HomeMy WebLinkAbout04-13-15 . � 15�56111�1
REV-1500 `""'"' l'ii
enns Ivania orcicw�useorv�v
PADepartmentofRevenue P,.,TiY CmuntyCotle Yee= FileNumber
BureauoflnaividualTaxes INHERITANCETAXRETURN
PO BOX�8o6m �
Harr�sburg,PA»iz�o6m RESIDENT DECEDENT � � � � U � ��
ENTER DECEDENT INFORMATION BELOW
Sociel Secu�ity Number Oatc of Death M61DpY"YY pa�e o/Bltlh MMOJYYYY
� ia � 5 Z � i � d5oy ISc� �
�ecetlenfs Las�Neme Suf(ix DecedaN's Firs�Name MI
eLL � oTl �T � Pltl" nl D
Q/Applicable)En[er Surviving Spouse's Information Below
Spouse's Last Nama SuRix Spouae's Firs�Name MI
Spouae's Social Seariry Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS 6ELOW
O 1.On9inal Re�um p 2. Supplemental ReNm O 3. Remaintler ReWm(Date of Dea�M1
Priorlo 12-13-82)
p 4 Limltetl Esta�e O 4a. FWure Interesl Compmmise(date of O 5. Faderal Es�ate Tax ReWm ftaquirad
dee�h afler 121282J
p 6_�acetlanl Diad Testate O ]. �ecetlent Maintainetl a Living Trusl 8. Total Number of Sa(a Deposlt Boxes
(AVac�CopyotWillJ (FtlacM1Copyo�Tms[J
O 9. GJgetlon Pmceetls Recaived O 10. Spousal Poverty Cretlit(Dale of�eeN O 11. Elec6on�o Tax under Sec.9113�A)
Be�wesn 12-3�-91 and 14�95� (At�aoh SCM1etlule O)
CORRESPONOENi- THIS SECiION MOST BE COMPLETEO.ALL CORRESPONOENLE AN�CONFIDENTIAL TA%INFORMATION SXOULO 6E UIRECTE�T0:
Name �aylime Telephone Number
G L � R i R WI NT cIQS � v �{ ZS�v US7o
I RE��s,E,z oF�-,���,�,00��� '
�
� o ; � �
Pirsl Line o(Adtlress I � A � j
�4 t� ocKw� � � Ci 2C �C- �� `�� � � �' ,� �
-_ > � �. ,
Secontl Line af Aaaress I�i - w �� :$
1� � 3ox � � � ' ' �; �; -n =,� =;
GityorPoslORlce S�ate ZIPCotle I- t�ILEtr3
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i rv r- m
� r � � c c� � Sp ,el NGs W1� Zs'y- I 1 � 3:3/ W y �
GonespendenPs e-mail atltlress: (� Q (tJ G . C OY✓)
Ilntler DenelGes of per�ury,I tlaGara tM1et I M1ave exeminetl I�Is reW m.mdutling amompenying scM1etlules entl slelemen�s,an4lo Ihe Dast at my knmvletlge antl�elief.
It Is�ma,�vrred entl com0le�e.Oedarallon o�praparer o1M1er�M1en(M1e pe�sonel�epresenlative Is basetl on all Inlormalion ol wM1ioM1 yrepam��as eny knowledge.
SIGNNTURE OF PERSON RE'ePON519LE FOR FlLING RETURN DATE
AD�RE55
SIGNATURE OF PREPqRER OTHER THAN REPRESENTATNE DATE
ADDRESS i
PLEASE USE ORIGINAL FORM ONLY `
$Ide 1
L 1505611101 1505611101 J �.
l'
J 1505611201
REV-1500 E%
DecedenCs Social Securiry Number
oe�eae�rs rvame: � / �/
RECAPITfILATION
1. Real Es�a�e(SCM1etlule A). .. . . . . .. . . . . . . . . . .. . .. . . . . . .. . .. . . .. ... . .. . . 1. � .
2 S�ocks antl Bontls(Schetlule B) . .. . . .. . . . . . .. . . . . . . . . .. . . .. . .. . .. . ... . 2 -
3. Closely Heltl Corporalion, Patlnership or Sole-Proprielors�ip(Schedule C) . . .. . 3. ��..
4. Mortgaqes and Notes Receivable(Schetlule�) . .. . .. . . . . . .. . . . . . . . . .. . .. . 4. �.
5. Cash, 8ank Deposits antl Miscellaneous Personal Property(Schedule E�. .. . . .. 5. .
6. Joinity Ownetl Pmpetly(Schetlule F) (,� Separale Billing Requestetl . .. . . .. 6. .
1. InterVivos Transfers 8 Mlscellaneous Non-Pmbate P�opetly
(Schedule G) !� Separate Billing Requested. .. . . .. 1. .
B. Total Gmss Assets(total Lines 1 Nrou9h]I. . . .. . . . . . .. . ... . .. . .. . ... .. . 8. .
9. WnaralExpansesantlAdminisVebvaCosls(SchetluleH). . . . _. . ._ 9. � !S (� . �
10_ Debls of Oecedenl, MoriBaga Liablli6es antl Liens(Schetlule IJ_. . . . . . . . _ . . . 10. 1 / � / � . Q U
t
11. Total Deduclions(�o�al Lines 9 and 10)... . . . . . . . . .. . . . . . .. . . . . . . . .. . . .. 11. /� �' S � . GL
12 Ne[Value of Estate(Gne 8 minus Gne 11� . . . . . .. . .. . . . . . .. . .. . . . . . .. . .. 12. ,
13. Charitable and Governmental Bequesls/Sec 9113 Trusis for whlch
an election to tax has nol been matle(Schedule J) . . . . . . .. . .. . . . . . . . . .. . .. 13. .
14. Ne[ValueSubjec[toTax(LIne�2minuaLinel3J . . . .. ...... . ... ... ...... 14_ .
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES �
15- Amount of Gne 14 iaxabla �
at 1he spousal tax rate,or
Vansfers under Sec.5116
(al(12)X.0_ . 15 .
16. Amount of Lloe 14 taxdble
atlinealrate X.0_ . 16. .
1]. Amount of Line 14�axable
atsiblingrate % .12 . 1]. .
18. Amount o!Line iC taxable
at collateral rate X.15 . 18. .
19. TAX DUE . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. •
20. FlLL IN THE OVAL IF VOU ARE REpl1ESTING A REFUND OP AN OVERPAVMENT O
Side 2
L 1505611201 15056112�1 J
REV-1500 EX Page J Fle Number
DecedenYs Complete Address:
oECEDENT'S NAME '
� �
�fC�O� � 1 0 - -
srrtEErnooaEss
oJ 0 � (�-�-�t� Mer� f�d
cirv � . � �pA.�i S�u�(5 sraTE � � zia 17 z -
f
Tax Payments and Credits:
1. Tax Due(Page 2,Llne 19) (�)
2 CreDits/Payments
A.Prior Paymenis
B.�iSwunt ___
TotalCredl�s�A+B) (2�
3. Interest
(3)
4. If Line 2 is greater ihan Line 1 �Line 3,enterihe difference. This is the OVERPAYMENT.
Fill in oval on Page Y,Line 30 to requesl a refund. (4)
5. I(Line 1 t Line 3 is grealer than Line 2,enter�he difference.This is Ihe TA%DUE. (5)
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did tlecedent make a iransfer and'. �es No �
a. retzin ihe use or income of ihe propetly�rensferred _. ... ... ... ❑ �
6. retain�he right�o designate who shall use ihe property Iransierred or its inrqme ... ... ❑ ��
c. retain a reversionary in�erest _....... ..... ._ _. .,. ❑❑ �
tl. receive Ihe promise for hfe of either paymenls,benefils or care'+ ._ ...
2. If Oeath ocarred afler Dec 12 1982 did deceden�Vansfer pmpetly wdhm one year oi death ❑ ��
without receiving adequa�e consideration7. ..... __ ._. ,�/
3. �id decedent own an"in trust for or payable upon death bank acwwt ar seari�y at his or her tlea1M ._ ❑ "cd ,
4. �od decedent own an intl vidual rebrement account annwry or other non probata propedy which �
ntainsabenefciarydesgnahon� ...... ._.. .._ .._. ._ ❑ L�
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Por dates of death on or afler July L. 1994,ano before Jan. 1, 1995,the tax rate imposed on Ihe net value of�ransfers to or for ihe use oi the surviving spouse
ls 3 percent�72 P S.§9116(a)(1 1�O�.
Por dates of death on or afler Jan. 1, 1995, the tax rete imposed on Ihe net value of Iransfers to orfor ihe use oi the surviving spouse is 0 percent
�72 PS.§9116(a)(1.1)(li)].The staWte tloes not exempt a transfar ro a surviving spouse from lax,and Ihe statulory requiremeNs for tlisclosure of assa�s and
filing a tax relurn are s�ill applicable even if the surviving spouse is�he only benefciary.
For tlates of dea�h on or a�er July L 2000�. �
• The�ax rete imposed on Ihe net value of�ransfers from a deceased child 21 gears of age or younger at dea�h to or for ihe use of a naWral parent, an
adoptive paren�or a stepparent oi ihe child is 0 percent�72 PS-§9116(a)(1 2)].
. Thetaxratelmpasedonthanetvalueoftransferstoorfor�heuseo(thedecedenPsllnealbaneficiarlesl54.5percenCexceplesnotedin�72P.S.§9116(a)(1�].
. The tax rete Imposed on tha net value of transfers�o or for the use of Ihe tlecedenYs siblings is 12 percent(72 P.S. §9116(a)�1.3)].A sibling is tlefined,
under Secfion 9102,as an Indlvidual who has al least one parent In comman with�he dacedent,whether by blootl or adop�ion.
1X�uMrwo(Weimw�y—Inl[mY RernrvcAml¢
ra.� Income Taz Retum for Single and
104OEZ loiM FI9B With No DepontleMs �vs� ZO'J.4 omnno.i5+sm�a
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nna�n
Form(s)W-2 t8302
ry�e_ 2 Tazablc inrcresc If Me mpl is over 81500.You canno�use Fmm 1090FZ. 2
naclnxe.bmtlo 3 � 1 �pAlastnPe lF dd"d d ( ��sWclions) 3 �I
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paymcnt.
4 Add lines 1,2,and 3.Thia is yow adjuclM grata locomu 6 a09Z98
5 If sommne cm clvm ym�(or ywr spouse if ajoim rtrvm)os a depcndcnl��k
[he aOP��cabk Oox(es)below nnd emer�he umou�[fiom Nc worksM1ec�on bnck.
❑ You ❑Spouse
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520,300 if inerried Rliogjoinfly.Sx buk forfsplwtion. 5 101
6 Sub�ac�lia5fromlioea.lfW�eSi�largerWavline4.rn�v-0-.
'ILis iz your mxoble iuwme. ► 6 00
] FeDeal iorome taz Wchhela from Pmm(s)Wd ena 1099. ] 335 55
Credits, � se �m.a��m��c�eic� c�+�w«m�s� ea o0
andTax b Nomuablecombazpayelmiov. 86 �
� 9 Atld linu]anJ 8a These arc ow m�al ymmti and crMib. ► 9 335.55
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ins�eucuo�s.Then,enmr iirc�fmm�M1c�able on`his line. 10 00
Il Hdnc�are:i�dividualra sibili (seeiiuwerions) Full- arcovene �i �
t2 AddlinalUandli.Thisis ourblWlu. 12 �
Relund �3a If live 9 is lager than line 12.eubvact live 12 fmm IiM 9.This is yow ntmd.
lf Fu�m tl5X8 is attazhe4�M1�here ► ❑ 13a 335.55
xa.e i�m�«Kiy
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Preparer F;�;,E,H.
UseOnty F""��� •
Firtn'se0]ress� Plmeno.
FoeD'od�.yRi.�nAqmdPapeexohRedrriimAtlNatia,aeeimnuvliom Cu.Nn�i329W Form1040EZ (201C1
--.. .. ..y,... Giw'v Wmom
�(q R«�kv.cll Gr.
p0 Box 611
BerkeleySpgs.N'V 25411
��, 88�$ Ailocation of Refund (Including Savings Bond Purchases) OMBNo.15C5-00)4
.���������������».,�..;��,�,.,� �014
oepemmen�amat�aesun nnacnmem
�nimW Revenue Smnw ►Attech b your Inwme tex reWm. Pq.58
Nerre�s)sM1own on re4m YoveoWl em�iy�0r
S�e ��.e,v� p 1=�� io�
Direct Deposit
Complete ihis part R you want us to tlirectly tleposR a portion of ydn refuntl to one w rtwre accounts.
1a Amount to be deposHed in frst account(see ins[ructions) . . . . . . . . . . . . . 7a 3 j
b Routing number y- � � u y a ►c [VJChecking ❑Savings
d Account number q G J G 3 �L 1
2a Amount to be tleposi[ed in secontl accoun[. . . . . . . . . . . . . . . . . . 2a
6 Rouling number ►e � Checlting ❑SaNngs
tl Accoum numDer
3e Amount lo he deposited in thirU account. . . . . . . . . . . . . . . . . . . 3a
b Routing number ►c 0 Checking ❑SaNngs
A Account number
U.S.Series 1 Savings Bond Purchases
Comple[e this part if you want to buy paper bdMs wM a portion M your refurW.
