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HomeMy WebLinkAbout05-12-15 REV-1500 EX(02.11)(FI)l]!jr 1505610105 OFFICIAL USE ONLY PA Department of Revenue pennsylvania 28o6oi o�o1.1-i OI ..Y 11 County Code Year File Number PO BOX 8o6 Bureau Individual.Taxes INHERITANCE TAX RETURN t i l Harrisburg,PA 17128-o6oi RESIDENT DECEDENT 0 ©Cf S 1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 09/30/2014 07/08/1924 Decedent's Last Name Suffix Decedent's First Name MI Stauffer Jacob R (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI , Spouse's Social Security Number - -" - THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 4W 1.Original Return O 2.Supplemental Return t= 3. Remainder Return(Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) COD 6. Decedent Died Testate O 7.Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule 0) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: „ Name Daytime Telephone Number Andrew C. Sheely, Esquire 717-697-70750 rn REGISTER O,WILLSUS EYONL'�—' a, C7 First Line of Address 127 South Market Street - ' Second Line of Address 't n4 P.O. Box 95 _r cn City or Post Office State ZIP Code '✓DATE FILED co Mechanicsburg PA '17055 - - Correspondent's e-mail address:andrewc.sheely@verizon.net Under penalties of perjury,I declare that 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 personal representative is based on all information of which preparer has any knowledge. SIGNATU OF PERSON RE ONSIB FOR FILI ETURN DATE • / /2 Z© A". Laure . Stauffer, Co-Executor, 11 East Coover Street, Mechanicsburg, PA 17055 SIGN RE OF PREPAR T REPRESENTATIVE DATE AD RES Andrew C. Sheely, Esquire,9 South Market Street, P.O. Box 95, Mechanicsburg, PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 1505610105 4� 1 1505610205 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: Stauffer, Jacob Robert ; RECAPITULATION 1. Real Estate(Schedule A). ... .. . .. .. . ... .. ... .. .... ..... ... .. ... .. .... 1. 146,000.00 2. Stocks and Bonds(Schedule B) ... .... .... . .. ... .. ... ... ..... ......... 2. 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ... . . 3. E 4. 'Mortgages and Notes Receivable(Schedule D). .......... ..... . .. .. . ..... . 4. l 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E).. .... . 5. 159,194.52 6. Jointly Owned Property(Schedule F) O Separate Billing Requested .. .. . . . 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested... ... .. . 7. ; 2,800,422.6 617.1 8. Total Gross Assets(total Lines 1 through 7).... .... ..... ... . ... .. . .... . . 8. 3,105,617.1 9.-,Funeral Expenses and Administrative Costs Schedule H I 14,195.64 10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1)..... .... .... . . 10. 9,683.20 11:?Total Deductions(total Lines 9 and 10). ... ... . .... . ..... .. .. . .. . . .... .. 11. 1 23,878.84 12. Net Value of Estate(Line 8 minus Line 11) . .... ..... ... .. .. .. ..... .... .. 12. 3,081,738.3 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. ( 3,081,738.3 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 :...... ......._......._......-................._.._..._........ ......__......_...._._..__.._�__..__._._.._.-.., �__.....__....-._._....---....._..._..__...____..._........__.._..._._. __ , E (a)(1.2)X.0_ 1 15. 16. Amount of Line 14 taxable at lineal rate X.0 45 3,081,738.3 16 138,678.22 17. Amount of Line 14 taxable at sibling rate X.12T R 17. i 18. Amount of Line 14 taxable at collateral rate X.15 i 18. f 19. TAX DUE .. . .. . ... . .... ... . .. .. . ..... . .. .. . ..... ... 19. 138,678.22... ... ... .... ... z 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 �; 1505610205 1505610205 REV-1500 EX(FI) Page 3 File Number0 q5 Decedent's Complete Address: DECEDENT'S NAME Jacob Robert Stauffer .............. ......... ............. ...... ...... STREETADDRESS 100 Mt.Allen Drive ............................. ....... .......... ............ ................... ...... ............ ......... .................. CITY STATE zip Mechanicsburg PA 17055 Tax Payments and Credits: 11. Tax Due(Page 2,Line 19) 138,678.22 2. Credits/Payments A.Prior Pa'yments ..................... .........131,000.00 f B.Discount 6,894.53 Total Credits(A B) (2) 137,894.53 3. Interest (3) 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) 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 783.69 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.......................................................................................... El 0 b. retain the right to designate who shall use the property transferred or its income............................................. El 0 c. retain a reversionary interest .............................................................................................................................. El N d. receive the promise for life of either payments,benefits or care?.................................................................... El 0 2. If death occurred after Dec. 12,1982,did decedent transfer property within one year of death without receiving adequate consideration?............................................................................. ............................ El 0 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. El 0 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation? ..................... .................I......... ....................................................... 0 El 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 stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value oftransfersto 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 tra6sfers to or for the use of the decedent's siblings is 12 percent[72 P.S. §9116(a)(1.3)].A siblihg is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. COMMONWEALTH OF PENNSYLVANIA REV-1162 EX(11-96) DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT.iS0601 HARRISBURG,PA 17128.0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 020023 STAUFFER LAURIE D 112 EAST COOVER ST MECHANICSBURG, PA 17055 r, ACN ASSESSMENT AMOUNT CONTROL NUMBER -------- fold 101 $131,000.00 ESTATE INFORMATION: SSN: FILE NUMBER: 2114-0951 DECEDENT NAME: STAUFFER JACOB ROBERT DATE OF PAYMENT: 12/12/2014 POSTMARK DATE: 12/12/2014 COUNTY: CUMBERLAND DATE OF DEATH: 09/30/2014 TOTAL AMOUNT PAID: $131 ,000.00 Aj REMARKS: RECEIPT TO ATTY CHECK# 1003 INITIALS: HMW SEAL RECEIVED BY: LISA M. GRAYSON, ESQ. YS REGISTER OF WILLS TAXPAYER REV-1502 EX+(11-08) def-, pennsylvania SCHEDULE A DEPARTMENT OF REVENUE REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Jacob Robert Stauffer,,aka J. Robert Stauffer 21-14-0951 All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F, Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1 Decedent's real estate located at 119 East Coover Street, Mechanicsburg, Borough of $146,000.00 Mechanicsburg, PA 17055,Tax Parcel No. 17-24-0787-039.Value per attached appraisal of Appraisal Solutions. I TOTAL(Also enter on Line 1, Recapitulation.) $ $146,000.00. If more space is needed, insert additional sheets of the same size. Main File No.144 e i { r i t I APPRAISAL OF REAL PROPERTY LOCATED AT: ° 119 E Coover St Deed Book 16X Page 090 Mechanicsburg,PA 17055 FOR: Estate of J.Robert Stauffer do Andrew Suety,127 S.Market St,Mechanicsburg,PA 17055 AS OF: ' 09130/2014 BY: Brett Lechthater,PA State Cert Gen Appr Appraisal Solutions 16 San Juan Drive Mechanicsburg,PA 17055 Form 6A6—°WmTOTAi"appy rA software by a la mode,inc.—1-600-ALAMODE ?" Man File No.14-k er Pae# :.Yry1 a'. SUMMARY OF SALIENT FEATURES �1 Sut ject Address 119 E Coover St Legal Description Deed Book 16X Page 090 City Mechanicsburg County Cumberland State PA Tp Code 17055 Census Tract 0115.00 Map Reference Metro:2846/H-8 Sale Price $NA Date of Sale NA Borrower/Clterd NA Lender Estate of J.Robert Stauffer Size(Square Feeq 1,338 Prue per Square Foot $ Location Average Age 60 Years Condition Above Average Total Rooms 6 Bedroons 3 Baths 1.0 Appraiser Brett Lechthater,PA State Cert Gen Appr Date of Appraised Value 09/30/2014 Final Estimate of Value $ 146,000 Form SSD—WhTOTAV appraisal software by a la made,inc.—1-800-AIAMODE REV-i5o8 EX+(u-io) _I t pennsyLvania SCHEDULE E hL j DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT 1 ESTATE OF: FILE NUMBER: Jacob Robert Stauffer, J. Robert Stauffer 21-14-0951 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 Belco CD account#895183 -value at date of death $47,652.14 2 PNC Bank Checking Account-principal$4,696.82,accrued interest$0.00 $4,696.82 3 Edward Jones Account#531-13743-1-7,value at date death $104,821.19 4 Donegal Insurance refund $296.00 5 2014 Federal Income Tax refund $1,200.00 6 2014 PA Income Tax refund $14.00 7 Thrivent Insurance refund $514.37 J t z TOTAL(Also enter on Line 5, Recapitulation) $ 159,194.52 r� If more space is needed, use additional sheets of paper of the same size. t t i � $ELC-0 COMMUN(7Y C REOR UNION BELCO COMMUNITY CREDIT UNION CAMP HILL BRANCH 3500 TRINDLE RD Inquiri.es' Call:800-642-4482 CAMP HILL PA 17011-4439 Account183 STAUFFER,JACOB R Effect: 10/03/14 Post: 10/03/14 Tlr:- 1151 ID DUE DATE PRINCIPAL INTEREST FEES BALANCE TRAM AMOUNT SEQ Withdraw from 60 MONTH CD 1000 Prev Bal: 47,645.14 1000 10/18/16 47,645.14- 0.00 0.00 ,0.00 , 47 ,645.14 #319832 Deposit to SAVINGS 0001 Prev Bal: 12 .00 0001 47,645.14 0.00 0.00 47,657.14 47,645.14#319833 Account;,X�L�IOCX183 Available Balance: S1000 0.00 Available Balance: S0001 47,652.14 s Authorized by r Join us on Thu, , Oct. 16 for Intl Credit Union Day at all_ Belco branches! Enjoy a free hot dog lunch and giveaways from 11-2, and register to win a $75 Visa gift card (one winner/branch), Ask about our ICU Day certificate special, and grab a sweet treat from the bake sale to benefit PA Breast Cancer Coalit. . . r ai s is Dec. 24, 2014 10: 19AM NNC bank NO. u/vu r. � December 17, 2014 Wanda Wert Mechanicsburg Branch PNC Bank RE: J Robert Stauffer SSN: 189-18-6995 ' DOD: 09-30-2014 Dear-Ms.Wert: In response to your request for Date of Death(DOD)balances for the customer noted above, our records show the following: Checking Account Account# 5070087386 Established: 01-01-1979 J ROBERT STAUFFER ANAMAE C STAUFFER DOD balance: .