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Home My WebLink About10-20-05 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTAT OFFICIAL RECEIPT BLOOM STEPHEN L 2100 LONGS GAP RD CARLISLE, PA 17013 ___un_ fold ESTATE INFORMATION: SSN: 180-09-0027 FILE NUMBER: 2105-0435 DECEDENT NAME: GROUP HELEN DA TE OF PAYMENT: 10/20/2005 POSTMARK DATE: 10/20/2005 COUNTY: CUMBERLAND DATE OF DEATH: 04/27/2005 TOTAL AMOUNT P REMARKS: CHECK#109 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS II REV-ll~2 EX(11-96) E TAX NO. CD 005 917 ACN SSESSMENT AMOU \JT CONTROL NUMBER -------- 101 I $5.82 I I I I I I I I AID: $5.8~ GLENDA FARNER STRASBAU GH REGISTER OF WILLS A Register of Wills of Cumberland County, Pennsylvania INVENTORY Estate of Group, Helen Y No. 21 - 05 - 00435 also known as Date of Death 4/27 /2005 , Deceased Social Security No. 180-09-0027 II Paul E. Group -------- ----"--,---.,-'- - .~---~->- The Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Invent ry include all of the personal assets wherever situate and all of the real estate located in the Commonwealth of Pennsylv nia of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the dat of the Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except hat which appears in a memorandum at the end of this Inventory. I/We verify that the statements made in this Inventory a e true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C. S. Section 4 04 relating to unsworn falsification to authorities. Attorney: Stephen~~B!()om Personal Representative _ Signature: ~g~~_ Paul E. Group L~Y-- , Signature: I.D. No.: 49811 Signature: Address: 2100 Longs Gap Road Carlisle, PA 17013 Address: 23 Church Road Carlisle, P A 17013 Telephone: 717/249-7717 Telephone: 717-776-7088 Dated: 1f/ ., &J CJ~ Personal Property PNC Bank, Checking Account #5 140 185 I 93 PNC Bank, Savings Account #5130332399 ) Sovereign Bank, Checking Account #1691032336 United Church of Christ Homes - Resident Refund Capital Blue Cross - Refund Knouse Foods Coop, Inc. - Pension Benefits Paid May & June 2005 Total Personal Property (Attach additional sheets if necessary) Total Personal Property and Real Estate 5,328.97 c) ; -';"" , -rl : c~5 " 02.84: ITl .... . - $5 ,174.07 $5 ,174.07 h~ -.' < ,';", c) .'. Sf1 ; ':::J /--:-1 l~'~) [ REV-1500 C~~MONWEAlTHOFPENNSYLVANIA I INHERITANCE TAX RETURN FILE NUMBER ---_ __ __ H:;:~~~r~~~~~~:::, ~__ RESIDENT DECEDENT J COUN~;CODE _~~___ ._~e~B~~ ---.----- ~ ~;;~T~;;n~~::R~T.~~M~::ITIA~- 1_ ~~~?;~;~~~~B:~________ ~ [DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) I THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~ l~i~~LrA~~~~RVlVINGSPO\JSE'SNAME (ILA~;~I~~: ;~ ~~DDLE INITIAL) ------ - -- ~--}-SOClAL SEC~~~~~~~ OEWIL'--S_ I I t ~ 1. Original Return -IT 2. - Su-pplem~rrtal-Retum - -- - - - --------0 3. RemainderRetum-(dateofdeathpliorto-12~1:f82) -- I 0 4. Limited Estate 0 4a. ~~:~;~~~erest Compromise (date of death after 0 5. Federal Estate Tax Return Required ~ 181 6. Decedent Died Testate (Attach copy 0 7. Decedent Maintained a Living Trust (Attach 0 8. Total Number of Safe Depositl Boxes I of Will) copy of Trust) i 0 9. Litigation Proceeds Received 0 10. Spousal Poverty Credit (date of death between 0 11.Election to tax under Sec. 91113(A} (Attach Sch 0) _____ __._____ 12-31-91 and 1-1-95) ____-____ ___ __. THIS' SECTIOIII MUST'.~I;COMPLE.TED..ALL'CORRESPQNPENCEiANPCOlllfl[)ElllfIAL..'('AX.INFORMA'riQj\(-SHOOLD$E QIRECTtDTO: t AME I COMPLETE MAiliNG ADDRESS Stephen L. Blooml ' Ilt~;~~~f~~I~t~~~, E:qU~re -----------------1 2100 Longs Gap Road ~ELEPHONENUMBER -------- ---- --------~I Carlisle, PA 17013 1717/249-771 'i. ___ ____________ I -.r -~,...--..-=----..- - ------.- 1. Real Estate (Schedule A) I 2. Stocks and Bonds (Schedule B) I I I REV. 1500 EX + 18~O) w ~ ",,:!Ul O~"" wQ.O ,,00 O~.J Q.al Q. <( ,~ UlZ Ww ~Q ~z 8ft 3. Closely Held Corporation, Partnership or Sole-Proprietorship z o ~ :3 ~ ~ ii: <( o w ~ 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) I 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) (1 ) None (2) None (3) None (4) (5) (6) (7) None 53,174.07 -_._------,-----._"--,--- --..- 86,930.54 None (8) (9) (10) 13,464.53 -----._------ 412.67 (11 ) .13,877.20 26,227 .41 (12) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (13) (14) 1126,227.41 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES -~-----~----'----'---'-- -,'-- -- -----,.-.---,.------.------ 15.Amount of Line 14 taxable at the spousal tax rate, x .00 (15) or transfers under Sec. 9116(a)(1.2) --._---- -- ---- -..-- -.- z 126,227.41 .045 (16) 5,680.23 0 16.Amount of Line 14 taxable at lineal rate x ~ -----._._-._---- --_._-_._-~+,-._---- i5 ~ (17) Q. 17.Amount of Line 14 taxable at sibling rate x .12 ~ 0 ----------- 0 ~ 18. Amount of Line 14 taxable at collateral rate x .15 (18) - -' ------'--- -------.-..----.-.--..- 19. Tax Due (19) , 5,680.23 20. 0 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. >> BE SURE TO ANSWER AU. QUESTIONS ON REVERSE SIDE AND RECHECK MATH << Copyright 2000 form software only The Lackner Group, Inc. ~I Form REV-1500 EX(~ev. 6-00) Decedent's Complete Address: STREET ADDRESS 442 Walnut Bottom Road 1-------------------__ CITY I \ STATE PA 171-------------- I ZIP 17013 Carlisle Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1 ) 5,680.23 5,390.40 -"-- 284.01 Total Credits (A + 8 + C) (2) ,674.41 3. Interest/Penalty if applicable D. Interest E. Penalty A. Enter the interest on the tax due. 