HomeMy WebLinkAbout01-22-15 �pennsytvarda EX(03-14)(F!) 1505614105
orn�xn+erz��vanrt
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
INHERITANCE TAX RETURICA Harrisburg,
a BOX 280601 rrisbur , PA 17128-0601 RESIDENT DECEDENT L j
ENTER DECEDENT INFORMATION BELOW
Social Security Nu_m_ber202-3Date of Death MMDDYYYY Date of Birth MMDDYYYY
[11022014`Y �� 04031946
Decedent's Last Name _ Suffix Decedent's First Name_ MI
Kelly � j Lran_�s!____.�... ._..,...: .._ L _ _1 _ _
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
CM 1.Original Return Q 2.Supplemental Return O 3. Remainder Return(date of death
prior to 12-13-82)
p 4.Agriculture Exemption(date of O5.Future Interest Compromise(date of O 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
IID 7. Decedent Died Testate O 8. Decedent Maintained a Living Trust 9. Total Number of Safe Deposit Boxes
(Attach copy of will.) (Attach copy of trust.)
O 10. Litigation Proceeds Received O 11. Non-Probate Transferee Return O 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
O 13.Business Assets O 14.Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NameDaytime Telephone Number
(Sean D. Kelly Y- [(717)877-9701
1
First Line of Address _
1060 Memory Lane
Second Line of Address
City or Post Office State ZIP Code_ cam_ n
MechanicsburgCl
_ !A] [!7050 ^ �
comcast.netllke34
Correspondent's email address: sY @
Cn
REGISTER p Vr SLS USE ONLY "r1
REGISTER OF WILLS USE ONLY f r
- - - -- —-'
DATE FILED MMDOYYYY ".) ►"
r
DATE FILED STAMP
PLEASE USE ORIGINAL FORM ONLY
Side 1
i ami iaii i��
1 0�iim
614105 1505614105
.J 1505614205
REV-1500 EX(FI)
Decedent's Social Security Number
Decedents Name: Frances J. Kelly
RECAPITULATION
1. Real Estate(Schedule A). ............................ .... .... .... .... 1. 0.00
2. Stocks and Bonds(Schedule B) ... ............ ................ .... .... 2. 101,360.00
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. 0.00
4. Mortgages and Notes Receivable(Schedule D). ................ .... ...... 4. 0.00
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).... ... 5. 7,548.00
6. Jointly Owned Property(Schedule F) C Separate Billing Requested .... ... 6. 0.00
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested........ 7. 0.00
8. Total Gross Assets(total Lines 1 through 7)............................. 8. 108,908.00
9. Funeral Expenses and Administrative Costs(Schedule H).. ........ .... .... . 9. 14,060.00
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)... ... .... .... . 10. 0.00
11. Total Deductions(total Lines 9 and 10).. ............................... 11. 14,060.00
12. Net Value of Estate(Line 8 minus Line 11) ... ............ ............ ... 12. 94,848.00
13. Charitable and Governmental Bequests[Sec.9113 Trusts for which
an election to tax has not been made(Schedule J) .. ............ .... ...... 13. 0.00
14. Net Value Subject to Tax(Line 12 minus Line 13) .. . ....... .... ........ .. 14. 94,848.00
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 +"-
(a)(1.2)X.0_ 0.00 15. 0.00
16. Amount of Line 14 taxable
at lineal rate X.0 45 94,848.00 16. 4,268.00
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. 4,268.00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Under penalties of perjury,1 declare 1 have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete. Declaration of preparer other than the person responsible for filing the return is based on all information of which preparer has
any knowledge.
