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Home My WebLink About05-2886 II .,. TERRENCE THOMAN, Plaintiff vs. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COTlNTY PENNSYLVANIA LINDA LEE THOMAN, Defendant CIVIL ACTION NO. dCO') - :Jf3~ IN DIVORCE and CUSTODY NOT r C E TO DEFEND You have been sued in court. If you wish to defend against the claims set forth in the fOllowing pages, you must take prompt action. You are warned that if you fail to do so, the case may proceed without you and a decree of divorce or annulment may be entered against you by the court. A Judgment may also be entered against you for any other claim or relief requested in these papers by the Plaintiff. You may lose money or property or other rights important to you, including custody or visitation of your children. When the ground for the divorce is indignities or irretrievable breakdown of the marriage, you may request marriage counseling. A list of marriage counselors is available in the Office of the Prothonotary at: Office of the Prothonotary Cumberland County Court House 1 Courthouse Square Carlisle, PA 17013-3387 IF YOU DO NOT FILE A CLAIM FOR ALIMONY, DIVISION OF PROPERTY, LAWYER'S FEES OR EXPENSES BEFORE A DIVORCE OR ANNULMENT IS GRANTED, YOU MAY LOSE THE RIGHT TO CLAIM ANY OF THEM. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE PA 17013 717-249-3166 YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. II f. TERRENCE THOMAN, Plaintiff vs. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA LINDA LEE THOMAN, Defendant CIVIL ACTION NO. 65"- .:l. U-p!, IN DIVORCE and CUSTODY NOTICE OF RIGHT TO COUNSELING You are one of the parties in the above captioned action in divorce. By virtue of Section 202 of the Pennsylvania Divorce Code, it is a duty of the Court to advise both parties of the availability of counseling and upon request of either provide both parties a list of qualified professionals who provide such services. Accordingly, if you desire counseling a list of marriage Counselors is available in the Office of the Prothonotary at: Office of the Prothonotary Cumberland County Court House 1 Courthouse Square Carlisle, PA 17013-3387 II ~ Ii TERRENCE THOMAN, Plaintiff vs. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA LINDA LEE THOMAN, Defendant CIVIL ACTION NO. ~S- .<. r 1'& IN DIVORCE and CUSTODY CONSOLIDATED COMPLAINT IN DIVORCE 1. Plaintiff is Terrence Thoman, a residing at 212 Pennsylvania. April Drive, Camp citizen of Pennsylvania, Hill, Cumberland County, 2. Defendant is Linda Lee Thoman, April Drive, Camp a citizen of Pennsylvania, Hill, Cumberland County, residing at Pennsylvania. 212 3. Plaintiff and Defendant are sui iuris and have been bonafide residents of the Commonwealth of Pennsylvania for at least six months immediately preceding the filing of this Complaint. 4. The parties are husband and wife and were lawfully married on May 7, 1988, in Dauphin County, Pennsylvania. 5. The marriage is irretrievably broken. 6. Neither Plaintiff nor Defendant are in the military or naval service of the United States or its allies within the provisions of the Soldiers' & Sailors' Civil Relief Act of the Congress of 1940 and its amendments. 7. There has been no prior action for divorce or annulment instituted by either of the parties in this or any other jurisdiction. II ~ 8. The Plaintiff has been advised counseling and of the right to request parties to participate in counseling. of that the the availability Court require of the COUNT I Request for a Fault Divorce Under 3301(a)(6) of the Divorce Code 9. The prior paragraphs of this Complaint are incorporated herein by reference thereto. 10. Defendant has offered such indignities to the Plaintiff, who is the innocent and injured sPOuse, as to render Plaintiff's condition intolerable and life burdensome. 11. This action is not collusive. 12. Plaintiff has been advised of the availability of counseling and that Plaintiff and Defendant have the right to request the Court to require the parties to participate in such counseling. WHEREFORE, Plaintiff respectfully requests that the Court enter a Decree of Divorce, pursuant to 330l(a) (6) of the Divorce Code. COUNT II Request for Divorce Due to Irretrievable Breakdown Under 330l(c) of the Divorce Code 13. The prior paragraphs of this Complaint are incorporated herein by reference thereto. 14. The marriage of the parties is irretrievably broken. " ,. 15. After ninety (90) days have elapsed from the date of the filing of this Complaint, Plaintiff intends to file an affidavit consenting to a divorce. Plaintiff believes that Defendant may also file such an affidavit. 16. Plaintiff has been advised of the availability of counseling and that Plaintiff and Defendant have the right to request the Court to require the parties to participate in such counseling. WHEREFORE, if both parties file affidavits to a divorce after ninety (90) days have elapsed from the filing of this Complaint, Plaintiff respectfully requests the Court to enter a Decree of Divorce, pursuant to 330l(c) of the Divorce Code. COUNT III Request for Divorce Due to Irretrievable Breakdown Under 3301(d) of the Divorce Code 17. The prior paragraphs of this Complaint are incorporated herein by reference thereto. 18. The marriage of the parties is irretrievably broken. 19. After a period of two (2) years has elapsed from the date of separation, Plaintiff intends to file his affidavit of having lived separate and apart. 20. Plaintiff has been advised of the availability of counseling and that Plaintiff and Defendant have the right to request the Court to require the parties to participate in such counseling. WHEREFORE, if two (2 ) separation and Plaintiff respectfully requests the pursuant to 330l(d) of the years have elapsed from the date of has filed his affidavit, Plaintiff Court to enter a Decree of Divorce, Divorce Code. II ~ I COUNT rv Request for Equitable Distribution of Marital Property Under 3104, 3323, 3501, 3502 and 3503 of the Divorce Code 21. The prior paragraphs of this Complaint are incorporated herein by reference thereto. 22. Plaintiff and Defendant have acquired property, both real and personal during their marriage from the date of said marriage until the date of their separation. 23. Plaintiff and Defendant have been unable to agree as to an equitable distribution of said property. WHEREFORE, Plaintiff respectfully requests the Court to equitably distribute the marital property of the parties, pursuant to 3104 and 3502(a) of the Divorce Code. COUNT V Request for Alimony Pendente Lite and Alimony under 3104, 3323, 3701, 3702 and 3704 of the Divorce Code 24. The prior paragraphs of this Complaint are incorporated herein by reference thereto. 25. Plaintiff is unable to sustain himself during the course of litigation. 26. Plaintiff lacks sufficient property to reasonable needs and is unable to sustain appropriate employment. provide himself for his through II r- 'I 27. Defendant has the means and ability to pay Alimony Pendente Lite and Alimony to Plaintiff. WHEREFORE, Plaintiff requests the Court to enter an award of alimony pendente lite until final hearing and thereupon to enter an Order of alimony in his favor. COUNT VI Request for Counsel Fees, Costs and Expenses Under 3104, 3323, 3502(e) and 3702 of the Divorce Code 28. The prior paragraphs of this Complaint are incorporated herein by reference thereto. 29. Plaintiff has employed Mary A. Etter Dissinger, of the law firm of Dissinger and Dissinger to represent him in this matrimonial cause. 30. Plaintiff is unable to pay the necessary counsel fees, costs, and expenses and Defendant is more than able to pay them. WHEREFORE, reserving the right to apply to the Court for temporary Counsel fees, costs and expenses, prior to final hearing, Plaintiff requests that, after final hearing, the Court order Defendant to pay Plaintiff's reasonable counsel fees, costs and expenses. COUNT VII Request for Confirmation of Custody Under 3104 of the Divorce Code 31. The prior paragraphs of this Complaint are incorporated herein by reference thereto. II ~ 32. Plaintiff is Terrence Thoman, residing at 212 April Drive, Camp Hill, Cumberland County, Pennsylvania. 33. Defendant is Linda Lee Thoman, residing at 212 April Drive, Camp Hill, Cumberland County, Pennsylvania. 34. Plaintiff seeks custody of the fOllowing children: Name Present Residence Age Nicole Lee Thoman 212 April Drive Camp Hill, PA 17011 14 Kayla Lee Thoman 212 April Drive Camp Hill, PA 17011 7 35. The children were not born out of wedlock. 36. who The children are presently in reside at 212 April Drive, the custody Camp Hill, of mother and father Cumberland County, Pennsylvania. 37. During the past five years, the children have resided with the fOllowing persons at the following addresses: Person Address Date Plaintiff Defendant Nicole Lee Thoman Kayla Lee Thoman 212 April Drive Camp Hill, PA 17011 2000 to the present 38. The mother of the children is Defendant who currently resides at 212 April Drive, Camp Hill, Cumberland County, Pennsylvania. 39. She is married to Plaintiff. 40. The father of the children is Plaintiff who currently resides at 212 April Drive, Camp Hill, Cumberland County, Pennsylvania. II r- 41. He is married to Defendant. 42. The relationship of Plaintiff to the children is that of father. The Plaintiff currently resides with Defendant and the minor children. The parties intend to separate in the near future. 43. The relationship of Defendant to the children is that of mother. The Defendant currently resides with Plaintiff and minor children. The parties intend to separate in the near future. 44. Plaintiff has not participated as a party or witness, or in another capacity, in other litigation concerning the custody of the children in this or another court. 45. Plaintiff has no information of a custody proceeding concerning the children pending in a court of this Commonwealth. 46. Plaintiff does not know of a person not a party to the proceedings who has physical custody of the children or claims to have custody or visitation rights with respect to the children. 47. The best interest and permanent welfare of the children will be served by granting the relief requested because Plaintiff can provide a more stable environment within which the children will grow and flourish. 48. Each parent whose parental rights to the children have not been terminated and the person who has physical custody of the children have been named as parties to this action. All other persons, named below who are known to have or claim a right to custody or visitation of the children will be given notice of the pendency of this action and the right to intervene: NONE. 49. Defendant shall have the right to reasonable and liberal visitation with the children. " r- ., , , WHEREFORE, Plaintiff respectfully prays your Honorable Court to grant custody to Plaintiff and,that Defendant be granted reasonable rights of visitation. Respectfully submitted, DISSINGER and DISSINGER ~ " Mary A. Ette Dissinger Attorney for Plaintiff Supreme Court rD # 27736 28 North 32nd Street Camp Hill, PA 17011 (717) 975-2840 'I VERIFICATION I, Terrence Thoman, verify that the statements made in the Divorce Complaint are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. ~4904 relating to unsworn falsification. ~. 1(2 / Plaintiff ~ ~ ........ C' -C:. '-<;) w G' t "-- I;"- --z ~ ~ ~ 1\-- ~ ~ -~ 1:A. ~ ~ --- ~ ~ :N ----..: () ~ ~ -';.l 6~j ~ ~{~: ~< - d ~C) ,E,: (--, ~-(j ~ >c ~ ~ \) '% '" '" " '-fo "\ ~ ~ <:::> = <= <- ~::rJ c:: ::;e I }J~ W 0 :;::1-'rj '"U O::J ::J;: "'~ ~ 0' ~ r- :n co -< II AGREEMENT AGREEMENT made this .-3.J.. day of f'1~ ,2005, by and between Terrence Thoman ("Husband"), of 212 April Drive, Camp Hill, Cumberland County, Pennsylvania and Linda Thoman ("Wife") of 212 April Drive, Camp Hill, Cumberland County, Pennsylvania. WITNESSETH: WHEREAS, the parties hereto are Husband and Wife, having been married on the 7th day of May 1988, in Dauphin County, Pennsylvania. There were born two (2) children of this marriage, said children being: Nicole Lee Thoman, age 14 years (DOB 2/16/91) and Kayla Lee Thoman, age 7 years (DOB 10/23/97). The parties have no other issue, living or deceased, and have no adopted children. WHEREAS, diverse unhappy differences, disputes and difficulties have arisen between the parties and as a result they have lived separate and apart since on or about May 11, 2005. A proceeding for the divorce of the parties will be filed by the Husband in the Court of Common Pleas of Cumberland. It is the intention of Wife and Husband to live separate and apart for the rest of their natural lives, and the parties hereto are desirous of settling fully and finally their respective financial and property rights and obligations as between each other including without limitation by specification: the settling of all matters between them relating to the ownership and equitable distribution of real and personal property; the settling of all matters between them relating to the past, present and future support, alimony pendente lite, alimony II and/or maintenance of Wife by Husband and of Husband by Wife; the implementation of custody/visitation arrangements for their minor children and possible claims by one against the other and against their respective estates. NOW THEREFORE, in consideration of the above recitals and the mutual promises, covenants and undertakings hereinafter set forth and for other good and valuable consideration, receipt and sufficiency of which is hereby acknowledged by each of the parties hereto, Wife and Husband, each intending to be legally bound hereby, covenant and agree as follows: 1. AGREEMENT NOT A BAR TO DIVORCE PROCEEDINGS Husband will file a mutual consent, no-fault divorce pursuant to the terms of Section 3301(c) of the Divorce Code of the Commonwealth of Pennsylvania, and this Agreement is contingent upon the Husband proceeding with said divorce, and Husband filing his Affidavit of Consent and Waiver of Notice of Intention to Request Entry of a Divorce Decree thereto upon the expiration of the waiting period, and it is contingent upon Wife signing her Consent and Waiver of Notice at the expiration of the ninety (90) day waiting period following service upon her of the Complaint in Divorce. On the ninety-first (91st) following service on the Complaint in Divorce on Wife, Wife shall transmit her signed and dated Affidavit and Waiver immediately to counsel for Husband who will immediately file a Praecipe to Transmit Record and Vital Statistics form to precipitate the prompt entry of a decree of divorce. 2. EFFECT OF DIVORCE DECREE The parties agree that unless otherwise specifically provided herein, this Agreement shall continue in full force and -2- II effect after such time as a final decree in divorce may be entered with respect to the parties. 3. INCORPORATION OF AGREEMENT IN DIVORCE DECREE The purposes of this Agreement are to effect a complete and final settlement, with reference to each party of: a. All of the respective property and property rights of the parties, b. The custody of the minor children of this marriage, c. The obligation of each party for the support of each other, and the parties agree that the terms of this Agreement shall be incorporated but not merged into any final divorce decree which may be entered with respect to them. 4. AGREEMENT NOT TO BE MERGED This Agreement shall be incorporated into the final decree of divorce of the parties hereto for purposes of enforcement only, but otherwise shall not be merged into said decree. The parties shall have the right to enforce this Agreement under the Divorce Code of 1980, as amended, and in addition, shall retain any remedies in law or in equity under this Agreement as an independent contract. Such remedies in law or equity are specifically not waived or released. 5. DATE OF EXECUTION The "date of execution" or "execution date" of this Agreement shall be defined as the date upon which it is executed by the parties if they have each executed the Agreement on the -3- II same date. Otherwise, the "date of execution" or "execution date" of this Agreement shall be defined as the date of execution by the party last executing this Agreement. 6. DISTRIBUTION DATE The transfer of property, funds and/or documents provided for herein shall take place on the "distribution date" which shall be defined as the date of execution of this Agreement unless otherwise specified herein. 7. FINANCIAL DISCLOSURE The parties confirm that each has relied on the substantial accuracy of the financial disclosure of the other, attached as Schedule A, as an inducement to the execution of this Agreement. 8. ADVICE OF COUNSEL The provisions of the Agreement and their legal effect have been fully explained to Terrence M. Thoman by his counsel, Mary A. Etter Dissinger, Esquire. Linda L. Thoman acknowledges that she has the right to choose counsel of her own for a full explanation as to the effect of the provisions of this Agreement and she has elected not to do so. She represents that she fully understands the facts and has been fully informed as to her legal rights and obligations and she acknowledges and accepts her legal rights and obligations and acknowledges and accepts that this Agreement is, in the circumstances, fair and equitable and that she is entering into it freely and voluntarily, after having received advice from counsel, and she acknowledges that execution of this Agreement is not the result of any duress or undue influence and that it is not the result of any collusion or improper or illegal agreement or agreements. -4- II By signing this document without counsel, Linda L. Thoman acknowledges that she will be bound by the legal rights and obligations set forth herein. She acknowledges and accepts that this Agreement is, in the circumstances, fair and equitable and that it is being entered into freely and voluntarily, after having chosen not to seek advice of counsel, and she acknowledges that execution of this Agreement is not the result of any duress or undue influence and that it is not the result of any collusion or improper or illegal agreement or agreements. In addition, each party hereto acknowledges that, under the Pennsylvania Divorce Code of 1980, 23 P.S. Section 101 et. sea., the Court has the right and duty to determine all marital rights of the parties including divorce, alimony, alimony pendente lite, equitable distribution of all marital property or property owned or possessed individually by the other, counsel fees and costs of litigation and, fully knowing the same, being fully advised of his or her rights thereunder, each party still desires to execute this Agreement, acknowledging that the terms and conditions set forth herein are fair, just and equitable to each of the parties, and waives his or her respective right to have the Court of Common Pleas of Cumberland County, or any other Court of competent jurisdiction, make any determination or order affecting the respective parties' rights to a divorce, alimony, alimony pendente lite, equitable distribution of all marital property, counsel fees and costs of litigation, or any other rights arising from the parties' marriage. 9. REAL ESTATE A. The parties have compromised with each other and agreed that the marital residence is worth approximately $127,000.00. They acknowledge that there is a mortgage balance of $58,434.00 against the marital residence. Upon execution of -5- II this agreement, Wife will pay Husband the sum of $30,000.00 and Husband will sign a Deed of Conveyance to Wife with the marital residence located at 212 April Drive, Camp Hill, Cumberland County, Pennsylvania, 17011, and thereby relinquish all his right, title and interest in the said property. Wife will hold Husband harmless on the mortgage balance. The parties acknowledge the Wife has requested Husband to remove himself from the marital residence. Husband has undertaken to do that and is attempting to acquire a separate residence of his own. In the event that he is denied a mortgage because of the outstanding mortgage balance on the residence at 212 April Drive, Camp Hill, PA 17011, Wife agrees that within thirty (30) days of date of demand, she will refinance the property or have Husband's name removed from the mortgage so that he may qualify for a mortgage loan on property he intends to acquire after date of execution of this agreement. The parties agree that any funds escrowed in the mortgage payments attributable to the mortgage on 212 April Drive, Camp Hill, Pennsylvania, shall be and are hereby assigned to Wife. The parties agree that any property acquired by Husband subsequent to the execution of this agreement, whether a contract was entered into before the execution of this agreement, shall not be deemed or treated as marital property. In the event that Husband's prospective lender requires a waiver signed by Wife as to any interest in and to that subsequently acquired property of Husband, Wife shall, upon demand, execute such a waiver of any right, title or interest in and to any said real estate to be acquired by Husband. B. The parties are the owners of a cabin in Huntingdon County, Pennsylvania. On date of execution of this agreement, the title may still remain in Wife'S name, but the parties agree -6- II that within thirty days of date of execution of this agreement, they shall make arrangements to get the real estate title to the cabin transferred to them jointly as joint tenants with rights of survivorship as to each other. The parties intend that when one of them dies, the property will vest, by operation of law, in the surviving party. The parties agree that each shall, within ten days of execution of this agreement, prepare a will which shall provide that in the event of his or her death, the cabin real estate will vest in the other party to this agreement, and in the event that individual predeceases or dies on or before the thirtieth day following the death of the other, the real estate shall be left equally to Nicole Lee Thoman and Kayla Lee Thoman or the survivor of them. It is the parties' specific desire that the children be third party beneficiaries to this agreement of the parties as to the cabin real estate. The parties agree that until December 31, 2005, Wife shall pay all expenses associated with the ownership of said cabin property which shall include but are not limited to taxes, utilities, and routine maintenance. Thereafter the parties shall equally share such expenses. In the event that either party wants to make an improvement other than for purposes of routine maintenance, they shall consult the other party and both parties shall execute a writing that sets forth the work to be undertaken and the cost to which they are will to share. In the event there is a disagreement as to sharing of an extraordinary expense, the party who wishes to undertake the expense may do so with no expectations of contribution by the other party, and no obligation by the other party fo that expense. C. The cabin referenced above was damaged by flood water, and the parties received $49,500.00 in insurance funds for purposes of repair of the cabin. The funds are currently held -7- II in an account jointly titled to the parties. That account shall remain jointly titled until such time as the restoration of the cabin is completed. All