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) 0.00 (4) (5) 5.82 (5A) (58) 5.82 Total Interest/Penalty (0 + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: a. retain the use or income of the property transferred;.................................................................................. b. retain the right to designate who shall use the property transferred or its income;.................................... c. retain a reversionary interest; or........................................................................... ........................... ............ d. receive the promise for life of either payments, benefits or care? ..................................._..........._.............. 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?..... ..................... ............................................. ......................................... ....... Yes No ~ I 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation?............................... .......................................... ............................ ................ o o o ~' ~I, ~i I IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF TtilE RETURN. ------------ -- --------- .. --------- -----------------------i------- Under penalties of pe~ury. I declare that I have examined this retum, including accompanying scheduies and statements, and to the best of my knowledge and belief. it is true. correct and "'lmplete. Declaration of !lreparer other than the personal representative is based on all Information of which preparer has any knowledge. __ _____ __..-+- _____ _ SIGNATURE OF PERSON RESPONSiBLE FOR FILING RETURN ADDRESS ~ATE PP~e ~ SIGNATUREOFPERSONRE~B~~ RETURN 23 Church Road Carlisle, P A 17013 _____LtL~Ap5_ _ ~tTE \ ADDRESS -ADDRESS------------ ---- -- --dATE 2100 Longs Gap Road Carlisle, PA 17013 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of 'he surviving spouse is 3% [72 P.S. 39116 (a) (1.1) (i)J. . For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is d% [72 P.S. 99116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclo$ure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. i For dates of death on or after July 1, 2000: : The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a n4tura' parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 39116 (a) (1.2)]. I , The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116 1.2) [72 P.S. 99116 (a) (1 )]. I The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P .S. 39116 (a) (1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. . SCHEDULE E CASH, BANK DEPOSITS, & MISC. COMMONWEALTH OF PENNSYLVANIA I PERSONAL PROPERTY IN~~'i:~~N;EDTtc":O~~fN I I _ _ _ ___ _~___l_~_~_~~__~~___~_________~____ ESTATE()f~- -~- - -H-I-~-~~-----------~-------~-------i FILENUMBER---- --- __u_ ro~~'__e_e~____~_____~______ _~___ _________ __L__~~=_OJ~QO~~~ _ __ _ Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with tllte right of survivorship must be disclosed on schedule F. : ITEM NUMBER --~-_._.- 1 DESCRIPTION --f---- VtLUE AT DATE OF DEATH -- -----.- ------- ---- -- 5,328.97 PNC Bank, Checking Account #5140185193 2 PNC Bank, Savings Account #5130332399 13,714.01 3 Sovereign Bank, Checking Account #1691032336 32,957.86 4 United Church of Christ Homes - Resident Refund 781.25 5 Capital Blue Cross - Refund 189.14 6 Knouse Foods Coop, Inc. - Pension Benefits Paid May & June 2005 202.84 TOTAL (Also enter on Line 5, Recapitulation) 53,174.07 *' SCHEDULE F JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Group, Helen Y 1 I I 1 L______ __ _,_ __' -.- .- lFILE NUMBER ----------- J___~~~~~043~_____ If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G. RELATIONSHIP Td DECEDENT SURVIVING JOINT TENANT(S) NAME ADDRESS A Paul E. Group 23 Church Road Carlisle, PA 17013 JOINTLY OWNED PROPERTY: ITEM . ~~~~-;r-D~T;-Tn~-:: na~o~;n~~~~T~~~u~:nPa~~~~~~c:unt ~:er N~M_B~R_r~~J~~~~_ ~~~_~~~~Ia~de~fying number. Attach deed for jointly-held real I I A I 09/ 10/200 I 1 PN C Bank, Certificate of Deposit #31900219220 2 I A i 06/28/19991 Orrstown Bank, Checking Account #106211105 3 A 106/15/20011 Sovereign Bank, Certificate of Deposit #3385027887 i i 4 A 02/12/19881 M&T Bank, Savings Account #015004200023098 5 A 02/17/2005 i Orrstown Bank, Prime Savings #706001901 - please I see attached documentation showing that funds used I' to open this account on 2/17/05 had been jointly held by same parties in same bank for more than one year I prior to decedent's death I I I I I I I \ Son ____1__ -- -1--; ------ - DATE OF DEATH % OF I pATE OF DEATH DECO'S rll . VALUE OF VALUE OF ASSET INTE~S:rDEtE~E~T~-'-N~E_~E~T 33,045.51 50%1. 16,522.76 4,830.53 50%1 2,415.27 I 50%1 10,905.01 23,922.74\ 101,157.261 I I I 5,452.51 50% 11,961.37 50,578.63 50% I TOTAL (Also enter on line 6, Recapitulation) 86,930.54 *' SCHEDULE H FUNERAL EXPENSES & AIlVINISTRATlVE COS1S ESTATE OF Group, Helen Y -1 FILE-NUMBER---------- ------__ ______ ____________~____________1____2~ - ~_=20~3~__ I I I ------'----~.__._--_.._---,.__.,-_._..__..__..- COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT --,----- __n___ __',.___ ____,_ ____ __..__ _~_...__. __ ____' __ __ . _._~_.