HomeMy WebLinkAbout01-0324
PETITION FOR PROBATE and GRANT OF LETTERS
Estate of. (JC9Q c.-{ -:JJor- f) 50" No. 21-01-324
also known as .J To:
Register of Wijls for the
, Deceased. County of ~u rYI ~}f' (" I Q wt in the
Social Security No. / ,q - .~t:l - 3 J 4 q Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of ageof older an the execut<' ;5
in the last will of the above decedent, dated ~(h \ e"\i' \)e'( ,;) I I IS l~
and codixil(s) dated
C}f'<.:l'fle~ lG ~o\\""c:::.,(0), rJp('c=o'S.c~d ;Jlq/q1
\ ~ I
named
,19_
(state relevant circnmstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in Qu.. ,,'n b f/' \ o...~
h e~ last family or principal residence at .~ 1 ~ f k<y,c.,
SOL'--\- h \"\"- ,ad. \-e -\ (\ ,,,-
(list street, number and muncipality)
County, Pennsylvania, with
et \ l (~o \ l\",,::\y.,
(
Decendent, then ~\qyears of age, died
at ~u. '\' \ \ ~--;\-e \\o<s ~ I-k\... ,
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
after execution of the will of e~ed for probate; was not the victim of a killing and was never adjudicated
incompetent: ~,
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
n\<.}, '\ ck
I',
,19 -;)cc I ,
$
$
$
$
33c3.S-f
1,~)7/.7~
4 t) '7 L-j. .J-- i-(
WHEREFORE, petitioner(s) respectfully req.u.est(s.) the orobat.e of the last will and codicil(s)
presented herewith and the grant of letters -\ CS-\C\.. \",,-'<2' !'\c\." \.;4=
(testamentary; administratioitlc. La.; administration d. b.n.c. La.)
theron.
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on
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEA~TH O~ PENNSYLVANIA l ss
COUNTY OF llu.I'i\ I .nlcu\0t . J
The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are
true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen-
tative(s) of the above decedent petitioner(s) will wiland truly administer the estate according to law.
affirmed and td u z z { ~
23 QQ'
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No. 21-01-324
Estate of
PEGGY J JOHNSON
, Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW MARCH 26 ~~, in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated NOVEMBER 2. 197')
described therein be admitted to probate and filed of record as the last will of
PEGGY J JOHNSON
and Letters TESTAMENTARY
are hereby granted to DEBRA JEAN PEDUZZI
'-__v (? ve
LL.fl//y /~ //h~~/Aj/~"-"dt-
,y R . er of Wills
FEES
Probate, Letters, Etc. .........
Short Certificates( )..........
Renunciation ................
JCP
$ 25.00
$ 3.00
$
$
TOTAL _ $ 33.00
.. .~~.~ .f~... .4QQJ................
ATTORNEY (Sup. Ct. J.D. No.)
5.00
ADDRESS
Filed
~~d~
PHONE
C~-U~.? ~:-/J
~-~, ('.<;. c:n<;
~,C,V o/c:r,
This is to certifY that the information hete given is correctly copied from an original certificate of death dul~ filed with
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filmg.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
me as
No.
-Q.......ll4 tn Q,,:-., Dr' "tf-
Local RegIstrar .
Fee for this certificate, $2.00
p
7247846
MAR 2 1 zua 1
Date
21-01-324
Hl05.1QAIN.2181
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
:,,'A'NT
IN
U.NENT
CKINK
NAME OF DECEDENT (f"". M~.l.._'
'.
AGE(l... -Yl
STATI fIlE NUMe"R
SOCIAl. SECURITY NUMBER
,,1.1
64....
IIRTHPI.ACl! 1<:"''''''
S\IH Of FCN9'l CClI.lnIJyt
-30
17 2001
COUNTY OF DEATH
=-"0
'110,
r.llmh
Old
-
......
_7
..
.?c.O ,...__..
MARITAL SWUS. MaIried
---
-~
W
..
'1.
MfHEA'S NAME (F"... MidcIe. l."1
11 Ed ar lfentzer
1Nf000000S NAUlt CT_
~ Debra J. Peduzzi
METHOO OF DISPOSITION
......GQ "'.........0 __$1...0
ow..._""
CEC€CENT'S
ACTUAL
AEStCENa
..........
ClI'l~tiOat
17..SlaI.
P::li
~
Mir'lr'lll'>tnn
...1
!
-'
27 Garland Ct 2
Ave
b.
21.
I Approximal.
:::-==
I
I 'l. l.
1./ :ll..
...00
PARTn: om.rSigniftcant~CIIllI1CrtK.ClngtodlNtt\.buI
'*1'HutIiftg it 1M UftdIIrtying cauM p.n it PNn' I.
CUE 10 (011 AS' CONsEQUENCE OF),
4.
WERE AU1OP$Y FINDINGS
JY.It.A8\.E PRIOR 10
COMfOlET1ON OF CAuSE
OF DERH?
MANNER OF DEATH
.........
_to
t6
o
o
DATE OF INJURY
(Mcnh.llay. _)
TIME OF INJURY
lHJUAy III 'MlAK?
oescFuBe HON INJURY OCCUMEo.
