HomeMy WebLinkAbout06-18-15 � Lsos6111o1
REV-1500 �"`°'"' 7�'
OFFILIAL USE ONLY
PA�epadment of Revenue P rybania
Bureau of Intlividual Taxes enn'"��"��'� Cocnry Cotle Year File Number
aoeoxisosoi INHERI7ANCETAXRETURN
tiarr sb�rq Pn a�ai8-o6oi RESIDENT DECEDEN7 � � �I 5 U I C U
ENTER DECEDENT INFORMATION BELOW
Sociel Secudty Number �ale of�eath MNODYVW Da�e ot Bitlh MM�DnVv
I a f 5 2 o i ¢ oSU�f I �i� ��
�ecetlenfs Last Name Suffix �ecetlenfs Firsl Nzme MI
i; � � � �T � � TrP �+ � N �
�If Applicable) En[er Surviving Spouse's Information Below
SpousesLastName Suflix SpousesFlrstName MI
Spouse.'s Social Securily Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WI�LS
FILL IN APPROPRIATE OVALS BELOW
� 1. Origlnfll ReWm O �� Supplemental Rewm O 3. Remainder Retum(�ate of�eatb
Pnor l0 12-13$2)
p 4. Limi�ed Esle�e O 4a.WWre In�eres�Compmmise(date of p 5. Fetle21 Es�ate Tex ReWm Requiretl
death etler 12-12�2)
O 6. Decadenl Dietl Tes�a�e O Z Decatlen�Main�ainetl a Living Tms� B. To�al Number of Sefe Oeposi�Boxas
(AtleCh COpy Of WIII) fA�taCM1 COpy O(Tlu6L)
O 9.Gtlge�ion Pmceetls Received O �0_Spousal Povetly Cradit(Dete of Dea�M1 O 1t Electlon lo Tax untler Sec.9113(AJ
Betwean 12J15t ena t-t-95) (AVecn SCM1odule O�
CORRESPON�ENi- THIS SECTION MUST 6E COMPLETED.ALL CORRESPONDENCE FNO CONFIOENTIAL TA%INFORMATION SHOUlO BE OIRELTE�T0:
Name Day�ime TelepM1one Number
( L021 �' IU! /� lC 62S 3c��� ZSc� �:� J�
� � �aea,rrTek�F wi��s-use o��'
=�� '�. ..�
First Line olAddress ' I ~
W
1� D (jG�C �o � � � � ',I
SecondLineofAdtlress i _ � `���
� ril
� o
onre r i�eo--
City or Post ofiice State ZIP Cotle � _ �—� v+
Ia � 2 lc L L L' �c S�/�u� Gs �t) l/ Z S� � /
CorrespontlenPs e-mail address: G �O�)Q'�al�.vt<v �YK�( /• C�
Untlarpenalliesofperryry.Itledere1�a11M1aveexamm�etlNisreWm,InclutlinBe mpanyingsc�etlulesantlsla�emenLs.endtoNeOes�olmyknowletl9eantlbeliel.
1�Is�me,co�reo�a d mmpla�e-Daclere�ion of prepe�e�otM1e�IM1an tM1e parsonal represanlalive Is besetl on ell loforma�on ol w�icM1 preparer M1as eny knowleUge.
SIGNATURE P SON RESPON3IB O$FlL G R �NTE/ .�
(�C, _ ���� /� /5
ADDRE �
'�����;X �// (�'-(_�i�-�a-,c��/LG�S �1��� �S—�! /
SIGNATURE OF PREPARER OTHER THNN REPRESENTFTNE �� �ATE
aooaEss `
PLEASE USE ORIGINAL FORM ONLV
Side 7
L 15056111�1 15056111�1 ��
�_i
J 15�56112�1 "
RE�-,5oo Ex
Oecetlenfs Social Security Number
oeceae�rs rvame:
RECAPITULATION
t. Real Estate(Schedule Al. . . . . . . .. . . .. . . . . . .. . .. . .. . ... . .. . .. . .. . .. . . . 1. . [J C
2 Stocks antl Bontls(Schetlule B) . . . . . .. . . .. . .. . .. . . . . . .. . .. . . . . .. . . . . . . 2. • QD
3. Closely Heltl Corporalion,Partnership or Sole-0mprie.brship(Schedule C) . . . . . 3. . U �
4. Motlgages antl No�es Receivable(Schedule D) . .. . .. . . . . ... . .. . .. . .. . .. . . 4. • �J G
5. Cash, Bank Deposits antl Mlscellaneous Personal Property(Schedule E). .. . .. . 5. . �j�
6. Jointly Owned Propetly(Schedule F) p Separa�e Billing Reques[etl . .. . .. . 6. . �)�J
]. Inter-Vivos Trans(ere 8 Miscellaneous Non-Pmbale Pmpetly
(Schetlule G) O Separate Billing Requestetl.. .. . . . . ]. .-��G\
B. Total Caross Assets(total Gnes 1 Ihmugh]). . . . .. . .. . . . . ... . . . . . . . .. . . . . 8. . L�u
9. Funerel Expenses and Atlministra�ive Cos�s(Schetlule H). . . . . . . .. . . . . . .. ... 9. � ( ( /�, �. 6
7
10. Debts of Decedent, Motlgage Liabill�ies antl Lians(Schedule I]. . . . . . . . . . _ . . . 10_ � ( ', � � . O U
11. To[al Deductions(lolal Lines 9 antl 10). . .. . . . . . . . . .. . . . . .. . . . . . . . . .. . .. 11. , C� �'.S '�. �7 C 1
12 Ne[Value of Estate(Line B minus Line 11) . . . . . . . . . . . . . . . . .. . . . . . . . .. . .. 12 , L �
13_ Charitable and Governman�el Bequests/Sec 9113 Tmsts for whicM1
an elec�ion to tax has no[been made(Sc�etlule J) . . . . . . . . . . .. . .. . . . . .. . . . 13. , c�<j
14. Ne[Value Subject[o Taz(Line 12 minus Line 1:1) ... . . . . . . . .. . . . . . . . . . . . . 14. , (,� ��
TAX CA�COLPTION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amounl of Line 14 taxable
at�he spoLLsal�ax ratn, o
�209�Bf8 UOdBI$2C. 0��6
(a)(12�X.0_ � 15 .
16. Amoun�of Line 10�axable
atllneala�e X 0_ . 16. .
iZ Amoun�of Gne 14 taxable
atsi�lin9 rate X .12 . il. .
18. Amount of Line 14�axable
al collaterel rate X 15 . 18. •
19. TAXOUE . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . 19. .
20. FILL IN THE OVAL IF YOII ARE REQIlESTING A REFUND OF AN OVERPAYMENT O
Side 2
L 1505611201 1505611201 J
Fev-isoo Ex aage 3 r�ie rvumeer
Decedent's Complete Address:
DECEOENTSNPME � _/
�je��([�vi ��t.Cs �c._S Ll _ D
sraEeTaoo Ess ' �� �
7G R �c,�i -yuc�' e �r�a c�
CITV � , STAiE��/1(�/.{�. ZIP
���1 I . 'NQ. �L� � / // 7�� �
Tax Payments and Credits:
1. Tex Oue(Page 2,Gna 19) (�) _
2 Credits/Payments
A.Prior Paymenis __. _.
B.Oiscoun� _
TolalCredils�A+B) (2) �
3. Interest
(3) _
4. If Line 2 is greater Ihan Line 1 +Line 3,en�er Ihe diHerence. This is Ihe OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund (4) _
5. If Line 1 4 Line 3 is greater than Line 2,enter Ihe tlifference.This is Ihe TAI(OUE (5)
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS 8Y PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Oitl 0eceden�make a Vans�er and Yes No
a. retain�he use or income of the pmperty Iransfened .... ..... .. .. ❑ �
b_ retaln Ihe�ight�o desgnale who shall use the property Iransferretl or As mcome .. .. ❑
c. retainareversionarymterest .._._. _... ..._ _ .. � -
d. receive the promise for hfe of either payments. benefts or care2_ ..... . . ._ _ � �
2. If death occurred aFler Dea 12, 1982,did decedent transfer pmperty withm one year of deeth �
withoulreceivingadequateconsideration? _....... .._...... ._._.. _._.. � �
3- Dld decedent own an"In Irus�for"or payable-upon-0eath bank accoun�or 6eadty a�his or her death?..._._._... ❑ �
4 Dad�e�a be eficiary desgnation�remen�account annuity or other non pmbale propetly which ❑ ��
� _._... .__.. _._.._ ..._....
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 a9er July 1, 1994,and before Jan.1, 1995.ihe tax rate imposed on�he net value of transfars to or for the use oi the surviving spouse
Is 3 percent(72 P.S.§9116(a)(1.1�(i)J.
For dates o(death on or aFler Jan. 1. 1995, ihe tax rete Imposed on ihe net value of Vansiers m or for the use o(the surviving spouse�is 0 percen�
[72 PS.§9116(a)(1.1)(ii)�.The staNte does not ezempta transfer Io a surviving spouse(rom tax,and ihe staW�ory requlrements fordlsclosure o(asse�s antl
illing a�ax reNrn are still applicable even d Ihe surviving spouse is the only beneficiary.
For da�es of death on or after July 1,2000�
• The lax ra�e imposed on Ihe net vaWe of Vansfere fmm a deceased chlld 21 years of age or younger al death to or for ihe use of a naWral parent, an
atloptive parent or a steppareN ot�he child Is 0 pemenl[72 P.S.§9116(a)�12)].
• Thetexretelmposedonthenetvalueofirans(erstoorfor�heuseofthedecedenfsllneal6eneT�cianesi54.5percenLexceptasnoted'm[/2P.S-§9116�a)�i)].
• The tax rete Imposed on the net value of Vansfars to or for the use of ihe tlecedenCs siblings is 12 percent[/2 PS. §9116(a�(1.3)].A slbling is de(ined,
under Section 9102,as an individual who has at least one parent in common wilh the decedent,whe�her by blood or adoplion.
INVENTORY
REGISTER OF WILLS OF COUNTY, PENNSYLVANIA
COMMONWEALTHOFPENNSYLVAMA i .
COUNTYOF J SS FileNumber � r � J~ ' OG` 1 O �.
Personal Representative(s)ofthe Estate of�>j�..�n C�M I) vi.ic��� S � � I i ' 1 I
deceued,depore(s)and say(s)tha[the i[ems appeazi�g in Ihe follow'vig inventory iudude all of the peisonal assets wherever siNate
and all of the real estate in the Commonwealth of Pennsylvania of said Decedent,that the valuation placed opposi[e each item ofsaid
inven[ory represenis itr fair value as of the da[e of[he decedenPs death, and[hat Decedent owued no real es[ate wtside of the
Commonwealth of Pennsylvania except[ha[which appears m a memornndum at the end of this inventory.