� Na name is entered on line Sc or 6c be/ow, co-ownership wil/6e assumed un/ess ihe 6eneficiary box is checketl.
See inshvctions/or more details.
4 Amount to be used for bond purchases for yourself(antl your spousa,ff filing jointy) . . . . 4
' 5a AmouM to 6e used to buy bonds for yourseM,your spouse,or someone else. . . . . . . I $a � �
b Enter the owneYs name(First then Last)for the 6ond registration
i � i i i i i i i i I I 1 t I i I I I I I I I I I I �I� I -�fTTT�
c N ou would lika to add a cmowner or berreticiary,erRer the name here(First than Las[).R h¢nerydary,also check here► ❑
ea Amount to be used to buy bonds for yourseH,your 5pouse,or someone else. . . . . . . � 6a � �
b Enter the owner's name(Frs[then Last)for Ne bond repisVaYon
�_7 � � � � i i i I I I I I I i I I I I I I I I I 1 l I�f�TT—I
c If you would like to atltl a co-owner or benefdary,e�rtar the name here(First then Last).If ben�cla ,also check here► ❑
PaperCheck
Canplete ihis part if you want a portion of your refuntl to be sent to you as a check.
7 Amourrt ro be refundetl check . �
Totai Nlocatlon M ReTund
8 Atltl lines 1 a,2fl,3a,4,5a,6a,and 7.The total mus[equal the refund amount shown m your tax
retum . 8
For Peperwork Retluc4on Act Notice,see your bz retum inshucUons, Cx.No_2iesfl4 Foim 8688(2oia)
COMMONWEALTH OF PENNSYLVANIA SHORT CERTIFICATE
COUNTY OFCUMBERLAND
oF Cu,p
e�' Z, LISA M. GRAYSON, ESQ.
2�� ��� 9!
J � Reqister for the Probate of Wills and Granting
� � '�n 0 Letters of Administration in and for
�� � �,��/ - C[II�ERLAND County, do hereby rertify that on
�_ �� �-� the 29th day of January, Two Thousand and
/
� FiPCeen,
f750- r.erters of ADMIN/STRATION
in common form were granted by the Register of
said County, on the
estate of STEPHENDOUGLASfLL/OTT , late of SOUTHAMPTONTOWNSH/P
�r;,,,.m;ewe�.,n
in said county, deceased, to GLOR/A B WINTERS and
«;,,c mnm.,ia,n
BON S ELLIOTT
(F)s[MMOk.Lasp
and that sarne has not since been revoked.
- IN TESTZMONY WHEREOF, I have hereunto set my hand and affixed the
seal of said office at CARLISLE, PENNSYLVANIA, this 29th day of January
Two Thousand and Fifteen.
File No. 2015- 00102
PA File No. 2J- 15- 0702
D=_re of Death 10/15/2014 -
S. S. #
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NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
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Sta[ement 3]9].5 335.5
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1749 HARRISBURG PIKE oO �o o�armwemrinc oou rvmyaieeepure O
CARLISLE PA 77013 �
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°'°"X OPTLST 16.0
STEPHEN 0 ELLIOTT
'!OB BALTIMORE NO .e F�'�^n'�"&'�"�^�,�E�m .
SHIVVENSBUNG PA 17457
us �wv.r. mio��meo, u �..e�,. m
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FIDELITV INVES7MENTS 5183.D2 Fa,mionsx Comncm,am.
INSTITUTIONAL OPERATIONS G0.
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COVINGTON, KV 41015 �oiena�,wd qeponmizircoma
35845 ac,pwad�(«n.�a���co•za� �Fa.rnm�om.mwnnnxa onyourletleniux
AHOLO OSA MOURLY 40IK SO.OD 50.00 reWm. lilhubim
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STEPHEN 0 ELLI�TT �oava�n��ma.�.l rt+usEw ean« S *x�.mm,m.ao�:e.mg
708 BALTIMORE RD siva�E m��m,saiomeim.��.i
SHIPPENSBURG, PA ll257 1 50.00 eevenueservm..
serovpercemageM 96iaa�.mpb�eecomrbnions fo<moumalbcable�olRR
�ayGrsVbmion Y.MinSyaas
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20150110040900671944
Form tOH9-P p�anmau oi meTreav�iy�imemal lieven�e Servi�e
iw�xem����r��A��r�u�r�Nei�
J 1400110050
PA-40 '1014 �o�-iaxFi�
Pennsylvania lnwme Tax Retum
PN�epeNnent of Revmue,Hxrsbuq,PA 11119 pFriciu usE a+�v
PLEASE PRIM IN BIACK INK.EN7ER ONE LEfTER OR NUMBER IN EACH BOX.FILL IN OVAL3 COMPLETELY.
Vou�SOGaI Security Number Spoux's Sodai Sewmy NumDar(�nraiy�ar) �.io�.sce me�rN�vo�.
�,.,�.s..�.����s.
Rnitlenry SNIw.Fill in only one oval.
Les[Name �� Sufiz '� R Pennsylvanu Resitlem
1 N NonreSitleN
� L {�1 L� j P PabYeer Fesitlant han
Your First Name MI _ amn m_ izota
S 1 � ` ,I � � � �E�E�g Flling 9IMu¢.
V� � YNL � S Sippk
Spouse's First Name MI �a��e J Mamed Fi�inq�oin�y
� nwNObtldt MMemeE.Filing5eparztely
F Pi�alRaNm.liWira�ereason:
Spouse's Last Name-Only i(tliRerem(rom Last Name above Sufiz
_� ✓ o oeceasea
First Line of AGdress iazpeyer
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CityorPostOflice State ZIPCode Fafinen. Fiunmiswa�aa��s�
�xWniNs ol yuur grt.es Income s
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Name of vTod tlishicl vTere you Ilved
DaytlmeTelephonaNumber Sr.�oolCWe on1v3V2ma:
`? I `J — 3 00 ��i � ra,�,�� s��;=�ti�
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1a. Gmw Campensetlon.Do not InGutle exempt incoma,wch as mmbat zone pay arM
qualiyin9 retirement benefits.Sea Ne instmctions. ._._..........__........ . 1a_ 3 �� � y. �-(F,
�b. Unreimbursetl Employea Business Fxpenses. ................................. ib. —
ic. Net CanPensatlon.Subtrad Line tb hom Line 1a............... ........._..... 1c � CJ � 4 5 (�
� 2. In[erest Incame.Gomplele PA Schetlule A if re�uired. .......................... 2. I' �j.L� �
t
3. Divitla�M antl CapWl Gxins Dlstrib�4ons Incane.Cqrtp�lete PA ScheEule B if requiretl. .. 3. —
a. Net Income or Loss irom the Ope2tlon of a Busineas,Profession or Farm. ... 1O9'" 4. �
5. Net Gain or Loss Rwn Ne Sale,Exchange or DisposiGon of Pmperry. ........ 1Oss 5. —
fi. Nel Incare or Loss hom Renls,Royal6es.PatenLs or Copyrig�Ls. ._......... LO95 6. �'
]. Estale or hust I�ome.Complete a�M submR PA Sehetlule J. .................... �. `
0. Gamblirg aM Lottery W nnings.Complete antl submit PA Sehetlule L ........._.. 8. _.
9. Tobl PA T�:able Income.AEtl only the�osNve incane artwunfs hum Liries tc,2,3,
4,5,6,7 antl 8.DO NOTADD any losses 2porteE on lines d,5 or 6. .........._.. 9. �L f. � ti SS
10. Other Deductlona.Enter tlie a riale code for the �
pqop type of deduction.
See tlre In�rupions(or additianal inhrtnatlon. ........................ 10. �
ii. AtlJustetl PA Tazable Income.SubtraM Li�10 from Line 9. ..................... H. � Ll 1 �1 .(.' �7
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Sitle i
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Social Secunry Number(shown first)
Name(s)
12. PATazLiability.MuklPlyLine11by3.Wpercenl�O.WW). ..................... 12 ' �.� . k f
13. Tolal PA Tex Withheltl.See Ihe inslructions. .................................. 13. f ��. � V
. .-1d. Credkhomyour2013PAInmmeTazreNm. .._............................. 14. �
� � 15. 2014 Es�imated Inslalirtrent PaymenLs. Fill in oval H including Form REV-0598. 15. ._
.. � 16. 2014 E#ension PaymenL ................................................. 1fi. �
:��. �. 1l. Nonresidenl Taz WilhhelE from your PA Schetlule(s)NRK-0.(Nonresitlants only) .... 1�. �
18. IDfal Eslimatetl PaymaMs antl CretlNs.Atltl lines 14, 75, i6 aiM 77. ........._. 18. �
Tax Forgiveneva Cretlk,submit PA Schetlule SV p¢pendents,Pa�t g,We 2,
19a F111ng5�aWs: Unmartietlor Martletl � Deceasad 19b. ppSNetluNSP. ...........
SepareMd
20. TOGI EligibilM1y Inmme M1om Part Q Line 11,PA StlieEule SG. . -
21.Tax Forgiveness Cradit feom Part�,Line 18,PA Sehedule SP. .... ............. 21. �-�
22. Resitlent Credit Submit your PA Schetlule(s)GL and/ar RK-1. .. . . ....._. .._. 2z. �"
23. TOWIOIperC�edi6.SubmilyourPA3chatlukOG. ...... . . ..... ..... .. ..... .. 23. �
24. TOTAL PAYMENTS antl CREDR3.Atltl Llnes 13, 18,21,22 antl 23. ........_.... p4. i � V�, .�L'
25. USE TA%.Due on intemel,mail oMer a oulrof3tate pmchases.See�he insWdions. 25 ,-
26. TAX DUE.I!ihe total of LJne 12 antl line 25 is more Nan Li�24,
.. entermedMerencenere. .._..............._.. ............._........... zs. h , G. '
27. Penalfies aM Interesl.See the insWCGons(or additional
information.Fill in wal i(inGutlirg Fortn REV-7630/REV4630A ...._ Zy. -
- 28. TOTAL PAYMENT DUE.See the instructions. ..._....._..................... 2B.
' 29. OVERPAYMENL If line 24 is more ihan�he tohal of Lir�e 12,Line 25 antl Line 27
enter Ne tliRerence here. ................................................. 29.
The tofal of Lines 30 Mmugh 36 must equal LIM 29.
� 30. Refund-Amount ot Line 29 you want as a check manatl w you.........REFUND 30.
31. Credtt-Amaunt o(Line 29 you vrant as a uetlit to your 2015 estimated acmunL .... 3t.
32. Refuntl tlonation line-Enter ihe oryanizaGon code a�W drnation amoun[. 3z
� SeetheinsWctions.................... ... ..........................
� � 33. Refuntl tlonation Ilne.Enter Ne organieaGon cotle antl tlonation amounL
� Seetheinsfructions. .......................... ..............._.... 33.
_. . 34. Re(und tlonation line Enter the oyanizafion cotle antl Gonetion artrount.
. . SeelheinsWctiars. ........... ........_... ....._......._....... 34.
� 35. Refuntl tlona6on line.En[er ihe organizaGon cotla antl tlonation amoun�.
� Seetheinstructions. ........._._.. ...............................
35.
�36. RePoM tlonaGon line.Enter Me oryaniza6on code antl tlonalion artrount
See Ne instructions. ..................... .......................... 36.
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L Iu���w����N����n 3���
1400210058 J
COMMONWEALTH OF PENNSYLVANIA SHORT CERTIFICATE
COUNTY OF CUMBERLAND
r ap cu,y
?4 - "�� � e�,p Z, USA M. GRAYSON, ESQ.
�l :� '�y y Register for the Probate of Wills and Granting
� ���i'� . ' - ���1i b Letters of ndministration in and for
�ti, �� �f� - C�MBERLAND County, do hereby certify that on
L-\'.�, �.. � �' .
���, 1� the 29th day of January, Two Thousand and
1750 Fifteen,
Letters of ADMfNISTRATION
in common form were granted by the Register of
said County, on the
estate of STEPHENDOUGLASfLL/OTT , late of SOUTHAMPTONTOWNSN/P
IFirsi.Mi�4/¢LaaO
in said county, deceased, to GLOR/A B W/NTERS and
ru',:r,ormme.�,:u
BON S ELLIOTT
iF�,�,.M,ea�a.�a„�
and that same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the
seal of said office at CARLISLE, PENNSYLVANIA, this 29th day of January
Two Thousand and Fifteen.