restoration work shall be set forth in a written document signed by the parties evidencing their agreement and understanding as to how the funds are to be utilized for repair and restoration. In the event that at the conclusion of the restoration there are any insurance proceeds left, the parties will equally divide that fund. It is the intention of the parties that restoration shall be completed no later than December 31, 2006, and any remaining funds be divided equally between them at that time. 10. PERSONAL PROPERTY Husband and Wife do hereby acknowledge that they have previously divided their jewelry, clothes, furniture, furnishings, rugs, carpets, household equipment and appliances, pictures, books, and works of art. Evidence of the division of the property is set forth on Schedule "B" attached hereto. In addition to the sum that Wife will pay to Husband under paragraph 9 above, she will pay Husband and additional $1,400.00 to equitably divide the personal property listed on Schedule "B". The $1,400.00 shall be paid upon execution of this agreement. The parties agree that the property set forth on Schedule "B" shall remain in the marital residence until such time as Husband has obtained his own residence and within thirty (30) days after settlement on his new parcel of real estate, he shall be permitted to remove the items assigned to him on Schedule "B". It is the intention of the parties to separate from each other and divorce with as little financial detriment to either -8- II as can be achieved under the circumstances and with as little emotional turmoil for the children as can be achieved. To that end, it is the desire of the parties that Husband remove himself from the marital residence as soon as possible. The parties acknowledge that Husband has already may an offer on a piece of real estate which has been rejected because it was contingent upon the parties to this agreement having a formal written agreement and resolving all domestic issues before he could proceed with purchase of the property. It is the parties intention that Husband will vacate the property at 212 April Drive as soon as he can find a property to which he can relocate as an owner, but in no event will he remain at 212 April Drive after July 1,2005. Wife shall continue to allow Husband to reside in the marital residence with no cost to him until such time as Husband settles on a piece of real estate which shall become his new residence, but in no event after July 1, 2005. In the event Wife breaches this agreement to allow Husband to reside at 212 April Drive through July 1, 2005, she shall be responsible for all living expenses incurred by Husband from execution of this agreement through July 15,2005. The parties will divide the financial accounts as follows: a. On June 3, 2005, all bills currently in the hands of either party that have been incurred in the normal course of the marriage shall be paid on June 3, 2005, and any funds remaining in any financial accounts, expect for the account set aside for the cabin restoration, shall be divided equally between the parties. Any bills received after June 3, 2005, for utilities at the property at 212 April Drive, whether incurred in part before June 3, 2005, or not, shall be the sole and exclusive responsibility of Wife. -9- II b. With regard to life insurance policies, each party waves any and all right they have in and to any cash value of the policies owned by the other. c. Each waives any claim they may have to the pension, retirement and/or profit sharing plan or other retirement benefits of the other. Husband has a retirement with TIAACREF worth approximately $43,700.00 as of the date of execution of this agreement. Wife has retirement accrued from a prior employer, HighMark, in the amount of approximately $21,113.00 as of date of execution of this agreement. Wife also has retirement with her present employer through Fidelity, which retirement account is worth at the present time about $42,100.00. Neither of the parties are the beneficiaries of a defined benefit plan. d. The parties will, on June 3, 2005, either close all credit cards or provide proof to the other party that the other spouse has been removed from financial responsibility on that card. The person removed from financial responsibility shall relinquish their card immediately to the other party. 11. LIFE INSURANCE The parties are the owners of whole life insurance policies. The parties agree that each shall name each other as irrevocable beneficiary on their life insurance policy until such time as the youngest surviving minor child of the parties attains eighteen (18) years of age. Thereafter the parties are free to designate anyone they choose as beneficiary on their life insurance policies. With regard to any term insurance issued to the parties by their employers, the parties acknowledge and agree -10- II I I: that each party is free to designate whomever they chose as beneficiaries on those policies. 12. MOTOR VEHICLES With respect to the motor vehicles owned by one or both of the parties, they agree as follows: a. The 2004 Chevy Silverado shall become the sole and exclusive property Husband subject to its liens and incumbrances. Husband assumes and holds Wife harmless for the lien on the Silverado to Sun Trust. In the event that Husband determines that he cannot afford to make the Chevy Silverado payments, Wife shall cooperate with him in arranging for the sale of said vehicle. In the event that Husband is not able to obtain the full amount needed to payoff the loan, the parties agree that they shall equally share any deficit and pay it immediately to the lien holder so that the title may be released to the subsequent purchaser. a. The 2001 Chevy Malibu shall become the sole and exclusive property of Wife. It is free of all liens and incumbrances. The titles to the said motor vehicles shall be executed by the parties, if appropriate for effecting transfer as herein provided, on the date of execution of this Agreement and said executed titles shall be delivered to the proper parties on the distribution date. 13. ASSUMPTION OF ENCUMBRANCES Unless otherwise provided herein, each party hereby assumes the debts, encumbrances, taxes and liens on all the property each -11- [I 'I I will hold subsequent to the date of this Agreement, and each party agrees to indemnify and hold harmless the other party and his or her property from any claim or liability that the other party will suffer or may be required to pay because of such debts, encumbrances or liens. Each party in possession of property to be awarded to the other warrants that all dues, fees, assessments, mortgages, taxes, insurance payments and the like attendant to such property are current, or if not current, notice of any arrearages or deficiency has been given to the receiving party prior to the execution of this Agreement. 14. LIABILITY NOT LISTED Each party represents and warrants to the other that he or she has not incurred any debt, obligation, or other liability, other than those described in this Agreement, for which the party is or may be liable. A liability not disclosed in this Agreement will be the sole responsibility of the party who has incurred or may hereafter incur it, and each party agrees to pay it as the same shall become due, and to indemnify and hold the other party and his or her property harmless from any and all such debts, obligations and liabilities. 15. INDEMNIFICATION OF WIFE If any claim, action or proceeding is hereafter initiated seeking to hold Wife liable for the debts or obligations assumed by Husband under this Agreement, Husband will, at his sole expense, defend Wife against any such claim, action or proceeding, whether or not well-founded, and indemnify her and her property against any damages or loss resulting therefrom, including, but not limited to, costs of court and attorney's fees incurred by Wife in connection therewith. -12- II 'I 'I 16. INDEMNIFICATION OF HUSBAND If any claim, action or proceeding is hereafter initiated seeking to hold Husband liable for the debts or obligations assumed by Wife under this Agreement, Wife will, at her sole expense, defend Husband against any such claim, action or proceeding, whether or not well-founded, and indemnify him and his property against any damages or loss resulting therefrom, including, but not limited to, costs of court and attorney's fees incurred by Husband in connection therewith. 17. WAIVER OF ALIMONY The parties acknowledge that inflation may increase or decrease, their respective incomes may change, that either may be employed or unemployed at various times in the future, that their respective assets may substantially increase or decrease in value, and that notwithstanding these or other economic circumstances, the parties acknowledge that they each have sufficient property and resources to provide for her or his reasonable needs and that each is able to support himself or herself without contribution from the other. Therefore, the parties hereby expressly waive, discharge and release any and all rights and claims which they may have now or hereafter have, by reason of the parties' marriage, to alimony, alimony pendente lite, support or maintenance and they acknowledge that this Agreement constitutes a final determination for all time of either party's obligation to contribute to the support and maintenance of the other. It shall be, from the execution date of this Agreement, the sole responsibility of each of the respective parties to sustain himself or herself without seeking any additional support from the other party. -13- II i: , I 18. TAX RETURNS AND AUDITS Husband and Wife represent that all federal, state and local tax returns required to be filed by Husband and Wife have been filed, and all federal, state and local taxes required to be paid with respect to the periods covered by such returns are paid. Husband and Wife further represent there are no tax deficiencies proposed or assessed against Husband and/or Wife for such periods, and neither Husband nor Wife executed any waiver of the Statute of Limitations on the assessment or collection of any tax for such periods. 19. TAXES FOR YEAR OF DIVORCE Husband agrees to be liable and obligated and shall timely pay and hold Wife and her property harmless from any liability of Husband for federal income tax (including penalties and interest) as shown on his separate United States individual income tax return for the tax year 2005. Wife agrees to be liable and obligated and shall timely pay and hold Husband and his property harmless from any liability of Wife for federal income tax (including penalties and interest) as shown on her separate United States individual income tax return for the tax year 2005. 20. PRESERVATION OF RECORDS Each party will keep and preserve for a period of four (4) years from the date of divorce all financial records relating to the marital estate, and each party will give the other party immediate access to these records in the event of tax audits. 21. AFTER-ACQUIRED PERSONAL PROPERTY -14- II Each of the parties shall hereafter own and enjoy, independently of any claim or right of the other, all items of personal property, tangible or intangible, hereafter acquired by him or her, with full power in him or her to dispose of the same as fully and effectively, in all respects and for all purposes, as though he or she were unmarried. 22. LEGAL FEES Each party will be responsible for their respective counsel fees and costs involved in securing a 90-day no-fault divorce to be instituted by Husband as Plaintiff. In the event, for whatever reason, either party fails or refuses to execute an affidavit evidencing their consent to the divorce, pursuant to ~3301(c) of the Divorce Code, that party shall indemnify, defend and hold the other harmless from any and all additional expenses, including actual counsel fees resulting from any action brought to compel the refusing party to consent. Each party hereby agrees that a legal or equitable action may be brought to compel him or her to execute a consent form and that, absent any breach of this Agreement by the proceeding party, there shall be no defense to such action asserted. 23. CHILD CUSTODY The parties agree that they shall have shared legal and physical custody. It is the desire of the parties that the children shall spend an equal number with Father as with Mother. The parties recognize that the children are very active and their activities are to be encouraged and continued. The parties also recognize that both parents have significant employment responsibilities and it is their desire to facilitate as much as possible the parenting by the other parent and insure that the -15- II children's daily and special activities continue to be encouraged and completed. The parties assure each other they will be as flexible as their work schedules permit so that the children may continue to engage in the activities they currently participate in. The following 2-week schedule will be followed by the parties: 1. In week 1, Husband will have the children Sunday through Monday morning when he will take the children to school. Wife will have the children from Monday after school until Wednesday morning when she will take them to school. Husband will have the children Wednesday after school until Friday morning when he will return them to school. Wife will get the children Friday after school and keep them until Monday morning of week 2. 2. In week 2, Wife will have the children until Monday morning when she will return them to school. Husband will have the children from Monday after school until Wednesday morning when he will take them to school. Wife will have the children Wednesday after school until Friday morning when she will return them to school.Husband will get the children Friday after school and keep them until Monday morning of the following week. The parties will share vacations and holidays as equally as possible. Vacation and Holiday schedules shall be provided to the other party at least thirty days in advance by written notice. The party first given notice, as determined by the postmark, share have priority over the other party. The parties are free to modify the terms of the custody schedule by mutual agreement from time to time. -16- II I i I , 24. CHILDREN'S EXPENSES Commencing June 3, 2005, the parties agree that Wife will pay for 100% of all medical insurance premiums for the children, 75% of all orthodontic care for the children, and 75% of the cost for all clothing and shoes for the children. Wife will pay 75% of the costs of all medical co-pays for doctor visits, prescription drugs, and any other medical expenses not covered by her medical insurance or Husband's dental insurance. Husband will pay 25% of the costs of any co-pays or medical costs or dental costs not covered by insurance. Husband agrees that he will pay 25% of all orthodontic costs for the children and 25% of all clothing costs and shoes for the children. Husband will pay 100% of the Dental premiums for the children. The parties shall, at the end of calendar month account to each other what they may have spent for orthodontic care and clothing and shoes. The parties will equally share the cost of all child care expenses incurred to permit the parties to be gainfully employed. The parties will not share costs of babysitting when it relates to requiring a babysitter in the event neither parent is available to care for the children during a period that is not related to employment of either party. The parent who is feeding the children shall assume all costs for food without seeking contribution from the other. 25. SPOUSAL SUPPORT, ALIMONY PENDENTE LITE, ALIMONY Husband and Wife agree and hereby do release and renounce any claim they may have against the other party for spousal support, alimony pendente lite, alimony and maintenance. 34. DEPENDENCY EXEMPTIONS FOR INCOME TAX -17- II I 1 The parties acknowledge that Federal Income Tax Filing will impact the amount of tax the parties have to pay and will ultimately impact the amount of money available to each party to maintain their households and support their children. In order to maximize the revenue available to both parties to support themselves and their children, the parties agree that they shall take their income tax information to one preparer and have the income tax preparer determine how the parties maximize the income available to both units and then allocate the child dependency exemption in such a way that the combined federal tax refund to both households is maximized. The parties will accept the determination of the income tax preparer at to which parent shall take the child dependency exemption. The parties acknowledge that the preparer may allocate both exemptions to one party or the other or the preparer may determine that the exemption shall be split between the parties. Each party shall execute and deliver to other party any and all forms or documents necessary for the other party to claim the child or children as his or her dependant under Federal,State or Local Law. 35. WARRANTY AS TO EXISTING OBLIGATION Each party represents that he or she has not heretofore incurred or contracted any debt or liability or obligation for which the estate of the other party may be responsible or liable except as may be provided in this Agreement. Each party agrees to indemnify or hold the other party harmless from and against any and all such debts, liabilities or obligations of every kind which may have heretofore been incurred by them including those for necessities except for the obligations arising out of this Agreement. -18- II 36. WARRANTY AS TO FUTURE OBLIGATIONS Except as set forth in this Agreement, Husband and Wife each represents and warrants to the other that he or she has not in the past or will not at any time in the future incur or contract any debt, charge or liability for which the other's legal representatives, property or estate may be responsible. Each hereby agrees to indemnify, save and hold the other and his or her property harmless from any liability, loss, cost or expense whatsoever incurred in the event of breach hereof. 37. PROPERTY RELEASE It is the intention of Husband and Wife to give to each other by the execution of this Agreement a full, complete and general release with respect to any and all property of any kind or nature, real, personal or mixed which the other now owns or may hereafter acquire, except and only except all rights and agreements and obligations of whatsoever nature arising or which may arise under this Agreement or for the breach of any provision of this Agreement. All property hereunder is transferred subject to all existing encumbrances and liens thereon. The transferee of such property agrees to indemnify and save harmless the other party from any claim or liability that such other party may suffer or may be required to pay on account of such encumbrances or liens. Such party will, at his or her sole expense, defend the other against any such claim, whether or not well founded, and he or she will indemnify and hold harmless the other party in respect to all damages resulting therefrom. The insurance on the property being transferred hereunder is assigned to the party receiving such property, and the premiums on such insurance shall be paid by the party to whom the insurance is assigned. By this Agreement the parties have intended to effect an equitable -19- II distribution of their assets. The parties have determined that the division of said property conforms to the criteria set forth in ~3501 et. sea. of the Pennsylvania Divorce Code taking into consideration the length of marriage; the fact that it is the first marriage for Husband and Wife; the age, health, station, amount and sources of income, vocational skills, employability, estate, liabilities and needs of each of the parties; the contribution of each party to the education, training or increased earning power of the party; the opportunity of each party for future acquisitions of capital assets and income; the sources of income of both parties, including but not limited to medical, retirement, insurance or other benefits; the contributions or dissipation of each party in the acquisition, preservation, depreciation or appreciation of the marital property, including the contribution of each spouse as homemaker; the value of the property set apart to each party; the standard of living of the parties established during the marriage; and the economic circumstances of each party at the time the division of property is to become effective. The division of existing marital property is not intended by the parties to constitute in any way a sale or exchange of assets, and the division is being effected without the introduction of outside funds or other property not constituting a part of the matrimonial estate. The division of property under this Agreement shall be in full satisfaction of all marital rights of the parties. 38. MUTUAL RELEASES Husband and Wife each do hereby mutually remise, release, quitclaim and forever discharge the other and the estate of such other, for all time to come, and for all purposes whatsoever, of and from any and all rights, title and interest or claims in or -20- II against the property (including income and gain from property hereafter accruing) of the other or against the estate of such other, of whatever nature and wheresoever situate, which he or she now has or at any time hereafter may have against such other, the estate of such other or any part thereof, whether arising out of any former acts, contracts, engagements or liabilities of such other or by law of dower or curtesy, or claims in the nature of dower or curtesy or widow's or widower's rights, family exemption or similar allowance, or under the intestate laws, or the right to take against the spouse's will; or the right to treat a lifetime conveyance by the other as testamentary, or all other rights of a surviving spouse to participate in a deceased spouse's estate, whether arising under the laws of Pennsylvania, any other state, Commonwealth or territory of the United States, or any other country, or any rights which either party may have or at any time hereafter have for past, present or future support or maintenance, alimony, alimony pendente lite, counsel fees, equitable distribution, costs or expenses, whether arising as a result of the marital relation or otherwise, except, and only except, all rights and agreements and obligations of whatsoever nature arising or which may arise under this Agreement or for the breach of any provision of this Agreement. 39. PERSONAL RIGHTS Wife and Husband may and shall at all times hereafter live separate and apart. Each shall be free from any control, restraint, interference or authority, whether direct or indirect, by the other in all respects as fully as if he or she were unmarried. Each may also reside at such place or places as he or she may select, except that Husband shall continue to reside at -21- II Ii I 212 April Drive through July 15, 2005. Each may, for his or her separate use or benefit, conduct, carryon and engage in any business, occupation, profession or employment which to him or her may seem advisable. Wife and Husband shall not molest, harass, or malign each other or the respective families of each other, nor compel or attempt to compel the other to cohabit or dwell by any means or in any manner whatsoever with him or her. Each party hereto releases the other from all claims, liabilities, debts, obligations, actions and causes of action of every kind that have been or will be incurred relating to or arising from the marriage between the parties, except that neither party is relieved or discharged from any obligation under this Agreement. Neither party will interfere with the use, ownership, enjoyment or disposition of any property now owned by or hereafter acquired by the other. 