I verify tha[the statements made in this Inveo-
tory are true and colrect I understand that false state- �
ments herein are made subject to the penalties of
IS Pa.C.S. § 4904 rela[mg to unswom fals�ca[ion to
autliorities.
Attoruey-- (Name) (Supreme Court LD.No)
(AAdress)
(Telephane)
onrEovora.rv us*aEvoeuce oeceoEnrssoc.sECNo
o-i '- / 7D� ,,,��te � �; �tlu ��zs ; � (
N7GURES MUST BE TOTALED
(Attacfi additiorm[shee[s as neededf
TOTAL: 0.00
NOTE Thc Memoandum of real esm¢autside thc Cammovweal�h of Peniuylvania may, ai�hc election oC�he personal represrn�a�ive include Ne velue of each
item,bm such figurcs should nov be ex�mdrd inm ihe�dnl oRlu Imentory- (See 20 Pa C S§3301(6/)
FmmRW�09 rev.l0.f3.06
REV-1592 E%f (01-14)
�� .; pennsylvama SCHEDULE A
°`°°°`"`"'°`P`"`""` REAL ESTATE
�«�Ea�.<N�E...a�an
aEsmerv.oeceoENr
FILE NUMBER:
ESTATE OF:
S}0o���a. �C�S �� � lo� �O� J� —OOIDo-2..
All real property owned solely or as a tenant in common must be reparteE at fair marke[value. Fair market value is aefine0 as[he price af which pmperty
woultl be exchangetl be[ween a willing buyer and a willing seller,neither being mmpelled to boy or sell,bo[h having reasonable knawle0ge oF the relevant fac[s.
0.eal property Na[is jointlY'^w^�w��h righ[o(survivorehip must be Eisclose0 on Schedule F.
Attacb a mpY of[he uMement shee[if the pmpeM has been soltl.
REM VALUE AT�PTE
IntluAe a m0Y of the tleed sAowing AecedenPs in[eresc If ownetl as Lenant'm mmmon. OF DEATH
IJUMBER pESCRIVlION
�. N �,� � � -
TOTAL (Also en[er on Line 1, Recapitulation.) S —�
If more space is neeGeO,use atltli[ional sheets of paDer of Ne same size.
� FEV45P3E%+(6�9��
� SCNEDULE B
COMMONWEALTNOFPENNSYLVANIA STOCKS & BONDS
INHERITANCE TA%RENRN
RESI�ENT�EGEOENT
FILE NUMBEN
E�T�1�,� � `{ < < (�I � ;�-�' ao �5-ooio �.
Ail propa'ly Idn9y�mvME wtlM1 tl9ht ol surviwrsh�p must be tlisclosetl on Schedub F
VFLUE AT OATE
NUMBER DESCRIPTION OF DEATH
,. "i� .uWe RiCe Qc��R�"U� 14GcvT 3UG� i7-rioZ -°7 2.SDU � �o
.1iw,ti�"�'l,i,MzfS��� (� — GI��iA 3 izlinlT�QS
�t�pNcu D. EGuo�
�„
TOTAL(Also enter on lina 2,Recapitulation) S �S�u
Ilf more space Is needetl.insetl addilional sheets of�he same siie)
RE�,s�^Ex�r' s'� gCMEDULE C
CLOSELY-HELD CORPORATION,
coMMONwea�rn ov aENt�sv�vawn PARTNERSHIP OR
INHERITPNCE TPX RETUPN
ResioeHToecEoeN. SOLE-PROPRIETORSHIP
ESiATE 0� � - ��/ � FILE NUMBEH _
'�GS / D o7(i� 5 ��U� O �.
Schetlule C�1 or G2(inclutling all suppotling inbrma�ion)musl be allac�etl for eac�closely-helJ corporotioNpan^ere�ip inleresl ol the tleceden�,otM1er than a
sole�proprielorshlp.See insimclions iw ihe suDPoning intormation lo be suhmtltetl lor sole-propriebrships.
ITEM NUMBER VPWEAT DATE
NUMBER DESCRIPTION OFDEATN
1. � V ' `��
TOTAL(Also enler on line 3, Recapitulation) S —
�II more space is neeCed,inserl aGEilional sheeis o�Ne same siza�
. Aeaismex,.osv)�
�� SCNEDULE D
MORTGAGES & NOTES
COMMONWEHLTHOFPENNSYLVNNIA RECEIVABLE
INHERITNNCE THX RETURN
FESIOENT OECEOENT
ESTATEcO,F�, T �� �'/f�� FILE NUM9ER
� � o20 � j — C�G( D �
pll proparly�ointly�ow�d wilh right of survivorship mus�be tlisclasetl on Schetlule F.
ITEM VAW E AT DATE
NUMBER DESCRIPTION OF DEATH
i � �2��
TOTAL(Also enter on line 4,Recapitulation) $ ----
Qf more space is ne¢tled,inserc additional sM1eets ol IM1e same size)
�. REv-eSogEX+(ii-io)
' � . pennsylvania SCHEDULE E
I� „�,>a,„F�,o.a��E��E CASH� BANK DEPOSITS & MISC.
mneauauce*Ax aeroar+ pER50NAL PROPERTY
esoEn*oeceoENr
ESTATE OF: ( I ,�� FILE NUMeER:
—a�01 �nv,.n �9c.<� 5 � av 1 S - 001 DZ
Indude Ne praeeds of IiFgation and the date the proceeds were recerved by the es[ale.
All property lointly owned with right of survivorship mus[be disclosed on Schedule f.
VAWE AT DATE
ITEM pF OEATH
NUMBFR DF.SCRIPTION _
�
I
TOTAL(Alw enter on Line 5, Recapltulation) ;
If more sDace is neetle0,use adeitional sheets of paper of Me ume size.
FEV-15o9E%+(oeao) �
�� pennsylvania SCNEDULE F
°`°""�"`"`a""°E"°` JpINTLY-OWNED PROPERTY
rvrEa�*nxce rnx aeruaH
PE5IDEM oECEoervi
ESTATE OF: FILE NUMeER:
5fe �� ��u�k�s ���ro� 3o»-od /Ua
If an asset became jaintly ownetl within aie Y��of[he decetlent's date of deaM,it mus[be rcported on Schetlule G.
SURVIVING]OMT TENAM(5J N0.ME(5) AODRE55 REL4TIONSH[G TO DECEDENT
A.
e.
C.
]OINTLY OWNED PROPERTY:
�£f1EP DRiE OESCR1Vf10NOFPROCERTY %Of oAiEOFOEnix
REM FORIOIHi N�FOE INQIIOENMIEOFFlHiXCWINSRNROXAN�BRHNKC011NiHIlMBERORyMIIAR .MlEOFUEFTI �Em'iEMS VRWEOi
NVMBEP iEN4M lO1M IOEMI%IN4 HIIMBFN.ATlALN DffD fOR H11NRV NEID PFAL ESTPiE. VNUE W 0.55Ff IMEESi CE�OENI'S IMEAf$!
1. P.
TOTAL(Nso enter on line 6, RefapiNla[ion) ;
If more space is neeOeQ use aeditional sheetr of paper of the ssme size.
aev-isro ex�t �os-o9)
���� ?pennsylvania SCHEDULE G
oEPr,A*MFr+*oFaE�F�uE INTER—VIVOSTRANSFERSAND
,NnEa�*A�+�E=Axa�a� MISC. NON-PROBATE PROPERTY
aesioEnr oeceoexr
ESTATE OF F[LE NUMBER
�-I��t� ���/m5 Ell� �,� a�, s - o� � :�
This schetlule must be mmpleted anG flee if[he answer ro any ot questions 1[hmugh 4 on page[hree oF Ihe REV-I500 is yes.
DESCRIPT[ON OF GROPERiY �ATE OF DEAiH %OF DECDS E%ClU90N TAXABLE
ITEM ixcwoETMExanErcme�uxsaea,mE�xuunaz�ivraoK�rrtexo
NUMBER mEonicoim+nsrm.>*rna<mrrarmEoeEnwanu�uT<rE. VNLUEOFFSSET INTE0.EST ivnauva�l VALUE
1.
�� � �
�
TOTAL(Also enter on Line 7, Recapitulation) ;
R more s0a<e is needee,use a0ei[ional shee[5 of paDer of the same size.
� .aev-ini Fx. cio-a9)
SCHEDULE H
� pennsytvania FUNERAL EXPENSES AND
�nreairnnce*�ixaEru«m pDMINISTRATIVE COSTS
Res�vevr oeceoenl
ESTATE OF F[LE NUMBER
��e�n�n ��'u� �5 Cl � � � auiS-ooi a �
DecedeM's Eebts must be re0ort¢d an ScheEule I.
ITEM DESCRIRION AMOIINT
NlIM6ER `
A. FUNERPL EXPENSES: (� � � �(J O°��
L �U pN �c�('r.J. �YSYY1 Q�Lfl o o�c e G-�
/{ � � � ( ��GD
�S'� 1�� I I V�',,,`2�C'Y� (Zn JD� cc� cf�-cl,vd. I �1 r1 S ��
Fle4a��U�.
e. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)ofversonaikevresentztive(s)__ _ . .. _ _. _ __-. --_.—
StreetA00ress .. . —�------�� — �—
City . _. .__ SWte_.. ._ZIP—__ .. —_
Veaqs)Cammission PaIG:__ _ —
2. Attorney fees:
3. Famlly Exemp[ion:pf decedenPs aEEress is not Ne wme as tlaimanPs,attach explanation.)
Claiman[
Street Atldress ___——_. .. _
City ._. .—_.__. ... . . . .—_. _ __. . —SGte- -__ZIP .___._
Rela[ionship of Claimant to Ottetlmt _ _ ._ ..
4. Probate Fees�. ^c�-� c'th�«U-Cd- � � S I��
5. Acmwtan[Fees:
6. Tax Return Preparer Fees:
].
70TAL(Also enteron Line 9, Recapitulation) { ', � �, t� ,�
��
If more suare Is neeCeG,uu aaai[ianal sheets of paper of Me same size.
RECEIPT FOR PAYMENT
LISA M. GRAYSON, ESQ. Receipt Date : 1/28/2015
Cumberland County - Register Of Wills Receipt Time: 12 :19:48
One Courthouse Square Receipt No. : 1080318
Carlisle, PA 17013
ELLIOTT STEPHEN DOUGLAS
Estate File No. : 2015-00102
Paid By Remarks: pMBRIA WINTERS
____________ __________'_
Receipt Distribution —-—-----'------------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS ADM 20 . 00 CUMHERI�FeND COUNTY GENERAL FUN
SHORT CERTIFICATE 25 . 00 CUMSERLAND COUNTY GENERAL FUN
INVENTORY 15 . 00 CUMBERLF�ND COUNY'Y GENERAL PUN
INH TAX RETURN 15. 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 35 . 00 BUMBERLANDRCOUNTYSGENER�L FUN
AUTOMATION FEE
________________
Cash 115 . 50
Total Received. . . . . . . . . 115 . 50
�wev-isiY�+:*ttz�oe)
jil pennsylvania SCHEDULE I
CSi oernarnerv*oraevExuE DEBTSOFDECEDENT�
,��Ea�r.��E*Ax aE*�=� MORTGAGE LIABILITIES & lIENS
aes�oexroeceoervr
�ESTATE 0 I /� �I—� FILE NUMBER
V�W��4 �k5 G �livl � ,�o1S - ODloa,
fteport de [s incurreE by[he tlecedent pNor M Eeath Mat remametl unpaitl at the date of Eeafh,mcludmg unrelmburced medical ezpenses
VAW E AT�ATE
��E�^ DESCRIPTION OF DEATH
YUMBER
1.
