HomeMy WebLinkAbout03-31-15 0 pennsylvania 1505614105
DEPnRIMENT O. EX(03-14)(FI)
REV-1500 OFFICIAL USE ONLY
County Code Year File Number
Bureau of Individual Taxes
PO BOX 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT c-,o
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
. .............
j 12262014 04011939
................ --- ......................... .....................................
Decedent's Last Name Suffix Decedent's First Name Ml
F_
Ellis Richard �q�
(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
M 1.Original Return C=:) 2.Supplemental Return C=:) 3. Rernaiinder Return(date of death
prior to 12-13-82)
C=:) 4.Agriculture Exemption(date of C=:) 5. Future Interest Compromise(date of CZ) 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
C=:) 7. Decedent Died Testate C=:) 8. Decedent Maintained a Living Trust 0 9. Total Number of Safe Deposit Boxes
(Attach copy of will.) (Attach copy of trust.)
C=:) 10. Litigation Proceeds Received C=) 11,Non-Probate Transferee Return C=) 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
O 13, Business Assets C=) 14.Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
1,Jacqueline M. Verney, Esq 243-9190
...........
First Line of Address
44 S. Hanover Street
Second Line of Address
............... ............. ...............................
j
City or Post Office State ZIP Code M
CD> Q
Carlisle 17013
. L.... ....... .. .. ... ........ .. ........ J__ =0 Z5 ;a
Correspondent's email address: T.
REGISTER100'WILLS USE ONLY P_C)
REGISTER OF WILLS USE ONLY
ONMMU66"Y'My 1_3
M
DATE FILED STAMP
PLEASE USE ORIGINAL FORM ONLY
Side I
1505614105 1505614105
1505614205
REV-1500 EX(FI)
Decedent's Social Security Number
Decedent's Name: Richard A. Ellis 1
RECAPITULATION
----------- ........
1. Real Estate(Schedule A). ... .. ..... .... ....... ......... 0.00
2. Stocks and Bonds(Schedule B) ...... ....... ....... 2. 0.00
3. Closely Held Corporation,Partnership or Sale-Proprietorship(Schedule C) . .. .. 3. 0.00
4. Mortgages and Notes Receivable(Schedule D)...................... . 4. 0.00 i
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). ...... 5. 3,759.79
6. Jointly Owned Property(Schedule F) C=) Separate Billing Requested ....... 6. 67,350.00
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) C=:) Separate Billing Requested....... , 7.
.............
8. Total Gross Assets(total Lines I through 7).. .......... .. ... ... .. . 8. 1 71,109.79
9. Funeral Expenses and Administrative Costs(Schedule H)............. ...... 9. j 4,062.58
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............... 10. 78,473.63
11. Total Deductions(total Lines 9 and 10).... ............................ 11. 82,536.21
12. Net Value of Estate(Line 8 minus Line 11) . .... ... . ... .. . .. .. .... . .. .. .. 12. -11,426.42
13. Charitable and Governmental Bequests/Sec.9113 Trusts for which
an election to tax has not been made(Schedule J) ... .... .. ... ...... ..... . 13. 0.00
1. ............
14. Net Value Subject to Tax(Line 12 minus Line 13) ... ....... .. ............ 14. -11,426.42
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15, Amount of Line 14 taxable
at the spousal tax rate,or
transfers under See.9116
(a)(1.2)X.0 15.1
16. Amount of Line 14 taxable
at lineal rate X.0 45 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.
0.
19, TAX DUE ................... .... ........ .. .. ...... ...... .. .... .... 19.(
00
20, FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C=)
Under penalties of perjury,I declare I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete. Declaration of preparer other than the person responsible for filing the return is based on all information of which preparer has
any knowledge,
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
ADDRESS
S� ATURE OF PR PARER HE,R THAN RSON RESPONSIBLE FOR FILING THE RETURN DATE
REV/Li q 17613
Side 2
1505614205 1505614205
REV 1500 EX (FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Richard A. Elles
STREET ADDRESS
125 Walnut Street
CITY STATE 717013
Carlisle PA
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
2. Credits/Payments
A.Prior Payments 0.00
B.Discount 0.00
(See instructions.) 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.
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) 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.......................................................................................... ❑
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑
c. retain a reversionary interest .............................................................................................................................. ❑ ■
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑
2. If death occurred after Dec. 12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation? ........................................................................................................................ ❑ ■
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 decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S. §9116(a)(1.3)].A sibling is defined,
under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-15o8 EX+(o8-12)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Richard A Ellis 21-15-0016
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, Orrstown Bank account#696315 3,087.44
2; Orrstown Bank account#696323 458.75
3 1999 Chrysler 300 213.60
TOTAL(Also enter on Line 5, Recapitulation) $ 3,759.79
If more space is needed,use additional sheets of paper of the same size.
12/15 Deposit. Inquiry 15:40:27
Research Services Account number: 696315
�t stmt balance: 3,087.44 Last stmt date: 12/25/14
gent balance: 3, 087 .44 Statement cycle: 25
=View 6=Print T=Tset Control: From To
Posted Check No S T/C Debit Credit Balance
7/10/14 1570 P 091 90.88' Co#rP.$,156-rAYE3 Zvi.' 37 .44
~_ 7/11/14 P 020 10,000.00 -&S ?V/( 10, 037 .44
_ 7/18/14 1578 P 090 950.00^mm2 Lo4%X3,c,) 9,087.44
_ 7/18/14 1579 P 090 500.00 -,-Im?- 8,587 .44
7/23/14 1580 P 090 1, 000.00 Sc2F 7,587 .44
7/30/14 1581 P 090 500.00--st7f 7,087 .44
_ 8/08/14 1582 P 090 1, 000. 00-5a 6, 087 .44
_ 9/02/14 1583 P 090 11000.00-sae 5,087 .44
_ 9/29/14 1584 P 090 3, 000. 00-56F 2, 087 .44
_ 10/20/14 1585 P 090 1, 000.00-+ 1,087 .44
_ 10/31/14 1586 P 090 500 .00-5ac= 587 .44
_ 11/25/14 P 020 5,000.00-/`kis 7, q 5,587.44
_ 11/25/14 P 053 2,000.00--3or � �" `�"r.3 3,587.44
,12/0,8/14 1590 P 090 500.00-YG� 3, 087 .44
_ Bottom
F4=Redsply F6=Bal Inq F7=Scan Fwd F8=Scan Bkwd F11=Prior bal F15=EFT F16=Sort
F17=Top F18=Bottom F19=EDI F20=Unfold F22=T/C F23=Checks
1/12/15 Deposit Inquiry 15:42:41
Richard A Ellis Account number: 6.96323
Passport ATM/Dr Card 1 of 1
Last stmt balance: 458.75 Last stmt date: 12/25/14
Current balance: 458.75 Statement cycle: 25
1=View 6=Print T=Tset Control: From To
Posted Check No S T/C Debit Credit Balance
12/10/14 C 163 1, 925.00 2, 106.72
12/10/14 2389 P 091 50.00 2, 056.72
_ 12/10/14 2567 P 091 30.00 . 2, 026.72
12/10/14 151 .01000000% 2, 026 .72
12/15/14 T 227 60.00 1,966.72
12/15/14 C 183 100.00 1, 866.72
12/15/14 C 183 110.23 1,756.49
12/15/14 C 183 250.00 1, 506.49
12/15/14 C 183 469.09 1, 037.40
12/16/14 C 183 130 .78 906.62
12/16/14 C 183 360.08 546.54
_ 12/18/14 421 P 091 87 .80 458.74
12/18/14 151 .00000000% 458.74
12/25/14 160 .01 458.75
Bottom
F4=Redsply F6=Bal Inq F7=9can Fwd F8=Scan Bkwd F11=Prior bal F15=EFT F16=Sart
F17=Top F18=Bottom F19=EDI F20=Unfold F22=T/C F23=Checks
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REV-iSog EX+(oi-io)
i pennsyLvania SCHEDULE F
DEPARINHERITANCE
MENT OF CETAXRETURN JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Richard A. Ellis 21-15-0016
If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G.
SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A.Marilyn Zatinsky 125 Walnut Street Carlisle, PA 17013 domestic partner
B.
C.
JOINTLY OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE of DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR JOINTLY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1, A. 03/21103 residential home 134,700.00 50 67,350.00
TOTAL(Also enter on Line 6, Recapitulation) $ 67,350.00
If more space is needed,use additional sheets of paper of the same size.
tili_u U 1? �'l0 PARCEL NO.: 04-21-0320-463
THIS DEED
MADE THIS S� day of Gt .wL. L , in the year of our Lord two
thousand three (2003).
BETWEEN MARILYN MILLER ZATINSKY, of Carlisle, Cumberland County,
Pennsyivania, hereinafter referred to as
GRANTOR,
AND MARILYN MILLER ZATINSKY and RICHARD A, ELLIS, of Carlisle,
Cumberland County, Pennsylvania, as joint tenants with right of
survivorship, hereinafter referred to as:
GRANTEES
WITNESSETH, that in consideration of One ($1.00) Dollar in hand paid, the receipt
whereof is hereby acknowledged, the said Grantor does hereby grant and convey to the
said Grantees, their heirs and assigns:
ALL THAT CERTAIN lot of ground with the improvements thereon erected situation
on the North side of Walnut Street in the Third Ward of the Borough of Carlisle,
Cumberland County, Pennsylvania, bounded and described as follows:
COMMENCING at a corner of lot now or formerly of Herman R. Smith on said
Walnut Street; thence along said Street, West 16 � feet to the corner of ioi now or
formerly of Mrs. Nellie Herman; thence along said lot now or formerly of Mrs. Nellie
Herman, North 110 feet to a proposed alley; thence East along said proposed alley,
16 Y2 feet to the line now or formerly of said Herman R. Smith; thence along said line
now or formerly of Herman R. Smith, South 110 feet to the place of BEGINNING.
CONTAINING 16 '/2 feet in front on the said Walnut Street by 110.feet in depth to the
said proposed ten foot private alley, together with the right of way over the proposed
ten foot private alley in the rear of said lot of ground.
BEING improved with a brick dwelling house known as No. 125 Walnut Street.
800X 275 PACE,?4i 6
BEING THE SAME premises which Christopher B. Wise and Melissa M. Wise,
husband and wife, by their Deed dated February 28, 2003, and recorded March 3,
2003 in the Office of the Recorder of Deeds in and for Cumberland County,
Pennsylvania, in Deed Book 255, Page 4656, granted and conveyed to Marilyn Miller
Zatinsky, Grantor herein.
SUBJECT, HOWEVER, to such recorded easements, restrictions and conditions that
may apply to the afore-described tract of land.
AND the said Grantor hereby covenants and agrees that she will warrant specially
the property hereby conveyed.
IN WITNESS WHEREOF, said Grantor has hereunto set her hand and seal the day and
date first about written.
SIGNED, SEALED AND DELIVERED
IN THE PRESENCE OF:
AA 1, I,t i
W T S MA N MILLS ZATINS CY
(SEAL)
WITN S
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF CUMBERLAND
ON THIS, theda of ,C 003, before,me; tfie
t y
undersigned officer, personally appeared, 11lIARILYN MILLER ZATINSKY, known to me ..,
or satisfactorily proven to be the person whose name is subscribed to the within
instrument, and acknowledged that she executed the same for the purposes therein,:.-
contained. :;,: ....
... ...... ... .
IN WITNESS WHEREOF, I hereunto set my ha; d official seal. :-'` '
AL)
J NOTARIAL SEAL - - NotaryF lic
RER1rE L.MURRAY, Nota ,
ry Public.'
ublir.
Cafttste Boro.Cumberland CO.,pA V
^+f.`�mrliss'r•r Ecr•!.P-rrcamb9Y?3,?J,S. ._
800; 275 PAC,1041
CERTIFICATE OF RESIDENCE
I hereby certify that the precise residence and complete post office address of
the within Grantees is: 125 Walnut Street, Carlisle, Pennsylvania 17013
Attorney for Grantees
� •n.f5
I Certify this to be recorded
In Cumberland County PA
Recorder of Deeds
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STREET reserved. Wd Jan 7 201 r
04-21-0320-463
4-21- 5 01:08:44 pM, ADANIS Cwwl "IX
edbook:002750416
tr>er:2A,
'Pertse Code:101 ARIIYN MILLS
page:0 04* R R
able Peet•1535 :. »" "i`t
an Status: T
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'!ding gssessediue 18000
a/Assessed Value�e13 116700
e price 1 4700
ate: un i pal t 900 Jul 26 2006 08:00:00 PM
nici
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REV-1511 EX+(48-13)
r pennsytvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Richard A. Ellis 21-15-0016
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1` Hoffman-Rath Funeral Nome 219 N.Hanover St Carlisle,PA 2,492.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City _ State ZIP
Year(s)Commission Paid:
2. Attorney Fees:
1,000.00
3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City _State ZIP
Relationship of Claimant to Decedent
4• Probate Fees: 250.00
S. Accountant Fees:
b. Tax Return Preparer Fees: 140.00
7. :Advertise Letters:Sentinel-$105.58;Cumberland Law Journal-$75.00=$180.58 180.58
TOTAL(Also enter on Line 9, Recapitulation) $; 4,062.58
If more space is needed,use additional sheets of paper of the same size.
