HomeMy WebLinkAbout08-13-15 (2) 1505610140
REV-1500 Ex 101-1
o' OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg,PA 17128-0601 RESIDENT DECEDENT -�;Ll 1!5
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYY^Y
1 0 2 8 2 0 1 4 0 9 2 6 1 9 3 9
Decedent's Last Name Suffix Decedent's First Name MI
M I T C H E L L L I L A M
(if Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
nX 1.Original Retum 2.Supplemental Return 3. Remainder Return(date of death
prior to 12-13-82)
4. Limited Estate 4a.Future Interest Compromise(date of 5.Federal Estate Tax Retum Required
death after 12-12-82)
6.Decedent Died Testate F1 7.Decedent Maintained a Living Trust 8.Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9.Litigation Proceeds Received 10.Spousal Poverty Credit(date of death 11.Election to tax under Sec.9113(A)
between 12-31-91 and 1-1-95) (Attach Sch.0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
D 0 U G L A S G M I L L E R ? 1 7 2 4 9 2 3 5 3
REGISTER OF WILLS USE ONLY
First line of address
C-rn
I R W I N & M c K N I IS H T P • C C= C>
C)
Second line of address
M
;z; �> r— rn
6 0 W E S T P 0 M F R E T S T R E E T r— -- M W :M M (--j
City or Post Office State ZIP Code !-- cn DATE FILED
ZD C--, C3 —0 --q -n
C A R L I S L E P A 1 7 0 1 3 c--) <0
M
Correspondent's e-mail address: czO Cf) C>
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIG A RE OFIERSON ESP NSI FOR FILING RETURN TE
4
ADD
60 WESI POMFRET STREET CARLISLE PA 17013
REPRESENTATIVE
ADDRESS
60 WEST F4FRET STREET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side I
1505610140 1505610140
1505610240
REV-1500 EX Decedent's Social Security Number
Decedent's Name: LILA M. MITCHELL
RECAPITULATION
1. Real Estate(Schedule A) . . . . . .. . . . .. .. . . . . . .. .. .. .. .. .. . . . . . . . . . . .. 1
2. Stocks and Bonds(Schedule B) . .. . . . . . .. . . . . . . . .. .. . . . . . . . . . . . . . . . . . 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . . . .. 3.
4. Mortgages and Notes Receivable(Schedule D) . . . . . . . . . . . . .. . . .. .. . . . . . . 4.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). . . .... 5.
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . .. . 6.
7. Inter-Vivos Transfers&Miscellaneous Noir Probate Property 5 ? 4 6 . 8 9
(Schedule G) X Separate Billing Requested . ... .. . 7.
S. Total Gross Assets(total Lines 1 through 7) ... .. . . . . . . ... .. .. .. .. . . . .. 8. 5 ? 4 6 . 8 9
9. Funeral Expenses and Administrative Costs Schedule H 9. 4 2 1 5 . 0 0
10. Debts of Decedent,Mortgage Liabilities,and Liens Schedule I 10. ? 3 6 . 1 1
11. Total Deductions(total Lines 9 and 10) . . . . .. .. .. .. .. .. . .. .. .. . . . . . . .. 11. 4 9 5 1 . 1 1
12. Net Value of Estate(Line 8 minus Line 11) . .. .. . . . . . .. ... ... .. .. . . . .. . 12. ? 9 5 . ? 8
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) . . ...... . . .. . . . . . .. . . . 13.
14. Net Value Subject to Tax(Line 12 minus Line 13) ... .... . . . . . . . . . . .. .. . 14. ? 9 5 . ? 8
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X.0 _ 0 ❑ 0 15. 0 . 0 ❑
16. Amount of Line 14 taxable
at lineal rate X.0_ 0 . 0 0 16. 0 . 0 0
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 0 0 17. 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 0 0 18. 0 . 0 ❑
19. TAX DUE . . .. . . . . . .. . . . .. ... .. . .. . . ... .. .. . . . .. .. .. .. . . . .. . . . . . 19. 0 . 0 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Side 2
1505610240 1505610240 J
REV-1500 EX Page 3 File Number
Decedent's Complete Address: 0 0
DECEDENTS NAME
LILA M. MITCHELL
STREET ADDRESS
51 MOUNTAIN STREET
LOT 2
CITY STATE ZIP
MT. HOLLY SPRINGS PA 17065
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
2. Credits/Payments
A.Prior Payments
B.Discount
Total Credits(A+B) (2) 0.00
3. Interest
(3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00
5. If line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ...................................................................... El0
b. retain the right to designate who shall use the property transferred or its income; ...............................