TOTAL(also enter on Line 10, RecapiNlation) ;
-aev-isi3 ex+ (oiaa)
� `^ pennsylvama SCHEDULE J
"�°'"`"T°`"`�`"�` gENEFICIARIES
INHERIiNNCE TPX PfTUNN
rvT OECEOErvi
ESTATE OF. Rf � FILE NUMBER:
o aol � —DO � UZ
RELATIONSHIP TO DECE�EM AMOUNT OR SMARE
IJUMBER NAME AND ADDRE55 OF PERSON(5)RKEIVING PROPERtt Oo Nat List Trvstee(s) OF ESTATE
[ TAXABLE D6TRIBUTIONS[Indude outngh[spouul tlis[ribu[ions an0 transfers unaer
Sec 91I6(a)111).]
i. I�.�w� Sc�-f-� t �1 �o� So� St� `��,
(�:is�. r"��-r1e �ei�e-r ���z -(�G-r�u�r s��o
ENiER DOiIAR AMOUNTS FOR�ISTftIBUTI0N5 SHOWN ABOVE ON IlNES IS THftOUGH 18 OF REVd500 COVER SNEFT,AS APPROPRIATE.
�I NON-TAXABLE DIS�RI9U�IONS
A. SPOUSI+L�ISTRIBUTIONS UNpER/�SECT/I�N 9113 FOR WHICM AN ELEQION TO TA%IS NOT TAKEN:
1. ��y�r� �Gd� l�1 � 1 ��
� SG �-'Ct P l��'<�-
9. CHARITABLE AND GOVERNMENtAL�6TRIBIf�I0N5:
l.
TOTAL OF PART II- ENTER TOTAL NON-TAXp6LE DISTRIBUTIONS ON LINE 13 Of REV-1500 COVE0.SHEET. F
RE",�,°E"*0�°" � SCMEDULE K
LIFE ESTATE, ANNUITY
COMMONWEhLTHOFFENNSYWANIN & TERMCER7AIN
INHERITANCE TA%RETUFN
aesioeNl oEc[oeNr Check Box 4 an flEV-0500 Cover Shce�
ESTA7E OF ��� FILE NUMBEH
S���1�]��s��i�l I i �fi � D � � - v o � � "Z
This schetlule is to be usatl for all single life,loint or successiva life estate antl�erm certain calculations For tlatas oi tleath pnor ro 5�1-89,
aRua�ial fac�ors fo�single life calcula�ions can be obtained from ihe Departmen�ot Revenue,$peciatly Tax Unit.
Actuarial(actors can be found in IRS Publication/45],Actuarial Values,Alpha Volume for dates of death trom 54-89 to 4-3099,
antl in A1eph Volume for dates of tleath from 5-1-99 antl thereaiter.
Indicete ihe rype of instrument which created ihe luture interest below antl atlach a copy ro the tax retum.
❑ WIII ❑ Intervivos Deed of Trust ❑ Other
. .
NAME�S)OFLIFETENANT�S) OATEOFBINTH NEFPESTAGEAT TEXMOFYEIIRS
DATE OF OEATX tIFE ESTATE IS PAYFBLE
❑Life or 0 Term of Vears
❑Lite or O Term of Vears
❑Life or �Term of Vears
❑Life or �Term of Vears
❑Life or 0 Term of Vears
1. Value of funtl trom whic� life estate is payable . ... . . . . ... . . . . .. . . . . . ... . . . . ... ... . . .. ...$
2. Ac[uarial factor per aPPmPnate teble .._ .. . . _. .. . . ... . . . . .. . . . . . .. . . . .. ... . . . . . . ... .
Interest table rate- O 3 1Y2% ❑6% ❑ 10% ❑Vanable Rate %
3. Value of Ilfe es[ete(Line 1 multiplletl by Line 2) . . . . .. . . . . ... . . . . . . . . . . ..... . . . . .. ... .$
. �
NAME�S)OF IJFE ANNURANT�S) DRTE OF BIHTN NEAHEST RGE AT iEpM OF YEAPS
OATE OF DEATH ANNVITY IS PAYABLE
� ❑ Lita or O Term of Vears
❑Life or O Tarm of Vears
❑ L'rfe or 0 Tertn ot Vears
❑ Life or �Tertn of Vears
1. Value of fund hom which annuiry is payable . ... . . . .... . . .... . . . . . . . . . . . ... . . . . . . .... . . .$
2. Check apPropriate block 6elow and enter wrzespontling(number) . ... . . . . ... . . . . . . ... . . . . . .
Frequency of payout-O Weekty(52) ❑ Bi-weakly(26) ❑ Monthty(12)
❑ �uanerly(4) ❑ Semi-annualy(2) ❑ Annualry(1) ❑Other( )
3. Amoun�ofpaYout�erPeriotl ... . . . ... . . . . .... . . . . ... . . . . .. . . . .. . . . . . . . . . . . . . . .... . . .$
4. Ag9regate annual payment, Line 2 multiplied by Line 3 ... . . ... . . . . ... . . . . ... . . . . . . . ... . . .
5. Annuiry Factor(see insVuc[ions)
Interest table rate-O 3 1/2% ❑ 6% O 10% ❑ VanaWe Rate %
6. Adustment Factor(see insiructions) . . . .... . . . ... . . . . ... . . . . _ . . . . . .. . . . .. ...... . . . ...
Z Value of annuiry- H using 31/2%, 6%, 10%,or if vanable rafe and period
peyou�is a�end o�period,calculation isr Lirn 4 x Lire 5 x Line 6 . .. . . . .... . .. . ...... .. . ...$
1t using vanable rate and penad payout is at beginning ot penoQ calculation is:
(Line 4 x Lirre 5 x Line 6)+Llne 3 ... . . . . .. . . . . . . .. . . . .... . . . . .. . . . .... . .. . . .$
NOTE:The values of�he funtls whic�creale ihe above tuNre in�erests must be repotletl as part of ihe estata assels on Schedules Athrough
G of ihis ta<return.Tha resWling life or annuity interest(s)shoultl be repotletl at the appmpnate tax rate on Lines 73 and 15 ihrough 18
Qi rtrore space is neeGed,insen atltlitional shee�s of�he same size)
qEV161dE%.�1°°� INHERITANGE TAX
SGMEDULE L
GOMMONWEALTH OF PENNSYLVANIP REMpINDER PREPAYMEM
�"aEsioENrEo cEOEi+°iN OR INVASION OF TRUST PRINCIPAL FILE NUMBEk ZL I} - ��C>I C Z
L ESTATE OF � � � �
(Last Name) (Firs[Name) (tAtlLle IniUal)
7his schetlule is appropriate only for estates of decedents dying on or betore Decamber 12, 1982.
This schedule Is lo be used for all remaintler retums when an election to prepay has been filed under the provisions of
Section 714 of Me Inheritance and Eatate Tax Act of 1961 or to report ihe invasion of tmst principal.
��, REMAINDER PREPAVMENT:
A. Election to prepay(led wiM ihe Register ot Wilis on
(Date)
B. Name(s)of Li/e Tenant(s) Da�e of Birth Age on date Tertn oi yeare income
or Annui�ant(s) of election or annuiy is payable
C. Assets: Complete Schedule L-1
1. Real Es[ate . . . . . . . . . . . .. .. . . . . .. . . . . . . . . . .$
2. Stocks and BoMs . . . .. . . . . . . . . . . . . . . . . . . . . .$
3. Cbsely Held Stock/PaMership . . . . . . . . . . . . . . .$
4. Mortgages antl Notes . . . _ _ . . . . . . . . _ _ . .. .5
5. Cash/Miu. Personal Pmperry . . . . . . _ _ . . . . . .$ "_
6. Total from Schetlule L-'I . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . .. . . . . . . . . . . . . . . . . .8
D. Credits Complete Schetlule L-2
1. Unpaitl Liabilflies . . .. . . . . . .. . .. . . . . . . . . . . . . .E
2. UnOaid Be9uests. . . . _ . . . . . . . . . . . .. . . . . . _ .y
3. Value ot UninGudable Asse[s . . . . . . . . . . . . . . . . .$
4. TOtal from Schedule L-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .
. . . .. . . . . . . . . . .$
E Total Velue of trust assets(line C-6 minus Line D47 . . . . . . . . .. . . . . . . . . . .. . .. . . . . . .. ..$
F. RemaiMer faMof(5ee Teble I or Table II in InsWclion Booklel) . . . . . . . . . . . . . .. . .. . . . . . ..
G. Taxable Remainder value(Line E x Line F� . . . . _ . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .$
(Also enteron Line 7, Recapdulation)
�. INVASION OF CORPUS:
A. Invasion ofcorpus
(MonN, Day.Year)
8. Name(s)of Life Tenant(s) Dale of Birth Age on date Tertn of years inmme
orAnnuftant(s) corpus orannuityispayable
consumed
G Corpus consumed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .. . .8
D. Remainder factor(see TaMe I or Table II in Insiructbn Booklet) . . . . . . . . . . . . . . . . .. . . . . . . .
E. Tana6le value of corpus consumed(Line C x Line D) . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .$
(Also enter on Line 7. Recapdulstion)
REV-1646 E%+ (l l-09)
�� pennsylvania lNHERITANCETAX
o ,.a,„ , . SCHEDULE L-2
wneannrv�er�xeruen REMAINDER PREPAYMENT ELECTION
aes�oeKroECEOEn�
-CREDITS-
I. ESTATE OF FILE NUMBER
II. ITEM N0. DESCRIPTION AMOUNT
A. Unpaitl Lia6ili[ies Qaimed against Original Estate and Payable from Asre[s
Reported on Schedule Ld (please lis[)
Total Unpaid LlabiGties -$
(indude on Section II, Line Dd an Schedule LJ
B. Unpaid Bequests Payable fmm AsseGs Reportetl on Schetlule L-1 (please list)
Total Unpaid Bequests $
(indutle on Sec[ion II, Line D4 on Schetlule L]
G Value of Assets Reported on Schedule L4 (other than unpaid bequests listed
under"B"a�ove) that are Not Included for 7ax Purposes or tha[ Do No[ Form
a Part of[he Trus[.
