer Initials $10,000.00 111-08-2013 111-23-2018 8837031F 630 I o0 7fi7 References in the boxes above are for Lender's use only and do not limit the applicability of this document to any particular loan or item. Any item above containing "«E" has been omitted due to text length limitations. Borrower: I IRVIN NELSON Lender: ACNE Bank 165 CME Newville Office NEWVILLE,PA 17241 16 Lincoln Square PO Box 3129 Gettysburg,PA 17325 ANNUAL PERCENTAGE FINANCE CHARGE Amount Financed Total of Payments RATE The dollar amount the credit The amount of credit The amount 1 will have paid The cost of my credit as a will cost me. provided to me or on my after I have made all yearly rate. behalf. payments as scheduled. 6.738% $1,839.80 $10,000.00 $11,839.80 PAYMENT SCHEDULE. My payment schedule will be 60 monthly payments of $197.33 each, beginning December 23, 2013. PREFERRED RATE FEATURE. The interest rate on this loan includes a preferred rate reduction. If the preferred rate reduction is terminated,the interest rate on my loan will increase to 6.990%. The increase will take the form of higher payment amounts. Following is a description of the event that would cause the preferred rate reduction to terminate. Description of Event That Would Cause the Preferred Rate Reduction to Terminate. Termination of Automatic Draft account with ACNB Bank. How The New Rate Will Be Determined Upon Termination of the Preferred Rate Reduction. The current rate will be increased by 0.25%. EXAMPLE OF EFFECT OF INTEREST RATE INCREASE. if the interest rate increased by 0.250% on December 8, 2013, my regular payments would increase to $198.49. SECURITY. This loan is unsecured,except Lender has reserved a contractual right of setoff in my deposit accounts. LATE CHARGE. If a payment is 16 days or more.late, I will be charged 10.000% of the unpaid portion of the regularly scheduled payment or $20.00,whichever is greater. PREPAYMENT. If 1 pay off early,I will not have to pay a penalty. I will look at my contract documents for any additional information about nonpayment, default, any required repayment in full before the scheduled date, and prepayment refunds. Amount Financed Itemization Amount paid to me directly: $9,914.00 $9,914.00 Deposited to Checking Account#152811 Amount paid to others on my behalf: $86.00 C-W CO1LJLL -�Rg%tVW t102'LGGI at mosP.--all -t-3 SIO'02'Cl'nn�,p OW un3 sa6eueW 93M Ilelaa Aespu11 a sel6no0 AdO3 X . �tiMa art�t-i 2054116503 d '_J ATE 5LWLE_QMETF9_N_V_MBER__A OUL C)� rylq ptrsorloj I _C( OUNT_NUrA_5EFl_ 08/0112014 y 33119171 2054116503 C)Lcff)W,I ACCOUNT SUMMARY Previous Balance: 267.84 Payments Received: 0.00 .5cx V k-\; -Lot I Balance Forward: 267.84 ry)y'!1)CL1_n._t Total Basic and Non-Basic Charges: 101.00 7 ACCOUNT BALANCE 368.84 FCna( (ji 165 CONODOGUINET MOBILE E Cycle 01 665- rvv% 133Z - 2867 1 AV 0.378 4 2M JUL13 1013 33 77 I IRVIN NELSON C-9 P-11 165 CONODDGUINET MOBILE EST 66& NEVVILLE PA 17241-9485 JUN14 1122 37 70 JUL 14 752 24 73 voi M 1111111111h 111JI11111111 Jill 11111+11111111 111111111111flIA111JAS O n D J F A A M J J METER# Date/Prev Rdg Date/Pres Rdg ; Idult KWH Dern Rdg 1 Dern Billed I P.F. f Rate 1 Rate Classification —1-111.9171 106,50 77341 j 07PI. 7603.3 , 1 752 1 .00-.1 .000 1, 0 y RES01 Residential BILLING DETAIL BASIC CHARGES NON-BASIC CHARGES Energy Supply prices and charges are set by your electric generation supplier.Your current price to