219 North Hanover Street
Carlisle,Pennsylvania 17013
I 717.243.4511
r
toll free 1.866.451.4511
fax 717.243.3723
www.hoffmanroth.com
FUNERAL HOME & CREMATORY, INC.
info@hoffmanroth.com
Christopher R Hoffman—Owner/President William E.Hoffinan- Vice President Robert A.Filbum III—Supervisor
David E.Feczko—Funeral Director Jill A.Lazar—Funeral Director&Preneed Counselor
March 6, 2015
Peter Ellis
69 Drawing Arm Lane
Martinsburg, WV 25403
Statement of Funeral Expenses for: Richard A. Ellis
Date of Death: December 26, 2014 Account Id: 17382-301
PACKAGE:
Immediate Cremation
OPTION 6-Cremation $ 2,390.00
` Sub Total: $ 2,390.00
TOTAL FUNERAL HOME CHARGES: $ 2,390.00
CASH ADVANCES:
12 Certified Death Certificates at$6.00 each $ 72.00
Coroner's Fee $ 30.00
Sub Total: $ 102.00
Peter Ellis Check 3 Mar 6, 2015 2,492.00
TOTAL FUNERAL EXPENSE: $ 2,492.00
Total Payments Made: $ 2,492.00
Balance: $ 0.00
circulation in the Borough of Carlisle,County and State aforesaid,was establlsned
December 13th,1881, since which date THE SENTINEL has been regularly issued in said
County, and that the printed notice or publication attached hereto is exactly the same as
was printed and published in the regular editions and issues of
January 22,2015 and Tanuary 29,2015 and February 5,2015.
�- - COPY OF NOTICE OF PUBLICATION
Affiant further deposes that he/she is not
interested in the subject matter of the
— fXE__oR NOTICE aforesaid notice or advertisement, and that
Letters Testamentary' me Estate or, all allegations in the foregoing statement as
i RICHARD gLgN..EfLLIS;latefof to time,place and character of publication
Borough:bf"Carlisle;rCumtie'rland ":
:'County;F'ennsyivama deceased; ` a e true.
have been grantedto the � �
:'undersigned '>
All persons knowing tfiemseives to be- i ` ' i
s undebte�d to said Estate will make uL—� L
The Sentinel JACQUELINE M.VERNEY AD NUMBER PAGE NO.
w w w.c u m b e r l i n k.c o m 44 SOUTH HANOVER STREET 436936 1 Of 1
� * CARLISLE,PA 17013 BILL DATE SALESPERSON
717-243-9190
02/05/15 robik
carusie shmrFNsa�Rc r:aN cWnv .— --
START DATE STOP DATE
01/22/15 02/05/15
AD NUMBER AD DESCRIPTION CLASS LINES
436936 EXECUTOR NOTICE LETTERS TESTAMENTA 10 PUBLIC NOTICES 18
Publication Insertions Rate Net Amount Gross Amount
3 THE SENTINEL-LEGAL 3 LGL $95.58
TOTAL AD CHARGE $95.58
3 MOBILE SITE MOB2 $3.00
3 PROOF OF PUBLICATION 01 PRF $7.00
Purchase Order Est. Ellis PAY THIS AMOUNT $105.58 $126.70*
*AFTER 03/02/15
Lee Enterprises no longer accepts credit card payments sent via e-mail.
Emails containing credit card numbers will be blocked. Please use the coupon
below to send credit card payment to our lockbox. THE SENTINEL
You may also send the coupon to a secure fax at 319-291-4014. c/o LEE NEWSPAPERS
Thank you for advertising with The Sentinel! Deadline for PO BOX 540
in-column legal ads is 4:00 p.m. two business days prior to WATERLOO IA 50704-0540
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CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, PA 17013
Tele: (717)249-8166 Fax:(717)249-2663
February 13, 2015
Cumberland Law Journal is published every Friday by the Cumberland County
Bar Association and is designated by the Court of Common Pleas as the official legal
publication for Cumberland County and the legal newspaper far publication of legal
notices.
TO: Jacqueline M. Verney, Esquire
RE: Richard A. Ellis Estate
Legal advertisements must be received by Friday Noon. All legal advertising
must be paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on following dates:
January 30, February 6, and February 13, 2015
Advertising Cost $ 75.00
Proof of Publication $ 0.00
Second Proof Request $ 0.00
Payment received $ 75.00
-------------
Total Amount Due $ 0.00
Becky H. Morgenthal, Executive Director
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16, 1929), P. L.1784
COMMONWEALTH OF PENNSYLVANIA
ss.
COUNTY OF CUMBERLAND
Lisa Marie Coyne,Esquire, Editor of the Cumberland Law Journal, of the County and
State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law
Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid,
was established January 2, 1952,and designated by the local courts as the official legal
periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly
issued weekly in the said County, and that the printed notice or publication attached hereto is
exactly the same as was printed in the regular editions and issues of the said Cumberland Law
Journal on the following dates,
viz:
January 30, February 6, and February 13 2015
Affiant further deposes that he is authorized to verify this statement by the Cumberland
Law Journal, a legal periodical of general circulation, and that he is not interested in the subject
matter of the aforesaid notice or advertisement, and that all allegations in the foregoing
statements as to time,place and character of publication are true.
A
Lisa Marie Coyn , Editor
- 1
SWORN TO AND SUBSCRIBED before me this
13 day of February, 2015
Notary
Ellis,Richard Alan,Jr.,deed.
Late of Carlisle Borough. COMMONWEALTH OF PENNSYLVANIA
Executor: Peter L. Ellis c/o Jac- NOTARIAL SEAL
queline M.Verney,Esquire,44 S. ! DEBORAH A COLLINS
Hanover Street,Carlisle,PA 17013. . Notary Public
Attorney: Jacqueline M. Verney, CARLISLE BORO.,CUMBERLAND CNTY
Esquire, 44 S. Hanover Street, My Commission Expires Apr 28,2018
Carlisle,PA 17013.
REV-1512 EX+(12-12)
pennsytvania SCHEDULE
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES &LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Richard A. Ellis 21-15-0016
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Santander Mortgage#0096202547 for 125 Walnut St.Carlisle,PA 1/2$49,210.15=28,667.65 28,667.65
2 Personal loan-Marilyn Zatinsky 125 Walnut St.Carlisle,PA 17013 7,907.71
3. American Express Credit card#2-52008
12,748.80
4 'Citi Credit card#1842/Ascencion Point claim 17,060.25
5 Citi Business card#4122 5100 0760 7347 2,971.54
6 Capitol One#5466-4100-2473-291 3,030,70
T Bank of America#4264 2814 0402 6386 2,170.62
8; Discover#3472
1,427.75
9 Pinnacle Health Emergency 6880 W.Snowvill Rd Brecksville,OH 461.00
10, Members First FCU#0000304971 loan 311.27
11 Cumberland Goodwill Fire Rescue EMS Inc P.O.Box 726 New Cumberland PA 17070 1,569.34
12; '.Hershey Kidney Specialists P.O.Box 517 Hazleton,PA 18201
147.00
TOTAL(Also enter on Line 10, Recapitulation) 78,473.63
If more space is needed,insert additional sheets of the same size.