Galculation as follows:
To[al Non lndudable Asse[s 5
(include on Section II, Line D3 on Schedule LJ
III. TOTAL (Also enter on Section I[, Line D-4 on Schedule L) g
If more space is needed, attach aAditional sheets of paper of[he same size.
aeH�sa>ex. (azao�
;5"i� pennsylvania SCHEDULE M
i��, oF �a.«Er. �aE�c��F FUTURE INTEREST COMPROMISE
INHEftRANCE TAX FETIPN
RESIOENT OECEDEM (Check Boz qa on REV-aSaoJ
ESTATE OF FILE NUMBER
This scheEule is appropriate only Ior estates of tleceEents who dieA aker Dec. 12, 1982.
This schedule is to be used for all fu[ure interests where the rate of tax that will be appiira6le when Me Future interes[ves[s in
possession and enjoyment cannot be establishetl with certainty.
Indicate below the type of iretrumen[that created Me Po[ure interest antl attach a copy to Ihe tax return.
❑ Will ❑ Trust ❑ Other
I. Beneficiaries
NAME OF 6ENERCIARY REtATIONSHIP DATE OF BIRTH AGE TO
NEAREST BIRTHDAY
I.
2.
3.
4.
5.
II. Por decedentr wha died on or aRer]uly 1, 1994, iF a surviving spouse exerdsed or intends[o exerdse a right of withdrawal within
Nne months oF the Eecetlent's tleath, check che appropriate box below and a[[ach a mpy of the document in which che surviving spouse
exercises such wRhdrawai nght.
❑ Unlimited rigM1t of withdrawal ❑ Limited righ[of withdrawal
III. ExO�anation ot Compromise Offer:
IV. Summary of Compromise Offer:
1. Nmountoffuture interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . $
2. Value of line 1 exempt hom taz as amounl Dassing to Uanties, etr. �
. (N5o indUde as part of total Shown on Line 13 of REV-1500.) . . . . . . . . 5
3. Value ofline 1 passing to spouse at apPropriate tax 2[e
Check one. ❑ 6%, ❑ 3%, ❑ 0% . . . . . . . . . . . . . . . . . . . . E
(Also intlude as part of totnl shown on Line 15 of REV-1500.)
4. Value ofline 1 taxable atlineal 2te
Checkone. ❑ 6%, ❑ 4.5% . . . . . . . . . . . . . . . . . . . . . . . . . . Y
(Also indude as part of total shown on Line 16 of REV-1500.)
5. Value of Line 1 Wxable at sihling 2te(12%)
(Also inclu4e as part of total shown on Line 17 of REV4500.) . . . . . . . . $
b. Value of Gne 1 [axable at mllateal rate (15%)
(Alw intlude as part of total shown on Line 18 of REV-150a.) . . . . . . . . §
7. Total value of PoNre interest(sum of lines 2 Mru 6 mus[equal Line 1). . . . . . . . . . .. .. . . . . . . . . . $
If more space is neetled, use additional sheets of oaoer oF the same she.
RE0.1849 EX+(�8-0B)
�� pennsylvama SCNEDULE O
�NHExrtnrv[ETn%ESHEfUPN ELECTION ONOEH SEC.2vf3(A) .
NESmEM oECEOENr (SPOUSAL DISTRiBUrIONS)
ESTATE OF FILE NUMBE0.
Do na[ complete this schetlule unless the es[ate is making Me election M bx asuGs untler Sectlon 2113(A) of Me InhaNtnnce antl
ESWte Tax Ac[.
If the election to more than one trus[or similar armngemenq a separate form mus[be Bled for each trust.
This eleaion applies ro the Trus[(manbl, re5i0ual q B,by-pass,Unifed CreAit,etcJ.
If a[rust or simllar arrangement mee[s the requirements oF Sec[ion 2113(A)and:
. a.The trus[or similar artangement is listetl on Schetlule 0 anG
b.The vaWe of Me trus[ar similar arrangemen[is entered in whole or in part as an asset on$rhedule 0,Men Ue transFemr's personal representa-
� tive may specifically idenUry the tmst(all or a fiactional portion or percentage)to be intlu�e0 in[he election to have such trus[or similar proper-
ty trea[ed az a baable tansfer in this esWte.If less than the entire value of khe trust or similar property is indudeC as a trxable t2nsfer on
ScneCule 0,[he personal representn[Ive shall Ge wnsitlereC ro have maGe Me eleWon only as to a fiacHon of che lmst a similar armngement.
The numea[or of thk Faction is equal ro the amount of Me[rust or similar arrangement intlutletl as a dxable aae[on ScheEule 0.The denomi-
nator is equal to the[otal value of Ihe tmst or simi�ar arranqement.
PART A:Enter the descnption and value of all interesGs, both Wxable and non-taxable, regardless of location, which pass to the
decedent's surviving spouse under a Section 2113(A) trust or similar arrengement.
oesv�mwn vmue
Part A Total $
PART B: Enter the description and value of all interests induded in Part A for which the Section 2113(A) ele[tion to tax is
being made.
Deunp[ion Value
Part 8 Total $
if more space is needeG,use aGdiGanal shee6 of paper of ihe sartre size.
. ?Ev-ti�26.- -_ -_
�. pe�nsytvama SCHEDULE I
�_�--_�--•�_•-= DEBTS OF DECEDENT,
_ - �-•���-{'• MORTGAGE LIABILITIES & LIENS
iSS:C9T 5�'
ESTFTE 0 /� �y FILE NUMBER
��PI�IXM���GS G '�loll aal � " OZ>� oa,
Report Ee ts incurred by the decedent prior M death that remained unpaid at the date of dea[h,intluEing unreimburs¢tl meElal expenses.
i iEN VAWE AT DAiE
ryp,u,g.� pESCRIPTION OF pEATH
- '���� ���wP a�c� ,a y
a> ��..�,A_a-m_A��ku� so .ov
Co��a,� Q �-`� l �3' r�
� ��-�p-�- �\c�k�r� �-�S�.-d.�a�
�r�, ��`_�hL�tYlhAlL.'�� �0�� ��`6�� 5 � �1�
�" �� �� 333`l . �
;
TOTAL(Alm en[er on Line 10, Recapitulatlon) ; � � !� ' . a �
IF more soace is neeAed,insert additional sheets of[he same size.
FEV-15�9Ex+(a1ao7
',`�'pennsytvania SCHEDULE F
oeranrnExrovaEveNUE JOINTLY—OWNEDPROPERTY
IIVHERiI/NCE TAX RFNRrv
RESIOENl�ECEO�
ESTATE OF. � FILE NUMBER:
S+e� � J��:.��.��5 CII� oTf a�� �- �d iva
71 an asset befame jolntly ownetl wkhin oM year af the tlecetlenPs date af dwth,it must be repoKaA on Schedule G.
SUHVMNG]OIMTENANT(5)NAME(5) ADDRESS REIATIONSHIPTOOECEDENT
A. I�.y� C"Y-1CC Q 0`5 �1Yil`,d-�moT-� {Zc�
V s�.,�'�.�.,� G'k �-� a�5� �� �--�
B.
C.
]OINTLY OWNED PROPERTY:
�a onh oESouanat�oFva�� tio� �a�o�oFnN
ICM l-00.10IM MApE INQUOEWUIECFFlIUNCNLIHSTII1JfIqiAXCSIVtI:_�h-`:_w��pa5:Y1N: WCOFOFPiH CE@E\'-" YqWEOi
NUMBER IEWW! IpIM IOEMIMfIyGN11MPIX�1.ATIOLFIp�iOtpl�_•�.v4E'AiE tiµt¢CFAS¢T IN-E� .�' _;�TFIrt51NIFABI
i. n. �y GCl2iC�1- F� vEfu,f '(a'.irin[�S �: Tl- TJ- T�
� O �oo(e 2�3 .a �eP��� v a3 �i s�- d�' N .c`t)
.� e ` o(� 1/.c.u.d.cJ�,a.(��C�Lt,�n.�_ J� e�e .�r� �- %Cca �*�
;
� I
� 70TAL(Also enter on Line 6, RecapiNlation) ;
If more space is needed,use addiHonal sheetr of Dapu of the sam¢sixe.
1 -•
aev-.sae Ex.t,.-.o)
� ; pennsylvania SCHEDULE E
�-� oEP.a,�E.*o.aE�Exoe CASH� BANK DEPOSITS & MISC.
� �^�E"�T^"�E�^""ET"A" PERSONALPROPERTY
PESIDENi�ECEDENT
ESTATE OF: , FILE NUM6ER:
��o��l��.,� �e�.��� � �� � �� 3� i 5- oo i aZ
�� Intivee the Dmceetls af litlgatlon ana[he Gate Me o�ceetls were re¢ivcd by the esta[e.
RII prvperty jaintly owned with right of survivarship mus[be Aiulosed on ScheEule F.
�TEM VALUE FlT�ATE
N I�BER DESCRIPTION OF DFATH
�l�� i '��'/��MIG �- ��.&'.'C.^L� QC�.�!aC �l
i � �' -L-
(;1 j��:tt_ C i%C-'J,l�iCt,t �nl .� .SZJi� ()
� ' f�_�-� `"`zC-`
�
i
I
TOTAL(Also enter on Line 5, ReppiNla[ion) �
� If more sparn is needed,use additional shee[s af paper of the same size.
aLON1A6YY1NiFA& o,-,� 282
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FG GO
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FIOELITV INVESTMENTS 5183.�2 r�m�wcn cem�.e.,re.
INSTCTUTiONAI OPERATIONS C0. -_--
100 MAGELLAN WAV I(W1C miu�w.am�wn ❑ ioui � Cupyt
COVINGTON, 1[Y 41075 roi .m.a n.i.w�„ fiw�numpynilM1
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� �C4PITAL TAS COLLtCIIVN tlUKtAU
19 S HASO\"ER ST STE 102 Hartisburg Division
CARLIAE P4 I'Oli-i366 2301 North Third Stree[
Harrisburg,PA 17110
Phone: (717)234-3217
Carlisle Division
19 S. Hanover Street
Cadisla PA U013
Phone: (717)'d3-3P_5
..:...:._.......AETO••:_DIGIT i- ' In: �OJ I68i2
_el�'3-9G>t0iT8' ];?IO Fcrz!`-:
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48 �10]iG0\fERti'A\'E
SHIPPENSBURG PA 1-'�--?6'_8
I���III���I��I�I�I�I�I���I���II�II����I�II��I��I��II��1�1�1�,1
You can now file mdre! r<`ya:wou�tl like to 5�you:reNm online, please 90 to www.caotaz.wm and click
or .,'+e YNe. H Fheg adnt 4 s very �:rr�par'an; t^a: Ya have lhis form wilh you since it wntains your
P�s�rai ifAinScaoo�n Mnn� �PIN) �N:rl� is oeea?tl So �e online. This PIN I5 unique to a laxpayer antl
arro�oe.se�Ri C�e��aye�s spase. Nsc r^.�: ar onrv file vour 2070. 2009 and 2008 retums ontine;
a, � -e¢r�u � ae �oieea irar�y I` :.a. �'are a balance tlue with the online filing, you vnll
�,P 7cvv^s n-a.z Y�•+•er.r¢'a��
'-¢a�¢ts�n s .w asaa�eC.� "vTMe oca eam�c +ncorrie tax (Eln. This taz is used ezcWsively
_a ya,r muew,�tp�:�. z�rarvC s xr�._r� �s:ca dstrict. This tax is diHerent ihan Ne federal and
g= � renve gss a^� e^a 2� ✓». ?wc :ases o! income. both of which are "Eamed": 1)
��IiP�6s-.-+7a aE 3. �E' �CY"5 �r :'� x a:,� of a business, profession or farm. Passive
rm..r a��s�C a r�.�c lvtle[s a�ta�rs � �9ntal income are no�taxable.