compare is$0.0729. Round-up donation 0.39 Adams Electric Cooperative Inc. 888)232-6732 TOTAL NON-BASIC CHARGES 0.39 1338 Biglerville Road Gettysburg,PA 17325-1055 ENERGY SUPPLY: Energy charge 752 kwh @ .07290 54.82 VVPCA 752 kwh @ .00200 1.50 TOTAL ENERGY SUPPLY 56-32 DISTRIBUTION: Access Charge 28.50 Distribution charge 752 kwh 9 .02100 15.79 TOTAL DISTRIBUTION 44.29 TOTAL BASIC CHARGES 100-61 -+*PAST DUE BALANCE-PAYME1114T_'REQUIREID To avoid disconnection ofyour-electric S-_rvjca,please pay I a f$251.3^.vol 08il%�201 4. I-a D a st du-3 z M,o u r, *L 3r- -its d a- payment a-zsistnmay ay De , avilabie by calling g58t232-6732. Further collection efforts May result irs addiflonal fees and security deposit. tx See insert for more dataft Detach here IMPORTANT INFORMATION FOR YOU I IRVIN NELSON Are these the correct phone numbers you will use to contact us? DATE BILLED METER NUMBER ACCOUNT NUMBER Primary correction:717-385-0983 Correction 09101)2014 33119171 2054116503 Business/Work:(000)-00-0-00 Correction PAWENT 08/21/2014 368.84 Mobile/Cell:(717)395-0983 Correction DUE Penalty on outst ndirva balances a w*M Addl work: (000)-00-0-00 Correction be appiiedt -,ter the=3.5 date Addl cell:(000)-00-0-00 Correction �Iu LU TO AVOID Dil"3'CONNLECTIUN.. S== F, - - E N!"ESSAGE 400252054116503000036884000036884080120148 IRA I. NELSON• Page: 2 of 3 165 CME Bill Cycle Date: 05/17/14-06/16/14 NEWVILLE, PA 17241-9485 Account: 464011717078 a `&t Visit us online at: www.att.com 717`385=n983 Other Charges and Credits'- Continued 12. PA State Sales Tax-Telecom 4.11 -Total-Government-Fees and Taxes 5.11 Other Charges and Credits Voice usage Summary Total Other Charges & Credits 16.01 . . ..s .. Nation 450 with Rollover Total Minutes Used 305 Total for 717 385-0983 76.00 t-'Plan Minutes' 450 Y r'.-' -- Total for Wireless accounts 76.00 +Mobile to,•;•Moblle Minutes4-�-4- Unlimited A_-Minutes USed' �uf__ 0 Night eekend.Minutes 5,000 Minutes Us_ed a. j - 122 :�•-.�=-�-=- -.-_� News You Can Use ? . : Directory Assist�'ance—, 5. Calts:Billed atS1.99 1 1.99 ALL THE LATEST SMARTPHONES.ALL AT AT&T! Check out all the greatest, like the new Samsung Galaxy S(R) 5, now! Unlimited Mobile to Any Mobile Unlimited Add a line and start connecting. Call 800-449-1672 or visit Minutes Used 1,050 www.att.com/addatine. Rollover Minutes Summary NEVER MISS A STORY Last Month's Rollover Balance, 1,361 With www.att.net you never have to miss an interesting story, or Current Month Added to Rollover + 145 search for it later.Simply select any news story or lifestyle Expired Rollover Minutes" 0 article, including recipes, to put into "My Saves"and read it at your NEW ROLLOVER MINUTES BALANCE 1,506 convenience from desktop,smartphone or tablet.Visit www.att.net, "Unused Rollover Minutes expire offer 12 brit periods. sign-in and create list - Data Usage Summary MOBILITY ADMINISTRATIVE FEE Messaging Unlimited Effective June 22, 2014,the Administrative Fee will be $0.61 Used 427 per line per month for Corporate Responsibility User lines. For more information about the Administrative Fee,please visit Data Pay Per Use www.att.com/additiona[charges. 6. MB Billed at$2.00/MB .,.. 1 _ 2.00 1 Gigabyte(GB)=10241413, 1 Megabyte(MB)=1024KB Surcharges and other Fees Important Informafiion 7. Administrative Fee 0.61 8. Federal,Universal Service.Charge 9. Regulatory Cost Recovery Charge f 0.66 LATE PAYMENT FEE 10. State Gross Receipts Surcharge 3.43 The late payment fee for consumer and Individual Responsibility Total Surcharges and Other Fees 6.91 User{IRU) bills not paid in full by the payment due date is $5. Government Fees and Taxes ELECTRONIC CHECK CONVERSION 11. 