Homicide
P.nding InvestigaUon
o
o
o PlACEOFJNJUAY.AI home. lann.ltIftt.lactory.offtc. U.
buiIdrlQ. etC.ISpec.M
....
... 0 ...0
...0
...0
-...
Could I'IOlI be det.rmlMd
iQ
v)
a.. 2....
CblTWlER ICh<<:JI only ~I
-CDl"IFYINQ PHYSICIAN (Ph'fSIC..... cll!fWylng cause ~ dHlh 'IIlI'herI,)(lotNf pf'IySICtan n.s P'onovnced dftalh ana cantllered Item 23)
To h-..ot""kl'101l'''''', ..1hOCC:urred......Ih.Uuh(.).ndmanner.. .1.'".... ................ ......................
:n.
'"I'tlIONOUNCINQ AND CERTIFYING PHYSICIAN IPh~.an 00Ih o>ronounc"'9 ONth and Cerl"yw'Ig tocause of doltll
To Ihe beet of my knowe.dg., death occur,ed at h time, dala. and plec.. and chHt 10 the caus-<.) and m.nne,.. s'ated.,
o
..,IEOtCAl EXAMINER/CORONEA
On the baef. ar ...mlnetlon a"dlar inv.stiganon,in Iny opinion, de.th OCcurred at th.Um., date, and place, a1\4 due to the caUH{I) Ind
31.~ner..stated...................... '" ..................... ............. .......... ...... ..........,..... '" ... 0
1.:4 \ 1.;1.1 \ 10 1
34.
M c eRE A & r,1 c eRE A
LiTI; R~, t. f.' ~ '., (;
,r. flit. (~
.. S Ell ij Ii
-.:;;;.:.::.::;.~::,:;:;:-~
L,\~:T \:ILL X';J TI:ST.'\:iE:-lT
21-0]-324
;~, P1.i.il~; ,) _ .J()!J:<;~',:(),\, u resident of LO\\1er 'iiff.lin TOh'nsllip
l: ur:l C r 1 all j ~: 0 un t y, Pen n 5 y 1 van i a, b e in g 0 f S 0 11 11 d
1. " "~I
;1-...;
and. P1elTlOr\ ,
1.;0 llai<:e, ilUblisfl and ,leclare tills to be nv
st
ill an\.l Testa.,
L:ent, heron,! re'l.;ol,ln~' any and all (';ills ;))' me heretofore !:laGe.
F I R,(; 1
i 11creby direct ny Executor, :Jercinafter naneu, to
i ' ~H' a 11 u v j u :: t deb t 5 and fun era 1 e x pen 5 e s ass 00 n a 5 rn a vue
convenientLY' done after m:/ \.tecease.
SleO;):
] ;;1\"0, dc'vise and bequeath all l'lV estate, be It
real, personal or mixed, to FlY husband, Charles ii. Johnson, for
his Ohn proper use aTH.: benoof forever.
Tl~IJU:
In the event my husband, Charles :\. Johnson, predc
ceases De or hE' Sl()ull~ perish in a common disaster, then T glVC,
c1cvisc anLl bequeath all my estate, be it real, person:ll or mixed,
to Uebra .Jean I'euuzzi or :lcr heirs.
F RTll:
I hereby nominate, constitute and appoint
llllsband
Cilarlcs .v. Johnson, to be t:1C Executor of this iiV' Last \\ill and
Testament.
In the event he is unable to servE:' as Lxecutor for
any reason whatsoever, then I name, constitute and appoiEt Debra
Jean Peduzzi to be the successor Executrix.
L~ WITNESS WHE:~EOE~, I ilereunto set my hand and seal to tnis
my Last Will and Testament, written on one (1) sheet of paper,
J a t cd t ;1 i 5 _~~~_.__ day 0 f ~ 0 v e m b e r, 1 9 7 5 .
"
P-'I<G'~.~;~Jf'~ 'S;;i.I'" "'S01 ;;,"
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.~. , _ ,..!..~,.-:.L.-':;;_,...._.__.__."......___
T 11 i sill S t r UITl e n t hf as by the T est a t r ix, Peg g y .J. J 0 h n son, 0 II
tile date hereof, signed, published and declared by her to be her
Last Will and Testament in our presence, who at 11cr request and
in her presence and in the presence of each other, \,,;e believing
her to be of sound mind and memory, have hereunto subscribed our
names as witnesses.
_ ,,,...L~_~:~~~.::.~..:..=, ,..,_._,.,.~~ :~.
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21-01-324
REGISTE OF WILLS OF COUNTY
o TH OF SUBSCRIBING WITNESS
dicil
"II presented herewith, (each) being duly qualified according to
present and saw
(each) a subscribing witness to the
law, depose(s) and say(s) that
the testat , sign the same and that \
request of testat_ in h
other subscribing witness(es)).
signed as a witness at the
(in the presence of each other) (in the presence of the
Sworn to or affirmed and subscribed before
me this day of
19_
(Name)
Register
(Address)
(Name)
(Address)
\
.:1
REGISTER OF WILLS OF Cu 'N\b-e-r\a~ COUNTY
OATH OF NON-SUBSCRIBING WITNESS
~ b r 0.. -=Sect""
9f1duz~.
u (Lhol a ~ hla; (\e#du~ Z{ I '3 y.