• ra. � 3:rrs x'^� �rre�- 9'�=��^t s.-__� ;s��s in our iunstliction where Ihe �ax ra�es are
�`�'•t ya,rif•ec t 5e s�ar� —:r^s .�.- � "-r ac resi0ence where there are different tax rates.
�al.i� 'aa�le' +�,rE �n.6 be free a -e za-e ---- 'a:z To view ihe tlifferent tax retes, visil our
UP2B!Q f�VE Cf dt^uAftYv�.
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It you are eRher seH-empayea�or are errn+., ��o. r a-cr..v=r IDat tloes nof withhold the correcl amount of
EIT, you are required to oay the taz �atpry 'c ar v�u We make every attempt lo identify Ihose
tazpayers in this categary arA mad L^zr!^rt:cce' ca,Tr' stubs. However, if you ft in this ca�egory antl
you do not receive payrt�ent coupor.s �.�xas "� _ =n-�� tst. please conlact our offce antl a ret will be
providetl. Please rerrember. the iaW:e c`a*rc�•e"_ •e��re the orooer forms does not allevia�e his/her
resoonsibiliN for am reauired filinos a^.4 x:ar^iz'� �2�
If after reading ihe er.Gesed inslructions ycu s^d�^a�.e a o;�sGon regardin9 your retum,contact one of our
offces and we vnll te happy to assist yw.
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5 TOTPLTPXABLEEARNEOINCOME(Atltlllre53antlC) ���a � �
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14 �iIAftTERLYPAYMENTS{WPWEVS'-=:ARS@.E2�/YAE���—'�='SYFTR 1 .. � . J���"�-
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15 CER➢FlED RESIOENTS OF THE HARi'<i1i�i��'�tE OPoJft-:M'„ZJNE KOP.
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!J OVERPAYMENTTOBECREDREOTGN:X'�Ea4E'aX i> �
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-�9>WSE'S NAME;SIGNqTURE,AND OTHHtlFOI�\1101151101A0 BE PRONOED�WRY IF�ME OR SNE IS�1150 FlLING ON THIS FOflM.
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VNDER PEJLl4�g#R�R1UR�r I OECLqRETHAT I HAVE EXAMINED THIS pETI}PN'ANU.YGCOMPANYIN69CNE0�1ESqNCSry!"(EMENTS. . .
AN[tT07HE8E5TOF.MTIQ10Wt��.EDGENNBELIEF.THEYARETR�IE.CORkEGT�:ANDCONPlETE. �.:'�. � •�-:., .
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CUMBERLAND COUNTY TAX BUREAU - -� - � � � �� � —
23 Watertord �r.,Suite 2�1,Mechanicsburg,PA ll050 :. _ ..
PHONE: 717-590-7997
weasrte�. www.mmxr.znsax.crz TAXYEAR ZOS4
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STEPHEN ELLIOTT pieaze msir v,ww.�vmeenanErazorg�or me i'ink
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vOU MU57 rJ\ TAXPAYER A 55 H XXX-XX-7581 T/P A- NAME i T/P B-NAME i
COMVLEfE �✓ 7pXpqYER B SS N
1.Gross Earnings from Employment Endose W-2s 1
2.Allowable Non-Rei-d;rsed Employee Business Evpenses Enc c.e ps sm ue 2
3.0[h2[EarneG'N-..�'= - -- ---- "'L/3099-R&tlutling C00E5 3A 4�� 109}C j
__ .-'...,__.,,,1?EaES',DIVIOENDS OP CAPIS4_5= 55
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9.Tn�mdiq _ _. -. .: ,_;. _� _ _ -. ". ___ _ 9
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Il Worteriy Esana[ed PaY�W���From Preyious Taz Vear 11
12.MiscGedit seewo t. �-:=. .-z=- ; - -:__'-_- �� 12 ... .-. . .. ... - -
13.Total o�10,11&Sz i3
14.REFUND/CREDIT sub�acc.rs:`-�- .:re3 '.�Te:P-,c�e:re-5: :: r-ramoune 1a
35.CPEDITTONE%TYEA0./CREOITTOSPOUSE 1..�.�•s ._. _—_ ❑ 15
16.TA%DUE i(�^esis3re�=r,r.;=��_-�z3-scbmzr.cne'_3-e- _-e? 16
NOTE Fmoun6 of 51.00 or more musi be paitl.
1l.PenalryakerApri115[h SE'�55iRUC"i0�u5 i�
IB.In[ere5take�Apr1115th iEE��mSTRUCTiONS SB
19.TOTPLAMOUNTDUE ❑-�elEplus�ineliplusLineie 19
MAKE CHECKS PAVABLE TO CUMBERLAND COUNTY TAX BUREAU.A FEE OF S20.00 WILL BE CNARGED FOR RETURNED CHECKS.
i a�ca�e��..e�x-.a�.es o�=e,i�.,rau ea�re e,am��ee m�:,em��am m;-x_a:,--.��owieaae a�a eerei,n��:a v�e,aa��a�e a�a�omr.�= �.���.
Si naiure-Tax a erP oace ocm acion E-Mail oa merele none
Si naNre-Tar a erB Da[e Ocm a[ian E-Mail Da imeTele M1one
Gre a 'sName Atldress PleasePrint Pre are�'sTele M1one
Tdxpaye�0:
-� �. ..-,. _. _ _.. zSC . ordomicile. lfyouand/oryourspouseM1avemovedduring�betanyearpleaze. , - -
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..�^(� . ..__: . =.dtofileasemndeamedb me[axreWmaslongazfhemove-nbrma[on�spmvtledb I .. a.._an-_
,+vmw'i. rv .. r% : -. , . -=z;hmur.icipaliryusing[beworksheetbelow.
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a�ane�a��.^s. +eC tlie cumEerland County Tax aureau antl with Me tax colleccar(or the non-member muniaipality/scM1ool disencx. ?ceese
.�a++e�ur^^mmamty/schaal disvici eamed inmme tax return with the Ccie eamed inmme nax return.
� Ciry/Sta[e/Zip Muni[ipaliry Re5itle0Fmm RestletlTo -r -.
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EMPLOYER SOURCEOFINCOMEINFORMATION
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officc locations are shnwn under tlie mlumn to Ihc riehl entilld "IF NO Paament or NO Refiind'CrediY'. Mailin� address lubels arr alsn
prorided on repk envclupe inc�ludcA in Ihu (orm packei. I(the�� nre missina please eAdress }our liling lo ihe miTeel Division und moilin_
addrees a�tlescribed bclo�c. Therc are i dislind 'zddiesses for mailing your rctun��sl b.a<d on whelher cou nre(I) makin�e tos pucnient �ciih
cnur relum.(2) rcyucsiin_a ta� re(und or<redil on �our reNm, or �3) flina wur reWrn witl� no puymeni or refunJ requetii. If a pa��ment Is
.ndoscd �ci1h ��nur reiw'n us. tlte "NAYMENT GNCI.OS6D" addresslubel cven il�our spouse is nlso flin� un the same reNrn ond has u
rcliinJ atdll nr no paymen� or nu rcliinJ'acdll. Likc�risc u REI�UND�CREUI C labcl aJdres mkes p�rcedence over u "No Pa��nteit� or NO
Rtfund'GeA iY'spousal situation.
The Harrisbur� Division serves resideNs oflhe Ibilo�ein munici�ives
._.. __ ._____
DAUPHIN COUNTY NERRY COUNTY JUNIATA COUNTY �
_'. —_ _
Ilanisbur Ciry ReedTm�nship AIIMunicipaliucs GreenHood lownship
Hiehspire Borouph � Steehon Borough
Final Retums(Form i3 U for residents ofthe municipalities directly above should be mailed�o zppropriate address as shown belo�s:
If PAVMENT Enclosed: If Requesfin�REFUND/CREDIT: IfNO payment or NO Refund�Gedit
C4PITAL TAX COLLCCTION BUREAU CAPITAL TAX COLLECTION BUREAU CAPITAL TAX COLLECTION 6UftEAU
PO BOX 605J i PO �OX 60689 _'i0 i N 3"O ST
HARRI�B�RG PA I"'G6-05J.' I�LARRISBURG PA 17106-0689 HARRISBURG PA 17I10-1893
The Carl-�Iz R•i.�on srnr .���o's ofthe follo��in�municipalities:
� Cl?IBERL4�DCOl'�Tl FRa]KLI� COl]Tl
'�. Carlisiz Bunw_h y t'.'_c ? . S.>e.�,es ' . r-^..,. = '- O �r 9:•au__
I Cooke Toansh:^,. �E. H�:;�. Xt . -�B..�..-.>h Pr*� : �.��....�._ _ _ ' _ "
' Dickinson T w=s^.I: ^.:�. = 3.Y�a.� � ,.� - _ _ " _' _ ' _ _ _- _
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Thr Crn�ii Daap.+hirz Di�aacw ser.es reside�ts of the fa�aic municipa'veies_
� DAIPHI.\ COC�T
, Pa�mr.e Bcrou� Prnlwecv:Borcwgh R z�t Hano�er To��nship �
Fina; Recums IForsn 5?i 1 tw r:sidznt�fthz muni.ipalffia dirzcd� abo�e should be mailed to appropriate address as sho�cn belou:
IfPA\'NE]7Endosed.- I(RequtstineREFWYD/CREDIT: IfNOpaymen�orlVORefund�Gedit
CAPITAL TAS COLLECTIO� BIREAC CAPITAL T:IX COLLECTION BUREAU CAPITAL TAX COLLECTION BUREAU
PO BOk W77 PO BOX 6626 425 PRINCE ST
HARRISBURG PA 171 I'_-Oi77 HARRISBURG PA 1711?-0626 HARR158URG PA 17109-1734
LOCAL EIT(SCHEDULE P)-PARTIAL YEAR RESIDENT PRO-RATION WORKSHEET
Special Note: A[ the \'ERl� �IIVI�fUS1 �ou should romple[e all the applicable shaded sec�ions on the Schedult P. It}ou ha�z prebiem�
completine sections �hat reyuirc calculations. file cour total annual figures on the i31 final rzlum and ��z'll do [ht pro-ratien basr� en :nz
informa[ion you have procided in the shaded bbcks. Otherwise,complere alI necessan sections�shaded& unshadedl and teel frre m gi�e m�a
call with am�questions.