$4,696.82.+0.00 accrued,interest' Interest paid 01-01-2014 thru 09-30-20I4 $ 1.04 YTD Please note that this office provides date of death balances for deposit accounts(MAs,CDs,Checking and Savings). We do not process any financial,transactions or provide statements. If you need assistance with any of these items,please call 1-888-PNC-BAND.(1-888-762-2265)or stop by your local PNC Bank branch office. Sincerely, National.Financial Services Center PNC Bank,N.A. Member FDIC This message is intended for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. 1f the reader of this message is not the intended recipient or the employee or agent responsible for delivering this message to the intended recipient you are hereby notified that any dissemination, distribution or copying of this communications is strictly prohibited. Tf you have received this communication in error,please note me immediately by reply or by telephone at 800-762-1775 and immediately destroy this faxed document. Page 1 of 1 Phil Gross III,ARMS® 2159 White Street Suite 24 EdwardJones Financial Advisor York, PA 17404 Bus.717-854-7997 MAKING SENSE OF INVESTING Mr.Stauffer(income Mgr Acct) October 13,2014 119 E.Coover St. Mechanicsburg, PA 17055-4220 Dear Mr.Stauffer: i I Re:Jacob Robert Stauffer Income Manager Acct 531-13743-1-7 Beneficiaries:Jay Stauffer& Laurie Stauffer As a service to our clients, it is our practice to provide estate valuations to assist in the preparation of tax documents.We are providing the following date of death values for account number 531-13743-1-7, registered to Jacob Robert Stauffer. Description Total Value Insured Bank Deposit $104,821.19 Sincerely, Kathleen Heilig Senior Branch Office Administrator Edward Jones, its employees and financial advisors cannot provide tax or legal advice.You should consult your attorney or qualified tax advisor regarding your situation. The information provided is believed to be reliable, but its accuracy and completeness are not guaranteed. Cost basis information may be from an outside source that has not been verified. Cost basis is provided for inf6rmation only and should not be used for tax purposes without the assistance of your tax preparer. www.edwardiones.com REV-1510 EX h(08-09) pennsylvania SCHEDULE G DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER Jacob Robert Stauffer, aka J. Robert Stauffer 21-14-0951 g This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (1F APPLICABLE) VALUE 1 Edward Jones Account#531-13557,principal$2,796,509.24,accrued interest $3;913,36.Beneficiaries: daughter, Laurie D.Stauffer, 119 E.Coover Street, 2800422.6 100 2800422.6 Mechanicsburg,PA 17055,and son,Jay R. Stauffer,222 Limekiln Road, New Cumberland,PA 17070 i r r 1 i TOTAL(Also enter on Line 7, Recapitulation) $ 2,800,422.60 If more space is needed,use additional sheets of paper of the same size. Estate Valuation ' Date of Death: 09/30/2014 Estate of: JACOB ROBERT STAUFFER Valuation Date: 09/30/2014 Account: 531-13557 Processing Date: 10/07/2014 Report Type: Date of Death Number of Securities: 31 File ID: 531-13557 Shares Security Mean and/or Div and Int Security or Par Description High/Ask Low/Bid Adjustments Accruals Value 31) 3494 FT (30283U215) UT47941TLCS20RSA Miscellaneous 09/30/2014 10.19000 9.92000 A/B 10.055000 35,132.17 Total Value: $2,796,509.24 Total Accrual: $3,913.36 Total: $2,800,422.60 Page 8 Disclaimer: This report was produced by Edward Jones DOD Valuation Service. This report was calculated using Esta'teVal, a product of Estate Valuations & Pricing Systems Inc. Please review all contents for accuracy and completeness. If you have questions, please, contact Edward Jones Valuation Service.-at 1-888-441-5475 (Revision- 7-.1.1) REV-1511 EX+(10-09) Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL.EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Jacob Robert Stauffer, J. Robert Stauffer 21-14-0951 Decedent's debts must be reported on Schedule I. r ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Myers Buhrig Funeral Home $3,946.76 is B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: $0.00 Name(s)of Personal Representative(s) Laurie D. Stauffer!Jay R. Stouffer Street Address 119 E. Coover St. /222 Limekiln Road city Mechanicsburg!New Cumberland state PA ZIP 1705511707( Year(s)Commission Paid: 2. Attorney Fees: APq �� � � ��7' $5,000.00 t'�,occ} C �S1��ef j� ��lr�e,� /� 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.) $3,500.00 Claimant Laurie D. Stauffer Street.Address 119 East Coover Street City Mechanicsburg state PA ZIP 17055 Relationship of Claimant to Decedent Daughter 4. Probate Fees: $475.50 5. Accountant Fees: $425.00 6. Tax Return Preparer Fees: 4� 7. Legal Advertising:Cumberland Law Journal,The Sentinel $233.68 B. Postage $14.70 9. i Reserves to conclude Estate administration,final accountings $600.00 s TOTAL(Also enter on Line 9, Recapitulation) $ 14 195.64 3 If more space is needed, use additional sheets of paper of the same size. J3ohrig': Wyers Funeral Home Crematory I October 7, 2014 Laurie Stauffer 119 East Coover Street