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Home My WebLink About08-28-15 .� REV-1500 EX`°2_,,, � 1505610143 OFFICIAL USE ONLY PA Oepartment of Revenue pennsylvania Counry Code Year File Number Bureau of Individual Taxes DEPARTMENTOFREVENUE Po Box.2sosol INHERITANCE TAX RETURN 2 1 1 5 0 0 0 7 6 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth O1 10 2015 04 14 1924 DecedenYs Last Name Suffix DecedenYs First Name MI BIVENS MERRILL R (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1. Original Return ❑ 2. Supplemental Return � g.Remainder Return(Date of Death Priorto 12-13-82) � 4. Limited Estate � qg.Future Interest Compromise � 5. Federal Estate Tax Return Required (date of death after 12-12-A2) 6 Decedent.Died Testate �. Decedent Maintained a Living Trust � 8, Total Numbe�of Safe Deposit Boxes � (Attach Copy of W ill) � (Attach Copy of Trust) � 9. Litigation Proceeds Received � 10.Spousal Poverty Credit(Date of Death � 11.Election to tax under Sec.9113(A) between 1231-91 and 1-t-95) (Attach Schedule O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number DUANE P STONE 717 432 2089 REGISTER OF WILLS U1SE ONLY •�� :-� First Line of Address C � ..� rn 3 N $ALTIMORE 5TREET � � �� ,:-� �.n.� ..� :' `,-, c=� , � Second Line of Address , ' , -- N a, '�.=� - r-� - ,;, Oo . _� DX1�fE RILED .,, e� City or Post Office State ZIP Code , � DILLSBURG PA 17019 ' � - � ►.-• --= c> , ►---� "._ rn ; f_.1 iJ3 0 CorrespondenYse-maiiaddress: Duane@StoneDuncan.COtfl � Cl1 � 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. SIGNAr�Jq PERSON E FOR FlLING RETURN DATE 1 Thomas D Scott 2�� S ADC)HESS � 15 East Eppley Drive, Carlisle, PA 17015 SIGNATII REPARER OTHER THA EP ENTATIVE DATE �,�_� Duane P Stone Z � ,�f,��. /� ADDRESS Stone, Duncan & Linsenbach 3 N. Baltimore Street, Dilisburg, PA 17019 Side 1 L 1505610143 1505610143 � J 150561U243 REV-1500 EX DecedenYs Social Security Number DecedenYs Name: B I V E N S, M E R R I L L R RECAPITULATION 1. Real Estate(Schedule A).......................................................................................... 1. 5 2 O , 0 0 0 . 0 0 2. Stocks and Bonds(Schedule B)............................................................................... 2. 2 , 7 4 0 . 0 0 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C).......... 3. 4. Mortgages&Notes Receivable(Schedule D).......................................................... 4. 5 Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)................ 5. 9 8 , 1 4 2 . 1 9 6. Jointly Owned Property(Schedule� ❑ Separate Billing Requested............. 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested............. 7. 1 1 3 , 2 8 2 . 0 0 g. Tota1 Gross Assets(total Lines 1 through 7).......................................................... g. 7 3 4 , 1 6 4 . 1 9 9. Funeral Expenses and Administrative Costs(Schedule H)..................................... 9. 8 8 , 5 5 4 . 2 0 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................. 10. 3 , 0 6 9 . 5 2 11. Total Deductions(total Lines 9 and 10).................................................................. 11, 9 1 , 6 2 3 . 7 2 12• Net Value of Estate(Line 8 minus Line 11)............................................................. 12. 6 4 2 , 5 4 0 . 4 7 �3, 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. 6 4 2 , 5 4 0 . 4 7 TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(12)X.00 15. 16. Amount of Line 14 taxable at�ineal rate x .oa5 6 4 2 , 5 4 0 . 4 7 �s. 2 8 , 9 14 . 3 2 17. Amount of Line 14 taxable at sibling rate X ,12 ��• 1 S. Amount of Line 14 taxable at collateral rate X .15 18• 19. TAXDUE................................................................................................................... 19. ZH , 914 . 32 20. FILL IN THE OVAL IF YOU ARE RE�UESTING A REFUND OF AN OVERPAYMENT. � Side 2 L 1505610243 1505610243 � REV-1500 EX Page 3 File Number 21 - 1 5 - 00076 Decedent's Complete Address: DECEDENT' NAME Bivens, Merrill R STREET ADDRESS 1 Longsdorf Way CITY STATE ZIP Carlisle PA 17015 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 28,914.32 __—--- 2. Credits/Payments A. Prior Payments 40,612.50 B. Discount 1,445.72 Total Credits(A +B) (2) 42,058.22 3. Interest (3) 0.00 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) 13,143.90 Check box on Page 2,Line 20 to request a refund 5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. �5� _ _ Make Check Payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred:.................................................................................. L �x� b. retain the right to designate who shall use the property transferred or its income:.................................... �� c. retain a reversionary interest;or.................................................................................................................. ❑ � d. receive the promise for life of either payments,benefits or care?.............................................................. ❑ [� 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without -- receiving adequate consideration?....................................................................................................................... � 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?...................................................................................................................... �� _1 IF THE ANSWER TO ANY OF THE ABOVE�UESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. o:��, For dates of death on or after July 1,1994 and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after January 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 tau 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)(j.2)]. •The tax rate imposed on the net value of transfers to or for the use of the decedenYs lineal beneficiaries is 4.5 percent,except as noted in [72 P.S.§9116(a) (1)]. •The tax rate imposed on the net value of transfers to or for the use of the decedenYs siblings is 12 percent[72 P.S.59116(a)(1.3)1. A sibling is defined under Section 9102,as an individual who has at least one parent in common with the decedent,wfiether by blooa or adoption. . � � � „ ' �� <� � � �„ � a � �� o rn � n � � �.�c�t �iYY �c��► �e�t�cn�er�t � � � N ; ; � ._r �:� ,.I ` �:��:r .,.,r C�..`l �y �� —p .7 --p,� . -�:a �-r Y .-� '�l OF _. _.._: � "s`; c� . �� N f- � MERRILL R.BIVENS cn p " Cp —'i BE IT REMEMBERED,that I,MERRILL R.BIVENS,of 1 Longsdorf Way, Apartment 30,Carlisle,Pennsylvania,being of sound mind,memory and understanding, do make,publish and declare this as and for my Last Will and Testament,hereby revoking and making null and void any and all Wills and Testaments and writings in the nature thereof by me at any time heretofore made. ITEM 1: I direct that all my just debts and funeral expenses be paid as soon after my demise as may be convenient. ITEM 2: All the rest,residue and remainder of my estate,of whatsoever nature and wheresoever situate,whether it be real,personal or mixed,including property over which I have a power of appoinhnent, I give, devise and bequeath unto my wife, HELEN S. BIVENS,absolutely,providing she survives me for a period of thirty(30)days ITEM 3: Should my wife,I-dELEN S.BIVENS,predecease me,fail to survive me for a period of thirty(30)days,or should we die simultaneously,I then give,devise and bequeath my entire residuary estate unto ANNA BIVENS SCOTT. Should ANNA BIVENS SCOTT predecease me, fail to survive me for a period of thirty(30) days,or should we die simultaneously,I then give,devise and bequeath my entire residuary estate unto EMILY SCOTT GEDDES and JANET SCOTT DONOVAN,per stirpes. ITEM 4: I direct my hereinafter named Executrix to pay all inheritance,estate, succession and legacy taxes of whatsoever nature and kind, to which my estate or the transfer of any property passing hereunder or otherwise passing by reason of my demise, may be subject and to charge such taaces against my residuary estate,it being my intention that none of the aforesaid taxes,either federal or state,on any property required to be included in my gross estate,under the provisions of any state or federal law now in force or hereafter enacted,shall be prorated among the persons interested in my estate to whom such property is or may be transferred or to whom any benefit accrues. ITEIo'I 5: I appoint THOMAS D.SCOTT and ANNA SIVENS SCOTT as Co- Executors of this my Last Will and Testament. Should THOMAS D.SCOTT and ANNA �IIVENS SCOTT predecease me,fail to qualify,cease to act or renounce probate,I then appoint, EMILY SCOTT GEDDES, as alternate Executrix of this my Last Will and '3'estamen4. ITEM 6: I direct that my Executors,Guardians,Trustees,or their successors shall not be required to give bond for the faithful performance of their duties in any jurisdiction. ITEM 7: My Personal Representatives shall have the following powers in addition to those vested in them by Law and by other provisions of this, my Last Will and Testament, exercisable without court approval, and effective until distribution of all property: 1. To retain any or all of the assets of my estate, real or personal, without restriction to investments authorized for Pennsylvania fiduciaries, as they from time to time may deem proper, without regard to any principal of diversification or risk. 2. To invest in all forms of prope:ty without restriction to inves�nznts authorized for Pennsylvania fiduciaries,as they from time to time may deem proper,without regard to any principal of diversification or risk. 3. To sell at public or private sale,to exchange, or to lease for any period of time,any real or personal property and to give options for sales,exchanges or leases,for such prices and upon such terms or conditions as they from time to time may deem proper. 