, depose(s) and say(s) that
c ----0. n e-:::!G h ns: cs r')
,
(each) a subscriber hereto, (each) being duly qualified according to
l kJ 'e... 0...'( 'e..- familiar with the signature of
codicil
testattl.&- of (one of the subscribing witnesses to) the ~ presented herewith and
~odicil
believes the signature on the ~ is in the handwriting of
wea,e..-
that
to the best of () \l..\ knowledge and belief.
Sworn to or affirmed and subs<.:ribed before ~ \\ Q Qp ( 0 ~~a /VI. .J~ 11 A ~
me this 23rd day of --+r d (Name) ~ \J . f)/J
~~ MAR~. H . -_ k'k2llilL ;;)'1 GClr-(arv1(1our-t J/;, (a r!;3'{ejIH1({)(3
/~Hr' e_'<'L/<j&pJRL/~ 1-1.."..0_. .a. (Address)r/ .
/ Register / ~ V if) llYljl/ l!..PLlu 11 (jiG
(Name)
21 Gar let0d (our+ l \) Ct~y lls.l e ) VJ4 /7 f) 13
(Address)
/I
./ flIIIl.
~
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent J..e~ 1-'t -S ),.,\-..~" (J t>
Date of Death:
f'{,\ u Y'C 'r--. \ '1 I "R06'
'1/ - ~ 60 f -63;;Lj
0. Admin. No.
Will No.
To the Register:
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on
Name
Address
\)~\1 ~0..
~'. ~~cl\'77~
,
~7 ha'ClO-nd C-t- il
Carl\~(-e P4
, 170(~
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date: 7 - :;--0 I
Signature
Name --4J~0- -q ed<A'OY-
Address J .<--/ (-,Cc ( .( Ci ev.J C-{ ({
Oa (' L'--; (-e
PA I(GI~~
Telephone t7 It
;)Cf 2)- d-.l/7 3
Capacity: //' Personal Representative
_Counsel for personal representative
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
'*
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 11128-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
REV-1541 EX AFP Cl2-DOl
DEBRA J PEDUZZI
27 GARLAND CT II
CARLISLE
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY,
ACN
07-16-2001
JOHNSON
03-17-2001
21 01-0324
CUMBERLAND
101
PEGGY
J
PA 17013
Allount Rellitted
}.,i
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV=is'4i-EX-AFP-fi'2-=oOY-NOTicE--OF-YtiHEififANClrTAiC-APPRA-isEiiENT~--ALrOWANCE-OR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF JOHNSON PEGGY J FILE NO. 21 01-0324 ACN 101 DATE 07-16-2001
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
25,693.88
.00
.00
(8)
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax paYllent.
25,693.88
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governll8ntal Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
(10)
6,130.44
2.547.16
(11)
(12)
(3)
(4)
8.677 60
17,016.28
.00
17,016.28
NOTE:
I~ an assessment was issued previously, lines 14, IS and/or 16, 17, 18 and 19 will
re~lect ~igures that include the total o~ ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate
16. Allount of Line 14 taxable at Lineal/Class A rate
17. Amount of Line 14 at Sibling rate
18. Allount of Line 14 taxable at Collateral/Class B rate
19. Principal Tax Due
TAX CR DITS:
PAYMENT
DATE
06-08-2001
RECEIPT
NUMBER
AA496697
DISCOUNT (+)
INTEREST/PEN PAID (-)
38.29
(5) .00 X 00 = .00
(6) 17 ,016.28 X 045 = 765.74
(17) .00 X 12 = .00
(8) .00 X 15 = .00
(19)= 765.74
AMOUNT PAID
765.74
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
804.03
38.29CR
.00
38.29CR
· IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
\. /6 c2c2o-~
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
'*
REY-!U7 EX iFP liZ-DOl
ReCCI(k(
Refd ~ .~~~tc
of DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
P 1 :4~OUNTY
ACN
12-31-2001
JOHNSON
03-17-2001
21 01-0324
CUMBERLAND
101
PEGGY
J
DEBRA J PEDUZZI
27 GARLAND CT II
CARLISLE
'02 FEB-1
Allount Rellitted
PA 17ollerk;
ClImbui:
I.
1-.",
I. ,
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
RE-y:i6(fj-E3r-AFP-(i2-:iioT------...-fNirER'i~fANcE--iA3r-Si'jrfEMENi-ifF-A'ifcoUiff--.-i.------------------ ---
ESTATE OF JOHNSON PEGGY J FILE NO.21 01-0324 ACN 101 DATE 12-31-2001
THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW
IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE,
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 07-16-2001
P R I NCI PAL TAX DU E : ......................................................................................................................_.................._...............................................................................