Fi-1e No. 2015- 00102
PA File No. 21- 15- 0102
Date of Death 70/15/2074
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INVENTORY
REGISTPR OF WILLS OF COUNTY, PENNSYLVArIA
CONMONW'EpL"IHOFPEhT151'LVA�IA 1
COLSTY OF f SS File Number � (j � �j — OG' 1 D �,�,
Pe�onal2epresenlative(s)of[he Estate of ��-oVi� FM � �t��c S � � � 1 ' I I
deceased,dapose(s)and say(s)tha[[he items appean�the folloa�ing inventory fnclude all ofthe pecsonal assals whecevec situa[e
and all of the ceal estate fn the Commonwealth of Peunsylvania of said Decedent,that[he val�alion placed opposite each item of said
invenlory cep�esenls its fair value as of[he dace of the decedenPs death, and tha[ Deceden[ owoed no real esmte o�tsfde of Ihe
Co�mionwealth of Penurylvania except[hat which appea�s i¢a memo�aodum at the end of this inventory-
I verify that the statcments made in this Inven-
tory ara true aud cortect I�ndecstand that false state-
menLs he�ein are made subject to the pcualties of
18 Pa.C.S § 4904 relati�g to unswom falsifica[ion [o
authori[ies.
A[toruey— (NameJ (Suprenie Court(D. No)
(Address)
(Te[ephone)
cn*ecroenrn w/ys*aesioencE oereoeNrssecsECNo
o—/ � " Gl /D� �mclZ �; �i�yi� lJ2i / ( �
FIGCRES MUST BE TOTAGED
(Atmch nd�Luonnf sheets as needeAJ
TOTAL: 0.00
NOTE TM1e Aiem antlum of rcal estate o aide �F< CommonwealtA of Pennsylvania may, at iFe elec�io�of ihe personal reOrcsenmtive indude ihe value of eac4
icem,bm sueh Ggures shauld mi be exiended ima�he miel of�he invemory. /See 10 Pn.C 5§�J0t�6�J
FormRW-09 rev.l0U.06
aev-soz Ex+ �m-io�
� �� 5' pennsylvania SCHEDULE A
�F�pp��E���f Nt�t��F REAL ESTATE
�rvveararcF r�xEr�erv
aesoevr oeceoervr
ESTATE OF: FILE NUMBER:
S�e`ol�,� l����<,5 C � � � �� �olS -oo � D �
All real property owned solely or as e tenant in common mus[be reported a[(elr market value. Fau market value is denneC as[he pnce at wh¢h pmperty
waultl be exchangee between a Wilfin9 buyer ana a willing seller, neither beiog mmOelleG ro buy or sell,both M1aving reamna�la knowle0ge of the relevant facts.
Real OroOerty that is jointly-owne0 wiM right of survivarship mus[be disclose0 on Schedule F. _
Attarn a copy of[he settlemen[sheet If the praperty�as been so10.
ITEM Include a mpY of Ne tleetl showing oeceEenPs in:erert i(owned as Cenan[in common. VALUE NT DATE
NOMBER OFDEATH
oesca�vnorv
� N �,� � ' -
TOTAL(Also enter on Line 1, RecapltulaPion.) $ --�
If more space is neeGeG,use a�alGonal sheets of paper of Ne same size,
REV-15�3 EX+�6-98)
� scNE�u�E s
COMMONWEALTHOFPENNSYLVHNIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESI�ENTOECE�ENT
ESTATE OF FILE NUMBEH
�r�l��5� �s �I �i�-t�" a o i s-oo i o ,�z.
All property jointly-owned wlth right ol survivors�ip must be tlisclosetl an Schetlule F.
ITEM VNW E AT�ATE
NUMBEP DESCRIPTION OF�EATH
, i �uu;e R�ee Q� ��R�� Rcc�'r 3o1� i7�oZ -°� ZSDo , ao
.So:,�� uumefi�� (� — GI��iA 3 w�r�rcRs
,St�pN�N D EC�io7T
TOTAL(Also enter on Ilne 2, Recapltulatlon) $ �SD� ���
(�111101B 6p2C016IIBBdBd.I115Ch ddd1�l0IIdI5hBB�60��hB 52III2 SIZB)
RE°,s°°Ex"� s"[f SCREDULE C
Z Y .�
CLOSELY-HELD CORPORATION,
� coMMONwFa�1H oc aErvNsv�vaNin PpRTNERSHIP OR
INHEFITANCE TAX RETURN
aesioENroeceoenr SOLE-PROPRIETORSHIP �
ESTATE 0 I "�'" � FILE NUMBEfl
�r�/I,�-n �ktA�lat Gll, o� aU� s -oo� o �
SCM1atlula C-1 or F2 pnduding ell supponing m(ormetlon)musl be avacM1etl for each ciosely-heltl wrporatiorvparmersM1lp Inlaras�ol�he tlecetlent otM1erihen a
sole�propriatorsM1ip_See Ins�mctions for�M1es�pportinq Informa�ion to ba submittetl for sole-proprietorehips.
ITEM NUMBER VALUE AT�ATE
NUMBER DESGRIPTION OF DEATH
1. � ,c-�n r� .
v i `—<i
TOTAL(Also enter on Ilne 3, Recepitulelion) $ —
Q!more space Is needed Inser.addtionel ehaete al�he same s¢a)
REV-150P E$+I l-W�
��, SCHEDULE D
coMn,ouwEa�rH oF aENNsv�vnwn MORTGAGES & NOTES
iNHeai.nNCErnxaeruaN RECEIVABLE
aEsioErvroECEOErvr
ESTATE OF�� ��x C U I U� FILE NUMBEF
� a01 � - Ool Z� �
All property jain�ty-owned with righ�a�survivorship must be tlisclmetl on Schetlule F.
ITEM VA W E AT DATE
NUMBER �ESCFIPTION OF DEATM
1 � ���
TOTAL(Also enler on line 4, RecapiWlation) I S ---��
QI more space s needetl,inse�atlditional shea�s oi iM1e seme size�
PEV-15o8-rT't(�1,�0) .
jil pennsylvania SCREDULE E
}��) CASH, BANK DEPOSITS & MISC. �
;��=uT^��E^^x a�*�a" pERSONAL PROPERTY
uesr ervr o¢eoe�*
ESTpTE OF: FILE NUMBER:
_ ���jeu �� _ E I ��� _ a� is- �o � aZ
indu�e[he pmaetls of li[igatlon an0 che tla[e the pmceeds werc rtcelved by the estate.
All property jointly owneE wiN righ[of survivarship mus[Ee dis<losetl on Schetlule F.
ITEM VA W E AT DATE
NOi-0BER DESCRIPTION . Of DEATH
I
TOTAL(Also enter on Line 5, Recapitulation) S
. If more space is needed, use additional sheets of pa0er of the same size.
AEv-i5a9 Ex+(m-io)
u�� pennsylvania SCNEDULE F
"`"p�"`"'°`P""Vu` ]OINTLY-OWNEDPROPERTY
INHERIiPNIF iAX 0.HORN
NSI�ENT DFCEf]FNi
ESTATE OF: �" —�,�� /- FILE NUMBER:
�?� ep �,n �llQ(( ��45 G��/ o� 30/ � - !�d �Ov2
I/an asset became joinHy ownetl within one year ot the deredenPs tlate o�tleath,it must De reported on ScheAWe G.
SURVIVING JOMTTENAM(5) NAME(5) PDDRE55 RELATIONSHIPTO DECEDENT
0. _
8.
C.
]OINTLY OWNED PROPERTY:
LeiiER oPiE OESCRIPTION OF FROPERN °rt Oi DA�E Or oEAiH
REM FORIOINi MP�E INQU�ENPHEOFFlNPNCALINSiITJII�NAN�B4NKPCCAUNiNUMBE0.0P5IMIUR �FLEDFDEAiH �FCFOFM1i'S VPLOE�f
NUM.BFR iENANi IOiM I�fNTIiY1NGNC9E0..AIIACH�EE�fOR10�MLYHEL�REFLE5T4iE VAWEOFASSH IN`E0.ESi �ECE�ENTSIMf0.Ki
1. A.
TOTAL(Also enter on Line 6, Recapitulation) S
If more space is needed, use a4Gltional sheets of paper of[he same size.
ftEV-]516 EX—(08-097 .
� pennsylvania SCHEDULE G
Pa��ME.�*��AE�F��E INTER-VIVOSTRANSFERSAND
���EaR�^-E*^�aE'�a" MISC. NON-PROBATE PROPERTY
x�s�cen.oECEo=rvr
ESTATE OF `�� I , 1�� /�S �/// L L FILE NUMBER
"� �✓ Ll � � 02 O l S ' D l D �--
This schedule must be mmple[ed anA fle0 ,f[he ansv�er b any of questions 1 thmug�4 on page Ihree of[he AEVd500 is yes.
DESCRIPT:ONOFPROPERIV DATEOFDEATd 960FpECD'S EXCWSION I TA%ABLE
ITE�N in;mrre*rervmeoFme;nvsrecn,i�:uc=_unan=_xio.00Kme:ex�
NUM9EA .*eo�ivuusreaev+ouavrovnc�cro�wa�a_sraie. VALUEOFASSET INTEREST (r.aovc;.+eiv, VALUE
1.
�' � � �
,
� �
� �
�
TOTAL(Also en[er on Cine 7, Recapltulation) $
If more soace��s nee4e0,use aatlitional sheets ol paoer of the saTe size.
aev-isire%+ Opae1 ,
�� pennsylvania SCHEDULE H
oF�aA*ME��oraEvcwF FUNERAL EXVENSES AND
:��Ea�T^��E�^xaE��'^ ADMINISTRATIVECOSTS
aesm�rvr oece�enr
ESTATE OF �� I �I ��U } �/ / �` � FILE NUMBER
Z luz-/� � o70/ S 'UO/ D o�
Decedent's Eebts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES'. . � ( � � 1 5�J U cr
1. ��U�� �-UnVP—C.� �}6tvl L/ �Ln v o�c e G.l�c�lw�.J
/� � ��od
�f� �� III.Y�MG.�C' Y�{ �Zy�JDicc� c.���
��
e. ADMMISTRATIVE COSTS: �
1. Personal Representa[ive Commissions:
Name(s)of aenonai aevresentative(s)
Shee[Adtlress _
City ._ .__. . 5[a[e ZIP .
Year(sJ Commission PaiG�,
1. A[tomey Fees:
3. Fdrtll�y E%Pf00f1011: (If 42CPd¢OL'S dddfP55 IS�OL[h¢SdfIIP d5 Cldiflldll['S�BLtdLh P%p�dOdI100,�
Claimant
Street AdGress
City 5[a[e ZIP
Relationsh�ip of Claiman[ro DeceOent.__._
4. Probate Fees: �.c� c��W�.C'� � � S•� �
5. Acmuntant Fees'.
6. Tax Retum Preparer Fees:
],
TOTAL(Also enter on Line 9, RecaOitulation) $
If more space is nee0e0,use addtional s'�eets ol paper of Ne same size,
RECEIPT FOR PAYMENT
LISA M. GRAYSON, ESQ. Receipt Date : 1/28/2C15
Cumberland County - Register Of Wills Receipt Nome : 110803�8
One Courthouse S4uare
Carlisle, PA 17013
ELiIOTT ST�PHEN DOUGLAS
Estate File No. : 2015-00102
Paid By Remarks: GLORIA WINTERS
DMB
___ ____ ___ _ _ _________ _ _ _
Receipt Distribution -- --- - - ------- - - - - -
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS ADM 20 . 00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 25 . 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
Cash
115 . 50
Total Aeceived. . . . . . . . . 115 . 50
kELLtiL2E%+ (d2-OB? '
�� pennsylvania SCHEDULE I
oE=a�*ME���FaF�F���F DEBTSOFDECEDENT,
�^�r^��^��E*�+aE*�a� MORTGAGE LIABILITIES & LIENS
vesmervr�eceoervr
ESTATE 0 FILE NUMBER
s�e�o �I�S EII�o-t� ao � � - oa� oa.
ReOort Oe [s in<urred by the OeceEent priar to dealh tha[remained unOaiA a[[he tlate of death,induAing unreimbursed metlical expe^ses.
ITB9 VALIIE AT�PTE
NUMBE4 �ESCRIP�ION OF D'_A'H
1.
TOTAL(Also en[er on Llne 10, RecaOitulation) ;
If more space is neeGetl, Insert additlonal shee6 of[he same size.
qFV-YS]3'EX+(61-LO) �
� pennsylvania SCHEDULE J
` BENEPICIARIES
rmex�mrvce*w.vemarv
aesmervr oecEoervl
ESTATE OF: FILE NUMBER:
1 0� �015 -DOI OZ
REUTIONSHIPTO DECEDENT AMOl1NT OR SNARE
NUM9ER NAME AND F�DRE55 OF PERSON(5)RECEIVIN6 PRO'ERTV Do Not ListTrustee(s) OF ESTA'E
I iA%aeLE DISTRIBII?IONS p�tluDe outnghtspousaltlishibutionsana transka w0er
Sec St16(aj (12).]
i. 13� Scff� ell��o—� So,n Sd °7�
l.�is�. �"-r�E ��iSu' ��,�z -(��rf �r s�c �o
ENTER DOLLF�AMOUNTS FOR DISTRIBl1T10N5 SHOWN ABOVE OV LI�ES l5 THAOUGN t8 OF REV4500 COVER SHEET,AS APGROPRIATE.
» NON-TAXABLE�14RI8UTIONS
F. SPOUSAL�IST;IBUTIONS ONDER SECTION 9t13 FOR NIFICH AN ELEQION TO TAX IS NOT TAKEN'.
1. ��'\ �Ca� � � � I ��
�1 S 4 rnc`-C i C� li '� 0
9. CHARITABLE AND GOVERNMENTAL�ISTRIBUTIO�YS:
1.