Instrne[ions: Use one (I) Schedule P per ta�pa�er. Partial year residents must file a retum �cith each tac offce of the area cou residzd in
durin�[he pear. Unless [he employer provided separate W-2 f'orms 1'or each area of residence. pou are rcyuired to pmrate earnines. ne� protits.
and unreimbursed business expenses. and �ac �cithholdines based on the number of mon[hs(or dacs)you lived in each area and tl�e number of
months (or days) you worked for each emplo}'er. You musl also prorate anc olher [asable inco�ne and �our business ne� pmfi�lsl los>Iz-i.
Complete (he workshee� lo derermine your prorared ta�able income (or each location andior different tac rn[e. Whtn calculating wur pm-
ration percentages(°/a). be sure m onl} use like daps as found in Ihe rows(W-2 Wa_es.Other Income. Net Profit& Net Loss)and the columns
(Location/Rale). Number o(Months: Count as a tull month any pattial month [hat �ou moved into prior m the 16'�' of Ihe month. and am
partial month that �ou moved oul o(after Ihe I>'° ol�he montl�. Use [his same lo2ic In calculalin� manths worked for each emplocer. This
ivle is generally permifled, however. ifthe o�her m,c officz you're required lo file wifh tloes' not accept Ihis me�hod. or iftax rates dtfTer in the
nmas you lived, you may be reyuired �o use a pro-raiion method m the da�e versus[o the momh. W'e will advise you and adjusc your remm if
this is the case.
VPLIVATE�bY THE BUftEAU. TO HRVE YOUR COP\'VALI�ATED AY MpIL
RETURN 90TH iHE BUHEAU'S AND iPXPAVER'S COPiES ALONG WITH A SELF
ApDRL55ED STµ1GED ENVELOPC.
www.ca tax.com
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0 TA%ABLE W-2 EARNINGS LESS EBEs(Suplrac�Line 2 imm Lme il II
0 OTHER TP%ABLE EARNED INCOME INO INTERESi OR�NI�ENDS�,LiST Tvc= .
5 TOTNLTAXABLEFARNEDINCOME�Atltlbr=_s3aru^<i -
6 NET PROFIT FROtd OUSINE55 PRCFcSE:0502=:iN A- c Fs..a '. _a-�r==_— _ -__: - .o: .
NETLOSSES�..FftG!BJSMEccv4nc5c'Jh]?-4V -- - - _ - - __ - _ �..
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' CERTIFIEO RESIDENTS OF T4E HARRISBJRG 1(EYSTONE OPPORTUNfiYZONE KOZ� �
15 TOTALWITHHOLOINGSdPPYMENT5�A04Line513.19dnOt5) -
1i TA%BAUNGEDUE(SubVacLLnet6fmmLlnel2)PAYMENTNOTNECESSARYIFLESSTHANStAO i� .
_ _
�p INTEREST&PENALTY(Se^Instmtlions) ie �
"s RETGRNSFlLE�AFTERTHEDl1E0ATEM4YBE5UBJEGTTOAD�ITIONALGO5T50FCOLLECTION 's � � .Zp,Q�, .'��
2;�TOTAL BP'.ANCE DUE�Atlo Gnes tZ 1 B antl 19)Make cM1eck payable b"CTCB" Place Socal secunly NumDer on Chxk m . . �
' �'�TR==�'MEH* Ss.z.:Dre!2hamLinei6)IFLESSTHANZERQENTERZERO i� �
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Op raxeiceurqunreae.�rt���:jr ���� ,,;;;.�.� :�� . ELLIOTT STEPHEN
3 3 1 773 7905 �. G7HFC �„{r�wwroo�m,
8 awus€serceaecountr+i��l��,,yPW3CiRMD Ff S�WE
.. uxufEil�ix ?'s-r,,�44r,kMer.w
.�,�.M�y,e,,,�� 38 �10\TGOMERY AVE
M���� o � � .�E§ �Y�D SHIPPEISBURG PA 17257-1628
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760 E.Washing�on SL Chambers6urp. PA 17201 CAR�NUMBEF $ECURfTY CODE
� 3a931 p�,�OUPlrTOBECHARGEDTOCRE�iTCARD E%PIPATIONDATE
oosaze AMOUNT PAID: $ $
o�o� PATIENT NAME: STEPHEN D ELLIOTT SIGNATURE
ACCOUNT NUMBER: H00053340337
pu�lldl�ld��lulh�ir�muuq�n��uldihuh��id���,hl hh��p�pqurliPrPd�ry����id����pqi��nhli�w�llrb
STEPHEN D ELl10TT GHAMBERSBURG HOSPITAL
708 BAL7IMORE RD 760 E. WASHINGTON ST.
SHIPPENSBURG. PA 17257-94ffi CHAMBERSBURG, PA 1 7201-27 51
3693 YT9 N�W�ri4Z000481
{TAUI�� L L:L'RNiOP CF I"' i . .,.
� . .�
FINAL �7�:�►plrylt:���;
Notice Dade: 0126/15
$ Pa6ert tiane: STEPHEN D ELLIOTT
- Accwi Nunber. H00053340337
"s $enice pate: 10/0?J14
Balarrx Due: $26fi24
Yar axaak balar�ce�The Chambersburg Hospital is overdue and will be
placed wilh a mlection agency if paymeM is rot made within 14 days. It is
vnportant that you respard promptly to avdd tivs overdue account being
reflecLad m yotr aeQt hsYory-
For yoir�, re dder the opom of payn�rt by the major credit cards
sfws�a6aie. Nso.peynieet maf be made ariv+e at www.summitheatth.org.
If yov�have yueslions corkenilfg your accarR ar would like to dscuss payment -
arrangements, please call us at (71�267-7129. option 2.
If payment has been forwarded or anan9ert�errts aheady made, please disregard
this notice with our thanks.
SEE BACK FOR ADDITIONAL INFORMATION
HIGHMARK D
�����d.��,.r����'�
ABOOT YOUR AOSPTTAL BILL �
Our Pazient Accomu oftice is open for yow conveuience during the follouing houn: y h.
Monda tci i'hursde 8:00 AM m 6:00 P�i
Frida 8:00 AM to 4:30 P41
Saturda 8:00 AM to 12:00 Noon
Call us et(717)267-7129 or(717)267-7169 if you have quesGons about yow biil or if you'd like to requesc ss:_._at� �
If we eie wable to enswer becauu we are helping other panents or ifyou are calling after business hours,pleau te:^s u��
We will reNm your cell as soon as possible.
We are also available to help you in person at 760 East Washington Street,Chambe=sbwg,PA. We are locarec a e;.,ci� .
campus,and parking is convenien[.
Yow bil]covcrs ihe wst of nu[sing and tecWical services,supplies,equipment,and facilities used for your cz�e. _��s+�'"..
bill your insurance compauy. You will only receive e bill iE ,
! a balance remains after your iosurance company has paid ��
! payment is not made in a reasonable emomt of time
J your insmance company requested infortnation from you that wu not provided,such as coordinatiov of br.r:`_ a a-aoa
questionnaire
� ✓ yoar caze is not covered by insurence
P6ystcfan Charges
Physician chazges for emergrncy room care and EKG readings are included on your hospital bi1L All other physician chazpes.�,s �
radiologists,anu[hesiologiscs,pathologists,cardiologists,hospitalists,family physicians,and specialis[s bill separatety:a aea�+�a:
Below are phone numbees oftm requested.
Charnbttsb Anesthesia Associates 800 827-3458
Chaznbersbur Ima in Associatw 717 263-1383
Chambersb Patholo Associates 800 210-7345
Summit Physiciau Services 717)263-9555
Peyment OpHons �
Patients may pay by cash,chxk,or credit card. Credit card payment is accepted by phone,mail or in person.Uninsured pa[ients are offa�
a pmmpt pay diseount of 35°/if the'v hospitel bill is paid within 30 days. The discomt is bazed on roral charges .
If a patlen[is unable[o pay the endre bill a[once,we offer interest-free payment opqons. ]f a paymen[plan is necessary,i[is importan�
that you contact us to set up an agreeable aaengemenL Below are payment guideiines. (We have the ability W set up auromatic paymm:
that are deducted out of your checking account each month ifyou wish.)
Accomt Balance Miuimum Monthly Payment
525 to$250 $25.00
5251 to$1,000 $50.00
aioo� waz,000 s�oo.00
$2,OOItoS3,000 5�50.00
�s,om ro sa,000 azoo.00
sa ooi �o ss o0o azso.00
55,000 and above Please cal us to �scuss a
payment plen,not to exceed
a term of 60 months.
Summit Care Program
If you are concemed about yow ahility to pay for hospifal services,please contact us to get more [nfolmaCou zxut n_
Summit Care Pmgram. Assistance is available based on need,and patients must q�alify through an appliwuee prccesz.
Income,liquid essets,end household size are considered. Patients may be eligible for discount�nupng from 2";io 17"..
Address Cheuges
17�e address infortnetion we have on record for you is shown on the front of this lener. Pleaze comact ac'vn.medu�rt.r a.
of ihis infortnation is no[cortect. � �
31B318N
- oi/ai/zois oi/aeizo�s
. . STGTEMENT OF 8<L4NCE OOE 0999 102
��� PAYMENT �UE ���
SOCIAL SEWRITV N�M9ER: �63-54-i581
IF THE NAME �4 L1'�8455 SC�V cE__•
IS INCORGEC-, P_=_�= =C3i=.- pMOtINT ENCLOSED: $
PAVMENT MdOE BY � CHECK � MONEV ORDER
S D ELLi��a'1 MGIL VOUR PAYMENT T0:
708 BAi.�SlSC:2Z. �A17
SHIPPEIISBv�C. ]�A _ 'CJ =-Q==- �F UC 8EN'cFITS dN0 ALLOWGNCES
-�\: = PAVMENT SERVSE$
- =]X 6]503
-_2Z___3G. PP 1]iCo-989=
......�................ ...�.} ES� i k'£�T:AM -% �"'✓4'iPa �_'v tC.:i =>+MCM1T "•�•••'•r�....rtrr�r�a♦
REQt,'FST FOR PAYMENT DUE
{�* r�.vr� �:-�icate no recent pa}mznt acti�ity.
1"our.fieci :��:ex, xs:�s:�ti 4 mr.�.Y�za-�ab4e[e tLz 'Penos�M1ania C�nemplo�ment Cumpensalion Fund". Pleasc
indui;�•o�ea tiaa aci-�-• �+cr.e tst fa� of thz chzel I:cau are unablz to pav in(ull,partial paymen[will be accepted.
lo�eiut A c»�Y�r��d�tfr enpaid halaaee_ Pavmeut receiced af[er the i5lh o(last mouth may m[show
,,c_n.: y:�=as
Cnder Pesnstrania Law,you are required to repay this debt, with interest. If
fiill pa}ment is not received the Department has the right to pursue legal
action to recocer the debt.