--L- ------, ',--- --------.,------ --.. ---'--'--,--- ---- -_._---_._-'-_.,-----~--- Debts of decedent must be reported on Schedule I. - -ITEM --- -------~-- ----- ----- -T- - -------- NUMBER' DESCRIPTION I AMOUN!T ~..--- -----------------------------------_____...1___ _____ A. I FUNERAL EXPENSES: ! 1 I Funeral Service - Hollinger Funeral Home & Crematory, Inc. I 8,680.50 I I I I I I I I I I I I 2 Funeral Reception Refreshments - Barbara Griffie 375.00 B. I I ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Social Security Number(s) / EIN Number of Personal Representative(s): Street Address City State _ Zip I Year(s) Commission paid 2. Attorney's Fees Stephen L. Bloom, Attorney and Counsellor at Law 4,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City Relationship of Claimant to Decedent State Zip 4. Probate Fees Cumberland County - Register of Wills 197.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. I Other Administrative Costs Legal Advertising - Cumberland Law Journal 75.00 2 Legal Advertising - The Sentinel 137.03 TOTAL (Also enter on line 9, Recapitulation) I I ~------~--- -- I ~3,464.53 __ _1_____ _____________ ~,... !I SCHEDULE I ~ DEBTS OF DECEDENT, MORTGAGE I COMMONWEALTH OF PENNSYLVANIA II LIABILITIES, & LIENS \ INHERITANCE TAX RETURN RESIOE~~OECEDENT _~_ ___ _ ___ _____~_____J_ _____ _ ----.....--.-...- --.------.- E~~TEOF _Gm~p,H~~n~ _ . .. ___ _ __ __ ___ m _rltE~~~;~~~5_~ ___ Include unreimbursed medical expenses. ITEM NUMBER 1 DESCRIPTION AMOUNT Final Telephone Bill - Sprint 29.19 2 Medications - PharMerica 112.84 3 Radiology - Smith Radiology, Inc. 9.21 4 Nursing Supplies - United Church of Christ Homes 58.59 5 Reimbursement of Pension Overpayments - Knouse Foods Cooperative, Inc. 202.84 TOTAL (Also enter on Line 10, Recapitulation) 412.67 REV-1513 EX+ (9.00) *' I I I --- - ~ -- - ---- ~ -- SCHEDULE J BENEFICIARIES I I I ______~_________ _~______ fF"-e NUMBER- - - ---- - - - -- i 21-05-00435 -------[----..--..------------ - --I" -----.---- -,- . . .1. R:~~1~~~:O _II_~~~?~~~TRA~RA-RE I Son Entirt Residue I I I COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Group, Helen Y NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) Paul E. Group , 23 Church Road Carlisle, P A 17013 i Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet II. !NON-TAXABLE DISTRIBUTIONS: IA. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT ,BEING MADE la. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS I I I I ! TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI I - LAST WILL AND TE~T AMENT I, HELEN GROUP, of Gardners, Cumberland County, Pennsylvania, being of soun4 and disposing mind and memory, do hereby make, publish and declare this to be my Last Wi~ and Testament, hereby revoking any and aU former Wills or Codicils by me made. 1. I direct that all my just debts, funeral expenses, testamentary expenses and all inherit~nce taxes (whether such taxes may be payable by my estate or by any recipient of any property )~hall "6'eparctwfrom 'myl"e-si~~' [n..~ l.l.....il:1.d..dJl~~..... Jhy d~~~c WlU as part or \ 'the administration of my estate. My Executor shall have no duty or obligation to obtain reimburse~ent for any such tax so paid, even though on proceeds of insurance or other property not passing u~der this Will. - 2. I direct that I be buried in my lot at the Mt. Tabor Cemetery. 3. I give, devise and bequeath all of my estate, both real and personal property, unto my s<\ln, PAUL E. GROUP, absolutely. IIi the event PAUL E. GROUP shall predecease or fail to survive me by more than thirty (30) days, then I give devise and bequeath all my estate, both real and persoqal property, unto my daughter-in-law, ANNA L. GROUP. In the event ANNA L. GROUP sh$ll predecease or fail to survive me by more than thirty (30) days, then I give devise and bequeath a.ll my estate, both real and personal property, unto my sister, WILDA CRUM, with substitution <1>f Issue. 4. I nominate, constitute and appoint my said son, PAUL E. GROUP, as Executor of my estat~. In the event he is unwilling or unable to so act, then I appoint FARMERS TRUST COMPANY!, Carlisle, Pennsylvania, as Executor of my estate. 5. I direct that my Executor shall not be required to file a bond to secure the faithfu~ 1-/ &, H.G. Page 1 of 3 Pages perfonnance of his duties in any jurisdiction. 6. I authorize and empower my personal representative, in his sole and absolute discretipn, to purchase or otherwise acquire and retain any investments of which I die seized or any real or personal property of any nature~ to sell, lease, pledge, mortgage, transfer, exchange, dispose of or grant options in regard to any or all property of any kind forming a part of my estate for such tenns and such prices as he may deem advisable~ to borrow money for any purposes connected with the protection and preservation of my estate~ to mortgage or pledge any real or personal property forming a part of my estate or to join in or secure the partition of same; to compromise any dlaims or demands of my estate against others or of others against my estate; to make distribution in kind and to cause any share to be composed of cash, property or undivided fractional shares in property different in kind from any other share~ to employ agents, attorneys and proxies and to delegate to them