TOTAL OF PART II - EMER TOTAL NON-TAXABLE DISTRIBUTIONS ON LME 13 OF kEV4500 COVER SHEET. $
If more space is nee0etl, use atltli�onal sheets of paper of the same size.
.aev-�sa.ex.��zos� e � SCFIEDULE K
�' LIFE ESTATE, ANNUITY
COMMONWEHLTHOFPENNSVLVANIF & TERMCERTAIN
INHERITANCE TAX RETIIFN
aEsioeNr oeceoeNr Check Box 4 an REV4500 Cover Sheet
ESTATE OF FILE NUMBER
�� ea/��e�„ �6,.c��5 l�Jl i �fi � o � � —Uv , o Z
This schedule is to be used for all single life,joint or successive life estate antl term cetlain calculations For tlates oi death prior m 54-89,
acNarial factors for single lite calculations wn be obtained irom ihe �eparlment of Revenue, Specialty Tax Unit.
Actuarial factors can be found in IRS Publication 1457,ACWarial Values,Alpha Volume for dates ot tlea�h from 54-89 to 4-30-99,
antl in Aleph Volume for tlates ai death from 5-1-99 and ihereaiter.
Intlica�e the rype of insimment which createtl the fuwre interest below antl anach a copy to the tax reNrn.
❑ Will ❑ Intervivos Deed of Trus[ ❑ Other
. �
NAME(5)OFLIiETENANT�S) DATEOFBIFTH NERflESTFGEAT TERMOFVEANS
UATE OF DEATN LIFE ESTFTE IS PAYABLE
❑ Life or �Term o�Vears
❑ Life or �Term oi Vears
❑ Life or 0 Term of Vears
❑ Life or 0 Term of Years
❑ Life or O Term of Vears
1. Value of funtl iram which life estate is payable .. . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Actuarial factor per appropriate table . . . . . . . . . . . . . . . . . . .. . . . . . .. . . . . . . . . . . . . . . . . . . . . .
Interesttable rate—� 31/2% ❑ 6% ❑ 10% ❑Varieble Rete ,o
3. Value oi life esta[e(Line 1 mWtlplied by Line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .$
�
NRME�S)OF LIFE ANNURANT(5) OATE OF BIHTH NEANEST RGE AT TEHM OP YEAflS
OATEOFDEATH pNNUliVISPAYABLE
❑ Li�e or 0 Term af Vears
❑ Life or 0 Term of Vears
❑ Life or �Term of Vears
❑ Li�e or 0 Term ol Vears
1. Value of(untl fmm which annuity is payable . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
2. Check appmpriate block below antl enter correspontling (number) . . . . . . . . . . . . . . . . . . . . . . . . .
Fraquency o�peyout—0 Weekly (52) ❑ Bl-weekly(26) ❑ Monthty(12J
❑ Quartedy(6) ❑ Seml-annually(2) ❑ Annually (1) ❑Other( �
3. AmountofpayoutPerPeriod . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
4. Aggrega�e annual paymem, Line 2 mul�iplietl by Line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Annuity Factor(see instmctions)
Interes�tablerate—�31/2% ❑8% ❑ 70% ❑VariebleRate m
6. Atljus�mentFacror(seeins�mctions) . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
]. Value of annuity— If using 3ll2%, 8%, 10%, or Ii varieble rate antl period
payout is at entl oF period. calculation is'. Line 4 x Line 5 x Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .$
Ii using variable rate antl periotl payoutis at beginning of period, calculation is:
(Line 4 x Line 5 z Line 6)�Line 3 . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . .$
NOTE The values oi IDe funds which create the abave fuWre in�erests must be reported as part of ihe estate assets on Schedules A thmugh
G oi this tax retum.The resutling life or annuity interest(s)shoultl be reportetl at the appmpriate lax rate on Lines 13 and 151hrough 18.
(If more space is naetled,Insen addhlonal eheets o��he same size)
HFV16°°E".j30°� + INHERITANCETAX
scNe�u�E �
coMmoNwEn�rH oF PENrvsv�vnHin REMAINDER PREPAYMENT
�"AesioENr�oEceoeNi�" OR INVASION OF TRUST PRINCIPAL F��E Numeea ZGI 5 - �>c-1 � Z
I. ESTATE OF
R- < �G � C I
(�as�Name) (Firs�Name) (MitlJle ini�ial�
This schedule is appropriate only for estates of decedents dying on or before December 72, 1982.
This schedule is to be used for all remaintler reWms when an election to prepay has been fletl under ihe provisions ot
Section 714 0(the Inheritance and Estate Tax Act of 7961 or to report Ihe invasion of imst principal.
�[, REMAINDER PREPAYMENT:
A Eleclion to prepay filed with the Register of Wills on
(Date)
B. Name(s) of Life Tenant(5) Dale Of BiRh Age on tlate Term oi year5 income
or Annuitant(s) of election or annui�y is payable
C. Assets'. Complete Schetlule L-1
1. Real Es�ate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ —___
2. Stocks and Bontls . . . . . . . . . . . . . . . . . . . . . . . . . .$
3. Closely Heltl StocWParinership . . . . . . . . . . . . . . .$ _
4. Motl9ages and Notes . . . . . . . . _ . . . . . . . . . . . . .$ ..
5. Cash/Misc. PersonalProperly . . . . . . . . . . . . . . . $ .
6. Total(rom Schedule L-1 . . . . . . . . . . . . . . . . . . . . . . . . . . _ . _ . . . . . . . . . . . . _ . . _ . . . . .$
D. Credits: Complete Schedule L-2
1. Unpaid Liabililies . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. UnPaid Bequesis . . . . . . . . . . . . . . . . . . . . . . . . . . .$ _ "_
3. Value of UninGutlable Assets . . . . . . . . . . . . . . . . .$
4. Totalfrom Schedule L-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
E. Tolal Value of trust assets(Line G6 minus Line D>) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..$
F Remainder factor(see Table I or Table II in Instmction Booklep . . . . . . . . . . . . . . . . . . . . . . . ..
G. Tazable Remaintler value(Line E x Line Fj . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ _
(Also enter on Line 7, Rewpitulation)
III, INVASION OF CORPUS:
A. Imasion of corpus
� (Month, Day,Year)
B. Name(s)of Lite Tenant(s) Date of Birth Age on tlate Term of years inwme
orAnnuitant(s) wrpus or annuiry is payable
consumed
C. CorPus consumed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
D. Remaintler factor(see Ta�le I or Table II in Instmclion Booklet) . . . . . . . . . . . . . . . . . . . . . . . . . _
E. Taxable value of wrpus consumed (Line C x Line D) . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Also enteron Line 7, Recapitulalion) �� �
� �Ev--�ww Ex- (ii-e�)
�� pennsylvania lNHERITANCETAX
o , SCHEDULE L-2
E ,A„E,.o,AE�EN�.
�rvrea:mrvcernraeuarv REMAINDER PREPAYMENT ELECTION
arsnervroeceoev
-CREDITS-
I. ESTATE OF FILE NIIMBER
II. ITEM NO. DESLRIPTION AMOUNT
A. Unpaid Lia6ilihes Claimed agamst Onginal Es[ate and Payable from Asse[s
Repor[ed on Schedule L-1 (please list)
Total Unpaitl Liabilities $
(indude on Section II, Line D-1 on Schedule L)
e. Unpaid Bequests Payable from Assetr Reported on Schedule L4 (please list)
Total Unpaid Bequestr 5
(indude on Section II, Line D-2 on Schedule L)
C. Value of Assets Reported on Schedule L-1 (o[her than unpaid bequests listea
under"B" above) that are Not Induded for Tax Purposes or that Do No[ Porm
a Part of Ihe hust.
Calculatian as follows:
Total Non Indudable Assets $
(indude on Section II, Line D-3 on Schedule L)
III. 70TAL (Also enter on Section II, Line D-4 on Schedule L) $
If more space is needed, attach addi[ional sheets of paper of the same size.
.0.wd6a��Ex+f02-]0�
j�';, pennsylvania SCHEDULE M
t�� oe na*Mcr+.or wEVEnuE FUTURE INTEREST COMPROMISE
INHERRANCF TqX RETUPN
aes:oervroeceoervr (Cheek Box qa on REV-a5oo)
ESTATE OF FILE NUMBER
This schedule is appropriate only for estates of Ee<etlents who dietl aker Dec. 12, 1982.
This schedule is ro be used for all fuNre interests where Ihe ra[e af tax that will be applicable when the future interest ves[s in
possession and enjoyment canwt be establisheE with certainry.
Indicate below the rype of instmment that created Ihe future interest and attach a copy to the tax re[um.
❑ Will ❑ Trust ❑ Other
I. eeneficiaries
NAME OF BENEFICIARY REUITIONSHIP �ATE OF BIRTH AGE TO
NEAREST BIRTHDAV
1.
2.
3.
4.
5.
IL Por decedents wha tlied on or after]uly 1, 1994, if a surviving spouse exercised or in[ends to exercise a righ[ of withdrawal within
nine months of the decetlent's Oeath, check the appropnate box below and a[tach a mpY o`the document in which the surviving spouse
exercises such wi[hdrawai ng�t.
❑ Unlimited right of withdrawal ❑ Limited right of withdrawal
III. Explanation of Compromise Offer:
IV. Summary of Compromise Offer:
1. Amaunt of future interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
2. Value ofLine 1 exempt fmm tax as amoun[ passing [o oharities, e[c.
(Also intlude as part of total shown on Line 13 of REV4500.) . . . . . . . . $
3. Value of Line 1 passing to spouse at apDropriate tax ate
Check ane. ❑ 6%, ❑ 3%, ❑ 0% . . . . . . . . . . . . . . . . . . . . $
(Nlso indude as part of[otal shown on Line 15 of REV-I500.)
4. Value of Line 1 taxable a[linealrate
Check one. ❑ 6%, ❑ 4.5% . . . . . . . . . . . . . . . . . . . . . . . . . . 8
(Also indude as Oart of total shown on Line 16 of REV-1500.)
5. Value of Line 1 taxable at sihling rate (12%)
(Also indude as part of total shown on Line 17 of REV-1500,) . . . . . . . . $
6. Value of Line 1 [axable a[mllateral rate (15%)
(Also indude as part of total shown on Line 18 of REV-1500.) . . . . , . . . $
7. TOWI value oF fuNre interes[ (sum of Lines 2 Mru 6 must equal Line 1) . . . . . . . . . . . . . . . . . . . . . . . $
If more space is needed, use aatlitional sheets of paper oF the same size.
'REV-16J8 EXt(OP-0B�
�� pennsylvama SCIIEDULE O
�rvHeartANCEi�ES�PErUarv ELECTIONUNDEfl5ECm117(A)
RESIDENT DE[eoervT (SPOUSAL DISTNIBUTIONS)
ESTATE OF FILE NUMBER
Uo not mmplete [his schedule unless Me estate is making the elec[ion to Wc assets under SeQion 2113(A) of [he Inheritance anE
Esta[e Tax AQ.
IF[he election[a more than one hdst or similar arrangement,a separate form mus[be fleG for each hust.
This election applles to the Tmst(marital, resitlual A, 6, by-pass, UniFletl Credit, etc).
I!a trust or similar a«angemen[meets the requirements of SeRion 2113(A)an�:
a.T�e[mst or similar arrangemen[I5 listed on Schedule 0 an0
b.The value af[he tmst or similar arrangement is entered in whole or in part as an asset on Schetlule q then the transfemr's personal representa-
tive may speoFlcally IOenofy[he hus[(all or a fac6anal Oortlon or percentage)ro be'mclu0etl in the eleRlon ro have such trus[or simllar pmper-
ry heated as a taxable hansfer in thls esta[e.If less[han the entire value of the tmst or similar pmperty is inclu0ed as a taxable t2nsfer on
Schedule 0, [he personal representa[ive shall be mn5idereG ro have made the elec[ion only as to a faRion of the trust or similar arrangement.
The numera[or of this fraction is equal to the amowt o�Me trus[or similar arrangement induded as a taxable asset on Schedule 0.The denomi-
nator Is equal[o Ne total value o![he hus[or similar ar2ngement.
PART A: Enter the descrip[ion and value of all interests, both taxable and non-taxable, regardless of location, which pass [o the
decedenCs surviving spouse under a Section 2113(A) trust or similar arrangement.
oucnpoo� vawe
Par[A Total $
PART B: Enter the description and value of all interests induded in Part A for which the Sedion 2113(A) election to tax is
being made.
oucripno� vawe
Part B Total $
If more space is needed,use aCGitional sheets af OaOer of the same size.
'aev-is�z'ex> ¢z-ae) I
�� pennsylvania SCHEDULE I
oE :a.MEN=oF wF�FN�E DEBTS OF DECEDENT,
��v�Ea:*+.•�r*<x a��a� MORTGAGE LIABILITIES & LIENS
zes�oEn�oeceoenr
ESTATE OF FILE NUMBER
5+�,�.��u�1u5 G ll�ot� � �� -o�� o a.