40. GENERAL PROVISIONS This Agreement shall be effective from and after the time of its execution. 41. WAIVER OR MODIFICATION TO BE IN WRITING No modification, recission, amendment or waiver of any of the terms hereof shall be valid unless in writing and signed by both parties and no waiver of any breach hereof or default hereunder shall be deemed a waiver of any subsequent default of the same or similar nature. Any oral representations or modifications concerning this instrument shall be of no force or effect excepting a subsequent modification in writing, signed by the party to be charged. 42. MUTUAL COOPERATION -22 - II Each party shall on demand execute and deliver to the other party any deeds, bills of sale, assignments, consents to change of beneficiaries of insurance policies, tax returns, and other documents, and shall do or cause to be done every other act or thing that may be necessary or desirable to effectuate the provisions and purposes of this Agreement. If either party unreasonably fails on demand to comply with these provisions, that party shall pay to the other party all attorney's fees, costs, and other expenses reasonably incurred as a result of such failure. 43. LAW OF PENNSYLVANIA APPLICABLE This Agreement and all acts contemplated by it shall be construed and enforced in accordance with the laws of the Commonwealth of Pennsylvania. 44. AGREEMENT BINDING ON HEIRS This Agreement shall be binding and shall inure to the benefit of the parties hereto and their respective heirs, executors, administrators, legal representatives, assigns and successors in any interest of the parties. 45. INTEGRATION This Agreement constitutes the entire understanding of the parties and supersedes any and all prior agreements and negotiations between them. There are no representations other than those expressly set forth herein. 46. ENTIRE AGREEMENT Each party acknowledges that he or she has carefully read this Agreement, including all Schedules and other documents to -23- II which it refers; that he or she has discussed its provisions with an attorney of his or her own choice, or has waived the opportunity to do so, and has executed it voluntarily and in reliance upon his or her own attorney; and that this instrument expresses the entire agreement between the parties concerning the subjects it purports to cover. 47. INCORPORATION OF SCHEDULES All Schedules and other instruments referred to in this Agreement are incorporated into this Agreement as completely as if they were copied verbatim in the body of it. 48. OTHER DOCUMENTATION Wife and Husband covenant and agree that they will forthwith, and within ten (10) days after demand therefore, execute any and all written instruments, assignments, releases, satisfactions, deeds, notes or such other writings as may be necessary or desirable for the proper effectuation of this Agreement. 49 . NO WAIVER OF DEFAULT This Agreement shall remain in full force and effect unless and until terminated under and pursuant to the terms of this Agreement. The failure of either party to insist upon strict performance of any of the provisions of this Agreement shall in no way affect the right of such party hereafter to enforce the same, nor shall the waiver of any breach of any provision hereof be construed as a waiver of any subsequent default of the same or similar nature, nor shall it be constructed as a waiver of strict performance of any obligations herein. -24 - II 50. SEVERABILITY The parties agree that each separate obligation contained in this Agreement shall be deemed to be a separate and independent covenant and agreement. If any term, condition, clause or provision of this Agreement shall be determined or declared to be void, unenforceable or invalid in law or otherwise, then only that term, condition, clause or provision shall be stricken from this Agreement and in all other respects this Agreement shall be valid and continue in full force, effect and operation. Likewise, the failure of any party to meet her or his obligations under any one or more of the paragraphs herein, with the exception of the satisfaction of the conditions precedent, shall in no way void or alter the remaining obligations of the parties. 51. HEADINGS NOT PART OF AGREEMENT Any headings preceding the text of the several paragraphs and subparagraphs hereof are inserted solely for the convenience of reference and shall not constitute a part of this Agreement nor shall they affect its meaning, construction or effect. EXECUTED in triplicate on the day and year first above written. r;~]yy (/ Terrence M. JR- Thoman /"'1 / / /. ~"',:::-~ ~d Linda L. v' //. Thoman -25- II r COMMONWEALTH OF PENNSYLVANIA ss COUNTY OF CUMBERLAND On this :?} day of h7~ ,2005, before me a Notary Public, personally appeared Terrence M. Thoman , known me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. In witness whereof, I hereunto set my hand and seal. Notarial Seal ~ Usa R. Bankert, Notal)! Public East Pennsboro Twp., Cumbe~and County My Cormlission Expires Jan. 22, 2007 Member, Pennsylvarna Associallon Of Notanes to ){We 1< DtvtUu.X;( Notary Public COMMONWEALTH OF PENNSYLVANIA ss COUNTY OF CUMBERLAND On this 3/ day of IY/cu..r ' 2005, before me a Notary Public, personally appeared Linda L. Thoman, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. In witness whereof, I hereunto set my hand and seal. Notarial Seal Usa R. Bankert, Notal)! Public East Pennsboro Twp.. Cumbe~and County My Commission Expires Jan. 22, 2007 Member. Pennsylvania AsSOCIation Of Notanes \""-1' , ,/jiiJie I( 0& r:.J0;/>::( Notary Public -28- II SCHEDULE "A" -26 - JELCO g STATEMENT OF ACCOUNT ~ommunity Credit Union L getting you tlwre Page TERRENCE M THOMAN JOINT OWNERS LINDA L. THOMAN 2 MAIN OFFICE: 403 N. 2nd Street P.O. Box B2 Harrisburg, PA 171 DB STATEMENT PERIOD From To 0401 PREVIOUS BALANCE ~ ~ SAVINGS 1144' 0430 DIVIDEND 09 11451 THE ANNUAL PERCENTAGE RATE IS 1. 00 THE ANNUAL PERCENTAGE YIELD IS 1. 00 THE ANNUAL PERCENTAGE YIELD EARNED IS 0.96 0430 NEW BALANCE 1145, TOTAL DIVIDEND YEAR-TO-DATE for all savings except IRA. Dividends shown. if $1 0 or Over, will be reported to the Intemal Revenue Service for this calendar year. .INnrCATFR EFFFCTIVE DATE 0.38 TOTAL FINANCE CHARGE YEAR _ TO-DATE for all loans. 0.00 NOTICE: See reverse side (or important information. 0700545 UCP CENTRAL PA PAYROLL ACCOUNT 925 LINDA LANE CAMP HILL, PA 17011 Taxable Marital Status: Single Exemptions,' Allowances: Federal: 0 State: N/A Local: 0,1% Additional Tax EarninQs Regular Ins Ben Waiver P T 0 Retro Pay Float Holiay Holiday Social Security Number: 200-46-0343 rate hours this period .29.9938 '67.: 50 2,024.58 30.00 224.95 129.38 . . 29.9938' 7.50 G,os"::BsV( . . .' : 42!4QS;91 : Deductions S tatulory Federal Income Tax Social Security Tax Medicare Tax PA Stale Income Tax Lower Allen Income Tax PA SUI/SDI Tax Other Checking Dental Gsra($)Contrib OPT PI Std Term life United Way(Cap) 4()~B($)C9Q,trib ..".'" ""', -,-. " . " Nef;PilWl..i;,:> ... .. "."O.QO : -415.81 -147 :84 -34.58 -73,20 -47.93 .2,17 -.1,476,46 -24.47* -24.09* -14,00 -26,62 .19.38 -6.00 -96,3.6* :,::.>::::;,::~::;:, .:.:.z-:.:.}:<,~. ':':-:":;'5:' .. .. .,', -, ~ ~ '",. .,' " -. .. "'-" , : " '",.;,.,' " " iii" 1'-. , ,.,\ "~""' "'.-- TE,RRENCE"M THOMAN /p" } " =--= ,-= -=--= - ...._-<-. .. year to date 19,977.48 300,00 873.85 129,38 432.60 432.60 22,145,91 3,696.67 1,357,88 317.57 672 , 3~ 352.79 19.93 244.70 221.46 38,00 266.20 60.00 885,84 Earnir..,s Statement ~ @ PeriOd Ending: Pay Dale: 05/14/2005 OS/20/2005 TERRENCE M THOMAN 212 APRIL DR CAMP HILL,PA 17011.5006 * Excluded from federal laxable wages Your federal taxable wages this period are $2,263.99 Other Benefits and Information N 4038 Er Match this period 120,45 48.18 total to date 442,92 Grp Supp Ret An Eib Balance Pto Balance 221,46 340,26 109.25 Important Notes VOID AFTER 180 DAYS O,gg'AOP,In:: ....., 0.- :;:-;< !"';::"-;.. :g~ t ~Yi;;,:fft,?<,., "." <,'<.-" ~I ~ 'r '" f .,045045455844 , "amount $1;476.,46 , NON-NEGOTIABLE Comfort Care of Holy S ~, Inc. EMPLOYEE NAME SSN . EMPLOYEE NUMBER ADVICE NO. THOMAN, LINDA 208-58-2482 208582482 11605 FOR PERIOD ENDING RATE DEPT NET PAY CURRENT NET PAY YTD 04/16/05 24100 1,969,95 15,920,94 PTO(VACl STD (SICl GROSS CURRENT GROSS YTD 195,91 299.45 2,985,12 23,881,27 EARNINGS HOURS RATE CURRENT YTD DEDUCTIONS CURRENT YTD REGULAR BO.OO 2,983.96 22,379.70 401(k) 208.88 1,671.04 BS MI 109.16 218.32 EX LIFe 1,16 9.68 FIT 288.74 2,332,96 2PTO SC 1,193,69 F ARMST 21.78 43.56 AN GIV 10,00 70,00 3HOLlDA 298.40 MEDWI 41,69 335,71 - PA WlH B8.22 710,50 PASUTA .2,69' 21.52 CMPHIL 57.47 462.82 . OASDI 178.24 1,435,44 UWAY 0 6.00 48.00 - -VISION " 1.14 9,78 BS PPO 500,94 , EMT-CC 42.00 LTDBuy 38.16 I OPT-CC 10.00 TOTAL EARNINGS 80.00 $2,985,12 $23,881.27 ACH BANK ACCOUNT AMOUNT - ACH PSECHE Acct 208582482 1,969,95 I . I TOTAL DEDUCTIONS $1,014.01 $7,950.75 . . . PLEASE DETACH AND RETAIN THIS PORTION FOR YOUR RECORDS Comfort Care of Holy Spirit, Inc, 205 Grandview Piace Camp Hill, PA 17011 ADVICE DATE 04/22/05 ADVICE NO. 11605 PAY One thousand nine hundred sixty nine and 95/100 Dollars PROC. LEVELlDEPT CCARE 1 24100 ADVICE AMOUNT 00..00$1,969,95 TO THE ORDER OF LINDA THOMAN 212 APRIL DRIVE CAMP HILL PA 17011 UNITED STATES NON NEGOTIABLE AUTHORIZED SIGNATURE Payroll Advice Only. This is NOT a Check \ ~OLY stINI The Spirit of Caring TO: From: Date: RE: URGENT - PLEASE REVIEW This memo effects benefit eligible employees Fellow Employees \/'0 Karen Fulton, Benefits Mana~T-D 1\!~ April l, 200S c...: ~ Benefits Information Open Enrollment benefit changes were effective on this pay AprilS, 200S payroll. Please take a moment to review your pay advice and IF YOU HAVE BENEmS through Holy Spirit Health System, here are ~ofthe deduction codes YOU may see on your pay stub depending on the benefit(s) you elected. Code: BS m IT BS MI IT BS BA FT Vision FSA DE FLIFE FSTD FarmCr! 401kLOAN 401(k) MEDWV Benefit: High Option Full Time Mid Option Full Time Base Option Full Time ~ BS m.4, BS m.s, BS m .6 BS MIA, BS MI.S, BS MI.6 BS BAA, . BS BA.5. BS BA.6 Benefit: High Option part Time Mid Option Part Time Base Option Part Time OptiChoice Vision Dental (part-timelfull-time) ,Delta Dental (part.time!full-time) Dependent Care FSA ME Medical FleXIble Spending Farmington Life L TD EN Farmington SID Farmington Critical Care Long Term Disability Buy Up 401(1<) Loan Fidelity 401(1<) Retirement 40lk CU 403(F) 40 I (k) Catch Up 403(b) Fidelity (no match) $50.00 Medical Waiver Bonus (will be listed on the left hand side of pay stub under earnings) Please review your payroll advice and yerify that you are enrolled in the appropriate benefit deduction(s). Affiliated Corporations: your deduction codes may appear differently. There are too many codes per each center to list them in this memo. Hospital: Karen Fulton Cathy Gossard 763-2189 972-4127 Affiliates: Denise Deslongchamp Nadine Martin 972-4484 972-4002 If YOU find a discrepancy (or do not understand a deduction code) with your benefit selection through the payroll deductions, you must respond to Human Resources immediately. Current elections can not be changed until next Open Enrollment 2006 unless you have a life-eyent change, which must be reported within 30 days of the eyent. Thank you for your consideration. . . .ER i!l EXF?RESS Financial Advisors \ HIGHMARK INC. May 31,2000 LINDA L THOMAN 212 APRIL DRIVE CAMP HILL, PA 17011 !~?()CJ _ '4'</'7- 7 ~;).7 Your Personal Identification Number (PIN) is: 86046 You will need this number and your social security number to access information and request transactions on your Plan account, You may need to provide additional information to verify your identity. . Your PIN and social security number will identify you as the only person who can access information on your acroun! For this reason, keep your PIN confidential. If you lose YOur PIN or think it may be stolen or if unauthorized transactions occur, immediately contacl the telephone service representatives through your toll-free number. , If you make a transaction or request, it will be processed and cannot be cancelled, American Express Trust Company will honor transactions and requests we believe are authentic. By using your PIN you are authorizing and consenting to the transaction and you are agreeing that we will not be held liable for any loss or expense arising from a telephone transaction unless lhe loss/expense is the direct result of negligence on our part, You agree that our records will be binding to all parties. If you would like to change your PIN, you can do so by calling the automated phone system through your toll-free number. . 3 ~ n . , . x ~ ~ . o o 3 :;- !!'. ~ 3 . 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S.g 6-g = 0 ~~ . ~ ~~ ;;;-6' ~ ~ '" ~ ~ ~ Z Q 0 ". ~ ~ 0 ~ 6 X 0 0 w ;;: . ". j Z S CJ I ~ ?' I G) I ~ l> ::J:J ^ Z < m C/) -j ~ m Z -j "D r- l> Z ~ g ~ ;;: ~ "' N o '" _._..c_ ___~. ..._ ^" '" LINDA L THOMAN ~ 212 APRIL DRiVE :; CAMP HILL, PA 17011 '" 14H 20858 Spin-Off of American Express Financial Advisors Recently, the American Express Company announced its plans to spin off the American Express Financial Advisors unit (AEFA) to its shareholders, subject to appropriate regulatory and other approvals. This spin-off will include the Retirement Services organization, which administers your retirement plan and provides retirement and financial education at your company It is expected that the new entity will begin trading as a public entity in third quarter 2005. Although AEFA will change its name and become its own business entity, we want to reassure you that key cornerstones of our business will not change. We will continue to provide you with the high quality service you've come to expect and deserve. Our commitment to serving you is steadfast. Thank you for your business and continued support. Page 140f14 1111I1111I/1///1111111111I1111111111I111111111111/1111I/1111111111I 11111 111111111111I 1M SM1017 1013140 MRDFM EA10S "l.~tl~iity, Holy Spirit Hospital ,-,', LINDA THOI'iAN 212 APRIL DRIVE CAMP HILL. PA 17011-5006 ENV#40022504 405894073116 A Your Account Summary Beginning Balance . . , Employee Contributions Emp loyer' Contributions Change in Account Value Ending Balance, . $40,775.04 1,253.28 895.20 -800.27 $42,123,25 Your Personal Rale of Return This Period' , .1.9% ~'.Yearto ~ate.,. ' . -'. '," " " . _ ,'," " ",-1.9% Your Persona[ Bate of ,Return i,s cidculated with a time~wejghted, ' I~,rmula:/wid,efy us~d'bififl"an6i.al 'an~_ly~ts, to,ca:l,cLiI~'t~ i~vestll1ent';- -'>Eiaiiiings~ Jt ref(ects"the ,r~s_ul,ts ~~f your 'inv:esim,ent',selec'ti~~s; as ',". -- ;'w~l! as any ?-ctiyity ,i,n'the p_la'~ acco,urt(s) s:ho,Ym,':T~ere,~re other" Person~al Rate, of ,Return formulas used that may y,ield different , .. results;' Remember that past' per'form'ance is no 'glb;.ani~e, of future "re'sult's:-' . ',; ': ^ ^ "" ':''',." "'" ,,'''', , ,,~ Retirement Savings Statement ,,<--.- , ," \ "'-',': Y>t"" -:_ ;, ~l.><(~_",< , Ja;;~:i'~Y h~~95 :~~'rch31:12iJ65\ . ;<< ',- ;:- ~," " -- , ',,', , ','^, :' ,''':' ~ For'online access/ to.g on::Clt: http://www.fidelity.com/atwo rk For information, call: (800)343-0860 " '<" 'f"",':"-,,',-, YourAsse(Allocation' ,:;~. , '. II Stocks 85% , iii Bonds; 5% I I :"t:',A.::"" .". I Your fn-~~stmerit~-,are gurfen.iiY'~llocatecr among th-e dfsp'(aye{{ .] ,asset classes., Per~entag;es "aod,~bta:!S iitay not be exact ,due_'to' ! roun.ding. '.:>, --c',; . ..~ :, ',.,'1',. >,;' , -, ",-,;1 . The Additi~nal Fund Informatie>'n ~ection lists the alloc~tio-n of your blended fun?s: "'. , " ','- -, Account Value Jhis se.c~ion displ~ys.lhevaIU~: of Y,~ur accoun~_f~r..'the period, in both shares and dollar~. In "IOStir/ent Shares on Price on Price'on 03/31/2005 12/31/200403/31/2005 ar et a ue on 03/31/2005 Rememb~r'tha\ a ;;i~idend p~~inenl-to-tU;;d ;h~~eholders redue'es the share price ~t the fund, so 'a-d.cieas~ in the share price for the sra'ternent period dO'es' n~t necessari~y "refl~ct Jow'~"r fund-'perl~rm~nc'e:' ", ,," . ", '"" :. .- _', _', ":'__>-<' " '_, '_ ' ; ^' " " " ,', <~', 'c:,' ":',, ',' . .~',,', :'" ,:;:,:::,:', ,':;q,:: _;,~":<:';'-:' :,":,:.',',:,":^,^,;,:'-, ;~'~:<',/,__" _~, " }",::~" _ ; " _ "",', "_" '_'_ :>.-':~\'<' '. -":'_', " ,_ " __ ' _' ' _ ',' " " '_,".-', _' , , ,', " ~'Som~,_.of your';n<e,sirrle~t~ ~t~',Ciassiiied ~s",a~'BI~nd~d ,ln~est'merlt: ~Ie~d~d f~vestril_e,n,t.s may incl~de" a',mixt~;~~,of s'to~k~.~bonds~ "~-~d/oi' short'term assets:",:P!,ea~~}e~e~,~? ,th,6 ',:A1d!tion~:d,I~~'es'h1ia~t)r::.fom,ation" ~,e~tion~,to de,tyrmine' the_ -a[l,o~_ati~,n- ~'f your'-brended investrrients',und~rlying assels. !,~e ~sse-: ~:~~,_~:g~,~~c oJY~~,r ?~~~lio isr~~~~.~~:9'in the: pia, ~hart in the, ",,?ss13t _~f1ocatio"n"".;;ection,,_.' , . Blended Investments' Fid Freedom 2035 3,754.300 Market Value on 12/31/2004 $11.44 $40,775.04 40,775.04 $42,123.25 42,123.25 2123:25 ' $11.22 22504 40022504 OOOt 20050406 4038 Fidelity Investments, P.O. Box 770002, Cincinnati, OH 45277.0090 . Please read this statement carefuJ1y. Any error must be reported to Fidelity Investments within 90 days Page 1 of 5 ') Holy Spirit Hospital. .,-,.' ,'. Statement Period: 01/01/,20.05 to 03/31/20.0.5 ..' <.yj:t' "."-'>'< >'::~,,_r; - -',,' .. ';:-":',' ~,' Your Contribution Elections as of 04/06/2005 Th!s section, displays !h'e funds in Y.thich 'ybur}uture c6ntri~utio!:1~_ ~1If be jn/e-sle~,. .' . . Investment .Fid Freedom 2035 Total '. Employer Match , 100% ':,;',100% . Rollover _' ;'100%:_,",- ".1'00%. Investment Fid Freedom 20.35 Total .. . . "" :', 'Rollover-After. . "Tax . 10.0.%., 1000;" . '. ~ ; . .' Rollover Ira 10.0.% . "00% 403(b) Rollovers 100% 10.0.% "'^; . .-,',,';',' -,':.- Your Account Activity " '...... '. : , Use this section as a summary of transactions t~at occurred in'your accountduring the statement perio~. , .' E';'p;;y:"'~"' "'E,i;p;~yer' ;. Emple,yer . Deferral . .. Match" '. . Discretionarv $24,732,15 $14,013.22. $2,029,67. .1,253.28.,. 0.00 . . 0.,00" " ... -4~~:~~ -.. -~~~:~~ . .. -3g:~~ $25,500.39'.~" $14,632,22 '$1,990..64, ~~; /,~::>~'/ :\:"/;":'~!:~?:':';~'_:<i"-'- ":";,.,,. o' ,\100:00-:-% ,,- ..... " '$25,50.0.39 .. '''<. '. ..,.. ~~.o.o.: . Activitv Beginning Balance. . Employee Contfibution's . EmployerContributions . Change in Account Value Ending Bal~nce '. ", ":100..00. %'. $14,632.22 " "10.0:0.0 . .'$1,990.6~ 'Dividend's 8< tnt~'rest , $0..00. . $0.00 ....,<. >, ,,"., >""'",^,;-,- ..;. >>..,-' ." \>';;',~:;; 1.:,.",. .,,,,.'!." YoGr_Tr~'~~~ctionj)eiail:;:T.':,'\:;~:: ,;,. ........ ... ':. ;'~~;i~;\:~~,"._ This section':";.(ill provide you with detailed day t9. day activity in you(account.during~th8'statemal)-t period;>, .1 ''-q """'^o"'"','" ~',.',- ,,' . ,-, '.,,' :_,~,'>".~,;'--' "::''';'':-~' <Y"~'<!,~'if;i""il;:A':,~ '1,,>, "~~:." ;';':H_~,,~ "_"_"_~ ,~_ :-:;. Fund ,'<" '"-:-'-",,,-::,' - Trade Date 'Transaction TVD~' , . Shares --,- , En,pl~Y~~Deierral' .' . Fid Freedom 20.35 " '," '-,'.'<' -,- ">:~',~:(,~:'~,:;:~,,:_~\>;: '., ' : ~ C'j'_ . . Roiiover-457(bl . <'~_100%;, '100% ',""..: ,";' -',' " ,o,^.' ',,:2~ ih,,''',~~ .,_ ,', , '>-.., ::f~:;~i,::);.",-;.:, . Total For Plan $40,775.04 1 ,253.28 .. 895.20 .. -80.0.27 ; $42;123,25. 010 ~'.'- q ,'--.;:'" - '. ;,",':"::,', ",':,-, , $42(123.25 ",;.' $0.:0.0 , -", ':':, " '" ~:' ::::::'~.:: ;:},",~~>i',;; ,-- . >,,,:-:~;::;,,::>;;1,:' .J-'r;Y ..:, c,;./_' . Price ;;:;-:;j,i', '. ,":'}~:1'~~:',t:;';,~~)~' 5'!:: ; ,:~ :7;;~~~~:;~'3~?~,;~?;:1;;' , , .contribution Contribution ContrIbution ;Contribution '.Contribution' , 'qp',ritr}bu'iion. )8.633 '.~ ..$11.21:\,' i 1'8.784,;.......... .:~$11.12 .' ,"18A69,,~ '-;'0 "'~:~$1f.3r,( ;, 18.50t .".":',; -.'$11.29 1188','403368 :":;~'~, ".$1 1:58 .$11.33: .. ;.~ $20.8.88 . . ;$20..8.88 $208.88 $208.88 .$208.88 $20.8,88 01/06/2005 0. 1/20./20.05' 0.210.2/20.05 . .. 0.2122/20.05 03/04i2o.o.5 .' 03/18/2005' . . . " .', '. ' Employer Match . Fid Freedom 2035 0, ": '''- _' 0.1/0.6/2005 . Contribution 0. 1/20./20.0.5 Contribution 0.210.21200.5 . 'Contribution 02122/20.0.5 ' . Contribution'.' ". . 0.3/0.4/20.0.5 CODtribUtion" , 0.3/18/200.5 ..Contribution . . . .13.3)0 '13.417 -: 13.192. .. ,,13.215.' 12.884' . '13.169 A Message from Fidelity Your statement. At your convenience. 2250.4 400.2250.4 000.1 20.0.5040.6 403B Fidelity Investments, P.O. Box 770.0.0.2, Cincinnati, OH 45277-0.0.90 ',--,-,,'" ',' ,;:$11.21 '$1 t:12 -",' , 'i:;':-$11'.31,:; . .. ".$11.29 . ';'$11..58 ,." ""$11.33 . $149.20 . $149,20. '. ',$149.20 '''$149.20.', $149.20. . $149.20. ,-:, Page 2 of 5 I. ,<-,"",j.-' i' c'-~ ~ "- ~,;< Holy Spirit Hospital. Statement Period: 01/01/2005 to 03/31/2005 A Message from Fidelity(contiriued) . -.' - , '.-'.' -'~ '<>" " . Statemeht-On.Demand from Fidelity Investments is an exciting, convenient, 'hew service that lets plan participants who use NetBenefitsSM fa access and print out your personal account statement^on'line,virtually ,any tirIle, day,or njght~ as often as you want going back as fai as 24 monthsiSin:Ply.1og on to Fidelity.com/atwork and select aplan, This service offers the following features:' 1 Explains the key features of this new Statement.on.Demand feature. 2 Offers a choice on how to receive your online statements. 3 'Asks' you to indicatea statement delivery method. (If you r~ques1 ;ohave' yo~r ~itatemeri,t(fe!ivered electron'ically, "y'ou m~st'provide an email address) Log onto Fidelit{~omfatwork today. -' , ".,' ", . -,.' , - . '. . .- Your Account Information 04/06/2005 General Information Status Code ::: 'Active . ,".- , .., , ,'" '- A Message from Fidelity Investments -,".- :: . .., . ". - " - . . . - Take the New SO-Second Retirement Ch'allengeSM " --- '.. , , ' " . . . '. . .-. ". ' . . . ' . '.' '. '. '. . '. ~ In about one minute you can learn if there are .ways you can make a big difference in the .quality' at y'our'life after'you retire.'. . , "'. ""'.: ~" '. ,- - :' ,-: ,-' , , . " ",,' .: ' - ' : . ~" ',' ,'" The New SO-Second Retirement ChallengeSM was created to he'lp'you achieye 'one of the mosi important goals of your life n your . futurefinanical security. It's eight quick questions that can help you identify savings opporjunities you may have missed. ,_. : '; . .. ~, ,~t:-':""':- > &,~',y,.'_, .,. ";'/:Iif'-:'-'':~=,~. '~' - <;~ ,:- '- ",,':', ;,'," " '" ,-' " ,,\ Ci: """ . .'-, ' .' .', - ,'-~.' . --- i .1;.;: "-:',' It's fast, it'Hun, it's i~teractive." ....... '.: :' f. :i' . ':, '.''-': .'> "~' :' : .':, .5. :'" ' It's ti;"e to take TheCha'lIenge arid ~~t'your score. Then learn what you can do to make the most of yOurworkplacesavirigs plan. ,,' -,' '-, .' - . -, To take th~ New SO-Second Retiremen{ Challenge, and to access other yaluable tool~ ari~ information, visit www.fidelity.com/a.twork. ' ..' ':"', ,'- - , '.