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Date Loans Interest Payments Total Notes W r
2010-02-23 $1,500.00 $1,500.00
2010-03-23 $12.50 $1,512.50 -=
2010-04-23 $12.60 $1,525.10 i
2010-05-23 $12.71 $ `"
1,537.81 ' P >
2010-06-23 $12,82 $1,550.63 r , , �'e.
+
2010-07-23 $12.92
$1,563.55
2010-08-23 $13.03 $1,576.58
» 2010-09-23 $13.14 $1,589.72
2010-10-23 $13.25 $1,602.97 , .
2919-11-23 $13.36 $1,616.32
2010-11-26 $6,000.00 $7,616.32r
2010-12-23 $63.47 $7,679.79 '
2011-01-23 $64.00 $7,743.79
2011-02-23 $64.53 $7,808.32
2011-02-24 $1,000.00 $8,808.32
2011-03-19 $1,000.00 $9,808.32
2011-03-23 $81.74 $9,890.06
2011-04-23 $82.42 $9,972.48
2011-05-23 $83.10 $10,055.58
2011-06-23 $83.80 $10,139.38
2011-07-14 $100.00 $10,039.38
2011-07-23 $83.66 $10,123:04
2011-08-03 $100.00 $10,023 04.
2011-08-23 $M53. $10;10 :56
2011-08-24 i.' $100.00 $10,006.56
2011-09-23 $83,39 $10,089.95
201140-16 $100.00 $9,989.95
2011-10-23 ' $83.25 $10,073.20
2011-10-31 $100.00 $9,973.20
2011-11-23 $83.11 $10,056.31
2011-11-26 $100.00 $9,956.31
2011-12-19 $100.00 $9,856.31
2011-12-23 $82.14 $9,938.45
2012-01-23 $82.82 $10,021.27
y 2012-02-11 $100.00 $9,921.27
2012-02-23 $82.68 $10,003.94
2012-02-29 $100.00 $9,903.94
2012-03-23 $82.53 $9,986.48
2012-04-20 $200.00 $9,786.48
2012-04-23 $81.55 $9,868.03
2012-05-23 $82.23 $9,950.27
2012-05-30 $100,00 $9,850.27
2012-06-23 $82.09 $9,932.35
2012-06-26 $100.00 $9,832.35
2012-07-23 $81.94 $9,914.29
2012-08-23 $82.62 $9,996.91
2012-09-23 $83.31 $10,080.21
Page 1
Sheetl
2012-10-11 $500.00 $9,580.21
2012-10-23 $79.84 $9,660.05
2012-11-23 $80.50 $9,740.55
2012-12-23 $81.17 $9,821.72
2013-01-23 $81.85 $9,903.57
2013-02-15 $300.00 $9,603.57
2013-02-23 $80.03 $9,683460
2013-03-23 $80.70 $9,764.29
2013-03-26 $100.00 $9,664.29
2013-04-23 $80.54 $9,744.83
2013-04-23 $81.21 $100.00 $9,726.04
2013-05-18 $81.05 $100.00 $9,707.09
2013-06-15 $80.89 $200.00 $9,587.98
2013-07-23 $79.90 $9,667.88
2013-08-17 $80.57 $200.00 $9,548.45
2013-09-23 $79.57 $9,628.02
2013-10-23 $80.23 $9,708.25
2013-11-23 $80.90 $300.00 $9,489.15
2013-12-23 $79.08 $9,568.23
2014-01-15 $79.74 $200.00 $9,447.96
2014-02-14 $78.73 $200.00 $9,326.70
2014-03-27 $77.72 $100.00 $9,304.42
2014-04-30 $77.54 $100.00 $9,281.95
2014-05-18 $77.35 $500.00 $8,859.30
2014-07-11 $73.83 $500.00 $8,433.13 ERS check
2014-08-26 $70.28 -.-$200.'00- $8,303.41
2014-09.30 $69.20 $200.00 $8,172.60
2014-10-91 $68.11 $200.00 $8,040.71
2014-11-28 $67.01 $200.00 $7,907.71
Page 2
Y
Oki � s
7601 PENN AVE S, SUITE A600
MINNEAPOLIS, MINNESOTA 55423-5004
TELEPHONE 612-243-8620 Hours (CT): 7:00 am - 7:00 pm M -TH
FAx 877-326-8784 7:00 am - 5:00 pm F
TOLL-FREE 866-285-2387
February 24, 2015
The Estate of RICHARD ELLIS
Attn: JACQULINE VERNEY
44 S HANOVER STREET
CARLISLE PA 17013
Re: Our Client: American Express Bank, FSB
Account No: ***********2008
Unpaid Balance: $12748.80
Reference No: 10792830
Dear Sir or Madam:
Per your request, enclosed is the documentation for the above mentioned account.
Thank you for your attention on this account. Please contact us at 1-866=285-2387 to discuss this matter.
Cordially,
DCM Services, LLC
Enclosure
This company is a debt collector. We are attempting to collect a balance due from the assets of the Estate
and any information obtained will be used for that purpose. Calls may be monitored or recorded for quality
assurance purposes.
NOTICE: SEE PAGE TWO FOR IMPORTANT INFORMATION - Page 1 of 2 -
4203
NOTICE OF CLAIM
(Filed Pursuant to 20 Pa.C.S. § 3532)
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE OF RICHARD A ELLIS , DECEASED
No. 2015-00016
To the Clerk of the Orphans' Court Division:
Enter the claim of AscensionPoint Recovery Services LLC on behalf of Citibank,N.A. - ITI MASTERCA.RD
XXXXXXXXXXXX 1842
(Claimant)
in the amount of$ $17,060.25 ,against the above entitled Estate.
The Decedent,who resided at 125 WALNUT ST,CARLISLE,PA
(Street Address)
17013 3836,died on 12/26/2014. Written notice of said claim was given to
(Date of Death)
PETER L.ELLIS
(Personal Representative or his/her counsel)
at 69 DRAWING ARM LANE MARTINOURG WV 25403
(Address)
on 1/28/2015. y�
(Date)
060 'APRS Representative
200 Coon Rapids Blvd. Suite 200
(Street Address)
Coon Rapids MN S5433-5876
(City,State,Zip)
Robin LeDonne—IL Bar#6294763
(Claimant's Counsel)
200 Coon Rapids Blvd. Suite 200
(Address)
Coon Rapids, MN 55433-5876
(888)806-9074
(Telephone)
CLMFRMPA v1.l 20121120
,. ^:, e• .: •„a•"•.m:-7^�'�`S""fi�fi `5t 1"�M'"^,'."t�,r; ;;,r.y ''"1`,'°f r 4 'cr
.� taw o. !$: •� � Y��rF
..