Report De [s incurretl Ey the dece0en[prior to tlea[h[ha[remained unpaid at the datr of Eea[h,incWCing unreimbuned meEi[al expenses.
iTEM VALL'E AT DATE
�\'UMB:R DESCRIPTIOV OF�EATH
� ����.� I� ��Q a c�c� ,a y
a> ,�,p �,�, so .oz�
c�,�Q � a� ; �
� �- �-����, ��-�.d�� i �+ 3 �
�
��, �;� c,m;��n� Y�c���-� ��l�i� 5 , (� o
�� �� 3 3 3'� . �{3
TOTAL(Also enter on Line ]0, RecapiNlation) 5 I � !) I � � �
If more soace is neetle0,insert aaGiFonal sheets of the same size.
REVa5n9 EX+(oi-�o)
`�: pennsylvania SCREDULE F
�y� °` """""o`p`�`��` )OINTLY-OWNED PROPERTY
INNEFI166'CE iAN RETUBN
RE9�EM DfCFOENT
ESTATE OF: /' �( FILE NUMBER:
S� E � � �Rci��tS G��lo( ( a0/ � — DO �G�
If an asset bxame jointly ownetl within one year o([he 0ecetlenPs date of death,it must be rcportetl on Schedule G.
SURVIVING]OMT TENANT(5J NAME(5) ADDRE55 RELATIONSHIP TO DECEDENT
A, �,.-1`x� C"Y-1CC G ��5 �YY10t-'L �, V _
s�P_��u�� � Pk �-, a�� ��
e.
�.
JOINTLY OWNED PROPERN:
LERfP DAiE �E$CWFiIONOFPROFfR1Y %Of ORlE0F0EAlH
il£H FORJOIM AIFOE M[LUDElWMEOFFlNANCI>LINSTINlIONPHDBPNMPCCOU^RSUM9E0.pR51M11AR �AIFOFDUTN pKE0ENT5 VAWEOf
IIMBE0. IENANi )OINi n IOEMIfY1N6NIIMBER.FIIKNOfEpFOPIOIMLYXELO0.EPLEAPIF. VqWEOFASSEf IMEflF4 OECE�ENT5MlE0.E5i
r, i. a. p��y Yml2��� `�-tvFfC.0 `�X.1r �nqS 'v— Yy- �
� O ace(c �d � ,e�..,-�'v v �3N c� d�4 .�°0
.3 e ° e(�- 11�wa��l eA��c�,v�„�Sl,i,ur,c_ l�e ct; ,vo �- l ov�o i+t�
�J
TOTAL(Also enter on Line 6, Recapitula[ion) $
If more space is needeQ use aaditional shee[s of paper of[he same size.
.NEV-15a0{X+�_a-�o) I �
j i� pennsylvania SCHEDULE E �
�sl CASH, BANK DEPOSITS &MISC. j
iN„ea;r<r�ce.axan�ax PERSONALPROPERTY I
,�esmErvr o�cEOFrn
ESTATE OF. . /� FILE NUMBER:
�,A. /c � l. � io �U � S — (�� � ��
InduGe t�reetls of IlHgatlan and[he�a[e[he pmceetls were receNee by Me estate.
All propertylointly ownetl wi[h right ot survivarship must be disclosed on Schedule F.
ITEM VPW E AT DATE
PI i�18ER DESCRIPIION OF DEATH
�(�� ��Cr��'aLv�t� �l ��1,�2�.� ���" o C ��
��'> '��,1 �' e �ja�`� �t,� ��/,? 1�—
�� �.��t;"tiC �(.� �v�a0
I
i I
I
TOTAL(Also enter on Line 5, ftecapitulation) ;
� If more space is neetleG,use aGdiGanal sheeLs of paper of[he same size.
Capital Tax Cullcetion Bureau
CAPITALTAX COLL�CTION RURFAU
19 S HANOVGR ST STF. 102 Harrisburg Uivision
CARI.ISI.F PA 170133366 2301 North'I�hird Street
Iiairisburg,PA 17110
Phone: C717)2343217
C�rlisle Division
19 5. Hanover Stree�
Carlisle, PA 17013
Phone pl7)243-3725
...+......++r.
'•AUTO"5-DIGIT 17257 103 109 16812
3317737905101787 2010 Form 531
ELLIOTT STF.PHEN 01
48 MONTGOMERY AVL
SH�ppENSBURG PA 17257-1628
�ui���ui�n�i���i�i�ui�ui��i��uu����u�u�u��u�i���u�
You can now file onlinel I(you would like to fle your return online, please 90 lo www.caotax.com and click
on Ihe link. if fling online, it is very important that you have Ihis form wi�h you since it conlains your
Personal Identifcation Number (PIN) which is needed to fle online. This PIN is unique to a tazpayer and
cannot be used for ihe taxpayer's spouse. Also, vou mav onlv fle vour 2010 2009 and 2008 returns online;
any older reWms must be completed manually. If you have a balance due with ihe online fling, you will
have options to make your remittance.
The enclosed form is your annual reWm for the local earnetl income tax(EI�. This tax is used exclusively
by your municipality(city, township, or borough)antl school district This tax is diflerent than ihe federel and
state individual income taxes in ihat it taxes ony tv✓o classes of income, both of which are "Eamed": i)
COMPENSATION and, 2) NET PROFITS from the operation of a business, profession or farm. Passive
income items such as interest.dividends, capital gains.and rental income are not taxable.
If you moved during 2010 between different school tlistricts in our iuristliction where ihe tax rates are
tliHeren�, you will need�o fle separa�e reWms with us for each resitlence where there are diRerent�ax rates.
Such "multiole" re�ums must be filed at Ihe_same CTCB o(tice. To view the differen� tax ra�es, visit our
website or call one of our offices.
If you are either self-employetl ar are employetl by an employer�hat tloes not withhold ihe correct amount ot
EIT. you are required to pay the tax quartedy to our Bureau. We make every attemp� �o iden�ify �hose
taxpayers in �his category and mail them Ihe proper payment sWbs. However, if you ft in �his ca�egory and
you tlo no� receive paymen� coupons (Forms 521) by April isL please comac� our office and a se� will be
provitled. Pleese remember, the fa'lure of a�axoaver to receive the pmper forms does not allevla�e.hig/her
res�onsibiliN for any requ red Fllinqs andbr pavmen(5 of�ax.
If afler reatling�he enclosed instruc�ions you still have a question regarding your returq con�act one of our
offces and we will 6e happy to assist you.
�
__ _ , . _
OONOTSTAPLEHERE! USEPAPERCLIPONLVI '10� 0 *^*orriceuscov�v-eorvorwaireirv.ni.eaew
L
e[iVArv pv n�eiL�s mn i6
v,eira�r�.couec*ior+euaeao LOGALEARNEDINGOMETAX - .
RETURN(FORM 531)
ID COMSiiiOiE PapOF OF RLING TME tMPAVEP'B GJW MU6i BE vwLlpAtED 6Y irvE
BOREBV. iC NqVE VOOP GOGV VALIDATE�9Y MAIL,RETUPN 90iH iHE BVREAVS FN�
TP%PPVER'SCOPIBFIONG WITHASELFA�OPEBBEDSiAMPEDENVELOFE
www.capWx.com
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2 EMPLOVEE BUSME55 ESPENSES(EBEs)(A[IecM1etl Fetleral Form 2106851a1e Sc�etlule UEI I � I I � �
3 TPXABLE W�2 EhRNING3 LE66 E9B(6u�Vect Line 2 fmm Llne 1) I a �
4 OTHERTA%ABLEEARNE�INCOME�NOINTERESTOFOIVIDENDS)LISTTVPE� _ —�� _ _ _ _ � __
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5 TOTAL TA%ABLE EARNED INCOME(Atltl Lines 3 antl 4) I �
6 NETPROFlTFROMBUSINESSPROFESSIONORFARM�AtlachFeEerelanO5Wte5chedulesQFantllo�K-1 (ID65)) I I .. ,. ' k'%".. '" .
. _..- _ __ L .
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� NET LOSS ES FROM BUSME55.PROFESSION OR FHRM AtlacM1 Fetleral antl Slale ScM1eOules Q F antl/or N-t 1065 � � �� ' � ' � �
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0 SubhactLine]ImmLine6QFLE55THNNZERO.ENTERZERO� I e I �--_
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10 TOTAL?P%ABLE EARNED WCOME AND NET PROFlTS(htltl L es 5 and 8) � � xtr� I �
—
�p TAXLIABILITY�. MWtply�Youneedl ompleteSCM1eG IeP�- I L � � ��1.�� : �
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AXES WITHHELD EXCEPT PHILA�ELPHIA INCOME TA%�Fmm a0ac�eG W�25.Box 19) II > I. . � _... _.
10 �UHRTERLYPqVMENTSNND/ORlASTVEAR'SOVERPHYMENTGRE�ITEDTOTHISVEAR _ . _ I � � ' ,. T �.: -� � �r..
�
CREOITSFORTH%ESPAIDTOPHIlAOELPHIAANDlORSTATE50THERTHANPA�HTfHGM$CH.G7AN�/ORCREDITSFOR I �s I I
15 CERTIFlE�RESIDENTSOFTHEHARRI590RGKEYSTONEOPPORTUNIT'ZONE(KOZ)
_ _
i6 TOTAL WITHHOLDINGS 8 PATMENTS(H00 Lines 13.14 an015) ' ; `
P TPJf BALANCE DUE(SuOVact Line i6 hom Line 4)PAYMENT NOT NECESSARY IF�E55 THAN 51 00 I I � .. . �::_
._ --_. . -... ._. _ . ' � ,, ..
y '
18 INTEREST 8 PENFLiV(See InsVuctons) I 0 I" '• ��)1 �
_
i9 RETURNSFlLEDAFTERTHEDUE�ATEM9VBESUBJECTTOHDDITIONALCOSTSOFCOLLEGTION I 19 I I
20 TOTAL BHWNCE DUE(Htld Llnes 1]anU 18)Make c�eck payable�o"QGB" Place Soci I securry Numberon CM1eck I xo .0 ' �.y � .�.
... .�_,� � — .��_ ..
21 OVERPAYMENT(SubVact Line 12 fmm Line 16)IF LE55 THAN ZERQ ENTER ZERO � � � I �� � . � �..
22 OVERPqVMENTTOBEREFUNDE� I �� I I
b�RECT �... Tanpy A', B',o(BOTNrSa �nqSo�C�ackingPccl.l ROUTINGNO. I ACCOVNTNO.
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29 OVERPHTMENTT06ECREDITE�TONEXTYENR'STHX I L � �
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�� TYPE OR PMNT INFpRMATION 6ElOW.IF GREPRINTEq CHECK FOH ACCURACYANq MAKE CORR€G90NS WHERE NECESSARY �.
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ANO TO THE�BEST OF MY KNOWLEDCE PNO�BELIEP;THEY ARE TROE,LORftEGT AND COMPLETE. � _ _ . _
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TqXPAYEF'SCOVY
FORM531�-fINALEARNEDINCOMETAXRETURN ^«=�nanw-z�:,ioss:a�a/o� -��,a �^,��
appwpnatempiesof5tate5c�etlules a.,ob�.+.�.u.o��aeo�a�mme�.,re.�..�+.,o-
CUMBERLAND COUNTY TAX BUREAU ���a ������������e�.�•� ,�_�:.����,^�
23WatertordDr.,Suite201,Mechanicsburg, PA17050 s�z.o,W�s�zsoe.��a.svcc �-
PHONE: 717-590-7997
w�osite www.cumbedandtax.org TAXYEAR 2014
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FUILYEA0.RE510ENT VES LJ NO ❑
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STEPHEN ELLIOTT piea:e vi:ic www.mmberiana�a..org ror me i��nk
]OB BALTIMORE RD ana usemese vir�numbers.
SHIPPENS6URGPAI]25Y9482 Tp%PAVERm PH]ZC
TA%PAYER B:
IF YOU MOVED DURING THE TAX YEAR COMPLETE THE FOLLOWING MOVE INFORMATION:
�,�n o�� ���.
ea o�� o,�a o.:
YOU MU57 �\ TAXPAYER A SS# XXX-XX-7581 T/P A-NAME i T/P B- NAME i
COMPLETE �Z� TA%PAYER B SS#
1.GrossEarningstromEmploymenF. Enciosew-xs 1
2.Allowable Non-Peimhursed Employee Business Expenses Endoze PA Sch Ue 2
3.0[he�Ea�nedlncome Enclose1099-M6C/1099�RExclutlingCODE53-9&6/1099C 3
00 NCT INCLU�E IMEREST,�NIDEN�S OR CAPITAL GAINS
4.TexableEa�nings LinelminuzLlne2PWSLine3-CANNOTBE<50.00 4
S.Ne[P�OfLS A[[avM1 GA 5cM1 C,F PK-1 and/orNRK l 5
'0.epart 5 Larp Proflt on reoerse zlde only
NtacM1 VA SCM1 C,F,PK-t and/o�NRKS 6
6.NetLoss •aepvtSLarp�ossonreversesideonly
].Subtotal subnact�ine6fmm�ines iF�eSSrHANZEaqENlEaz[ao. )
8.Total Earned Income �ine a pluz iine) e
9.TaxLiabiliry �ineamW�iplled�y2xare_ (se Instmctlons) 5
10.Earned Inmme�an Withheld 10
11.Quarterly Es[imated Payments/Credit Fram Previous Tax Vear 11
12MiseCredl[ �eeworks�eemneackof�orm�mcaicuaen¢�n��.aaeipnia/om��s.n��ormi 1]
13.To[al of S0,11&12 ii
14.REFUND/CREDIT Subvacv�ine9tmmLinel3 NOTE�.IlmoreNan5100,enteramoonc 14
15.CPE�RTONE%TYEAR/CPEOITTOSPOUSE rvext�va� ❑ syo�.. ❑ 15
16.TAXOUE IfLine9lsgreater[hanLinel3-Sub[rac[Cinel3tmmline9 16
NOtB Amounis of$1.00 or more muzt be paiE.