SIGNAJURE OF S R SIBLE FOR FILING RETURN DATE
cG 01/19/2015
ADDRESt
1060 Memory Lane, Mechanicsburg, PA 17050
SIGNATURE OF PREPARER OTHER THAN PERSON RESPONSIBLE FOR FILING THE RETURN DATE
ADDRESS
ilii Side 2
1 56 42 5 1505614205
REV-1500 EX (FI) Page 3 File Number
Decedent's Complete Address:
DECEDENTS NAME
Frances J. Kelly
STREETADDRESS
1565 Williamsburg Way
CITY STATE ZiP
Mechanicsburg PA 17050
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 4,268.00
2. Credits/Payments
A.Prior Payments 0.00
B.Discount 213.00
(See instructions.) Total Credits(A+B) (2) 213.00
3. Interest
(3) 0.00
4. If Line 2 is greater than Line 1+Line 3,enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 4,055.00
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.......................................................................................... ❑ N
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ E
c. retain a reversionary interest.............................................................................................................................. ❑ E
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑
2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑
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? ........................................................................................................................ ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1,1994,and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent or a step-parent 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-35o3 EX+(8-32)
pennsytvania SCHEDULE B
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Frances J. Kelly 2014-01073
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1' FPPTX 4.496$43.98 197.73
2 GTDDX 1.163$33.77 39.27
i 3 IEGAX 2.963$20.77 61.54
4 ESMAX 5.001$13.89 69.49
5 ASIAX 5.869$33.43 196.20
I 6 ►JH 200$141.58 28,316.00
71 JATTX 16.811 $24.71 415.39
8' JPGTX 1.495$10.42 15.57
9: JAMCX 2.82$37.77 106.51
10 JNBAX 509.109 $10.41 5,299.82
11 JSOAX 34.471 $11.77 405.72
12, OIEX 4.535 $13.99 63.44
13 PECAX 248.942 $24.63 6,131.44
14 VHIAX 3.44 $14.73 50.67
15 :KACVX 3.26 $18.50 60.31
16 OSMAX 1.805 $32.52 58.69
17 ODMAX 1,296 $39.51 51.20
' 18 PADAX 158.179 $9.79 1,548.57
19 SPRAX 35.17 $21.56 758.26
20 PFSAX 1.299 $15.90 20.65
21' PEEAX 250.082 $41.16 10,293.37
22 PHLAX 115.06$51.12 5,881.86
23 RSIAX 246.042 $10.40 2,558.83
24 RSVAX 6.05 $37.78 228.56
TOTAL FROM PAGE 2 38,531.21
TOTAL(Also enter on Line 2, Recapitulation) $ 101,360.27
If more space is needed,insert additional sheets of the same size
SCHEDULE B(PAGE 2)
STOCKS AND BONDS
VALUE AT DATE
ITEM DESCRIPTION OF DEATH
25. RSMOX 889.46 $19.64 17,468.99
26. GPAFX 40.276 $64.62 2,602.63
27. XLF 200.00 $23.84 4,768.00
28. XLV 200.00 $67.27 13,454.00
29. SGRAX 4.536 $52.38 237.59
Total page 2 38,531.21
REV-1508 IX+(o8-i2)
[j f pennsylvania SCHEDULE E
DEPARTMEMOFREVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Frances J. Kelly 2014-01073
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. LPL Financial,4707 Executive Dr,San Diego,CA 92121,Insured Cash Acct#4688-0832 769.00
2. PNC Bank 249 5th Ave.,Ste.30 Pittsburgh PA 15222,Checking Acct#51-1202-4624 2,479.00
3. Furniture/Household Goods 3,800.00
4. 1992 Toyota Camry 500.00
I
j
E
f -
TOTAL(Also enter on Line 5, Recapitulation) $ 7 548.00
If more space is needed,use additional sheets of paper of the same size.
COMMONWEALTH OF PENNSYLVANIA SHORT CERTIFICATE
COUNTY OF CUMBERLAND
OF glut
I, LISA M. GRAYSON, ESQ.
O, �� Register for the Probate of Wills and Granting
DO Letters of Administration in and for
CUMBERLAND County, do hereby certify that on
the 12th day of November, Two Thousand and
Fourteen,
1750 Letters TESTAMENTARY
in common form were granted by the Register of
said County, on the
estate of FRANCES JEAN KELLY late of HAMPDEN TOWNSHIP
(First,Middle,Last)
a/k/a FRANCES JEAN GRANT
in said county, deceased, to SEAN D KELLY
!First,Middle,Last)
and that same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the
seal of said office at CARLISLE, PENNSYLVANIA, this 12th day of November
Two Thousand and Fourteen.
