HomeMy WebLinkAbout03-02-15 --� REV-1500 EX(02-11) ST 1505610143
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO BOx.280601 INHERITANCE TAX RETURN 2 1 14 0520
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
11 15 2013 02 25 1959
Decedent's Last Name Suffix Decedent's First Name MI
BOOK LEONARD R
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name Mi
BOOK DEBRA S
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
® 1. Original Return ❑ 2. Supplemental Return ❑ 3,Remainder Return(Date of Death
Prior to 12-13-82)
❑ 4. Limited Estate ❑ 4a.Future Interest Compromise [35. Federal Estate Tax Return Required
(date of death after 12-12-82)
❑ 8 Decedent Died Testate ❑ Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
❑ 9. Litigation Proceeds Received ❑ 10.Spousal Poverty Credit(Date of Death ❑ 11.Election to tax under Sec.9113(A)
between 12.31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
DUANE P STONE 717 432 2089
REGISTER OF WILLS USE ONLY
First Line of Address
3 N BALTIMORE STREET rTi
Second Line of Address = s _ °T;> a
-� o-)
DATE ILED r a
City or Post Office State ZIP Code a
DILLSBURG PA 17019 w
c�
Correspondent's e-mail address: Duane@)StoneDuncan.Com _q r_0 r" rnt—'
4
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to'the best of my krOw)edge and be ief,
it tr ,correct and comRlal4k.Decla&ation of preparer other than the personal representative is based on all information of which preparer has any knowledge.
(GNAT RE OF PERSON R SP NSIBL OR FILING RETURN
Jessica N. Book 12—DATEE
- 2d S
ADDRE
925 W.Trindle Road, Mechanicsburg, PA 17055
SIGNATU OF PREPARER OTHER THA REP ESENTATIVE DATE
. � Duane P Stone :2 - Z Z 0
ADDRESS
Stone, Duncan & Linsenbach
3 N. Baltimore Street, Dillsburg, PA 17019
Side 1
1505610143 1505610143
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: BOOK, LEONARD R
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. 12 , 942 . 20
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested............. 7.
8. Total Gross Assets(total Lines 1 through 7).......................................................... 8• 12 , 942 . 20
9. Funeral Expenses and Administrative Costs(Schedule H)..................................... 9. 13 , 132 . 36
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................. 10. 2 , 780 . 89
11. Total Deductions(total Lines 9 and 10)..........................:....................................... 11. 15 , 913 . 25
12. Net Value of Estate(Line 8 minus Line 11)..:.................:........................................ 12. - 2 , 971 . 05
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. - 2 , 971 . 05 .
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.
16. Amount of Line 14 taxable
at lineal rate X .045 16.
17. Amount of Line 14 taxable
at sibling rate X •12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 18.
19. TAX DUE................................................................................................................... 19. 0 . 00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑
Side 2
1505610243 1505610243
REV-1500 EX Page 3 File Number 21 - 14 - 0520
Decedent's Complete Address:
DECEDENT'S NAME -
Book, Leonard R
STREET ADDRESS
925 West Trindle Road
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
2. Credits/Payments
A. Prior Payments
B. Discount
Total Credits(A +B) (2) 0.00
3. Interest
(3) 0.00
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 0.00
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;.................................................................................. ❑ ❑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?....................................................................................................................... ❑ ❑x
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?...................................................................................................................... ❑ F
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.§9196(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 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 decedent's lineal beneficiaries is 4.5 percent,except as noted in
[72 P.S.§9116(a)(1)].
•The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.&&9116(a)(1.3). A
sibling is defined under Section 9102,as an individual who has at least one parent in common with the decedent,wfiether by bloo�or adoption.
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN CASH, BANK DEPOSITS AND MISC.