1].PenaltyakerAprill5th SEEINSTPUCriorvs 1)
18.Interes[afterAprill5th SEEINSTRUQIONS 18
19.TOTAL PMOUNT DUE �ine 16 pluz Line D pluz line 18 19
MAKE CHECKS PAYABLE TO CUMBERLAND COUNTV TAX BUREAU.A FEE OF$20.00 WILL BE CHARGED FOR RETURNED CHECKS.
1 cedare untler penaltles ol per��rv�f���I M1aoe exum%ne4lM1is reNm antl�o[M1e best ot my knwledge antl belle[tt Is a Cue.accua:e antl mmplete reNm.
Si nature-Tax a erA �ate Oow a�ion EMail �a imeTele M1one
Si na[ure-Tax a erB Date O¢u ation E-Mail �a imeTele �one
Pre a r'sName Atltlress PleaseGrint Pre a r'sTele hone
5-Corporation Profi[/loss Repor[ . ,
TaxpayerA: Taxpayer0:
MOVE INFOPMATION: ihe eamed Income�ax Iz bazed on your rezidence or tlomlcile. If you antl/o�yow spouse have movetl dunng[M1e[ax yeaq pleaze mmple[e[he
v Informationbelow. Ityouneedatltlltlonalspare.pleaseu5eampyorattacM1aseparatepage_Pmratelnmmeandtaxwith�eltlbV�henumberolmonthslneacM1
nicipaLry usinR�he employer/sowce of mwme Info�matlon below. I(you antl/or yow spouse M1ave movetl fmm one CCT�member munlcipality[p ano[M1e�CCTB
ember munldpallry during tFe tax yeaq you do not need to Ole a semnd camed Inmme tax remm av lonft as IM1e mwe'mfonna�ion�u pmvitletl below.Pmrate earned
ome and taxwithheltl bV�he number o(moniM1e In eacM1 munlcipallry using Me woM1SM1eet bclow_
PLEASE NOTE. If Vou M1ave moved!mm a non-member munlcipality/s�M1ool dlshitt or moved m a nommember muN6pallry/scM1ool dlzV i[t during[he yeaq you are
required[ofleearnedincome[axrefurnswitM1cheCumbedandComryTanBureauantlwitM1lhelawmllectorforthenon-membermunicipaliry/scM1ooldis[dct Vlease
provide a mpy of[he non-member municipality/scM1ool tlis[ricf earned inrome tax remrn with[he CRB earnetl inwme cax remm.
TAXPAYER A
S[reetAtldres Gry/State/Zip MunicipalitY AesldetlFmm NesidedTo pofMontM1s
(V.0_Boxesarenotacmptable) (MM/�D/VVVY� �MM/��/VYVV� Fulded
EMPLOVEH SOURCEOFINCOMEINFORMATION
Localrax
[mployerNameandAtltlress S�ate/LocalWages Wlthheld EmployetlFom EmployedTo botMontM1s Prorated pmratedtax
(WlBox16/18) (W2Box19� (MM/��/YVYYJ �MM/�D/YYVv� Fmployetl Eamings
TA%GAYER B
S[reEtAddress Oty/Sta[e/Zip MunldpaLry AesitletlFmm NeaidedTo ttolMontbs
(P.O.Boxesareno[acceptable) (MM/DD/YYYV� �MM/D�/VVYV� 0.esitle�
EMPLOVER SOUFCEOFINCOMEINFORMATION
Localiar
EmployerNameandAdtl�ess S[a[e/LocalWagev WI[hM1eltl EmployetlFrom EmploycdTo bOfMon[hs Pm�ated pro�[edTax
(W2Bm16/18) IW�0ox19� (MM/DD/1NYVI (MM/DD/VVYV� EmploVetl Earnings
NON qEQPROCAL STATE�S)/FHIIADELVHIA CPEOIT WORKSNEET: Actual Inmme taxetl by otM1er zta[e(z)(Inmme for wMlch Ilabillry was wlmlatetl)as shown on Ne otM1er
sta�e's reNm,or for PhlladelpM1ia cretllt as sM1own on W 2 or az reportetl ro[M1e Clty oi PFilatlelphla.�o no[uze business pnvilege[aa.Please note,NI5 nedlt cxnnot exceed
your eamed Inmme ta�Ilablllty on the mmme taxed by otM1er ztate(s�.Calculations must be mmpleted for eacF state where Inmme was taxed.
NEQUIREO: VOumurtattachmpiuofoffiers2te'Snoo-residenttaxreNm,pA40antlPAS[M1edule6.1(mplesarenotrerelved,yournu[ofstatecretlitrequestwillbe
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�q OUARTERLY PqYMENTS NND/OR WST YEAR'S OVERPAYMENT CREDRED TO THIS VEHR
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te TOTAL WITHHOLDINGS&PHVMENTS(Atltl Lines 13, 14 antl t5)
P TPX BAtANGE DUE(Subtract Llne 18 irom Lme 4)PAYMENT NOT NECESSHRY IF LE55 THAN E1D0
i8 INTEREST&PENALTY�See Ins�mdions)
19 RETURNSFlLEDHFTERTHEDUEDATEM4YBESUBJEGTTOA�DITIONFlLCOSTSOFCOLLECTION �5 �
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DAlP11IVCOU�TY � YEIZRYCOCVTY JLVIAT4COLNTI
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I'inal Remnis(Poim �31) (or residenis oflh< munlclpeililics dlrectly abocr should be mailed m apprnprlale adJm+.�s sho�+n bcla��:
IfNAYMENTEnclosed: IfRequcslin� RGFUND/CREDIT: IfNOpocmentnrNORefund'Qedii
CAPITAL TAX COLLLCII(1� HURLAG CAPI1�ALl�AX COLLLC I10� 13UKLAL' CAPIIAL TAX COLLGCTION BUREAL
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IIAItI115BUItG PA 1�106-U>�7 I IAHItISf3CRG PA 1 7 1 06-0689 HARRISBURG PA 17110-189i
The Carlisle Division serves residena ofthe followin�munidpafities:
CUMBERLANDCOUNTY '; FRANKLIYCOUNTY' �
C uiislc Burou�h T L �1�IOin Tu�tinsliip N. Newton laHnshi Shi cnsburo la�+nshi Oirsmun Barou,h
_— _. .
Cookc To��nsh� 'v1t I loll � 5 nn s Horoueh Nenn lbwnshi Southam ron iownshi Soulhanipmn Tu�rmhip
Dickinson Trntnship i 've�+bur� 6oroueh S. Middletown Tov.nshi U PrenkCord l ownshi Shi ensbw-�Bomueh
— . _.. - _. _ �___
� Ilo�ewdl Tnwnshi � Ve�+'ville Horoueh S 'Je��ton To�crehi U. Yli(Flin Ta��nshi
_— _- ... _ .—
L FranA(ord Io�rnship N. Middlemn lb�rnship Sh�ppensbur 6oroueh W. Pennsboro Tov.�uhip_ �
Final ReWrns(Form 531)for«videms ofthe municipnlitics direclly above should be mniled to approprlare address az sho��m below:
IfPAVNENTEndo�ed: !fR�qe=,r;�__ µ@c�iryp/rrgED!T: ICNOpr.vmeetortiORefimd'Credi;
CAPITAL TAX COLLECiION BL'RE/�U CAPI'iAL TAX COLLECTION BUREAU CAPITAL l AX COLLECI ION I3URGAU
PO BOX d00 PO BOX 698 19 S HAAOVER ST STE 102
CARLISLE PA 1 70 1 3-0300 CARLISLE PA 17013-0698 CARLISLE PA 17013-3336
The Central Dau ihin Division serves' residenLs ofthe following municiPatities_
DAUPHI� COUNTY �
_——_— _.____ . .__.
Pas�ane Borou�h Penbrook Elorou�h West flanovee lbwnship � �
Final Itelurns[Ponn J31) Ibr msidents ofthe municipalities dreetic above should be mailed to approprieie address as sho�vn beloe-
If PAYMGN'f Lndosed: I(Requesting REFUND/CREDIT: I(NO paymen[or NO Refund�Credil
CAPITAI.TAX COLl1:CfION 13UILLAU CAYII�AL I�AX COLLGC I IOV BUREAU CAPITAL I�AX COLLGCTION BURHAU
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HARRISBURG PA 1 7 1 12-03 77 tIARRISBURG PA 17112-06�6 HAkRISBURG PA 17109-1734
LOCAL EIT(SCHCDULB P)- PARTIAL YEAR RESIUENT NRO-IiATION WORKSHEET
Special Nute: A� the VERY MINIMUM you should compie�e all �he applicable sheded s'ections un the Schedule P. Ifyou have problems
completing seciioiu Ihat rcyuire calculalians. lile yom� Io�al nnnual figures on �he t31 final relurn and we'll do Hte pro-ration based on the
information �nu have provided in [he shaded blocks. Othenvise, comple�e ell cecessap�sections(shaded& unshoded)and feel free to _ive us a
call �t'i�h an.questions.
Instrue[ions: Use one (I1 Schedule P per taspa��er. Vanial year residenls must fle a remrn with cach Inz offcc of Ihe �rea �nu resideJ in
durin�tha�eor. l,'nless Hte employer provided separa�e W-� forms for each arca of residcncc, �vu are reyuired m prora�e earnines. net proGts,
ond unreimbursed busincss expensez, and la� ui�hholdines 6ascd un Ihc number o(months(or da�s)you lived in each area and the number nf
iunmhs (ur days)}ou �carked li�r endi mnplucer. Vou must xlvn prora�e am other tasable income and cour business net profiqs)'loss(es�.
Complete thc �v�akshea lo dctermine your prorared tasable income (or each Iocalion and�or dil�erent tas inte. When calculnting�our pro-
relion percenlagcs 1°-e). hc surc Iu only iue like dace es (ound in the ro�tis 1 W-? Wa;es, Other Income. Net Nrofit�X Net Loss)and the columns
(LocalinnRale). Number of MoNhs Couni as a full inon�h any panial moNh Htat}ou moved into �rior to the 16°i of lhe mnnth, and om
pxrtial month that)�ou nioved out nf aficr Ihc I�°i ol Ihe momh. Use this same lo�ic in calculatlne monlh. �wrked (or each eniplo�cr. This
mlc Is gcnernlk permitted.hoN�ever. ifthe o�her ta� otGce�ou're ayuir�d tu Illc�cith does noi uccep� Ihi� mclhod.ur if ma raics dllkr in Ihc
areas�ou liced.�ou ma� 6e requiicd lo use u pru-raGon ine(hod m �he dnle eereus tn Ihe munth. We tiill uJcltic ruu end ndjurl vour refurn if
this is Ihe cuse.
� MAKE CHECKSPAVABLETO:
IF PAVING BV MASTERCARD VISA OR DISCOVER FlLL OUT BELOW.
��Chambersburg. � o,Eq�qpp � ° �°��Eq
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760 E WashinBton SL ChambersburB� PA »Z�� CAF�NUMBER SECURITY CODE
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oasase AMOUNT PAID' $ $
oioi P.4TIEM NAME: STEPHEN D ELLIOTT IGNATURE .
ACCOUNTNUMBER: H00053340337
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STEPHEN D ELLIOTT CHAMBERSBURG HOSPITAL
708 BALTIMORE RD 760 E. WASHINGTON ST.
SHIPPENSBURG, PA 17257-9482 CHAMBERSBURG, PA 17201-2751
3E931'i9 NO W QV W Z000081
PLEASE�E-ACI�AND RCT'JRN TOP PORTION W TII YOl1R PAVMENT
n 0050 p�lOb
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FINAL NOTICE
Notice Date: 01/26/15
9 Patient Name: STEPHEN D ELLIOTT
Account Number: H00053340337
4 Service Date: 10/02/14
Balance Due: $266.24
Your account balance at The Chambersburg Hospital is overdue and will be
placed with a collection agency if payment is not made within 14 days. It is
important that you respond promplly to avoid this overdue account being
� reflected on your credit history.
For your convenience, we offer the oplion of payment by the major credit cards
shown above. Also, payment may be made online at www.summithealth.org.