- - '., >, '" ' For a printed version of :~he 60-Secon9 Re't,irerrient Challenge, .or ~o increase your reiireme;nt,pl~n contributi<;ms, c~1l a Fidelity Retirement Services Specialist at the number listed on the top right corn'er of your statement Specialists are available Monday through Friday, 8 A.M. to midnight, ET. . 398540 Investment Fee Information . ;., ~ , '; , " - - , Fidelity Select Health Care 'Portfolio iss'es~~s a short-term trading fee 0'f'0,75% forsharei.heldless .than 30 days. Fidelity pverseas Fund assesses.',!'short-term trading fee 'of 1.00% for.shares held lessthan 30days,. ( . 'f : . . Fidelity Low-Priced Stock Fund assesses a short.term trading fe'e of 1.50% for shares held less th,m 90 days. . ' Fidelity Mid-Cap Stock fund assesses 'a ,short-term trading fee of 0.,75% for shares' held less than 30 days.' Fidelity Small Cap Stock F~nd assesses a short-term trading fee 01.2.00% for shares held less than 90 days. 22504 40022504 0001 2005040S 403B Fidelity Investments, P.O. Box 770002, Cincinnati, OH 45277.0090 Page 3 of 5 ,;'" '^ HofySpirit Hospital . Statement Period: 01/01/200510 03/31/2005 , ",,''''-', -, Fund Performance ,',. . ' You can use this section to keep track?f the histo~ca'l periormance of the funds/other investments in',which you'rlil[nV'esled: As you review this update; please remember that perfprmance data stated represents pastperjormaf)ce whic.h. does ho,t gU6!r,af)te,f!",:::'" future results. Investment returf) and principal valLie 6fan investment will fluctuate; therefore; yo4 m,ay have ,a gain or 105,5, ~hen you sell your units. Curren,t pe,rform,ance,may be ,higher orJowe.r than perlorm~mce ?tatec!~ To If!arn. ,rr;.ore"or t~ obta;dthe most rscent, ' month-endperforma'nce information, contf1ctFicfelity using the inform~tion listed 0(1 the first page of this statement (your pran's toll free number and/or web,site)." ,-,' , , , ' , ' " Before investing in any investmimt option, pfease carefully consider the investrnent objectives, risks, charges and expenses:' For this and other information" call or write Fidelity fo:'~ ,fre,e fT!utual fund or varia;ble an'Ju{t}: pro.spectu?:., Read it carefully before y()ulnvest. Your holding periodm~y'diff~nrom t'he':ti~e p,eriods s:hoWn below:, '~"':' .._ '_ ,;, ." _ " - Foreign investments, espeda!{y those in'emerging 'markets"involve greater'risk and may offer greater potential relurns than U.S. investm'ents.,'This risk includes political and economic uncertainties.of foreign countries, as well as the, risk of currency fluctuation. .' , ' '. - Lower-quality debt securi,ties invol\(e, greater 'risk of defC\ultor price chctng:es due, to potential changes~inthe credit quality of the)ssuer." ' ".:_>' - ,Investments in mortgage 'securities,~e subject to prepayment risk.. whic,h can limit the 'pote!)tial for gain dur[ng a declining Interest rate,enviroh'ment ahd increase the potential for I?ss, ina rising,intere,_s,trate en vironment'_" ' ,'", ,_': ,::".'" ___'" '_ _"",'":,, ' . Bec~use.of their n~rrow focus, 'sector ,funds may be- more volatile than funds tha(dive'rsifyacross. many'sectors. - l~vestments in smaller compani,~s r1J~y involve greater risks than those"r~ larger, [11o.fe ".veU kno~n:co,'~panies. ' ,"- , ~,'" ," " ~, ,'" Investment " - " , . ' -', " - "'--'" " :", " Av~rage A'nn~al To.tal Return as o.f, O~i31i2005 ,: ",,' , , , - " , . Fid Freedom 2035 1 Year 5 Years' 10 Years Life To Date ::,,-: '-., InceDtion Date 1/06/2003 ' Dow Jone; Index, 3.66% 1.23% LB Gov't Credit Bond Index' .' 0.40% 7.29% ~ '. ,~~~~~~r9~~;~ex,:. ; ,.t~:~~~,;>,. ,X~~y.: .; .' " ,q~~:';r~~, " .Total returns'are hlsto and include the change In share value and reinvestment of dividends and capital gain d,stnbutlons, if any. Cumulative . . ". returns are'ieportod Mof the'periodsshown. Life of fund figures are from commencement date to the period shown. Due to regulatory requirements', ,thailV.jag.)lnij~;'lj6tal~luins ;'rer.poited.as .o.f. the mo,) re.cent?ale~dar quarter f~r.the peri?d, shown'a~d are calc~I':ted using a standard .,..:".;,:,... . donnula. :rhe'figures do not Include the effect of sales charges, if any, as these charges are waived for contributions madelhrough your company s",.. . . . emptoy.e b'.nofit'plan:;lf sales charges were included, 'returns wo'uld haye been lower::'Each fund's share price .rexcepl moh'e! market funds): Yield: ", .' ' and(etLir~~~i'J ,1{arlfind y,ou:may have a g,~i,~ o'rloss ,Y{hep you ,sell. yoi.J,r shares. For funds no longer ,offered throughyo.urpfa'n,: short-:terrr'qradjng: ~, " " fees' will. n~fapply t,o ,your-~ccou'nt:,~",'?.-.~:'- c "':' ::';::,""" ,:" '~<:-., :/, ~:-.-~' ,1, :,:: ,:' ,',: :,"! :-:" ,':,: ,-,,' '",''', ':l_': ,'" , : 'r: '\ .- ," :" "', ',;__ ~ _, :,:' "~-:,' :_, ,<"',/'"',::,, -;;,";. :,-:,:::'_':::':;,: FidelitY is teinporarily reimbursing a portion' of tlie Fidelity Freedom Funds' expenses. Absent such reimbursement, returns and yield would hays been 16werancqhe~,e'~p'3ns,~r~tiQ:,w~~I,d have been,l1igher.'> ":';',:: ' " _', -':_ , ',_. '~"_:"'" ..:_ -:-' ::' :_ ''''''-' ',': : ':'~2_,":':_':,+," > ", ,;,.',,;,\'<_,\":::' :, -:", . TheDow Jones .I_ndustria,r"Average (DQl,~"Jones},is_an ~ninanagedi~dex_of eom:mon stock~.of the 30 major industrial comP<lnres and assumes reinvestinent'6fdivider:lds.;>",~:,,,,,,_<,<,,,,,:,,,~,~":'",;",~:.','.. ':::,::",':"~__,:":__,,,:,,,,_ ,""",',, '_ "':' , "':' ':,:,"',' ',,", . The Lehman Brothers GOy't Cr~dii B6~d ind~x (LB Gov't Cr~djl) is an unma'nagect toia'1 return 'Index comprised 01 certain'pubiic obligations 'of the " U:S.",Tr,easury:'u.S.:govern~erit agencf~s; ,q'uas_i_.federal agencies" corporate,~ebt guaranteE;id by the U:S:' government,ah'd public fixed rate;.,and__:~ non-conve~ble inveslri1l3~t~radedoh,1fiis!iccorp?rate 'd~"bt '_Is'sues _incluqe.~ i,n this_ in,d~,x have ~t lea~t o!!e, year,to_~~!urity. ,;"";:'s',, ,_, ~::~' ',(;:'_::'~') ;"",-":;: ~ The_ MSCI EAF!; Index (Morgan Stanrey Capital [nlernaticlnaJ Eu'rope; Australasia, and Far East, Index) _is an unmanagedJndex and includes, the: reinvestme,rit of,div'idends.,lt is designed to r~pr~sent tl1e:pe;iiorm~Hice 'of.-C1e"veloped stock markets outside the_United,States:and Canada, The Mscr EAFE-lndexis a regi'stere,d.serv,ice, mark of Morgan_Stanley andha,s beehlicens_e<;f far u~e by'FMR Corp." ,',,< ,'_, ' _ ,,,' .' " .-,', , ~ ,T~~ ,S&~. So.9:Js ~ f.egi,~te.re,9_~8~i.cle: Q,ar~,of .t~~ ,M~GC~w):Ii11, C6rnpani~~-, Jnc,:.-?r\~,~,?s:b~en I,i~~n~ed f(ir u's~ by,Fidelity,Distribut<?rs ,C9rp~(~tj,q~"" . and Its affIliates. It. IS"Cl WIdely recognIzed, unmanaged index of.5O,O, U.s. common stocks:-, :: _, ' :, ',.' ,,_:,,_. '^ ,,_ ", ' " _'.': ,,_' __,;'!__~ Fi,delity InvesVrients I~stitutil?,r)af Services Co,m.p-~,,!Y:'fl}C.. 82 D'evonshir~ ~treet Boston_. ,MA 02109 >' ; " , '. _,~,_.,., :)" "I:'><~__~" ""..::,~' "":";'j, _ /: "'(:;',").-:'-,;" c,.' ,~ ., 'CC" ';" 6.12% N/A N/A .H Indices 1 Year' "-, , 5 Y ei,,;' , " ': ,>. '.:"<-:\:,; :>:;j'''',(i..;'S'::,::':'}: ')~:;:-;~?.\;','?:l,';;~':X {>~L',;:''b->~i:;~f:~:; c -^ g" ~:":_? ' ' Additional Fund Information.;'.' .". 'U~e)ryjs^'se9ti.afl,t~ aeter'm'jn~ ,the 'as"set'allocatfonof your Mended investmeii'ts:-' ,', , ,--',"'" ,,'h,';',~: " ", " " ':,"c-, ~<;.F" '~~:t~'.':/" c.-" ," '~'~; ; ", ""';:." ','., "', "','" ' Blended Investment ""Stocki': 'Bonds Fid Freedom 2035 ,85% 15% "', ;",~. , .';'" :,,~ <' ,/ 0"-'-- ^,--."" :\1',.' Shaft-Term 0% " """ ',' , ' , ' , ' , , " , Blended In~eslm~n't~ a'lJoc~te p~rtions of their'portfoJio in' more than one asset class. The asset allocation of your blended investments is reflected above. ' - . 22504 40022504 0001 20050406 403B Fidelity Investments,'p.O. Box 770002, Cincinnati, OH 45277.0090 Page 4 of 5 I . ':, ~\'~>[;'~-.:i',\:i;:s ':{~':.~f~.,:',. :::~:::- '.1'1\'<.'..J-~ ;,,":', ,':-:'.:i,~;, ' ~ t.,;",:, ".7.;"";';' <."~ ~\:': \ ' <", ~:' " . Holy Spirit Hospital StaiementP~riod: 01/01/2005 to 03/31/2005 . ',"',- , " , '.',' YOUr Statement Glossary / A verage Annual Total Return '''. . . .". '. . . . The average annual return of your inv~stment is calculated by using a change in sh,are price pJu~ dividends and interest and dividing by the appropriate number of years. Please note that these numbers, reflect past performance,'only and assuma the reinvestment of all dividends and interest. 'Yqur individual performance, may not m,atch th~se,nu.rnbers exa_ctJy dep~ndi!lg on the liming of yourin~,estmen~: ' , . Change in Account Value .~~ ~ ~ . The appreciation \=If depreciation of you~_holding due to price 'chang,es in the funds in whic.h you are invested" plus any dividends and interest earned ,during the s~a,~e,ment periad. ',_ , ' " Contribution Cantributians ars investments made to. your retirement plan either thraugh salary reduction or by your'employer during the current statement period. Contributions not received befa~e the end af)he reporting period y!i11 be reflected an yaur next statement. Dividends and Interest '. ~ ." , . A distribu'tion_ af i!lcame from yaur 'furid(s) that is a resultof a dist~ibutionof earnings from its underlying investments. This amci~'nt is 0 .- aU~?fT1atic.~If'y:re!nve,ste,d ,i~t~ r9~ur accoun,r ""', ' Exchang'e ..' . . . . . .:" , , .,~" . .' - , Moving, s~6~res..fram ?he"jnv~stfl1en\'toa,n~thei' t;y _sefli~g' ~h,~r~s ~nd using the pra,ceeds'lo buy s,hares of anather i~~e'stfl1ent , ' Mark~t Value ~ ~',. ",The, dallar value af the _investments In your accaunt an _<:1, specific day. You can calculate your market value by using the, following , , farmula: :Mark~tva,l.ue '" ,NUmber af ,~~,~Ies in y~aur acc~,u,nt ~.Pri~,e ,per share of the f~nd. ' , Price '_ _'_ ,.- , __,.-__.." _', : _ "",'.-:__,_, '_: '-", ,_,,: .-,,', ,': :::'_" '" ,_;,.' __ '" '. The var~e 'o.f,one share af each investriJenf iny~ur' acc~,u~t is the 'share 'price.: It is dete'rmined by tak1ng'the.tataJ vaJu~ af the whole mutual .', fund an a,given day,:subtracting experls'es,and_ dividing the' result by the number: af shares outstanding. '., , ...Sh.... ""'.;'/,:~.'; '." ares , ' _,', , " "_ '," ;_": -': '_~-:-__, "" ,"-,'- Your units of own'ership o'f each invesfment in "y~ur'acci:lunt. ' " .' ,;-,<" . ' . ,", -, ,-' ',.- ,~ . - " "" ,-", - >,;""" ;" ' ,,,", "," --,'," ",. ; . :',' ";, - ,.- ': ' _",:, ::: "', SO'rh~",~p~ci~r',informati?n :ab,out" ~ther "s'e'ctions in',yo'u,r account state'm'ent. ;":'ss'ef AlI6cation~ ";. ~..~ . ~ . Market Indices'. . ~, ;Y6ur'j'nvestmen'ts may be divided into {lir~:!8 major as-s'et'dass,es': A market inde~ can ,measure the genera! trends in 'th,e p:e:j-j~"m,a.nbe 'oI ',StacRs\-Bonas;'and Shott~Term, Investinents,,'These ass.et classes ce,rtain types of se'c~i'ities. Youcan.use the~e, indices tel:' comP,are th~ repres~n[ the,:different type~s of,~nderlyil19"S~cl.friiie's__:tnat m~y'be he'rd' . performance .caverage~annual return) pf the "funds _i,n which y~u'are . .~,:~.?: rs'" ,eto'~C;:~k'}S~,~,\.:f"~.;",d(,is.}.:y:.~,o-wn.,.-,,::;,,, ~_,<~~ ~":'.':"".::~=~':':'-'~~'~~._;.': ': ~:';: i,."", ",~":":",: ~" "", ':, _in~,e,sted :-:,i~h .,t:h~ ~~,?~~~~~_~,?~, ~~ t~~,:ap~f,opnate ,n:;,ar~~t ,~nd~~: ' ' .' '. .~ + DOI'fJon,eslndu'striaIAver~ge ':. '-:~ ,.,'. '.< . ,">":',, ,~~;;$tof~{ci.'m"asId:'~'Qro0'th,"c,o.~~one',!~,ta:yo.l;lr portfalio:' T.~ey", " '; ::" ^ ,_:', .."yo'u carruse,this index to com'pa're to. the performance.of some :,,:r~present m~nershlp o~ equity In e~ cQlJ1panY:__,Stoc~s have the,,'- ' ., bf your stock h.J"rids~' This is a price.weightea,average:,of 30 ' 'potential, to. outperform other ,typ;es of investments over the_ ' a~,~.~ely t~aded,blue,'phip s,t?cks'; 'primarily ihdus,triaf st~cks. long-term. 'However, stocks"tend to. have wider price.f.luduations ' " ;.-_~'. -' :- '_ ,', __ , ayer shart pe'riods af time than ot~er securities.' +, Lehman Bros. 'Gov/Corp Bond ., . . . You can use _tDis index to.'corripare_ to the performance 'of some · Bonds , , __ ' ", " " ' __ of yaur bond .fun'ds: It is an !lnmanaged total, retu'rn index Bonds ,can add an income_ portion to yaur partfolio.. The,Y comprised af cert~in public obJjgatjon~ 'of the U.S. Treasury, represent alaan to a 'corporatian or government agency"and ,_:' . U.S. Govemment agencies,'quasi-federal,agencies, carparate provide the 9pportunity far higher, current incame than short-term debt guaia~teed by the U.S:,gaver~ment and public fixed rate, investments: Unlike shorHerm' investments, hawever, bond and non-convertible investment-grade dom,estic corporate debt prices.tlu?,tuate,~it~ ~~ang,es !n i~ter~'strates,: ' Issuesinclu~ed,jn this rn.de~ have at least one year to. maturity. ' " .." ' . + Short-Term . . . . .... ._.~ '. Morgan Stanley EAFE. . " Shart:Term iiive~tments can add stabWty to-'y6u'r poitfoH~. "They .You can use this tndex 10 campare tothe performance af some provide current income and seek to. preserve the-value, of,your of your inter~atjonat stock funds. It is an index.of approximal~ly investment., Thei~lsa ,tend to provide'the' lowest returns over' t,040 cOl!,panies representing the stock. markets of Europe, ' ,the tong~term: ExamP!,es of thes,e, in,vestments jnclud~, ' , , , Austral,ia, New ~,~ala,nd ~nd the Far E,ast. " ~~7:~;;~~~sOf dey~~its (CDs)Jreas~l)! Bills and Money Market . Standard and Poor's 500 . ~ ~. " '. . Yoti can use, this ,index to compare to'the performance,of some cif your.-'stoc:,kJunds.<1t Js an index'of ~oq'stocks of.l3-rger' . e,stablished,pu~licly traded firmsJ, S'ec:::ause the,'lnde.>~'is _capitalizatk~,n weighted (the'price'oteiach stoc~'i~ myltiplied by the number of s'h?res outstanding), companies with the greatest market value r,ave the, greatest influence on the index. ,,',," ; 22504 40022504 Fidelity Investments, P.O. 0001 20050406 4038 Box 770002, Cincinnati, OH 45277,0090 Page 5 of 5 , \Veb Center \1/W\V, tiaa-creLorg Automated 24-Hour Information 800 842-2252 Personal Assist.loee 800 842-2776 M-F. 8am-lOpm ET Sat., 9am-6pm ET January 1/ 2005 - A1arch 31/ 2005 730 llurd Avenue, :lew York, NY 10017-3206 lC{)94/6,8J6:S8 1",111",111"""11,,,11,1,1,11,,,11,,,,11,,,,,/1,,1,1,11,,/ TERRENCE M THOMAN 212 APRIL DR CAMP HILL PA 17011-5006 portfolio summary Beginning value as of: Changes during the period: Employer contributions Your contributions Net investment gain/loss TIM Traditional interest Ending value: this Quarter $43,568,53 (12/31104) this year $43,568,53 (12/31104) 442.93 1,107.31 -1 ,471.20 78.59 $43,726.16 442.93 1.107.31 -1,471.20 . 78.59 $43,726.16 total value as of 03/31/05: $43,726.16 '/ ~ . Are you taking advantage of the new ta'\:-deferred contribution limits for 200S? You can contribule up to $14,000 ($18,000 for those age 50 and over) on a pre-tax basis. To learn how much you can contribute to maximize YOur savings, go to www.tiaa-cref.org/calcs and click au "Calculate TDA Contribution Limits" or call us at 800 842-2776. 111111111111111111111111111111111111111111111111111111111/111111111111111111111111111 your investment results & returns Guaranteed _~1'IAA Traditional _____ _ interest credited ._____.__ this quarter interest credited thj~~i!,r_ value as of 03/31/02 _ ___$78.59 $78.59 $7~29__ $6,02).34, $78.59 $6,023.34 gainsllosses this _quarter gainsllosses t~_~~r value as of 03/31/05 Equities ~REF Growth CREF Global Equities -1.330.04 -141.16 -$1,471.20 -1,330.04 -141.16 -$1,471.20 25,462. 62 12,240.20 $37,702,82 total value as of 03/31/05 $43,726.16 For current interest rates, rates of total return and expense charges for all TIAA-CREF accounts as of 03/31/05, refer to the enclosed perfomlance card. For the most current performance information, visit our Web Center at \V\\'W.tiaa-cref.org. A guaranteed annuity backed by TIAA's claims-paying ability, TIAA Traditional guarantees your principal and a specified interest rate, plus it offers the opportunity for additional amounts in excess of the specified rate. asset allocation total value by asset class EJ Equities 86% . Guaranteed 14% To transfer funds or change your allocation of future contributions, visit OUf Web Center or call OUf Automated Telephone Service at 800 842-2252. To create a personalized portfolio allocation, go to www.tiaa-creLorg/calcs or call 800842-2776. 2OC94 account values as of 12/31/04 as of 03/31/05 Retirement Annuities TIAA C517610-6, CREF U517610.4 TIAA Traditional CREF Global Equities $4,594.29 $9,719.20 (125.5090 units @$77.4383 ) $20,535.99 1352.4530 units @$58.2659 ) $34,849,48 CREF Growth Group Retirement Annuities TIAA 3242822-9 , CREF 4242822.7 TIAA Traditional CREF Global Equities $147.97 $263.45 13.4020 units @$774383 ) $503.13 18.6350 units @$58.2659) $914.55 CREF Growth TIAA 3248062-6 , CREF 4248062-4 TlAA Traditional CREF Global Equities $690.92 $1,229.Q2 (15.8710 units @$774383) $2.347,65 140.2920 units @$58.2659 ) $4,267.59 CREF Growth Group Supplemental Retirement Annuities TIAA L388287.9 , CREF M388287.7 TlAA Traditional CREF Global Equities CREF Growth $356.64 $793.12 110.2420 units @$77.4383 ) $2,387.15 140.9700 units @$58.2659 ) $3,536.91 total value: $43,568.53 contributions $4,789.23 $9,937.16 (129.8540 units @$76.5256) $20,338.93 1367.7820 units @$55.3016 ) $35,065.32 $150.17 $260.34 13.4020 units @$76.5256 ) $477.53 18.6350 units @$55.3016) $888,04 $701.19 $1,214,54 (15.8710 units@$76.5256) $2,22821 140.2920 units t!l!$55.3016 ) $4,143,94 $382.75 $828.16 (10.8220 units @$76.5256 ) $2,417.95 143.7230 units t!l!$55.3016) $3,628.86 $43,726.16 The following lists all contributions made to your TlAA-CREF courracts this quarter. The effective date reflects when funds began participating io the investment results of the TIAA-CREF accounts. You may also want to review your pay stub to determine when funds were actually reduced from your salary. 1111111111111111111111111111111111111111111111111111111111111111111111111111111111111 contributions {continued} ---------- Retirement UCP Central PA Remitted this quarter , , , Annuities TIAA C51761 0-6, CREF U51761O-4 Total employer: $442.93 i Total employee: $885.851 Grand total: $J,328.7Sj effective percent unit/share no. of amount date contribution allocated price x unit/share allocated 12/22/04 $144.56 10% TIAA Traditional N/A N/A $1446 25 % CREF Global Equities $76.5445 04720 $36.14 65 % CREF Growth $57.9896 1.6200 $93.96 12122/04 $131.58 10% TIAA Traditiona! N/A N/A $13.15 25 % CREF Globa! Equities $76.5445 04300 $32.90 65 % CREF Growth $57.9896 1.4750 $85.53 01127/05 $131.58 10% TIAA Traditional N/A N/A $13.15 25 % CREF Global Equities $75.3682 04370 $32.90 65 % CREF Growth $55.6322 1.5370 $85.53 01127/05 $ 13 I. 58 10% TIAA Traditional N/A N/A $13.15 25 % CREF Global Equities $75.3682 04370 $32.90 65 % CREF Growth $55.6322 1.5370 $85.53 02/11/05 $131.58 10% TIAA Traditional N/A N/A $13.15 25 % CREF Globa! Equities $77.1013 04270 $32.90 65 % CREF Growth $56.9344 1.5020 $85.53 02/11105 $131.58 10% TIAA Traditional N/A N/A $13.15 25 % CREF Global Equities $77.10 13 04270 $32.90 65 % CREF Growth $56.9344 1.5020 $85.53 03/03/05 $131.58 10% TIAA Traditional N/A N/A $13.15 25 % CREF Global Equities $78.396! 04200 $32.90 65 % CREF Growth $56.5680 1.5120 $85.53 03/28/05 $131.58 10% TIAA Traditioml N/A N/A $13.15 25 % CREF Global Equities $76.0755 04320 $32.90 65 % CREF Growth $55.1004 1.5520 $85.53 03/28/05 $131.58 10% TIAA Traditional N/A N/A $13.15 25 % CREF Global Equities $76.0755 04320 $32.90 65 % CREF Growth $55.1004 1.5520 $85.53 03/30/05 $131.58 10% TIAA Traditional N/A N/A $13.15 25 % CREF Global Equities $76.3109 04310 $32.90 65% CREF Growth $55.5463 1.5400 $85.53 Group UCP Central PA ! Remitted this quarter $",% Supplemental TIAA L388287.9, CREF M388287.7 I Retirement I Total employee: Annuities 2CQ9~ contributions (continued) effective percent unit/share no. of amount date contribution allocated price x unit/share a lJocated -..------ -- ] 2/22/04 $24.09 10% TIAA Traditional N/A N/A $2.41 20 % CREF Global Equities $76.5445 0.0630 $482 70 % CREF Growth $57.9896 0.2910 $16.86 12/22/04 $21.93 ]0% TIAA Traditional N/A N/A $2.19 20% CREF Global Equities $76.5445 0.0570 $4.39 70% CREF Growth $57.9896 0.2650 $15.35 01/27/05 $21.93 10% TIAA Traditioual N/A N/A $2.19 20% CREF Global Equities $75.3682 0.0580 $4.39 70 % CREF Growth $55.6322 0.2760 $15.35 01/27/05 $21.93 10 % TIAA Traditional N/A N/A $2.19 20 % CREF Global Equities $75.3682 00580 $4.39 70% CREF Growtll $55.6322 0.2760 $15.35 0211 1/05 $21.93 10% TIAA Traditional N/A N/A $2.19 20% CREF Global Equities $77.1013 0.0570 $4.39 70 % CREF Growth , $56.9344 0.2700 $15.35 0211 1/05 $21.93 10% TIAA Traditioual N/A N/A $2.19 20 % CREF Global Equities $77.1013 0.0570 $4.39 70 % CREF Growth $56.9344 0.2700 $15.35 03/03/05 $21.93 10 % TIM Traditional N/A N/A $2.19 20 % CREF Global Equities $78.3961 o 0560 $4.39 70 % CREF Growth $56.5680 0.2710 $15.35 03/28/05 $21.93 10% TIAA Traditional N/A N/A $2.19 20 % CREF Global Equities $76.0755 0.0580 $4.39 70 % CREF Growth $55.1004 0.2790 $15.35 03/28/05 $21.93 10% TIAA Traditional N/A N/A $2.19 20% CREF Global Equities $76.0755 0.0580 $4.39 70 % CREF Growth $55.1004 0.2790 $15.35 03/30/05 $21.93 10 % TIAA Traditional. N/A N/A $2.19 20 % CREF Global Equities $76.3109 0.0580 $4.39 70 % CREF Growth $55.5463 0.2760 $15.35 for your information Please review your statement and notify us within 60 days if any infonnation is incorrect. TIAA-CREF will not be responsible for any losses that arise if you do not notify us within this time frame. You can always check your aCcount information on our Web Center at \nvw,tiaa-cref.org or call us at 800 842-2776 if you have any questions. Any transactions posted after the close of this quarter will appear on your next Quarterly Re>iew. 1111111111111111111111111111111111111111111111111111111111111111111111111111111I11111 for your information (continued) " Helpful definitions Portfolio summary: a high-level overview that totals all your retirement Contracts together and sho\\'s you how this value changed from the beginning of the quarter to 03131105, and from the beginning of the year to 03131/05. Net investment gainlloss: the dollars earned as a result of the performance of your funds invested across all the accounts. TrAA Traditional interest: the dollar amount of interest earned on your TIAA Traditional annuity values. A specified amount of interest is guaranteed. Asset allocation: a breakdown of how your total retirement portfolio is allocated across five major asset classes - equides, fixed income, real estate, money market and guaranteed. Effecthe date: tbe date funds begin panicipating in the investment results of the accounts. TIAA-CREF Individual and Institutional Services, LLC 2C09~EOS - , - Home 10015 & Information l> '(our f>.ccount > Loan Information current Loan Inform.tion for: Terrence \IIi Thoman current principal Balance: $5B,433.62 property Address: 212 April Drive C.mp Hill , PI' 17011 Your Total Monthly payment: $835.65 Next payment Due Date: 06_01-2005 current Escrow Balance: $1,249.32 Misc Fees: $0.00 Late Fees: $0.00 /~ ,c.