171 X
IR
c. retain a reversionary interest;or ................................................................................................ 1771d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ El
2. If death occurred after December 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ❑
(91
3. Did decedent own an"in trust for'or payable-upon-death bank account or security at his or her death? ......... ❑ ❑X
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation?.................................................................................................. ❑ 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in
72 P.S.§9116(1.2)[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined,undE
Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-1510 E:X+(08-09)
pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
LILA M. MITCHELL 0 0
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE,THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH %OFDECUS EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER.-ATTACH ACOPY OFTHE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IFAPPUCADW VALUE
1. GLENBROOK LIFE ANNUITY 4,600.00 100.00 4,600.00
CONTRCT#GA 0591642
BENEFICIARY: MARTHA M. FITZ
159 SOUTH CHURCH STREET
WAYNESBORO, PA 17268
2. PNC BANK 1,146.89 100.00 1,146.89
CHECKING ACCOUNT#5003248577
TOTAL (Also enter on Line 7,Recapitulation) S 5,746.89
If more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
LILA M. MITCHELL 0 0
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. HOLLINGER FUNERAL HOME&CREMATORY, INC. 3,000.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Years)Commission Paid:
2. Attorney Fees: IRWIN & MCKNIGHT, P.C. 1,200.00
3. Family Exemption:(If decedents address is not the same as claimants,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees:
5 Accountant Fees:
6. Tax Return Preparer Fees:
7. REGISTER OF WILLS- FILING FEE 15.00
TOTAL(Also enter on Line 9,Recapitulation) $ 4,215.00
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
pennsylvania SCHEDULE
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES 8t LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
LILA M. MITCHELL 0 0
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 SHIPLEY ENERGY- FUEL 325.75
2. COMCAST-CABLE 171.75
3. CARLISLE PHYSICIAN SERVICES-MEDICAL 155.07
4. BARBARA J. BOISE, TAX COLLECTOR-TAXES 9.21
5. CARLISLE REGIONAL MEDICAL CENTER-MEDICAL 74.33
TOTAL(Also enter on Line 10,Recapitulation). $ 736.11
If more space is needed,insert additional sheets of the same size.
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
LILA M. MITCHELL 0 0
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec.9116(a)(1.2).)
1. MARTHA M. FITZ Collateral
159 SOUTH CHURCH STREET ANNUITY PROCEEDS
WAYNESBORO, PA 17268
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size.
'
Standard Checldng Statement Of- TWBANK
PNC Bank
Primary account number:50-0324-8557
Page I of 3
For the periost 1012512014 to 11/21/2014 Number of enclosures:0
0020117For 24-hour banking,and transaction or
LILA M MITCHELL interest rate information,sign on to
51 MOUNTAIN ST LOT 2 PNC Bank Online Banking at pne.com.
MOUNT HOLLY SPRINGS PA 17065-1431 For customer service call 1-888-PNC-BANK
Monday-Friday:7 AM-10 PM ET
Saturday&Sunday: 8 AM-5 PM ET
Para servicio en espafiol, 1-866-HOLA-PNC
Moving? Please contact us at 1-888-PNC-BANK
®Write to:Customer Service
PO Box 609
Pittsburgh PA 15230-9738
Visit us at PNC.com
TDD terminal:1-800-531-1648
For hearing impaired clients only
Standard Checking Account Summary Lila M Mitchell
Account number: 50-0324-8557
Overdraft Protection has not been established for this account.
Please contact us if you would like to set up this service.
Overdraft coverage-Your account is currently Opted-Out.
You or your joint owner may revoke your opt-in or opt-out choice at any time.
To learn more about PNC Overdraft Solutions visit us online at pnc.com/overdraftsolutions.
Call 1-877-588-3605,visit any branch,or Sign on to PNC Online Banking,and select the*Overdraft
Solutions"link under the Account Services section to manage both your Overdraft Coverage and Overdraft
Protection settings.
Balance Summary
Beginning Deposits and Checks and other Ending
balance other additions deductions balance
1,565.19 .00 418.30 1,146.89
Average monthly Charges
balance and fees
1,236.52 .00
Transaction Summary
Checks paid/ Check Card POS Check Card/Bankcard
withdrawals signed transactions POS PIN transactions
0 0
Total ATM PNC Bank Other Bank
transactions ATM transactions ATM transactions
0 0 0
Overdraft and Returned Item Fee Summary
Total for this Period Total Year to Date
Total Overdraft Item Fees (OD) .00 72.00
Total Continuous Overdraft Fees(COD) .00 35.00
Total Overdraft Fees .00 107.00
IVA
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Hou�^�w uneral Home ���� Crematory, Inc.u�
Eric LHollinger,Supervisor
November 13, 2O14
Maratha M. Fritz
S1Mountain St. Lot 2
Mt. Holly Springs, Pal7OGS
The 1-unena|Service for Li|aM. Mitchell
�
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.