4. To allocate receipts and expenses to principal or income or partly to each as they from time to time may deem proper. 5. To borrow money from persons or institutions,themselves included, and to mortgage or pledge any or all real or personal property as they in their sole discretion shall choose, without regard to the dispositive provisions of this instrument. 6. To comprcmise any claim or controversy as�erted by or against my estate or trust estate. 7. To make distribution in cash or in kind or partly in cash and partly in kind, and in such manner as they may determine, and at valuations fmally to be fixed by them. IN WITNESS WHEREOF,I have hereunto set my hand and seal this 20�'day of May,2014. WIT'NESS: � ,r.-� . ..�,-.;' �.P:vG�,� IZ '��civPiv►�(SEAL) MERRILL R.BIVENS � � r�-� COMMONWEALTH OF PENNSYLVANIA . :SS COUNTY OF CUMBERLAND . We, MERRILL R. BIVENS, JAN M. WILEY, ESQUIRE and DEBRA L. WILEY, the Testator and the witnesses respectively, whose names are signed to the attached or foregoing instrument, being first duly swom, do hereby declare to the undersigned authority that tlie Testator signed and executed the instniment as his Last Will and Testament and that he had signed�villingly(or willingly directed anothe:to sign for him), and that he executed it as his free and voluntary act for the purposes therein expressed, and that each of',the witnesses, in the presence and hearing of the Testator, signed this Last Will and Testament as witness and that to the best of their knowledge the Testator was at the time eigliteen(18)years of age or older,of sound mind and under no constraint or undue influence. �'�2ev�,f� lc' f�.Gv�•►� MERRILL R.BIVENS �'� .,., i� f TNESS . ��b�'�.�°°fc WITNESS S�uorn to and subscribed i before me this 20th day of May,2014. �l cv�.�c�.�.�.�- � NOTARY PUBLIC MY COMMISSION EXPIRES: �i1((��, COMMONWEALTH OF PENNSYLVANIA Notarial Seal Sa�ah Ann Kuhn,NoWry Public Franklin Twp.,York Caunty My Commission Expires Nov.16,2016 M:MBER,PENNSYIVpNL1 ASSOCIA7ION OF NOTARIES COMMONWEALTH OF PENNSY�VANIA REV-1 162 EX(1 1-96) DEPARTMENT OFREVENUE BUREAU OF INDIVIDUAL TAXES DEPT.280601 HARRISBURG,PA 1 71 28-060 7 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 020422 WILEY JAN M THE WILEY GROUP 3 N BALTIMORE AVENUE DILLSBURG, PA 17019 ACN ASSESSMENT AMOUNT CONTROL NUMBER '_____'_ fold _'__'____' _'_"___ 101 � S40,612.50 ESTATE INFORMATION: Ssrv: 20�-�6-soo3 � FILE NUMBER: 211 5-0076 � DECEDENT NAME: BIVENS MERRILL R � DATE OF PAYMENT: 03/27/2015 � POSTMARK DATE: 03/25/201 5 � CouNrY: CUMBERLAND � DATE OF DEATH: 01/1 O/201 5 � � TOTAL AMOUNT PAID: 540,612.50 REMARKS: RCPT TO ATTY CHECK# 1044 INITIALS: DB1 SEAL RECEIVED BY: LISA M. GRAYSON, ESQ. REGISTER OF WILLS TAXPAYER �-� pennsyl�vania E SCHEDULE A INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT . .._-- -__ .._- _ -- ---- - -- --- -- __-.__. ESTATE OF Merrill R FILE NUMBER Bivens, 21 - 15 -00076 ___ _- ---- -- ---- - All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be excF�anged between a willing buyer and a wilfing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on schedule F. Attach a copy of the settlement sheet if the property has been sold. Include a copy of the deed showing decedenYs interest if owned as tenant in common. -- - -- -------- - -------- — ---- ITEM VALUE AT DATE OF NUMBER DESCRIPTION DEATH — - _ - ------ - --------- 1 61 Acres- Geibs Road, Peters Twp, Franklin County farm land-appraisal 520,000.00 TOTAL(Also enter on Line 1, Recapitulation) 520,000.00 Previous edilions are obsolete fortn HUD-1(3/86)ref HanC600k 43052 A. Jett1e1T1e11t �7t8teTT1eI1t . U.S.Departmc�3f Housing and Urban Development B.T of Loan OMB A roval No.2502-0265 1. ❑FHA 2. ❑FmHA 3. $�Conv,Unins. 6.File Number 7.Loan Number 8.Mortgage Insurance Case Number 4. VA 5. Conv.lns. 2015-0512 0562814410 NA is arm is mi o grve you a a emen a a se emen ms . un pa o a y e se men agen are own. Q.NOI6: Items marked'(p.o.c.)"vrere paitl outside ihe cbsing;they are shown here br infortnation purposes and are not incWtletl In the mtals. TIdEEX�7fBSS$0�2fflEfl�$YSt2fi1 WARNING:I!is a crime to knowingly make false statements to the UniteC States on Nis or any oMer simAar lolm.Penalties upon convictan can indude a fine ana im risanment For detads see:Tine te u.S.Code Sectlon�OOi and Settion ioto. Pflfifed OFi/25/2015 ffi OJ:35 TND D.NAME OF BORROWER: Jamie L.Hartman and Jami L.Hartman ADDRESS: 2879 Mercersbur Road St.Thomas PA 17252 E.NAME OF SELLER: The Estate of Merrill R.Bivens ADDRESS: 15 East E le Drive Carlisle PA 17015 F.NAME OF LENDER: AgChoice Farm Credit,ACA for itself and/or as AgenUNominee for AgChoice Farm Credit,FLCA ADDRESS: 921 S.Center Ave.PO Box 716 New Stanton PA 15672 G.PROPERTY ADDRESS: 62 acres(+I•)on Geibs Rd,St.Thomas,PA 17236 Peters Townshi H.SETTLEMENT AGENT: FC Settlement Services PLACE OF SETTIEMENT: 109 Farm Credit Dr. Chambersbur PA.17202 I.SETTLEMENT DATE: O6l26/2015 J.SUMMARY OF BORROWER'S TRANSACTION: K.SUMMARY OF SELLER'S TRANSACTION: 100.GROSS AMOUNT DUE FROM BORROWER 400.GROSS AMOUNT DUE TO SELLER 101. ConVact sales rice 520 000.00 401. Contract sales rice 520 000.00 102. Personal ro e 402. Personal ro e 103. Settlement char es to bonower line 1400 226113.42 403. 104. A I funds to Loan#122739-01 3159.39 404. 105. 405. Ad'ustments for items aid b seller in advance Ad'ustments for items aid b seller in advance 106. Cit ltown taxes 406. Cit/town taxes t07. Count taxes 06126/15to12131115 137.58 407. Coun taxes 06/2fi115to12131f15 137.58 108. SchoolTaxes O6l26N5to06/30/15 14.61 408. SchoolTaxes 06126N5to06/30115 14.61 109. 409. 110. 410. 111, 41 t. 112. 412. 120.GROSS AMOUNT DUE FROM BORROWER 749 425.00 420.GROSS AMOUNT DUE TO SELLER 520152.19 200.AMOUNTS PAID BY OR ON BEHALF OF BORROWER 500.REDUCTIONS IN AMOUNT DUE TO SELLER 201. De osit or eamest mone 5 000.00 50t. Excess De sit see instructions 202. Princi al amount of new loans 390 000.00 502. Settlement char es to seller line 1400 26 004.00 203. 6cistin loan s taken sub'ed to 503. Existin loan s taken sub'ecl to 204. 504. Pa off of First Mort a e Loan 205. Loan#122739-20 to A Choice 354 425.00 505. Pa off of second mort a e loan A Choice Farm Credit ACA 206. 506. 207. 507. Inhert.tax escrow to FCSS 5 000.00 FCSS 208. 508. 209. 509. Ad'ustments for items un aid b seller Ad'ustments for items un aid b seller 210. Cit/town taxes 510. Cit Irown taxes 211. Coun taxes 511. Coun tattes 212. School Taues 512. School Taxes 213. 513. 214. 514. 215. 515. 216. 516. 217. 517. 218. 518. 219. 519. 220.TOTAL PAID BYIFOR BORROWER 749 425.00 520.TOTAL REDUCTION AMOUNT DUE SELLER 31 004.00 300.CASH AT SETTLEMENT FROM OR TO BORROWER 600.CASH AT SETTLEMENT TO OR FROM SELLER 301. Gross amounl due from borrower line 120 749 425.00 601. Gross amount due to seller line 420 520152.19 302. Less amounts aid b/for borrower line 220 749 425.00 602. Less reduction amount due seller line 520 31 004.00 303.CASH FROM BORROWER 0.00 603.CASH TO SELLER 489148.19 SUBSTITUTE FORM 1099 SELLER STATEMENT:The inbrmation contained herein is important taz informatlon antl is 6eing fumishetl ro Ne In[emal Revenue Service.Ii you are required[o lile a retum, a negligence penalry or other sanction will be imposed on you it[his item is required lo he reported and ihe IRS determines Iha[it has not been reported.The Contract Sales Price tlescribed on line 401 above constitutes ihe Gross Proceetls ol this transaction. You are required by Ww ro provitle the settiement agent(Fetl.Tac ID No:25-1008018 with your wrrec!ta�cpayer identilication number.Ii you tlo not provide your correct[axpayer itlentiibation number,you may be su6ject to civil or criminal penalties imposed Oy law.Untler pena�ties ol perjury,I certily Nat Ihe number shown on[his s�atemen[is my correct[azpayer identHication number. TIN: _- / _ SELLER(S)SIGNATURE(S): / SELLER(5)NEW MAILING ADDFE55: SELLEfl(S)PHONENUMBERS: (H) (W) Previous editions ere obsole[e fortn HUD-1(3/8fi)ref Hantlbook 43052 U.S.DEPARTMENT OF HOUSING AND URBAN''"VELOPMENT File Number:2015"''2 PAGE 2 SETTLEMENT STATEMENT TitleEx ress SetUeir._.:,S stem Printed 06125/2015 at 09:35 TND L. SETTLEMENT CHARGES PAID FROM PAID FFOM 700.TOTAL SALES/BROKER'S COMMISSION based on rice$520 000.00 4.000=20 800.00 BORROWER'S SELLER'S Division of commission Iine 700 as follows: FUNDS AT FUNDS AT 701. $ 20 800.00 to REIMau Real A enc SETTLEMENT SETTLEMENT 702. $ to 703. Commission aid at SetBement 20 800.00 800.ITEMS PAYABLE IN CONNECTION WITH LOAN 801. Loan Ori ination Fee %A Choice Farm Credit ACA LR 275.00 802. Loan Discount % 803. A raisal Fee to A Choice Farm Credit ACA LR 350.00 804. Credit Re R 805. A lication fee to A Choice Farm Credit ACA LR 375.00 806. 