911 Service Fee .1.00 Paying by check authorizes AT&T to use the information from your check to make a one-time electronic fund transfer from your account.Funds may be withdrawn from your account as soon as the same day your payment is received. If we cannot process the transaction electronically,you authorize AT&T to present an image copy of your check for payment.Your original check will be destroyed once processed.if your check is returned unpaid you agree to pay such fees as identified C 2012 AT&T Intellectual Property.AU rights reserved. ME 901 6,003.019207.01.02.0000000 NYYYNNNY 38455.38455 CL. ; Affordable health insurance options are now available! Call(717)960-3604 to learn more. ZYMI, 'T ELL Patient Name Ira Irvin Nelson L— Online at Account Number 9579552 (available 2417) Date of Service June 09,2014 Service Type Emergency Room Services By phone-717-960-161010 insurance Nairne Pbshrn 378 Ppo Name of Insured Ira Nelson By check-return section below with check Policy Number QDG1 19846869001 Amount Due From You Amount due from you is$150.00 as of 07/2712014 for The charges listed belovf do not refiectitthe discount that Emergency Room Services performed on Jbne 09,2014. you and your insurance company received. Pharmacy 683.96 Total Charges $5,254.94 Lab 23.76 Discounts/Adjustments Given -$3,418.92 Supplies 138.50 Insurance Payments Received -$1,686.02 Emergency Room 4,408.72 Amount You Paid $0.00 TOTAL CHARGES $5,254.94 A-mount Due From You $150.00 3269-HMASTMT-2267687-1748207459-P;10147323-1-908;34868326-1;1 The amount shown on this statement is outstanding at this time.Your prompt payment will be greatly appreciated. MASTERCARD DISCOVER VISA NASA AMEX 361 Alexander Spring Rd. Save Time and Postage. Pay your bill Online or by Phone RffldNAL Carlisle,PA 17015 Today. It's Fast, Easy, and Secure. -CIL www.carlislermc.com PATIENT' Up NAME STATEMENT DATE I DATE DUE Patent Financial Services: Ira Irvin Nelson Estate 07/2712014 ON RECEIPT ACCOUNT NUMBER AMOUNT DUE AMOUNT PAYING 717-960-16110 9579552 $150.00 $ Check box if address below is ihm rrad or changed and kK k--t--ch atge(s)on back REMUT THIS PAIVENT STUB TO: 0009990101 IRA IRVIN NELSON ESTATE CARLISLE REGIONAL MEDICAL CENTER 165 CME PO BOX 281442 NEWVILLE, PA 17241-9485 Atlanta, GA 30384-1442 111 11111 1111111111111 It 11111111 111111 It'll Iv fill 11111(1111111 11111111111 1111111 Is 1111111111 fill 00000557955200000015000IRAIRVINNELS4NESTATE 0 PA Central CREDIT UNION Page 01 of 02 Summary of Account Activity Payment Information Account Number 0004109733000013357 New Balance 2,073.60 Previous Balance 2,284.96 Payment Due Date 07/06/2014 Payments&Credits 500.00 Minimum Payment Due 42.00 Purchases/Debits/Drafts 264.99 Amount Past Due: .00 Fees Charged .00 Late Payment Warning: If we do not receive your minimum Interest Charged 23.65 payment by the date listed above,you may have to pay up ti)a New Balance 2,073.60 $25 late fee. Statement Date 06/09/2014 Minimum Payment Warning: If you make only the minimum Days in Cycle • 31 payment each period,you will pay more in interest and it will take Total Credit Line 10,500.00 you longer to pay off your balance.For