SOCIPL SECURITY NJwBER: 163-54-�581
=33:E55_M1G CATE DESCRIPTION YOUR INCREASE VOl1R OECREASE
C�31/14 UC INTEREST INCREASE 1.02
t;30/14 UC INTEREST INCREPSE 1 A2
12/31/1< UC INTEREST INCREASE 1.04
PREVIOUS BALANCE BALdhCE ]EC3c�5° BALANCE INCREASE NEW BALFNCE
$140.08 5 0.__ $ 3.06 $193. 14
B:1\KRi:PCCY"DISCLAIMER
MPORTMT:If ynu are a ae�mr m an eneam=Fav:.-_r cr:ae:r.e tu.i.ncrowrya�ment diseha�ged in a baniuupteycase,this Oocument is for
informational purposs onlr and dces nci,v�s_:w�c L a:�.mn�e::AL-..ec:merya�mem.Please provide the departmem with infoemation io wn�ing
eonarning your uvwing bankrvp�n'.ase er.cuc brsc:a.4c:�.-.er.x.:nen�ae��e(etlowing adtlress:
Office of UC Benefits,Claiman[ Senices, P.O. Box 67503, Harrisburg,PA 17106•9894.
I��I��R�A��IIIIII�
IICd45 I�) PEV 05/19
UNOER THE PG �C LAW YOU A4E Rc5?Oh5-3_c =" --_ �=\S --_ = a+p�� '� ' _ _
ADOITION, THE PA UC LAW REOUIRES �i -- �=3-`_i`�- _\ n\ _ - ' -=s �t4'� .�f.
WITHIN GIFTEEN (15) CALeNOAR �AYS dc-=2 -_ '_"- '] VC'=="v-t=4 C' ' ' =rY._" �
RATE OF INTEREST, WHICH IS NRRENTC• [C\'_ �3) -?iC'c\' =_. _i: :_ _ __?- -: =�y � *� ' ,�J.
NING OF EACH C4LEND4R tiEAR.
. �:+:':��,
CGLWl4TI0N OF INTEREST
THE INTEREST WILL 8E CdLCULATE� AS SIMPLE rNTEREST AND WILL Bc GSSE� - - - '- L�4-- g
___ _. __' ..•r
OP A MONTH THAT THE FAULT OVERGAYMENT REMGINS IJNPGIO. THIS ASSESSNEti- �___ 2= �_-1'C:i�,s'
LATED BV COMPUTER AT THE ENO OF EGCH MONTH PS SHOWN IN THE FOLLOMING:
E%AMPLE: VOU HA� A $550 FAULT OVERPAYMENT ANO OURING THE MONTH MADE A PA�•�=\' -= SS r-".?.r
THE OVERGAYMENT BAIANCE TO 8500. THE INTEREST PSSESSEO FOR THE MCY- �.___ _.E i. '�2. '.3"',:E.�
❑NPAID FAIILT CURRENT YR. TOTAL YRLV. MONTMS AMOc\ -_ " `��
OP BA�ANCE INTEREST RATE INTEREST IN YEAR ASSESSE= _-= C+'- ��'"`�-
5500.00 X 0.09 = $a5.00 / 12 = 5_.-e
��
IF Y011 HAVE GNV OUESTIONS CONCERNING YOUR REPAVMENT OBLIGATIONS OR THE INFORMATION C]��_� T �Ci� �
FO4M, PLEASE CONTPCT THE UC SERVICE CENTER AT BB8-313-]284.
*'" OVERPAYMENT ACLOUNT ALTIVITY (CONTINUEO) *'*
PR�CESSING OATE DESCRIPTION YOUR INCREASE VOOR �E_4Ei5=
11C�335 IBI fVEV 05110
� , »_�„�r �MC
PO BOX 16346
PII1SBilRGH,PA 15242-0346
��A���1�...��� C.t��:i:t \1::. ,_;.....:r.c (.;,!::�;�ac
2121��bleabw�Rad,ribbvcl.PA 15215
�O B�:IGiK.litbbv�i!�152JZJ3if
Fac i{12:. 437-5286
02-27-2C15
ACCdA(f �BfIACATIDM
di�h�mrlll6��un��rmihh�lidiu.in�pl�ilmpi.i,i, aars� a� -+nsaz++.cr.�z
STEPHEN D EWOTf ���9����� ���
708 BALTIMORE RD ����r ���
SHIPPENSBURG PA 77257-9t82 ��� - �
O�tat Oea'4e : tt31�b!S
Areast Dsas .f Tl6.9}
Your accoun�with CHAMBERSBURG HOSPITAL(ER)in ihe amount of 57865.80 is seriously past tlue.As a result,your account
has been assigned to Credd Managemenl Company for resoWtion. - � �
To resolve�his matler quickly and in a mannar beneficial to you,remil ihe full amount shown in Ne endosetl envelope.You may
also make a cretli�card or check payment on our websi[e,www.oavanc.com,or call 1-868-368-1557�o discuss your outstanding
balence. To receive proper credd,payment should be made payable to Credit Menagement Company with your account number
(shawn above)indiqted on your check or money order.
Please nWify us rf an insurence carrier or an attomey is involved in Ihis matter. If payment has been made on ihis accroun[directly
to Me a6ove aedtor,pleasa nole your check number and date of paymenf on ihis letter and retum it to us, in the enclosed
e�rvelape.
SM�pray.Galhy SchwH 566368-1557
BusMsa Fbura EST:Nonfrl 5:00 am to S:UO pm and Sat 9:00 am to 1:00 pm
FEOQ2AL LAW P.L 95-109
This is a�aYampt b cdlect a debt.My information obtained vnll be used for ihat purpose.This communicatlon is trom a debl
coferJoc lXie�you nalify iMs office,wehin 30 tlays after receivirg Nis noBce,that you dispute ihe validity of ihls tlebt or any
pp5un fiaepf,yis dfice wip assume that this debl is raid. If you nofrfy ihis office in writing within 30 days fiom receiving this
rq6c8 p�s[you Aispule tl�e raYtlAy d tlus debt or ary portion Nen.rof,Mis oifice will obtain verificeUon of[he tlebt or a copY of a
j,dgne��t and mai you a copy d sud+}IdyreN a verification. If you requesf in wnUng,wilhin 30 deys efter recaiving this notice.
Ytiq dRce wi porfAe rou riY�tl�e rare antl adtlress of tlie original creddor, "rf diRe2nt from ihe curten[creditor.
Pf.BA.�OPLACB ATm RBIVRN]4➢S PORIfON RI It3E ENCLOSID ENVEIAPE--____—_________""""_—_______
Fmm:
Yoa maypq odine by visiting ow ouGue peyment eysrcm et
Q� ,� ChangeofAddress:
� wwwnev�crom
You msy use oiv convairnt`SCAN SO PAY" opfiev Ly C�,$��8,ZIP:
� � scaming thc QA code�ivg yom�ert phore.
� Telephone: Work:
Make your check or money oMer payable to: qmount Due : $7865.60
%
Amounl Enclosed
Credit Management Company Aeeount Number :4455251
P O Box 16346 Agent Number : 21
Pittsburgh PA 15242-0346
�'IIIII'�I'�1'��"��I'�I�����I'�1�'�I'll��'���I��"�II"�III�'�I� Enclosing this notice with your payment
will expedite cretlit to your account.
}AI
. a .��_��,�P �MC
PO BOX 16346
PCI7'SBURGH,PA 15242-0346
������������� Crcdit Af:n.iecmr�it Compesn
2121\oblertown Read,Pkbbv¢.PA 152�5
P O B�:1G3Jf,rab6v6Y PA 152J2J3Jf
Fa�c 1472)937-1286
OZ-L�-2C15
ACCW!(f D0RiF7GATpN
�p�pr,hq�ip�r�nldri�P6•�•lxlPrNrdrNa•�Nld• crea�c��ss�mc -iosarn��aas
Paoar�„e. �=oors.s��*e �
STEPHEN D ELLIOTT ��r :�
708 BALTIMORE RD ���n� _Z�
SHIPPENSBURG PA 7725f-9182 D�,,�Q� . q}3�_�z
Aenart Der :S 3337.s3
Your account with CHAMBERSBURG HOSPITAL(OP)in the emount of$3337.43 Is seriousy past due.As a result,your account
has been assigned to Credi[Manegement Company for resolutloa . ..
To resolve this matter quickly and in e menner beneflclal to you, remit the full amount shown in the endosed envelope. You may
also make a credit card or check payment on our website,www.oevcmc.com,or call 1-866-368-155710 diwuss ywr outstanding
balance. To receive proper credR,payment should be made payable ta Credit Management Company with your account number
(stq�aEwe)intlicaoe0 on your check a money order.
Reeaa nolfy us C ai nararre ranier a an�torney is invdvetl in ihis matler. I/payment has been made on ihis account direc[ly
�o ihe apo+e ee�r,pieaae nole ypr d�edc numbef and date o(payment on this letter end retum it to us,in the enclosed
e�nelo0e.
5�11.C�!Eeisdl�liFi�•1567
Br.�s IY��ESF iRFA�.Y�a b i!pw and Srt 5.00 am W 1:D0 pm
i�AL UIM Pl fS1M
TAs s a��epl b e�d a Oe1t My ifoinrfu�aEila�etl�i be useC 6or tha[purpose.This communication is hom a debt
rnfeds iyyi p'e�y fs�,�s�3Y Aays��g tla5 nolice,thN ynu dispute Na ralidity of ihis debt or any
pne(ienlisad �s dfos ii a�aelu[�s A�![s rafd M yw m6fy ws ofFce in wnUng within 30 tlays from receiving ihis
neis Nr�w dyii i��iYp d�s YI vay pafm laed.Rs oliae wi ohtain verification of ihe tlebt or a copy of a
pd�pwt a��i�m a a�da��s�svdirafon. M 7ou rep�n wing.wihin 30 days after receiving ihis notica,
t�s�s i vorie 7��i�r��ra!aAdes d ne ari��ai oe�r.a difaerd han tlie current uetldor.
. nat�narwcawrIDaeivut ttvs eoxnot+u+n�eNctos�etrveWee---"----------'-------
. . — _ . . . From: . _ . . .
Yo�may p.y od'we by viatiog oia oWine payment sysrem et
Q� Q Change of Addiass:
� � ..�oa.�.�om
�� xo� �r �� oQ �w.rnim -sca.� ro rwr opioo uy City.State.ZiP:
� J • . 9CB�1�(h[QB[Od[ItlD§fDQ�Yl[�OR.