807. Ori .fee Loan#122739-20 to A Choice Farm Credit ACA LR 500.00 808. Mt satfee to A Choice Farm Credit ACA LR 96.00 809. 810. 811. 900.ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE 901. Interest From 06/2612015 to 07l0112015 $ Ida 5 Da s LR 308.75 902. Morl a e Insurance Premium for to 903. Hazard Insurance Premium for to 904. 905. 1000.RESERVES DEPOSITED WITH LENDER FOR 1001.Hazard Insurance mo. $ /mo 1002.Mort a e Insurance mo. $ /mo 1003.Cit Pro e Tax mo. $ /mo 1004.Coun Pro rt Tax mo. $ /mo 1005.School Taxes mo. $ Imo 10D9.A r ateAnal sisAd'ustment 0.00 0.00 1100.TITLE CHARGES 1101.Settlement or Closin Fee 1102.Abstract or TiUe Search 1103.TiUe 6camination 1104.TiUe Insurance Binder 1105.Doc Pre-Subordination to Dillon McCandless Kin 150.00 1106.Nota Fees 1107.Attome's fees includes above items No: 1108.TiUe Insurance to Chica o Tkle Insurence Com an 2 980.00 includes above items No: 1109.Lender's Polic 390 000.00 •2 350.00 1110.Owner's Polic 520 000.00 •630.00 1111.100 No Viol,300 Surve,900 E to Chica o Title Insurance Com an 150.00 1112.Closin SvcLtr to Chica o Title Insurance Com an 125.00 1113. 1200.GOVERNMENT RECORDING AND TRANSFER CHARGES 1201.Recordin Fees Deed$87.00 �Mort a e$97.00 ;Release$ 184.00 1202.Cit ICount tax/stam s Deed$5 200.00 •Mort a e$ 5 200.00 1203.State Ta�stam s Deed$5 200.00 ;Mort a e$ 5 200.00 1204.Addtl Mt to record Deed$ •Mort a e$139.00 139.00 1205.Record Subordination to Recorder of Deeds 40.50 1300.ADDITIONAL SETTLEMENT CHARGES 1301.Tax Certification to FC Settlement Services 4.00 1302.Wire fee to FC Settlement Services 18.00 1303.Courier fee to FC Settlement Services 20.D0 1304.Pa off#05229745-12 to A Choice Farm Credit ACA LR 136 076.47 1305.Pa off#122739-17 to A Choice Farm Credit ACA LR 18 420.20 1306.Pa off#122739-18 to A Choice Farm Credit ACA LR 29171.58 t307.Pa off#122739-19 to A Choice Farm Credit ACA LR 31 533.92 1400.TOTAL SETTLEMENT CHARGES enter on lines 103 Section J and 502 Section K 226113.42 26 004.00 HUD CERTIfICATION OF BUYER AND SELLER I have carelully reviewed Ihe HUO-1 Settlement Statement antl to ihe best of my knowletlge antl beliei,d is a e and acarate statement of all receipts and disbursements matle on my account or Dy me in Mis Vansactbn.I furth r certNy that I�ave received a copy ol the HUD-1 Settlement Statemenl ��-� -t ��Np� mie . a man ami . - The Esta[e ot Merrill R.Bivens ✓ � �!�G� ✓(��./��?� y: omas . co, xecu or na . rvens co o-zecu or WARNING:IT IS A CRIME TO KNOW INGLY MAKE FALSE STATEMENTS 70 THE The HUO-1 SeMement Slale ent hich I have preparetl is a true and accumte account ot this UNITEO STATES ON THIS OF ANV SIMILAR FORM.PENALTIES UPON CONVICTION transac6on.I have caused r will use ihe funds to be diSDursetl in accordance with this 5fatemenL CAN INCIUDE A FINE AND IMPRISONMENT.FOR DETAILS SEE TITLE 18: �'- U.S.CODE SECTION 1001 AND SECTION 1010. �� I S SETTLEMENTAGEN DATE: REV-1503 EX+(6-98) SCHEDULE B COMMONWEALTHOFPENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ___: .-.. . _... . ___ _- .__. . ___ . ..__ .._._'_'__- . . FILE NUMBER ESTATE OF BIVeC1S, Merrill R 21 - 15 -00076 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM DESCRIPTION UNIT VALUE VALUE AT DATE OF NUMBER DEATH -----______- ---- - --- ---- --- - 1 0.00 i I 2 � Cumberland Valley cooperative Assoc. 2,740.00 � Stock nos 6510,8441 & 10613 � ; � I � � il � � il I i � I I _______--------- � --- - _- TOTAL(Also enter on line 2, Recapitulation) 2,740.00 DATE Q�2�1��].�J 0 2 4 8 0 6 cu��a�� va�� o��a�� . y REFERENCE Df�TE DESCRiPTION VOUCHER RIMOUNT 02f05/15 STQCK PURCHASE 1I0�655 480.04 r02 f 05/15 STQGl� PURCHASE ' 110656 77Q�_00 02/�5/15 STQCK PURCHASE 11a657 1490.40 ,,_�:_��__�T,�:RBIVENS ESTf�E,. MERRILL R. , 2740_OQ ) _ �-G'._acvc_s... r...a��—.rs� -._ . . . . � W ��5�� . ��a�� e 02 4 8 0 6 �� Transaction Services 908 MT. ROCK ROAD Provided by Weils Fargo Bank,N.A. x,�'` P.�. B�X 350 . 66-156(531 �� SHIPPENSBURG, PR 17257 , PH: 717-532-2191 a e� • �� ' a2�so� o�/i2/i� ****�2�a-a.00* Two thousand seven hundrec! forty 'and i�Ofl00 PAY MERRILL R_ BIVENS ESTFY�� y TO THE �<��/L�y_..__ '� ORDER Stone, Duncan, & Linsenbach AC ' -- _ -- --. . -.__ _ ...._� or- � M. Balti.more Streat Dillsburg, � ,� PA 17419 - ___..._._ .--_._ �� _..._.�--- -_____- - ----"-'' �� i�'0 24806ii' �:053 �0 L56 L�: 2079900606876i�' �� pennsylvania SCHEDULE E �� DEPARTMENTOFREVENUE CASH BANK DEPOSITS AND MISC. INHERITANCE TAX RETURN � RESIDENTDECEDENT PERSONAL PROPERTY - -- --- --___ . .-:-- - ---- ----- - --- -... - ___... — FILE NUMBER ESTATE OF Bivens, Merrill R 21 - 15 - 00076 Include the proceeds of litigation and the date the proceeds were received by the estate.All property jointly-owned with the right of survivorship must be disclosed on schedule F. _ --------- ---------- ITEM VALUE AT DATE OF NUMBER DESCRIPTION DEATH -- ---_ __. _ _ _. _ ---- — — __. 1 F&M Trust- checking account#3440048 65,896.40 2 F&M Trust- Money Market Acct#7141947 23,086.79 3 CNA: Long Term Care (M) 129.00 4 CNA: Long Term Care (H) 3,999.00 5 CNA: Long Term Care (M) 1,290.00 6 CNA: Long Term Care (M) 3,483.00 7 CNA: Long Term Care (H) 258.00 ------ ------ -- — TOTAL(Also enter on Line 5, Recapitulation) 98,142.19 o � � � � � � � fD x � o � � p v �o m � d d s � m � c N O 7 N � n � C n p� N � p � O � O "'� M N A � c � Z 3 v m v � �m N N o � m T � o � � � 3 N v 91 �I � � N Ip ? r C O � i O W U T Z N n N —� � W N W �D � N � � O y e+ C7� � N � W W Ut S1 O OD � Qo cD 7 W � � A N O � � W � C1 W � � C N a � N � � N � W (T y O O� � -�w Lt � � � W d c�0 O � pf O � � � 1D 2 � 2 � D <° cp m c° � � =� � -� o � � �� w W a°a° O m � m � f N fp N N fD N --� N (J� N N W ` N � O O N O O 3 Oo O N (n N W a N S N G Conti�ental Casualty Company Check Number: 401076781 To: MERRILL R BNENS 2088457325 Date: O1J12/2015 Invoice Number Date Voucher Number Amount Discount Paid Amount 00000000022002162502 O1/12/2015 01487375 $129.00 �0.00 $129.00 TOTA!S: $224.00 5�.00 y129.00 Continental Casuatty Company Adminisbered eyc 401076781 �� 333 S.Wabash Ave Long Tertn Care Group,Inc Chicago,IL 60604 11000 Prairie lakes Drive 50-937/213 1-800-262-1037 Eden Prairie,MN 55344 DATE AMOUNT PaY One Hundred Twenty Nine Dollars and 00 Cents Jan 12,2015 $129.00 VOID AFfER 6 MONTHS FROM MONTH OF ISSUE �the Order of: MERRILL R BIVENS � '..i �� G�� j _`\ t, � a ✓�J 15 E EPPLEY DR �—� CARLISLE, PA 170154379 JP Morgan Chase Bank,N.A. Sy2cuse,NY r1Po S�T ��'40 �076 ?8 L��' �:0 2 L309379i: 630 15 L�099509��' Conti�e:�tai Casualty Company Check Number: 401078290 To: HELEN 5 BNENS 2090120230 Date: 01/15/2015 Invoice Number Date Voucher Number Amount Discount Paid Amoun't 00000000022002164505 O1/15IZ015 01489040 $3,999.00 $0.00 $3,999.00 TOTALS: $3,999.00 $0.00 �3,999.00 Continental Casualty Company Administered ey: 401078290 �� 333 S.Wabash Ave 1..ong Term Care Group,Inc Chicago,IL 60604 11000 Prairie Lakes Drive 50-937/213 1-800-262-1037 Eden Prairie,MN 55344 DATE AMOUNT PaY Three Thousand Nine Hundred Ninety Nine Doilars and 00 Cents Jan 15,2015 $3,999.OQ VOID AFTER 6 MONTHS FROM MONTH OF ISSUE �the Order of: HELEN S BNENS /,� a1��J 15 E EPPLEY DR `1 `�., V CARLISLE, PA 170154379 �'~� JP Morgan Chase Bank,N.A. Syracuse,NY `'��0 S �•` ii'40 L078 290��' �:0 2 L309379�: 63� L510099509�►' ContinenYal Casualty Company Check Number: 401082867 To: ESTATE OF MERRIIL R BNENS 2088957325 Date: 01/28/2015 Invoice Number Date Voucher Number Amount Discount Paid Amount 00000000022002170471 O1/28/2015 01495525 $1,290.00 $0.00 $1,290.00 TOTAlS: $1,290.00 $0.00 $1,290.00 Member FDIC � � ...." "v•�—Ctt_ __' '�. �_ . "' .. . �. _ — '_' >1 `"=t?ts C::^ .-.:......i..'ftl. i.� _" �.�.. t+1a�:L`�L� `_.._..,"r." _.._�.'.�t'.c .._i:: -'R'_� .ut( .��_.. THIS IS YOUR RECEIPT.DEPOSITS MAY NOT BE�VALLABLE FOR IMMEDIATE WITHDRAWAL.BANK SYMBOL.TRANSACTION NUMBER ANO AMOUNT OF DEPOSIT ARE SHOWN ABOVE.WIl2(1 R18KI(19 3 CJBPOSIf,aiways obtain a�officiat receipt.Checks and oiher items are received for deposit subject to the provisions of the Uniform Commercial Code or any applicabie collection agreement.-— -- Continental Casuaity Company Admin'�stered ay: 401082867 �� 333 S.Wabash Ave t-on9 Term Care Group,Inc Chitago,IL 606Q4 11000 Prairie lakes Drive 50-937/213 1-800-262-1037 Eden Prairie,MN 55344 DATE AMOUNT PaY One Thousand Two Hundred Ninety Dollars and 00 Cents Jan 28, 2015 $1,29Q.00 VOID AFfER 6 MOfJfHS FROM MOMN OF ISSUE �the Order of: ESTATE OF MERRILL R BIVENS 15 E EPPLEY DR ��ti� � .�� a�G�y��J CARLISLE, PA 170154379 JP Morgan Chase Bank,N.A. Syracuse,NY �(�PO S � � ii'40 L08 2B67►i' �:0 2 L309379�: 630 15 i0099509ii' Continentai Casuaity Company Check Number: 401090985 To: ESTATE OF MERRILL R BNENS 2088957325 Date: 02/18/2015 Invoice Number Date Voucher Number Amount Discount Paid Amount 00000000022002181247 02/18/2015 01504450 $3,483.00 $0.00 $3,483.00 TOTALS: $3,483.00 $0.00 $3,483.00 Continenbl Casualty Company adm'nist�red sy: 401090985 �� 333 S.Wabash Ave �0�9 Term Care Group,Inc Chicago,IL 60604 11000 Prairie Lakes Drive 5Q-937/213 1-800-262-1�37 Eden Prairie,MN 55344 DATE AMOUNT paY Three Thousand Four Hundred 6ghty Three Doltars and 00 Cents Feb 18,2015 $3,483.00 VOID AFfER 6 MONTHS FROM MONTH OF ISSUE �the Order of: ESTATE OF MERRILL R BNENS /,'��,,y _ e f��y�� 15 E EPPLEY DR V �L� ! CARLISLE, PA 170154379 JP Morgan Chase Bank,N.A. �L�OS i� Syracuse,NY C�:>�'�'� ��'40 L090985��' �:0 2 L309379�: 630 L5 L0�99509��' Continental Casuaity Company Check Number: 401092590 To: ESTATE OF HELEN 5 BNENS 2090120230 Date: 02J23/2015 Invoice Number Date Voucher Number Amount Discount Paid Amount 00000000022002183293 02/23/2015 01506189 $258.00 $0.00 $258.00 TOTALS: - $258.00 $U.00 a258.00 Member FDIC � TRUST =.,. �-=f=.