such power as my personal representative considers desirable and to pay reasonable compensation for such services as may be rendered by such agents, attorneys and proxies~ atIld to execute and deliver such instruments as may be necessary to carry out any of these powers. IN WITNESS WHEREOF I have hereunto set my hand and seal this 8th day ofFebmary, 1995. I~~ .1J~ Helen Group (SE~) SIGNED, SEALED, PUBLISHED AND DECLARED by the above-named Testatrix, as and for her Last Will and Testament, in the presence of us, who at her request, have hereunto subscribed lour names as witnesses thereto, in the presence of the said Testatrix and of each other. ~ I~~ [~- yl~d_ 7/7. ~ r< Page 2 of 3 Pages COMMONWEALTH OF PENNSYLVANIA ) : SS. COUNTY OF CUMBERLAND ) L Helen Group, Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and execut~ the instrument as my Last WiD; that I signed it willingly; and that I signed it as my free and vol~ntary act for the purposes therein expressed. ) ~N A~ ,_A.",-u..-~ Helen Group Sworn or affirmed to and acknowledged before me by Helen Group, the Testatrix, tltis 8th day of February, 1995. NotamI Seal Tricia L James. NoIary Pt.tJIo My~~~~N taryPublic COMMONWEALTH OF PENNSYLVANIA ) : SS. ) We, &e.~k) L 6l.OOM A~D 0A~thf M. G~~e. the witnesses whose names are signed to the attached or foregoing instrument, being duly qu~ified according to law, do depose and say that we were present and saw Helen Group, the Testatrixi sign and execute the instrument as her Last Will; that the Testatrix signed willingly and that the Testatrix executed it as her free and voluntary act for the purposes therein expressed; that each of us, ~ the hearing and sight of the Testatrix, signed the Will as witnesses; and that to the best of our know~edge the Testatrix was at that time 18 or more years of age, of sound mind and under no constrailnt or undue influence. COUNTY OF CUMBERLAND ~~~ "'&idress I 0 ~. J-I; ~ J... .:5r-rr:e T- o"' f:....rI.-"'f ~" fJj:} /701 '3 .-. /; >d~-~~. ~ . Address ;' a.. -~~ -. t' ( A!.-eC"-4--. -7 ~ / :5 Sworn or affirmed to and subscribed before me this 8th I\'otarial Seal Tricia L Jatnes. NoIaIy PubIo Carlisle Born. CumberIai1d County My Colr.mss.on ~ Nov. 24, 1f/1Jl PSJoP 1 nf1 Pl'lOPQ JUL-18-2005 19:24 PNCBRNK 412 768 3458 P.01 QPNCBAN< July 18. 2005 Stepben L. Bloom 2100 Longs Gap Road Carlisle, P A 17013 RE: &tate of Helen Group, dc:crased SSN: 110-09'()()27 DOD: 4tl71200S Dear Mr. Bloom: In response to your request for Date of Death balances for the customer noted above, our records show the followina: Certificate of Deposit Ac:coum _31900219220 Established 09/1012001 HELEN Y GROUP PAUL E OROUP DOD balance: 533,000.00 + S4S.51 acaued interest Chec:kiag ACC01Iat Account #5140185 193 Establisbed 04/01/1963 HELEN Y aROUP DOD balance: $5,328.49 + 5.48 accrued interest SaviIIp Accoullt Account#S130332399 Established 03/11/1993 HELEN Y GROUP DOD balanQC: 513,701.36 + $12.65 accrued interest Page 1 0(2 JUL-18-2005 19:24 PNCBRNK 412 768 3458 P.02 Please note that this office only provides date of death b.J~t'~ for deposit accowrts (lRAs, CDs, Checking and Savings IlCC01lIltS). We do DOt procell UJ fiIIada! tnDlactiou or proYlde ltatemeDtl. If you DCecl assisteDce with any of these items, please ealI1-888-PNC-BANK (1-888-762-2265) or atop by your local PNC Bank branch office. Sincerely, @J~WiJk- Rachelle Wells 1-800-762-1715 P7-PFSC..04-F 500 first Ave. Pfltlbuqh PA 15219 Page 2 of2 MlIlIDbcr FDIC TOTRL P. 02 tb ~. Dank' · ..., J .'. ,.... .... . ~:re .',:; J., . .,. ....., ,;, Sf.4CC8SS is ~ \ft canlCt~ 611IbJ1l&DI Court Ordered Processing / MA 1 MB3 02-10 P.O. Box 841005 Boston, MA 02284 June 9, 2005 Stephen L. Bloom Attorney at Law 2100 Longs Gap Road Carlisle, P A 17013 RE: Estate of Helen Y. Group Date of Death: 4/27/05 Dear Mr. Bloom: Per your request, enclosed please find the account information as of the date of death fo~ the above-named decedent. For your information, accrued interest is not included in the date of death balance. Please feel free to contact me if I can be of any further assistance. Very truly yours, ~ o.~a.J0>>~ Laurie DiGiandomenico OAG Team Leader (617) 533-1789 Enclosures Sovereign Bank ESTATE OF SOCIAL SECURITY #: DATE OF DEATH: Helen Y. Group 180-09-0027 April 27, 2005 Account #: 1691032336 Type: In the name of: Helen Y. Group Date of Death Balance: Int.(YTD) from 1/1/2005 to Accrued interest to date of death: Other Info: Closed 6/6/05 Checking Open date: 7 /3l/~004 $32,956.08 4/26/2005 $1.78 $305.51 2/13/2005 $0.00 i I I Open date: 1/4/11983 I I I $0.54 i Account #: 2894020797 Type: In the name of: Helen Y. Group Date of Death Balance: Closed prior Int.(YTD) from 1/1/2005 to Accrued interest to date of death: Other Info: Closed 2/13/05 Savings Account #: 3385027887 Type: CD In the name of: Helen Y Group or Paul E. Group Date of Death Balance: $10,886.38 Int.(YTD) from 1/1/2005 to 3/31/2005 Accrued interest to date of death: $18.63 Other Info: Closed 5/16/05 Open date: ~ I. $59.63 Page 1 of 1 St3tement United Church of Christ Homes Thornwa~d Home 442 Walnut Botton Road Carli.sle, PA 17013 ~'a u l Group ~.:: Church Rd ~'arlisle, PA 17013 a':".e :Jescription BALANCE FORWARD 'J:) tJAYMENT ;/13;05 Beauty & Barber 3v J5 R0cm & Board - Priv iI3~, OS Ream & Board - Priv ; 3D 05 ~able Television Days Quant 1.00 30 26 1. 