Mechanicsburg,PA 17055 Dear Laurie: 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 $ 4,474.00 Less: Contract Addendums (222.24) Subtotal: Invoice#11346 $4,251.76 Less: Terms Discount (305.00) Your Balance Due by October 30,2014 $3,946.76 We have enclosed a complete invoice for your records. Please call us at any time that we may be of service. With Warm Regards, use a Michelle L. Haag Treasurer Enclosure Walking with Those in Grief Robert"Bob"L.Bubrig,Jr.,FD,Supevisor•William"Bill'L.Christopher,FD Phone: (717)766.3421 Fax: (717)795.7291 • 37 East Main Street • Mechanicsburg;PA 17055 • www.Myers-Buhrig.com Directors@Myers-Buhrig.com RECEIPT FOR PAYMENT ------------------- ------------------- LISA M. GRAYSON, ESQ. Receipt Date : 10/03/2014 Cumberland County - Register Of Wills Receipt Time : 11 : 19 :47 One Courthouse S uare Receipt No. : 1079345 Carlisle, PA 1713 STAUFFER JACOB ROBERT Estate File No. : 2014-00951 Paid By Remarks : LAURIE STAUFFER DMB ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 260 . 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 30 . 00 CUMBERLAND COUNTY GENERAL FUN INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 35 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check# 3125 $375 . 50 Total Received. . . . . . . . . $375 . 50 �9ssoc+A�°� CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717)249-3166 Fax:(717)249-2663 March 20, 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 for publication of legal notices. TO: Andrew C. Sheely, Esquire RE: Jacob Robert Stauffer 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 the following dates: March 6, March 13, and March 20, 2015 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 0 .00 ------------- Total Amount Due $ 75.00 Payment received by [he Sentinel ANDREW C.SHEELY AD NUMBER PAGE NO. vww.cumber!ink.corn 127 SOUTH MARKET ST 437504 1 Of I MECHANICSBURG,PA 17055 BILL DATE SALESPERSON 717-697-7050 qtr .0 03/11/15 ebycl START DATE STOP DATE 02/25/15 03/11/15 AD DESCRIPTION CLASS LINE 437504 EXECUf0R*S NOTICE LETTERS TMAME 10 PUBLIC NOTICES 28 * 2 cols Publication Insertions Rate Net Amount Gross Amount 3 THE SENTINEL-LEGAL 3 LGL $148.68 TOTAL AD CHARGE $148.68 3 PROOF OF PUBLICATION 01 PRF $7.00 3 MOBILE SITE MOB2 $3.00 Purchase Order Est Jacob Robert Sta PAY THIS AMOUNT $158.68 $190.42* *AFTER 04/05/15 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 t 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 date of insertion. For questions, call (717)240-7130. Retum this portion with your payment Legal THE SENTINEL E] Check# []Credit Card Ad Number 437504 c/o LEE NEWSPAPERS El ® n 'ME] a n E.W&M. Billing Date 03/11115 PO BOX 540 WATERLOO IA 507040540 Acct#: I I ITT] Amount Due $ 158.68 E)p.Date:M M Name on credit card Signature Please make checks payable to: THE SENTINEL 000116 THE SENTINEL E ANDREW C. SHEELY c/o LEE NEWSPAPERS 127 SOUTH MARKET ST PO BOX 742548 MECHANICSBURG,PA 17055 CINCINNATI OH 45274-2548 loll 21540200000004375040000000000000001904200000158686 REV-1512 EX+(12-08) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF. FILE NUMBER Jacob Robert Stauffer, aka J. Robert Stauffer 21-14-0951 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• West Shore EMS-final bill $137.48 2. Alert Pharmacy-final bill $285.86 3. Holy Spirit Hospital-final bill $45.00 4. Pinnacle Health Medical Group-final bill $550.00 5. Borough of Mechanicsburg-sewer,final bill $126.00 6. Brett Lechthaler,Appraisal of residence $350.00 �I 7. Pinnacle Health Hospital-final bill -$150.00 8. Messiah Lifeways-final bill $5,804.00 9. Social Security reimbursement $2,125.90 10. Cumberland County Recorder of Deeds-misc.recording fees,charges-title review $80.50 11. Capital Area Health Associates-final bill $10.00 12. Mercantile Adjustment Bureau,LLC-final bill $18.46 ' r i i TOTAL(Also enter on Line 10, Recapitulation) $ 9,683.20 If more space is needed,insert additional sheets of the same size. ucacrar 1 wN yr uruunur QUANTITY UNIT PRICE AMOUNT Stretcher One Way Trans Member T2005 1.0 128.33 128.33 Stretcher Van Mileage T2049 7.3 4.77 •34.82 l� �l Total Charges 163.15 DESCRIPTION OF.PAYMENT. RECEIPT PAYMENT..DATE AMOUNT. SUBSCRIBER WRITE-OFF ADJ 09/25/2014 25.67 Denied by Insurance-SENIOR BLUE 09/25/2014 0.00 Total Credits '25.67 PLEASE PAY THIS AMOUNT—INVOICE DUE UPON RECEIPT --� 3.748 RETURNED CHECK FEE—$31.00 STAUFFER J ROBERT 25322964W ppTIENT NAME. CALt.NUMBER: AMOUNT PAID ; . 09/29/2014 :. IMPORTANT MESSAGES: This service is not covered by your insurance. Please remit payment to our office. Y WEST SHORE EMS -BLS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011-1708 i s. r PlI. i N3NCI 219 North Baltimore Ave A FINANCE CHARGE OF 1.50 %- PER MONTH PHARMACY SIMMCes, Mt Holly Springs, PA 17065 (AN ANNUAL PERCENTAGE RATE OF 18.0%-) OR A Responsive. Innovative. Reliable. 800-266-9954 (717)486-8606 MINIMUM SERVICE CHARGE OF $ 1.00 WILL BE" CHARGED www.A]ertPharmacy.com ON ALL AMOUNTS 30 DAYS OR MORE PAST DUE STATEMENT OF ACCOUNT IF•.YOU 1 RECEI 'A NEW'INSURANCE CARIJ=FOR`YOIIR .. PRESCR1PTIONS,-BE.SURE TO SFIPPi,Y-IIS WITH-A COPY. Date 09/30/2014 PMT DUE. . 