File No. 2014- 01073
PA File No. 21- 14- 1073
Date of Death 1110212014
S. S. #
Register Of MYS
eputy
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
REGISTER OF WILLS CERTIFICATE OF
CUMBERLAND COUNTY GRANT OF LETTERS
PENNSYLVANIA
it o C
No. 2014- 01073 PA No. 21- 14- 1073
Estate Of: FRANCES JEAN KELLY
0 Z tFirst,Middle,Lost)
alkla: FRANCES JEAN GRANT
Late Of: HAMPDEN TOWNSHIP
CUMBERLAND COUNTY
Deceased
1750 Social Security No:
WHEREAS, on the 12th day of November 2014 an instrument dated
April 29th 2005 was admitted to probate as the last will of
FRANCES JEAN KELL Y
(First,Middle,Last)
alkla FRANCES JEAN GRANT
late of HAMPDEN TOWNSHIP, CUMBERLAND County,
who died on the 2nd day of November 2014 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, 1, LISA M. GRAYSON, ESQ. Register of Wills in and
for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby
certify that I have this day granted Letters TESTAMENTARY to:
SEAN D KELLY
who has duly qualified as EXECUTOR(RIX)
and has agreed to administer the estate according to law, all of which
fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE,
CA RL ISL E, PENNS YL VA NIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my office on the 12th day of November 2014.
Ragister or wing"..4
/� J7 A/Lzlt
veputy
**NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST)
'a
la'a Vitt anb Te5tamefic
=c
OF ry
FRANCES J. KELLY
I, FRANCES J. KELLY, of Upper Allen Township, Cumberland County, Pennsylvania,
being of sound and disposing mind, memory and understanding, do hereby make, publish and
declare this as and for my Last Will and Testament, hereby revoking and making void any and
all Wills or Codicils at any time heretofore made by me.
ARTICLE I
DEBTS
I direct the payment of all my legal debts, and the expenses of my last illness and funeral
from my Estate as soon after my death as conveniently may be done.
ARTICLE II
TANGIBLE PERSONALTY
I give and bequeath certain items of tangible personal property to those individuals who
survive me as are designated on an undated list or memorandum authenticated by me which I shall
place with my Will and which refers to this Will or is found with a copy thereof; provided that no
such list or memorandum shall be valid unless it is received by my Personal Representative within
sixty(60) days of my Personal Representative's qualification.
j. '
I give and bequeath the remainder of my motor vehicle(s), household goods and personal '
effects and other tangible personalty of like nature (not including cash or securities), together with
any existing insurance thereon,unto my son, SEAN D. KELLY,provided he survives me.
ARTICLE III
REST, RESIDUE AND REMAINDER
I give, devise and bequeath all the rest, residue and remainder of my estate, of whatever
nature and wherever situate, unto my son, SEAN D. KELLY, or his-then-living issue, per
stirpes, should he predecease me.
ARTICLE IV
ALTERNATE DISPOSITION OF REST,RESIDUE AND REMAINDER
In the event that my son, SEAN D. KELLY, predeceases me without living issue, I give,
devise and bequeath all the rest, residue and remainder of my estate, of whatever nature, in equal
shares unto those of the following who survive me: my sister, JUDITH A. HIMES; my sister,
MARGARET J. JOHNSON; my brother, WILLIAM H. GRANT; my brother, BENNETT F.
GRANT; and my brother, RICHARD R. GRANT.
ARTICLE V
UNIFORM TRANSFERS TO MINORS ACT
In the event any beneficiary of my Will has not reached the age of twenty-five (25) years at
the time for distribution of his or her share, distribution of said share may be made in the discretion
of my Personal Representative after considering the age and needs of the beneficiary, either
directly to the beneficiary or to a Custodian for such beneficiary until age twenty-five (25) under
the Pennsylvania Uniform Transfers to Minors Act, 20 Pa. C.S.A § 5301 et seq., or the applicable
Uniform Gifts to Minors Act or Uniform Transfers to Minors Act in the state of residence of such
beneficiary as the case may be. My Personal Representative may designate as such Custodian any
institution or person, including my Personal Representative, qualified to act as a Custodian for such
beneficiary under such Act in effect at the time such distribution is made. A receipt for any
payment or distribution so made shall be a full discharge therefor to my Personal Representative,
who shall not be responsible to see to, or be liable for,the application of such proceeds thereafter.