RESIDENT DECEDENT PERSONAL PROPERTY
FILE NUMBER
ESTATE OF Book, Leonard R 21 - 14-0520
Include the proceeds of litigation and the date the proceeds were received by the estate.All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 EK Services Inc. November Per Diem 100.00
2 EK Services Inc, October Per Diem 100.00
3 2005 Godfrey Pontoon Boat and Trailer 9,475.00
4 Members 1 st Account 1,283.04
5 401 K Contractors Plan 1,984.16
TOTAL(Also enter on Line 5, Recapitulation) 12,942.20
. r
.SERVICES,INC NE CUMBERLAND;PA 17670.31 " n 21715
. .
Leonard R
Book, �!,,,� 7/30/ 4. .
;Per Diemt 40.00
Per Diem 20.00
Per Diem" 20.00 `
Pei Diem 20A0
a...
Checking account NOVEMBER 2013 PER DIEM 100.00
a .
t
r .
v
1 `
• j
,r
EX.-SERVICES,INC --NEW CVMBERL.AND PA 17070-.3151
21 14 .
Leonard R.Bot7iC 713012014
`Per"biem 20.00
Per Diem 20.00
Per Diem .20.00
;Per Giem 20.00
Per-Diem - -- 20.00
Checking account &L OBER 2013 PER DIEM l 100.00
ti
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2005 Godfrey Pontoon Boats TUSCANY Series 240 ES(*) Standard Equipment, Boat Va... Page 1 of 2
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Boat Cover-20 ft.thru 25 ft. $170 $195
Trailer:(chanaA)
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ch TOTAL PRICE: $12,730 $8,305 $9,475
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.. .
&R RETIREMENT
11� STATEMENT
E.K.SERVICES,INC.
260 OLD YORK RDeno : C 0 er , roug ecem er , 1
NEW CUMBERLAND,PA 17070
THE
'Il'I'Illll �I�I� II r I I. .I I. Ir I Contra ctors
III II Ilulllllll 111 f lu nl II
9771 AT 0.384 F84523-000977-0 Plan
�
LEONARD R BOOK
925 W TRINDLE RD
MECHANICSBURG,PA 17055-4073 -71-- Powered by
I, Fringe Benefit Group
Contractors and Employees 401(k)Profit Sharing Plan
YOUR RETIREMENT YOUR WAY
..:��.5-.,''-- ....>rw-..{, am�wye- .-3.x t. .,..' �S'�l?����a=n-`, �•=r=i fN _!::�,ks,,'i.-.Y .�"3'�. :�°(1c.�}_r : -' i7
You can use your computer'or smart phone at www contractorsglan corn to central time at the same phone number
review contributions,generate statements,review investment returns and' ;protect your future by,keeping your money in your re tirement account.It 1
fund information sheets,update your contact information"and,.if applicably;: 'grows tax.free until you quit work and really_need it. After you no longer work r
change your investments. We've recently updated the site,so give it aaook 'fot.the company sponsoring this plan,you may,request apayment or tax-free
and let us know what you think! Call 800-933-3863(option 1)anytime for rollover from your account,in a lump-sum payment or by choosing an annuity
your account balance information or to manage your investments. Our option after the plan's required waiting period.
customer service representatives are available toll-free,7 a.m.to 7 p.m.
7AQC60NTINr'0RMATI0N
Your Contribution Your Account Your Account Balance
Allocation Allocation Beginning Balance $162.09
40 Contributions(+) $2,260.07
Investments gain or loss(+/) $25.23
Withdrawals() $0.00
Other(+/-) $0.00
®TARGET MATURITY Ending Balance $2,447.39
(100.00%)
Vested Balance $2,447.39
Your Contribution Allocation:Your contribution allocation pie shows how Account Rate of Return for the Period 4.03%
you've directed your contributions to be spread between investments in Your Year to Date Rate of Return 1.98%
different asset classes.
Your Account Allocation:Your account allocation pie shows how the
money in your account is actua/lyspread between investments in different
asset classes.Because different investments grow at different rates,your
account allocation can get out of balance with your contribution allocation.