10 24/14 9 .} m STAUFFER, JACOB R STAUJA LAURIE STAUFFER GRP-47 119 E COOVER ST I PAGE 1 MECHANICSBURG PA 17055 Amount Pa t PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT ALERT PHARMACY SERV. INC.219 NORTH BALTIMORE AVE. MT HOLLY SPGS, PA 17065 D' • • '� • • f- x�y, K. 3,.' '�T`•' �Y-r" `' r._7L•'7"`�`,k r• 9.✓-� .'"^, f •.,;!3 -, - ' Y''� *'rS .C�F'-F•.tR :,;J2tCM yR .r,�'- r- 88 27 14:` �I513 -OZrS.`8 4 QS7y� '; 9231531 ; 30 + , E,EVf2TAYRf}XINE 50 Q1 « r r3` 7 74- 0© ' 7.74' �� 08J ' �1_4 i 3232212 '30 F PAOPRP.ZOi,E 40M� Ql ]3 54=. .•0.0 13.54• 2# fI, I�4 �82S6G2 ;" I7 '„ GIaIICQ�sAI+IINE 50fT M 01 * 2 82 QQ 2 82- .�: QBT,i4 }9136545 �369��r��,4 1ETO.EROL�DL 25 MO" Ol S 135 ' 0-0 8] 24` �33E640 pfd' GASAPEAPPIld 300 MG 01 9 93 aQ 9 93 �yf92t424$i =�z'*Q ' I1'ItiIF3E 3Q MG 01 7 74 w Od 7 74' 54 3 '.%F91'S" ' t2- �,61L _•?'7a'.1 "'r+"� 2' -•t` h - � }..-¢-' a CY,So-+ - r4 .,x F t k^ r T.' . 1 544 8 Cr823232r1� . _E3PR$7OLE'°40MG,: f}? •­rOQ•- 5 87, 8 �z X321 22 t z ' `$2E -_2f3MG `'� X01 Q.e• y ._q.,�r. y, r- ,:. z :i` °� c-s,� t.. A _. { S 'S 411 0 5. 6D, " @8�2 , y�rs.��I3�6�45 �y2�5 gi. M$TO�ROfAi, 25 35+ l � 'r.✓Q a`C,..-. - ti )E 1Q'MG f)1 *•3 35 , 2 8� �$�:, 23 13sslQTi22Q$ NE 5U €, ' 07 ' 35 jB� � w923344 � l� ' , "bi `FORI�3 SUNIG izrl Ol "'• r S 2 O6 ` r *' "Q :2 06, Sl YJ 4`'� z9-23Gb"TO --s2 '-. sR�I,� GF R}? FOR..., ' Q3 * 14 53•-. ,,,, 5 „ 00 • - .'-3:4 53' ` 834 r h�326631 „15 r� n�urEI23C#f�{3I�E_�0 5 �E 0 8 QQ Ra xi. Y fro 8.00 . 92393942$ 403ZPLEbANTIBIOTIC; 0'1 13-66 ff9/ZfI4�' x Aa fYm�nt=Tack You = 109 69 OQ 109.69 NSF tie F y S w £ACi3 e a f t K. _ a. �t� � � �'” ��-r'�r � �.`3c c�.ek v#.+� a •*.� r; ,t --*' r'^ c- 'f �1 =..._, �,� -.e �. •ti.� r a f -. y.. +•rf :,E �I � r :i c- Y�•1`.:T^^.'S . .i.�' syr-,,f`k -'r'"mu1 .�^' -}`<.w x 3'. i� ''•' :,� .:G ,i` S" ; a••'��'•ari.�� *S ..Yah � K _ � a' K.t"L`- `�� s i sy s! -ti DO NOT SEND PAYMENT The.amouni date will autamaftallY be _. ;4 } - rdeducted from your account,.as requested . 00 x , k'•�{ " �'' - - 24 -.85- 14, 77 LEGEND NON LEGEND TOTAL TAX FOR -MONTH FOR MONTH Previc"aatazi E+�ses�his,noei� P1naace Charae TOTAL eft ;ES Tow"Payment d Cnd'ds I AMOUNT Dl1 s - 335 81 + 56 12 + `b. .00 = 192..93 - 175.89 = 17 . 04 fORALL. RWCYV ZEL_ATM iNQ Rf S RLEASE CALLAlert Pharmacy Services,Inc at 11 800-266-9954 Statement Terminology on reverse 219 North Baltimore Ave A FINANCE CHARGE OF 1.50 's PER MONTH a4yse. INc Mt Holly Springs, PA 17065 (AN ANNUAL PERCENTAGE RATE OF 18.016) OR A Responsive. Innovative. Reliable. 800-266-9954 (717)486-8606 MINIMUM SERVICE CHARGE OF $ 1.00 WILL BE CHARGED www.AlertPharmacy.com ON ALL AMOUNTS 30 DAYS OR MORE PAST DUE STATEMENT OF ACCOUNT IF YOU RECEIVE A NEW INSURANCE CARD FOR YOUR P"SCRIPTIONS BE SURE TO._SUPPLY US WITH:A _'COPY: Date 09/30/2014 PMT DUE 10 24 14 STAUFFER, J ROBERT STAUJA2 242 MESSIAH CIR GRP-7W MECHANICSBURG PA 17055 PAGE 1 �b Amount P, PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT ALERT PHARMACY SERV. INC.219 NORTH BALTIMORE AVE. MT HOLLY SPGS, PA 17065 ' ' ' CITY • TOTA ** Pic` 1V1T' �`FOR'1ft. UF'I''EB .T ROBERT -STAUJA2 - -031301 `T 231`Z4" 9 4 251 3 NOVOI,OG FLE$PEN 1 01 45.o o "'.00 45.00 0.9 2'4 4 9.245992 88 JOHNSON'S BABY SH 01 * 2..26 .00 2.26 09'%24�I4 9245994 36 TEARS HATURALE FR 01 11.62 .00 11.62 09/25 j14,, 924-643.6 6- D15XT5"c_45kSS/20ME 01 14._00. .QO 14.00 7 09 25, " 92464 8 . I FLUCONAZOLE 100MG 01 1_03 .00 1.03 Q9/25j14:° 8269933 1. IV. PUMP #9:01029 Z 01 12.89 :00 12.89 IV".Pump #94I029 .Z Ol 78.24 .0:0. .78:24 0229I4 , X442656': 30" IARAZPAI�f yl MG (11 2:71 00• 2- .7,1 Bg 9 3 4 2 05549.9 3.O T' MORPHINE SULFATE 0127 429}r914�' X247315 2: PERIPnT:'IV ST-A_. _0:1 8'6.31 - 00 86:31 0,!W9714, 4-k42676 = 2: .0:5 Ala 01 1.49 .OQ , 7.49. - . 00 168.63 100 . 19 1 I LEGEND NON=LEGEND I TOTAL TAX FOR MONTH FOR MONTH i Prunus RAariee Charges this Month Finance Charge TOTAL,CHAR(iESTO P-r-t&c AMOUNT Dt .00 + 268 . 82 + .00 = 268 . 82 . 00 = 268 . 82 FOR.ALL-PI#ARMAGY RELATED INQUIRES PLEASE CALL Alert Pharmacy Services, Inc at 1-800-266-9954 Statement Terminology on reverse F'S 'i 2'. i fir k 4� Important Message We have received the explanation of benefrts from your insurance company(s)and have 4 �j applied whatever payments anti/or adjustme6ts are appropriate. Please make payment for the balance due of$50.00 OR take advantage of a H OM P t T A L 10%prompt payment discount and remit$45:00 The Spirit of Caring on or before 11101/2014. w Here are 3 convenient ways to pay: 487$1595 1. Make payment online at www.hsh.org.f') J ROBERT STAUFFER 2. Mail tear-off coupon below with payment 119;E COOVER ST in the enclosed envelope. MECHANICSBURG PA 17055-4220 3. Call Customer Service below to make 9 payment by phone. Account Summary Charge Patient Name: Stauffer,J Robert Previous Balance: •f)0 Statement Date: 10!02!14 Total Charges: $6,257-80 Service Date(s): 09/08/14 Payments/Adjustments: 06,207.80- Account Balance: $50.00 Account Number: 48781595 Please Pay This Amount: $50.00 OR Medical Record Number. 