ARTICLE VI
POWERS OF PERSONAL REPRESENTATIVE
My Personal Representative shall have the following powers in addition to those vested
in them by law and by other provisions of my Will applicable to all property, whether principal
or income, including property held for minors, exercisable without court approval and effective
until actual distribution of all property:
A. To make distribution in cash or in kind, or partly in cash and partly in kind, and in
such manner as they may determine.
B. To retain any or all of the assets of my estate, real or personal, without restriction to
investments authorized for Pennsylvania fiduciaries, as they deem proper, without
regard to any principle of diversification or risk.
C. To invest in all forms of property without restriction to investments authorized for
Pennsylvania fiduciaries, as they deem proper, without regard to any principle of
diversification or risk.
D. To sell at public or private sale, to exchange, or to lease for any period of time any
real or personal property and to give options for sales, exchanges or leases, for such
prices and upon such terms or conditions as they deem proper.
t
E. To allocate receipts and expenses to principal or income or partly to each as they
from time to time think proper.
F. To compromise any claim or controversy.
G. To make such elections, decisions, concessions and settlements in connection
with all income, estate, inheritance, gift, generation skipping or other tax refunds
and the payment of such taxes as my Personal Representative and/or Trustee shall
deem appropriate, without obligation to adjust the distributive share of any person
thereby affected.
ARTICLE VII
TAXES
I direct that all estate, inheritance, transfer and other taxes of similar nature payable by
reason of my death, together with any interest or penalties thereon, and imposed with respect to
any property,whether or not disposed by this Will, shall be paid out of the residue of my Estate.
ARTICLE VIII
PERSONAL REPRESENTATIVE
I name, constitute and appoint my son, SEAN D. KELLY, Executor of this my Last Will
and Testament. Should my son, SEAN D. KELLY, fail to qualify or cease to so act, I name,
constitute and appoint my sister, JUDITH A. RIMES, alternate Executrix to complete the
administration of my Estate. I direct that no fiduciary appointed herein shall be required to post
bond for the faithful administration of the duties required in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will
and Testament,this r? day of z 2005.
2 {SEAL}
FRANCES J. KECXY
Signed, sealed, published and declared by the above-named Testatrix, as and for her Last
Will and Testament, in the presence of us, who at her request, in her presence and in the presence
of each other,have hereunto subscribed our names as witnesses.
r.,
r `
AFFIDAVIT AND ACICNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF CUMBERLAND
We, FRANCES J. KELLY, (rcc�d + and
i� r~' , the Testatrix and the witnesses, respectively,� ,° It�
whose names are signed to the a tached or foregoing instrument, being first duly sworn, do hereby
declare to the undersigned authority that the Testatrix signed and executed the instrument as her
Last Will and that she had signed willingly and that she executed it as her free and voluntary act for
the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the
Testatrix, signed the Will as witness and that to the best of his/her knowledge the Testatrix was at
that time eighteen years of age or older,of sound min and under no constraint or undue influence.
FRANCES J. KEL
r a
Witness
Witness
Subscribed, sworn to and acknowledged before me by FRANCES J. KELLY, Testatrix,
and subscribed and sworn/to before me by !�—IM tGX 11 4, t/YF-?a and
, witnesses, this day of
2005.