-__, __. _�. __.... _---- -.. ....:.�....�"t_� . -�. ._`_'___ i.��,:Li ,_o-i-3�:__..._ "�`" '__�._ .. _.1. ___'__ . -_. '..._.. THIS IS YOUR REGEIPT.DEPOSITS MAY NOT BE AYAILABLE FOR IPAMEDIATE WITHDRAWAL.8.1NK SYIv180L.TRANSACTION NUMBER AND AM1AOUNT OF DEPOSIT AflE SHOWN ABOVE.WIIC'f1 fY18I(�t1CJ 3 dePOSII,aiways obtain an otiicial receipt.Checks and other items are received for deposit subject to the provisions of the Uniform Commercial Code or any applicabie collection agreement. Continental Casualty Company Adm�nistered By: 401092590 �� 333 S.Wabdsh Ave t_ong Tertn Care Group,Inc Chicago,IL 60604 ilo0o Prairie takes Drive 50-937/213 1-80Q-262-1037 Eden Prairie,MN 55344 DATE AMOUNT PaY Two Hundred Fifty Eght Dollars and 00 Cents Feb 23,2015 $258.00 VOID AFTER 6 MONTHS FROM MONTH OF ISSUE �the order of: E�ATE OF HELEN S BNENS � d/G�� 15 E EPPLEY DR CARLISLE, PA 170154379 ]P Morgan Chase Bank,N.A. C[�'� �� Syracuse,NY ��'40 �09 2590��' �:0 21309379�: 630 L5 L0099509��' REV•1510 EX+(OB-09) � pennsylvania � DEPAR"fMEN'fOFREVENUE SCHEDULE G INHEHITANCETAXRETURN � INTER-VIVOS TRANSFERS & RF�'°E"T°E�E°E"T _ MISC. NON-PROBATE PROPERTY ESTATE OF Bivens, Merrill R FILE NUMBER 21 - 15 -00076 --- _-_---------- ---- This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes. _ _ -- - — -- --- - —_ _-- �_ ITEM � DESCRIPTION OF PROPERTY %�F TAXABLE VALUE DATE OF DEATH EXCLUSION Include the name of the transferee,their relationship to decedent DECD'S (IF APPLICABLE)� NUMBER VALUE OF ASSET �NTEREST and the date of transfer. Attach a copy of the deed for real estate. -- ----__.__ ._ _ .__ ..__-------- — — — —� --- -- -- ._— -- — --------....--- _._.. 1 Edward Jones Account, doe Merrill R. Bivens and siz,342.02 612,342.0 I 0.00 He►en S. Bivens, number 528-13867-1-3, Joint Tenants with Right of Survivorship ( Helen S. Bivens !� predeceased Merrill by 4 days), TOD to Anne B. Scott � I 2 � 2009 Chevrolet Aveo5 Base,VIN# a,2e2.00 3,000.00 282.00 ', KLiTD66E69B624448 Transferred to Brian Donovan, ; grandson in law I 3 I Money under gift tax exclusion to Emily S. Geddes 14,000.00 3,000.00 11,000.00 I 4 Money under gift tax exclusion to Robert J. Geddes, ia,000.o0 14,000.00 , IV �, 5 I. Money under gift tax exclusion to Janet S. Donovan i a,000.o0 3,000.00 11,000.00 ' I 6 Money under gift tax exclusion to Brian P. Donovan 14,000.00 3,000.00 � 11,000.00 I , 7 Money under gift tax exclusion to Anna B. Scott ia,000.o0 3,000.00 11,000.00 8 Money under gift tax exciusion to Thomas D. Scott 1a,000.o0 3,000.00 11,000.00 9 '; Money under gift tax exclusion to Emily S. Geddes �, 14,000.00 3,000.00 I 11,000.00 � 10 Money under gift tax exclusion to Robert J. Geddes, 1a,000.o0 3,000.00 11,000.00 IV 11 II Money under gift tax exclusion to Janet S. Donovan 14,000.00 3,000.00 11,000.00 � 12 � Money under gift tax exclusion to Brian P. Donovan ia,000.00 ! 3,000.00 11,000.00 I � I � ! -- ---- ------------ -_ _- --- — TOTAL(Also enter on line 7, Recapitulation) 113,282.00 Account Hoider(s)Merriil R Bivens&Helen S Bivens Account Number 528-13867-1-3 0PA J-wA � � � i Account Type Joint Tenants With Right of Survivorship,TOD OP ' PO Flnanclal Advisor Jason R. Mathis, 717-432-3717 c "� �'� � 8 Tristan Drive,Suite 2, Dilisburg, PA 17019 ~�°""'� Statement Date 1an 1-Jan 30,2015 Page 1 of 4 ---,. i., *r� : 00035426 01 AV 0.378 Ot TR 00140 EJADD023 000000 MERRIIL R BIVENS& AccessingYour Tax Forms Made Easler HELEN 5 BIVENS 15 EAST EPPLEY DR M• You may view, print and downioad your Edward Jones tax information CARLISLE PA 17015-4379 � anytime through Online Account Access.There's no need to print and fax multiple pages of your Edward Jones tax forms because you may securely share them electronically with your tax professional through I��1��'I��'��I'��'�'1�1��'�'��'11'��11'��I�P1��'�� Online Account Access. All Forms 1099 will be issued to clients by Feb. 15. � This Perlod Thls Year �b`17�36�.3? Beginningvalue ( l�N 1S � $599,217.25 $599,217.25 Assets added to account 0.00 0.00 Income o.00 0.00 1 MOOth Ag0 $599,217.25 Assets withdrawn from account 0.00 0.00 i Yeer Ago $568,376.78 Fees and charges 0.00 0.00 3 Years Aga $311,818.00 Change in value 18,143.12 18,143.12 5 Ye�rs Ago $0.00 Ending Value $617,360.37 � - � � � • . Amount Amount Federally Tax Exempt Municipal Maturlty Maturlty Invested Wlthdrawn Bonds Date Value Slnce Inceptlon Since Inceptlon Yalue Irtterest received on Federally Tax Exempt Municipal Bonds is generally exempt from federal income tax.However, irtcome may be subject to federal alternative minimum tax(AMT)and stete taxes. Consult with your qualified tax praf�ssional about your situation. Adams County RA Gen Obligation 4.00�o 5/15/2032 $100,000.00 $101,504.95 — 5106�245.Q0 Blackhawk PA Sch Dist GO 4.375% 3/1/2030 100,000.00 100,946.95 — 107,551.00 Mc Keesport PA Mun Auth Swr 4.25% 12/15/2030 100,000.00 100,009.90 — 107,747.00 Un ited PA Sch Dist GO Ltd Tax 4.375% 11/15/2034 100,000.00 101,429.95 — 107,592.00 Amount Amount Exchange Traded& Invested Withd�awn Closed End Funds Price Quantitp Slnce IncepUon Slnce Inceptlon Value v Nuveen Municipa!Value Fund 10.18 4,781 50,04327 — 48,670•58 0 M Nuveen PA Invt Quality Mun Fd 14.55 6,353 100,977.74 — 92,436.15 0 Nuveen Sel TX Free lncome Port 14.78 3,188 50,114.86 — 47.118•64 a w Total Account Value $617,360.37 � 0 � � • . � � • . �� 8/21l2015 2009 Chevrdet Avea5 LS Hatchback Sedan 4D Trade In Values-Kelley Blue Book I�'�' ' �ZIP CODE:17015 � Sign in(or Sign up) `��5;}KaIC � �..�c.`36"i��dto:?:a ( ��:�8'.s�£si"�u+te�� I �s�Y"��."4`€c�G9F�' E re`',;1iiaYCi;`.��a �€i�3�`ai`a" � �>N�{:.«�YC:� ,;i:5i':: •r Pop�lar at KBB.com ., b�; � � - � �� \ \�,� � Class of 2016:New Cars Ready to Roil � ' Advertisement � Why ads? Chevrolet... • Aveo __ • 2009 • Go ' Nome> Car Values> Chevrolet> Aveo > 2009 > Category> Style >Options> " AveoS LS Hatchback Sedan 4D Your Blue Book°Value � Find Your Next Car Show Used Car Prices � Print report �� r l t � ,ey��:(AveoS LS Hatchback Sedan 4D � +"��r��°i; ��a3a�asc��.�20000 ) Change_.__�_ _ ._.. \ � _. . ��y� ��i.. ��:. Edit options �Check specs I � � T"€azs�€�� Get an Instant , Sell to a � , ' • � � � 1 � s.cs��c.a[e€� Cash Offer � Private Party , � � M��:�,,.��K�� Gst7hc�Histlorys i�alTfisl�e�rl. Next Step: Find a C�r ��. . Advertisement Why ads? Tradr-ir�'vat�se Browse reviews,photos,specs ��8� : and more. � �______.______._�._.... � '�' � 5��ra�;a�ycs��h�utd p�y a �,- ' ' _ �,.,�. __ Have a vehicle in mind? ' Make ` � Model �'� � — �,.;, , „,� Go �..�. '�: �� . � �a a,. : ve►y Good cor,d�t�o� ', Instant Cash Offer �� Advertisement Why ads? Trade-in Values valid for your area through 8/27/2015 Find dealers ready to buy your Track this car's values car-today! ', Get your offer ' Tell Us About This Car - - , Owners like you rated the 2009 Aveo 7 out of I Write your own review ' 10. Next Steps to Selling Your Car ,.. . �. ::... ... �._N,..... n .,..�....uu.�.. � ... ....,.,� ..._..... .�.a.......� ,.. �.�.::. ., �... .,... .. R Recently Viewed Cars � My Saved Cars Save car $�1 � http;//www.kbb.com/chevroleUaveo/2009-chevrolet-aveo/aveo5-Is-hatchback-sedan-4dl?condition=very-good&vehicleid=226340&i ntent=trade-in-sell&m i leage... 1/2 Merrill and Helen Bivens Gifts in their Final Year 18 Aug 15 8 Jan 14- 10 Jan 15 DATE FROM TO AMOU NT 3/20/2014 Merrill Anna B.Scott 50.00 3/20/2014 Merrill Brian P. Donovan 50.00 4/12/2014 Merrill Robert J. Geddes,V 50.00 5/6/2014 Merrill Scott P. Donovan 50.00 S/17/2014 Merrill Michael A.Geddes 50.00 5/23/2014 Merrill Emily S. Geddes 50.00 6/15/2014 Merrill Janet S. Donovan 50.00 8/13/2014 Merrill Claire E. Donovan 50.00 8/23/2014 Merrill Thomas D.Scott 50.00 9/30/2014 Merrill Joshua T. Geddes 50.00 10/1/2014 Merrill Thomas D.Scott 1,000.00 11/1/2014 Merrill Anna B. Scott 1,000.00 12/25/2014 Merrill Emily S. Geddes 100.00 12/25/2014 Merrill Robert J. Geddes, IV 100.00 12/25/2014 Merrill Robert J. Geddes,V 100.00 12/25/2014 Merrill Joshua T. Geddes 100.00 12/25/2014 Merrill Michael A.Geddes 100.00 12/25/2014 Merrill lanet S. Donovan 100.00 12/25/2014 Merrill Brian P. Donovan 100.00 12/25/2014 Merrill Claire E. Donovan 100.00 12/25/2014 Merrill Scott P. Donovan 100.00 12/25/2014 Merrill Anna B.Scott 300.00 12/25/2014 Merrill Thomas D.Scott 300.00 12/30/2014 Merrill Robert J. Geddes, IV 50.00 1/2/2015 Helen Emily S.Geddes 14,000.00 1/2/2015 Helen Robert J. Geddes, IV 14,000.00 1/2/2015 Helen Janet S. Donovan - 14,000.00 1/2/2015 Helen Brian P. Donovan 14,000.00 1/2/2015 Helen Anna B.Scott � 14,000.00 1/2/2015 Helen Thomas D.Scott � 14,000.00 1/5/2015 Merrill Emily S. Geddes �`" 14,000.00 1/5/2015 Merrill Robert J. Geddes, IV � 14,000.00 1/5/2015 Merrill Janet S. Donovan � 14,000.00 1/5/2015 Merrill Brian P. Donovan � 14,000.00 TOTAL 144,050.00 REV-1511 EX+(10-09) �� pennsylvania ��H � DEPARTMENTOFREVENUE FUNFJ�Lp�SAND IN HE R ITANCE TAX RETU RN /�ry�'w11�Tp/�T7�/C/�/1cT+�� RESIDENT DECEDENT !YJIYI Irh7 1 f1f11 1 V G\.