---= Investor Rela\\ Current Interest Rate: 6.BBOJo Date payment Last Receive, ~5-02-2005 N5F Fees: $0.00 . Interest Pa~d Totallnt€Cest Paid Prior Year: I '.... "-- 1 l> Your AccoLlnt > Loan Information Business Partners I Current Lo.n Information for: Terrence M Thoman Property Address: 212 April Drive Camp Hill, PA 17011 Your Total Monthly Payment: $835.65 Current Escrow Balance: $1,249,32 Mise Fees: $0.00 Jntl~re.st Pa:d Year-to-date: $1,697.67 Escro''v Escrow Type Name: Escrow Vendor Name: Annual Payment: Next Due Date: Amount Last Paid: Date Last Paid: Escro';'/ Escrow Type Name: Escrow Vendor Name: Annual Payment: Next Due Date: Amount Last Paid; Date Last Paid: cscr~:.." Escrow Type Name: Escrow Vendor Name: Annual Payment: Next Due Date: Amount Last Paid: Consumers Tools & Information Current Principal Balance: $58,433.62 Page I 01'2 ------ Investor Relati Current Interest Rate: 6.880/0 Next Payment Due Date: 06-01-2005 Late Fees: $0.00 https:/ /www.americanhm.com!account/ detai Is.aspx Date Payment Last Receive, 05-02-2005 NSF Fees: $0.00 Total Interest Paid Prior Year; $4,230.82 HAZARD INS ERIE INSURANCE GROUP $670.00 01-01-2006 $670.00 12-13-2004 BOROUGH TAX CAMP HILL BOROUGH $504.00 04-30-2006 $504.00 03-17-2005 SCHOOL TAXES CAMP HILL 50 $1,499.00 08-31-2005 $1,499.00 5!l2/2005 , . ' ~kTHIS.I~tn. -'~J.\'U:in"I"'i 'ii<;lI.-'\l<f.""'~"~':~"~:<;:'~~;':,::;>~J~~ ~._~~~~: ~Q3~0AI,.V8.W'B7\.'tD L:L:~~~~.tS~~.,t~.J~'~~~!:;~'-""'~~"';;";"'~'~~~'(J ' 'O':~::3~~!~~~~t \. '~.:.t?~.i,r~~~~l~r;"i~ ',";',' "t .~C,~~.~,~.:,~-,:.:~~.'~:~~,~!_SD ~~;;:~~:~~'~'"."':;~":~':'_;~>'<' " _. , n. .' < '-c-' ,,'.O'dAssess~dVarue-.' .<t,L6~')2004_..);1\"" ft.l~Y/ASs~:Ss,~dYalu'~,,;;: ~~",oc:~~~,4r:"; (~5'~;r'~,>:,~- . ~',_'>' .,' ~. '.(2aOO~ Marketx-t6Q%)"~ ~.~:.;_:Markel VaTlie.., ":,{2Q04 Marke(x 100%}_~., l ':L~~,fB~:lE 'PB: ;~-,:,; , :::',;':~;l:~:H~,ifi:J, ;~~;;;~~~tn~ ~.~~.j~YH~::iIi " . TAXABLE ':: :': ;y::::. .... ;~~Z~'~~~'~,'~~;!;.,,{~2.-:~.!:,~['.'~i,~2E:~.JEfi~n.~~~~/i~~~h'X~(~~"~~.1,-':,~<;~.-~:~:~~;~~.~l~~~'5~,':~.';;,~..J - :";':",-/':,'~~':-:,',->-,,-::':<:,,:, ,.".~. . .... ~ .', --.- ... .. - '. -. .. . . ::/::e~~'::: '~~:}~~~i:' .~l;,: }~~l~~~~,;:t,~i~.~~~l ~~~~~2:r~J~1~~~/., ' Pr~p~'rty -.TYP:s,('; It ~~, _ _i'~ ,.:" ~.," '." '.',-- c', -;-' ':Gr~?b)fQ(r~(ee~-y~iq~r~Re!YJ~"-~2ffi'{;~~[rD_.~:q~}?r,~~!'f~i'~?LF~y.cb ~y~fy~s,,:l/:"~~;; f,. :: Residential ;\Builfug', ,:,;,;",:, ,; ::,' ~<,;::},~ "_.~~:,:': ~~~_c:prn~ff3ff!?Gti,~(RI1IY,M'p,?.I:(.apph~t'.Q_r:t'~O('-J!PP!PYF';~:A1!,~P:ph9?tioQs .mu~.t _b~~" ';') ,'.. :,,'... ,", ..' :.::':~~~:::' n<:' 'received by lhe As~essment OJ:fice,by .4;30,p.m..9nOctober,15. 20Q4.:lThose,' " . d.... .'. ._.';:::' .previoi!sly i'ljpr~v.eiJ (oi.C/~ifrfJi.~~(!re,en310 n.Dt n'eed. to1:e,apply:"-;, ;,:{ . , '.,:. :.:::;;0 ~::;~~:.:':~:~~i;~~~;~,~;~~;~~::~:;~~~.~;~~:.~J '~~~;~::~~~r ~:;i::,:.:~f: ~;~~:~::;;: ;~:; ~~;;;~; '~ ' . c. '<', 'r~~_ ,'. --- .~- .,.;>:.; , " ~" . y~ ~ ~ I "-'. ~.,/~. _".. . "'~:..::':."~:~ '.~:._.'.,.'_~_.,-.',:';;.{,'-.'..s~"',~."._:',,.'.v:o/.; '~~.:;Jl~~..'~~.~.~.',~.~~".~~:~: 'l';.'~:,~'..,':'O~.:,''':--.-''.'.<~.'''':-'''',:',,',<,~_...,',',.i.,:.-;::--,' : ",'" ~_ ~:~ __~".:'; '_,,_ ':: _ :..<'_.;_ .' . '. , ,,;s:.~':;-:'n:,.~.~-: :~":~';~{~~,'''~~':~~~:,;~.~,-~.~".,:,i;.~..,,:::~,~.::.:,' .-<-." , ,..c_~:,;.:;~,,-,-_.. ,,'_ . ,~. -~'-. -"\,-,. :. ,,~. ..,:;'.;<!. ':-,,,,,,--,-:,:; ,::,:.",:"c; {:>\~,;<"~:'_ ":~~r::,. F:j1~,,:' ,~. -.' '-_ ,_ . _.,_;; ,:_.~.~, >~"'~~:.i{:~2,',;;{i;~~,:,~^~:,~,.-,t:-;!;:f'~,;~ .,. ,. ,'- ....,,-- ",'".',.;,;:.'" ,-,.,- ." - 0: -, ,1.~ ,...,<,. :- .~: _,d:;-_ '-,"......:_' .-' '-"- -:<. ~;':.\, '.,. :hi;",:" ",,~.' '~,.;:.- ~__ ;".::":::' .. ',!,.-,,:r. ; . , ,', .,.:..:: ._';~:;:,;<.,. ,;c~T~,,:?::~;K:.::::;.:/:<: ..... ,," ....~.... Pennsylvanfa),:wrequires that ail rea!e'9tal~ be jatued asofth~' m~st rec.~rill;oufJtji:.widejeJss~ssri1~;;i The'last; ;:', ' ': reassessment, or,tax base year, was 2000., 'Smce (helast reassessment]n 2000, propertle~.have bee.n,a~sessecla( 100%, of. . Year 2000 value7the"Pie:OeferinineiJRafio').'lhi:trie'w tax base yf!f,rwill be'ih'e,'Year 2001, 'with the new.'assesseci vatues~, . ~'..;~~;~?$&~i~~~e!f~~1f~~Jj~r~~a:~~1::tt~~tJji!~~~~i~~~~?JjJ~~JJi}i~f~~f.~S}iiil~1rl~~&~~~~:: ':.' When'iht. :n"Vi2004 tax"base iSdefeif{,jriecfaftei thfs',ea'ssessrri"hi, 'all taxirig ilis/rietS a'/e'req,drecl bylawt"/owerfhe . .mittage ;,ate by the same proportion that the tax base \verit up. "THe law'provider; thaffn the first year afterreas~essment (2005), the' countY and al(townshfps 'iiniI boroughs may not Incroase.overafl re'venue on their existing taxbase by more than live 'percent (5%) arid schooidistricfs may not increase'overall revenue 'on' thei/iixlstihg iaxbaseby mare than ienpi!fr;ent. (10%), .The county and the other taxing bodies,will inakethe$e' decisioiis'n.ext year"ancl may choose not to increase overall "'ven'ue: Of course, some inclivldua/'s taxes will go up or down by more than those percenfages. The essential point is that an incre,ase In market values does 'not n'~c_es~ariIy mean'a .corre,~poriding inc'rease in'taxes: In'dividual cha-nges in taxes will depend upon aspecific prc;>perty's change as compared to the overall change tor the taxing district. ;'.' ',,' --, '",' ,..', .:. " -- --' - , . TheESTIMATEDimpad statement printed below is ourbest estimate of change, based on 2004 COUNTY tax figures. THIS ESTIMATE DOES NOT INCLUDE ANY BOROUGH, TOWNSHIP,OR SCHOOL DISTRICT IMPACT. . ESTIMATED COUNTY TAX 'IMPACT: Current 2004 County mills = Adjusted 2004 County mills 2.352 2.138 $ $ 282 270 2004 County Tax BEFORE Reassessment. 2004 County Tax AFTER Reassessment. .. ,,"""""'"' """" """" """,,, ,CR''''' ",,,,, ",,,,,, RECEIVED FRO~ 08/01/03 10 07/31/04. --- UNU~ LIFE INS CO OF ~ERICh GROUP REFERENCE CODE: 742 Sl~lE~ENl OF hCCOUNl CER1lFICh1E O~NER: IHOtlAN, LINDh L 212 hPRIL DR C~P HILL, Ph 17011 ~ PeS OF 07131104 02101/00 2799148 100,000.00 ~ 100,001.25 ORIGINPeL EFFEC1IVE DPelE CER1IFIC~1E NU~BER SPECIFIED ~OUNl OF LIFE INSURANCE CPeSH PeCCU~ULPeTION VPeLUE 101PeL DE~1H BENEFIl 11.90 3.00 0.00 ~ ____ 14.90 ~ SPECIFIED ~OUNT OF LIFE INSURANCE COS1 DEPENDENl CHILD(REN) COST ($10,000.00) AD~INIS1RPe1IVE COSl CPeSH PeCCU~UL~TION CONIRIBUIION 101PeL tlON1HL~ PREtlIU~ NONE CERIIFICPelE LOAN PeCIIVIl~ 44.76 134.10 i42.8u- 36.00- 0.00 ~ 1.25 SlPe1EtlEN1 PERIOD SU~~ BEGINNING CPeSH VPeLUE CONIRIBU1IONS RECEIVED" Spt.Ont.D p..t\UUtH 1J<' LtfE lNSI.I\\ANCE COS1 DEPENDENl CHILD(REN) COSl AD~INISIRPeTIVE COST IN1ERES1 CREDI1ED ENDING CPeSH VPeLUE '" 0,,0' """"'" ,'" ,';0'"'' ""'" ,; "",'0 " """, 0',,,"'0; >0"' ,"' """"""'," OR'" nee OF ~ERICPe. FOR UPD~1ED lNFORt\A1l0N "'IC,P,. C,. C~LL OUR 1_800-557-0739. . , . ~'.. ~,~ '.' --' 771007422799148 \D ~~/' \r ~/ n -\- OU YJ '0 S\~ \l AND ADtllNIS1ERED INSURANCE COtlPANY 10LL-FREE NUtlBER, .' \ Date Last Paid: https ://www.americanhm.com/accountl details.aspx Page 2 of2 08-17-2004 AbO'.lt Us I Con:act Us I S:ten~aJ i Sc':~r't'j ; L:cersi,.;. ! :;~i'/cC'i ~ 5/12/2005 ~ \MetLlfe ~ \ Contact :trnu \letLife Representative at: Sales Ot, ,Agency Information: 5 6L/0 3 4 PhoneNumber-717-691-5900 Address - 4550 LENA DR S-101 MECHANICSBURG PA 17055 MetLife Client Services Operations PO Box 8000 Johnstown PA 15907-8000 Annual Policy Statement as of February 18, 2004 Policy Number 915 006 110 A Face Amount of Insurance #BWNDYSK * * PNAIC #PBSQQZBBQG///449# LINDA L THOMAN 212 APRIL DR CAMP HILL PA 17011 $50,000 Policy Issue Date February 18, 1991 Annualized Premium $438.00 Name of LINDA L THOMAN Insured (s) This statement is not a bill. It assumes premiums due through February 17,2004, are paid. It does not include premiums due February 18, 2004, or later. See Page 2 for details. Life Insurance Policy Whole Life Life Insurance Death Benefit Policy Cash Value Total Current Death Benefit $53,255.05 Total Current Cash Surrender Value $4,586.03 Dividend Information 2004 Dividend $149.00 Policy Riders None Special Notes: The current dividend scale for this policy is lower than the prior scale, reflecting investment experience. Your policy loan rate decreases to 6.25%. If you have questions regal-ding the effect of the dividend scale and/or loan interest rate on your policy, please contact your Representative or MetLife as described in the Notice below. IMPORTANT POLICY OWNER NOTICE: You should not consider replacement of your policy without obtaining a comparison of your policy and the proposed coverage. If you have any questions about your policy, you may contact your MetLife representative at the address shown above, or by cailing MetLife at 1-800-MET-5000 (1.800-638.5000). Page I of 2 '1 One of the most attractive features of your life insurance policy is that it pays dividends. MetLife shares a portion of its surplus (earnings) with policyholders through the distribution of declared policy dividends. We've paid dividends without interruption since 1915. Each year dividends are credited to your policy provided premiums are paid to the policy's anni versary date. Here are the dividend options offered by MetLife: . Additional Paid-Up Insurance-You can use your dividends to add to your insurance coverage through the purchase of additional paid-up insurance. Paid-up insurance provides you with more life insurance coverage without having to pay additional out-of-pocket premium payments and without having to take a medical exam. In addition, paid-up insurance has an immediate cash value, which grows on a tax-deferred basis over time. This dividend option is not considered taxable as long as you do not cash in the additional insurance. . Dividends with Interest- Y ou can leave your dividends on deposit the way you do with a savings account. Interest is earned on these funds and the total amount of your Dividend with Interest balance grows over time. Each year we will send you and the Internal Revenue Service an official tax report (I099-INT) showing the taxable interest. Moreover, if dividends under this option plus other policy payments received in cash exceed your investment, future dividends would be taxable. . Premium Reduction-You can apply your dividends to pay all or part of your premium. . Cash Payments-You can receive a check for the amount of your dividend. . One-Year Term Coverage-You can use your dividends to purchase one-year term coverage, which can be an inexpensive way to increase your insurance protection. (Not available on all policies.) Your insurance policy describes your contractual rights and includes complete information regarding the dividend options that are available. If you wish to change your dividend option, simply contact your local MetLife representative at the telephone number listed on the front of this statement. 18QOOII1693(119~) Printed in l..i SA NYHO-HB16SB ,. . - - ~ "\ Annual Policy Statement as of February 18, 2004 Policy Number 915 006 llO A Name of LINDA L THOMAN Insured (5) Base Plan Additional Paid- Up Insurance (AI) Total Policy and Rider Benefits Death Benefit $50,000.00 $3,255.05 $53,255.05 Cash Value $3,850.00 $736.03 $4,586.03 Your monthly premium of $36.50 will continue to be withdrawn from your bank account. Your 2004 dividend of $149.00 purchases additional paid-up insurance. Please note that paying insurance premiums more often than annually (more often than once a year) will cost more than paying them once a year. Loan Information Additional Paid-Up Insurance: Prior Balance Additional Insurance Earned on Prior Balance Paid-Up Additions Purchased by Current Dividend Total Additional Paid-Up Insurance $2,529.2< $65.7E Your policy has no outstanding loan. $660.0i $3,255.0: Total Additional Paid-Up Ins. Cash Value $736.0c Page 2 of . . ~ MetLifeO 1': O. BOX 336 WARWICK RI 02887-0336 ) POLICYHOLDER ANNUAL STATEMENT PERTOD ENDING FEBRUARY 17, 2004 POLICY NUMBER 915006116UL METLTFE CLIENT SERVICES OPERATIONS PAGE 1 #BWNDYSK * * ULANN #PBSQQZBBZA2//634# TERRENCE M THOMAN 212 APRIL DR CAMP HILL PA 17011 DISTRICT 56L /034 TELEPHONE: 717-691-5900 INSURED ISSUE AGE STATUS PLAN ********,'* POLICY SPECIFICATIONS ********** TERRENCE M THOMAN 28 ACTIVE FLEXIBLE PREMIUM LIFE DATE OF POLICY DEATH BENEFIT TYPE~ PLAN CODE~ FEBRUARY 18, 1991 INCREASING 631403 SPECIFIED FACE AMOUNT ACCUMULATION FUND SURRENDER VALUE DEATH BENEFIT * REFLECTS SURRENDER ************* POLICY VALUES *************** BEGINNING VALUES ENDING VALUES TO AND INCLUDING FEBRUARY 18, 2003 FEBRUARY 17, 2004 50,000.00 50,000.00 4,350.91 .4,829.27 4,250.91 4,729.27* 54,350.91 54,829.27 PENALTY OF 100.00 EFFECTIVE DURING PAST POLICY YEAR ,'"'"'"'"',,,,,,,, IMPORTANT INFORMATION TO MONITOR YOUR POLICY STATUS ""',,h',,',,',,',,', THE FOLLOWING SECTION CONTAINS CALCULATIONS THAT WILL REMAIN IN FORCE BASED ON: 1) PAYMENT OF THE BILLED/SCHEDULED 2 NO FURTHER PREMIUM PAYMENTS SHOW YOU HOW LONG YOUR POLICY PREMIUM OF $35.00 .......'..'. IF YOU CONTINUE TO PAY PREMIUMS AS SCHEDULED, ON THE BASIS OF CURRENT INTEREST RATES AND COST OF INSURANCE CHARGES, YOUR COVERAGE WILL REMAIN IN EFFECT UNTIL OCTOBER 2043. IF YOU CONTINUE TO PAY PREMIUMS AS SCHEDULED, ON THE BASIS OF MINIMUM GUARANTEED INTEREST RATES AND MAXIMUM COST OF INSURANCE CHARGES, YOUR COVERAGE WILL REMAIN IN EFFECT UNTIL NOVEMBER 2034. IF YOU MAKE NO FURTHER PREMIUM PAYMENTS, ON THE BASIS OF CURRENT INTEREST RATES AND COST OF INSURANCE CHARGES, YOUR COVERAGE WILL REMAIN IN EFFECT UNTIL DECEMBER 2029. IF YOU MADE NO FURTHER PREMIUM PAYMENTS, ON THE BASIS OF MINIMUM GUARANTEED INTEREST RATES AND MAXIMUM COST OF INSURANCE CHARGES, YOUR COVERAGE WILL REMAIN IN EFFECT UNTIL MAY 2021. IF ANY OF THE ABOVE INFORMATION DOES NOT MEET WITH YOUR OBJECTIVES, PLEASE CALL YOUR REPRESENTATIVE AT THE TELEPHONE NUMBER LISTED ABOVE OR CALL OUR CUSTOMER SERVICE CENTER AT 1-800-MET-5000 FOR ASSISTANCE. ).~ ;', "', ~';; .'..'..'..'. .0 MetLifeO ,'~ ,'r ,', ,'r: ,'r: ,', i;; ,'r: ~'r: ,'r: ,'r: ~'r: ACTIVITY FOR POLICY YEAR ENDING ON TRANSACTION PREVIOUS BALANCE PAYMENT MONTHL Y SUMMAR Y PAYMENT MONTHLY SUMMARY PAYMENT MONTHL Y SUMMAR Y MONTHL Y SUMMAR Y PAYMENT PAYMENT MONTHLY SUMMARY PAYMENT MONTHLY SUMMARy PAYMENT MONTHL Y SUMMARY PAYMENT MONTHL Y SUMMAR Y MONTHL Y SUMMAR Y PAYMENT PAYMENT MONTHL Y SUMMAR Y PAYMENT MONTHL Y SUMMAR Y MONTHL Y SUMMARY PAYMENT INTEREST CREDITED TOTALS PAYMENT PAR T SURR POLICY NUMBER FEBRUARY 17, 2004 GROSS AMOUNT INSURANCE EFFECTIVE EXPENSE CHARGES INTEREST DATE CHARGES BASIC/RIDERS CREDITED 02/18/03 35.00 02/18/03 02/18/03 35.00 03/18/03 03/18/03 35.00 04/18/03 04/18/03 05/18/03 35.00 05/19/03 35.00 06/18/03 06/18/03 35.00 07/18/03 07/18/03 35.00 08/18/03 08/18/03 35.00 09/18/03 09/18/03 10/18/03 35.00 10/20/03 35.00 11/18/03 11/18/03 35.00 12/18/03 12/18/03 01/18/04 35.00 01/20/04 FROM 01/18/04 TO 420.00 0.00 1.40 4.00 1. 40 4.00 1.40 4.00 4.00 1. 40 1.40 4.00 1. 40 4.00 1.40 4.00 1. 40 4.00 4.00 1. 40 1. 40 4.00 1. 40 4.00 4.00 1.40 02/17/04 64.80 7.87 7.87 16.72 915006116uL PAGE 2 ,'.,',;'r:,',,'.,',,',"i'i'.,',;',,', ENDING ACCUM. FUND 4,350.91 4,372.64 4,411.09 4,451.35 4,457.45 4,531.25 4,570.87 4,611.11 4,651.36 4,657.34 4,731.12 4,770.72 4,777.28 4,829.27 TOTAL INTEREST CREDITED DURING THE POLICY YEAR: CONSISTS Of A GUARANTEED AMOUNT OF S 180.19 (BASED ON 4% INTEREST) AND AN ADDITIONAL ~~OUNT Of S 37.41 (BASED ON CURRENT RATES). *** CONTINUED ON NEXT PAGE """ 7.87 7.87 18.53 17.97 7.87 18.47 7.87 17.89 7.87 18.51 7.87 7.87 18.52 17.85 7.87 18.45 7.87 7.87 17.87 18.43 18.39 94.44 217 . 60 . 0 MetLife" .~, POLICY NUMBER 915006116UL PAGE 3 ADDITIONAL ALLOWABLE PAYMENTS IN THE NEXT POLICY YEAR WITH REGARD TO THE GUIDELINE PREMIUM ARE $ 12,636.40 **"INTEREST RATES APPLIED TO NEW PREMIUMS EFFECTIVE DATE 02/01/2003 03/01/2003 04/01/2003 05/01/2003 06/01/2003 07/01/2003 08/01/2003 09/01/2003 10/01/2003 1110112003 12/01/2003 01/01/2004 02/01/2004 ~', ~': 1~ )', ;': ,'r: ;'r: ,', l'r:.k ,'r: ~';; ,'r: LOAN ACTIVITY ************* ,'r; RATE 5.250 5.250 5.250 5.000 4.750 4.750 4.750 4.750 4.750 4.750 4.500 4.500 4.500 ,'r; )~ ;'r: NONE )'r: .. CURRENT RATE IS 4.500 FOR NEW PREMIUMS .. MINIMUM GUARANTEED RATE IS 4.000 .. .. INTEREST RATE PAID ON FIRST $ 1,000.00 ~. DEPOSITED INTO POLICY VALUE IS 4.000 .. ***************************************************************************** .. IIlPORTANT POLICY OWNER NOTICE: YOU SHOULD CONSIDER REQUESTING MORE .. DETAILED INFORMATION ABOUT YOUR POLICY TO UNDERSTAND HOW IT MAY PERFORM ~ IN THE FUTURE. YOU SHOULD NOT CONSIDER REPLACEMENT OF YOUR POLICY OR .. MAKE CHANGES IN YOUR COVERAGE WITHOUT REQUESTING A CURRENT ILLUSTRATION. .. .. YOU MAY ANNUALLY REQUEST, WITHOUT CHARGE, SUCH AN ILLUSTRATION BY .. .. CONTACTING YOUR AGENT AT THE TELEPHONE NUMBER LISTED AT THE TOP OF PAGE I .. .. OF THIS STATEMENT, CALLING 1-800-638-5000 OR WRITING TO METROPOLITAN .. .. LIFE INSURANCE COMPANY AT THE ADDRESS SHOWN ON PAGE 1 OF THIS STATEMENT. .. ~ IF YOU DO NOT RECEIVE A CURRENT ILLUSTRATION OF YOUR POLICY WITHIN 30 DAYS* .. FROM YOUR REQUEST, YOU SHOULD CONTACT YOUR STATE INSURANCE DEPARTMENT. .. ***************************************************************************** OTHER IIlPORTANT INFORMATION SOME OR ALL OF THE INTEREST RATES CREDITED TO YOUR POLICY, WHICH ARE BASED ON MARKET RATES, WERE LOWER THAN THOSE CREDITED IN THE PRIOR YEAR. TO SEE HOW THESE CHANGES AFFECT YOUR POLICY AND IF ANY ADDITIONAL PREMIUMS ARE NEEDED, PLEASE REFER TO THE POLICY STATUS INFORMATION ON THE FIRST PAGE OF THIS STATEMENT OR REQUEST A CURRENT ILLUSTRATION. .'..'.-'. CONTINUED ON NEXT PAGE .'-.'-.'. OM~W \ , . POLICY NUMBER, 915006116UL PAGE 4 ON FLEXIBLE PREMIUM LIFE, THE DECLARED INTEREST RATE APPLIES TO AMOUNTS IN THE ACCUMULATION FUND OVER $1,000. THE 'INTEREST RATES APPLIED' INFORMATION SHOWN ABOVE REPRESENTS THE DECLARED RATE APPLIED TO NET PREMIUMS RECEIVED DURING THE MONTH INDICATED. THIS RATE WILL STAY IN EFFECT UNTIL THE BEGINNING OF THE CALENDAR MONTH OF RECEIPT IN THE SUBSEQUENT YEAR, IRRESPECTIVE OF ANY CHANGE IN THE DECLARED RATE FOR AN INTERVENING MONTH. THEREAFTER, THESE FUNDS WILL BE REINVESTED EVERY 12 MONTHS ON A CALENDAR MONTH BASIS, AT THE DECLARED RATE THEN IN EFFECT. THIS RATE MAY DIFFER FROM THE RATE WE SET FOR NEW PREMIUMS. IF YOU HAVE ANY QUESTIONS ABOUT THIS STATEMENT OR NEED ADDITIONAL INFORMATION, PLEASE CONTACT YOUR REPRESENTATIVE AT THE TELEPHONE NUMBER LISTED ON THE TOP OF PAGE 1 OR CALL OUR CUSTOMER SERVICE CENTER AT 1-800-MEI-5000 (1-800-638-5000), MONDAY THROUGH FRIDAY BEIWEEN 8 A.M. AND 5 P.M. EST. "\ Linda L & TerreGce M Thoman 212 April Drive Camp Hill, PA 17011 2004 U.S. INDIVIDUAL INCOME TAX RETURN SUMMARY Adjusted Gross Income Taxable Income Total Tax Total Payments Refund Effective Tax Rate $ $ $ $ $ 127,654 99,495 16,042 17,966 1,924 12.57 % Listed below are forms and related worksheets for your review: - Form 1040 Individual Income Tax Return IF YOU PLAN TO FILE ELECTRONICALLY: After you file your return electronically, you will receive instructions on how to complete the electronic filing pro.cess'. IF YOU PLAN TO MAIL YOUR TAX RETURN: When you print your filing copy of your tax return, you will receive instructions on where to mail1your return. K2E? TEIS PAGE FOR YOUR RECO~DS -- DO NOT MAIL. , Form ., 040 Department of the Tre?sury - Internal Revenue Service 2004 1(99) U.S. Individual Income Tax Return IRS Use Only - Do not write or staple in this space. For the year Jan 1 - Dee 31, 2004, or other tax year beginning ,2004, endina ,20 OMS No. 1545-0074 label Your frrstname MI last name Your soda! security number (See instructions.) Linda L Thoman 208-58-2482 II a joint return, Spouse's first name MI last name Spouse's social security number Use the IRS label. Terrence M Thoman 200-46-0343 Otherwise, Home address (number and street). If you have a P.O. box, see instructions. Apartmenlno. A Important! A please print or type. 212 April Drive You must enter your social Citj, town or post office. [f you have a foreign address, see instructiOf1S. State ZIP code security number(s) above. Presidential Camp Hill PA 17011 d Total number of exemptions claimed. . . . . ... 7 Wages, salaries, tips, etc. Attach Form(s) W.2 Sa Taxable interest. Attach Schedule B if required b Tax-exempt interest. Do not include on line 8a .............1 Bbl 9a Ordinary dividends. Attach Schedule 8 if required b g~~lj~sq~~) .................................. . . . . . . .. . ../ 9 bl 10 Taxable refunds, credits, or offsets of state and local income taxes (see instructions) . 11 Alimony received 12 Business income or (loss). Attach Schedule C or C-EZ 13 Capital gain or (loss). Att Sch 0 if reqd. If not reqd, ck here. . . . . . . . . . . . . . . . . . . ... 0 14 Other gains or (losses). Attach Form 4797 ... 15a IRA distributions. ... .1 15a[ I bb Taxable amount (see instrs) ,. 16a Pensions and annuities.... ~ Taxable amount (see instrs) . 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E. 18 Farm income or (loss). Attach Schedule F 19 Unemployment compensation. 20 a Social security benefits . . ..1 20 a I 21 Other income 22 Add the am~unt;- i;; the far-right Zo~;;n-f~ Tin-es7-U:;-r;ugh-21. Thisis-y;u-;: t~t~lin~o~-;'" 23 Educator expenses (see instructions) 23 24 Certain business expenses of reservists, performing artists, and fee-basis government officials. Attach Form 2106 or 2106-EZ . 25 IRA deduction (see instructions) 26 Student loan interest deduction (see instructions) . 27 Tuition and fees deduction (see instructions) 28 Health savings account deduction. Attach Form 8889 . 29 Moving expenses. Attach Form 3903 30 One-half of self-employment tax. Attach Schedule SE . 31 Self. employed health insurance deduction (see instrs) 32 Self. employed SEP, SIMPLE, and qualified plans. 33 Penalty on early withdrawal of savings 34a Alimony paid b Recipient's SSN . ~ 35 Add lines 23 through 34a 36 Subtract line 35 from line 22. This is your adjusted qross income. BAA For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see instructions. ElectIOn Campaign (See instructions.) Filing Status Check only one box. Exemptions If more than four dependents see instructions. Income Attach farm(s) W.2 here. Also attach forms W-2Gand 1099.R if tax was withheld. If you did not get a W,2, see instructions. Enclose, but do notattach,any payment. Also, please use farml040-V, - Adjusted Gross Income ~ Note: Checking 'Yes' Will not change your tax or reduce your refund You Spouse Do au, or our spouse If fllln a Jo!nt return, want $3 to 0 to thiS fund? ... Yes X No Yes X No 1 Single Head of household (with qualifying person). (See 2 Married filing jointly (even if only one had income) instructions.) If the qualifying person is a child but not your dependent, enter this child's 3 Married filing separately. Enter spouse's SSN above & full name here ... name here. ... 5 Qualifying widow(er) with dependent child (see instructions) 6a X Yourself. If someone can claim you as a dependent, do not check box 6a. " " " " '_ " " ' _, _, _", J- ~~6~sa~~e6~e~ b X Souse No. of children on6cwho: . lived with you . . dldllOt live with you due to divorce or separation (seelllstrs) '. Dependents on6cnot entered above . c Dependents: (2) Dependent's social security number (3) Dependent's relationship to you (4) " qualifying child for child taxcreLlit (seeinstrs) (1) First name Nicole L Thoman Ka 1a L Thoman Last name Dau hter Dau hter 193-72-7002 161-78-9261 n 75. I b Taxable amount (see instrs) . 10 II 12 13 14 15b 16b 17 18 19 20b 21 22 , 24 25 26 27 28 29 30 31 32 33 34a 35 .. 36 FOIAOl12 11110/04 2 2 Add numbers ..I on lines ~ ... above..... 7 8a 4/ 128,281. 18. 9a 75. -720. 127,654. 127,654. Form 1040 (2004) orm ln a errt:....-.:e oman - - age 2 Ta:i and 37 Amount from line 36 (adjusted gross income) ............ . . . . . . . . . ". . . . . . . ... . ". .... 