If your account allocation varies from your contribution allocation by more
than 10%,you may wish to rebalance your account.
ffl-
ODD977 02 010010 00 0
c
,- YOUR i 1 i j
Contributions Beginning Total Vested Vested
by Source Balance Contributions Gain/Loss Distributions Other Balance %' Amount
Deferral T2 $0.00 $318.08' $1.80 $0.00 $0.00 $319.88 100 $319.88
Totals $162.09 $2,260.07 525.23 $0.00 $0.00 $2,447.89
$2,447.59
YOUR RETIREMENT PLAN DISCLOSURES
The Importance of Diversifying Your Retirement Savings account all of your assets,including any retirement savings outside of the
To help achieve long-term retirement security,you should give careful Plan.No single approach is right for everyone because,among other
consideration to the benefits of a well-balanced and diversified investment factors,individuals have different financial goals,different time horizons
portfolio.Allocating your assets among different types of investments can for meeting their goals,and different tolerances for risk.It is also
help you achieve a favorable rate of return,while minimizing your overall important to periodically review your investment portfolio,your investment
risk of losing money.This is because market or other economic conditions objectives,and the investment options under the Plan to help ensure that
that cause one category of assets,or one particular security,to perform your retirement savings will meet your retirement.goals. ... .
very well often cause another as category,or another particular. For More Information
security,to perform poorly.Although diversification is not a guarantee For information regarding individual investing and diversification,please
against loss,it is an effective strategy to help you manage_investment risk. go to the Department of Labor's website at
In deciding how to invest your retirement savings,you should.take into isww.doLgov1ebsa/investing.htrnL
.- EXPENSES
Expenses for plan administration and recordkeeping are charged to Other Plan Expenses
your account.The amount of these fees and expenses for the Investment Contract Charge ($1.99)
quarter ending 12/31/2013 was$14.09.
- - -- __-_ Trust-Expenses --
Trustee Fee ($0.16)
�- YOUR ACCOUNT
Beginning Contri- Fund With- Ending
Balance butions Transfers Other drawals Earnings Balance
EQUITY
American Funds Growth Fund of America 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Harbor International Instl 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Nationwide Mid Cap Mkt Index Instl 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Vanguard Small Cap Index 0.00 0.00 0.00 0.00 0.00 0.00 0.00
BOND
Nationwide Short Duration Bond Service 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Page 2 of 3
Im' YOUR - - - - - -
Beginning -Contrl• Fund With- Ending
Balance ".UutiUS Transfers Other drawals Earnings Balance:`
BOND ,
PIMCO Total Return Instl 0.00 0.00 0.00 0,00 . O.DO 0.00 0.00
CASH EQUIVALENT ,
ACA Loan Line 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Dreyfus Instl Pref Money Market Prime 0.00 0.00 .0.00 0.00 0.30 .0.00 0.00
LOAN 0:00, 0.00 0.00 0.00 ` 0.90 0.00 0.00
TARGET MATURITY
M&N Retirement Target 2020 Fund Instl 162.09 2,260.07 . 0.00 0.00 0.00: 25:23 2,447.39
M&N Retirement Target 2010 Fund Instl 0.00 0.00 0,00 0.00 0.00 0.00 0.00.
M&N Retirement Target 2030 Fund Instl 0.00 0.00 0.00 0,00 -0.60 0.00 0.00
M&N Retirement Target 2040 Fund Instl 0.00 0.00 0.00 . 0.00 0.00 0.00 0.00
M&N Retirement Target 2050 Fund Instl 0.00 0.00 0.000.00 0.10 0 00, .0.00
STRATEGIC ALLOCATION r
M&N Retirement Target Income Fund Inst 0.00 0.00 0.00-' 0.00 opo .0.00 0.00
Totals 162.09 :2,260.:07 0.00 ;
0.00' 0.00 25.23_ 2,447.39
000977 02 02 0010 00 1
Page 3 of 3
vA
No. 0000887872
-
MEMBERS 1St Issued.By:Moneygram Payment Systems,Inc.