RICHARDA ELLIS
How to reach us '
ELLIS RESEARCH SERVICESwww.citicards.com
Member Since 2005 Business Account.4122 5100••.0760 7347 .1-800-750-7453
Billing Period:.91/o6/r4-'12/03/14 Po Box 6235 Sioux Falls,SD 57117 6235
Account Summary.
pay/me dqc ; Previous balance $2,981.08
�,971.�4 '/ d
baln��e Paymen s Cre its/ .
Adjustments $200.00
� yBeB Q1J lB 1�2/ :I1i� Purchases +$146.83
Cash.advances +$0.00
CARDHOLDER SUMMARY Total Cardmembers:11 Fees' +$0.00
Cardholder Card number ending 1n..................... Amount .
...................I........................
. +$43 63
RICHARD'A ELLIS **********:�*5009 $146'.83 New balance e $2,971.54
...................... ..... S
Credit Line $3,100
Includes$500 cash advance line
a ............................. $ .....
Available Credit-Line 128
Ai
includes$128 available.for cash advances
a
ankufrorIri�� l
a� a
°.
Total ThankYou'Member'
Available Point Balance: 2,11®2'
as of 11/30/14
>See pagwe'3 for more information
'about y'oA16r-rewards t
Please print Address Changes on the.reverse side
P.ay.onllne www.citicards.com
P.O.Box 6004 4a Minimum payment due $7.2&.63
Sioux Falls,So 57117.6004 Pay by phone. 1-800-750-7453 New
. balance $2,971.54
1.54
'Pay by mail Use.this coupon payrneht due date 1;2/29/14
Your State men t.ls Inside o Enclose a valid check or money order payable
to CITIBUSINESS CARD.No cash. r forelgR Amount:enclosed: $
currency. m,
• Write the last four digits of your.
account nuriber on your check. Business Account ending in 7347
VT00133898 1 AV 0,381 U8066038`TMN 010603 06,00:..
Ill'll"��[111��I���IIn."II"'��'I1�'INL1��'�Illlll'�"l�i".111"1lEI, : .
"N
CITIBUSlNESS CARD
RICHARD A ELLIS. Processing Center
ELLIS RESEARCH SERVICES.•, Des Moines;IA 50363-000,5
'. 125 WALNUT ST 1 1 tit i t
CARLISLE PA 17013.3836 . ' "GIII1111'"111111111"►I"��.'1"InL�IIIIII"I��ull�llu"I�III"IIIII
x,5000 1[100726J 0297'154 00200.00 041225],0007607347 0316
.............
Tr�, 1 Post Date Description of Transaction ordredit
-THANK YOU -$250.00
1 11/13/14 PAYMENT 13Y PHONE 6W641431716YJ7Z02SQXD
Total Payment For This Period -$250.00
1111 w=1 1 110
Trans Date Post Date Description of Transaction or Credit Purchase Type Reference Number Amount
10/22/14 10124/14 CCBill.com *Web Notio+8885969279 MLT MT142970231000010029121 $%95
10/23/14 10/24/14 SHEETZ 00002634 CARLISLE PA MT1 42970254000010001140 $42.09
11/07/14 11/08/14 SHEETZ 00001917 CARLISLE PA MT1 43120235000010006548 $36.34
Total Purchases For This Period $138.38
Trans Date Post Date Description of Fees Reference Number Amount
Total Fees For This Period
Detach and return bottom portion with your payment. 100750 5 18 0000000201 STMT91 D P 6241 GM01 See reverse side for Important Information
----—-----------—--------------------- ---------------------------------------------------------------------
Account Number: 54664100-2473-291
Cappital 74 New Balance $3,030.7
Ohe' Minimum Payment Due $83.(
Payment Due Date 12/13/201
Include account number on check to Capital One Card Services. I
not send cash. Please send your payment 7 to 10 days prior to thi
payment due date to ensure timely delivery.
1005721 01 AB 0.403 "AUTO T8 0 6254 17013-383600 -C42-P05736-112 100 AMOUNT .ENCLOSED $
I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
RICHARD A ELLIS
125WALNUT ST CAPITAL ONE CARD SERVICES
CARLISLE PA 17013-3836 PO BOX 71107
fij�w CHARLOTTE NC 28272-1107
y-ee
00303072000083000005466410024732916dOlOOO
► ,. meriCard BankofAlr�erica,
RICHARD A ELLIS ;
Account•Nurnber:4264.2814.0402 63$6:
Decembet.6=January
Account I:riformation: +' ;u+ p•
www.banko'' rica"com'' s f "
Mail b111ing•inquirfes to: New Balance Total' $2,170x62 $2 110:97
Previous Balance.
Bank of America Current-Payment Due .... $80:00 Payments.and Other Credits.. 0:00
P.O.Box 982235 Pasibue Amount, :$51,00. Purchases and'Adjustments............. 0:00
El Paso,.TX 79.9982235
Fees 6arged:...:..:..:........:.:..:......:.::..:..........::25:00
to: Total MiCinumInterest Charged ....... : ...34.65
Mail Payment
4131,00,
•
Bank of.America
Y ,...._.....,,_,..,....:,.214/15
1. .......................
P.O:Box 15019 New 3alanee Total ........:.... , $2,170,e
. .
Vilmington,i?E 19986-5019 Late Pai.ment.Mrnirlg:•If we•dohot receive your•Total Minimum Payment by
Customer Service; the date listed above.,you may have to pay.a late,fee;of up to$35,00 and,. Total Credit Llne.,,. .. $2;400.00
1.80b,799.6701.. Your APRs.may be increased-up;to the Penalty APR of.,2.9.99%. Total Credit Available ...,. ..,:...$229.38
TotaFMWrh6ni'P4ment Warning If you make only the Total•Minimum '. Cash.Credit'Line .,....... ;.,...,,..$750,00
(1.800.346.3178 TTY) payment each period 'you will.pay.more in.Interest and it.wiil take you longer Portion of:CreditAvailabie•for C6eh.,,.$229,38
to pay offyour balance.,.For example: Statement Closing Date ,.,,....:,.....,......1/7/15
• Days in:,B'illing.Cycle' . .
Only the.'7otal12',years: .:.:. •; : : . $4.424.92:;
Minmym Payment'
If you,.would like'jn:formation,about':cre'ditcounseling,services',.call .......
18563£7f7523 :::.:...:......:....:...........................................................................
Trensectlon Posting' � Relen3ncs ' Accoune '
este Oate Description Number Number Amount, rote/
., F08&• i
:01/04 '01/05 LATE FEB'.FOR PAYMENT DUE 01/04
$25
' 21]0 25.00
TOTAL FEES•FCR TH1$IPERLOD 0
' 0.