� Telephone: Work:
Make your eheek or money ader payabM to: qmount Due :$ 3337.43
%
Amount Enclosed
Credit Management Co�any AceountNumber : 5529409
P O Hox 16346 Aqent Number : 21
Pittaburgh PA 15242-03�6
�'lllll'�I'�1'��"��1'�I�����I'�1�'�I'll�����••NI'diN�'�I� Enclosing ihis notice with your payment
will expedite cretlit to your account.
MI
� �. �.,�P CMC
PO BOX 16346
P[I'1'SB[JRGH,PA 15242-0346
�����������1� (.rc<i':t \ls'.�,:_:..__ C ..;t;n:;a
zui�.a�s..■e..t rmsvar.ra isz�
r o sa icuc,rmsa�re i�x+a.a3ac
Ce-e'-2:_5 =ar �452: 937-'2B6
NLC01/(T OBtTflUlill7M
�i�in��wii.�.�.h%����4r4�i4�l�Y�M a+.��-�c�saT,r:�o�;
STEPHEN D ELLlOTT �����" �"'� ��x�
�os sunMorte rm �"�~"�� :��
SHIPPENSBURG PA 7725T-9la2 ��� ��
!I�La�Q�sye '.aS-72-4t
lWsuut 4Dns .i &' t2
Your accoun[with CHAMBERSBURG HOSPITAL(OP)in Me amount of 517.72 is seriousy past due.!ts a result,your acwunt
has been essigned to Crad'R Menegement Compe_m for lesolutlon. _ __ . .. . . . . . .
To resolve ihis maNer quickly end in a manner beneficiel to you, remit t�e tull artwunt shown in the endosatl envelope.You may
also make a credit cartl or check payment on our wsbsite,www.oavcmc.com,or call 1-886J88-7557 to discuss your outs[anding
balance. To receive proper credit.payment ahould be made payeble to Credit Manegemenf Compeny with your account number
(shown above)indicated on your check or money order.
Please nobry us iF an insurance cartier or an attomey is involved in ihis matter. If payment has been made on this account tlirectly
to Ne aDove cred'Ror, please note your check number and date af payment on this letter and retum it to us,in the enclosed
�
SlnnrNy,Catlry Schor/t-868-368-1557
Businsaa Hou�s EST: Mon-FA 8:00 am to 8:00 pm antl Sat 9:00 am to 1:00 pm
FEDERAL UW P.L 95-109
TTis is an atbmpt W collect a debt. My information obtained will be used far ihat purpose.This communication Is irom a tlebt
coRector. Urde�you no[ify ihis ofice,wilhin 30 days afler receiving ihis notice,Ihat you dispute ihe velidiry of this debt or any
porlion tl�ereof,this office will assume that this tlebt is vaitl. tf you nolify Mis office in wnting within 30 daye from recelving ihls
na6ce tl�yau dispute the waiidiry of this debt or arry por�on thereof,ihis office will obtain verification of ihe debt or a copy of a
judgneN and ma�you a copy of wch judgmaM or�erificalion. N you requwt in writing,wRhin 30 days afler receiving this notice,
Ces Mca wi9 provida you with tlie name antl ad�ess d the original credRor, rf tlifferan[from the curtent cretli[or.
PLFAfiE DbTACFI AND R6MtN THIS PORifON IN THE ENCLOSED ENVEIAPE---
. _._.__ _____—_ . .. —
--- —`—----� � From:
❑� , � Youmeypeyonlioebyvimeogoivou4vepeymeutaymmee
❑ ,�,.����.�om Change of Address:
� � or
You maY iee om cwveoieW "SCAF! i0 PAY" option Dy CiIY, SMd�B,ZIP:
�. � sca�iog Poe QR code�iug yom smu�p6om.
� Telephone: Work:
Make you�eheek or money order payable M: qmounl Due : E 17.72
a
Amount Enclosed
� Account Number : 6906093
Credit Management Company
P O Box 16346 qqent Number : 21
Pitteburgh PA 15242-0346
�'lllll'I��I��II��II��I�I��II��iI�'�t'Ilil�ll��ll���li'•IIII�'�I� Enclosingthisnoticewithyourpaymen[
will expedite credit to your account.
:..�
� �_,� �„��. �MC
PO BOX 16346
PITI'SB[1RCdi,PA 15242-0346
I■���.,������ (.a-�:_t \(.:.'':''...,.;�:t C�.::➢.peln
:121�MInY�Rr<r5mbe¢.t�152�5
[O ia tGIK MmYt�!�1�Li2J.iK
=a �:s7z;33'-+.295
Ce-:'-�'_"
ICC� �AT�If
O�/!C9�Af'a�11�[o'P'!
a __,�- �e��Y!��p�� 'rmr-"* �Yi�fit 8���,�y 7
�+ T J�Viv��VO!Y���I'�fa � +��iY
�+ ��� 7��e��I . �.�� _�
SF�����-.: . . � 11f-�M
�II�t�! _Y2t7.E
r x,t
� ����L��r St. :
7. .
a $:t a��l��'x w� ^, l� � .- ..
Yar m�t�iNl {��iiil�ffi"s�rl P�tlue.AS a resufl.Your axount
IwO��a�� , ����
�Y Of a � y��.:
To asr�r + I���!���f'�r��7�4����a'��'°`"^�^�e endosed enveloDe.You mey
�+w�i��� II fll II� I ��II�Ylrl�liL�i Q� ���-�557 to diwuss your outstanding
�. �IM� � � � ��IIIIMi��r1��YLl�eB Maregement Company wiM your account number
� �2� a�e�er. H payment has bean made on ihis accoun[diredy
�� ' � ��� Ye d�nst m tlds letler and reW m it to us, in ihe encbsed
rr��
� f�
liii�ir�!^a/SttM ao Lo 7:00 pm
���
'�y��lyl./y�•iiiawr(n��Ynei�i pp used for that Durpou.This communication is from a de6t
�C,Mys��tjfsulf�e,w��n 30 tlays efa'eoefwg tlfs rqfice,Na�you tlispute Ihe validiry of Nis tleb[or any
;��/�R,fis�i��i mm�me tliat tlds deht is vafM.N yau nofify this office in wriUng within 30 days hom receiving this
: �.�ipb tn veftlily d tlus deM or a�ry pptlon B�ered,tlus office will obtain verificatlon of the tlebt or a copy of e
��:��.��/�u a iopy of wch judgment w verificafion. H you request in wri6ng,wilhin 30 deys after receiving this notice,
` �16i�aiiie yw wih the name and address of fhe orginal credAor.'rf diflerent hom Me curren[c2ditor.
_____'PLEASE DETACH AND RESURN iH15 PORI'[ON W i}IE 6NCLOSm ENVEIAPB"'____—__"_—_______""""______
�¢;:._
From:
Yoa mey pey odioc by vivtivg aiv odwe paymeM ryzhm at
�� � aA���� Change of Adtlress:
�� • � Yw� �e oe =mvut'SCA� i0 tal' �po�A Cdy. SGfe. ZIP:
�.J . . r�L�eQla����i�e
� Te�eptwre: Wortc:
��7���Q�1�l�A�� Me�o�rK Due :S 217.35
Amo�rR Enciosed
a
CYedit �t Oo�QanY Actount Nunber :2079729
P O Boz 163i6 ��� � 21
PittHbnxcJE PE 15242-0346
�rqHHn��h��•,hrv4ul�hl Endosirg this no�ce with yrour payment
will expedite credit W your account.
. .�. „�� �MC
PO BOX :63i6
PIIISBLR(�i.PA 152#2-0346
��������,�/�� (r;,^.:! �I:.::.:_��;::�,,: c�.,,:,;p,,ny
zui�.aw...s.va.rmn�.re iszK
r o a.:ics+c,rsmr�r ra isawu
C Z-�--'__" =az ti72'i 9Ci7-1286
ACCOt/R pB(Ii�'.A7pM
�I����I�� Cad�r HGSRTAe..5T5 tJF+�/�VC.:N CO[1MY
STEPF9i D Bf.K7Ti �"�Y si�c 5.�_:!O�f.ST�E.'ef J
7�894�"i1pR�fm Am���t :]l�it
�gA ".'L�-� a'�etltfJ� .-��
II��tOr :f�6.70 . . ..
Yav a¢art w+h FIOSPITALISTS OF FW WQJN COUNIY'en tlie anqunt of E46.70 is seriously past due.As a result,your
aocwr�has been assigned W CredN Manegement Company fir resoWtlon.
To iesdre ih"s matler quickly and in a menner beneficial to you,remit lhe full amount shown in the enclosed envelope.You may
also make a credit carU or check payment on our website,w�vw.oavcmc.com.or call i-866-368-1557 to tliscuss your outstanding
Daiar¢e. To receive proper credit, payment should be made payable b Credit Management Compeny with your account number
(sJwrn aDove)intlicated on your check or money order.
Pfeaee ra�ty us if an insurance cartier or an anomey is inwivetl in Nis matlec 11 payment has been made on this account directty
b frr abwe aedior,Wease note your check number and date of payment m this IeCer and retum it to us, in the enclosed
a'+ia+o0�
. l�d�CC�SHqr/7-668368-1557
Ws iirs ESf:Mon�frl 8:00 am to 8:00 pm and Sat 9:00 am to 7:00 pm
iiK LIN P195-109
�� isssl�{[b cdlect a debt My infortnetion o6Wined Mi16e used tor that qapose.This communicatlon s(ran a deE[
2r,.:: ai��.liis you rptiry this ofice,wilhin 30 tlays afler receivng Vis ndice,Mal you Wspute Me validtty W ttvs CeM o�arry
���=:;;'��:�li1rlr�f,If�dfice will essume thet this debt is valid. H you nddy tltis ofRce"vn r+ti'g witAin 30 days from receni+g etis
�,� iilYrs�qi0e Ne validity M ihis deb[or any porton iheraof,mrs ofl'ce w�a0fan rerifimtim of tlie ded ar a mpy d a
�.,��tat uoi you a copy of such judgment or verification_ tl you request m w'Yg,rYtin 30 Aays afler recefrrg ts nai�e.
.�.'i1M�is�prwtle you with the name antl aetlress of V�e onyrW aedrar.[dfiereiti from eie urieru cretl�6Or.
"'Y
-----PLHASE DETACH Alm RENRN THIS PORIION II1]HE ENCf.OSm ENVELOPE
" From:
;� Yaa�rpryodioebymmgavodwepaY�v[sy'%rema� Chan9eofAddress:
� ia��.om
�� � .. ���cw. ro rar ow�M ��b. Sfate. Zip:
��ie R ut�w��rt�is.
Telephone: Work:
����_�������� AmountDue :$46.70
� Amount Enclosed
x�'���_ : ���� �� Aeeount Number :3652782
a� � �,�� �. qgant Number :27
'�. .�!1 �-�'��i
Encbsirg this notice with your payrrrent
".}"r' . , . . rri�l e�credR to ya�r account
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