Professional Service
Cremation Package 8-6navesideService $2695.00
Merchandise '
Snap Cube 100.00
Vault 150.00
AT THE TIME FUNERAL ARRANGEMENTS WERE MADE,WE ADVANCED CERTAIN PAYMENTS TO OTHERS
4SANACCOMMODATION. THE FOLLOWING |5ANACCOUNTING FOR THOSE CHARGES.
Cash Advances
Opening ofthe Grave $350.00
Lot and Deed 400.00
Certified Copies ofDeath Certificate (1O@ $G) 60.00
Cumberland County Coroner's Authorization 30.00
New/spaperNotice-Sendne| 193.73
Clergy 75.00
Flowers 30.00
Total Charges $4083'73
Discounted 1083'73
Total Due $3000,00
501 NORTH BALTIMORE AVENUE ° MOUNT HOLLY SPRINGS, PENNSYLVANIA 170*5 (717)486-3433 ~ PAX(717) 4eu-3u/u
vww.hoOiogerfuuecelhornezoro '
40%4,
Sheer 37654700000000000066406
376597 11/25/14
Due Date: 12/1W14 $66.40
KOI1IGN'S 011. SERV
P. O. BOX 116
NEWVILLE, PA 17241
PHONE: 776-3533 or 776-5685
DATE
SOLD TO ,. w.�,s ,�::��=�`%'.�
` ' $.00 $65.40
ADDRESS_ -' f<., ,;s-'f ,Z f�.. :fir'• Vis' 't I $1.00
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TERMS: NET 15 DAYS. INTEREST OF 1114% PER MONTH ADDED TO
ALL ACCOUNTS OVER 30 DAYS, OR 15% ANNUALLY. I
PAYMENT Q CHECK Q CASH Q THIS DELIVERY Q C.O.D. Q CHARGE ,
RECEIVED ' 1
Is Q A/C OLD BALANCE �21,76LL Q NOT FULL I II ! 1
1
f 1
THIS INVOICE HAS BEEN ACCURATELY COMPUTED AND AUTOMATICALLY PRINTED
a f
1 i t
Q CLEAR ULSD 15 MV2 82-SOY-15-ppm sulfur. � 1fi •
Q DYED ULTRA LOW SULFUR DIESEL-15-ppm sulfur dyed.Non-road or tax exempt use only. I
f I I
(] 1DYEp ULTRA LOW SULFUR KEROSENE-K1-Non-road or tax exempt use only. g 1
REMARKS
r _
i
=08mEa � 1 � $00 _.�$66�40.
SKgN HERE ___
BUDGET ACTJV:T7 j
Gals. Reading-Start"
Gals. Reading-Finish
a, NON-BUDGET ACTIVITY I.; 566.40
Sales Sequence Number
Priceper Gallon-Cents ~~� - :A;s si.oa �6s.4o {
E�n
_ .,, � i, ��6.4a
Product Cost
Tax
Total Price f t 376597 ia I
11/25/14 'Page: I
,ut:r.vtauurr�CCu:
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protection plans,24/7 repair
services are just a phone cal! . " :
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`-_::r: _..i�1
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comcasl. Account Number 09547 370793-03-1
lk
Billing Date 11/28/14
Unpaid Balance $96.35-Due Now
New Charges $75.40-Due 12/25/14
Total Amount Due $171.75
Contact us: www.comcast.com 1-800-XFINITY Page 1 of 3
W,
W.-
LILA MITCHELL E,
=2Ei
• Previous Balance 96.35
For service at: Payments-received by 11/28114 .0-00
51 MOUNTAIN ST LOT 2
MT.HOLLY SPGS PA 170655-1431 Unpaid Balance - Due Now 96.35
New Charges-Due by 12/25/14 75.40
News from Comcast see below for more information
Total Amount Due $171.75 ,
Questions?Call 1-800-XFINITY(1-800-934-6489)
Disconnect Warning:Payment for services received is now
seriously past due-All past due charges must be paid
XFINITY TV
5999
immediately. Failure to comply may result in disconnection of
services without further notice.Thank you for your prompt
Other Charges&Credits 11.00
payment.