362814 Discounted Amount of$45.00 if paid an or before 1.110112014 Insurance Information z Please call Customer Service at 717-7692138 Ins. 1: KME.SENIOR BLS to add or make corrections to your insurance', ,Ins. 2: information, or to make arrangements for a Ins.3 „} y payment plan. If you are unable to make Ins.4: iY .1.1t payment, please contact the Patient FinanciaU 4 r( Advocates Office at(717)763-2885 to discuss i financial assistance options. Please!Vote: Your physicians will bill separately for professional services_ is J+ ' Important - - Full payment on your account balance is now due. If this bill does not reflect the" PI N NAC LE H EALTH correct insurance information please contact Medical Group our office immediately to resolve the issue. For account information Please call(717) 231-8960 or(800) 565-6229 for Out of Area, V't Calls. See details on the back of this statement. J R.STAUFFER If payment has been sent, please disregard. 119•E COOVER ST Payment can be made online at: MECFIANICSBURG PA 17055-4220 httos://bilipay.ninnaclehealth.org or make Check payable to: PINNACLE HEALTH MEDICAL GROUP 3! Account Summar Financial Summary Responsible Party: J R.Stauffer Total Changes: $550.00 Account ID: 460902 Payments and Adjustments: $.00 Bill Date: 10/29/14 Bill Number: 17237173 ' Please Pay This Amt: $550.00 Insurance Information Contact Us Keystone Senior Blue HMO For questions, call Customer Service at: 717-231-8960 for local calls or ; 1-800-565-6229 for Out of Area +� Customer Service Hours: P I Mon-Wed-Fri 8:00 AM to 4:30 PM Tues-Thurs 8:00 AM to 6:00 PM ------------------------------------------------------------------------------------------------------------------------- Bill Number. Pleasa P This Amount: 17237173 �50.00 Patient Name: 4'-),Pl NNACLF HEALTH J ROBERT STAUFFER Po SOX 1129 Medical�P I ® E ® � L® HARRISBURG PA 17108-1129 Card Number. Sec Code" Exp.Date: Signature: Amount Paid: ElCheck box if your address or insurance information has changed. Please make changes on back. The Security Code is the last 3 digits on the back of your credit card,by your signatut Make Check Payable To: PINNACLE HEALTH MEDICAL GROU 00017177 002 0.72 Pay online at https://bilipay.pinnacieheatth.or-g. J R. STAUFFER Please do not send cash through the mail. 119 E COOVER ST MECHANICSBURG PA 17055-4220 PINNACLE HEALTH MEDICAL GROUP ; PO BOX 1129 HARRISBURG PA 17108-1129 t 0000000000001723717300000000046090200000055000201410294 i E. 2 t BOROUGH OF MECHANICSBURG 36 WEST ALLEN STREET 'MECHANICSBURG,PA 17055 (717)691-3310 UTILITY BILL i ACCOUNT NO: 2535-0 LAST PAYMENT: DATE:07/18/14 AMOUNT:126.00 LOCATION: 119 E COOVER ST PREVIOUS BALANCE: 0.00 BILLING DATE: 10/15/14 CURRENT CHARGES: , 126.00 DUE DATE: 11/17/14 TOTAL DUE: 126.00 PREVIOUS READING CURRENT READING USAGE Billing Period: 14t01t2014 to 12/31/2014. SEWER 06/05/14 1000 09/05/14 2000 5000 The Borough Office is open from 8:30 AM to 4:30 PM, Monday through Friday. You may also pay your bill on the Borough's Website at www.mechaniesburgborough.org. r �< the 9 After hours payments may be deposited in the box to right of the front entrance to the Municipal Building. DESCRIPTION UNITS FLAT USAGE TOTAL SEWER-REGULAR RATE 1.00 85.00 0.00 85.00 If you have any questions,please feel free to contact the REFUSE-4 BAG REG 1.00 41.00 0:00 41.00 Borough Office at(717)691-3310. The Borough Office will be closed on November 26th&29th, 9; December 25th&26th,2014 and January 1,2015: Water Usage History 4�t , 8 j i I:x ' 4I It i� ,m; STATEMENT To. scuss'.payment,call: The amount shown below represents your Customer Service financial obligation to: ' PINNACLE' HEALTH (888)467-2563 Pinnacle'HealthHospitals Hospitals.: (717)221-1294 PO Box 2353 Harrisburg,PA 171052353 Representatives Available: For all other inquiries- Mon-Thu 8:OOAM 6:OOPM Fri 8:00AM-S:OOPM (717)221-1294 5. MESSAGE: Thank you'for choosing Pinnacle Health Hospitals.The balance on your account is due.If you need assistance or have insurance coverage,please call our customer service department.If you need to make arrangements for payment,we have representatives available to assist you. Financial assistance is available for the uninsured and underinsured who apply and qualify.For more information,please call or see our website at wwwjiinnaciehealth.orPlbiilpay., You may also pay online at haps:11billtaay.pinnaclehealth.or� HOSPITAL.SERVICE DATE PATIENT NAME ACCOUNT NUMBER 09/15/14 J ROBERT STAUFFER 1677035 FOR YOUR HOSPITAL SERVICES: Pharmacy, $ 2256.10 Laboratory $ 1223.50 Emergbncy Room $ 926.00 EKG/ECK/EEG ..' $ 170.00 0�- other Therapeutic services $ 538.00 Room & Board $ 7110.00 Q supplies $ 28.00 Q Therapy $ 1253:00 Radiology• $ 498.00 Miscellaneous $ 512.00 (0� original Billed Amount: $14514.60 Total .insurance Paid: $-7640.78 Total Adjustments: $-6723.82 Patient Payments: $0.00 Patient Responsibility: $150.00 1941.1VIA, I F-*1 FAI h Eel � $150.00 MESSIAH L d L C SII C 11 Forth PB-01 Lifewayse at MESSIAH VILLAGE 100 MT.ALLEN DR.,MECHANICSBURG,PA 17055 RESIDENT- 7T, UNITl MT::DATE 31301 0026 09/30/2014 'RESI[)E�tT S:' f LAURIE STAUFFER JACOB R. STAUFFER 119 EAST COOVER STREET MECHANICSBURG, PA 17055 T©TALAMOUNT:DUE:.:, $5,804.00 DATE DU8'.' 