00 Statement Date: i.- / or: ., _J: V J... , ~: 0 C S Due Date: OS/25/ 005 Re: Helen Y Group Account Nr: 627 Rate 19.00 204.00 204.00 15.75 Charges 6,210.64 19.00 -6,120.00 5,304.00 15.75 Payments 6,210.64 Balance 6,210.64 .00 19.00 -6 101.00 797.00 78~.2S 11 UNITED CHURCH OF CHRIST HOMES REMITTANCE ADVICE MEMO INVOICE DATE INVOICE NUMBER AMOUNT DISCOUNT NET RESIDENT REFUND THORNWALD HOME HELEN GROUP 5/11/2005 627-1 781. 25 781. 25 -" ." .~ United Church of Christ Homes 30 North 31st Street UCCH Camp Hill, PA 17011 (717) 303-1502 DATE 05/18/2005 WACHOVIA BANK, N.A. LANCASTER, PA 17603 3-50 310 n I,: 1 < ;~.~ f....' '-- L I 1,)1..) CHECK NO. 21198 AMqUNT $781.~5*** PAY SEVEN HUNDRED EIGHTY-ONE AND 25/100 DOLLARS TO THE Estate of Helen Group c/o Paul Group 23 Church Road Carlisle, Pa 17013 ~ ORDER TWO SIGNATURES REQUIRED IF $~.ooo OR MORE NOT VALID AFTER 90 bAYS OF 1/10 2 . l. q 8111 I: 0 3 .0 00 5 0 3 I: 2 0 0 0 0 la jOg 8 l. 3 3111 + Capital BlueCross CHECK NUMBER: 30006197 fl~ ~ GROUP I SU~GROUP 10: 00900001 - 07/08/05 HELEN Y GROUP CIO THE ESTATE OF HELEN Y GROUP ATTN: STEPHENLBLOOM 2100LONGSGAPRD CARLISLE, PA 17013 m Explanation Of Refund..... Refund Reason: Subscriber Deceased-Helen Y Group-180090027 Total Refund Amount: $189.14 He<ll1h care benetit programs issued or adnunlstered by Capital BlueCross and/or Its subsidiaries. CapItal Advantage Insurance Company~ and Keystone Health Plan-K CFmlral Independen\ (ICPnseB~ of the Rille CI()S~ .tn(j Blue St"eld AssocIation Communications Issued by Capital BlueCross In its capacity as administrator 01 progmms and provIder relations for all companies NF-49 (5/2005) .: I 1-1 J....'i'I.i..::I :I~'J J!1:1~" ::t'.:li':J::t:a 'I..~ [el .!"l.If::a~ .'I'JII: [.1... ~ [Il.' ~ [,..: I =-tt: 'lll~ 1., ~ I :'.'l"I..:l :i~', r.:.1:1 :.wstt: l:l~ ~tI: ,.\...... :1.11 ~ :r.!.llJ ~(~ :[.]1. ~ I. CHECK NUMBER: 62-4 + Capital BlueCross 30006197 311 ~ Cap/lal Advantage Insurance Compa~ serves as claIms paying agent 07/08/05 on behall oll18ell, Capital BlueGrass. and Keystone Health PIa..- Central Independent Licensees 01 the Blue Cross and Blue Shield Association PAY TO THE ORDER OF: HELEN Y GROUP C/O THE ESTATE OF HELEN Y GROUP ATTN: STEPHEN L BLOOM 2100 LONGS GAP RD CARLISLE, PA 17013 VOID AFTER 180 OAtiS H ~ rll CHECK AMOUNT: +"'+UU~*$189.14 a~~ Mellon Bank. N.A., Philadelphia, PA Payable Through Mellon Bank (DE) NA Wilmington, DE III lOaD b ~ q 7111 1:0 II ~OOO'" 7.: 2111 q b? b l bill -- 11 - - ..- ~ M&I' Investment Group PNC BANK A/C #: 5140185193 H2000874C KNOUSE FOODS COOP INC BARG EMP RET TR EMPLOYER 16-6265706 HELEN Y GROUP MONTHLY PENSION PAYMENT 05/01/05 $********101.42 GROSS CURRENT 101.42 YEAR TO DATE 507.10 ADVICE OF CREDIT ~ M&T Irwestment Group H2000874C KNOUSE FOODS COOP INC SA HELEN Y GROUP DATE 0 5 / 0 1 / 0 5 I 'j CREDIT ONE HUNDRED ONE DOLLARS AND FORTY TWO CENTS**** AMOUNT $ * * * * * * * 101. 42 TO THE ACCOUNT OF HELEN Y GROUP 23 CHURCH RD CARLISLE PA 17013 Ale #: 5140185193 NON.NEGOTIA~LE :1 II ~ ORRSTOWN BANK August 30, 2005 TO: Stephen L Bloom Attorney at Law 2100 Longs Gap Road Carlisle, PA 17013 FROM: Timothea Moose Cust. Service Specialist P.O. BOX 250 SHIPPENSBURG PA 17257-0250 RE: ESTATE OF Helen Y Group DATE OF DEATH: April 27, 2005 IT IS HEREBY CERTIFIED THAT THE ABOVE NAMED DECEDENT HAD, ON THE AE~OVE DATE, THE FOLLOWING ACCOUNTS WITH ORRSTOWN BANK: ' CHECKING ACCOUNTS ACCOUNT NO. TITLE OF ACCOUNT DATE OPENED PRINCIPAL & ACCRUED IINTEREST 106211105 HelenYGroup 6/28/99 4,829.64 .89 Paul E Group SAVINGS ACCOUNTS ACCOUNT NO. TITLE OF ACCOUNT DATE OPENED PRINCIPAL & ACCRUED I~TEREST 706001901 Helen Y Group 2/17/05 100,933.27 223.99 ' Paul E Group CERTIFICATES OF DEPOSIT ACCOUNT NO. TITLE OF ACCOUNT DATE OPENED PRINCIPAL & ACCRUED I'NTEREST I PO Box 250. Shippensburg, PA 17257 · (717) 532-6114. (717) 532-4143 Fax. www.orrstown.com m1 M&TBank 499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12 Phone (888) 502-4349 Fax (302) 934-2955 August 29, 2005 Stephen L Bloom Attorney and Counsellor at Law 2100 Longs Gap Road Carlisle, Pennsylvania 17013 Re: Estate of Helen GroulJ Social Security: 180-09-0027 Date of Death: April 27. 2005 Dear Sir or Madam: Per your inquiry dated August 23, 2005, please be advised that at the time of death, the above-named decedet1t had on deposit with this bank the folIowing: . I. Type of Account Savings Account Account Number 015004200023098 Ownership (Names of) Helen YGroup >I< Paul E Group >I< Opening Date 02/12/88 Closed 06/06/05 Balance on Date of Death $23,912.91 Accrued Interest $ 9.83 Total $23,922.74 "'For further account information, regarding ownership and any changes, Closures and/or reimbursement o~ funds, etc., please call the Mt Holly Springs Office # 717-486-3038. Sincerely, '?fan:/~~ Nancy Clagett Records Management Sent By: OPERATION, CENTER' To: STONEHEDGE DR At: 92400804 -- . , .. . p/fe f #-1. 0~(\ , ~. I ~ i--- :Qc(a~CJZ -- Sci-lac LE fj :1- -r~\ 5 l~ LpG "tCr-I4-) I~ 7175302639; Sep-12-05 1:42PM; Page 1/2 .1UW AcColJlT ~.~. ~6AN-K f' n. In Jl. 'u 0 I..' TOW N~. 'A I ~ 14.' . , Member FDIC . _ OF ACCOUNT. CONIIIJItIIIIM..--oII! " ',' 717~6-7200 ' IfOW! PHONf: o INUMDIJAL PReSENT ., IiMI'LQVER o JOINT. WITlf sU~P In noi... AI)ORESlI. _Ift~ o JOINT - NO SlIIMVORllHlP . t':--- I o """"'*'I TEU I o TflUST . 