ary Public
1 :235921 _
Notarial Seal
Kristee K.Myers,Notary public
Lemoyne Boro,cumberlww county
My commission Expires pec,2,2006
Member,Pennsylvania peon a Notaries
,i
1 -
Investment Account Strategic Asset Management
Statement Period
October 1 to October 31,2014
ACCOUNT INVESTMENT SUMMARY as of October 31,2014
Investment Type Amount Percent
Cash and Cash Equivalents $769.11 0.75%
Equities and Options
Fixed Income
Mutual Funds, .,-�..�-----��-..__.__•_---101.360.27-.��.99.25°/a
ETFs and Closed-End Funds
Total $102,129.38 100.00%
EARNINGS SUMMARY as of October 31,2014
Estimated Annual income $1,027.00
memo
LPL Financial
Investment Account Strategic Asset Management 4698.0832 page 2 of 16
46880832
Performance Checking Statement
PNC Bank PIVCBAIVK
Primary account number:51-1202-4624
Page 1 of 3
For the period 11/18/2014 to 12/17/2014 Number of enclosures:0
000742 For 24-hour banking,and transaction or
FRANCES J KELLY DECD interest rate information,sign on to
1565 WILLIAMSBURG WAY PNC Bank Online Banking atpnc.com.
MECHANICSBURG PA 17050-7390 Tt For customer service call 1-888-PNC-BANK
Monday-Friday:7 AM-10 PM ET
Saturday&Sunday: 8 AM-5 PM ET
Para servicio en espaflol,1-866-HOLA-PNC
Moving? Please contact us at 1-888-PNC-BANK
CO Write to:Customer Service
PO Box 609
Vittsnurgn FA 15230-3738
13 Visit us at PNC.com
® TDD terminal:1-800-531-1648
For hearing impaired clients only
IMPORTANT ACCOUNT INFORMATION
Effective February 22,2015,the information below amends the Account Agreement for Personal Checking,Savings and Money Market
Accounts.Please read this information and retain it with your records.
Closing Your Account
You or the Bank can close your Account at any time by providing written notice.If we close the Account,we will mail you a check for the
final balance.If you close the Account,you will still be responsible for any outstanding checks written,or service charges or overdrafts
incurred,before,during,or after the time you closed the Account.We are not required to close the Account at your request until all known
authorized or outstanding items(including checks,ATM,point-of-sale,ACH and other electronic transactions)have been paid from your
Account and any outstanding disputes(including but not limited to disputes regarding electronic transfers,ACH transactions or other
unresolved internal research requests/disputes concerning the Account)have been resolved.We will not reopen a closed Account except as
necessary to resolve any outstanding disputes.Any items presented for payment after an Account has been closed will be returned to the payee
and you will be liable for any associated charges.Any additional deposits or electronic credits(including Social Security,pension payments
and automatic payroll deposits)will be returned to the originator.
memommummoom
Performance Cheeldng Frances Kelly Decd
Interest Checldng Account Summary
Acama=:e:mmmmlber: 5"-"202-4624
Overdraft Protection has not been established for this account.
Please contact us if you would like to set up this service.
Overdraft Coverage-Your account is currently opted-Out.
You or your joint owner may revoke your opt-in or opt-out choice at any time.
To learn more about PNC Overdraft Solutions visit us online at pnc.com/overdraftsolutions.
Call 1-877-588-3605,visit any branch,or Sign on to PNC Online Banking,and select the"Overdraft
Solutions"link under the Account Services section to manage both your Overdraft Coverage and Overdraft
Protection settings.
Balance Summary
Beginning Deposits and Checks and other Ending
balance other additions deductions balance
2,478.95 .02 .00 2,478.97
Average monthly Charges
balance and fees
2,478.95 .00
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Funeral H6rrie ` eiatoryC (Dro
LF
November 14, 2014
Sean Kelly
1060 Memory Lane
Mechanicsburg, PA 17055
Dear Sean:
Thank you for allowing us the privilege of serving you and your family. We know that financial
statements can be confusing, so below is a summary of your account.
Statement of Goods& Services $ 15,507.00
Less: Contract Addendums (529.72)
Subtotal: Invoice#11385 $ 14,977.28
Less: Terms Discount (917.00)
Your Balance Due $ 14,060.28
We have enclosed a complete invoice for your records.
Please call us at any time that we may be of service.
With Warm Regards,
Michelle L. Haag
Treasurer
Myers.Buhriig 1.119
Funeral Home And Crematory,.Ltd.
Mechanicsburg, PA 17055
DATE
(717) 761-3421 _L
1I 1v
GEiVED FRO
DOLLARS
FOR
1
AMOUNT OF ACCOUNT [:] CASH
THIS PAYMENT CHECK B Yang
BALANCE DUE M-o• THANK YOU
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