P.O:Bax 9476,Minneapolis MN 554$0 "
FEDERAL CREDIT UNION
Drawee::!,. BOKF,NA
f@P.O.BOX 40 EUFAULA,OK
�. _
M Mechanicsburg,Pennsylvania 17055 ,• 49-55
R _ 1031 DATE
x 02412414
*** ONE THOUSAND TWO HUNDRED EIGHTY-THREE DOLLARS AND ***
*** 04 CENTS *** $1; 283.04:
PAYEXACTLU¢ op 1 1, 283-dollars 0 4 Cents OFFICIAL CHECK
Drawer:.MEMBERS 1 ST FEDERAL CREDIT UNION
TO THE JESSICA N. BOOK
ORDER OF TWO SIGNATURES REQUIRED FOR CHECK OVER 2,500.00,
115000088 ?8 Z 211•..; 1: LO 3 1,00 5 5 LI:O L600 L L 304 78 2t1'
MEMBERS IST FEDERAL CREDIT UNION-P.O.BOX 40,!. MECHANICSBURG,PENNSYLVANM 17055. N9. 0000887872
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REV-1511 EX+(10.09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNER&W� ��ND
INHERITANCE TAX RETURN
RESIDENT DECEDENT �ING I1F�11 1 V E COSTS
ESTATE OF Book, Leonard R FILE NUMBER
21 - 14 -0520
Decedent's debts must be reported on Schedule.1.
ITEM
NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT
A. 1 Cocklin Funeral Home Inc. 11,273.86
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representatives)
Street Address
City State Zip
Year(s)Commission Paid
2. Attorney's Fees Stone, Duncan &Linsenbach 1,500.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills 158.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1 Administrative Reserve 200.00
TOTAL(Also enter on line 9, Recapitulation) 13,132.36
l
Scott D. Brenneman Tei: (717) 432.5312
Supervisor,Funeral Director Fax: (717) 32-5711
Be,ly� 1. Cocklia
Funeral DirectorOCK.LIN
In PA: (800) 7805312
FUNERAL.HOME, INC.
30 N. Chestnut Street
Dillsburg, Pennsylvania 17019
www.cocklinfuneralhorne.com
2/12/2014
Jessica N. Book
119 W. Harrisburg St.
Dillsburg, PA 17019
Services for: Leonard R. Book
Services On: 11/20/2013
Description Billed
Fees for Services
Mileage to Berwick Hospital $262.50
Traditional Service Package $3,925.00
Antique Gold-Crepe $3,495,00
Graveliner $950.00
Certified Copies $90.00
Newspaper Notice-Harrisburg $322.20
Newspaper Notice-Banner $35.00
Newspaper Notice-New Castle $194.16
Cemetery Equipment $200.00
Clergy Honorarium $100.00
Cemetery Property $800.00
Opening and Closing Grave $900.00
Sub-Total $t"11,273.86
Payments to Date
Jessica N. Book 01/22/2014 ($11,273.86)
Sub-Total ($ 11,273.86)
Statement Total $0.00
FORE
Funeral Planning
Yenns IvanEN SCHEDULE I
P Y
DEPARTMENT REVENUE DEBTS OF DECEDENT,, MORTGAGE
RESIDENT DECEDENT LIABILITIES & LIENS
FILE NUMBER
ESTATE OF Book, Leonard R 21 - 14-0520
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
1 Paradigm Emergency 192.53
2 Berwick Hospital 832.05
3 Berwick Area Ambulance 1,286.00
4 J.P. Harris Associates (tax delinquencies) 470.31
TOTAL(Also enter on Line 10, Recapitulation) 2,780.89
0
STATEIV7T OF.ACCOUNT (2)
PARADIGM EMERGE;. Y PHYSICIANS State, Date: January 15,2014
PO`BOX37885 ACCOUNT.NUMBER. BER60025517
PHILADELPHIA; PA 19101-7885 Patient.Name:.,LEONARD BOOK
Tax ID 4. 45-5546314
Account`Balance: $192.53
-Amcian"tPending
:Insurance: $0.00
I Ir ��II I .I I. r II. Ir r III I 1 I Amount Due From
fill Ilu u:' III- II i l uil LIII I I I .I r II:i1i �� --
Patient(Current) $0 00 - –
020518 '000006002551:7=07 Amount Due From - -- =- =-
,. #BWNJFDB- Patient(Past Due) $192;53 ^
#O 000000BER321211# Pay This Amount $192'53, -
LEONARD.BOOi<.. _
925„W TRINDLE RDYOUR ACCOUNT IS NOW SERIOUSLY - -----
MECHANICSBURG PA 17055-4073 -PAST DUE,AND A DELINQUENCY,
REVIEW IS,BEING.CONDUCTED: Please –-- -- – —--
refer to:coupon;be19w,for payment
instruction's.