�.J7 1�7 . _._----- --- �- - - - --- — __-.-- FILE NUMBER ESTATE OF Bivens, Merrill R 21 - 15-00076 _ -- --- --- -- — — DecedenYs debts must be reported on Schedule I. __ _ _ ---- — - — - � ------ ITEM AMOUNT NUMBER FUNERAL EXPENSES: DESCRIPTION — -- - ----- - — --- ---— A. 1 � Hoffman-Roth- Service deposit 2,000.00 2 , Hoffman-Roth Funeral Home (M) � 1,208.87 I 3 � Hoffman-roth Funeral Home (H) 694.89 4 � Royer's Flowers-memorial service I 185.50 5 Office Max (service bulletins) 30.74 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions j Name of Personal Representative(s) I' ��, Street Address � City State Zip I IYear(s)Commission Paid 2. � Attorney's Fees Stone, Duncan &Linsenbach, PC 79,381.00 3, Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation) Claimant I Street Address � �i City State Zip IRelationship of Claimant to Decedent 4. Probate Fees Register of Wills 225.00 Register of Wills 510.00 i � 5. I AccountanYs Fees 6. I Tax Return Preparer's Fees II 7. ; Other Administrative Costs 1 Allenberry Resort (funeral luncheon) 1,675.00 �, II TOTAL(Also enter on line 9, Recapitulation) 88,554.20 Sdied��e H Fu�er�l E�er�ses& COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ��m(x� RESIDENT DECEDENT _ .----------- -- --- ---- ---- --_ _... FILE NUMBER ESTATE OF Bivens, Merrill R 21 - 15 - 00076 ----— - -- ---------- — ----------- — -- ---_ 2 � Everett Marble &Granite Works (tombstone) � 450.00 3 Dilisburg Banner- advertising 93.20 4 �'�� Cumberland Law Journal-Advertising 75.00 5 I; Landex - Deed Search to SDL 25.00 6 I Administrative Reserve 1,000.00 7 I� Diakon Lutheran Social Ministries (Chaplian Honorarium) � 500.00 � ' I � I I I il ii Page 2 of Schedule H TI�i+��V11`'�1��CVT� �1—��+'rt3 f Q tJ� :�.N�1'��.5��'1' ��s��rr��avE �,s►.� �'�� t� c��.��.�,r��, ��i��a� � 1��"�{ �"� l $ �� o�c�, �p � ��-��.� ��K�� wa '��s� �•�-. �io� v�� K 4� , ` �B��S j� �.�.�a�,ra�;� r�� Q��y� "�w�Ga*i �1'�� '�� ti "i � n��nca �: c 3 � 38 2 24 i�: � �� 894 �la�` ��C15 ,�-.,�...��. :- -, � , � _ :±P �� ` '; �' `.i '��. ;� _ �.� � - ' ::��rr � 3p3�.�1.`�'fl��tC � y � Y��;; � � Urrstcawn Banik r�� Sh:��p��sbuxg� �A ��:��►7� a -� �� i>teesne= 7�7-�32-�114 ' m � �u� ��te. 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'^"'''"-h°'f'7'°nroth.com � info�-hAffmanroth_com Cl�ristopi�e;I-I.I 1o13inan—O��rer;Pmsident t,Tilliam t.HoS3i��an-Vice President Roben A.Filbum Ilt—Suoen�isor Da��id E.Feczko—Fimetal Director Jill A.i_arar-1=uneral Directar�c�Przneed Counseior February 11, 2015 Anna B Scott 15 East Eppley Drive � Carlisle, PA 17015 Statement of Funeral Expenses for. Merrill Reid Bivens Date of Death: January 10, 2015 Account td: 17400-009 PACKAGE: $950.00 iess$100.00 from Humanity Gifts for transportation Humanity Gifts Registry $ 95�.00 Sub Totaf: $ 950.00 FACILITIES AND PROFESSIONAL SERVICES: Use of Facilities/Staff for Viewing $ 250.00 Equipment and Staff for Memorial Service $ 320.00 Sub Total: $ 570.00 MERCHANDfSE: Memorial Folders $ 55.00 Acknowledgement Cards $ 55_00 Sub Total: $ 110.00 TOTAL FUNERA!HOME CHARGES: $ 1,630.OQ CASH ADVANCES: ' 20 Certified Death Certificates at$6.00 each $ 120.00 Newspapec Notice-Sentinel , --_ $ 436.47 Newspaper Notice-Chambersburg Public Opinion "- $ 222.40 Sub Total: $ 778.87 Thomas D. Scott Check 2805 Jan 14, 2015 1,000.00 Humanity Gifts Check Jan 21, 2015 100_00 CC VA Check 913233 Feb 9,2015 100.00 TOTAL FUNERAL EXPENSE: $ 2,408.87 Total Payments Made: $ 1,200.00 Batance: $ 1,208.87 3/19/2015 : Image vev,� -- .. �-� -- - - —'��<'°`-- M�RRILt R BIYENS ESTAT� �,�1307 .r�O 'r�' ANNA B SCt�F-T,E�CECUTRD€ " THOMAS D SCOTT, EXEGUT�R �s e-c� �S I. i S E EPPLEY�R. 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CREEui�TORY, INC. inrosnom�noruotn.com Ciiristoph�r H.No;in�an—O��n�rPre;ident tYiili�vn E.1-foftnl�i-Vicc President Rober r1.Filbum ilI—Su}:en�isor Da.•ic r.fec>>:o—Funeril Dirzcior Jill:�_L�!ar-1"uner��l Dir�ctor�,.'rei�eed Counselor February 11, 2015 Anna B. Scott 15 East Eppley Drive Cariisie, PA 17015 Statement of Funerai Expenses for_ Helen S_ Bivens Date of Death: January 8, 2Q15 Account id: 17397-�06 PACKAGE: �950.OQ less�100.00 from Humanify Gifts for transportation Humanity Gifts Registry $ 950.�0 Sub Totai: $ 95Q.00 i1f1ERCHANDiSE: Register Book $ 55.00 Memorial Folders $ 55.00 Sub Total: $ 'f 90.d0 TOTAL FUNERAL HOME CHARGES: $ 1,06Q.00 C�►SH ADVANCES: 20 Certified Death Certificates at�fi.00 each � 120.00 Newspaper Notice-Sentinel � 407.49 Newspaper.Notice-Chambersburg Public Opinion -_ � 207.40 Sub Totai: $ 734.89 Thomas D. Scott Check 2805 Jan 14, 2015 1,000.00 Humanity Gifts Check '15890 Jan 21, 2015 � 100.00 TOTAL FUNERAL EXPENSE: $ 1,794.89 Tota!Payments Made: $ 1,100.00 Batance: $ 694.89 ; ' j "II-IC?M�4�I}.SCC?7�' ��'� 2�CI$ ANNA B.SC�3'�"`t' Tt�'°�.�'W9`3`.�� .�+sr��[��v� �� ChEti.LS1-�PA i�oi�..�79 �ns� �_ �� i $ rn�r��► ��i�"� _�J � � �;��#C7 � ,,: r�r�r.�c�-- . � � �—�-�yy//�� r. . ��{� � ��•� ' �� i. . , _._,_ .:�. .--. ,.. .,, _._.-�...,�...,.�.��' rfr� � � � � M . • �� Q��h�ti� �f�Waif.�1 t3ME �41N�')��7 T�' f...._. .. :� ��a++� ::,... �_.:.� - �: 23L3� 2 �4 ��: � �+� ��943r ��QB ._.,,.... __ _ _. ,., ,.� - f� _ � . _ . _ _ . . ^� i.-.. - - - �. -' �� 4 +r � _ � _� .�� .r - . . � .. ' .. . ' ' ... . . . _�'��'�� ' - ' '_ `a•��-'7 S/7�.t� - - w,��j�� _ _ _ : ,. _ �� i - _ _ � - , � _ � _ ... • - ti y • � . .. �� - � . �" � � Order: 7 JQ.�H Clerk: 325 Sale Date: 01/15/2015 Time: 11:41 -- �e��very�ate: 01/31/2015 �oW� SAT store: 52 �e�ivery Code: LOCAL First Loc - oeti�ery Address: MERRILL & HELEN BIVENS HOFFMAN ROTH 219 N HANOVER ST , CARLISLE, PA 17013 I IIIIII IIIII IIIII�I'I)(IIII III)I��) w�re: This is a change of order!!CLK:325 PN Qty. Description Designer Amount 23 1 FUNERAL ARRANGEMENT $175.0� VASE ARRGT-PHEASENT FEATHERS-5 -QUEEN ANN LACE -WHEAT-CATTAILS-YEL .SNAPS-SUNFLOWERS- RED ROSES- DELPH -GLADS-ORANGE GERB w Amount $175.00 Phone $0.00 Delivery $0.00 SubTotal $175.00 Coupon $0.00 Discount $0.00 Tax $10.50 Occasion: � Register Seq: REG#1 Total $185.50 C orange gerbs solidago curly wiilow __ card handwrite—You� loving Daughter and Family -- A R 0 Customer. 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ORDER BY PHONE 1-877-OFFICEMHX ORDER BY t�lEB ��w��.off i cedepnt.com RECEIPT FOR PAYMENT ------------------- ------------------- LISA M. GRAYSON, ESQ. Receipt Date : 1/22/2015 Cumberland County - Register Of Wills Receipt Time : 13 : 19 : 14 One Courthouse S quare Receipt No. : 1080249 Carlisle, PA 17613 BIVENS MERRILL R Estate File No. : 2015-00076 Paid By Remarks : STONE DUNCAN & LINSENBACH PC wz ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 90 . 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE � 50 . 00 CUMBERLAND COUNTY GENERAL FUN INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 35 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check# 1694 $225 . 50 Total Received. . . . . . . . . $225 . 50 1694 ;TONE DUNCAN & LINS�ENBACH PC � w1��5 � ��-��//'�' �,�t�rr�land C�n�� sk� � ; � � zss� � �, , , � - ' r i . 1 f�G�s ��b�' �M� � � , � � , ,\ ., , , 2112/2015 Prir�t�ew MERRIl.L R 81yENS EST�kTE '��t�{�7 �� AWNA B 5CO3T,E�iE�UTRIX 'f1�I�N1AS D S�OTT, EXECUT�R 15�ERRLEY DR. p�� CAHLI6IE,PA 7J475 � �.t�� Y � � t� � �� .c�o� ` ehvT��rFr� 3 Olii)EIZ�F• � -- — � ��'�,U�� N�ik�O �� L V� � �Oj�O rj�GLAit$ LJ � � f� � . � � ti3�. 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Baltimore Street Dillsburg PA 17019 �qTE INVOICE NO. 432-3456 01/29/15 1257176 BILL TO Jan M. Wiley, Esquire 3 N BALTIMORE ST Dillsburg PA 17019 TERMS DUE DATE Net 30 02/28/15 ITEM DESCRIPTION QTY RATE AMOUNT 6 Legal Merrill Bivens Estate Jan 29 3 9.80 29.40 6 Legal Merrill Bivens Estate Feb 5 3 9.80 29.40 6 Legal Merrill Bivens Estate Feb 12 3 9.80 29.40 66 Notary 5.00 5.00 4 i i� �.I I I ,� �IV :I i� ;,�i °� � _ f �� JAN WILEY IOLTA - '� ' ' � 10 4 0 , i. q ;� � � , � 3 � � ( NBALTIMORE6TF�EET i �� j � � � �- �� fcolFZBhleltl'"CheckFteuA^�� DILLSBURG,PA 17019 \ °"' ` �Protec6onkrBusiness ^ y �� k � i ) PAY � ` DATE � � S.��'� '3-7615-360 TO THE ' � ORDEROF �r �,'�5 U /r'� �I j�/..�/JN_L � � � � �'l � Zc7 `�l �c�e-� �-�-�-,►—c� , — �— — ' -- a� o . � _ '_ �OLLARS a F � �` IJ � Y � ��Cit�zens Ba� � �� ti..� � _, , , FOR��` �r✓� ri.S L��j � � � . ) � �� . �.� •r• _ F_P i � � ` / .. , . ..... _, U / J / � � O O O O O� . � � �� - .. / ... . . o° o °o° o °o ii■00 i040u■ �:036076 � 50�: 6 23648 2 253n■ °o ° o°o ° o° 0 o a o 0 Total $93.20 ��G c.�J`� � �'�. � —=�, i�i ��ssoc��`�� CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717)249-3'166 Fax:(717)249-2663 February 20, 2015 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publicat�� for Cun�uer�a��d Cour�ty and the iagai newspaper for publicatiar� of legai notices. TO: Jan M. Wiley, Esquire RE: Merrill R. Bivens Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: February 6, February 13, and February 20, 2015 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director Landex Remote Receipt Page 1 of 1 Please print and keep this statement for your records. Print Staternent Cont�nue,; �LA1@i��EX Reynote Transaction Date: 6/2/2015 3:16:57 PM BRIAN LINSENBACH (WT1850) STONE DUNCAN& LINSENBACH, PC 8 NORTH BALTIMORE ST DILLSBURG, PA 17019 l � � I �� Transaction ID: 7229432364 J��d"'' Card Owner: Brian Linsenbach Order Number: 190183 Trans# Count.y Site Amount 426189 Franklin County $25.00 Card Total: $25.00 Card statement will show: www lc�ndex.com Your Credit Card order was processed successfully! Thank You for using LANDEX! _ � �� ^_ ' � � 106�7 � ,� — , � , —. ,— ; � , ' ?JAN INILEY IOLTA � �� 3 N BALT,IMORE STREET� � Q��mCeus��utl i� �� DILLSBURG,PA 17019 — �-p �[ � � 3-7615-360 DATE `L�> /�r � PAY J� n ORDER OF �� 1�` �h��/�! �C � �� .,�/"�.,� � �� 0 1. `'I`_�'—(✓ � 'r 'v ""' _ �": � DOLLARS � � .