8a'AAATE AGRI!EMBrn . LfIlGTl1 or EMPI.01'-j o AEVOCASL! TRlm DE9IO~ ~ DiFINEO IN pMW)US EMPLOVEfl ' ' I THIS AGRffMEHT (NMw lUld MdrMa 01 ~ ADDAE8$ I 'l'l!.L , L. t),U'E or DIRT>< 12-J~16 OWNl!RItlIP Of ACCOUNT. IUIIIIIEM PUR_ IlUSlNESS I o lIOUll'AOPfllETOR8lllP COUN'fV & STAn: I OF ClMNlIZATIOtl o CORPORATION: O~ o NOT roo P..oF!T I o Mm'NERSHII' oWTtiORlZAllON D.liTal ;-p o UNITED LJ.'lIIUlY COMMNY ONO f!oCS1MlLE GlGNA'TUllfiSJ1 yea 0 ,~ I I N;me wid <<dcbwoa ot _... wIIo will ~'W- vour Iocllll"'" I I rRY~mNJ( IllllL _.2 '. '..*. BY K. R'RR'1'7.TltR .~ FORN: OCASlt:bl ~ . . . 'rift OF ACCOUtlT IIINEW ,[JrEll$OHAl lII,cHl'CKINQ o EXISTINIl O8USIiCai; :'O'SAVlH6S' ACCOUNT N.AMIi ACQOUNT OWNER MAII~ . AODIUiM BEI..EIl Y. GJlDllP PAUL B. GBOUP 4228 CARLISLE lW.AD GARDRKRS. PA 17324 IUI'IIl<< of .~I.... """,Ired lor IOilIllIt1Iw.I 0 ThIe II ,,-.porary __ lNGHATUAElII.1'HE imlHlliirlGHllD'ACiREEIII 'I'D nil! "IlIIIInI mnu 4>>I1'IWIU 1 D t OF 1* ~ ~ ACKNOWLEDoe", fleCI.PT OF A C;OIiliot.sTltD GO"" ON TODAY" DATI!. TN UHDUlSlG"ID AUC AC::IUIOWU!DQi(i) ~ Of' A COP\' QP AND AOIIUCII TO 'r.tlii 'llIUAS OFTHI!' ~ fXlFunci.Av~Iy~ .fJ~~ IX] Eleclron'" funcll __ ~ iJ . ' , :6)~ (31 'denUlYl... _', {41 o AUYHORlZm SIGNER (.......) aKlIv_, Aooounll OnlY X AOIlITlONAl, I'fFORM.(\'IO/Cl 1IACll.\If" W11ltHOL_ Cll.ftTll'leATlONS o UEMPT NlCWtIHTa ~ I am III -.. 'lKlIIM ""dar 1M In....... Rev...... *"'- RegulaUono. I o NOllASelDllHT ALI!Na jl. 11/11 I10l a lInIIId - ~ Of "I M1..IndI~ 1.../lll\hera c:MIan.... rui_ of th. UnII8d 9Ialn; . ' a&h......-= . --u. ..-.&0- _-"t__ .. -t...... ill TIN: 180-09-0027 , IYl TAXPAVBR Ul. __Ii" . Thot ~ IdtJrllI\lcatloll ;r.:;,.bot anowII &bon (TIN' I, my torr.o! tupav.r l_hcJallon .runb..... ...:.:....;, ," ,.-...:~ 1...111...111......11..11.1..1.1 HELEN Y GROUP % PAUL GROUP 23 CHURCH ROAD CARLISLE PA 17013 O.~N BANK II :=~f~:T ...... C H E C KIN G A C C 0 U N T S HOMETOWN INVESTMENT ACCOUNT ACCOUNT NUMBER PREVIOUS BALANCE 1 DEPOSITS/CREDITS 1 CHECKS/DEBITS SERVICE FEE INTEREST PAID CURRENT BALANCE 106211105'" 73,895:35 14.97 21,983.81 .00 117.80 52,044.31 . CHECK SAFEKEEPING Statement Dates 9/03/02 thru DAYS IN THE STATEMENT PERIOD AVERAGE LEDGER AVERAGE COLLECTED Interest Earned Annual Percentage Yield ""2002 Interest Paid 9/3P/02 i 28 73,12~.1l 73, 12f.1.11 11 V . 80 Earned 2.12% 1,18~.74 ACTIVITY IN DATE ORDER DATE DESCRIPTION TRACE NO 9/05 DEPOSIT 003012840 9/30 Interest Deposit 9/30 HOlf~TOWN II~VES~~~~ WITHDRAWAL 002076000 t2Er~lJQ - SC~ O;U~ F/ :c-r"E]'--\ -:; I~ / )G " 1 2 Oy J4-) AMOUNT 14.97 / 117.80 V- 21,983.81- i B~CE 73,91~.32 74,02~.12 52,04it.31 ~ [I -- ._-~-----_.-.._-- I _._._.._----~_.~..__.__.~- --- CheckinglSavlngslClub------ ~---- r------ Debit Da~e;';~t~~,~; Customer Name Description Checking (53) Misc. Debit (66) MMA Debit (77) Correction (50) Closing Acct., ~ (52) Hometown Investment Withdraw Account Number t. /-. . ' !. ....-:! t '/j I Savings (58) Regular wid (50) Closing Acct. Club I (51) Closing Aqet. Prepared By 'e.tomer Signature - eli, ('-~ ", ,1./1 I,L \ '/'; I~IV I~'~~ t2tr-&-8\JLE - SL.~a0U=:- FI 'Ll~ 5 A C Pb- -"3 (j;:: 14) Sent By: OPERATION .CENTERj 7175302639j 'PA(!,): #: c1 orrstown Bank Hanover Street Office 22 South Hanover St Carlisle, PA 17013 (888) 677 -7869 Br: 8 JOINT" NO SUAVIVORSHII. It;;~.~~ .~ o TRuST - SEPARATE AGREeM~NT: o REVOCAtfLE TRUST Oi=::~~IOrS OEFINED IN THIS AGREEMENT ~-.~ .~,-.. ~".[~~ p1f(\ "9-~j OWNERSHIP Of ACCOUNT. BUSINESS PURPOSE o SOLE PROPftIETORSHIP o CORPORATION; 0 FOA PROFIT 0 NOT FOR PROfIT o PARTNERSHIP o BUSJNESS~ COUNTY III STATr; OF ORGANIZATION: AUTrlORlZA nON DA no; BY KATHY A COHICK DA TI: OPENEO INIllAL DEPOsrrl '0' o CASH ~ CHECK 0 HOME TELEPHONE I 8USINESS PHONE' ORIV~R'S LICENSE" E-MAIL EMPLOYER MOTHEfI"S MAIOEN NAME Name tnd IIddros' of someone who Will lI/waVS know your lOcation: _ BACKUP WITHHOLDING CEATIFICATlOIllS TIN: 180-09-0027 ... ~ TAXPAYER I.D. MJM8ER - The Taxpayer Identification Nl,lmber shown above (TIN) is mv correct taxpayer .Identiflcation number. ~ ElACKUP WITHHOLDING . f am not 5ublect to backup withholding either bota".... I ha"e not been notifiad that I em lIubJoct to backup withholding as II result of II failure to report all intefeSt or dividend., or !he Internal Revenue Service h.. notified me that I am no longar sub~ct to backup Withholding. o EXEMPT RECIPIENTS - I am an exempt recipient under the Intemal AevonU8 Service AsgU/lIltions. liGNA TUftE: I RIr1lfy .....,...... .f,.q.y tM.~ ~a6I. tlalI ,..,~.1:C;;: y'~"""" U.S. r.sitlent a1_ . x ! "",/ [ ~f'M-'D8" ' ~ glllQ2 8Ink<vs Syll8m..lnc.. St. CICUCl. MN Form MP~(;.LAZ.,,^ 11/22/2000 (\E:0a2c."NLC - g}1-~-ULE" F -- jITf:.7'1 5 A C P f\Gt.- 4- 0/:: 14) - Sep-12-05 1:42PMj ~ Page 2/2 ACCOUNT NUM8l:R . CIP# Q000425 _~ 18"2005 MONEY MAKER CHECKING ACCOUNT ACCOUNT OWNI;Rl8) NAME .. ADDRfS9 HELEN Y GROUP PAUL B GROUP 23 CHURCH ROAD ~ISLE PA ~7013 !!i"NEW TYPE OF gg CHECKING ACCOUHT 0 MONEY MARKET o NOW Thle Is your Icheck one); (!f] Permenont 0 Temporary o EXISTING o SAVINGS o CERTIFICATE! OF DEPOSIT o i account agr.,~nt. Numbsr of signatures reQuired fur wlthdrawa' 1 FACSIMILE SIGNATVRElSI ALLOWED? 0 YES g] NO [x ] SIGNAT\JRE(SJ . The underllgned "llr.. to the _ml' lated on ."!IrY p.... of lb. fOM'l MNI ecknowledgo r~ of . com . ~. T1le undw.JlJfMId turtt.r lIUIhoriJ. 