765.74
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
06-08-2001 AA496697 38.29 765.74
12-17-2001 REFUND .00 38.29-
TOTAL TAX CREDIT 765.74
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
lIE IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1,
NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A ""CREDIT"" (CRJ,
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. J
..
~~
.,' -
STATUS REPORT UNDER RULE 6.12
Will No.:
Ptqq~
3-/7-01
t:i//-Cfl - 03;2C(
~
.:Jo A 11561"'1
Name of Decedent:
Date of Death:
Admin. No.:
HC;J /(JI
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the
following with respect to completion of the administration of the above-captioned estate:
1. State ~h..7ther administration of the estate is complete:
Yes itA No 0
2. If the answer is No, state when the personal representative reasonably believes
that the administration will be complete:
3. If the answer to No.1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes ~ No 0
b. The separate Orphans' Court No. (if any) for the personal representative's
account is:
c. Did the personal representative state an account informally to the parties
in interest? Yes 0 No 0 .1 a/Yl ~ dAft p#rS6/l
c. Copies of receipts, releases, joinders and approval of formal or
informal accounts may be filed with the Clerk of the Orphans' Court
and may be attached to this report.
Date: .2~LbJ$ ^ n, .In, c- () del u "'0)
Signaf;e =r-
121 hra. -:r P-eduz Lt'
Name
/},'7 Garland C~ u.,f II
C>:tr/i'S/T!' I PI) 17~13
r
Address
7 17 - OJr../ 3 -;/'17-3
Telephone No.
Capacity: E::rPersonal Representative
o Counsel for personal representative
..
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Phone: (717) 240-6345
" .~.
Date: 2/07/2003
DEBRA JEAN PEDUZZI
27 GARLAND COURT 11
CARLISLE, PA 17013
RE: Estate of JOHNSON PEGGY J
File Number: 2001-00324
Dear Sir/Madam:
It has come to my attention that you have not filed the Status
Report by Personal Representative (Rule 6.12) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO.
103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after
July I, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing will become delinquent on: 3/17/2003
Your prompt attention to this matter will be appreciated.
Thank You.
Sincerely,
~7lI teli/4t,,'h ~
DONNA M. OTTO ~~
DEPUTY REGISTER OF WILLS
cc: /File
Counsel
Judge
REV-l500EX (6.DO)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
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REV-1500
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
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OECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
"30\-\('>$0'("-. ~e. -:s .
DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
-11-01 a-ln-3'
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
~
OFFICIAL USE ONLY
FILE NUMBER
....,
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COUNTY CODE YEAR
-~~"--
NUMBER
01. Original Return
D 4. limited Estate
D 6. Decedent Died Testate (Attach copy of Will)
D 9. litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of death after 12-12.82)
D 7. Decedent Maintained a living Trust {At\act1 OOPYOfTrU5t)
D 10. Spousal Poverty Credit (date ofdeath between 12.31-91 and 1-1-95)
SOCIAL SECURITY NUMBER
I , q - 'SO - "3 I 4 q
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (date of death prior to 12-13-82)
D 5. Federal Estate Tax Return Required
" 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113{A) (Attach Soh 0)
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NAME
FIRM NAME (If Applicable)
COMPLETE MAILING ADDRESS
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Q.A..~\\'Sk, ~I\ nO\.,
(1) - D- OFFICIAL USE ONLY
(2) - 0-
(3) - 0-
(4) o -
(5) ;;J 5/ 'A 'I? f8
(6) . 0-
(7) - 0-
(8) ~ 5'/ '" '13 . irS'
(9) (., I 130. 'I' "
(10) a,S'n.1 c..
TELEPHONE NUMBER
"111- .;;1,43-.;;1.413
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
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5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mort9age liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (line 8 minus line 11)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (line 12 minus line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
'.0_ (15)
,.0~(16)
16. Amount of Line 14 taxable at lineal rate
1'1/ OIlA' olli'
17. Amount of line 14 taxable at sibling rate
, .12 (17)
, .15 (18)
18. Amount of line 14 taxable at collateral rate
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
(11)
(12)
(13)
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''1/01 (., .::18
(14)
/"1, OI16."'~
7~". 74
(19)
,,"'5.'7'1
Decedent's Complete Address:
STREET ADDRESS
CITY
c.ou..
1\
,
(\,
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
.
$3Y..;lCj
.1) <>f6
Total Credits ( A + B + C ) (2)
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty ( D + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, e.nter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
IIOI~
ZIP
1(,,5.'74
3 ~ .~C\
- 0-
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
'1;}....,.4IS
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5A)
(5B)
7;).'1.1./5"
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred;.......................................................................................... 0
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0
C. retain a reversionary interest; or..............................................................,..........................................,................ 0
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0
2. If death occurred after December 12, 1 982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0
3. Did decedent own an "in trust fo~ or payable upon death bank account or security at his or her death? .............. 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0
No
~
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1!9
111
~
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IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of pe~ury, I declare that I have examined this retum, including accompanying schedules and statements, and to the besl of my knowledge and belief, it is true, correct
and complete.