If you have an American Express Card,use it to enroll in Taxes,- Surcharges&Fees 4.41
AutoPay.You can also enroll in Comcast's Ecobill process Total New Charges $75.40
today to say goodbye to checks,stamps,envelopes,and even
your paper bill. Learn how at www.corncast.co gymWccount
Hearing/Speech Impaired Call 711
Detach and enclose this coupon with your payment.Please write your account number on your check or money order.Do not send cash.
le—,-
ocomcast. Account Number 09547 370793-03-1
*Z7. Payment Due by Due Now
PO13OX 985
TOLEDO OH 43697-0985 Total Amount Due $171.75
AV 01 004762 196218 23 B**5DGT Amount Enclosed $
Ili till,.11111'11116.111.1111 fill-, Make checks payable to Comcast
LILA MITCHELL
51 MOUNTAIN ST LOT 2
MT. HOLLY SPGS PA 17065-1431Hill III-III I1111111111111111111111111111111
COMCAST CABLE
P 0 BOX 3006
SOUTHEASTERN PA 19398-3006
09547 370793 03 1 2 017175
7"A 1/25/14 Account No: CPS9589709
-21
LN
Billing Statement For: Numero De Cuenta:
-J- L Medical billing.Technology-driven. Lila Mitchell Page Number: 1 of 2
V
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For care received at: Carlisle Regional Medical Center Patient: Lila Mitchell
Provided by Carlisle Physician Services Acct No Numero De Guenta: CPS9589709
:�: v,--.;ar Room Ph-ysidari's bili which ;1,_; Insurance On File: Medicare Of Pa- Novitas
Q!w);3 11F,;{,. rc.;'o you, na*rpital :all. Your insurance company has How to reach us:
processed your claim and the balance is now your CD For credit card and electronic check payments
responsibility. For a summary of charges, please see the lIIIIII= visit:
back of this statement.
What you owe now: S"!55,07 TOLL FREE: 877-358-0145
Para preguntas, por favor Ilame al
-822-3370
866
N OW D U E.
Ntav; jnsuia;-ice cr,,hranqe of add ress/te.tephoti e information?
Pie�2se comp!ete the form on the back of the payment
o
Voucher, ® Have questions or inquiries? Please email us
at
Nue--.' ��;icum c 4-,7,7-r;Uo ale direccicn/telefono? Por favor
r.c'M e t: . fon-nul';2,,,;c) en :;,=, parte posterior de la hoja de
z�--ra a-yucla. flann* al 866-822-337).
111101111IMMi 3691-APOLLOSTM-2443511-1825420370-P; 10869819-1-101;35372429-1; 1
Detach and relum bottom portion with payment. Plea7sa;Ac 6,P.0s r!ysb*;n C-oslc wel-n yu,11 1:c=,!
f--F&F On
-------------
MENTS
Medical billing.Tech no logy-d riven.
Return mail Processing Center
PO Box 3475
Toledo,OH 43607-0475
Do Not Send Payments or Correspondence To This Address
RETURN SERVICE REQUESTEDvIN PATIR"!:4A-*,I-
Lila Mitchell
W L CPS9589709
_j IL,40�14 $155.0,7—..-
NewAddr'ss?Ct7cck here and writc your new address on the bark ANtiz
48
�vvice'.
006956 LILA M MITCHELL CARLISLE PHYSICIAN SERVICES
0101 0
51 MOUNTAIN ST 0 Mailstop: 47348973
MT HOLLY SPGS, PA 17065-1431 (n(?, PO BOX 660827
DALLAS, TX 75266-0827
47348973000000000000000000OOOCPS95897091125201400000155073
BARBARA J BOISE,TAX COLLECTOR TAXPAYER'S COPY
406 NORTH WALNUT STREET
MT HOLLY SPRINGS,PA 17065 KEEP THIS PORTION FOR YOUR RECORDS
TEMP - RETURN SERVICE REQUESTED
***** REMINDER NOTICE
IIIIIIIIIIIIII�IIIIIIIIJ��IILIIIIIIIIIIJ111111i11�'I'Illllllll
001261`"`-*`"" -**'AUTO"5-DIGIT 17007
MITCHELL,LILA I IIIIII VIII VIII VIII 111111111111111111111111 IN51 MOUNTAIN STREET LOT 2
MOUNT HOLLY SPRINGS PA 17065-1431
To review the assessment data for this ppropertyy, go to:
www.courthouseonline.com>AssessmentOffice>Cumberland>PropertyRecords.
Then enter control# 23000692 and password
. . .. ........I. ....... .. ........... ........... .... ..... ............ ......................................................................... ...... ........