1he fIIwJcW InItltut1oi'l 0 wrify emit and employment hlllory Nld/or ....... . c;rldit r. . agency pr""" . credit ~ on tho \lndM'aIfned. .. . rIM undersigned al&o Idcnollllledge the rllCelpt of a copy DgrM to tho tenn. of tit" 1vllowInt dl.~urel.); IitJ Depo.it Account tiI Fu~s Availability [}t i Privacy I&l Electronic Funds Tranlder (]: Truth In Sllvino~ o . 1I~JI.~~ i ] pod 1'- ~ (pCJ/I) i HELEN Y GROUP . I 180-09-0027 D.O.B. 12/1.p/16 (11: [x 1.0.11 (21: [x 1.0.# (3): [x PCI4/ ~ ~~ ] PAUL E GROUP 168-3~-8627 O.O.D. 05/ir/47 ] I.D.f_ 0.0.8. (4): [x ] 1.0.# . 0.0.8. .----l-- I o Autlloriz..A SiQner (individual Accounts Onlyl [x 1.0.' ] ._._ 0.0.8. (psg. 1 01 2J I' Inquiry Page 01 of 11 17:16:15 elF number: YEING$T G000425 Phone: (H) (717) 776-7088 Birth date: (B) (000) 000-0000 12/10/1916 Tax ID number: 180-09-0027 Br#: 008 Account type: Money Maker Checking Account number: 108006345 1 of 1 2718/05 1. 00 0/00/00 ..";~"" '. i~ 12/24/04 2/18/05 .00 Yes 0/00/00 37 Deposit 9/08/05 HELEN'Y GROUP · PAUL E GROUP 23 CHURCH ROAD CARLISLE PA 17013 Closed Messages Available Balance: Collected balance: Current balance: Date last active: Last deposit: 12/19/03 Date last overdrawn: ~ opene0 Date last statement: Date last contact: Date Closed: Accr~ed interest: Service charge: SC Waive expiration: Service charge code: .00 .00 .00 .00 .00 .00 .00 Tiered 31 Yesterday's balance: Last stmt balance: Avg collected bal: Avg ledger balance: Interest rate: Stmt/Service chg/Int cycle: Automatic NSF fee: SLatement/Passbook code: User code: Waive ATM Foreign Fl=Addl functions F5=History Yes Statement More. . F4=Swe~p Inquiry F24=Mo.tre Keys Fee (Y,N)....... Y F2=Image F6=Messages f3=Exit F8=Maintenance . - .<"C LL.......l""-. L;LC ~( :r---r-E:~\ S-- A. (2E 1::- 02(:..~LC -=>" ---=---' L p b. SO(-=' l 4') 9/08/05 HELEW Y- GROUP Closed Messages Last stmt balance: Current balance: l=View 6=Print T=Tset Posted Description 10/31/04 Interest Rate Change 11/30/04 Interest Deposit 11/30/04 Interest Rate Change 12/27/04 Debit Accrual Adjustmen 12/27/04 Telephone Transfer Debi 12/31/04 Interest Deposit 12/31/04 Interest Rate Change 1/31/05 Interest Deposit 1/31/05 Interest Rate Change Inte ' Deposi t Inquiry Account number: .00 .00 Last stmt Statement Control: from Check No 2/18/05 fhterest Rate F4=Redisplay F7=Scan forward F16=Sort F17=Top F18=Bottom F8=Scan backwards 12EF CS2-t:::.l'iL l:: - =:;c.-~-\t:" t Ult F: (' P G. b 0 ~ /4-) .:z::-rE:/'V\ s A date: cycle: Amount 1. 7000% 145.01 1.7000% .56- 4,000.00- 148.58 1.7000% 144.91 1. 7000% II 17:16:49 108006345 1 of 1 2/28/05 - 31 To Balance 1104,072.65 1104 , 21 7 . 66 1104 , 21 7 . 66 1104,217.66 1100,217 . 66 100,366.24 1pO,366.24 190 , 511.15 1 0,511.15 1. 0,586.05 I .00 , .00 Bottom F11=Prior bal 'F15=EFT F22=T/C F~3=Checks i ! II O~N BANK Date 9/30/02 PRIMARY ACCOUNT ENCLOSURES .... 1...111...111111'1111..11.1..1.1 HELEN Y GROUP PAUL E GROUP 23 CHURCH ROAD CARLISLE PA 17013 C H E C KIN G A C C 0 U N T S MONEY MAKER CHECKING ACCOUNT ~ER . ------=: PREVIOUS BALANCE 1 DEPOSITS/CREDITS CHECKS/DEBITS SERVICE FEE INTEREST PAID CURRENT BALANCE . 0 100,000.00. .00 .00 .75 100,000.75 CHECK SAFEKEEPING Statement Dates 9/28/02 thru DAYS IN THE STATEMENT PERIOD AVERAGE LEDGER AVERAGE COLLECTED Interest Earned Annual Percentage Yield Earned 2002 Interest Paid 9/~0/02 i 3 23,3~3.33 7,3~7.93 I I .75 i 1. 25% .75 ACTIVITY IN DATE ORDER DATE DESCRIPTION 9/30 DEPOSIT 9/30 Interest Deposit TRACE NO 002075990 AMOUNT 100,000.00 .75 BA~CE 100,O~O.OO 100,O~O.75 I 12~E,2ENCE -- S.C-\-\ t b L- L ~ (P~. 7 or.:: (4) - J-( e/'v\ S A. 1-/ DEPOSIT TICKET I-V---::J CASH ~ 60-15038 313 . J....... I i ~_ .1 / '-/ DATE >~ DEPOSITS M~Y NOT BE AVAILABLE FOR IMMEDIATE WITHDRAWAL SUB TOTAL ~ StGIi HERE FOR CASH RE'CEIVEO ,It' HEOoJlRHi L~ES~EfNfi ~ ~ : ORRSTOWN MNK. .'- DEPOSITOR'S $<;' , COpy ~ I: 0 ::l . ::l . SO ::l b I: . 0 aDO b :i ~ 51/' J:2..c ~-tl2E-N CE $c.Hc l)uL € r-- / :L'tcJ'.-'\ 5 f\ C/G- ~ o~ 11..\-) - I~ i~ I~/. .~ " II ~ I' I' ORRSTO~N2/28/05 13)\]\J~~~RY ACCOUNT ENCLOSURES ..-. '.. ..,. . .. . . )'i',. - " ~ : . I, , I III. "I" I , I '" 11,,/ " " , 1.1 HELEN Y GROUP PAUL E GROUP 23 CHURCH ROAD CARLISLE PA 17013 WE PUT THE LOW IN LO~~S! ASK ABOUT OUR SPECIAL LOW RATE HOME EQUITY LINE TODAY! CALL 1-888-0RRSTOWN ABOUT THIS LIMITED TIME OFFER! C H E C KIN G A C C 0 U N T S i'.CCOUNT TITLE HELEN Y GROUP PAUL E GROUP ACCOUNT NUMBER PREVIOUS BALANCE DEPOSITS/CREDITS 1 CHECKS/DEBITS SERVICE FEE INTEREST PAID CURRENT Bl'.LANCE 100,511.15 .00 100,511.15 .00 74.90 .00 ECK SAFEKEEPING atement Dates 2/01/05 thru DAYS IN THE STATEMENT PERIOD J'.VERAGE LEDGER AVERAGE COLLECTED Interest Earned Annual Percentage Yield 2005 Interest Paid 2/2'18/05 I 28 61,02~.62 61, 02~. 62 7~.58 Earned ~ . 71 % 21r.81 I I -+--- i , ACTIVITY IN DATE ORDER DATE DESCRIPTION TRACE NO AMOUNT , BALl1\JCE 100 , 5 8 r~ 0 5 .00 I I i Qtr-0'2aJL~ ~ ePG. <1 O~ :s'L l-\~~GLE r-- f' L-n~]'\-'\ .5 I~ l4 ) I:A.1 A rrJ' rrl I~ ....... Checking/S~vings/Club Debit Date _~,.: ,/:/A.,./ ..1 , ' '. ~ A h~,~' ,A ,J.'f"ior. .Account Number ..\ .r/.:,,....,. 1 Customer Name .- Description /.;> >< ,;; " ,<..<:,,;';(' / -....-- / --/ -t.... ..--..,..--.. / .: ',J' ,./' , Checking (53) Misc. Debit (66) MMA Debit (77) Correction (50) Closing Acct. / ,)(). .,:;- xC. ()S- . / (52) HometoVl(nlnvestment Withdrawal Savings (5~) Regular wid (50) Closing Acct. (51) Closing Apct. X' Customer Signature ,r;,.