= � u ��Citizens Bank� � � � � � � FOR `r Jt��}7� ��7L�1. ' !.%e.F,(/ti KX�'GIY�I�LLv1�Qi�, — �..` � •a, �, V � ° ° ° ° ° u'OOL067n' �:036076L50�: 6236482253n' I � °�° � °� � o � 0 0 0 0 0 0 o a o � a � o �� 3/19/2015 : Image Vewer s��_.9+r.a. - _�..:s - 1VIEHRtLL R B1�ENS ESTATE �s°1307 r�� AMf�iA S S�COTT. EXE�I�TRIx TFtOfiNAS D SCOTT, EXECUTOR 15 E E�P�EY DR. '� ��4� 'r CAA L�SL E.PA 1 T013 �n� � rr.� rnniE -- L��IC�� '�'� '�4G��.1MxN�i��c� � ��•�d -� - � � O�tl]F.R UF --- ' ,� - � ��1� �{��'�� O�/y� ��b� —Ui)i.LARS W .:�:-.. t � � rr�.�� # �.147uCf �-�R. �� --- �`A�� , �� 3L3�43��: � ;� L9QF9�i' D502 � * . ---=�_._:��i.7.-.�Y . � .. ' � T :��' 3.� . . p � R � ; _ �� • ' ";,':a � � x �,- W: �%- '-� • ; T�1 � �s C r � � {' �� - ' i.� _ �'�" m $ T C �� ' . . . �.� � � 7C' , _ 7i z_.� _. . .. :r� � J (p fIF --_ �R��:'�`z"•�„r •...�.►r+��r- -- '� `', ..�-r-..r.... _ ...�r�rrq � �.:. ....�.�� • (Y ' x - - �'�1. _�x. w�.i i_,i_�z_�..�, r x` �- ��.- - R ^" - ' + :�� . r . . -� � . - . . . .. � � •r i ir3'�: �-- ,� � fn r E . �p 7 � e� � • • a_. 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Through visits,worship services, Bible studies, Hoiy Communion, bedside prayer, counseling, etc., the Chaplaincy team lives out Diakon's mission to love our neighbors through acts of service. � Giving Opportunities Diakon Continuing Education Fund for Chaplaincy Your gift to the Diakon Continuing Education Fund for Chaplaincy will support the continuing education of our chaplains. Other purpose that you may wish#o support. Pfease spec'�fy on this form (below). ---------------------------------------------------- Name of Chaplain Rev.Judv Straver to whom we may acknowledge your kindness_ Enclosed is my gift of$ 500.00 Check made payable to Diakon Lutheran Socia!Ministries. Please charge my gift of$ #o: MasterCard Visa Credit Card# Expiration Date CVC Code Cardholder Name Cardholder Signature Please use this gift for: Diakon Continuing Education Fund for Chaplaincy - Other(please be very specific): Your Name ��1 a • S��T Daytime phone#��"��`� 2`f 9� S 22 Z Address �S ��S l �g�E`� '�2LVE � CJ�t2LlSLt � (� � ��-� tS'-�3�}`'� Mai!your gift�this form to: Diakon Lutheran Social Ministries, 798 Hausman Rd.,Ste 300,Allentown, PA 18104 Call Tol!free: 1.877.342.5667,option 2,ext.21219 Thank you so much for your generaus support ��w'.TIIAQUi.OKt IILtiR,T' --'—'� �'� DIAKON OFFICE OF ADV!�P1C�i�i�EP.; � „z,.,:�„�,�,.,.::�:,«,., �; pennsylvania SCHEDULE 1 DEPAFTMENT OF REVENUE DEBTS OF DECEDENT MORTGAGE INHEHITANCE TAX RETURN 7 RESIDENTDECEDENT LIABILITIES & LIENS __ .....- ---- - ------------------- - - - FILE NUMBER ESTATE OF Bivens, Merrill R 21 - 15 - 00076 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. - - — - — — ---- ___-- ITEM DESCRIPTION AMOUNT NUMBER -------- — — ---------- ----- -------_ _- --_- - 1 Diakon Lutheran Social Services 649.84 2 Diakon Lutheran Social Services (Cumberland Crossings) 1,062.00 3 Omnicare of King of Prussia 3.23 4 Omnicare of King of Prussia 106.57 5 Home Instead-Hospice: Helen 581.68 6 Diakon Lutheran SS- CC bill (H) 10.80 7 2014 PA Income Tax (est) 203.00 8 Aspire Business Solutions (tax preparer) 152.50 9 Denise Garnes, Tax collector 265.70 10 Checks for Estate acct. 34.20 TOTAL(Also enter on Line 10, Recapitulation) 3,069.52 THC�IVtAS I�.S�O7T �'��'� 2 8 0� �:*�hlA 1�,SC��'T �s�-r�i�r�E.EY Dltl�E v,,,� �`�,�Pk�l S c��.�s«„�� t�a�.�-��s _._ _.- ! �"nY-R� �{J�' 1�V L�.� �GI��S,. 1�k,t��t�i�,��+�L�c,� � � �v��+ OT � ,� � ti1k�,1it�1t4iF � �"a�?C 1'Ut��+� �'�Ti�.�C""� �"►� � ��1 b� _l��,a�rs � �."! 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I �_��_ - =`�: STATEM ENT Page: 1 of � �� f=�,�t � I�'�� N � invoice# Account# Date �'��' UITHERA��1 SOCIAL�11NISTRIES 488205 11359CCNC 12/31/2014 -��;�>�' Cumberland Crossings Retirement Communit}r 1 LongsdorF Way Carlisle, PA 17015-7623 Due Date Amount Due Amount Paid ` Facility#(717)245-9941 1/23/2014 '.�95"84 � Business Offce#(717)240-6040 � y' �� $� Anna SCott ' Resident Name 15 East Eppley Dr. Bivens, Merrill R Carlisle , PA 17015 Piease make check payabie to Diakan Lutheran Social Ministrie� Merrill R Bivens Cumberland Crossings Retirement Community 12/31l2014 Anna Scott Date Description Units Net Balance From Throu h Char es Credits RESIDENT RESPONSIBILITY 11/30/2014 Balance Forward $0.00 12/05/2014 12/05/2014 BeautyBarber Services 1.00 Each 14.0 12/18/2014 12/31l2014 Personal Laundry .45 Month 24.8 12/29/2014 12/29/201 T an�spo atio p Mile � _. 4j_j� S.OQ ,jVlil� ��1f5`0 j�-�7-� s' i-�-!S� �; t��(c� �-►c� ��( ( �Jt � � !+r! �.��z�c�n t�`t vr�+�n `t o�tN t3�1� tS � 1 If you have changed Insurance Companies for 2015 please supply the Business Office with updated copies of your cards. a � F; i _' �e. j �rl:. j TOTAL BALANGE DllE ��'.�-` ;� m 1 F cv � 280 6 1 �«��S THOiVIAS D:S�UTT �-�� 2$0 7 h:�lNA B.SC(�T7 �s��r��Y��.�r��siv� r�h,� �.�,J�,N�S GktLf�SL�,�'A 1;E�i�#:1� r._��._� � �n'r xri _ '�t l�4�� Lti� �� f+�r W t��t'�.tC�S � � t ��rin Z ��O � �t�i��:�r�� ,.. � �N�" '�'�'��i'�J1�+Di �tX.'C�l�� c�-.-►- ��«� .""'�—,�" ixx,�; �j ��.' � � 5k � �� Tlt1t�K 4JlE21R 1JN►�U •�� f►�wo ��V� �� ' a�'��P� ��'�� r +�: 2 � i 3B � 24 i�: c l�8 �6?�943� ��l� '� ...�,_,.� � -� s :�, ° :, , a � t � , _;" � �; s r� :� � . { _ , �� w �' � « �g'» �� $ "'� �'� : � �, '� - �� ;� r w , � �� .� PFt - EfA � � � _��_ =..��"�='�.�a��3.-t��`*'"�t"'�T�i-�.�=�&�---�----=�__—t-�� w � p 3 Ti �r � m � . . . .� �' � ' i i:� ��+� � ' ;� as %�� a�`�tnS'} � �� - - , -,s.s� � ��,—�r • m ;� �:, "�-'y '�'� 1 -�r� �q+.""`.+�`�v' .�.r4 �� ' 6 =3 � t �',i �if/J-�'J�+ � = �j_ , � � � :� �� : � - _ ►,� 4 r' �� Sfy � - _ � �� ►�'� _rn.� � •n r . ,-f ��rJ C� u x_ � " _ - V� ' . ' �'4 �e 3"74 . � �� ':t' CJ7 e: =' , � =,: � n : ci __- ,r...�..,�..�,_.._.��_..�, ; m ��` STATEMENT Page: 1 ot � ��, ,� � N invoice# Account# Date ,:�� DIAK '' t'�%` LUTHFRAN tiOCiAL ti11N(STf:IES 488024 8888CCPC 12/31/2014 ��;i �,:.: �� : .y� Cumber(and Crossings Personal Care 9 Longsdorf Way ` Carlis(e, PA 17015-7623 Due Date Amount Due Amounf Paid Facility#(717)245-9941 1/23/2014 $8;�9�98-' ��, �� O6�-� o0 Business Office#(717)240-6�4Q ~' Resident Name Anna Scott 15 EaSt Eppley Dr. Bivens,Helen Shinham Carlisfe , PA 17015 Please make check payab(e to Diakon Lutheran Social Ministries Helen Shinham Bivens Cumberland Crossings Persona!Care 1?J31/201� Anna Scott Date Description Units N t Balance From Throu Char es Credits RESIDENT RESPONSIBILITY 11/30/2014 Balance Fonrvard ��3��'� 12/09/2014 Payment Received Ck#1841 .00 Day -4,351.00 12/01/2014 12/31/2014 Semi Private Suite Level 2 c� 0�. Day 1;480:0 i��` 01/01/2015 01/31/2015 Single Suite Level,� 12/04/2014 12I04/2014 BeaufylBarber Seniices 1.00 Each 16.0 12/12/2014 12/12/2014 Beauty/Barber Services 1.00 Each 16_0 12/23/2014 12/23/2014 Beauty/Barber Senrices 1.00 Each 16.4 12l31/2014 12/31/2014 Phone-Enhanced Service Phone Enhanced Se 1.00 Each 33.0 12/31/2014 12/31/2014 Sales Tax Sales Tax 1.00 Each 1.9 //��"01UStf^Q 8� TM`h�t �tu�ml -- -- �3�/�,v.� t S If you have changed Insurance Companies for 2�15 please supply the Business Office with updated copies of your cards_ ! � �, � .�.`J _ ��. � OTAL BALAf�CE DUE `�� ; � ��: M ��c� � Z 8 0�- � .. :-. ,�� ,�.�,5 � ��1, 4;�� oru�c�.�� .��:� �8�.l �r�t�B.S�t��'r ��r�.r�t�r�r�t�� u�re ��Aw ti*� c.�usu�.P� �:�a�.� --_ � t}.tv.�,�} �p►N�G�taE, d�` ��rG� � �[L�r'�i 1� 1 � � .2� N TbiF_CNitlq4l�t' � r��L � ��f+� L7['IfJ.A_3� �i r'., � 1F� wt,�y��@ar i �L.i''��TT")1 IL°!IR M CYI11tT t-'f�]�1 p /� r�#�y..�A ��,lY'i��r! t_2 ��j�� w�r_�ttf '�'�fs'Z'.�-�� il'�'t�itL.�'yii� �a.s�y, as ' #: � � � �� w ��: L� ��iL� '�8q�� $ �r � � ..�..�.� ___. _._.._ _ ___ _.__ __. t � � _ � _ � _ - _ _ , t _ - ; _ _ � , - � _ - _� � :* = - �* v ,. - . '., � ci - � r • _ _ ?'t�.�u'��tt:-11Uldi:�:-��F��it�i°14�F:�'�#k�%n�� -: "' ' - .T 1��l�1'�t}L�1��1�J�$.�1� i�=35�'�.�,�d�f€it'��t[�nC�4�!!1. _ ; _ _ _ � ,�rr�y4�:?3 oi v�thin narn�d p�y��thv�t � ; � � ' � !�3��!"t�!''Ia�uc�ICe FIt�M Titlf��9it��4.'�.'J��}3 i�� - - _ ;� � =, - - _ - _ � , - ,� ' � r = - a - X . _ i - f_ � �� "�"��l��l�l� �}� ��t�� OMNICARE OF KING OF PRUSSIA _�� a��E��w►v�,PA� �aR s PAGE: 1 of 1 ACCOUNT NO: 9024.93 .� RETURN SERVICE REQUESTED 34285 �NVOICE NO: PH1324093 � DX NO: KOPDX BILLING HOURS: 8:00 AM TO 6:00 PM INVOICE DATE: 01/11/15 oos,s, Phone: 877-670-6323 FACILITY: 9024 CUMBERLAND PERSONAL CAR o,o, PATIENT NO: 93 You may atso view/pay your biiis at: PATIENT NAME: BIVENS,MERRIL� https:/lmyomniview.omnicare.com AMOUNT DUE: 3.23 TAX: 0.00 �ili��lhi{�ii��il�ll{h��l��ii��ln��uilld��id��lmi�li�i MERRILL BIVENS • C/O ANNA SCOTf DUE�ATE: OZ/05/20I5 15 EAST EPPLEY DR CARLISLE, PA 17015-4379 �,r,noutaz�uE: 3.23 34285'T9AOAUGOL009476 49AOB6ST6:1.1 KEEP.