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIBLE FOR FILING RETURN DATE
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ADDRESS
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SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
(\a.\"\\~\t"l PA
"013
ADDRESS
DATE
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the nel value of transfers to or for the use of the surviving spouse is 3%
[72 P.S. ~9116 (al (1.1) (i)).
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0.% [72 P.S. ~9116 (a) (1.1) (ii)].
The statute does not exemof a transfer'to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if
the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 20.0.0.:
The tax rate imposed on the net value of transfers from a deceased chiid twenty"ne years of age or younger at deeth to or for the use of a natural parent, an adoptive parent,
or a stepparent of the child is 0.% [72 P.S. ~9116(a)(1.2)).
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)).
The tax rate imposed on the net value of transfers to or for the use afthe decedent's siblings is 12% [72 P.S. ~9116(a)(1.3)). A sibling is defined, under Section 910.2, as an
Individual who has at least one parent in common wilh the decedent, whether by blood or adoption.
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ACCOUNT NO. ACCOUNT TYPE
8892247415 N&T FIRST WITH INTEREST
STATENENT PERIOD PAGE
NAY.OI-NAY.30,2001 1 OF 1
00 0 04345N NH 017
8007
EST OF PEGGY JOHNSON
DEBRA PEDUZZI, EXEC
27 GARLAND COURT II
CARLISLE PA 17013
INTEREST PAID YEAR TO DATE
16.69
STDNEHEDGE
BEGINNING DEPOSITS & OTHER CURRENT ENDING
BALANCE OTHER ADDITIONS CHECKS PAID SUBTRACTIONS INTEREST PD BALANCE
NO. ( AHQUNT lID. ( ANOUNT NO. ANOUNT
19,593.83 1( 26.21 51 2,383.45 1 9.92 7.61 17,234.28
ACCOUNT SUMMARY
POSTING . DEPOSITS,INTEREST CHECKS & OTHER DAILy
DATE . TRANSACTIoN.DESCRIPTIoN & OTHER ADDITIONS ... SllBTRACTlDNS I BALANCE ....
05-01-01 BEGINNING BALANCE $19,593.83
05-04-01 DEPOSIT 26.21 ,. "0.04
:Jis-09-^ E ANERICAN CHK ORDER 9.92 19,610.12)
05-17-01 CHECK NUNBER 0099 50.00 19,560~12
05-18-01 CHECK NUHBER 0100 85.00 19,475.12
05-21-01 CHECK NUHBER 0098 l,48U.DO 17,995.12
05-22-01 CHECK NUNBER 0101 166.60 17,828.52
05-30-01 INTEREST PAYNENT 7.61
05-30-01 CHECK NUHBER 0104 601. 85 17,234.28
ENDING BALANCE $17,234.28
ACCOUNT ACTIVITY
L
CHECKS PAID SUHHARY
98 05-21-01
101 05-22-01
1,480.00
166.60
99 05-17-01
104_ 05-30-01
50.00
601.85
100 05-18-01
85.00
ANNUAL PERCENTAGE YIELD EARNED = 0.48 X
WHEN IT CONES TO PROTECTING YOUR FANILY, YOU NEED HDRE THAN JUST AN INSURANCE POLICY... YOU NEED TO
PLAN NOW! NIT INSURANCE SERVICES, A DIVISION OF NIT BANK, NATIONAL ASSOCIATION OFFERS SOLUTIONS: LIFE,
DISABILITY, LONG-TERN CARE INSURANCE. STOP INTO YOUR NEAREST NIT BANK BRANCH DR CALL US AT
1-800-350-9285. INSURANCE PRODUCTS_ARE NOT FDIC-INSURED_HAVE NO BANK GUARANTEE_HAY LOSE VALUE INSURANCE
PRODUCTS ARE OBLIGATIONS OF THE INSURERS THAT ISSUE THE POLICIES.
L.OU8A (12/93,
''''0'506'''.''0''',.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
ESTATE OF
t>e9~ ~ "3. "30,","050'"
Include the proceeds of litigation and the date 1I1e proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1,
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6.
DESCRIPTION
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VALUE AT DATE
OF DEATH
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9-'!'l.Il,
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TOTAL {Also enteron line 5, Recapitulation) $ as. t"Q;3. ~li'
(If more space Is needed, insert additional sheets of the same size)
REV-1511 EX+ (12-99) _
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
'"?'€~3. ~ :r.
FILE NUMBER
:30'1-..... '& 0.....
Debts of decedent must be reported on Schedule J.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
~"",\,,-e. t\LO'!>S \=-I()......~
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B. ADMINISTRATIVE COSTS:
1 , Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)JEIN Number of Personal Representati....e(s)
Street Address
City
State ~ Zip
Year(s} Commission Paid:
2.
Attorney Fees L-o..w O,5;.\c.c oC; lY\~o.c' S.
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3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
State _ Zip
Relationship of Claimant to Decedent
4.
Probate Fees
.33.6C
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $ ~ I 1:5 O.<.(<{
(If more space is needed, insert additional sheets of the same size)
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Egger Funeral Home, Inc.
IS Big Spring Ave.