Pay your bill securely online anytime at www.MyMedicalPaytnentscom;.: `.
Date'.. 7F 4.1Description Charge Paid By '.P,aid B .: 'Paid.By Amount:. Due From PATIENT, .
First fns: Other Ins. Patient Adjusted Insurance:BALANCE' -
11/15/13 1 92950 CARDIOPULMONARY RESUSCITATION $1,046.00.'
DX 427 5 DR BASHA/BERWICK HO$PrrAL CENTER
12/06/13 INSURANCECLAIMDENIED-DEDUCl1BLE -s0.00
-12106/13, INSURANCE CONTRACTUAL ALLOWANCE5.853.47 $192.53 =
- — - {
TOTALS: $1;046.00 $0 00 $0 00 $0 00 $853.47•� $0.00 $192:53
iMP'
ortant Messages:
Tlirs statement is for the direct treatrfienYand/or Supervision of care"you recentlyy race yed from an Emergency`,Physician,afBarwick Hospital Cerner. The fees for this private
pphysiciagaie billed separately from any Hospital charges or other professional fees for which you may also be responsible. Therefore,should you receive a bill from the
hospital ar other physician's for chaiges in connection with this visit,it will not included the items listed on this statement .
"Payment Plan's"Accepted
Questions-about,""this statetnent?/Llame'de Lunes-a Vlernes?
Call'1 800=355 247.0 Monday.through Friday'9 30AM 4.00PM.
Your automated system access code is1235 60025517, or.you-can.send email to
billing gypstions@emcare.com.
95213=R1 7009Qlei3se.detach and-return bottom portion with your rdrnittance: �
-------------- ------------------------------
LEONARD BOOK STATEMENT.OF ACCOUNT
925 W TRINDLE RD Statement Date: January 15,2014
MECHANICSBURG PA 17055 4073 ACCOUNT NUMBER: BER60025517
YOU MAY PAY THIS BILL WITH YOUR CREDIT CARD I Patient Name:LEONARD BOOK
PLEASE SEE REVERSE SIDE. Payment Due By: PAST DUE
Make Check/Money Order payable to: Amount Due: $192.53
Amount Enclosed:
Go Green-pay online at
PARADIGM EMERGENCY PHYSICIANS www•MyMedicalPayments.com
The insurance information in our rile appears below.Please make any corrections
PO BOX 37885 and/or additions on the reverse side of this form and return it to us.Thank you.
PHILADELPHIA, PA 19101-7885
I I Ir It KEY11 KEYSTONE HP CENTRAUCAPITAL BC
.r t t n u u n I I I I III'u u u III r I n I t I t I ' I I III n r t t n r i YWV80154348300 00501767 23045
If your address has changed, check this box.
and complete the reverse side of this form
0205180000060025517000192530000000000001
'MASTERCA DISCOVER VISA' eRi AMERICANEXPRESS
Berwick Hospital Center
701 E 16th St
Berwick, PA 18603-2316 Save Time And Postage Pay Your Bill Online at
w .w.berwick hospitalcom
It's Fast, Easy And Secure.