` "'_'aORTION FQRYOUR RECORQS-RETURN-: '-'--- '"STJS YYITH PuYMENT III�IAI��BO�I��I BIVENS, MERRILL 9024 GUMBERLAND PERSONAL CARE , .. . _r �. _ ... a , . _, . : ,> v`�.,. . .. . , • . .8 ,y . - e ,. �. �, ._ .. . .i 6 8�.� � .. firq.g. ��:-��- . � _ .� : � 'M1 .,�.� . i 9024.93 i 01/11/15 � DATE RX N0. TRANS DESCRIPTION PHYSICIAN NDC N0. 9UANT AMOUNT TYPE Medicare D Plan: UHC/AARP/EVERCARE/SECURE H./SIERRA/UNISO 1Z/13/14 R2371289 CHARGE WARFARIN SODIUM 3MG TABLET (COPAY) GUISTWII'E 51672-4030-07 5 3.23 RX Messages - Finance Gharges may be assessed at a MONTHLY PERIOD RATE OF 1.50°k(ANNUAL RATE OF 18.00%)6ased upon an unpaid balance outstanding 30 days or more_ PREVIOUS BALANCE CHARGES FINANCE CHARGE TOTAL CNARGES PAYMENTS & CREDITS AtAOUNT DUE 0.00 3.23 0.00 3.23 0.00�. 3.23 � 34285'"T9AOAUGOL009476 �I�ISURE flROPER CREDi t --.. '� A�ID .. "�NIS PORi"lOi�ly T�iE Ei�GLQSED EiVVtLOPE. �scza�c _PI?8SE cit2Ck ii 2@ov2 2dd�2SS iS ir1CO��eCI 8fld i�diC8tE ChBnge Cn�Ev2tSe SidB. IF PAYING BY F+tASTeRGARD,DISCOVER,4ISA QR AiuIERICAP!EX?RESS.FILI OUT BELOW. CHECK CAA�J USING FOR PAYtv�ED!i ACCOUNT NO: 9024.93 ' ❑ ❑ 'i ❑ _" ❑ INVOICE NO: PH1324093 � ,�+as-r�scaac � �isccr�ta .�- I visa a:,��t:cnriex.rpes:. DX NO: KOPDX ''�.RDNUi�.S9EA INVOICE DATE: 01/11/15 FACILITY: 9024 CUMBERLAND PERSONAL CARE siur„n;Re �:,�,,.4r£ PATIENT NO: 93 PATIENT NAME: BIVENS,MERRILL Y ,, , _ � AMOUNT DUE: 3.23 11��1��I�1��116�1��1�'{til��"1�'��'�'1'1I�11U��1�11�1� OMNICARE OF KING OF PRUSSIA RMOUN i ENCLOSED $ 3'23 P.O. SOX 740391 CINCINNATi, OH 45274-0391 O�OD�09024a937�PH132409320�DKOPDX90�0�003232 �� ' 2'�' � < < ( (23�(S `i�-�OM�.,S I7.SCC?7'T �,s ��'�' AhTNA�i.SC�J'�"I' t�r•�'r�r��t�v� „A�.: Z 3�i,,�r� i S CAltt.l51.�,F� i_7l1L5�39 i P1�Y Tt) UM�I'�� C� CS� Y—�'�!' [S� 4_��St� � � C�Gi.� �- '� 'tl yL�Mtt.►£R 4R f ; 3 _ � ` t�fi� 1�t�4� ��.k �.�. ��/tD� �.�� .� � �� ,�� .� ��z�r-�� ►��s _ _ � � 1a � � • �� s ��. C� �� BQ�. �� [� � � ..�..��.� � . � � ... � � W _ -. . . - - � R ' � 7(� _' � �, "" .. y . - . .��I�t°?L�T�1�('l4`:4�{��t�'th',�1F7�C?t��s�ik;atkl�t - t" ; � - �CtL�(��7Qi��-�2 �5��13'�t„��dlt k�a Account _ �` - ��Di�E,a7 �T�thm nafied p�}�E v.�t3�o�t� t a s � - :.e!�,�car�'r�e�1i��Fifiin Th�r��nk-��A?��st�� , _ -- � � .: - . { :. --_ _ " - �4 + _ _ - _ - ti- � = } " _ ' t - - :. 3 , ;- n 4 �_. _._..___ , - _ _ _. ;s �1�� ST��oF ��,� OMNICARE OF KING OF PRUSSIA V ALLENTOWN,PA sR s PAGE: 2 of 3 ACCOUNT NO: 9024-92 .� RETURN SERVICE REQUESTED 34285 INVOICE NO: PH1324092 DX NO: KOPDX BILLING HOURS: 8:00 AM TO 6:00 PM INVOICE DATE: 01/11/15 oos,so Phone: 877-670-6323 FACILI7Y: 9024 CUMBERLAND PERSONAL CAR o2os PATIENT NO: 92 You may also view/pay your bilis at: PATIENT NAME: BIVENS,HELEN https:llmyomniview.omnicare.com AMOUNT DUE: 106.57 TAX: 0.00 Ihl��lh��l�li�i�lhl��liil��li��l�i��ili��il�l�i��li HELEN S BIVENS ' C/O ANNA SCOTT DUE DATE: 02/05/2015 15 EAST EPPLEY DRIVE CARLISLE, PA 17015-4379 annouNr�u�: 106.57 34285*T9AOAUGOl009475 49AOB6ST5:2.3 KEEP"" .:"PORTfON FOR YOUR RECORDS-RETURN ;": ` ;:STUB WITH PAYMENT I Q��N��W�� BIVENS, HELEN 9024 CUMBERLAND PERSONAL CARE s e .. 9024-92 01/11/15 DATE RX N0. TRANS DESCRlPTION PHYSICIAN NDC N0. QUANT AMOUNT TYPE 12/17/14 R2372460 CHARGE MUCINEX DM BI-LAYER 600MG-30MG TAB.SR 12H GUISTWITE 63824-0056-34 14 9.20 OTC 12/19/14 R2373254 CHARGE PRAVASTATIN SODIUM 80MG TABLET (RP:PRAVACHOL GUISTYITE 00093-7270-70 30 7.00 RX CPRAVASTATIN)} (COPAY) 12/19/74 R2373253 CHARGE LOSAR7AN POTASSIUM 50MG TABLET (COPAY) GUISTWITE 00093-7365-90 30 7.00 RX 12/19/14 R2373253 CHARGE CIPROFLOXACIN NCL 500MG TABLET (RP:CIPRO) (COPAY) GUISTblITE 00172-5312-70 6 4.63 RX � 12/21/74 R2373964 CHARGE PREDNISONE 10MG TABLET (COPAY) GUISTNITE 00054-0077-29 5 1.80 RX ' 12/23/14 R2374600 CHARGE CIPROFLOXACIN NCL 500MG TABLET (RP:CIPRO) (COPAY) GUISTWITE 00172-5312-70 6 4.63 RX 12/29/74 R2376417 CHARGE MUCINEX DM BI-LAYER 600MG-30MG TAB.SR 12H GUISTWITE 63824-0056-34 14 9.20 OTC 12/30/14 R2377076 CHARGE GARLIC SOFTGEL 7000M6 SOFTGEL GUISTNITE 74312-0123-26 30 3.05 OTC 12/30/14 R237701 CHARGE CRANBERRY 400MG CAPSULE GUISTWITE 47469-0760-33 60 9.82 07C 12/30/14 R2353652 CHARGE ALLOPURINOL 300MG TABLET (COPAY) GUISTNITE 00378-0181-05 15 6.01 RX 12/30/14 R23047281 CHARGE MULTIVITAMIN CTAB-A-VITE) TABLE7 GUISTWITE 00904-0530-80 30 2.99 OTC Messages -- Finance Charges may be assessed at a MONTHLY PERIOD RATE OF 1.50°k(ANNUAL RATE OF 18.OU°h)based upon an unpaid balance outstanding 30 days or more. PREVIOIlS BALANCE CHARGES FINANCE CNARGE TOTAL CHARGES PAYMENTS & CREDITS AMOUNT DUE 45.29 106.57 0.00 151.86 -45.29 106.57 L TU INSURE PROPER CREDIT, -"'� ':' A[JD "`:'"" "-'. THIS PORTtON INTHE ENCLOSEd ENVELOPE. 3a285*TSAOAUGOLoo9475 y�azsac `PIB3S2 Ch2Ck i1 HbOV6 3dd�E5S IS I�COR2Ct dfld i�OiCdt2 Chd�gP O!7�E�2�S?Sid2. !F PAYING BY ttiASTERCAR�,DISCOVER,VISA dR AMERICAN EXPRESS,FILI OUT BELOVJ. CHECK CAA�USMG FOR PAYME�JT ACCOUNT NO: 9024-92 (� ❑ �Q ';❑ ❑ INVOICE NO: PH1324092 FAAS7ERClRD DlSGOVER ; VISA AtAERIGAfJ�XFRc5S DX NO: KOPDX GAflD NUMBER INVOICE DATE: 01/11/15 FACILtTY: 9024 CUMBERLAND PERSONAL CARE SIG"7ATUFE �kP��rE PATIENT NO: 92 PATIENT NAME: BIVENS, HELEN ,, , _ • AMOUNT DUE: 106.57 il��d��l�i��lll�ll��I�'�ill��"t�'��'�'1'll�llll��id61� /0��S� OMNICARE OF KING OF PRUSSIA AMOUNT ENCLOSED � � P.O. BOX 740391 CINCINNATI, OH 45274-0391 000�0�9024-9230PH1324092400�KOPDX90��0106570 � � � 2'�1 � i ( /�3115 2/1?12015 Print View �� MERRILL fl E�IVENS ESTkTE ��°1�p� �� AI►INA B S�Ct7TT�EXECUTFiIx TNONIAS D S�GO�T� �XECUT�R �5 E �pPLEY DR. � � �+� C�RLI�uIE� P�14 7�Q7� trnik: i 3 P,1Y h?TN F �+fM4� S NSs�1'r�+ ,.�J � ��, #� ��k111.k t�E --- j �1� �i"'��C'��n±�°t"�"a�. � ��t�a.,�---�— - - . . . , c► � . -- rxru�Rs u �,` � � , � �. � �rr Yee.Kw..M sa+� titt:�nc,��t C+� � �ret�`tt►L �iY�S �1f!""�� ► �:� � i 3�4 30 6�: L �•�� L 9C�7 q��' 0 5� � } ' _ .(_'�-f P � ` ' r a /'� • . T' :; . . U L� �- - � . � . � :. �: :r ' j � 3 � `3• s: -T -� ' :.--� G � . rC � � � = I � ��r � T�� /� M:� 3 1 y� s�o � I . z Y+ R•.r• c� �� , . ;,�-: b m —�---- • �--�' �--—�—',—S_ �• ?�� `s-$�'�`;'3�}�3?+Ty_]=��.:s�=�,�3�C:�;t ',1R.:':::'.L"��b lIS2r;:.k�k�.Y •-�.n :p'O� m n � � S�, n q �Y ��7�•fi T G. . .. .� �� ' . �).� '�'Z- Q jt7p_{ O.� ^�,,...�, .r y - � .��' ��`mW�� , p �!' 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Cariisle,PA 17015 Amount Due on This tnvoice: $581.68 Other Outstanding Balances: �0.00 nnai�ta Yotal Outstanding: $581.fi8 Home Instead ��2 Enclosed: ;5 5002 Lenker Street � � �� ' 6� ' Suite 101 _________ _.____- Mechanicsburg, PA 17050 — -- - — -- - _ .�e� ____ _ �_ ��-- _ _ __ _•--<_ _ ,�--_v—�..— --,._...._::.,_� _�__ - =-- — _ . �i' MERRILL R BNENS ESTATE �3°1307 `j �� AN{VA B SCOTT,EXECUTftIX 5��' �' '' THOMAS D SCOTT,EXECUTOR ��' �' 15 E EPPLEY DR. t �'`(�t� � , ii 'I CARLISLE,PA 17015 D:�re � ��: ' [i t r:��iurE�r_ � 'i� ��'^'�� l NS'�'�l�-0 � � S�6 L.fe� �, � oaUrr.oF � zl V ��V� �� C�uri� t�O'n� � 6$�l d a �-�.�- DOLLARS IJ �ya�. � t3' �`C�//�� `i _- � F�i ,, www.lmVusmnHnecrom �n �� , �}. ,,. 'i^ �i ' 4tvSp�ck. ; i�Et.��c ��'G�v�.�l��f'C�/�N ,K, '; �� aiF�io ----- i ;, �:03L304306�: LL�� 19079ii' 050L � .� -- ---- ��-..�..:�..--- -- -- -�.. — _-- _ _-__ -.. ..�.�.... '' ---- - ---— -- --=--�- _ .._..._..._�: ��-� = � SP� �E 3l19/2015 : Image Viev�r _�,�.,�.«r_-u.,..� - -a,��.�.ti MERHILt R'B11�ENS E3TAT� ��°y��}� �� ANN�4 B SCfJTT� EXECUTRIX 7HOMJ�s�D SCf3TT, E![EGU��R �5�ENPLEY OR. � ,S �"�� CARiISLE. PA �7015 a�TE } ; PAYTt?TME ��7`�� V 1«`'� �CkA"�.+ I�►tl��S� � 1 �� - C�K�}l:R Oi - � � _ + � �1C� t�.�+�-� �#�t�� [3C3i.t.ARS � ;� � � ..�� ..�y �C�� .�r:wr��i�'��. �1.�r+i�� C --------- �---- ------"' � r:0 � � 3Q4306�: i �� z �a ?�� d5D6 � ��d--.�� Lr.--.�.4�..�—_� c .J • ,ri� ' • � � � � K �� ?_ xiy(, � . ' � =�ra C]Q . b � a"� •c.•s�J - � �. 70 r • � �`€ � •li� a •� j�i -�7�5 � . �,` � . . , —' � .��t_��.r � . . . .� �� _' '" ' ' • "' • � • •;�•,1�`' - ��'�� n • .�:�^G'��:�� xg� � ' • . . �� ' �a m�,—�y � ' ' - ' � a�Q_.f�.> �T� � . _ , - =CSO ��-iTr �� `iin�::� �� .�� r— C':, �` . �.`� r � � � �'-�C C� . ,�a'<.�.;�--o �� . . � ' i;,�C� �'V1��C� � •i v�,�'��'_' �•- � - . -z . �� • � ' �, - �i�9 '-,�t•e . 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R �I i �' . ��+�Y+�II�r�•or-�T� � . , m . . httpsJltiprd.metavarrte.c�i/MainSer�let/Irr�geViev� 1/1 �?'��_ Pa e 1 of 1 ��J�; STATEMENT 9 � �i � � I�KO N In�oice# Account# Date � LUTI�fEftAN SOCIALb41N1STRfES 516492 8888CCPC 01/31/2015 Cumberfand Crossings Persona( Care 1 Longsdorf Way Cartisfe, PA 17015-7623 Due Date Amount Due Amount Paid Facility#(717)245-9941 y23I2015 �10.80 Business Office#(717)240-6040 Anna SCott Resident Name 15 East Eppley Dr. Bivens, Helen Shinham Carfisle , PA 17015 Pfease make check payable to Diakon Lutheran Social Ministries Helen Shinham Bivens Cumberfand Crossings Personai Care �i13ii20 i5 Anna Scott Date Description Units Net Balanca From Throu h ha es Credits RESIDENT RESPONSIBILITY 12/31/2014 Balance Forward $8,259.00 01i15/2015 Payment Received Ck#2807 .00 Day -3,282.00 01l01/2015 01/31/2015 Singie Suite Levei 2 -22.00 Day -4,977.00 01/09/2015 01l31/2015 Phone-Enhanced Service Phone Enhanced Se 1.00 Each 10.1 01/Q9/2d15 1/31/2015 Sales Tau Sales Tax 1.00 Each 0.6 � � i - _ i � i TOTAL BALANCE DUE ��o.ao (�-�N� � 3/19/2015 Print l�ew .:�.,�—s-___,_-___- ... _-------_-_-_—'--___-=�_-�--:::-_,_�:�._-_____---,"----•---- --_---'-7` -- t•n�� NIERAI�.t R e1VE�1S ESTA7� ��13fl7 5�9 tl ANNA B S�DTT, F}CECU�RII� � � rH��n�s �s�arr, Ex��ur�R �;� : 15�EPPLEY DA, � � �� ; •'� ChRLISLE.Ph y7Q15 uAit� '� � ; i � = ��nr m ri ir. �}�, �1��'�. {� �� [?RDCRC}T I �. �� y S �� "�[I�R�� tl.