Newville,PA 17241-
(717)776-3414
Apri1S,2001
Debra Peduzzi
Carlisle, PAl 70 13
The Funeral Service for Mrs. Peggy Jane Johnson
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
1. Professional Services
Funeral Director & Staff
FUNERAL HOME SERVICE CHARGES
SELECTED MERCHANDISE:
sandhurst II
#5 Reg
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED
AT THE TIME FUNERAL ARRANGEMENTS WERE MADE, WE ADV ANCED CERTAIN PAYMENTS TO OTHERS AS AN
ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES.
CASH ADVANCES
Cemetery Charges
Certified Copies
Clergy Honorarium
TOTAL CASH ADVANCES AND SPECIAL CHARGES
SUB-TOTAL
INITIAL PAYMENT / DISCOUNT / CREDITS
TOTAL AMOUNT DUE
T'
.
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Page 1
$2845.00
$2845.00
$1695.00
$843.00
$5383.00
$400.00
$12.00
$25.00
$437.00
$5820.00
$5820.00
I:.C T Ut(ANI I I:. VVUt(I'\.~
P.O. Box 187
.. Newville, PA 17241-0187
Phone: 717-776-5118
INSCRIPTION FORM
Date 5-q- Q (
Cemetery PrCJsp.ec.+ JJ f II
Deceased {Je~ ~+:e:s
Date of Death lYJa Jch / '1 .:ltX"J /
I /l . I
Other name on marker W, fl-Ft'ard C {;r/1-~S
Location in cem. I:!: :n~ S<':e./'1 "f);~. A
Type of Letters
match
(i-he"~ Io~
Person ordering \)phrlL .pPtil!7-z.i
Address ~.rl ~\""IG.nd c.A- {I (I a.r k<;/e I .P4 17CJ(3
I
Phone :J.. 1../..3 -ri.. 4-7 ~
Price $ 85
.
Paid :f> ~S-
I agree that the above information is rr~ect. II .
Signe~~ok)....q i:2~'
Per Arlene
Please fill in all info.,sign and return
with payment. thank you
c
Billed
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DateJDr. ~o.l.Jcol 60-'9&13'3
$, d~~':qp
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Law Office of Michael J. Hanft
19 Brookwood Avenue, Suite 106
Carlisle, P A 17013
Ph:(717) 249-5373
Fax:(717) 249-0457
Peggy J. Johnson
27 Garland Court 2
Carlisle, PA 17013
April 5,2001
File#: 2019-001
Attention: c/o Debra J. Peduzzi lnv #: 2795
RE: ESTATE ADMINISTRATION
DATE DESCRIPTION HOURS AMOUNT LAWYER
Mar-19-01 Telephone call from Deb Peduzzi; Telephone 0.30 37.50 RLW
call to Deb; Locate materials for Deb
Mar-29-01 Several calls from Deb regarding banking 0.40 50.00 RLW
issues, EIN number, etc.; Prepare Form SS-4
Totals 0.70 $87.50
Total Fees & Disbursements $87.50
Previous Balance $45.00
Previous Payments $45.00
Balance Due Now $87.50
o..^"
0' 00
Q~ ~~ ~
V
RECEIPT FOR PAYMENT
-------------------
-------------------
Cumberland County - Reqister Of Wills
Hanover and Hiqh Streee
Carlisle, PA 17013
Receipt Date c
Receipt Time
Receipt No. ..
L:
JOHNSON PEGGY J
File Number 2001-00324
Remarks
AC
------------------------ Distribution Of Receipt -----------------
Transaction Description Payment Amount Payee Name
PETITION FOR PROBA
SHORT CERTIFICATE
JCP FEE
25.00
3.00
5.00
CUMBERLAND COUNTY GENI.atAI< F~'
CUMBERLAND COUNTY GENERAl, Fl.;..;
BUREAU OF RECEIPTS & cttTR M ~ r
Cash
Total Received.........
$33.00
$33.00
b)
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COMMONWeALTH OF PENNSYl VANI^
INHER~ I~CE TA.X ReTuR.~
RE.SlrIl=NT OF.CfOFNT
ESTATE OF P,
eOOu :r. Jol-,.....SOf'\
'.....-.J
Include unreimbursed medical expenses.
ITEM
NUMBER
06/07/01
1.
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07:43
REGISTER OF WILLS ~ 7177764428
NO. 528
GJ02
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LENS
I
I
FILE NUMBE
7.
DESCRIPTION
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~!j
RECEIPT"'. Dm qU<tlQ\ "0. 2343
RECEIVED FROM I:..J,1l~__~~
ADDRESS ~
::!2:::~.<>I<>"- u.. ~>..,-;;. 7~~
i"'~':"~'~~I,' 0 CASH n ~
r:'<',;';:~::;(~""_.'------i.-\ ~K 1_
f~'i=:~~.':..=t~j o~~~:: BY'- ".k.. =..:' 1~8L817
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to ., -..