example: Available Credit 8,426.40 If you make no You will pay off And you will end up additional charges the balance shown paying an estimated Questions?View your account information online at using this account and on this statement total of... wWw.pacentralku.com or call our Customer Service Center each month you pay.. in about... toll free at 1-866-891008 or 1-571-325-3025. Only the minimum 14 years $3,801.89 Send Willing inquiries and Correspondence to: payment P.O.Box 182477,Columbus,OH 43272-4935 $69.76 3 years $2,511.36 Mail Payments to: (Savings=$1290.53) P.O.Box 2711,Omaha,NE 68103-2711. If you would like information about credit counseling services, call 1-866-891-6008. Account Summary . Deferred Annual Balance New Interest Deferred Percentage Subject to Interest Minimum Plan ID Plan Description Balance Expiration Date Interest Rate(APR) Interest Rate Charge Payment Due 10001 CASH ADVANCE FLAN .00 N/A .00 12.90006 .00 .00 .00 10002 PURCHASE PLAN 2,073.60 N/A .00 12.90008 2,158.83 23.65 42.00 10003 BALANCE TRANSFER -00 N/A .00 12.90008 .00 .00 .00 10004 CONVENIENCE CHECKS .00 N/A .00 12.9000$ .00 .00 .00 Y ` {v)=Varixhle Rate - - .--------------------- ----------------------.............---------------:--------------- - -- (transactions continued on.next page) TEAR OFF THS PAYMENT STUB AND MAIL WITH YOUR CHECK OR MONEY ORDER TO THE ADDRESS BELOW. PA Cwtiml ❑Check this box to indicate any CREDIT UNION ADDRESS CHANGES detailed on back. 959 East Park Drive Harrisburg,PA 17111-2810 Payment Due Date New Balance Past Due Amount Minimum Payment Due 07/06/2014 2,073.60 1 F .00 42-00 ` " Account Number 0004109733000013357 Please write your account number on your check.In order to receive payment by your due date,we suggest mailing at least five(5)days prior to the date.See reverse side fir important information. .................. MAKE CHECK PAYABLE TO: 00456 PENNSYLVANIA CENTRAL FCU P.O. BOX 2711 I IRVIN NELON OMAHA, NE 68103-2711 LOT #165 CME NEWILLE, PA 17241-9485 I1IIts 11Iullil1L,ItIIIIIIIII Is181u1111111INgill I I„milli IIIsIIII oll3INIIIIIIIIIlluii.,luioil IIlul 00041097330000133570000000420000000207360.7 Mailing PA Central Account Number CREDIT UNION 0004109733000013357 Page 02 of 02 Important Messages _ THANK YOU FOR CHOOSING PENNSYLVANIA CENTRAL FCU FOR YOUR CREDIT CARD NEEDS. Transaction.Summary Transaction Posting Plan Date Date Reference Number Transaction Description Number Amount Transactions 06/03 06/03 00000000000603201110021 LOCKBOX PA324ENT 00000 500.00- 06/07 06/09 VT141601539000010000165 OLLIES BARGAIN OUTLET CHAMERSBURG PA 10002 264.99+ Interest Charged 06/09 06/09 19999999980609998674370 INTEREST CHARGES ON PURCHASE 10002 23.65+ TOTAL INTEREST CHARGED FOR THIS PERIOD 23.65 'tom -- 2014",Total Year.to-Date Total fees charged in 2014 .00 Total interest charged in 2014 124.57 PENNSTATE HERSHEY ` ' 1 st Statement Ike Muton.S.Hershey Message Pa e 1 of 2 ortant iV Medical Center ' Po sox 643291 This bill represents the portion remaining after your Pittsburgh,PA 15264-3291 insurance company has processed your claim. Please send your payment for the full amount due. If you have any questions concerning how your insurance company processed your claim, please call them. IRA NELSON 1VOM7 165 CONODOGUINET MOBILE EST NEWVILLE PA 17241-9485 �IlllihlllllIIII'lf1,ll-l.lllllfill 111411111111111111111111lie FinancialAssistance Account Summary -A' Patient