'***' REMINDER NOTICE '`**'*
Payable To: BARBARA J BOISE,TAX COLLECTOR Office Hours: OPEN THURS 6-8PM
406 NORTH WALNUT STREET CALL FOR AM APPOINTMENTS
MT HOLLY SPRINGS,PA 17065 LISTEN FOR CLOSINGS ON PHONE
Bill No: 523
PHONE(717)486-3480 Bill Date: 03/01/2014
Control No: 23000692
MAP NO: 23-32-2338-043.-TR08354
Desc: 2 STOVERS MHP Assessed Value: Land:0 .Improvement: 1,800 Total: 1,800
Discount Face ena y
STOVERS M.H.P.
LOT 2 County RE 2.195 $3.87 $3,95 $4.35
County Lib 0.143 $0.25 $0.26 $0.29
Munic.R/E 1.857 $3.27 $3.34 $3.67
Fire Protc 0.216 $0.38 $0.39 $0.43
$1"FEEFORDDITI11111 111�1ONAL RECEIPTS Mun St Lt 0.239 $0.42 $0.43 $0.47
Tax Payer:
MITCHELL,LILA TAX AMOUNT DUE
51 MOUNTAIN STREET LOT 2 $8.19 $8.37 $9.21
MOUNT HOLLY SPRINGS PA 17065-1431 If Date Of Payment is on 3/1/14 thru 4/30/14 5/1/14 thru 6130/14 711/14 or Later
-•• • •
.... . .......... ................................ . . ... ...... ...........I.............. I.... ...... .. .... ............I......... .......
..
***** REMINDER NOTICE
Cumberland County Pennsylvania elts
TAX COLLECTOR COPY -RETURN WITH PAYMENT FOR PROPER CREDIT Bill No: 523
MITCHELL,LILA 2 STOVERS MHP Bill Date: 03/01/2014
51.MOUNTAIN STREET LOT 2 STOVERS M.H.P. Control No:23000692
MOUNT HOLLY SPRINGS PA 17065-1431 LOT 2 MAP NO:23-32-2338-043.-TR08354
Payable To: Assessed Value: Land:0 Improvement:1,800 Total: 1,800
BARBARA J BOISE,TAX COLLECTOR Discount Face Penalty
406 NORTH WALNUT STREET
MT HOLLY SPRINGS,PA 17065 County RE 2.195 $3.87
County Lib 0.143 $0.25
PHONE(717)486-3480
IIIIII IIIII IIII IIIII IIIII IIII IIIII IIIII IIII III Fire0.216 $0.38 $0.39 $0.43
St Lt
Mun St Lt 0.239 $0.42 $0.43 $0.47
TAX AMOUNT DUE $8.19 $8.37 $9.21
If Date of Pavment Is On 3/1/14 thru 4/30/14 5/1/14 thru 6/30/14 7/1/14 or Later
Are you ,,1t sarneo ne you skriow Vtiiou,-"- h3Mn in
SLE Affordable health insurance options are now available!
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Patient Name Lila M Mitchell
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Account Number 9589709 (available 24/7)
Date of Service October 28, 2014
Service Type Emergency Room Services By phone -717-960-1680
Insurance Name Medicare Outpatient
Name of Insured Lila M Mitchell lf�
,Z,I' qy check-return section below with check
Policy Number XXXXXX884A
$74.Z3
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Amount due from you is$74.33 as of 11/23/2014 for The charges listed below do not reflect the discount that
Emergency Room Services performed on October 28, you and your insurance company received.
2014. Emergency Room 3,631.38
Total Charges .$3,631.38 TOTAL CHARGES $3,631.38
Discounts/Adjustments Given -$3,321.68
Insurance Payments Received -$235.37
Amount You Paid $0.00
Arnou Duse Fri rn You $74.33
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W3269-HMASTMT-2443269-1825201595-P; 10869077-1-1586;35371638-1; 1
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The amount shown on this statement is outstanding at this time.Your prompt
payment Will be greatly appreciated.
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MASTERCARD 01scovER VISA AMEXA
361 Alexander Spring Rd. Save Time and Postage. Pay your bill Online or by Phone
RF—iONAL Carlisle, PA 17015
Today. It's Fast, Easy, and Secure.
www.cadislermc.com
PATIENT NAME STATEMENT DATE! DATE DUE
Lila Estate Mitchell 11/23/2014 UPON RECEIPT
Patient Financial Services: J.
ACCOUNT NUMBER I AMOUNT DUE AMOUNT PAYING
717-960-1680 95897091$74.3
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REMIT THIS PAYMENT STUB TO:
005889 LILA ESTATE MITCHELL CARLISLE REGIONAL MEDICAL CENTER
0101 51 MOUNTAIN ST PO BOX 281442
MT HOLLY SPGS, PA 17065-1431 Atlanta, GA 30384-1442
00000958970900000007433LILAESTATEMITCHELL 7,