37 127,654. Credits 38a Check {B You were born before January 2, 1940, B Blind. Total boxes ,L If. _ Spouse was born before January 2,1940, Blind. checked'" 38a Standard l b If your spouse itemizes on a separate return, or you were. du.l.status Deduction - allen, see instructions and check here..................... ..... ............ ... 3gb 0 for - . People who 39 Itemized deductions (from Schedule A) or your standard deduction (see left margin). 39 15,759. checked any box '40 Subtract line 39 from line 37 ............. 40 111,895. on line 38a or 41 If line 37 is $107,025 or less, mUltip~ $3,100 by the total number of exemptions claimed 38b or who can be claimed as a on line 6d. If line 37 is over $107,02 ,see the worksheet in the instructions... ......... 41 12,400. dependent, see 42 Taxable income. Subtract line 41 from line 40. instructions. If line41 is more than line 40, enter .0. ............................... 42 99,495. 43 Tax (see instrs). Check if any tax is from: a o Form(s) 8814 b 0 Form 4972 . 43 18,342. . All others: 44 Alternative minimum tax (see instructions). Attach Form 6251 44 Single or Married 45 Add lines 43 and 44 . ............. .......................................... .. 45 18,342. filing separately, 46 Foreign tax credit. Attach Form 1116 if required. 46 $4,850 47 Credit for child and dependent care expenses. Attach Form 2441 47 1,200. Married filing 46 Credit for the elderly or the disabled. Attach Schedule R . 46 jointlx or QualifYing 49 Education credits. Attach Form 8863 . 49 widow(er), 50 Retirement savings contributions credit. Attach Form 8880 . 50 $9,700 51 Child tax credit (see instructions) 51 1,100. Head of 52 Adoption credit. Attach Form 8839 . 52 household, $7,150 53 Credils from: a 0 Form &396 b 0 Form 8859 . 53 54 Other credits. Check applicable box(es): a 0 Form 3800 b 0 Form c OSpecify 54 8801 55 Add lines 46 through 54. These are your total credits. 55 2,300. 56 Subtract line 55 from line 45. If fine 55 is more than line 45, enter .0. .. 56 16,042. 57 Self. employment tax. Attach Schedule SE 57 Other 58 Social security and Medicare tax or. tip income not reported to emplqyer. Attach Form 4137. 58 Taxes 59 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required. 59 60 Advance earned income credit payments from Form(s) W.2 . 60 61 Household employment taxes. Attach Schedule H .................. 61 62 Add lines 56.61. This is your total tax .. 62 16,042. Payments 63 Federal income tax withheld from Forms W.2 and 1099 . 63 17,966. 64 2004 estimated tax payments and amount applied from 2003 return. 64 If you have a qualifying 65 a Earned income credit (EIC) 65a child, attach I b Nontaxable combat pay election..... .../ 65b[ SChedule EIC. 66 Excess social security and tier 1 RRTA tax withheld (see instructions) 66 67 Additional child tax credit. Attach Form 8812.. . 67 68 Amount paid with request for extension to file (see instruction s). 68 69 Other pmts from: a 0 Form 2439 b 0 Form 4136 c o Form 8885 69 70 Add lines 63, 64. 65a. and 66 through 69. .. 70 17,966. These are your tolalpayments Refund 71 If line 70 is more than line 62, subtract line 62 from line 70. This is the amount you overpaid . 71 1,924. Direct depOSit? 72a Amount of line 71 you want refunded to you. .. 72. 1,924. See instructions . bRoutingnumber .......1231381116 I ,. c Type: . .~. ~'h'e~~i~'g' . o Savings and fill in 72b, . d Account number...... .10450454558 I 72c, and 72d. 73 Amount of line 71 you want applied to your 2005 estimated tax. '.. "I 73 I Amount 74 Amount you owe. Subtract line 70 from line 62. For details on how to pay, see instructions .. 74 You Owe 75 Estimated tax penalty (see instructions) . 175 I Third Pa 00 you want to allow another person to discuss this return with the IRS (see instructions)? . U Yes. Complete the foHowing. I2J No Joint return? Your signature Date Your oCcupation Daylimephone number See instructions. ~ Finance Keep a copy SpoLOse's signature 1/ a ioint return. both must sign. Dale Spouse's Occupation for your records. ~ Computer Analvst I D," Check if self-employed 0 Preparer's SSN or PTIN Preparer"s ~ Paid signat'.."e Preparer's F:rm'sname Self-Prepared Use Only (oryol.>rsit .. self.employed), EIN address, and ZIP Code Phone no. F 1 b40 (2004) Oesi Sign Here rty nee " L' d L & T M Th 208 58 2482 p DeSigneeS Pho.ne Personalldenbflcatlo.n name ,. no. ,. number (PIN) ,. Un~er penalties of periury, I declare Ihat I have examined this retum and accompanying schedules and statements. and to. the best o.f my knowledge and belief, they are true, correct, and complete. Declaration o.f preparer (other than taxpayer) is based an allln/o.rmatlon of which preparer has any k,~.owledge. FDIA0112 11110/04 Form 1 040 (2004) -, SCHEDULE A (For';' 1040) Itemized Deductions Department of the Treasury Internal Revenue Service (99) Name(s) shown on Form 1040 Linda L & Medical and Dental Expenses Taxes You Paid (See instructions.) Interest You Paid Casualty and Theft losses Job Expenses 20 and Most Other Miscellaneous Deductions (See instructions.) Other Miscellaneous Deductions Total Itemized Deductions ~ Attach to Form 1040. .. See Instructions for Schedule A (Form 1040). Terrence M Thoman Caution. Do not include expenses reimbursed or paid by others. 1 Medical and dental expenses (see instructions) . 2 Enter amount from Form 1040, line 37. . . . . .! 2 r 3 Multiply line 2 by 7,5% (.075) ,...............,...,..,...,.... 4 Subtract line 3 from line 1. If line 3 is more than line 1, enter -0.. 5 State and local (check only one box): a [KJlncome taxes, or_ -I- b 0 General sales taxes (see instructions) I 6 Real estate taxes (see instructions) 7 Personal property taxes 8 Other taxes. List type and amount... _ _ _ _ _ _ _ _ _ _ _ _ _ OMS No. 1545.0074 2004 07 I Your social security number 1208-58-2482 1 3 4 5 5,986. 6 2,024. 7 1,941. . 8 9 9,951. 10 4,607. t. 9 AddlinesSthrough-S:-::-::-::-::-::-: -: -: -: -: -: -::-::-: ,- - - - -- 10 Home rntg interest and points reported to you on Form 1098. 11 Home mortgage interest not reported to you on Form 1098. If paid to the person from whom you bought the home, see instructions and show that person's name, identifying number, and address ... ------------------------------- ------------------------------- ------------------------------ ------------------------------- Points not reported to you on Form 1098. See instrs for spcl rules. Investment interest. Attach Form 4952 if required. (See instrs.) ................................................. Add lines 10 through 13..,...,...,.,....... Gifts by cash or check. If you made any gift of $250 or more, see instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other than by cash or check. If any gift of $250 or more, see instructions. You must attach Form 8283 if over $500 Carryover from prior year. Add lines 15 throuqh 17 . 19 Casualty or theft loss(es). Attach Form 4684. (See instructions.) . Un reimbursed employee expenses - jOb travel, union dues, job education, etc. Attach Form 2106 or 2106.EZ if required. (See instructions.) ... --------------- ------------------------------- ------------------------------ 21 Tax preparation fees 22 Other expenses - investment, safe deposit box, etc. List type and amount .... _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ i~~c~10E~~u~_~X2~~~~___________~~. ~ 23 Add lines 20 through 22 23 24 Enter amount from Form 1040, line 37 . ./241 127,654. 25 Multiply line 24 by 2% (.02) 25 26 Subtract line 25 from line 23. If line 25 is more than line 23': enter -0. 27 Other - from list in the instructions. List type and amount .... 11 12 46. 13 14 . . 15 897. .. 16 258. 17 18 19 20 21 70. 70. 2,553. 26 ---------------- 28 Is Form 1040, line 37, over $142,700 (over $71,350 if MFS)? --------------------------------------------- [;;:]NO. DYes. 27 Your deduction is not limited. Add the amounts in the far right column for lines 4 through 27. Also, enter this amount on Form 1040, line 39. Your deduction may be limited. See instructions for the amount to enter. . 28 , BAA For PaperNork Reduction Act Notice, see Form 1040 instructions. (See instructions.) Note. Personal 12 interest is 13 not deductible. 14 Gifts to 15 Charity If you made 16 a gift and got a benefit for it, see instructions. 17 18 -~ FDIA030 I 11/02/04 4,653. 1,155. o. 15,759. Schedule A (Form 1040) 2004 . SCHEDULE D (F 0 rrn 1 040) \ Department of the Treasury Ir,lernal Revenue Service (99) Name(s) shown on Form 1040 Capital Gains and Losses ... Attach to Form 1040. ... See Instructions for Schedule 0 (Form 1040). ... Use Schedule D.' to list additional transactions for lines 1 and 8. OMS No. 1545-0074 2004 12 I Part I Linda L & Terrence M Thoman YOur social security number I Short-Term Capital Gains and Losses - Assets Held One Year or Less 208-58-2482 (a) Description of properly (Example: 100 shares XYZ Co) (b) Date acquired (C) Date sold (Mo, day,yr) (Mo, day, yr) Cd) Sales price (see instructions) (e) Cost or other basis (see instructions) (f) Gain or (loss) Subtract (e) framed) 2 Enter your short-term totals, if any, from Schedule 0.1, line 2 . 2 3 Total short-term sales price amounts. Add lines 1 and 2 in column (d) . . . . . . . . . . . .. 3 4 Short.term gain from Form 6252 and short.term gain or (loss) from Forms 4684,6781, and 8824 4 5 Net short.term gain or (loss) from partnerships, S corporations, estates, and trusts from Schedule(s) K.1 5 6 Short.term capita/loss carryover. Enter the amount, if any, from line 8 of your Capital Loss Carryover Worksheet in the instructions. . . . . . . . . . . . . . r 6 7 Net short-term capital gain or (/oss). Combine lines 1 through 6 in column (f) . 7 I Part II I Long-Term Capital Gains and Losses - Assets Held More Than One Year (a) Description of (b) Dale acquired (c) Date sold (d) Sales price (e) Cost or other basis (f) Gain or (loss) wopertY(Example: (Mo.day.yr) (Mo. day. yr) (see instructions) (seeinslructions) Subtract (e) from (d) 00 shares XYZ Co) 8 JDS Uniphase 02/16/01 10/18/04 153.50 1,339.67 -1,186.17 American Greetings 01/24/01 10/18/04 629.49 309.99 319.50 RPM 01/24/01 10/19/04 337.00 189.99 147.01 9 Enter your long-term totals, if any, from Schedule 0.1, line 9 9 10 Tota/long-term sales price amounts. Add lines 8 and 9 in column (d) 10 1, 120. 11 Gain from Form 4797, Part I; long.term gain from Forms 2439 and 6252; and long.term gain or (loss) from Forms 4684, 6781, .nd 8824. '.. ...... . .. .... ..... ................. .. 11 12 Net long.term gain or (loss) from partnerships, S corporations. estates, and trusts from Schedule(s) K.1 12 13 Capital gain distributions. See instrs _ 13 14 Long-term capital loss carryover. Enter the amount, if any, from line 13 of your Capital Loss Carryover Worksheet in the instructions. '. 14 15 Net long-term capital gain or (loss). Combine lines 8 through 14 in column (t). Then go to Part III on page 2 .. ............. ......... ..... ...... .. .. '.. ............ . 15 -720. BAA For Paperwork Reduction Act Notice, see Form 1040 instructions. Schedcle 0 (Form lIMO) 2004 FOIA0612 11/02/C4 Scheduie D (Form 1040) 2004 " Linda L -"Terrence M Thoman 208-58-2482 Page 2 I Part III I Summary 16 Combine lines 7 and 15 and enter the result. If line 16 is a loss, skip lines 17 through 20, and go to line 21. If a gain, enter the gain on Form 1040, line 13, and then go to line 17 below............................. 16 -720. 17 Are lines 15 and 16 both gains? o Yes. Go to line 18. D No. Skip lines 18 through 21, and go to line 22. 18 Enter the amount, if any, from line 7 of the 28% Rate Gain Worksheet in the instructions .......... .. 18 19 Enter the amount, if any, from line 18 of the Unrecaptured Section 1250 Gain Worksheet in the instructions .............. .. 19 20 Are lines 18 and 19 both zero or blank? o Yes. Complete Form 1040 through line 42, and then complete the Qualified Dividends and Capital Gain Tax Worksheet in the instructions for Form 1040. Do not complete lines 21 and 22 below. o No. Complete Form 1040 through line 42, and then complete the Schedule 0 Tax Worksheet in the instructions. Do not complete Jines 21 and 22 below. 21 If line 16 is a loss, enter here and on Form 1040, line 13, the smaller of: . The loss on line 16 or } 21 -720. . ($3,000), or if married filing separately, ($1,500) , Note. When figuring which amount is smaller, treat both amounts as positive numbers. cc 22 Do you have qualified dividends on Form 1040, line 9b? .-,'- c. . c. ;'->~,/,:1';;!' h ,~'~ . [R] Yes. Complete Form 1040 through line 42, and then complete the Qualified Dividends and Capital Gain . ) " ~. " :. :,. Tax Worksheet in the Instructions for Form 1040. '-.,,. -.-"~ .': c o No. Complete the rest of Form 1040. ",;,'; ~ .. -- ~ ,.. ~ .. .. ~:'; ,.o'v.- .---.. FDIA0612 11/02/C4 Schedule D (Form 1040) 2004 ~-orm 2441 (.lIild and Dependent Care Expense", Department of the Treasury Internal Revenue Service (99) Name(s) shown on Form 1040 ~ Attach to Form 1040. ... See separate instructions. OMS No. 1545.0068 2004 21 Linda L & Terrence M Thoman Your social security number 208-58-2482 Be/ore you begin: You need to understand the following terms. See Definitions in the instructions. . Dependent Care Benefits . Qualifying Person(s) . Qualified Expenses Persons or Organizations Who Provided the Care - You must complete this port. (If you need more space, use the bottom of page 2.) 1 (a) Care provider's name (b) Address (e) Identifying no. (d) Amount paid (no., street, apt no., city, state, and ZIP code) (SSN or EIN) (see instructions) Tender Loving Care 220 St Johns Church Rd r--------______________ Learni~ Center Camp Hill PA 23-2182402 4,350.00 Childrens Center ~g~~!~)~~e~!~rJ_~~h2~~____ Camp Hill PA 25-1569477 3,066.00 Did you receive dependent care benefits? No Yes .... Complete only Part II below. .... Complete Part III on page 2 next. I Part II I Credit for Child and Dependent Care Expenses Caution. If the care was provided in your home, you may owe employment taxes. See the instructions for Form 1040, line 61. 2 Information about your qualifying person(s). l!...lQu have more than tw~quallfyinc persons, see the instructions. (a) Qualifying person's name (b) Qualifying person's social (e) Qualified , security number expenses you incurred and paid in 2004 for the person First Last listed in column (a) Nicole IThoman 193-72-7002 1,533. Kay1a IThoman 161-78-9261 5,883. 3 Add the amounts In column (c) of line 2. Do not enter more than $3,000 for one qualifying person or $6,000 for two or more persons. If you completed Part III, enter the amount from line 32 . 3 6,000. 4 Enter your earned income. See instructions. 4 73,180. 5 If married filing jointly, enter YOur spouse's earned income (if your spouse was a student or was disabled, see the instructions); all others, enter the amount from line 4 5 55,10l. 6 Enter the smallest of line 3, 4, or 5. 6 6,000. 7 Enter the amount from Form 1040, line 37 . I 7 I 127,654. 8 Enter on line 8 the decimal amount shown below that applies to the amount on line 7 If line 7 is: If line 7 is: But not Decimal But not Decimal Over over amount is Over over amount is $0- 15,000 .35 $29,000- 31,000 .27 15,000- 17,000 .34 31,000- 33,000 .26 17,000- 19,000 .33 33,000 - 35,000 .25 19,000 - 21,000 .32 35,000 - 37,000 .24 8 X 0.20 21,000 - 23,000 .31 37,000 - 39,000 .23 23,000 - 25,000 .30 39,090 - 41,000 .22 25,000- 27,000 .29 41,000- 43,000 .21 27,000 - 29,000 .28 43,000- No I'mit .20 9 Multiply line 6 by the decimal amount on line 8. If you paid 2003 expenses in 2004, see the instructions. 9 1,200. 10 Enter the amount from Form 1040, line 45. minus any amOunt on Form 1040; line 46 .. 10 18,342. 11 Credit far child and dependent care expenses. Enter the smaller of line 9 or line 10 here and on Form 1040. line 47. . . . . . .. . .. . . .. . . . . . . . , . .. .. . . . . . . . l' 1,200. BAA For Paperwork Reduction Act NotIce, see separate Instructions. Form 2441 (2004) FDIA3212 llJ16fC4 Form 1040 Line 43 ") Qualified Dividends and Capital Gain Tax Worksheet - Line 43 .. Keep for your records 2004 Name(s) Shown on Return Social Security Number Linda L & Terrence M Thoman 208-58-2482 Before you begin: See the instructions for line 43 to see if you can use this worksheet to figure your lax. If you do not have to file Schedule 0 and you received capital gain distributions, be sure you checked the box on line 13 of Form 1040. 1 Enter the amount from Form 1040, line 42. 1 99,495. 2 Enter the amount from Form 1040, line 9b 2 75. 3 Are you filing Schedule O? o Yes. Enter the smaller of line 15 or 16 of Schedule 0, but do not enter less .0. . . 3 0 . D No. Enter the amount from Form 1040, line 13. 4 Add lines 2 and 3 4 75. 5 If you are claiming investment interest expense on Form 4952, enler the amount from line 4g. Otherwise enter .0, . 5 O. ' 6 Subtraclline 5 from line 4. If zero or less, enter .0, 6 75. 7 Subtract line 6 from line 1. If zero or less, enter -0. 7 99, 420. 8 Enter the smaller of: · The amount on line 1 or } · $29,050 if single or married filing sep, $58,100 if married filing jointly or 8 58, 100. qualifying widow(er), or $38,900 if head of household. 9 Is the amount on line 7 equal to or more than the amount on line 8' [Xl Yes. Skip lines 9 through 11; go to line 12. . D No. Enter the amount from line 7 . . . . . . . . . . 9 10 Subract line 9 from line 8 . 10 11 Multiply line 10 by 5% (.05) 11 12 Are the amounts on lines 6 and 10 the same' Cl Yes. Skip lines 12 through 15; go to line 16 o No. Enter the smaller of line 1 or line 6 .. 12 75. 13 Enter the amt from line 10 (if line 10 is blank, enter 0) 13 O. 14 Subtraclline 13 from line 12. . 14 75. 15 Multiply line 14 by 15% (.15) . 16 Figure the tax on the amount on line 7. Use the Tax Table or Tax Computation Worksheet, whichever applies. 17 Addlines11,15,andI6 18 Figure the tax on the amount on line 1. Use the Tax Table or Tax Computation Worksheet, whichever applies. 19 Tax on all taxable income. Enler the smaller of line 17 or line 18 here and on Form 1040, line 43 15 11. 16 18,331. 17 18,342. 18 18,344. 19 18,342. \ Tax Payments Worksheet .. Keep for your records 2004 Name(s) Shown on Return Linda L & Terrence M Thoman Social Security Number 208-58-2482 Estimated Tax Payments for 2004 (If more than 4 payments for any state or locality, see Tax Help) Federal State Local Oate Amount Oate Amount ID Oate Amount 10 1 04/15/04 04/15/04 - 04/15/04 2 06/15/04 06/15/04 06/15/04 3 09/15/04 09/15/04 09/15/04 - 4 01/18/05 01118/05 - 01/18/05 - 5 a b c d Total Estimated Payments. Tax Payments Other Than Withholding Federal State 10 Local 10 (If multiple states, see Tax Help) 6 Overpayments applied to 2004. .... 7 Credited by eslates and trusls .... - 8 Totals Lines I through 7 ......... 9 2004 extensions. Taxes Withheld From: F edera' State Local 10 Forms W-2 17,966. 4,198. 1,787. 11 Forms W-2G 12 Forms 1099-R . 13 Forms 1099-MISC and 1099.G . 14 Schedules K-l . 15 Forms 1099-INT, OIV and 010 16 Social Security and Railroad Benefits. 17 Form 1099,B . St Loc - - 18 a Other withholding St Lac - b Other withholding St Lac - c Other withholding .. St Lac - - 19 Totai Withholding Lines 10 lhrough 18c 17,966. 4,198. 1,787. 20 Total T.x Payments for 2004 17,966. 4, 198. 1,787. Prior Year Taxes Paid In 2004 State 10 Local 10 (If multiple states or localities, see Tax Help) 21 Tax paid with 2003 extensions. 22 2003 estimated tax paid after 12/31103 - 23 Balance due paid with 2003 return . l. PA 24 Other (amended returns, installment payments, etc) - 1 'Federal Carryover Worksheet .... Keep fo~ your records 2004 Name(s) Shown on Return Linda L & Terrence M Thoman Social Security Number 208-58-2482 2003 State and Local Tax Information (See Tax Help) (a) (b) (c) (d) (e) (I) (9) State or Paid With Estimates Pd Total With- Paid With Total Over. Applied LocallD Extension After 12131 heldlPmts Return pavment Amount PA 3,490. l. Tot.ls. 3,490. l. Other Tax and Income Information 2003 2004 1 Filing status. 1 2 MFJ 2 MFJ - 2 Number of exemplions for blind or over 65 (0 . 4) . 2 3 Itemized deduclions after limitation. 3 14,898. 15,759. 4 Check box if required to itemize deduclions . 4 -LJ ~ 5 Adjusled gross income.. 5 116,964. 127,654. 6 Tax liability for Form 2210 or Form 2210.F . 6 13,239. 16,042. 7 Alternative minimum tax ........................... , 7 8 Federal overpayment applied to next year estimated tax. 8 IRA Information 2003 2004 9a Basis of Taxpayer's IRA(s) as of 12131 9a b Basis of Spouse's IRA(s) as of 12131 . b lOa Taxpayer's excess IRA contributions as of 12/31 10 a b Spouse's excess IRA contributions as of 12131 . b 11 a Taxpayer's excess Archer MSA conlributions as of 12131 11a b Spouse's excess Archer MSA contributions as of 12131 b 12a Taxpayer's excess Roth IRA contributions as of 12131 12a b Spouse's excess Roth IRA contributions as of 12131 b 13 a Taxpayer's excess Coverdell ESA contributions as of 12131 13a b Spouse's excess Coverdell ESA conlributions as of 12131 b 14a Taxpayer's excess HSA contributions as of 12131 14a b Spouse's excess HSA contributions as of 12131 . b Loss and Expense Carryovers 2003 2004 15a Short.term capital loss . 15. b AMT Short-term capital loss b 16 a Long,term capital loss 16a b AMT Long.term capital loss. b 17a Net operating loss available to carry forward. 17a b AMT Net operating loss available to carry forward b 18 a Investment interest expense disallowed ... 18a b AMT Investment interest expense disallowed. b 19 Nonrecaptured net Section 1231 losses from: a 2004. 19 a b 2003 . b c 2002 . c d 2001 d e 2000 . e f 1999 . f " Federal Carryover Worksheet pa_" 2 2004 Linda L & Terrence M Thoman Loss and Expense Carryovers (conl'd) 2003 2004 20 AMT Nonrecap'd net Sec 1231 losses from: a 2004. 20a b 2003. b c 2002. c d 2001 d e 2000. e I 1999. I Credit Carryovers 2003 2004 21 General business credit. 21 22 Adoption credit from: a 2004. 22a b 2003. b c 2002. c d 2001. d e 2000. e f 1999. I 23 Mortgage inlerest credit from: a 2004. 23a b 2003. b c 2002. c d 2001 . d . 24 Credit lor prior year minimum tax . . . . . . . . . . . . . . . . . . . . . . . ! . 24 25 District of Columbia first.time homebuyer credit. 25 26 Amount overpaid less earned income credit. 26 3,476. Other Carryovers 2003 2004 27 Section 179 expense deduction disallowed. 27 28 Excess a Taxpayer (Form 2555, line 44) .. 28a foreign b Taxpayer (Form 2555, line 46) b housing c Spouse (Form 2555, line 44) c deduction: d Spouse (Form 2555, line 46) d 208-58-2482 Charitable Contribution Carryovers 29 2003 Carryover of Other Property Capita' Gain charitable contributions from: (a) 50% (b) 30% (c) 30% (d) 20% a 2003 b 2002 c 2001 d 2000 e 1999 . 30 2004 Carryover of Other Property Capital Gain charitable contribulions from: (a) 50% (b) 30% (c) 30% (d) 20% a 2004 . b 2003 c 2002 .. d 2001 e 2000 Linda L & Terrence M Thoman ~, Schedule A Line 16, Noncash Contributions 208.58-2482 DoneelDescription Amount Salvation Army Food Bank of Central Pa 232.50 25.00 Tolal 257.50 ...-'> " -, Linda L & Terrence M Thoman 212 April Drive Camp Hill, PA 17011 2003 U.S. INDIVIDUAL INCOME TAX RETURN SUMMARY Adjusted Gross Income Taxable Income Total Tax Total Payments Refund Effective Tax Rate $ $ $ $ $ 116,964 89,866 13.239 16,715 3,476 11. 