Name NELSON IRA I .If payment of your medical bill is a concern,we may be able to assist Statement Date 06/12/14 you. Penn State Hershey Medical Center provides financial Service Date(s) 05/20/14 assistance based on income,family size and assets for medically necessary services. Please contact our office to discuss what Type of Service OUTPATIENT options you may be eligible for. Account Number 20962416 oApplications can be obtained on our website at www.penr.statehershey.org or by contacting our office. New Charges/Adj $0.00 o Patient Financial Services is conveniently located on the New Payments/Adj $0.00 campus of the Penn State Hershey Medical Center,Academic Account Balance $16.00 Support Building,90 Hope Drive,2nd floor,Suite 2106. .Pharmacy Drug assistance programs are also available. Amount Pending Insurance $0.00 Amount You Owe $ 16.00 r-- r-ACC01111tActivio;Contact For billing questions or insurance changes: DATE DESCRIPTION AMOUNT Para preguntas acerca de su factum o contamos con representantes que hablan Espanol para asistirte. 05/20/14 OP VISIT,EST PT,LEVEL 80.00 Phone: (717)531-5069 or(800)254-26.19 06/01/14 BLUE SHIELD PAYMENT HOSP -225.28 In Person:90 Hope Drive Hershey,PA Suite 2106 06/01/14 BLUE SHIELD CONT ADJ HOSP 161.28 Available Hours:INlonday 8a-8p Tuesday-Wednesday-8a-5:30p TOTAL 16.00 Thursday-Friday 8a-3:30p Written Correspondence: �V Penn State Milton S.Hershey Medical Center \ �' Patient Financial Services Department \�1 p PO Box 854,MC A410 Hershey,PA 17033-0854 Please Note: Yoit inay:receii-e a separate bill for'I olir pli)siciali selvices. HERSHEYST-01 ..................................................................................................................................................................................................... PENNSTATE HERSHEY Statement Date: 06/12/14 , Patient Name — Account Number— Date0u& WM. S.Hershey NELSON IRA 1 20962416 Upon Receipt. 4W Medical Center Amount D66 Amount Paid PO Box 643291 Pittsburgh,PA 15264-329116.00 16.00 $ Statement / Hospital Imo. Check here if your address or insurance information has changed. CHECKS SHOULD BE MADE PAYABLE AND �•1 Please indicate changes on the back of this page. SENT TO: To pay by credit card: For your convenience,you may pay by Visa, MasterCard or Discover Card. Please indicate your credit card preference,provide the account information,and sign below. NIS HERSHEY MEDICAL CENTER PO Box 643291 Lj Pittsburgh,PA 15264-3291 Account No. IhhlllllllllllIIP14nllrll�111111 'llllllnlnll.q..11,l. Expiration Date CW Code Signature X 0000000209624160520140612140000001600 Remit To:Walgreens Specialty Pharmacy 55358 Collect Ctr Dr Page 1 Chicago,IL 60683 ACCOUNT NO. DATE IRA NELSON 15438018211 08-04-14 165 CUTE NEMILLE,PA 17241 BILLING DEPARTMENT HOURS OF OPERATION:Monday-Friday,8AM-5PM EST AMOUNT REMITTED BilCmg Questions please cad 9-866-7568857 PLEASE DETACH AND RE'T'URN WITH YOUR PAYMENT -----------------------------------------------------------------------------------------------------------------------—-------- DATE Rx# DESCRIPTION CHARGES PAYMENTS BALANCE 07-01-14 Beginning Balance 45.00 45.00 Payme t Due On Receipt. Name: IRA NELSON Address: 165 CME NEWVILLE,PA 17241 THANK YOU FOR YOUR BUSINESS CURRENT 30 DAYS 60 DAYS 1 80 DAYS 120 DAYS AMOUNT DUE 0.0ol 0.001 45.00 0.001 0.00 1 45.00 Dispensing Coca#ions Camegie,PA Canton,III Frisco,TX Beaverton,OR