• ' Interest charged . - ':� -
01/67' 01/07 interest Eharged.on Purchases 29.•06
01/07 01/0T Interest Charged on Balance Transfers.•, "
5.59
continued orrnext,page ,;. "' ' '
06 0021706x-00013100.000:53000004264281404026386.
BANK OF AMERICA. Account Number' 4264 2814 0402 6386.
.P.O.BOX.15,019'. . � —
'WILMINGTON DE 15886T'6019.' New 8a,lance Total.. ...... $2,170.62
(IIIILLI111AIIIIIIIiII,II1111iI�FIuI111II�17IIIIIIIIIIIf1IlIIIII Total Minimum Payment Due. .. . . .. ............ 131,00
Payment Due.Date....,. 02/0'4/15
SS 0110' N 745.363 1.' ' 15947' #001 AT 0.40.6 < e
' q \
RICHARD A ELLIS Enter payment amount $
125 WALNUT ST
CARLISLE PA 1.7013-3836 ,
OCheck hero fors Change of mailingaddisss,orphone numbers.
Please provide all colrectlons on thereverse.�ioa.
III'IIIIIIIIIIIIIIIIIIII,III�IIIIIIIL'I�I�IILII1,1111.III,IIIIIIIIIIIII Mali this coupon along with your•eheck payable to:Bank pt Amerie,a
+ c'31_r n n 3 Criilk nag'7 LL.nL.n P apk.l�lie
n,
�z.
DI-SCOVEW Discover" More® Card
Account number ending in 3472
Open Date: Nov 19,2014-Close Date: Dec 18,2014
Cardmember Since 2006
Page 1 of 8
ACCOUNT SUMMARY PAYMENT INFORMATION
Previous Balance $1,497.10 New Balance $1 427 75
Payments and Credits $100.00 Minimum.Payment Due $51.00
Purchases +. $0.00
Payment Due Date January 13,2015
Balance Transfers + $0.00
Cash Advances + $0.00 Late Payment Warning:If we do not receive your minimum payment by the
Fees Charged + $0.00 date listed above,you may have to pay a late fee of up to$35.00 and your
Interest Charged + $30.65 purchase and balance transfer APRs for new transactions may be increased up to
New Balance $1,427.75 the Penalty APR of 24.24/o variable.
Minimum Payment Warning:If you make only the minimum payment each
See Interest Charge Calculation section following the period,you will pay more in interest and it will take you longer to pay off your
Transactions section for detailed APR information balance.For example:
ry
Credit Line $7,0.0.0._ fyof»�ic°{e¢
d
avtd7rdtYf ch �e Y���?dill "a 4yffb ,' Apd�AufY+,Ilend, r+
w
Credit Line Available $5,572R 'st �SdanCl�2eacl� dfa} d y bac#it1�ip �itig}autieshrna}edtb�al
Cash Advance Credit Line $1,900 Only the minimum payment 5 years $2,463
Cash Advance Credit Line Available $503 $57 3 years $2,044
441-9
You may be able to avoid interest on Purchases.
See reverse for details. If you would like information about credit counseling services,call 1-800-347-1121.
�r.. sm 850 max REWARDS
FIC
740 f
ago Cashback Bonus® Anniversary Month
May
-o Opening Balance $ 1.67
min 30o Your FICO®Credit Score on 12/12/14. New Cashback Bonus This Period + $ 0.00
FIOD'Score meter More at Discover.com Redeemed This Period_ _ —$_ _0.00
Cashback Bonus Balance $ 1 .67
To learn more,log in at Discover.com
Make Check payable to Discover. - NOTICE:SEE REVERSE SIDE FOR IMPORTANT INFORMATION
Please fold on the perforation below,detach and return with your payment.
Payment Coupon Pay Online M Pay by PhoneAca�uta4ut,� er
Please do not fold,clip or staple. 0 Discover.com W4P 1.800.347-2683
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000018627 01 AV 0.378 T6 18 SDSI RA01 69 ��+i 1 4 r t j r�
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RICHARD A ELLIS �` Amountn�losedi� x x:' $
125 WALNUT ST "x..�>:�1 =..,� t ..r. z ..,. ..
CARLISLE PA 17013-3836
PO BOX 71084
CHARLOTTE NC 28272-1084
Illluullululllllllllllllllllul►IIIIIIIIIIIIIIIIIIIIII 1111111
Phone and Internet payments must be received by 5PM ET to be credited as of the same day.
Address,e-mail or telephone changed?Note changes on reverse side.
000001986458909463826014277500500000005100
IF PAYING BY CREDIT CARD,FILL OUT BELOW
Wi ---I --
PINNACLE HEALTH EMERGENCY 0 VISA[ MASTERCARD= 0 DISCOVER 13AMER.EXRUz
6880 VV. SNOWVI LLE RD#210 CAFONUMBER MUST INCLUDE 3 DIGIT
BRECKSVILLE, OH 44141-3255 SECURITY CODE FROM
BACK OF CARD
NAME AS IT APPEARS ON THE CAM W."'M AMOUNT
I I fill'
CUSTOMER SERVICE PHONE:1(865)563-8981 -T
CUSTOMER SERVICE HOURS:8:00-6:00 Mon-Fri Eastern
TO MANAGE YOUR ACCOUNT ONLINE,PLEASE VISIT US AT: 12/19114 $4 1.00 PH8 3006618
www.MyMedAccount.com
CHARGES AND CREDITS MADE AFTER STATEMENT SHOW AMOUNT
DATE WILL APPEAR ON NEXT STATEMENT. PAID HERE
MAKE CHECKS PAYABLE/REMIT TO:
114854-2
RICHARD A ELLIS PINNACLE HEALTH EMERGENCY
2 125 WALNUT ST DEPARTMENT SERVICES LLC
CARLISLE PA 170*13-3836 PO BOX 8500-55168
PHILADELPHIA, -PA 19178-5168
E] Please check box If above address Is Incorrect or insurance To 7 M PLEASE DETACH AND RETURN TOP PORTION WITH
information has changed,and indicate change(s)on reverse side, YOUR PAYMENT IN ENCLOSED ENVELOPE
-- SE VICE
DATE CARE GIVER DIAGNOSIS DESCRIPTIO 0 R AMOUNT
09118/1'4' LEV
115; 81,
10/02/14: P E0N .
ED06
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..".-. *.P.VCEOF-SERVICE:--21-INPAT-!Ehh-,-'22:-OUT-PA-"ENT--23-EMERGENCY-ROOk
FINAL NOTICE
RICHARD A ELLIS was seen at PINNACLE HEALTH WESTas-noted below.Your account.is,NOW OVERDUE.Unless you pay the balance before 01/03/15 your
account will be turned over to collections for Immediate action. In that case,any further correspondence you receive will be from the collection agency.We would
much rather work with you to resolve this than turn It over to a collection agency. Please send the entire balance due for all dates of service or contact our office
immediately to discuss arranging a payment plan.If you have mailed your payment within the last 5 days,we thank you;please disregard this notice.Thank you for your
prompt attention to this matter.