10/31/2014 DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE $ -------------------------------------- —AMQUNT REMITTED. DATE ;: DESCRIPTION RATE Dmfs CHARGES CREDITS BALANCE Balance Forward 6,226.91 wf, i ix 09/22/14 PAYMENT RECEIVED -THANK YOUM 6,226.91 0.00 T'.. 09/15/14 MEAL CREDIT 9 1.00 12.00 -12.00 flsr5 :RltIUBIL2DttJR [I♦IC SEltl r_1I4Tk09f5 , .__2x9043Q *�* Enhanced Llvin� *** vF .._._.i �._ ....:_-...mss_.,e.s.,_....�s:..�.e,. :�,;� ..: :. ..• -PULL-UPS-PREVAILS $i't►9ltillx " ELI[ .# [�f ► A'` ICLEx9t4 -0St07 °� J84G1700,' M 7r r 13$6 b0 .F,. 4304:OQ 09/08/14 MEAL CREDIT 7.00 84.00 4,220 00 !UEL .u': g8 ?Q 8�01;58 � 0,' "y "`; ;84431 �l 10 Page 1 RESIDENT# CURRENT OVER 30 OVER 60 OVER 90 . OVER 120 TOTAL AMOUNT DUE 31301 5,804.00 0.00 0.00 0.00 0.00 $5,804.00 RESIDENT NAME JACOB R. STAUFFER N/A Please Please make check payable to Messiah Lifeways at Messiah Village. A 1%finance charge may be assessed on accounts for which payment has not been received by the due date. If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. 189-18-6995A Page 5 of 6 j s PAYMENT STUB • Return the bottom portion of the stub with your payment. Use the enclosed envelope to mail your payment to us. • Do not send cash. .i • Do not enclose any correspondence with your remittance. Send any correspondence to: Social Security Administration, Mid-Atlantic Program Service Center, 300 Spring Garden Street, Philadelphia PA 19123. , • If you have changed your address or telephone number, be sure to check the box below and write your new address or telephone number in the space provided. • If you pay by check or money order, include the Social Security Account Number as shown below and make the check or money order payable to "Social Security Administration." • If paying by credit card, complete the appropriate information below and return it in the enclosed envelope OR to pay by phone, call 1-800-527-4400 TOLL FREE during the hours 8:30 AM to 4:00 PM ET. Please have this notice and your credit card available when you call. SSA-53-EP DETACH HERE. DO NOT STAPLE. ACCOUNT NUMBER: 189-18-6995 A pMASTERCARD ❑VISA []DISCOVER J ROBERT STAUFFER Credit Card Number Exp Date AMOUNT DUE: $2,125.90 DATE DUE: January 2, 2015 PAYMENT � Cardholder's Signature Date AMOUNT $ A Check box if your address or [] telephone number has changed. Make changes below. SOCIAL SECURITY ADMINISTRATION PO BOX 3430 PHILADELPHIA PA 19122-9985 2189186995A0000000030000000090002125900002125900002125900R00000000000 CUMBERLAND COUNTY RECORDER OF DEEDS RECEIPT Inv Number: 174466 Invoice Date: 12/18/2014 3:28:21 PM RECEIPT Reg/Drw ID: 0301 Customer ID:SHEELY Last Change: Receipt By:COUNTER By: KW ANDREW SHEELY P O BOX 95 MECHANICSBURG,PA 17055 Chg# Charge/Payment/Fee Description Amount Inst#/Inst Date Municipality 1 DEED $80.50 201429364 MECHANICSBURG Grantor-STAUFFER,ROBERT 12/18/14 3:28:24 PM BOROUGH-2ND Grantee-STAUFFER, LAURIE D Total Pages:6 WARD Consideration- $1.00 Tax Basis- $0.00 Return Via-MAIL PARCEL IDENTIFICATION NUMBER 17-24-0787-039- Fee Detail: AFFORDABLE HOUSING FEE $11.50 COUNTY RECORDING FEE $11.50 IMPROVEMENT FEE-COUNTY $2.00 IMPROVEMENT FEE-RECORDER $3.00 JCS/ATJ/CJEA FEE $35.50 PARCELS FEE $15.00 PER NAME FEE $0.50 STATEMENT OF VALUE FEE $1.00 STATE WRIT FEE $0.50 MECHANICSBURG 2 MUNICIPAL REALTY TAX FEE $0.00 SCHOOL DISTRICT REALTY TAX $0.00 TOTAL CHARGES $80.50 PAYMENTS CHECK:0103 $80.50 TOTAL PAYMENTS $80.50 AMOUNT DUE $80.50 PAYMENT ON INVOICE ($80.50) BALANCE DUE $0.00 Date:Dec 18,2014 3:31:02 PM Page 1 CAPITAL AREA HEALTH ASSOCIATES IO/08/14 2160 100 MOUNT ALLEN DRIVE MECHANICSBURG, PA 17055-6100 RIVAITJ • O E� o 0 o Payment Due Upon Receipt 10.00= a m fV t Q I Q! O O F � • a U U J,ROBERT STAUFFER CAPITAL AREA HEALTH ASSOCIATES 119 EAST COOVER STREET 100 MOUNT ALLEN DRIVE MECHANICSBURG PA 17055 MECHANICSBURG, PA 17055-6100 RETURN • . .• - • LOWER MESSAGES EXPLAINED V. BELOW � ' • • Nis= • *** Balance Due. This Is After Your Insurance Processed. Please Pay. *** *** Thank You *�* *** Please Pay upon Receipt. If there are billing questions, *** *** Call 877-856-2279, X 2517 or 2516 *** *** Monday-Friday between 7:30a.m. and 3.45k.m Thank you. *** Insurance Charges pending to Prv: 197.73 Ins Pay/Adj against Ins pending 0.00 -88.14 109.59 04/24/14 1 2 OFFICE VISIT EST LEVEL 2 99212 782.1 52.77 07/16114 KEYSTONE SEN Payment 0.00 07/16/14 Not Covered Adj . -16.07 07/16/14 Capitation AdJ' . -26.70 07/29/14 Check-Personal Payment 10.00 0.00 05/22/14 1 2 OFFICE CONSULTATION 2 99242 602.8 90.00 _Adj' 08/27/14 Check-Personal Payment 10.00 _SO�OD- 0.00 06/17/14 1 2 OFFICE VISIT EST LEVEL 3 99213 250.00 88. 14 !; 08/11/14 Capitation AdJ' . -78.14 08/27/14 Check-Personal Payment 10.00 - 0.00 06/24/14 1 2 OFFICE VISIT EST LEVEL 3 99213 602.8 88.14 08/11/14 Capitation AdT . -78-14 08/27/14 Check-Personal Payment 10.00 0.00 07/10/14 1 2 OFFICE VISIT EST LEVEL 3 99213 373.00 88. 