If you have questions concerning your account or would like to discuss payment
arrangements, please call us at (717) 267-7129, option 2.
If payment has been forwarded or arrangements already made, please disregard
this notice with our thanks.
SEE BACK FOR ADDITIONAL INFORMATION
HIGHMRRK�
i��niaii��mwiiN��NMnnw�nua
� _ . _� ., . . .. _.
AHOU7 YOUR AOSPITAL BILL
Our Paticnt Accounts ofFcc is opcu for your conveuience duriug[he following hours:
Monda [o Thursda 8:00 AM to 6:00 PM
Fd AM 4' PM
Saturda 8:00 AM to 12:00 Noon
Call us at(717)2674129 or(717)267-7169 if you have questions about your bill or if you'd like m request an itemized copy of your bill.
If we are unable to answer because we are helping other patlenis or if you are calling afler business hou`s,please fal free to leave a message.
We will retum your call as soon as possible.
We are also available to hclp you in person at 760 East Washing[on Stree[,Chambersburg,PA. We are located a block from[he hospital
campus,and parking is convenient.
Your bill covers the cost of nursing and technical services,supplies,equipmrnt,and facilities used for your care. In most cues,we will
bill your insurance company. You will only receive a bill if:
/ a balence remains after your insurance company has paid
J paymen[is not made in a reasonable amount of time
,/ your inswantt company requested infortnation from yo��hat wes no[provided,such as coordina[ion of benefi[s or accident
questionnaire
� J yow care is not covered by insurance
Physlclan Charges
Physician charges for emergency room care and EKG readings ere included on yoar hospi[al bill. All other physician charges,such as
radiologists,anes�hesiobgists,pathologists,cardiologis[s,hospi�alis[s,femily physicians,and specialists bill separa[ely for their services.
Helow are phone numbers often requested.
Chambersbur Anesthesia Associates 800 827-3458
Charnbersbur Lna in Associates 717 263-1383
Chambersbur Pa[holo Associetes 800 210-7345
Summi[Phyeician Services (717)263-9555
Payment OpNona $
Patients mey pay by cuh,check,or credi[card Credit card payment is accep[ed by phone,mail or in perwrt Uninsured patie¢fs are offer�l
a prompt pay discount of 35%if their hospital bill is paid withi¢30 days. The discount is based on total charges. m
If a patient is unable[o pay the entire bill at once,we offer interes[-free payment options. If a payment plan is necessery,it is important
that you coutact us to set up an ageeable arraugement Below are payment guidelines. (W e have the abitiry ro set up automatic payments
that are deducted out of yo�u checking acooun[each month if you wieh.)
Account Balance Minimum Monthly Payrurnt
S25 to 5250 $25.00
5251 to SI,000 $50.00
siomwaz,000 a�oo.00
$2,001 to 53,000 I50.(10
$3,001 to 54,000 52(10.00
$4 001 �o$5 000 5250.(10
5,000 and above Pleace call us to discuss a
payment plv�,not to exceed
a term of 60 months.
Summit Care Program
If you are concemed abou�your ability to pay for hospital services,please contact us to get more information about our
Summit Care Program. Assistance is availeble based on need,and pa[ien[s must quelity through an application process.
Income,liquid assets,and household size aze cansidered. Patienu may be eligible for discounts ranging from 25%to 100%.
Address Chunges
The address infortnetion we have on cecord for you is shown on the front of this letter. Please contact us immediately if any
of this infortnation is mt corzect.
]IB31BN
�p, COMqNWEALTH OF GENNSVLVANSA STATEMENT MAILING
, . p.., OEVANTMENT OF LABOR & INOUSTRV DATE DATE
9�REA� OF UC BENEFITS ANO ALLONANCES
O1/O1/2015 O1/08/2015
�... STGTEMENT OF BALANCE �UE �994 ��2
*wW GGYMENT ��E "'
S�CIAL SEC�RITV NUM6ER: �63-54-�581
IF THE NAME OR ADDRE55 SHOWN BELOW
IS INCORRECT, PLEASE CORRECT AMO�NT ENCLOSEO: $
PAVMENT MADE BY � CHECK � MONEV ORDER
S D ELLIOTT Mp�� voue aarmeNT Ta:
708 BALTIMORE ROAD
SHIPPENSHURG� PA 17ZS�I Bl1REA4 OF OC BENEFITS PND 4LLOWANCES
ATTN: IlI PAYMENT SERVICE$
P.O. BO% 6]503
HARRIS8l1RG, PA 1]106-9894
*ax+.Ef+x*+••*vv+r•�•** pETACH HERE & RETl1RN TOP PORTION WITH VOUR PAVMENT *w'��"""""'•""`*«rrr
REQUEST FOR PAYMENT DUE
Our records indicate no recent payment activiry.
Your chcck or moncy ordcr shuuld be made payablc to lhe"Pennsylvaoia Unemployment CompensaHon F'und'l P1c654
'�l d y '�I secu �[ b�r n Ih-h �•oCthe check. If you nrc umble[o pay in full,par[ial paymenl will be aceepted.
In[erevt will con[inue tn be assessed against[he mpaid balanm. Paymcnl �cccival n[ter the 15th o(lest month may uot show
on Lhis slatcmcul.
Under Pennsylvania Law, you are required to repay this debt, wi[h interest. If
full payment is not received the Department has the right to pursue legal
action to recover the debt.
SOCIAL SECURITV NOMBER: 163-54-�581
PROCESSING �ATE �ESCRIPTION YOl1R INCREASE VOl1R OECREASE
10/31/14 UC INTEREST INCREASE 1 .02
11/30/14 11C INTEREST INCREASE 1 .02
12/31/19 UC INTEREST INCREASE 1 .02
PREVIOUS eALANCE BALANCE DECRE45E BALANCE INCREASE NEW BAL/NCE
$140.08 8 0.00 $ 3.06 $103. 14
BANKRUPTCY DISCLAIMER
IMPOR'1 AhT:lf you are a ticbioe in an ovgoiug banAmp�cy ceu or have had youv ovevpxymem DiseM1ergca in a benkeup�rycase Mis document is for
informetionalpurpos ontyu�dJucsnmconsiiwteanxuempiwmllcc�youroverpaymem.Pleascprovidcthcdcpenmcnlwnhlnfortnetioninwnting
ennecming ynur onguiny Dankmp�oy oase or ynur dischargee ouerpayment at the fo0owiny addrcss:
OfCice of UC Benetits, Claimant Services, P.O. Box 67503, Harrisburg, PA 17106-9894.
UC-3R5131 flEV 05I16 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
NOTICE OF INTEREST CHARGES ON FPULT OVERPAVMENTS
UNDER THE PA UC LAW VOU ARE RESPONSIBLE FOR REPAYING THE FULL AMOUNT OF YOUR FA�LT OVERPAYMENT. IN
ADDITION, THE PA �C LNW REOUIRES V0� TO P4V iNTEREST ON ANV FAULT OVERPGVMENT AMOUNT NOT REPAID
WITHIN FIFTEEN (15) CALENOAR DAVS AFTER V00 RECEIVED NOTIFICCTIpN OF VOUR FA�LT OVERPAVMENT. THE
RATE OF INTEREST, WHICH IS C�RRENTLY NINE (9) PERCENT PER YEPR, IS S�BJECT TO CMANGE AT THE eEGIN-
NING OF EACH CGLENOAR VEGR.
CALCOLATION OF INTEREST
THE INTEREST WILL 8E CALCULATED d5 SIMGLE INTEREST AND WILL 6E ASSE55ED FOR EACH MONTH OR PRACTION
OF A MONTH iHAT THE F4�LT OVERPAVMFNT REMAINS UNPAI�. THIS ASSESSMENT WILL 8E AUTOMATICALLV CALC�-
LATEO BV COMP�TER AT THE END OF EACH MONTH AS SHOWN IN THE FOLLOWING:
E%AMPLE: Y0� HAD A $550 FA�LT OVERPAVMENT AND DURING THE MONTH MADE A PAVMENT OF $50, WHICH RED�CED
THE OVERPAVMENT BALANCE TO $WO. THE INTEREST 455ESSE� FOR THE MONTH WO�LD BE $3.�5.
UNPAID FAULT C�RRENT VR. TOTAL VRLV. MONTH$ AMOUNT OF INTEREST
OP BALANCE INTEREST RATE INTEREST IN VEAR ASSESSE� FOR MONiH
$500.00 X 0.09 = $45.00 / 12 = $3.�5
IF Y0� HAVE ANV QUESTIONS CONCERNING YO�R REPAVMENT �BLIGATIONS �R THE INFORMATION CONTAINED ON THI$
FORM. PLEASE CONTACT THE UC SERVICE CENTER AT eBB-313-�204.
'rw OVERPpVMENT ACCOUNT ACTIVtTY (CONTIN�ED) *�*
PROCESSING OATE DESCRIPTION YOUR INCREASE VO�R DECREGSE
UC�325 IB) PEV 05/16
�, �„�,. �MC
� �PO BOX 16346
PITTS9URGH,PA 15242-0346
II��I������I��II���II�I�I�I�����I����II�I�I��I�������������� (:�rdii Alauu�i��w�m Cu�npunc
2121 Noblestown Road,Pittsburgh,PA 15205
P O Boa 16346,Pittsburg6 PA 15242-0346
0 2-2 7-2 015 Fax: (412)937-1286
ACCOUNT IDENTIFICATION
III�II'll'I'IIIII"11��'II'���II'II�IIIIIII�III��I����III��I�I�I� Creditor: CHAMBERSBURG HOSPITAL(ER)
STEPHEN D ELLIOTT Patient name: ELLIOTT, STEPHEN D
708 BALTIMORE RD Account Number : 4455251
SHIPPENSBURG PA 17257-9482 Agent Number : 21
Date Last Charge : 03-i6-11
Amount Due : $ 7865.60
Your account vnih CHAMBERSBURG HOSPITAL(ER)in ihe amoun[of$7865.60 is senously past due. As a result, your account
has been assigned to CredH Management Company for 2solu[ion.
To resolve this matter quickly and in a manner benefcial to you, remit the full amount shown in Ihe enclosed envelope. You may
alw make a credit card or check payment on our website.www.oavcmc.com,or call 1-866368-1557 to discuss your outstanding
balance. To receive proper credi�, payment should be made payable to Credit Management Company vnih your account number
(shown above)indicatBd on your check or money oMBr.
Please notiy us it an insurence carrier or an ettomey is involved in this matter. If payment has been made on this account direcHy
to ihe above credilor, please note your check number and date of payment on ihis letter and reNm it to us, in the enclosed
envelope.
Slncerely, Ca[hy Schor/1A66-368-1557
Buslnsss Hours E57: Mon-Frl 5:00 am to 8:00 pm antl Sat 9:00 am to 1:00 pm
FEDERAL LAW P.L. 95-109
This is an attempt to collect a debt. Any information obtained will 6e used for Ihat purpose.This communication is from a debt
collector. Unless you notify this office,wilhin 30 days atler recaiving Ihis notice,that you dispute lhe validity of ihis deb[or any
portion ihereof,this office will assume that ihis debt is valid. If you notify this offce in wnting wiMin 30 days from receiving ihis
notice that you dispute[he validity of this debt or any portion ihereoi, this office will obtain venfication of the deb[or a copy of a
judgment and mail you a copy of such judgment or verification. If you request in wri[ing,within 30 days a%er receiving this notice,
ihis office will provide you with the name and address of the original credifor,'rf different from ihe wrtent creditor.
--------------"----'-------------PLBASE DETACH AND RENRN THIS POR]'fON IN iHE ENCLOSED ENVELOPE----------"---------'---'------'--'--
From:
�� � You may pay odive by visitlog om odive peymem sysrem at
��oy � ....vav�m<<om ChangeofAddress:
- `�� , � ro� �y �se o� �m�.m�em �scnu ro enr� opnon by City. State, Zip:
� � scaooiug We QR code uviug yom smart phooe.
� � Telephone: Work:
Make you�check or money order payable to: Amount Due : $ 7865.60
Amount Enclosed
Credit Management Company AccountNumber :4455251
P O Box 16346 Agent Number : 21
Pitteburgh PA 15242-0346
�'lllll'�I'�I'��"��I'�I�����I'�I�'�I'll�l�ll�l��"�II"�III�'�I� Enclosingthisnoticewithyourpayment
will expedite credit to your account.
5-.�
PO BOX 16346 ���
P[TTSBURGH,PA 15242-0346
������������������������������I�������������������I�������� (:n'dn AI�ur.i�rnu'�n Canip:wc
2121 Noblestawn Roed,Pittsburgh,PA 15205
P O Box 15346,Pittsburgh PA 15242-0344
o z-2 7-z 015 Fax: (472)937-7 286
ACCOUNT IDENTIFICATION
�II'I'I"I�I����I����IIIIII'I�I�II���IIIII�I�I�I�III�I��'I�IIIII' CrediWr: CHAMBERSBURG HOSPITAL(OP)
STEPHEN D ELLIOTT Patient name: ELLIOTT,STEPHEN D
708 BALTIMORE RD A�count Number : 5529409
SHIPPENSBURG PA 17257-9482 P.9ent Number : 21
Date Last Charge : 0831-72
Amount Due : $ 3337.43
Vour account with CHAMBERSBURG HOSPITAL(OP)in ihe amoun[of$3337.43 is seriousy past due. As a resWt, your account
has been assigned to Credi�Management Company for resolution.