STMT DATE 0-30 DAYS PRIMARY INSURANCE
.00 1 31-60 DAYS 61-90 DAYS OVER 90 DAYS DARYINSIUR-ANCE
12/19/14 461.00 .00 .00
PATIENT'S NAME LOCATION OF SERVICE ACCOUNT NUMBER
RICHARD A ELLIS I PINNACLE HEALTH WEST PH8 3006618 4.00
PLEASE VISIT US AT:www.MyMedAccount.com
CUSTOMER SERVICE PHONE:1 (855)553-8981 PERSONAL BALANCE: $461.00
CUSTOMER SERVICE HOURS:8:00-6:00 Mon-Fri Eastern INSURANCE BALANCE: $.00
WORKERS COMP.BALANCE: $.00
] SECONDAI
R
PINNACLE HEALTH EMERGENCY
DEPARTMENT SERVICES LLC
PO BOX 8500-55168
PHILADELPHIA,PA 19178-5168
1011 STATEMENT
W-1 W. 1i SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION 0---4 -f A 4 4 AC=A n
Page 1 of 1
A
' st
I,,:.,FEDERAL CREDrr UNION
Share/Loan List
For Account: 0000304971 RICHARD A ELLIS
Account Type: General Member
Membership
Member Type SSN Home Number
RICHARD A ELLIS Primary ***-`*-
717-218-9818
125 WALNUT STREET
CARLISLE,PA 17013-3836
Share Description Rate Maturity Date Available Balance
S0000 REGULAR SAVINGS $0.00 $5.00
DEPOSIT TOTAL $5.00
Loan Description Rate Due Date Payment Avail/DQ* Balance
S0006 UNSECURED 12.89% 01/01/2015 $99.07 P $29.55* $311.27
LOAN TOTAL $311.27
1 /1A/1)n1c
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A
nvorce:Number
BtilgC7ff ` '4~t z �4 2 =j,' ' � 'y 14-254958 1/1/2015 $1,569.34
New Cumberland, PA 17470-0726
QUESTIONS ABOUT THIS BILL? phone: 877-214-6018 Espafiol: 866-724-4114 Fax: 717-214-6020 Ernail: info@ambulancebillingoffice.cam
• r
Date of Service: 12/19/2014 08:21 t:;. Please visit our website to provide insurance or make payment, and
Patient Name: ELLIS, RICHARD A.
for additional payment options and frequently asked questions:
From: <Public Location> �` www.ambulancebi.tlingoffice.com
To: Carlisle Regional Medical Center
• ' ME S.
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_Total 1,;,569.34 0.00 0.01
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Card Number
Please make any corrections to address below.
Name on Card Expiration
Electronic Check Deduction RICHARD A. ELLIS
Please send a voided check OR provide information below: <+
125 WALNUT STREET
Bank Routing Number Checking Account Number CARLISLE, RA 17013
Signature
IF PAYING BY VISA OR MASTMARD,FILL OUT BELOW
Hershey Kidney Specialists Inc
P 0 Box 517 _ O�I'® MAsreRCAaO
cArmRute�n om.wTe u�ouNT
Hazleton, PA 18201-0517
810fUTURE MUST INCWDE 3 DIGIT
SECURITY CODE FROM
RETURN SERVICE REQUESTED BACK Of CARO
•OT I✓' TA 'r,"s'=i 0`9'"'j0 s G.'U� Oso Ali
Page 1 of 1 01/28/2015 147.00 12140446
Phone:800-450-6208
Patient Acct#s: 12140446. . .Bill#s:2511
CHARGES AND CREDITS MADE AFTER STATEMENT SHOW AMOUNT
DATE WILL APPEAR ON NEXT STATEMENT. PAID HERE
MAKE.CHECKS PAYABLE/REMIT TO:
'IIII�IIII'I�"I�IIIIIIIIIII"11�1�11"IIIIIIIII'llloll 118083.77 Hershey Kidney Specialists Inc
RICHARD A ELLIS PO Box 517
125 WALNUT ST Hazleton, PA 18201-0517
CARLISLE PA 17013-3836 I..�III��L�JJII����„IIII���JJ����IIL��LrJIL��IL��II
Please check box H above address is Incorrect or Insurance A I PLEASE DETACH AND RETURN TOP PORTION WITH
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Total: 147x00
Yt• ,i•t •a
CURRENT OVER 30 OVER 60 OVER 90 OVER 120 . PAY THIS '
147.00 0.00 0.00 0.00 0.00 AMOUNT $ 147,00
.Patient Acct#s: 12140446. . . Bill#s: 2611
4� •`=`F•�eel Ybu;'Hairr RecMiued�Thts`Brll
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';:This Balance Is Youri?sponalbllitj+ IfrYou k
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Total Account Balance 147.00
,
0f, STATEMENT
Mkyi SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION 118083-ST-77
REV-1513 EX+(01-10)
..& pennsylvania SCHEDULE ]
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF, FILE NUMBER:
Richard A. Ellis 21-15-0016
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under
Sec.9116(a)(1,2).]
I. Peter Lewis Ellis 60 Drawing Arm Lane Martinsburg,WV 25403 son 1/3
2. Elisabeth Haller Ellis Lebuffe 28 Pacific St Dunedin 9010 New Zealand 'daughter 1/3
3 Christi Price 822 Pacific Ave.Alameda,CA 94501 :daughter 1/3
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size.
LAST WILL AND TESTAMENT
I'D CD
OF
RICHARD ALAN ELLIS "� ":� � M
CGZ? 0
I, RICHARD ALAN ELLIS, of 125 Walnut Street, Carlisle, 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 former Wills, Codicils, or writings in the nature thereof,by me at any
time heretofore made.
FIRST: I hereby direct my Personal Representative to pay all my just debts, funeral and
administrative expenses out of my estate, as soon as practicable after my death.
SECOND: I direct that all taxes which may be assessed in consequence of my death, of
whatever nature and by whatever jurisdiction imposed, shall be paid out of my estate as a part
of the administration of my estate.
THIRD: My final arrangements shall be made in accordance with the requests I have made
known to my Personal Representative.
FOURTH: I give and bequeath such of my personal property as may be listed on an unsigned
memorandum kept with my Will to persons named thereon,provided they survive my death.
Should such a memorandum not be found with my Will, it shall be conclusively presumed that
none was prepared, and all of my personal property shall be considered a part of the remainder
of my estate.