14 08/12/14 Capitation Ad'J -78.:14 08/27/14 Check-Personal Payment 10.00 0.00 09/18/14 1 8 L NURSING FACILITY CARE SUB 99308 527.7 83.41 10/08/14 Capitation Adj . -73.41 10.009 L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make payment. DATE LAST PAID AMOUNT • - • - • • - Total BalaT 08/27/14 40.00 10.00 0.00 0.00 0.00 0.00 109.59 0..00 119.59 WAKE CAPITAL AREA-':HEALTH ASSOCIATES •, :HECK 100 MOUNT ALLEN .DRIVE . "AYABLETO. MECHANICSBURG, PA 17055-6100 Payment Due Upon Receipt 10.00* Ph: (877)-856-227 Acct#: 2160 PAT# 1-J ROBERT STAUFFER PRV// 2-WEBER, JENNIFER E, D.O. Date: 10/08/14 PRV# 8-Sams, Michael D.O. Page 1 of 1 REV-1513 EX+(01-10) pennsylvairiia SCHEDULE •( DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: f Jacob Robert Stauffer, aka J. Robert Stauffer 21-14-0951 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).] 1. , Laurie D.Stauffer, 110 East Coover Street,Mechanicsburg, PA 17055 Daughter 50% 2. Jay R. Stauffer,222 Limekiln Road, New Cumberland,PA 17070 Son 50% 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: 1. ,B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: ` i. 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 TEST"ENT OF I ROBERT STA UFFER I, I ROBERT STAUFFER, of the Borough of Mechanicsburg, County of Cumberland and State of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby i revoking and making void any and all former Wills by me at any time heretofore made. I direct the payment of all my just debts and funeral expenses as soon after my I decease as the same can be conveniently done, including the payment out of the principal of my general estate, of all inheritance, estate and succession taxes which may be assessed in consequence of my death. With the respect to my funeral, I direct that their be no public.funeral or public viewing and that my remains be cremated with the ashes to be disposed of as my Executors may so decide. 2. I give, devise and bequeath all the rest, residue and remainder of my estate, real, personal and mixed,whatsoever and wheresoever the same may be situate, to my wife, ANAMAE C. STAUFFER, absolutely and unconditionally. s� 1 kt In the event that my wife, ANAMAE C. STAUFFER, should predecease me, or k should she die within thirty(30) days from the date of my death,then in such event, I dirdct the settlement and distribution of my estate to be made in the following manner, to wit. STAUFFER (a) I give, devise and bequeath all the rest, residue and,remainder of my estate, real, personal and mixed,whatsoever and wheresoever the same may be situate to my son, JAY R. STAUFFER and to my daughter, LAURIE D. STAUFFER, share and share alike. (b) In the event that my son,JAY R. STAUFFER,should predecease me, then in such event, I give, devise and bequeath my entire estate, of whatsoever nature and wheresoever situate to my daughter, LAURIE D. STAUFFER and in the event that my daughter, LAURIE D. STAUFFER, should predecease me,then in such event, I give, devise and bequeath my entire estate, of whatsoever nature and wheresoever situate to my son,JAY R. STAUFFER. LASTLY, I nominate, constitute and appoint my wife, ANAMAE C. STAUFFER, Executrix of this my Last Will and Testament and in the event that my said wife should predecease me, or should she be unable or unwilling to serve in such capacity for any reason, then in such event, I nominate, constitute and appoint my son,JAY R. STAUFFER and my daughter, LAURIE D. STAUFFER, Co-Executors of this my Last Will and Testament, in her place and stead, and in all instances, I direct that my personal representative shall be; -2 - excused from posting bond or other security for the faithful performance of their duties, in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal this I 771 day of September, 2010. (SEAL) J. Robert Stauf er of 7 4, �4 k' yjyj { j! t j 3 - COMMONWEALTH OF PENNSYLVANIA ) SS COUNTY OF CUMBERLAND ) 1,J. ROBERT STAUFFER, the testator, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the same instrument as my Last Will and Testament; that I signed #willingly, and that I signed it as my free and voluntary act and deed, for the purposes therein expressed. _XSEAL) �tauffe J. Robert 6 r Sworn and subscribed to before .1/'; ti me this 17V, day of September, 2010. NOURIAL SEAL "ElDl M NELSON N0t0rV Public Notary Public [NOW4CMAGWROUSK my commission Expires,run COMMONWEALTH OF PENNSYLVANIA) SS COUNTY OF CUMBERLAND ) We,the undersigned, JENNY CRONE and JOHN M. EAKIN,the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, depose and say that we were present and saw the testator,J. ROBERT STAUFFER, sign and execute the instrument as his Last Will and Testament; that the said testator executed it as his-free and voluntary act for the purposes therein expressed; that each of us, in the hearing and sight of the testator, signed theWill as witnesses; and that, to the best of our knowledge, the testator was, at the time, eighteen (18) or more years of age, of sound mind, and under no constraint, duress or undue influence. Sworn and subscribed to before me this day of September, 2010. Notary Public NOTARIAL SEAL 14EIDI M NELSON -4 - NOWY Public