Please review the name and-address fisted below'. 653499C(PC1
as well as the patient name If any of the .
006573 0101 information is incorrect, please call the number.
listed below:
101 Make Checks Payable To
ESTATE OF LEONARD BOOK BERWIGK HOSPITAL CENTER
925 W TRIND.LE RD PO BOX 503171
MECHANICSBURG, PA 17055-4073 ST. LOUIS, MO 63150-0001
hill fit If 11111111h11 lip II'll. III 1IIIIIui�1.11.11111111id1.11 .I
a• Oil= que Date pay This Amount
11/28/13 6002551 LEONARD BOOK 12/12/13 $832.05
-
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Are`yoit or someone you$ noY witliout l3ea�th Ynsurance`�
_ ___ Affordable health insurance options are now a allable1
AM
TOTAL INSURANCE. PATIENT PAYMENTS` ADJUSTMENTS: ACCOUNT.,,
CHARGES PAYMENTS TO DATE : TO DATE :. TO DATE BALANCE 'PAY THIS AMOUNT'
$5;095.25 $-625.60 $-3,637:60 $832.05 $832:05
If you have any questions please.call: 888=861-2271
Berwick Hospital Center
701 E-16th St'
Berwick, PA 18603-2316
Statement Date: 11/28/13
Description of Service: Emergency Room Services
Patient: LEONARD BOOK
Account Number: 6002551
Dates)of Service: 11/15/13 - 11/15/13
Please see reverse side for important information.
Illktillllltlflll 12-CHSLTR-38447-983309923=P;4683695-'1-151;33913870-1;1
j
Berwick Area Ambulance Assn
PO BOX 90
DANVILLE,PA 17821-0090
(800)369-7544
Patient name: BOOK,LEONARD 1 un Number: 13-134494
Date of c Il: 11/15/2013
From: SL PER 8 430 W THIRD ST
LEONARD BOOK To: Be wick Hospital Center
925 W TRINDLE RD
MECHANICSBURG,PA 17055 Primary payer: Ca ital 13 lue Cross
Secondary payer: Pa dent Pay
Payment
Description Payer Check# Quant it3 U flt Price Date Amount
ALS 2 $1,150.00 $1,150M
Mileage 8 $17.00 $136.00
PAY THIS BILL ONLINE AT WWW.EMSBILLPAY.COM
OR CALL THE NUMBER ABOVE TO PAY BY PHONE PLEASE PAY THIS5 AMOUNT $1,286.00
............ ............ _..................................................................._. .......... i.
DETACH ALONG LINE AND RETURN STUB WITH YOUR PAYMENTT1[ANK YOU.
i
Patient name: BOOK,LEONARD Run Number: 13-134494 AMOUNT $
NCLOSED:
Date of call: 11/15/2013 Current date: 12/26/2013
REMIT TO: Berwick Area Ambulance Assoc.
PO BOX 90
DANVILLE,PA 17821-0090
Our records indicate that your insurance carrier may have processed your claim directly toy u. Pleas remit payment promptly or contact
your insurance carrier regarding the status of your claim.
FORM 2
IS`n(AI T FOR. DELINQUENT _AX S
. . HARRIS ASSOCIATES LLC
COMMONWEALTH OF PENNSYLVANIA
DELINQUENT
TOMS ATTN P ROLL VV TAX COLLECTOR
COUNTY YORK LEONARD BOOK 11/7/2013
119 W HARRISBUR T APT .
BOROUGH/TWP DILLSBURG (B) DILLSBURG, PA 17C19
SCHOOL DISTRICT i
BOOK LEONO2
YEAR COUNTY TWP/BORO SCH DIST TAXES: Occupation (OCC) Per Capi a (PC)
2012 YO DILL NORT SCH PC j
2011 YO DILL BORO OCC BORO PC
2010 YO DILL NORT SCH PC BORO OCC BOR C
2009 YO DILL NORT SCH PC BORO OCC BORO PC
Your Personal Tax(s) and Penality(s) now stand at 449-5
Mileage
Service Charge , op
Distraint Fee 5.0
Total ;70
I I.