FIFTH: I hereby give, devise and bequeath the remainder of my estate, real,personal or
mixed, whatsoever and wheresoever situate, in equal shares, share and share alike,to: PETER
LEWIS ELLIS,ELISABETH HALLER ELLIS LEBUFFE and CHRISTINE ELLIS
PRICE. In the event that any of my before named beneficiaries are not living at the time of my
death, their share shall be divided equally among the issue of said deceased beneficiary,per
stirpes. In the event that any of my before named beneficiaries are not living at the time of my
death, and do not have issue surviving, their share shall lapse or be divested and shall be
divided equally among the surviving beneficiaries.
SIXTH: I hereby nominate, constitute and appoint PETER LEWIS ELLIS to be Executor of
this my Last Will and Testament. In the event that he is deceased, unable or unwilling to serve
in said capacity, then I nominate, constitute and appoint ELISABETH HALLER ELLIS
LEBUFFE as Executrix. In the event she is deceased,unable or unwilling to serve in said
capacity,then I nominate, constitute and appoint CHRISTINE ELLIS PRICE as Executor. I
direct that my personal representative(s) shall not be required to give bond or security for the
performance of their duties in any jurisdiction. In the event that my personal representative
desires local legal support, I recommend Jacqueline M. Verney, Esquire, but said
recommendation is not determinative and is left to the discretion of my personal representative.
viz
SEVENTH: In addition to the powers conferred by case law, by statute and by other
provisions of this Last Will and Testament, my personal representative, and any successors in
that capacity shall have the following discretionary powers applicable to all real estate and
personal property held by them, which powers shall be effective without Order of any Court
and which shall exist and continue until the time of actual distribution:
A. To retain any property of any nature received by them for whatever period it shall
be deemed advisable;
B. To invest and reinvest all or any part of the assets of my Estate without regard to
statutes limiting the property which a fiduciary may purchase;
C. To sell, transfer, exchange or otherwise dispose of,any part of the assets of my
Estate, for cash or on terms, publicly or privately, or to lease, without liability on the
purchasers to see to the application of the proceeds, and to give options for these
purchases without the obligation to repudiate them in favor of a higher offer;
D. To execute and deliver any deeds, leases, assignments or other instruments as may
be necessary to carry out the provisions of this Will;
E. To borrow money, if necessary to facilitate the administration and closing of my
Estate, including the right to borrow money from any bank, and to mortgage or
pledge any asset of the estate as security;
F. To loan to, and to purchase assets from, my Estate,'even if also acting as Executor
thereof;
G. To assume continuance of the status of any beneficiary with regard to death,
marriage, divorce, illness, incapacity and similar incidents or matters in the absence
of information deemed reliable without liability for disbursements made on such
assumption;
H. To make any distribution hereunder either in kind or in money, or partially in kind
or partially in money, considering of course the reasonable wishes of the
beneficiary. Distribution in kind shall be made at the appraised value of the
property distributed, as it is set forth in the Inheritance Tax Return filed in my
Estate;
I. To exercise any subscription right in connection with any security held hereunder,
to consent to or participate in any recapitalization, reorganization, consolidation or
merger of any corporation, company or association, the securities of which may be
held hereunder; and to delegate authority with respect thereto,to deposit
investments under agreements, to pay assessments, and generally to exercise all
rights of investors;
J. To continue in any partnership,joint venture,joint ownership or other business
enterprise of which I am a part at the time of my death;
K. To compromise claims;
L. To continue for whatever period of time my personal representative shall deem
necessary any ownership as a tenant in common or as a partner, in real estate or
other property and to act as I would have done had I been living;
M. To do all other acts in their judgment necessary or desirable for the proper
management, investment and distribution of the assets of my Estate;
N. I direct that my personal representative shall be compensated for the services they
render as Trustee and Executor under this my Last Will and Testament;
O. Should any changes occur in the Internal Revenue Code or Pennsylvania statutes
after the date of the execution of this Will which affect the tax liability of my estate,
then to the extent possible and as may be permitted by law, my personal
representative shall have the power and discretion to interpret this Will and to
administer my Estate in a manner which results in the lowest tax liability possible;
P. Should the principal of any Trust herein provided for be or become too small, in the
TRUSTEE'S discretion, so as to make establishment or continuance of the Trust
inadvisable,my TRUSTEE or my Executor may make immediate distribution of the
then remaining principal and any accumulated or undistributed income outright to
the person or persons and in proportions they are entitled to income. Upon such
termination, the rights of all persons who might otherwise have an interest as
succeeding income beneficiary or in remainder shall cease.
IN WITNESS WHEREOF, I hereunto set my hand and seal this day of
e'w'\aw 2012,
64k
RICHARD ALAN ELLIS
SIGNED, SEALED, PUBLISHED and
DECLARED in the presence of:
PERSONAL PROPERTY MEMORANDUM OF
RICHARD ALAN ELLIS
2.
J.
I
4.
5.
6.
7.
S.
9.
10.
11.
12.
AFFIDAVIT
We, Richard Alan 6u-,e-u
the Testator and the witnesses,respectively, whose names are signed to the attached or
foregoing instrument, being first duly,sworn, do hereby declare to the undersigned
authority that the Testator signed and executed the instrument as his Last Will and
Testament and that he had signed willingly, and that he executed it as his free and
voluntary act for the purposes therein expressed, and that each of the witnesses, in the
presence and hearing of the Testator signed the Last Will and Testament as witness and
that to the best of their knowledge the Testator was at that time eighteen(18) years of age
or older, of sound mind and under no constraint or undue influence.
TESTATOR, 44� NQn U�.,residing 0, 604 SIC 4
WITNESS,
-e AIL residing at
WITNESS, residing at
Subscribed, sworn to and acknowledged before me by Richard Alan Ellis,
Testator, and subscribed and sworn to before me by
andb t a� the witnesses, this i".4 - day of
2012.
Notary Public
COMMONWEALT H OP PENNSYLVANIA
Notarial kal
Valerie F.Gsell,Notary Public
Carlisle Boro,Cvmberiand County
L-±Iy-CaRMt-i2n-Expires OcL 91,2014
Mefter,PBR!*14!vaslP A&od=,-s a Notaries
ACKNOWLEDGEMENT
I, Richard Alan Ellis,the Testator whose name is signed to the attached or
foregoing instrument, having been duly qualified according to the law, do hereby
acknowledge that I signed and executed the instrument as my Last Will and Testament;
that I signed it willingly, and that I signed it as my free and voluntary act for the purposes
therein expressed.
RICHARD ALAN ELLIS
Sworn r affirmed and acknowledged before me by Richard Alan Ellis; the Testator,
this /`� day of�L�i;� �r�/��f��,�� , 2012.
`�— COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
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Not PublicValerie F,Gsell,Notary Public
Carlisle®oro,Cumberland County
Mir Coltmission Expires Oct 9,2024
Per`,c?e?,Pwmw vbo to A5rciation of Notaries