+l�� 0�+��_��t7� .-----�� —�- � � --. 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FIRST LINE OF ADDRESS 2 � � _ --- _ ___ _ 5 EAST EPPLEY DRIVE SEGOND LSNE OF ADDRESS _ - '�;T� ;�ATE ;ZZF i PHONE NUMSER Make check or money order ;C A R L I S L E i P A �17 015 ?717-2 4 9-52 22 payabie to the Pennsyiva�ia Department of Revenue DEPART�t��' US� a�1L� � �— � � __ ._u.,,�.�= _....�..--.,e_� -_.�- ___�— —.��...___ �_ �..�:.:.----_�� _=,W =__— _ __ _ ----� � MERRILL R BfVENS ESTATE ��1307 S 1 O �� ANNA B SCOTT,EXECUTRIX �' � THOMAS D SCOTT,EXECUTOR ;� '� 15 E EPPLEY DR. t 3 YKI��S ��; CARLISLE,PA 17015 D:\TE � 4 t;4 . � i�s I'A1"1'O"IHF f,�-SP�� QuSY�SS SC��.V�I�S � � �SZ•SO ;i b" ORDGR OF < <� ;?, •� ;3� �p►� �,ts N�ol1.rro C�,�C�t^i-'Ns o oU,l� S°`�o o �^ DOLLARS 8 d..,_a,�' � , r; �i` �� F: �{� TRUST r� . � �o��t� ;; (I www.imwswnnne.wm . 1 � `i nt��io 2cs14 TA'C �� ---------------- -------------"r !� � i:0 3 L 304 306�: L �� i90 79��' 0 5 LO 'tl 1� — --_�_.�.�—__—___. __�--_.--__- -_- -- - �� , _ ._.�.T ,> >� _..� _r..m �.�...�=-�,�.�� -- -- — _—�._ Aspire Busi nes nSol u�ons �J � � PO Box 325 0 " , - . Diilsburg PA 17019 3J12J15 398 Tom Scott 15 East Eppley Rd , Carlisle PA 17055 a- . . o . Tax Return Preparation Preparation and filing of Federai and State tax 1.5 hr 45.00 67.50 retums-Scott Filing/Sftwr Fee Flat software/electronic filing fee for tax retums 1 60.00 60.00 Tax Return Preparation Preparation and filing of Federal, State, and Local tax 2.5 hr 45.00 112.50 returns- Bivens Filing/Sftwr Fee Flat software/electronic filing fee for tax returns- 40.00 40.00 prorated for paper return All payments are due 15 days from the invoice date. TOt81 $280.00 Please make checks payable to Aspire Business Solutions and mail to PO Box 325, Dillsburg, PA 17019. Include the invoice number in the memo space. Phone# (717)586-1234 absllc.biz contact@absllc.biz 3/13�2015 Prir�V ew Ar\V.��.��.��i�M��Y�� •._--rrr�z�•�.�1��'��.��y��r�� .��__.� �T-- �� .... •. �� r� ...t . .�� MERRILL I��I�tENS ��ATE �,'�'1�D7 r��$ �ki+INA B SCOTT* �XECUTRI 'Ti�i�MAS I7 SC�'FT� EJ(�CU3 '. 15 E�PPLEY DP, t �� t� .' '�..._.� CAFiLISLE, PA 17G15 r�me .I` ��y t '� • I;t'�1'Q'tNf �}�''��C �� t� C-I.LCG-'l�� + "�.�o �. �' � i'� OR�F'ri nF_,,. / I �P' �I. � .. � . � �� -� �1�,'��"�� i1�. ��lb� �''_`�y U�LLARS � �',... � . a.,._..� :i " .- �. � .I� TRLJ�'C � �-�.�..,��' �� _ ,��,.�.�m., � ti,iti,a �� S-,R�Fi`��a �J�+-�i�C� � - _.--� � , �:� 3 � 3Q 4 3�6�: � �••� i qC7 ?9��' 0 5�8 : � - _ -- --•..,-.w..-= -�--.-_---.�.:-�----�--��...�-T---._--.__: - �� ._. ::� -� � - c �� '' - • C; ri •: ' .� : i �y • i' ' , . �� '_i� �a m f �' 'n' `� .. � ..��1 �rTi �i O �; ' . ' .-r: . _ f� ��.1 � U y . • . ' ' r11 �� . r ' � � i � �) � � -,� ' ' - • . :.' � Ua _°� ' ' ��t � r�` �.� . _r-,�.: };„��* �'L ' i�-� .�'::...'�:� 1 . .�;� � tiq_ �' ry�r,ll 1 -- - . � L _;�� r:� T:� . • _ . � � ... _r�r.�r'`�,, R.�1, ='� - .�. C� � . ,'.. 1 'r�r in�+ v�R�' .. . /y 1 '� :.' Cf Ft; ` � ' �� V� '.'.9 �`/ �� ,; . _ _- - �can Bank Nt�rcersbur , �� _� '-. 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MAFt O l, 2 015 16 9 2015 FRANKLIN CO REAL ESTATE TAX NOTICE 9,580 18415-2 MAKE CHECKS PAYABLE TO: DENISE GARNES • MON 2:OOPM-S:OOPM, TUES 2:OOPM-5:OOP 12563 LONG LANE _ JULY-HRS BY APPOINTMENT ONLY MERCERSBURG, PA 17236 CLOSED SUNDAYS AND HOLIDAYS PHONE: (717) 328-31a5 OTHERTIMES BY APPT OR DROP IN MAIL S COUNTY CTY LIB TWPBORO LIGHTS ` 10°/P 25. 5 M 10%P 1.05 M 10%P 1.6 M 10%P M %P �URING THIS PERIOD PAY THIS AMOUNT 240.82 9.86 15.02 MARCH-APRIL 265.70 245.73 10.06 15.33 I MAY-JL7NE 271.12 270.30 11.07 16.86 AFTER JUNE � 298.23i � LAND: 9,580 BLDG: TOTAL: 9,580 PARCEL# 18-OK13 .-027. -000000 V LOCATION BIVENS, MERRILL R & HELEN S GEIBS ROAD 15 EAST EPPLEY DRIVE CARLISLE PA 17015-4379 CLOSING DATE FOR THIS REAL ESTATE � BILL IS: 12/31/2015 DENISE GARNES 12 5 6 3 LOI3G LANE MERCERSBURG, PA 1�236 18-OK13 _-02'7.-000000 --_ BIVENS, MERRILL R & HELEN S � 15 EAST EPPLEY DRIVE CARLISLE PA 17015-4379 _ Deluxe OrderYro - Urder C;ontirmation t'age 1 oi 1 Deluse(�rderProb H21D � Tutoria� � Exit ne!<<y SwilchAqent � Order Branch Sup Ip iCs Order Search Order ConFrmation • The oreier has been submitted.You may print this screen for your records then eithe�place another order for this account,access another account or ExR. Order Contents _ ._ _ _ __ . _ _ __ _._ _ __ __ _ __ Confirmation#: 6 0 3 2 8 5 2 5 5 6 � Rautlng#: 03130430 Account#: �.1119p79 Estimated Orrler Total� $34.20..� �� Order Date: Ot/23/15 item 1: Product Descriptton Blu Safety Checks-SingleNVallei Imprint: MERR�LL R BIVENS ESTATE ANNA B SCOTT,EXECUTRIX THOMAS D SCOTT,EXECUTOR 15 E EPPLEY DR CAR�ISLE,PA 17015 Shipptng Method: Standard Trackable Deliv ( -70 days) Shipping Address: MERRILL R BIVENS ESTATE ' ANNA SCOTT 15 E EPPLEY OR CARLISLE,PA 17015-4379 USA ��"t'1pQ�"• nti The majority of consumers are activel ? Ftat Packaging �. Shipping Confirmafion y � concerned about the ' Gek+xe{u•Sen,li tltris arE�hivaecf�n � � a-� �amper es�stantma��m�package security of their checks� 5nn;roen y��u enter Ihe wnsumerz -- �C `' emall aatlress.��ew��senn o sriop�ng �ffe�Hlgh S@CUrity CheCkS .. ` Hfit�s «sm+at�,t?�ad.iri��ucFn�a,rm3,}e .:�� .... . •:,na ai.� „e rcr�asr rr-afrrt�cn � to help deter fraud. � ! ' Cuesti�ns�Cal-DBI�x2 . _� .. to11 trze al 87T.98t.d146. _ 'ACI Wwkiwide&AIM,IOit ..` � ��: . _,.._. .___..-. . ..__ . _.__.....�� Search for Another Account Recortl Print This Saeen3 SwitchAgent for Current AccouM Search Current Account Recorcl Exit; Privacy Security and Reliability Terms and CondiUons ?i�::�si: ;eL�� r.x<sat:�-�.t: d�am�a :rtr.c ::once. ...i tra;fonu'�r<s am:Ce pn;r�+;r�y, ...�:r�_s�ztc.. :u::::er;. ZO'�Dei:�za cnlCrcrisa i��tr�tio. ,��...A�i R�`t<i:es,.•r.�„ 9;:i!t!:�_,v�vr 1u.;1.5;: � C-��ELI�GS '��lL E S�� (�-�ov�� https://orderpro.deluxe.com/webapp/blueiceberg/deluxeport/DLXportServlet 1/23/2015 REV-1573 EX+(01-10) `_�� pennsylvania SCHEDULE J ' DEPARTMENT OFREVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT _..__..__._.._---� - ---- ---- —._..----�--�-------- ESTATE OF FILE NUMBER Bivens, Merriii R 21 - 15 - 00076 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER I NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$) RECEIVING PROPERTY Do Not List Trustee�s) ----- -- -------- — — - --- --- ----- — —— _ . ___ � TAXABLE DISTRIBUTIONS[include outright spousal distributions,and transfers iunder Sec.9116(a)(1.2)] 1 j i i 2 Anna Bivens Scott Daughter entire estate 15 East Eppley Drive iCarlisle, PA 17015-4379 i i I i I �Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate. I II� NON-TAXABLE DISTRIBUTIONS: A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN I i B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS I I � TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI O.00 _ _ - _ --_-- ---_--- ------------ REV-1649 EX+(09-12) ��, pennsyivania SqiEDULEp � DEPARTMENT OF REVENUE FI Ff"�q�UNDER SG�.9113(Q) I INHERITANCE TAX RETURN r�� RESIDENT DECEDENT - � . . �--- --_.- -- - - ---- ----- _.-_----------- --- ---- --- ------ .. _._.- . ..._.__. ESTATE OF I FILE NUMBER ____Bivens, Merrill R __ 21 - 15 - 00076 PART A- DEFERRING STATEMENT ---— --- - -- - -- ------------ -- -------- For all trust assets reportable for Pennsylvania inheritance tax purposes for which a deferral of tax is being elected under Section 9113(a), the personal representative responsible for filing the return and the trustee(s)of the trust in question hereby acknowledge the departmenYs Statement of Policy set forth at 61 Pa. Code§94.3 concerning any potential termination of the trust under 20 Pa.C.S. §7710.1 that occurs after the return was filed. Specifically, the signatories recognize each individual's assumption of liability for inheritance tax consequences that result from any termination of the trust under 20 Pa.C.S. §7710.1 that occurs after a return has been filed. Signature of Person Responsible for Filing Return Signature(s)of Trustee(s) ----------- -- — -- ---- ---- - ----- - - PART 6= ELECTION TO TAX AMOUNTS -- _ _— — ------- _ _ Complete this section only if making the election to tax available under Section 9113(a) of the Inheritance& Estate Tax Act. If the election applies to more than one trust or similar arrangement,a separate form must be filed for each trust. This election applies to the _—_ _ __ Trust(marital,residual A,B,bypass,unified credit,etc.). -- -- — --------- — — - -- ----- --- ------ nter the description and value of all interests for which the Section 9113 (A) election to tax is made. — -- - ---- --- -- _ ---- _ DESCRIPTION VALUE __ __ i .. ____ -- --- � ' I � i I � I I i —--- --�--------- --- — ___. -------- --------- Total -- - o.00 (If more space is needed, insert additional sheets of the same size) � , �% �I�� I "