32 % INSTRUCTIONS FOR FILING YOUR RETURN ELECTRONICALLY If you file electronically, make sure to follow the Electronic Filing Instructions to complete your tax return. Come back to TurboTax in 24 to 48 hours to check the status of your return. TurboTax will let you know if your return has been accepted or rejected by the IRS. If the IRS accepts your tax return, 1urboTax will walk you through the final steps of electronic filing. It may'involve printing and mailing some electronic filing forms. (DO NOT mail a printed copy of your tax return to the IRS. They already received an electronic copy of your tax return.) If your return is rejected due to an error, you have two options. You must fix the error and retransmit your return electronically, or you can mail a printed copy of your return to the IRS. To mail your printed return, follow the mailing instructions below. INSTRUCTIONS FOR FILING YOUR RETURN BY MAIL Your federal Form 1040 shows a refund of $3,476. Please mail your return to the following IRS address postmarked by Thursday, April 15, 2004 Internal Revenue Service Center Philadelphia. PA 19255-0002 Be sure to sign and date your return and include the proper amount of postage on the envelope. ATTACHMENTS Attach the first copy or Copy B of Form(s) W-2 to the front of your Form 1040. KEEP THIS PAGE FOR YOUR RECORDS -- DO NOT MAIL. , .' ') Form 1 040 Department of the Treasury - Internal Revenue Service 2003 \ (99) U.S. Individual Income Tax Return IRS Use Only Do not write or staple in this space For the year Jan 1. Dee 31, 2003, or other tax year beginning ,2003, ending ,20 OMB No. 1545.0074 Your/irstname MI last name Yoursodalsecuritynumber Label (See instructions.) Linda L Thoman 208-58-2482 If a joint return, spouse's tirst name MI Last name Spouse's social security number Use the M Thoman 200-46-0343 tRS label. Terrence Otherwise, Home address (number and street). If you halle a P.O. box, see instructions. Apartment no. A Important! A please print 212 Ao r il Drive You must enter your social or type. City. town or post of lice. II you hal/ea foreign address, see instructions. Slate ZIP code security number(s) above. Presi?ential Camo Hi II PA 17011 You Spouse lrrrr... Note: Checking 'Yes' will not change your tax or reduce your refund. ,.. Do OU, or our spouse If fllin a JOint return, want $3 to 0 to thiS fund? ... Yes X No Yes X No 1 Single 4 He.d of household (with qualifying person). (See instructions.) If the qualifying person is a child 2 X Married filing jointly (even jf only one had income) but not your dependent, enter this child's 3 Married filing separately. Enter spouse's SSN above & full name here ... name here.. ... 5 Qualifying widow(er) with dependent child. (See instructions.) 6a X Yourself. If your parent (or someone else) can claim you as a dependent on his or 1- No.o~boxes her tax return, do not check box 6a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~~~~de~bon. . . b X Souse ....- ~hii~:en (2) Dependent's (3) Dependent's (4) "if on 6c who: social security relationship qualiFying. lived number to you Cht~d~ f~;e~7tld with you .. (see instrs) . did not live with you due to divorce or separation (seelnstrs)... Add numbers ..I 41 d Total number of exemptions claimed. on lines ~ .. above..... 7 Wages, salaries, tips, etc. Attach Form(s) W.2 ..... 7 116,922. Income 8a Taxable interest. Attach Schedule B if required 8a 26. .... ... ......I...;j... b Tax-exempt interest. Do not include on line 8a .... 8b Attach Forms 9a Ordinary dividends. Attach Schedule B if required 9. 16. W-2 .nd W-2G b Qualified dividends (see instructions) I 9bl here. Also attach Form(s) 1099-R if 10 Taxable refunds, credits, or offsets of state and local income taxes (see instructions) . 10 tax was withheld. 11 Alimony received 11 12 Business income or (loss). Attach Schedule C or C-EZ 12 If you did not 13 a Capital gain or (loss). Att Sch 0 if reqd. If not reqd, ck here. ~O 13a get a W.2, see b If box on 13a is checked, enter post. May 5 capital gain distributions. .113bl instructions. 14 Other gains or (losses). Attach Form 4797 14 15a IRA distributions. .... .~ I: Taxable amount (see instrs) . 15b 16a Pensions and annuities.... 16a Taxable amount (see instrs) . . 16b 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E. 17 Enclose, but do 18 Farm income or (loss). Attach Schedule F 18 not attach, any 19 Unemployment compensation. 19 pay~ent. Also, 20 a Social security benefits . , . " . . " ..1 20 a I I b Taxable amount (see instrs) . 20b please use Form 1040-V. 21 Other income 21 22 Add the am~unts ~ the far-ri(;ht Zo~mn-f;r line; ithrou~h-21, Thisis-vou~ ~blin~o-m~ ~ 22 116.964. Adjusted 23 Educator expenses (see instructions) 23 Gross 24 IRA deduction (see instructions) .. 24 Income 25 Student loan interest deduction (see instructions) . . . 25 26 Tuition and fees deduction (see instructions) 26 27 Moving expenses. Attach Form 3903 27 28 One-half of self-employment tax. Attach Schedule SE 28 29 Self-employed health insurance deduction (see instrs) .. . .... 29 30 Self-employed SEP, SIMPLE, and qualified plans. 30 31 Penalty on early withdrawal of savings 31 32a Alimony paid b Recipient's SSN .. . ~ 32a 33 Add lines 23 through 32a 33 34 Subtract line 33 from line 22. This is your adjusted gross income. " ~ 34 116,964. ElectIon Campaign (See instructions.) Filing Status Check only one box. Exemptions c Dependents: (1) First name Nicole L Thoman Ka la L Thoman Last name Dependents on 6c not entered above . 193-72-7002 161-78-9261 Dau Dau hter hter If more than five dependents, see instructions. n 2 2 BAA For Disclosure, Privacy Act, and Papef'Nork Reduction Act NotIce, see Instructions. FDIA0112 10/17/03 Form 1040 (2003) Form 1040 (2003) Linda L & 1erre. " M 1homan 20 -58-2482 Paoe 2 Tax and 35 Amount from line 34 (adjusted gross income) ........... ....... 35 116,964. Credits 36a Check {8 You were born before January 2, 1939, 8 Blind. Total boxes 36a[ if: Spouse was born before January 2, 1939, Blind. checked ~ Standard b If you are married filing separately and yourspouse itemizes deductions, 36b 0 Deduction or you were a dual-status alien, see instructions and check here.. . . . . . . . ~ for - ~37 Itemized deductions (from Schedule A) or your standard deduction (see left margin) . . 37 14,898. . People who checked any box 38 Subtract line 37 from line 35 . 38 102,066. on line 36a or 39 If line 35 is $104,625 or less, multipl~ $3,050 by the total number of exemptions claimed 36b or who can 39 12,200. be claimed as a on line 6d. If line 35 is over $104,62 , see the worksheet in the instructions............. dependent. see 40 Taxable income. Subtract line 39 from line 38. 40 89,866. instructions. If line 39 is more than line 38,enter.0- 41 Tax (see instrs). Check if any tax is from a 0 Form(s} 8814 b 0 Form 4972 . ..... 41 16,089. . All others: 42 Alternative minimum tax (see instructions). Attach Form 6251 42 Single or Married filing separately, 43 Add lines 41 and 42.. ~ 43 16,089. $4,750 44 Foreign tax credit. Attach Form 1116 if required. . 44 Married filing 45 Credit for child and dependent care expenses. Attach Form 2441 45 1.200. jointly or 46 Credit for the elderly or the disabled. Attach Schedule R . . 46 QualifYing widow(er), 47 Education credits. Attach Form 8863 . 47 $9,500 48 Retirement savings contributions credit. Attach Form 8880 . 48 Head of 49 Child tax credit (see instructions) 49 1. 650. household, 50 Adoption credit. Attach Form 8839 . . . . .. . 50 $7,000 51 Credits from: a 0 Form 8396 b 0 Form 8859 . . . . . . . . . . . . . 51 52 Other credits. Check applicable box(es): a 0 Form 3800 b 0 Form c DSpecify 52 8801 2,850. 53 Add lines 44 through 52-. These are your total credits. 53 54 Subtract line 53 from line 43. If line 53 is more than line 43, enter -0- ~ 54 13,239. 55 Self. employment tax. Attach Schedule SE . 55 Other 56 Social security and Medicare tax on tip income not reported to employer. Attach Form 4137 . 56 Taxes 57 Tax on qualified plans, including IRAs, and other tax.fa1Jored accounts. Attach Form 5329 if required.. 57 58 Advance earned income credit payments from Form(s) W.2 . 58 59 Household employment taxes. Attach Schedule H 59 60 Add lines 54.59. This is your total tax ~ 60 13,239. Payments 61 Federal income tax withheld from Forms W.2 and 1099. 61 16,715. If you have a L 62 2003 estimated lax payments and amount applied from 2002 return. . 62 qualifying 63 Earned income credit (EIC) ...... ... 63 child, attach I 64 Excess social security and tier 1 RRTA tax withheld (see instructions) 64 Schedule EIC. 65 Additional child tax credit. Attach Form 8812. . 65 66 Amount paid with request for extension tofHe (see instructions) .. 66 67 Other pmts from: a 0 Form 2439 b 0 Form 4136 c o Form 8885 67 68 Add lines 61 through 67. These are your total payments. ~ 68 16,715. Refund 69 If line 68 is more than line 60, subtract line 60 from line 58. This is the amount you overpaid . 69 3,476. Direct deposit? 70a Amount of line 69 you want refunded to you. ~ 70. 3,476. See instructions . b Routing number. 231381116 .. c Type: [g] Checking o Savings and fill in 70b, .. d Account number 0450454558 70c, .nd 70d. .. ~I 71 I 71 Amount of line 69 you want applied to your 2004 estimated tax. Amount 72 Amount you owe. Subtract line 68 from line 60. For details on how to pay, see instructions ~ 72 You Owe 73 Estimated tax penalty (see instructions) . 173 I 8 Sign Here 00 you want to allow another person to diSCUSS this return with the IRS (see instructions)? 0 Yes. Complete the following. [ZJ No Designee's Pho.ne Perso.nal identification name .. no. .. number (PIN) .. Under penalties af perjury, I declare that I have examined this return and accompanying schedules and statements, ar,d to. the best o~ my kno.wledge and belief, they are true, correct. and complete. Declaration o~ preparer (ather than tax;Jayer) IS based an all Informatlan af which preparer has any knawledge. Third Party Designee Joint return? Your signat:..;re Date Your occupation Daytime phane number See instructions. ~ Finance Keep a copy Spouse's signature. If a joint return. both must sign. Date Spouse's occupatian for your records. ~ Com uter Analvst Preparer's I Date Check if self.employed n Preparer"s SSN or ~T1N Paid signature ~ Preparer's Firm's name 5elf-preoared Use Only (aryouIsif ~ self.employed), EIN addresS,a...d ZIP code Phone no. Form 1040 (2003) FDIAOl12 10/17;'03 SCHEDULE A OMS No. 1545-0074 Itemized Deductions (Form 1040) 2003 ~ Attach to Form 1040. 07 Department of the Treasury ... See Instructions for Schedule A (Form 1040). Internal Revenue Service (99) Name(s) shown on Form 1040 I Your social security number Linda L & Terrence M Thoman 208-58-2482 Medical Caution. Do not include expenses reimbursed or paid by others. and 1 Medical and dental expenses (see instructions) ..... O. 1 Dental 2 Enter amount from form 1040, line 35. . . . . .1 2 \ Expenses 3 Multiply line 2 by 7.5% (.075) 3 4 Subtract line 3 from line 1. If line 3 is more than line 1, enter .0. . . 4 Taxes You 5 State and local income taxes 5 6,235. Paid 6 Real estate taxes (see instructions) 6 2,015. 7 Personal property taxes . .... .... 7 1.680. (See instructions.) 8 Other taxes. list type and amount ... ------------ 8 ----------- ------------------- 9 9.930. 9 Add lines 5 through 8 .. Interest 10 Home mtg interest and points reported to you on Form 1098... 10 4.104. You Paid 11 Home mortgage interest not reported to you on Form 1098. If paid to the person from whom you bought the home, see instructions and show that person's name, identifying number, and address ... (See ------------------------------- instructions.) ------------------------------- ------------------------------- Note. 11 ------------------------------ Personal 12 Points not reported to you on Form 1098. See instrs for spcl rules 12 46. interest is 13 Investment interest. Attach Form 4952 if required. not deductible. (See instrs.) .... ....,... 13 14 Add lines 10 through 13 . . .... ........ 14 4,150. Gifts to 15 Gifts by cash or check. If you made any gift of $250 or more, Charity see instructions. 15 743. \ f you made 16 Other than by cash or check. If any gift of $250 OF a gift and more, see instructions. You must attach Form 8283 if got a benefit over $500 16 75. for it. see instructions. 17 Carryover from prior year . 17 18 Add lines 15 throunh 17 .. 18 818. Casualty and Theft Losses 19 Casual tv or theft loss(es). Attach Form 4684. (See instructions.) 19 Job Expenses 20 Un reimbursed employee expenses - job travel, union dues, and Most job educ.tion, etc. Att.ch Form 2106 or 21 06.EZ if Other Miscellaneous required. (See instructions.) . Deductions --------------- ------------------------------- 20 ------------------------------ 21 Tax preparation fees 21 (See 22 Other expenses - investment, safe deposit box, etc. List instructions.) type and amount . -------------------- ~i~~1~~~~~_~2~~~~___________J~. 22 79. 23 Add lines 20 through 22 23 79. 24 Enter amount from Form 1040, line 35 I 24 I 116,964. 25 Multiply line 24 by 2% (.02) 25 2.339. 26 Subtract line 25 from line 23. If line 25 is more than line 23,. enter .0. 26 O. Other 27 Other - from list in the instructions. list type and amount ... Miscellaneous ---------------- Deductions -------------------------------------------- 27 Total 28 Is Form 1040, line 35, over $139,500 (over $69,750 if MFS)? Itemized Deductions I2J No. Your deduction is not limited. Add the amounts in the far right column -~ for lines 4 through 27. Also, enter this amount on Form 1040, line 37. . 28 14,898. DYes. Your deduction may be limited. See instructions for the amount to enter. "\ BAA For Paperwork Reduction Act Notice, see Form 1040 instructions. FDIA0301 10/16/03 Schedule A (Form 1040) 2003 Form 2441 ") c. ..,a ana Depenaent Care Expense~ OMS No. 1545-0068 Department of the Treasury Internal Revenue Service (99) Name(s) shown on Form 1040 ~ Attach to Form 1040. ~ See separate instructions. 2003 21 Youfsocialsecuritynumber Linda L & Terrence M 1homan 208-58-2482 Before you begin: You need to understand the following terms. See Definitions in the instructions. . Dependent Care Benefits . Qualifying Person(s) . Qualified Expenses . Earned Income Persons or Organizations Who Provided the Care - You must complete this part. (If you need more space, use the bottom of page 2.) 1 (a) Care provider's name (b) Address (c) Identifying no. (d) Amount paid (no., street, apt no., city, state, and ZIP code) (SSN or EIN) (see instructions) Tender Loving Care J~Q. "?Ll.9b~s_ ~f!.u..r"f!. J.e!- - - - -- Learnin~ Center Camo Hill PA 23-2182402 7,275.00 See Additional Child Care Providers 1----------------------- 1.907.00 Did you receive dependent care benefits? No Yes ~ Complete only Part II below. ~ Complete Part III on page 2 next. Caution. If the care was provided in your home, you may owe employment taxes. See the instructions for Form 1040, line 59. I Part 11 I Credit for Child and Dependent Care Expenses 2 Information about your Qualifying person(s). If yOU have more than two qualifvinc oersons, see the instructions. (a) Qualifying person's name (b) Qualifying person's social (c) Qualified , security number expenses you incurred and paid in 2003 for the person First Last listed in column (a) Nicole 11homan 193-72-7002 1. 907 . Kavla IThoman 161-78-9261 7,275. 3 Add the amounts in column (c) of line 2. Do not enter more than $3,000 for one qualifying person or $6,000 for two or more persons. If you completed Part III, enter the amount from line 26 . 3 6,000. 4 Enter your earned income . 4 65,859. 5 \f married filing jointly, enter your spouse's earned income (if your spouse was a student or was disabled, see the instructions); all others, enter the amount from line 4 .......... 5 51,062. 6 Enter the smallest of line 3, 4, or 5. 6 6,000. 7 Enter the amount from Form 1040, line 35 . I 7 I 116,964. 8 Enter on line 8 the decimal amount shown below that applies to the amount on line 7 If line 7 is: If line 7 is: But not Decimal But not Decimal Over over amount is Over over amount is $0- 15,000 .35 $29,000- 31,000 .27 15,000- 17,000 .34 31,000- 33,000 .26 17,000- 19,000 .33 33,000- 35,000 .25 X 0.20 19,000- 21,000 .32 35,OQO- 37,000 .24 8 21,000- 23,000 .31 37,000- 39,000 .23 23,000 - 25,000 .30 39,000 - 41,000 .22 25,000- 27,000 .29 41,000 - 43,000 .21 27,000 - 29.000 .28 43,000 - No limit .20 9 Multiply line 6 by the decimal amount on line 8. If you paid 2002 expenses in 2003, see the instructions. 9 1. 200. 10 Enter the amount from Form 1040, line 43, minus any amount on Form 1040, line 44 10 16,089. 11 Credit for child and dependent care expenses. Enter the smaller of line 9 or line 10 here and on Form 1040. line 45 .......,...."..,..,.,......."..,..,..."."..... 11 1,200. BAA For PaperNork Reduction Act Notice, see separate instructions. FDIA3212 10130103 Form 2441 (2003) Linda L & Terrence M Thoman ) Form 2441 Additional Child Care Providers 208-58.2482 1 (a) (b) (e) (d) Care provider's name Address Identifying Amount (number, street, apt no., number paid city, state, and ZIP Code) (SSN or EIN) ------------------- ------------------. J:b i.Jji~.n.?_ t;,e.!',!~r_ _ _ _ - -. ~~~~iJl~~e~~~13sb~~. Camp Hi 11 PA 25-1569477 1,907.00 Total 1,907.00 Linda L & Terrence M 1 man 212 April Drive. Camp Hill, PA 17011 2003 PENNSYLVANIA INDIVIDUAL INCOME TAX RETURN SUMMARY Taxable Income 10tal Tax Total Payments/Credits No Refund or Amount Due $ $ $ $ 124.665.00 3,491.00 3.490.00 0.00 INSTRUCTIONS FOR ELECTRONICALLY FILING YOUR RETURN If you are filing your return electronically, make sure you come back to 1urboTax in 24 to 48 hours to check the status of your return. You will receive instructions at that time on how to complete the electronic filing process. Follow those instructions. IMPORTAN1: DO NOT taxing authority. tax return. mail a copy of your tax return to the state They already received an electronic copy of your INSTRUCTIONS FOR MAILING YOUR RETURN (NOT FOR USERS WHO FILE ELECTRONICALLY) Your Pennsylvania Form PA-40 shows no tax due or refund. The Pennsylvania Dept. of Revenue does not require that you pay a balance due of $1.00 or less. You may file the return without Form PA-V and payment if you wish. Be sure-to mail all pages of your return along with any required attachments. please mail your return to the following address by April 15, 2004: PENNSYLVANIA DEPARTMENT OF REVENUE NO PAYMENT/NO REFUND 2 REVENUE PLACE HARRISBURG. PA 17129-0002 Be sure to sign and date your return and include the proper amount of postage on the envelope. INSTRUCTIONS FOR SPECIAL FORMATTING Your printed state tax forms may look different than what you're used to seeing. Some states require us to include special formatting, such as bar codes, on computer-printed tax forms. This special formatting allows your state to process your return much more quickly and efficiently. If your state return has this special formatting, don't worry. Your forms are completely approved by your state taxing authority. Simply mail your state return to the address shown above. Page I KEEP THIS PAGE FOR YOUR RECORDS -- DO NOT MAIL. ~ ) 0300117108 .~ PA-40 - 2003 Pennsylvania Income Tax Return ENTER ONE LETTER OR NUMBER IN EACH BOX Do Not Use Your Preprinted Label 208582482 200460343 N THOMAN N LINDA L FINANCE R Occupation TERRENCE M COMPUTER A Occupation THOMAN 212 APRIL DRIVE CAMP HILL PA 17011 21100 1 a Gross Compensation. Do not include exempt income, such as combat zone pay and qualifying retirement benefits. See the instructions. 1 b Unreimbursed Employee Business Expenses. 1 c Net Compensation. Subtract Line 1 b from Line 1 a. 2 Interest Income. Complete and submit PA Schedule A, if over $2,500. 3 Dividend Income. Complete and submit PA Schedule B, if over $2,500. 4 Net Income or Loss from the Operation of a Business, Profession, or Farm. LOSS LOSS LOSS 5 Net Gain or Loss from the Sale, Exchange, or Disposition of Property. 6 Net Income or Loss from Rents, Royalties, Patents, or Copyrights. 7 Estate or Trust Income. Complete and submit PA Schedule J. 8 - Gambling and Lottery Winnings. 9 Total Pennsylvania Taxable Income. Add only the positive income amounts from Lines 1 c, 2, 3,4, 5, 6, 7, and 8. 00 NOT ADD any losses reported on lines 4, 5, or 6. 10 Medical Savings Account. CAUTION, 00 not deduct medical expenses or insurance. See the instructions, " 11 Adjusted Pennsylvania Taxable Income. Subtract line 10 from Line 9. PAIAC412 01107104 [iJ EC L ITJ~ITJ 0300117108 J N L Extension. Amended Return. Residency Status. PA ResidentlNonresidenVPart.Year Resident: from to Single/Married, Filing Jointly/Married, Filing Separately Final Return/Deceased Date of Death Farmers. 1a 124623 1b 0 1c 124623 2 26 3 16 4 0 5 0 6 0 7 0 8 0 9 124665 10 0 11 124665 FC 0300117108 -.J 1 0300217106 .-I PA-40 - 20'03 Social Security Number 208582482 Name(s): Linda L Thoman 12 Pennsylvania Tax Liability. Multiply line 11 by the rate shown on the Form PA-V instructions. 13 Total Pennsylvania Tax Withheld. See the instructions. 14 Credit from your 2002 Pennsylvania Income Tax Return. 15 2003 Estimated Installment Payments. 16 2003 Extension Payment. 17 Nonresident Tax Withheld from your PA Schedule(s) NRK-'. (Nonresidents only) 18 Total Estimated Payments and Credits. Add Lines 14, 15, 16, and 17. TAX BACKfTax Forgiveness Credit. 19a Filing Status: 01 Unmarried or Separated 02 Married 03 Deceased 19b Dependents, Part B, Line 2, PA Schedule SP 20 Total Eligibility Income from Part C, Line 11, PA Schedule SP. 21 TAX BACKfTax Forgiveness Credit from Part 0, Line 16, PA Schedule SP. 22 Resident Credit. Submit your PA Schedule(s) G and/or RK.1. 23 Total Other Credits. Submit your PA Schedule ac. 24 TOTAL PAYMENTS and CREDITS. Add Lines 13 and 18,21,22, and 23. 25 TAX DUE. If Line 12 is more than Line 24, enter the difference here. 26 Penalties and Interest. See the instructions. 27 TOTAL PAYMENT. Add Lines 25 and 26. 28 OVERPAYMENT. If Line 24 is more than the total of Line 12 and Line 26. enter the difference here. The total of Lines 29 through 35 must equal Line 28. 29 Refund - Amount of Line 28 you want as a check mailed to you. Refund 30 Credit - Amount of Line 28 you want as a credit to your 2004 estimated account. 31 Amount of Line 28 you want to donate to the Wild Resource Conservation Fund. 32 Amount of Line 28 you want to donate to the United States Olympic Committee. 33 Amount of Line 28 you want to donate to the Governor Robert P. Casey Memorial Organ and Tissue Donation Awareness Trust Fund. 34 Amount of Line 28 you want to donate to the KoreaNietnam Memorial, Inc. 35 Amount of Line 28 you want to donate to Breast and Cervical Cancer Research Fund. Your Signature Date Spouse's Sign~ture. if filing jointly L 12 13 14 15 16 17 18 19a 19b 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 3491 3490 o o o o o 00 00 o o o o 3490 1 o 1 o o o o o o o o Preparer or Company Name. other than taxpayer(s), based on all information of which the preparer has any knowledge. (Please Print) Self-Prepared [0'1' PAIA0412 01107/04 L 0300217106 Date I Peop,," 1,I'pho", oemb" 0300217106 .-I .