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GROSS SS
TOTAL GROSS UlIEARNED
ESTIMATED INTEREST
TOTAL INCOME USED
- PERSONAL CARE
ALLOWANCE
- COMMUNITY SPOUSE/
HOME MAINTENANCE
GROSS PATIENT PAY (53)
- MEDICAL EXPEN~ES
(See below)
NET PATIENT PAY (57)
NAME .:Ji;"-IIJS()/~ !Jm
RECORD NUMBER ;pq t,4 7
INITIAL
(;~j~1 MO/YR
70Q, 00
7tfl.OO
10, 7!f
715. 75
...:kJ ,Of)
o
his. '7S
8310
/YO! . R5
MO/YR
LESS MEDICAL EXPENSES PAID MONTHLY
Pd .
Cr:-t310C{
C.J(',
5- ~/- 0/
-,-
1 [
1_ _u __ ___ ____ __ __ _h___
I r \) !
----- - ------ ~ - ----- -~~-----
Patient Ledg;;';-n----nn--------------------
.. .._____._...._.w..._._
.,) :J
-.------------------------------
Done
L Pat i ent J
i Johnson,Peggy J
I 121 Hershey Road Lot#10
Cha"r"'t: ~
[ Guarantor J
Johnson,Peggy J
121 Hershey Road Lot#10
I ~' :I ! .".
I
I
I
I [Visit Dt Bill Di---~ P'r-..CtCedI.H-'e Checi..:/CC ~* Plan Amount] I
J [03/12/12I1J 1~;::'.:i792; 0"3/12/~:)i Chh~17(d,)7'0t<~; BluE~ b[ 0.00J J
j [03/12/01J Pa~,i1llent NotE' s.nf visits not covet"'ed ! +
1 02/05/01 155793 Asn? n DH 174.3 162.3 Off ly 50.00 (------- I
J [QH/29/0lJ 1=;~S160 2el Sub Ca'r"E'~ Low Level [ 50.00:1 I
j[03/12/01J :l~5~::,.1blll 03/12/01 Chj..::17&079G3 Bluf? S[ 0.1210JI
I [05/15/12I1J 1~;516121 05/15/QH Chi..; :tZi099 [ -50.00J I
I 01/29/01 155160 Asn? n OH 174.3 162.3 Off ly Full Paid (------- I
I ClZll/.t5/01J 1~;G401 26 Sub Car-.e, ['loder-'ate Level [ 24~?i.0~?I] I
I [02/26/01J 1C'i['401 iZl2/2['/01 Ch,,: 1 757896C'i Blue S[ -69. 00J I
1[02/26/01J 15[,401 02/26/01 Adj:Blue Shield Writeo Blue S[ -171.00J
I [01/1'3/iZllJ 156401 2[, Sub. Care, low Level [ 200.00J
1[02/26/01] 15[,401 02/26/01 Chk:17578965 Blue S[ -50.00J
! CEnt: f?l.*. Funct: i on l.<.ey ~ ] 1'1
+------------------------------------.---------------------------------------.----".
STATEMENT
PAYABLE TO:
John D Conroy, DO
Scott G Barnes, DO
Jennifer L Cadiz, MD
Michael E Klein, MD
Alfred R Leal, MD
Li Min Isaac liu, MD
MED ONC ASSOC PC
LEVEL
,163
---=u
PARTY:
, .
I
G HOME
PA 17241
~
.correct or insurBnce information
1 reverse side.
PlfASE OflACH THIS STUB AND RETURN WITH PAYMENT
CHARGES OR PAYMENTS MADE
AFTER CLOSING DATE Will
APPEAR ON NEXT STATEMENT.
r-----,
'n ._...n....... __ - _..__._........____._..... __n __ _..................._......_ ........_........... .._...m....... _."uun__....
1/31/01 PEGGY NON-CORING NEEDLE 6.00 .00 .00 .00
NOT COVERED BY PLAN
1/31/01 PEGGY IV INFUSION THERAPY UP 75.00 .00 .00 .00 75.00
NOT COVERED BY PLAN
1/31/01 PEGGY DEXAMETHOSONE PER 1 MG 25.00 .00 .00 .00 25.00
NOT COVERED BY PLAN
1/31/01 PEGGY DIPHENHYDRAMINE HCL UP 2.30 .00 .00 .00 2.30
NOT COVERED BY PLAN
1/31/01 PEGGY NSS-250 40.80 .00 .00 .00 40.80
NOT COVERED BY PLAN
1/31/01 PEGGY HEPARIN SODIUM PER 10 7.50 ..00 .00 .00 7.50
NOT COVERED BY PLAN
1/31/01 PEGGY OFC VISIT, EST LEVEL 5 118.00 .00 30.00 .00
PATIENT COINSURANCE
2/07/01 PEGGY TAXOL TUBING 8.00 .00 .00 .00 8.00
NOT COVERED BY PLAN
2/07/01 PEGGY NON-CORING NEEDLE 6.00 .00 .00 .00 6.00
NOT COVERED BY PLAN
2/07/01 PEGGY IV INFUSION TJFRAPY UP 75.00 .00 .00 .CO 75.00
NOT COVERED B PLAN
2/07/01 PEGGY DEXAMETHOSONE PER 1 MG 25.00 .00 .00 .00 25.00
NOT COVERED BY PLAN
2/07/01 PEGGY DIPHENHYDRAMINE HCL UP 2.30 .00 .00 .00 2.30
NOT COVERED BY PLAN
ECIAl COMMENT:
.ase note any insurance due (*J monies. If balance due is over 45 days please notify your employer and your insurance
'rier. We abate payment for 60 days and then you are responsible for payment in full. Please review your copy of our
ancial policy.