i
i
Certain taxes as herein apportioned and set forth,have been regularly and duly assessed and levied against you by the taxing YOU MU iT RET RN THIS NOTICE WITH PAYMENT
district or districts designated herein,in accordance with the Acts of the General Assembly of the Commonwealth of Pennsylvania Remit to: P. HARRISASSOCIATES LLC,Delinquent Tax Collector
in such cases made and provided;and notice thereof has been given you according to law and the payment thereof has been9
demanded more than thing(30)days since;and you have refused,failed or neglected to make payment of them. P.IBox 224, •Mechanicsburgg,PA 17055•(717)766-4357
THEREFORE,you are hereby notified that by virtue of authority in J.P.Harris Associates LLC,Delinquent Tax Collector,vested by the STAMPED,A DR SSED ENVEL P MUST ACCOMPANYl2EMITTANCES FOR RETURN OF RECEIPT.
acts of Assembly in such cases made and provided,and by appointment and designation by the above-identified governmental unit, (CHECKS A E I ECEIVED SUB E-T TO FINAL PAYMENT AND AT THE RISK OF THE TAXPAYER.)
we hereby cause and direct the following goods and chattels to be levied and distrained upon for the payment of said taxes and the P y rtreerat is to be made within (2 0) Da3Ls-
costs and penalties accruing thereon because of your delinquency. If your payment i,n mailed on or be r this date,then the above-identified governmental unit reserves all rights and
remedies availab et it,including bunim limited to distress and sale of goods as provided bylaw,P.516918.
AN
ALL OTHER GOODS AND CHATTELS.
YOU are further notified that we will sell the same to satisfy the said taxes,costs and penalties ata public sale to be held on yout pr 2mises after i aymg given(10)days public notice of said sale
by posting ten 00)written notices on the premises and in the public places in the neighborhood and by one advertisement i i a newspaper )f general circulation published in the county.
53 F.S.§6918.1bu have the right to a hearing before a District Justice prior to a Distraint Sale.You are entitled to receive awritter explanation of xur rights with regard to the assessment,audit,
appeal,enforcement,refund,and collection of certain school taxes.The written explanation is entitled JA Harris Associates LLC illof Rights Discloisure Statement.If you would like a copy,mail
us a request at the address on this notice. J.P. HARRISASSOCIATES LLC
This communication is from a debt collector,and is an attempt to collect a consumer"debt".
Any information obtained oil'be used f r that purpose. D e l i n 1 e n t Tax Collector
DATE TIME "� BY:
No failure to deman or colt ct any taxes by distress and sale of goods and chattels shall invalidate any ret rn made,or lien filed for nonpayment of taxes,or
any tax sale for the collection of taxes. 72 P.S. § 5511.17:Within ten days after the date of the levy,the alleged delin lent may appear at the office of the
district magistrate in the district in which the goods and chattels are located and demand a hearing on the merits of th llaim. 72 P.S. § 5511.12:Failure to
receive a tax notice does not relieve any taxpayer from liability for prompt payment of taxes imposed by tl'e taxing distr qt(s).
( NJnfit-s O;Pnd this Distraint Notice with Pavment.