- --.J 0301910014 WAGE STATEMENT ~~~~(e~)Y 2003 OFFICIAL USE ONLY Social Security Number (shown first) Name shown firs! on the PA-40 (e....en if filing jointly) Linda L Thoman 208-58-2482 See the instructions to determine if you may use this schedule for your Form(s) W-2. Do not submit your For.m(s) W-2 if using this schedule. Enter the required information from each Form W.2. Keep your original forms. IMPORTANT: Your Pennsylvania and federal compensation may be different. CAUTION: Do not use this schedule if: (1) your Formes) W.2 shows that you earned income in another state; or (2) you believe an amount on your Formes) W.2 is incorrect; or (3) your employer withheld Pennsylvania income tax at more than the 2003 tax rate. If any of these circumstances apply, you must submit legible photocopies of your actual Form(s) W-2. If you have compensation from forms other than Form(s) W-2, complete PA Schedule Me Miscellaneous Compensation below. Number of Form(s) W-2 2 If you need more space, you may photocopy this schedule or prepare your own schedule in this format. If Married Filina Jointlv: Indicate whether the Forms W-2 are for the Drimar taxoaver (T) listed first on the PA-40 or the soouse (S). (a) (b) (e) (d) TIS EIN from box b Federal wages from box 1 Pennsylvania compensation Pennsylvania tax from box 16 withheld from box 17 T 23-2465952 65859 70842 1984 5 23-1433882 51062 53781 1506 Totals. Add the amounts in column (c), and include on Line 1 a of your PA-40. Add the amounts in column (d), and include on Line 13 $ 124623 $ of Your PA-40 ................................................... 3490 PA-40 Me (09.03) Caution: The Department reserves the right to request your actual W-2 and 1099 forms. MISCELLANEOUS COMPENSATION 2003 Name shown first on the PA-40 (even if filing jointly) Socia) Security Number (shown first) See the instructions. Enter the required information from each form or statement. Important: Your federal wages and Pennsylvania taxable compensation may be different. Enter only your Pennsylvania amounts. Caution: If a Pennsylvania amount on a form is incorrect, you must submit the actual form with an explanation. If Married, Filina Jointlv: Indicate whether the Forms 1099 are for the r rimarv taxQaver en listed first on the PA-40 or the SDouse (S). (a) (b) (e) (d) (e) TIS Payer EIN or SSN, and Payer Name co:'ii Pennsylvania Taxable Pennsylvania Tax Federal Taxable lrgnr 1St ". Compensation Withheld Income Totals. Add the amounts in column (c), and include on Line 1a of yourPA-40. Add the $ $ amounts in column (d), and Include on Line 13 ofyourPA-40 . ,............... _, CODES: A Executor fee B Jury duty pay E Honorarium F Covenant not to compete H Other nonemployee compensation. Describe: I Early distribution from retirement or pension plan. C Director fee D Expert witness fee G Damages or settlement for lost wages, other than personal injury L 0301910014 PAIA06JI 09129103 0301910014 --.J Terrence M. Thoman Linda L. Thoman 212 April Drive Camp Hill PA 17011 4285 Your Loan Number: 0004574732 Pate: 10/19/04 Annual Escrow Account Disclosure Statement - Last Cycles Escrow Account History This is a statement of your actual escrow account transactions beginning November.2003 and ending November. 2004. Next to the actual activity is the anticipated activity. Anticipated activity represents the transactions we had projected as occurring during this cycle. We are providing it to you for information purposes. It does not require any action on your part. ----- Past Year Payment Breakdown _____ P&I ESCROW 01 SCRETIONARY SUBSIDY TOTAL 615.38 203.73 0.00 0.00 819.11 -- Payments to Escrow -- -- Payments from Escrow -- n Escrow Balance -- Month Anticipated Actual Anticipated Description Actual Description Anticipated Actual Starting Balance ===> 1018.64 907.15 Nov 0.00 . 194.41 0.00 *SURPL REF 82.92 SURPL REF 1018.64 1018.64 Dee 203.73 203.73 0.00 0.00 1222.37 1222.37 Jan 203.73 203.73 543.00 HAZARD INS 0.00 HAZARD INS 883.10 1426.10 Feb 203.73 203.73 0.00 0.00 1086.83 1629.83 M.r 203.73 203.73 0.00 0.00 1290.56 1833.56 Apr 203.73 203.73 0.00 *80ROUGH TX 525.68 BOROUGH TX 992.46 1511. 61 501.83 BOROUGH TX 0.00 BOROUGH TX May 203.73 203.73 0.00 0.00 1196.19 1715.34 Jun 203.73 203.73 0.00 0.00 1399.92 1919.07 Jul 203.73 203.73 0.00 0.00 1603.65 2122.80 Aug 203.73 203.73 0.00 *SCHDOL TAX 1498.58 SCHOOL TAX 407.46 TLP 827.95 ALP 1399.92 SCHOOL TAX 0.00 SCHOOL TAX Sep 203.73 203.73 0.00 0.00 611. 19 1031.68 Oet 203 . 73 203.73 0.00 0.00 814.92 1235.41 Nov 203.73 203.73 E 0.00 0.00 1018.65 1439.14 TOT 2444.76 2639.17 2444.75 2107.18 Under Federal law, when your actual escrow balance reaches its lowest point, that balance is targeted not to exceed 1/6th of the annual anticipated disbursements or $407.46. Your loan documents or state law may specify a lower amount. Under your mortgage contract or State or Federal law. your Targeted Low Point escrow balance (TLP) was $407.46. your Actual Low Paint escrow balance (ALP) was $827.95. By comparing the anticipated escrow transactions with the actual transactions you can determine where a difference may have occurred. An asterisk (*) indicates a difference in either the amount or date of our anticipated disbursements and the actual disbursements. The letter E beside an amount indicates that the payment or disbursement has not yet occurred but is estimated to occur as shown. AMERICAN HOME MORTGAGE SERVICING 7142 COLUMBIA GATEWAY DRIVE PO BOX 3050 COLUMBIA MO 21045-6050 1-800-444-7963 4285 Page 1 of Your Loan Number: 0004574732 Terrence M. Thoman Linda L. Thoman 212 April Drive Camp Hi 1 1 PA 17011 Date: 10/19/04 Annual Escrow Account Disclosure Statement - Pro iections Please review this statement closely - Your mortgage payment may be affected. This statement tells you of any changes in your mortgage payment, any surplus refunds, or any shortage or deficiency that you must pay. It also shows you the anticipated escrow activity for your escrow cycle beginning Oecember,2004-and ending November, 2005. Ant;c;pated HAZARD INS BOROUGH TX SCHOOL TAX Payments From Escrow 619.00 525.68 1,498.58 TOTA L Periodic Payment to Escrow 2.643.26 220. 27 (i/12 of "Total from Escrow") Ant;cipated Escrow Activity - December. 2004 throuQh November.2005 Ant;c;pated Payments -- -- Escrow Balance Compar;son Month to Escrow from Escrow Description Antic;pated Required Actual starting balance ===> 1,439. i4 1,101.37 Dec,04 220.27 0.00 1,659.41 1,321.64 0an,05 220.27 619.00 HAZARD INS 1,260.68 922.91 Feb,05 220.27 0.00 1,480.95 1,143.18 Mar,05 220.27 0.00 1,701.22 1,363.45 Apr,05 220.27 525.68 BOROUGH TX 1,395.81 1,058.04 May,05 220.27 0.00 1,616.08 1.278.31 Jun,05 220.27 0.00 1.836.35 1.498.58 uul,05 220.27 0.00 2,056.62 1.718.85 Aug,05 220.27 1,498.58 SCHOOL TAX 778.31 ALP 440.54 RLP Sep,05 220.27 0.00 998.58 660.81 Dc t ,05 220.27 0.00 1,218.85 881.08 Nov,05 220.27 0.00 1,439.12 1,101.35 DetermtninQ Your Required Escrow Balance If the Anticipated Low Point balance (ALP) is greater than the Required Low Point balance (RLP), then you have an escrow surplus.... your escrow surplus is.... 337.77 Federal law requires any surplus of $50.00 or more be automatically refunded to you. Borrower payment Calculations of Your New P&I ESCROW PISCRETIONARY starting with the payment due Payment Amount 615.38 * 220.27 0.00 12/01/04 -=> 835.65 If your loan is an adjustable rate mortgage, the principal & interest portion of your payment may change within this cycle in accordance with your loan documents. Note: Your escrow balance may contain a cushion. A cushion is an amount of money held in YOUr escrow account to prevent your escrow balance from being overdrawn when ;ncreases in the disbursements occur. Federal law authorizes a maximum escrow cushion not to exceed 1/6th of the total annual anticipated escrow disbursements made during the above cycle. Your loan documents or state law may require a lesser cushion. When your escrow balance reaches its lowest point during the above cycle, that balance is targeted to be your cushion amount. Your escrow cushion for this cycle 15 $440.54. * (See Reverse Side) c000230 00002GEOI4 SUR P L U S Account Number: 0004574732 Customer Name: Terrence M. Thoman Linda L. Thoman Surplus Amount: $337.77 THIS IS NOT A CHECK If your escrow surplus is $10.00 or more, your refund check will be mailed to you within 30 days. .---- ::OMMONWEAL'rn LAND TITLE INSURANCE COMPANY Settlement Statement e of Loan U.S. Department of Housing and Urban Development OMS No. 2502-0265 L Title Insurance No. D325015CP ::.Note: This shown. Items the totals. D.Name and Address 3. [Xl Conv. Unins. I 6. File Number I 7. Loan Number Conv. Ins. 04574732 form is fUrnished to give you a statement of actual settlement costs. Amounts paid to marked" (p.o.c)" were paid outside the Closing; they are shown here for informational of Borrower a.Mortgage Insurance Case No. IE.Name and Address of Seller and by the settlement agent are purpOses and are not included in Terrence M. Thoman and Linda L. Thoman IF.Name and Address of Lender )Columbia National Incorporated /6 Commerce Drive I Cranford, NJ 07016 G.Property Location 212 April Drive Camp Hill, PA 17011 Cumberland Count J. SUMMARy OF BORROWER'S TRANSACTION 100. GROSS AMOUNT DUE FROM BORROWER: LOl.Contract sales price L02.Personal property L03.Settlement charges to borrower (line 1400) L04.Payoff-Columbia National Incorporated FA 3674.00 64317.19 Adiustments for items aid b seller in advance L06.City/town taxes to c07.County taxes to 120. GROSS AMOUNT DUE FROM BORROWER 200. AMOUNTS PAID BY OR IN BEHALF OF BORROWER 201.Deposit of earnest money 202.Principal amount of new loan(s) 203.Existing loan(s) 204. 67991.19 69000.00 Adiustments for items un aid b seller !10.City/town taxes to 211.County taxes to 220. TOTAL PAID BY/FOR BORROWER 300. TOTAL AT SETTLEMENT FROM/TO BORROWER J01.Gross amount due from borrower (line 120) 302.Less amounts aid b Ifor borrower (line 220) 303. CASH ([ ] FROM) ([XX] TO) BORROWER 69000.00 67991.19 69000.00 1,008.81 H.Settlement Agent COMMONWEALTH LAND TITLE INSURANCE COMPANY Place of Settlement 17 SOUTH MARKET SQ. SUITE 2-A, HARRISBURG, PA 17101 Linda K. Trivel LKT K. SUMMARY OF SELLER'S TRANSACTION 400. GROSS AMOUNT DUE TO SELLER 401:Contract sales price 402.Personal property 403. 404. II.Settlement Date ) February 4, 2002 I Disbursement Date Februa 8 2002 Adiustments for items aid b seller in adVance -406.City/town taxes to 407.County taxes to 420. GROSS AMOUNT DUE TO SELLER 500. REDUCTIONS IN AMOUNT DUE TO SELLER SOl.Excess deposit (see instructions) S02.Settlement charges to seller (line 1400) 503.Existing loan(s) 504. Adiustments for items un aid b 510.City/town taxes 511.County taxes seller to to 520. TOTAL REDUCTION AMOUNT DUE SELLER 600. CASH AT SETTLEMENT TO FROM SELLER 601.Gross amount due to seller (line 420) 602.Less reductions in amount due seller {line 520) 603. CASH (( J TO) ([ 1 FROM) SELLER ;;-aRM 913 (4-88) HUn-I (3-86) RESPA, H8420S-2 D325015CP L. SETTLEMENT CHARGES Paqe 2 of Form Approved OMS No. PAID FROM BORROWER'S FUNDS AT SETTLEMENT . 2502-0265 PAID FROM SELLER'S FONDS AT SETrLEMENT 700. TOTAL SALES/BROKER'S COMMISSION based on rice $ Division of commission(line 700) as follows: 701. $ to 702.$ to 703.Commission Paid at Settlement 704. to 800. ITEMS PAYABLE IN CONNECTION WITH LOAN BOl.Loan Origination Fee a02.Loan Discount a03.Appraisal Fee S04.Credit Report a05.Lender's Inspection Fee aOS.Flood Certificate a09.DOucumentation Prep/Review SlO.Underwriting Fee Sll.Tax Related Service Fee 812. Courier Fee S13.Application Fee 1.000 t to Columbia National Incorporated . to 690.00 to to to to Columbia National Incorporated 13.00 to Columbia National Incorporated 225.00 to Columbia National Incorporated 21.00 to Columbia National Incorporated 54.00 to Columbia National Incorporated 30.00 to Columbia National Incorporated [POC $350.00] 900. ITEMS RE OIRED BY LENDER TO BE PAID IN ADVANCE 90l.Interest from 02/08/02 to 02/28/02 @$ 13.18 /day 902.Mortgage Insurance Premium for mo. to 903.Hazard Insurance Premium for yrs.to 276..78 1000.RESERVES DEPOSITED WITH LENDER 1001.Hazard insurance 10 mO~@$ l002.Mortgage insurance mo.@$ 1003.City property- taxes 13 mO;@$ 1004.County property taxes mo.@$ 1005.SCHOOL TAXES 9 rno.@$ L008.Aggregate Accounting Adjustment 23.83 per mo. 238.30 per mo. :39.21 per mo. 509.73 per mo. 101.10 per mo. 909.90 -180.69 1100. TITLE CHARGES .101.Settlement or C~osing fee .10l.Abstract or title search .103. Title examination .104.Title insurance bindeF '-106.Notary Fee (inclUdes above items No.: 10B.Title Insurance (incLUdes abOve items No.: -109.Lender's coverage 110.0wner's coverage $ $ l12.ENDORSEMENT PA 300 113.ENDORSEMENT PA 100 _ CO. 114.ENDORSEMENT PA 900 (ALTA 8.1) _115. EXPRESS MAIL Packet/Payoff to to to to to Linda K. Trively 15.00 to COMMONWEALTH LAND 1101 AND 1104) 69000.00 TITLE J****************I************** 605.48 1****************/************** 1****************1************** 1****************1************** to COMMONWEALTH LAND TITLE to COMMONWEALTH LAND TITLE to COMMONWEALrd LAND TITLE to COMMONWEALTH LAND TITLE 50.00 50.00 50.00 30.00 1200. GOVERNMENT RECORDING AND TRANSFER CHARGES _201. Recording fees: Deed $ Mortgage $ .204.RECORDING Satisfaction Pierce 205. RECORDING Subordination Agrt. 54.50 Releases $ 54.50 16.00 16.00 1300. ADDITIONAL SETTLEMENT CHARGES 1400.TOTAL SETTLEMENT CHARGES (entered on lines 103 SECTION J AND 502, Section K) ORM 914 (4-88) See page 3 for certification and signatures 3674.00 Page 3 of ~orm Approved OMS No. 2502-0265 Title Application No: D325015CP CERTH'ICATION I direct and authorize the Company to make the distributions indicated for my account on the attached HOD-I Settlement Statement, recognizing that the Company is not responsible for the accuracy or validity of disbursement amounts or the completeness of disclosure of charges made by others. Disbursements made hereunder are guaranteed by the Company. Funds deposited _ith the Company in connection _ith the settlement are not held in trust, and interest or other valuable consideration may be earned and retained by the Company an such settlement funds I have carefully reviewed aCCUrate statement of all that I have received the HOD-I Settlement Statement and to the best of my knowledge receipts and disbursements made on my account or by me in this -1 Settlement Statement. and belief, it is a true and transaction. I further certify Y.by,d, 'i t1;yn~ Borrowers Sellers Address Address Settlement Statement which funds to be disbursed K I have prepared is in accordance with a true and accurate account of , this statement. transaction. I have caused or Date WARNING, It is a crime to knowingly make false statements to the United States on this or any other similar form. Penalties upon conviction can include a fine and imprisonment. For details see, Title 18 U.S. Code Section 1001 and Sectio.n 1010. Form 471 (Rev. 11/a7) . ; ""~ .,.. . VCP Understanding Disabilities Creating Opportunities Central PA www.ucpcenlralpa,org May 24, 2005 925 Linda Lane Camp Hill, PA 17011 717-737-3477 voice 717,737-0158 tty 717-975-3333 fax mainoffice@ucpcentralpa.org To whom it may concern: United Cerebral Palsy of Central Pennsylvania, Inc. does not offer (and has never offered) a Defined Benefit Plan for our employees. If you have any further questions, please call me at (717) 975-0611. ~~ Jennifer Brubaker Director of Administrative Services @no~' ---ew " I / ~ U'''''''''',',/'II\'/'''''I'J.''''''JI''",r';'',,:/I.'''"'''''i'i """{'",I'"",., ,....",/.\1," -,' _' -II''''') {',\ "~', e A United Way Agency LI':^VE f\ I.EC/\CY n.., ,,/10, {(/'r,.,..r....:;i/'/"Ii"!' Please n!l/Icm/ler UCP C('//fral po! ill nJIIFlilfll/"cjinancia/ plulls I ...."!I'/I "'1,1,, "'!I'd.'r ,J~HOLY Sfm I , May 18, 2005 To Whom It May Concern: I am writing on behalf of Linda Thoman, Director of Business Operations at Comfort Care of Holy Spirit, Inc. Holy Spirit Health System does not offer any type dfDefined Benefit Program. We eliminated our Defined Benefit Program in 1998 and replaced it with a Defined Contribution Plan. Ms. Thoman began employment in December of 1999 and was never a participant of the old plan. Please feel free to contact me if you have questions Sincerely, N~~ William Shartle Vice President Human Resources The Spirit of Caring 503 North 21st Street' Camp Hill, PA 17011-2288 (717) 763-2100 II !I SCHEDULE "B" -27- '- -~, ROOM DESCRIPTION QTY TOTAL VALUE TERRY LINDA LIVING ROOM SOFA 1 $200.00 $200.00 WING CHAIR 2 $100.00 $100.00 SOFA TABLE 1 $50.00 $50.00 END TABLE 1 $35.00 $35.00 CURIO CABINET 1 $400.00 $400.00 FRAMED ART - KINKADE 2 $160.00 $160.00 FRAMED ART - SCUL THORPE 1 $30.00 $30.00 FLOOR LAMP 1 $10,00 $10.00 TABLE LAMP 1 $5.00 $5.00 KITCHEN REFRIGERATOR 1 $0.00 $0.00 STOVE 1 $0.00 $0.00 MICROWAVE 1 $50.00 $50.00 MICROWAVE CART 1 $15.00 $15.00 DINING TABLE 1 $75.00 $75-00 DINING CHAIRS 6 $120.00 $120.00 KAYLA'S BEDROOM DAYBED $0.00 DRESSER $0,00 NICOLE'S BEDROOM MATRESS SET- FULL ' 1 $0.00 MASTER BEDROOM BED & MATRESS - QUEEN 1 $1,200.00 $1,200.00 END TABLE 2 $500,00 $500.00 DRESSER 2 $50.00 $50.00 TABLE LAMP 2 $30.00 $30.00 15" TVNCR 1 $50.00 $50.00 FAMIL Y ROOM COMPUTER DESK 1 $75.00 $75.00 COMPUTER 1 $75,00 $75.00 LASER PRINTER 1 $250.00 $250.00 INKJET PRINTER 1 $25.00 $25.00 SOFA 1 $50.00 $50.00 ARM CHAIR 1 $25.00 $25.00 STEREO CABINET 1 $25,00 $25.00 STEREO RECEIVER 1 $200.00 $200.00 DVD PLAYER 1 $65.00 $65.00 VCR 1 $40.00 $40.00 42" COLOR TV 1 $250.00 $250.00 TABLE LAMP 1 $5.00 $5.00 FLOOR LAMP 2 $20.00 $20.00 WIRELESS ROUTER 1 $50.00 $50.00 LAUNDRY ROOM WASHER 1 $50.00 $50.00 DRYER 1 $75.00 $75.00 13" COLOR TV 1 $35.00 $35.00 BASEMENT EXERSISE BICYCLE $100.00 $100.00 UPRIGHT FREEZER $150.00 $150.00 STEREO RECEIVER $25.00 $25.00 '. CD PLAYER 1 $10.00 $10.00 TAPE DESK 1 $10.00 $10.00 RECORD TURNTABLE 1 $10.00 $10.00 STEREO SPEAKER SET 1 $10.00 $10.00 20" COLOR TV 1 $100.00 $100.00 LOVES EAT 1 $50.00 $50.00 SHED LAWN MOWER $200.00 $200.00 ROTa TILLER $35.00 $35.00 $5,095.00 $2,980.00 $2,115.00 , , 1 NOTES LINDA WILL PAY TERRY $800 BY PRIOR AGREEMENT LINDA WILL PAY TERRY $600 BY PRIOR AGREEMENT ALL OTHER FURNITURE IN NICOLE'S BEDROOM WAS LINDA'S PRIOR TO THE MARRIAGE () r--, ~; C,'':) 0 r..:~l ~. -n [/) 'I! r"i -"J rn:D ,- N -om ~r)C) ,"') .' '::~l() --0 ;2?~~ -'- N 1:5 ,n -' <,- ;,;:--\ .-~2 (., .,',0>- JJ 0". -< II 'I TERRENCE THOMAN, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA vs. LINDA LEE THOMAN, Defendant CIVIL ACTION NO. 2005-2886 IN DIVORCE and CUSTODY PLAINTIFF'S AFFIDAVIT OF CONSENT AND WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF DIVORCE DECREE UNDER SECTION 3301(C) OF THE DIVORCE CODE 1. A Complaint in divorce under ~ 3301(c) of the Divorce Code was filed on June 3, 2005 and served on June 6, 2005. 2. The marriage of Plaintiff and Defendant is irretrievably broken and ninety (90) days have elapsed from the date of filing and service of the Complaint. 3. I consent to the entry of a final decree in divorce without notice. 4. I understand that I may lose rights concerning alimony, alimony pendente lite, marital property, division of property or lawyer fees and expenses if I do not claim them before a divorce is granted. 5. I understand that I will not be divorced until a Divorce Decree is entered by the Court and that a copy of the Decree will be sent to me immediately after it is filed with the Prothonotary. 6. Plaintiff's and Defendant's Waiver of Notice in ~3301(c) Divorce are being filed with the Prothonotary as a part of their respective consent documents. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. ~4904 relating to unsworn falsification to authorities. Date: 9/1'6'(0 <: (~.~/ {2 Terrence Thoman, Plaintiff () ,..., ~~; ~ -~:! :,.-"; C!]: c;:':C: '. ,---~ ' :P: ~~: Z. _J -( o -n ~ :r! -n v r11r- N -om :nO '2cS _.j,.., -u >'c.. ,~ ::r;: '?c5 ~ C)i-n ,;~ W Xl .:;- -< ,. -;r . (i~i ~I-' ?tEeENED st.P ~ \) '1.005 DISSINGER & DISSINGER II TERRENCE THOMAN, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA vs. LINDA LEE THOMAN, Defendant CIVIL ACTION NO. 2005-2886 IN DIVORCE and CUSTODY DEFENDANT'S AFFIDAVIT OF CONSENT AND WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF DIVORCE DECREE UNDER SECTION 3301(C) OF THE DIVORCE CODE 1. A Complaint in divorce under ~ 3301(c) of the Divorce Code was filed on June 3, 2005 and served on June 6, 2005. 2. The marriage of Plaintiff and Defendant is irretrievably broken and ninety (90) days have elapsed from the date of filing and service of the Complaint. 3. I consent to the entry of a final decree in divorce without notice. 4. I understand that I may lose rights concerning alimony, alimony pendente lite, marital property, division of property or lawyer fees and expenses if I do not claim them before a divorce is granted. 5. I understand that I will not be divorced until a Divorce Decree is entered by the Court and that a copy of the Decree will be sent to me immediately after it is filed with the Prothonotary. 6. Plaintiff's and Defendant's Waiver of Notice in ~3301(c) Divorce are being filed with the Prothonotary as a part of their respective consent documents. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. ~4904 relating to unsworn falsification to authorities. Date: q/J%s ..., kciq Y' ~rp l Linda L. Thoman, Defendant 0 ..., c;:::> 0 ~: = -n "'" '""':) ,".' if) -4 cr r, :J: rn:o .~ -0 r ;2: \. . N -oC::; C~ - -:-:,~'-,; ~: , ~I(:') -' .." -,...;-(, ~:t~ CS -n ~ :.;;::: CJ ~ ~ rn Z .;~ -~ W 0;..,...,. -< <.f\ ::< ~~~..;.:\) ~~ 'l>\~~ ~~ \',' ,f", ,.- ", ~ ,( >y'-"-' - ,\)~:!:~\".-p, TERRENCE THOMAN, plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA vs. CIVIL ACTION NO. 2005-2886 IN DIVORCE and CUSTODY LINDA LEE THOMAN, Defendant PRAECXPE TO TRANSMXT RECORD To the Prothonotary: Transmit the record, together with the following information, to the Court for entry of a divorce decree: 1. Ground for divorce: 3301(c) of the Divorce Code. Irretrievable breakdown under !l 2. Date and manner of service of the Complaint: June 6, 2005, by United States Certified Mail, Restricted Delivery. 3. Date of execution of the Affidavit of Consent required by !l 3301(c) of the Divorce Code: By plaintiff september 18, 2005; by Defendant september 10, 2005. 4. Related claims pending: None. 5. Date Plaintiff's Waiver of Notice in !l 3301(c) Divorce filed with the prothonotary: i/:Lf ,2005. Date Defendant's Waiver of Notice in !l 3301(c) Divorce filed with the Prothonotary: 9(2../ , 2005. Respectfully submitted, DXSSXNGER AND DXSSXNGER Date: i(J-I (a') -----n ~ ~ tR Mary A. Etter Dis?t:i.. ger---- Attorney for plaintiff 28 North Thirty-second Street Camp Hill, PA 17011 717-975-2840 cc: Terrence Thoman Linda L. Thoman n ~:~~ ~'J , "'''-\-. ,.. ;.-. ~~~' ~ ....., = = c.n (.I) l'1 -0 o -n :i! rn ::D --r-Jh1 8? --..1 C.) ~~~ on'i ~ ....1 -< N -0 ~~ ~ (..) 0"> '+0'+'" '+00+' 'f. 'f. 'f. 'f. 'f. 'f. '" '" 0+' 0+' 0+' 0+' +. 0+' '" 0+' '" +. +. '" 0+' +. +. +. +. +. +. '" 'f. '" 0+''''''''''''' "''''''''''''''''''''''''''''''''''++.+++.+.+.++.+. +,+,++,+,+,+,+,,,,+,+,+,+,,,,"'+'+'+'0+''''''' O+'''''''''''''''''''O+'O+'O+'O+'+.+.+.+.+.+.O+'+.O+'+.~ 0+' 0+' 0+' 0+' 0+' 0+' +. 0+' 0+' +. 0+' +. + 0+' '" +. 0+' '" 0+' 0+' 0+' 0+' +. 0+' +. 0+' +. + + + + +. + + 0+' 0+' + 0+' + + +. +. + IN THE COURT OF COMMON PLEAS OFCUMBERLANDCOUNTY PENNA. STATE OF TERRENCE THOMAN No. ~005-2886 VERSUS LINDA LEE THOMAN DECREE IN DIVORCE t:A ): )S't,.A AND NOW, ~;n , IT IS ORDERED AND ~ ,ifJ1>~ DECREED THAT TERRENCE THOMAN , PLAI NTI FF, AND LINDA LEE THOMAN , DEFENDANT, ARE DIVORCED FROM THE BONDS OF MATRIMONY. THE COURT RETAINS JURISDICTION OF THE FOLLOWING CLAIMS WHICH HAVE BEEN RAISED OF RECORD IN THIS ACTION FOR WHICH A FINAL ORDER HAS NOT YET BEEN ENTERED; The Marraige Separation Aqreement of the pnrr;p~ 31 2005 is ine ATTEST~ ~ ~ ( PROTHONOTARY J. _~ :? ~~ _~~ 5C7~ /? ~ 12 ~ ~ -P{/ 5(/:?Je-~~ . . J, .. 4'_. ~ '10. f ------ --