To resolve ihis matler quickly and in a manner benefcial to yoq remit the full amoun[shown in[he enclosed envelope. You may
also make a credit card or check paymen[on our website, www.oavcmc.com,or call 1-866-368-1557 to diwuss your outstanding
balance. To receive proper credi�, payment shoultl be made payable[o Credit Management Company with your account number
(shown above)indicated on your check or money order.
Please notiy us if an insurence canier or an attorney is imolved in[his matter. If payment has been made on ihis account directly
to ihe above creditor, please note your check number and date of payment on this letler and retum it to us. in ihe enclosed
envelope.
Slnwrely,Cathy SchorN-e66•368-0557
Buslnns Hours EST: Mon-Fr18:00 am to 8:00 pm end Sat 8:00 am to 7:00 pm
FEDERAL LAW P.L.95-109
This is an atlempt to collect a debt. My infortnation oblained will be used for ihat purpose. This communication is from a debt
collectoc Unless you notiry this offce,within 30 days after receiving ihis notice,lhat you dispute ihe validity of[his debt or any
portion ihereof,this offce will assume iha[this debt is valid. If you notify ihis offce in wnting within 30 days from receiving ihis
notice that you dispute the validity of this debt or any pohion thereof,ihis offce will obtain venfcation ot lhe debt or a copy of a
judgment and mail you a copy ot such judgmen[or verifcalion. If you request in writing, wtthin 3�days afler receiving Ihis notice,
this offce will provide you wilh ihe name and address of Ihe onginal credttor, rf different from the current c2ditor.
------------------------------PLEASE DETACI{qNp pp'RJµN TFllS PORTION M I'}IE ENCLOSED 2NV0LOPE ----------------------
From:
You may pay odiue by Hsitiug ow odine paymeu�aysmm a�
Q Q w Change of Address:
' � wwoavcmc.com
�� Yoo mey uxe ow vwvcwe�ut "SCAN i0 PAY" op6ov by City, State, Zip:
� � . scemivg the QR coda usivg yow smerc phone.
.,� Telephone: Work:
Make your check or money order payable to: Amount Due : $ 3337.43
Amount Enclosed
a Credit L7anagement Company Account Number : 5529409
P O Sox 16346 Agent Number : 21
Pittsburgh PA 15242-0396
�'lllll'�I'�I'��"��I'�I�����I'�I�'�I'll��'���I��"�II"�111�'�I� Enclosing this notice with your payment
will expedile credit to your account.
��i
' . ' ;_�i.�_�u�r
PO BOX 16346
PITTSSURGH,PA 15242-0346 ��
II��I��I�III��II������������������������������I��I���������� Crrdi� AI�ur.iqi�n,eni (�,ompnnc
2121 Noblestown Road,Pittsburgh,PA 15205
P O Boa 16346,Pitfaburgh PA 15242-0346
o�-z�-z o i 5 Fax: (412) 937-7286
ACCOUNT IDENTIFICATION
����II��II��I'I"'III�IIIIII�"�I�III�I�III�I'III�IIIIII�IIII�I�I Creditor: CHAMBERSBURG HOSPITAL(OP)
STEPHEN D ELLIOTT Patient name: ELLIOTT, STEPHEN D
708 BALTIMORE RD Account Number : 6906093
SHIPPENSBURG PA 77257-9482 Aqent Number : 21
Date Last Charge :05-22-14
Amount Due : $ 17.12
Your accounl vnih CHAMBERSBURG HOSPITAL(OP)in the amoun[of$17.12 is unously past due. As a result,your account
has been assigned to Credit Management Company for resolution.
To resolve this matter quickly and in a manner beneficial[o you, remd the full amount shown in ihe endosed envelope. You may
also make a credit card or check payment on our website, www.oavcmacom, or call 1-8663684557 to discuss your outstanding
balance. 7o receive pmper credit, payment should be made payable to Credit Managemenl Company vnth your account number
(shown above)indicated on your check or money oMer.
Please nolify us if an insurance carrier or an aflorney is involvetl in ihis matter. If payment has been made on this account diredly
to ihe above creditor, please note your check number and date of payment on this letter and retum it to us, in the enclosed
ernelope
Slnceroly,Cathy Schod1368-368•1557
Business Hours EST: Mon-Frl 5:00 am to B:00 pm and Sat 9:00 am to 1:00 pm
FEDERAL LAW P.L. 95-109
This is an attempt to collect a debt My information obtained will be used for that purpose.This communication is from a debt
collectoc Unless you notify this offce,wdhin 30 days afler receiving this notice,ihal you dispule the validity of ihis debt or any
portion Ihereof,this offce will assume that Ihis debt is valid. I(you notify this oRce in wnting within 30 days/rom receiving�his
notice that you dispute the validity o(ihis debt or any portion ihereof,this office will obtain verification of the debt or a copy of a
judgment and mail you a coDY of such judgment or verification. If you request in writing,within 30 days after receiving ihis notice,
this offce will provide you wdh ihe name and address of the odginal creditor, it diRerent hom the current creditor.
--------------------------------------PLEASE DEiACH AND ftEN2N l'H15 POATION IN THE ENCLOSED ENVELOPE------------------------------
From:
❑� � Yoo vuy paY odwe by visinug om oWine paymem sys�em e�
❑ �,.oay���o� Change of Atldress:
�� You maY u+e oirt cauvenient `SCMI TO PAY^ oP�iou by Clly, $�3I8,ZIP:
�. � acamingN<QRcodeueiugyo�vsmertpbane.
� 7elephone: Work:
Make your check or money order payable to: qmount Due : $ 17.12
Amount Enclosed
~ Credit Management Company AccountNumber : 6906093
P 0 Box 16346 Agent Number : 21
PittOburgh PA 15242-0346
�'lllll'�I'�I'��"��1'�I�����I'�I�'�I'll��'���I��"�II"�III�'�I� Enclosing this notice with your payment
will expedite credit to your account.
s-n�
, .� ,,,« �MC
�PO BOX 16346
PITTSBURGH,PA 15242-0346
������������������������������������������������������������ (',mdli ��:in:igi•incm Cunipnm�
2121 Nobiestown Road.Pitlsburgh,PA 15205
P O Bo:16366, PiHsburgh PA 15242-0346
c 2-2�-z c 1, Fax: (412) 937-1286
ACCOUNT IDENTIFICATION
I'I"'I'�IIIII"I��IIp��IIIII�II'I���Id�IIII'I"II�'I'lII'IIIII ,nvar-���a Creditor. CHAMBERSBURGHOSPITAL(OP)
m „.�;� Patien[name: ELLIOTT, STEPHEN D
� STEPHEN D ELLIOTT Account Number : 2079M9
708 BALTIMORE RD Agent Number : 21
SHIPPENSBURG PA 17257-9482 Date Last Charge : 11-15-04
Amount Due :$217.35
Your account wi[h CHAMBERSBURG HOSPITAL (OP)in the amount of$217.35 is senously past due. As a result, your accounl
has been assignetl to Cretlit Management Company for resolution.
To resolve ihis matter quickly and in a manner beneficial to you, remil lhe full amount shown in ihe enclosed envelope. You may
also make a cretlit card or check payment on our website,www.oavcmacom, or call 1-8663fi8-1557 to discuss your ou[standing
balance. To receive proper credit, payment should be made payable to Credit Managemenl Company with your account number
(shown above) indicated on your check or money order.
Please notiry us if an insurance carrier or an attorney is involved in ihis matler. I(payment has been made on this accoun[diredly
to ihe above creddor, please note your check number and date of payment on this letter and reWrn it to us, in the enclosed
envelope.
Slncsrely,Cathy Schor/1A66-368-7557
Buslness Houn EST: Mon-Fr18:00 am to 8:00 pm antl Sat 9:00 am to 1:00 pm
FEDERAL LAW P.L. 95-109
This is an atlempt to collect a debt.My information obtained will be used for that purpose.This communication is from a debl
collector. Unless you notify this offce,wdhin 30 days afler receiving this notice,ihat you dispule Ihe validiry of ihis debt or any
portion thereof,ihis o(fice will assume t�at[his debt is valitl. I(you notify this oKce in wnting vnthin 30 tlays hom receiving ihis
nolice that you dispute the validiry ot ihis debt or any portion ihereof,this otfice will obtain verification of the debt or a copy of a
judgment and mail you a copy of such judgment or ver�cation. I/you request in writing,within 30 days after receiving ihis notice,
this offce vnll provide you wdh ihe name and address of ihe onginal creditor, if different hom ihe current creditor.
---------------------------------PLEASE DETACH ANll RE I URN TH15 PORi]ON IN THE ENCLOSED ENVELOPH ------------------------------------
From:
Yoo may pey odine by visiuog om odwe payment sysmm et
❑� ❑� �µ,og m om ChangeofAddress:
�� , � Yw maY use oia covvewent "SCAI� TO PAY^ opeoo by Ci�y. State,Zip:
�. � . scamivgtheQAcodeiuivgyo�rtsmartphoce.
� Telephone: Work:
Make you�check or money order payable to: Amount Due : $ 217.35
Amount Enclosed
Czedit Management Company AccountNumber : 2079729
P O Sox 16346 Agent Number : 21
Pittsburgh PA 15242-0346
�'lllll'�I'�I'��"��I'�I�����1'�I�'�I'll��'���I��"�II"�III�'�I� Enclosing this notice with your payment
will expedite credit to your account.
� � ,� �.,�� �MC
PO BOX 16346
PI7TSBURGH,PA l5242-0346
II��I��I�III��II�����������������������������I�I������������ (:redi� A[.m;i,rn,rn� Crnnp�u�c
2121 Noblestown Road,Pinsburg6,PA 15205
P O Bo:1434M1,Pinsburgh PA 15243-0346
Paz: (412)937-1286
02-27-2a15
ACCOUNT IDENTIFICATION
II�I�II�I"I'II'I��'IIII'1�11"I"'I�II'I�IIIII�I�'IIIII"II�I��I Creditor: HOSPITALISTS OF FRANKLIN COUNTY
STEPHEN D ELLIOTT Patient name: ELLIOTT,STEPHEN D
708 BALTIMORE RD Account Number : 3652782
SHIPPENSBURG PA 17257-9482 A9ent Number : 27
Date Last Charge : 03-02-08
Amount Due : $ 46.70
Your account with HOSPITALI5T5 OF FRANKLIN COUNN in the amount of$4670 is seriously pasl due. As a result,your
account has 6een assigned to Credit Management Company for resolu[ion.
To resolve Ihis matler quickly antl in a manner beneficial to you,remit ihe full amount shown in ihe enclosed envelope. Vou may
alw make a credit card or check payment on our website,www.oavcmacom, or call 1-866368-1557 to discuss your outstanding
6alance. To receive proper cred'R, payment should be made payable to Credit Management Company with your account number
(shown above)indicated on your check or money ordar.
Please notify us if an insurance carrier or an attomey is involved in ihis matler. I!payment has been matle on this account directty
[o the above creditor, please note your check number and date of payment on Ihis letter and retum it to us, in the enclosed
envelope-
Slnceroly,Cathy SchorH-866-368-7557
Buslness Hours EST: Mon•Frl 6:00 am to 8:00 pm antl Sat 9:00 am to 1:00 pm
FEDERAL LAW P.L. 95-109
This is an attempt to collect a tlebt. My information obtained will be used for Ihat purpose. This communication is from a debt
colleclor. Unless you notify Ihis offce,within 30 days afler receiving this notice,Ihat you dispute the valitliry of this debt or any
poAion Ihereof.[his office will assume Ihat ihis debt is valid. if you notify Ihis oKce in wnting within 30 days from receiving this
notice ihat you dispule lhe validity of[his debt or any portion ihereof,this offce will obtain vedfiwtion of�he debt or a copY of a
judgment and mail you a copy of such judgmenl or verifcation. If you request in writing,wilhin 30 days after receiving Ihis notice,
this offce will provide you with[he name and address of ihe onginal creditor, if differen�from the curren�creditor.
- --PLEASE DEYdCH MD REiUR9 iH1S PORiION IN THE ENC60SFD ENVEL�PB--------------------
From:
You may pay oolive by visiung ow odwe paymenroplem at
� � wwwoa���<om ChangeofAddress:
�� , � You may uve ow couvewenl •SCAN 'IO PAY" optioo by Ciry, SWte, Zip:
� � sca"�the QR code ueiog yow sman phoce.
� Telephone: Work:
Make your check or money orde�payable to: Amount Due :$46.70
Amount Enclosed
Credit Management Cospany AccountNumber : 3652782
P O Box 16346 Agent Number : 27
Pitteburgh PA 15242-0346
�'lllll'�I'�P��"��I'�I�II��I'�II'll'll��'��II��"III"�IIII'lll Enclosing this notice with your payment
will expedite credit to your account.
_ W � p �
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mp �' �
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(nrnm �
_ � _ �
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