REV-1513 EX+(01-10)
rrjj pennsylOF REVENUE vania SCHEDULE
DEPARTMENT
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Book, Leonard R
21 - 14 -0520
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not List Trustee(s)
TAXABLE DISTRIBUTIONS[include outright spousal
distributions,and Fronsfers
under Sec.9116(a)(1.2))
1 Debra S. Book wife
212 S. 2nd Street
Dillsburg, PA 17019
2 Jessica N. Book Daughter
119 W. Harrisburg St. Apt. 1
Dillsburg, PA 17019
3 Jordan S. Book son
119 W. Harrisburg St. Apt 1
Dillsburg, PA 17019
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
IIS NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
REV-1513 EX+(01-10)
I
tijff" pennsylvania
DEPARTMENT OF REVENUE SCHEDULE
INHERITANCE TAX RETURN
RESIDENT DECEDENT BENEFICIARIES continued
ESTATE OFF
Book, Leonard R FILE NUMBER
1 21 - 14 -0520
NUMBER NAME AND ADDRESS OF PERSON(S) RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
RECEIVING PROPERTY DECEDENT (Words) ($$$)
00 Not List Trustee(s)
TAXABLE DISTRIBUTIONS[include outright spousal
distributions,and transfers
Jt under Sec.9116(a)(1.2)]
—q4 Justin C. Book
Son
506 W. Main Street Apt. 3
Mechanicsburg, PA 17055
5 Amanda C. Stone daughter
214 East Roosevelt Avenue
Middletown, PA 17057
Page 2 of Schedule J
REV-1649 EX+(09-12)
Iffpennsylvania SCHEDULEO
DEPARTMENT OF REVENUE ELECTION UNDER SEC.911,-"
INHERITANCE TAX RETURN (SPOUESALD�IRJ I oNs)
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Book, Leonard R 21 - 14 -0520
PART A- DEFERRING STATEMENT
For all trust assets reportable for Pennsylvania inheritance tax purposes for which a deferral of tax is being elected under
Section 9113(a), the personal representative responsible for filing the return and the trustee(s)of the trust in question hereby
acknowledge the department's Statement of Policy set forth at 61 Pa. Code§94.3 concerning any potential termination of the
trust under 20 Pa.C.S. §7710.1 that occurs after the return was filed. Specifically,the signatories recognize each individual's
assumption of liability for inheritance tax consequences that result from any termination of the trust under 20 Pa.C.S. §7710.1
that occurs after a return has been filed.
Signature of Person Responsible for Filing Return Signature(s)of Trustee(s)
PART B — ELECTION TO TAX AMOUNTS
Complete this section only if making the election to tax available under Section 9113(a) of the Inheritance &
Estate Tax Act.
If the election applies to more than one trust or similar arrangement,a separate form must be filed for each trust. This election
applies to the Trust(marital,residual A,B,bypass,unified credit,etc.).
Enter the description and value of all interests for which the Section 9113 (A) election to tax is made.
DESCRIPTION VALUE
Total 0.00
(If more space is needed, insert additional sheets of the same size)
STONE, DUN CAN, 3 N. Baltimore Street
Dillsburg, PA 17019
&LI NSEN BACH, PC OFFICE 717-432-2089
Attorneys and Counselors FAx 717-432-0158
www.StoneDuncan.com
Duane P. Stone Jan M. Wiley
Jason B. Duncan' of counsel
Brian C. Linsenbach February 25, 2015
Also licensed in New Jersey
Register of Wills
Cumberland County Judicial Center
1 N Courthouse Avenue
Carlisle, PA 17013
Re: The Estate of Leonard R. Book
D/D: November 15, 2013
Dear Sir/Madam:
Enclosed please find an original Inheritance tax Return Resident
Decedent (REV 1500) to file with the Internal Revenue Service and two (2)
copies. Please time-stamp all and return to our office any un-needed copies in
the enclosed self-addressed pre-postage envelope.
Enclosed you will also find a check (#1003) made out to Register of Wills
in the amount of$15.00. This is for Additional Probate Fees. If you have any
questions please contact the office at (717)-432-2089.
Respectfully,
Tasha Christie, Paralegal
Stone, Duncan & Linsenbach, PC
Enclosures
The Key to Great Legal Services sM
0S POsTq
!��
/ ¢ PITNEY BOWES
02 1P $003.0VL
0002944106 FEB 26 2015
NAILED FROM ZIP CODE 170 19
STONE, D U N CA N,
AINSENBACH, PC
Attorneys and Counselors
8 N.Baltimore Street•Dillsburg,.PA 17019
(717)432-2089•Fax(717)432-0158