~11.llli:IIII~I~il'I;II!llll':!III;I,!,!1111!'!iltl\111.ill!Ill
:~'liil:i::II".ill:i:lr:rjllltJ
These charges are billed directly to the palient because either your claim was denied or proper insurance information is not available.
. It is the patient's responsibility to provide current insurance information (see bottom of reverse side).
DATE
DESCRIPTION
02/0]/0] 'Il 0] (I ('liE!:'!' ] VIEW 55.00
55.00
02/0]/OJ ()O () ~I~' IJI('r \11' FEE X RAY 23.00
23.00
O;~/O.l/O] HOW/() 'J"'l\tllll'()RT X RAY 2 PT SEEN 107.00
1 07.00
f;>
~J-
\)rr
L; ~~
Xb-- ~'b ~
PATIENT R SPONSIBI ITY:
CURRENT 30-
29-
29-
VER 120
B
CE DUE
CALL BETWEEN THE HOURS OF 9:00 A.M. TO 11 :00 A.M., AND 1 :30 P.M. TO 5:00 P.M.
TELEPHONE 1-800-370-9626, EXT: 640
NEW BILLING OFFICE NUMBER PLEASE CALL 1-800-532-9626
[7~) M&rBanl{
ACCOUNT NO. ACCOUNT. TY~E
8892247415 HIT FIRST WITH INTEREST
STATEHENT~ERIOD .. ~AGE
HAY.OI-HAY.30,2001 1 OF 1
00 0 04345H NH 017
8007
EST OF PEGGV JOHNSON
DEBRA PEDUZZI, EXEC
27 GARLAND COURT II
CARLISLE PA 17013
INTEREST ~AID YEAR TO DATE
16.69
STONE HEDGE
BEGINNING DE~OSITS.I . OTHER CURRENT ENDI"G
BALANCE . OTHER ADDITIONS CHECKS~AID SUBTRACTIONS INTEREST .~ BALANCE
NO. I AHOUNT NO. I AHOUNT NO. I AHOUNT
19,593.83 1 26.21 5 2,383.45 1 9.92 7.61 17,234.28
ACCOUNT SUMMARV
~OSTING ... . DE~OSITS,I"TEREST CHECKS & OTHER DAlLy
DATE TRANSACTIONDESCRI~TION .. I OTHER ADDITIONS .. SUBTRACTIONS ... ...BALANCE
05-01-01 BEGINNING BALANCE $19,593.83
05-04-01 DE~IT 26.21 .. "0.04
~-09- E AHERICAN CHK ORDER 9.92 19,610.~
05-17-01 CHECK NUNBER 0099 50.00 19,56r.1.2
05-18-01 CHECK NUNBER 0100 85.00 19,475.12
05-21-01 CHECK NUHBER 0098 1,480.00 17..995.12
05-22-01 CHECK NUNBER 0101 166.60 17,828.52
05-30-01 INTEREST ~AYHENT 7.61
05-30-01 CHECK NUHBER 0104 601.85 17,234.28
ENDING BALANCE $17,234.28
ACCOUNT ACTIVITV
L
CHECKS .~AID SUHHARY
98 05-21-01
101 05-22-01
1,480.00
166.60
99 05-17-01
104. 05-30-01
50.00
601.85
100 05-18-01
85.00
ANNUAL ~ERCENTAGE YIELD EARNED = 0.48 %
WHEN IT COHES TO ~ROTECTING YOUR FAHILY, YOU NEED HORE THAN JUST AN INSURANCE ~OLICY... YOU NEED TO
PLAN HOW! HIT INSURA"CE SERVICES, A DIVISION OF HIT BANK, NATIONAL ASSOCIATION OFFERS SOLUTIONS: LIFE,
DISABILITY, LONG-TERH CARE INSURANCE. STOP INTO YOUR NEAREST HIT BANK BRANCH OR CALL US AT
1-800-350-9285. INSURANCE PRDDUCTS.ARE NOT FDIC-INSURED.HAVE NO BANK GUARANTEE.HAY LOSE VALUE INSURANCE
PRODUCTS ARE OBLIGATIONS OF THE I"SURERS THAT ISSUE THE POLICIES.
L(JUBi-'I',2'83i
REV.1513 EX' (1-97)
-.
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
~
-::r
~o"'''''So,",
FILE NUMBER
e~9. "\ -
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) /7, ()/ I..,)'ii'
1. Debra. "3. Peo.'4'Z-u.. I ;/"/' Go....\o..--.i c.o.......~ II Da.v..~l\,"-er-
c.o..('\\S\ e I .p A no 13
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ /7. 61~.,';/8
(If more space is needed, insert additional sheets of the same size)