-( / - /'t) - i ~ ",- . Prepared By.., ~.:> .' 7[i ----.- ,,---.' ~~.~/ - -' k.E'I-t02..ENLl:.. ~ SCH-c:T)l;Lt:.- 'F/ ].::CEI'--i 6' A C ~ G - t 0 or: (4:) II ?~I'-. 1IL3 CIF# G000425 .... PRIME STATEMENT SAVINGS ACCOUNT OWNER(SI NAME & ADDRESS Orrstown Bank Stonehedge Office 427 Stonehedge Dr Carlisle, PA 17013 (866) 624-4229 ACCOUNT NUMBER Br: 6 HELEN Y GROUP PAUL E GROUP 23 CHURCH ROAD CARLISLE PA 17013 OWNERSHIP OF ACCOUNT. PERSONAL PURPOSE JOINT. NO SURVIVORSHIP (as tenants in common) o TRUST. SEPARATE AGREEMENT: o REVOCABLE TRUST DESIGNATION AS DEFINED IN THIS AGREEMENT Name and Address of Beneficiaries: ~ NEW o CHECKING o MONEY MARKET o NOW o EXISTIN KI SA VING~ o CERTlFICr TE OF DEPOSIT o I I TYPE OF ACCOUNT This is your (check onel: ~ Permanent 0 Temporary account greement. 1 : ~ NO I Number of signatures required for withdrawal FACSIMilE SIGNATUREIS) AllOWED? 0 YES OWNERSHIP OF ACCOUNT. BUSINESS PURPOSE o SOLE PROPRIETORSHIP o CORPORATION: 0 FOR PROFIT 0 NOT FOR PROFIT o PARTNERSHIP o [x ] SIGNATURElS) - The undersigned agree to the ter s stated on every page of this form and acknowledge receipt of a c pleted copy. The undersigned further authorize the financial institut on to verify credit and employment history and lor have a Credit~ reporting agency prepare a credit report on the undersigned. a individuals. The undersigned also acknowledge the receipt of a co y and agree to thll terms of the following disclosure(s): I ~ Deposit Account g] Funds Availability rn Truth in Savings ~ Electronic Fund Transfers ~ Privacy 0 ~ubstitute Checks o I I BUSINESS: COUNTY & STATE OF ORGANIZATION: AUTHORIZATION DATED: BY IMELDA N STEVIS N DATE OPENED . INITIAL DEPOSIT $ 100, 586 . 05 o CASH 0 CHECK ( HOME TELEPHONE # BUSINESS PHONE # [x ] (1) : DRIVER'S LICENSE # E.MAll EMPLOYER RETIRED MOTHER'S MAIDEN NAME HELEN Y GROUP 180-09-0027 D.O.B. 121/10/16 PoJ E: d~! (ptJ,'?.J ] PAUL E GROUP I 168-36-8627 D.O.B. 05/18/47 I.D. # (2): .[ ..X ~., . Name and address of someone w ,;. 1.0.# BACKUP WITHHOLDING CERTIFICATIONS TIN: 180-09-0027 ~ TAXPAYER J.D. NUMBER - The Taxpayer Identification Number shown above (TIN) is my correct taxpayer identification number. [X ] (3): I.D. # D.O.B. ~ BACKUP WITHHOLDING . I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all Interest or dividends, or the Internal Revenue Service has notified i me that I am no longer subject to backup withholding. i n EXEMPT RECIPIENTS - I am an exempt recipient under the Internal Revenue Service Regulations. [^ ] (4): 1.0.# D.O.B. o Authorized Signer (Individual Accounts Only) [x SIGNATURE: I certify under penalties of perjury the statements checked in this section and that I am a U.S. person {includin a U.S. resident al~ () ftJ. F$ 1 (Date) ] x 1.0.# D.O.B. (l-t:re(ZJ:::NGE - <:;CHt-\:)uLE r-:-, 1-l"6V\ S- A [PG. II 0 ~ 14-) ~eprint - 9/8/2005, 5:37pm . "'-"-DEPOSITI ~~JI~ ~ , 4. DATE ~-/7-o.s- I' CASHT CL RRr...CY t · r co ~ C H E C K S - -.TOol f/l .... r. .. s..!> r, TOTAL l I ~i~,> <^'.. J;h.(,.,(.:> i NET DEPOSJT J (~~tlt' ';"-1 6.:l-15roa 313 t If CrT...IR S )E Ft. ...~.:' T ........l I..-.t,,' 'u",......l,IJlt...,....I''t' h'I1t ORRSTOWN BE St'RE UCH filM I PROI>ERlY [...DOtUl i i 25 ,"00 100 $81;0 5." .: 50 30'" 5000': ?Ol; 00 ~qO *"- . l I I 'W''' " .,. ., tf', ..... fir I R" l .. ,..... ~ ... "'''' I '1 ~ 1 ,. I ,,^ ,., ... I ~ .... .... ~ -" .... ~ .... .... .... \D 01 " 0- U'! ~ Iol t.1 ... \D CD " 0- U'! . \101 t.) .... (;) ;:1 f'..."t J"ooo..) ~J ....."t -:.. ~ (:;, <::.! <':1 ("1 ~ I"l1 ;0 -t o -; > r- o ::z -t :I: I"l1 "T1 ~ Z . ".'1 ::~ -to ~--- ~~ oe--? 0'\ . ~ ~ "11 -; ::I: Vi -; n ?\ ~ -( o ~ > ,... n ::J: m n ;II; CIl -.J r- !l III :i t;) !( --...s . ..... ~ ) ~ I ~ 1 ~:=- l.... <. )II~ 1\1 '10..1.. .,a :JL """;: ,... t... ^ >>_, , "" ..,... i' I ..~ ,... ' :;. i:) V \1 V V'-' :J V .~.: l . ~ \.1 i i '" i 602~OO~0-1 ~fEP $ DO sac. Q: ~ n",~l-.ns .t't/~.U,",:" .. h 1"1- kit,.", 'r>_ n!1 .. ..~l-' rru:....L '-' J7 ,_ ,,', 10 NtXT BUSIN 55 [fA .. 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'h::r:-:&1-' 'Il{~;t< -' :-'fi9'if- :~~:::;~::':~~?~~:I~~'~~I~~~;~d'~':l\:~~; ',_I ..._I},., ',_,'. .I~___!I _-'1_ _':"~' -...:'':11 ,,- 11::1<:'- _-:1.-1'::1 :::tt _'.Descrlptlon. ,~.I p. .-t.:>:" t". -, ~ - _ - '1--,'. " -..' '-"1-" '.'1 -..' '-, i - ',- ,- --I' - ""1' ,'11-": --, -.' .-, '. " -I' -'\ ,-- ---,,-. :"'-, -. ..:-'!t:'J6'OtYIlll'x/-.".- -: '.- -_ _- -.: - ',.! "I' - - '1 " : Checki'nif"~ :~' i'~ :11- '::-, '-... :.~ ;-:: =..,~: :', ~Savings. -: ' -, ,- _ ,', ~: ' I -:: :- ' I:-~ :'11-__ ..: ( : ':Club ~ I ;': ~ -, -~ ~ -, ," __ :'-'".=1 ,-:,~ ~:: ,..:. : :(53\':Misc::oebit-.II." ,'_' ;,' :_" , - II,':, -..' '", ,"('ssrR'eg'ular wId ,=.' ,-:- ',:- ~-' .- ,:-.: ~: :-;(51).'Closing Accf II, ~ .-:~II-:, :--,.-- :' I -- (; - .- I I - . ~ ~ - I I I I . . I . _.~ 1 . - . I J' - I ~ - I - - I \. - ., -. - 1 J - - t 1 - - t. - - I ,. - I -.! - .- , -(6.6) ~~A Qebif - - : '- ,- , ' ~ '., ,-- " 1': -,IIJ5Q}~CI<?~ing ~cct.= - . -, - ,. ,-' .-, :- - .. -; -: :-'1:- '= I - - :-11 '_'.-~ ': I ~~ J::: i- I '.::-. : ca7 I,C -tf .,' ',' '_', .' ,I,. I , "-,' "- I. :" -.:": '::": -:' -' 1 . : II. - - _.! "I I, orrec lon' I . I I , . ' I , , , I -:. . , -, - , , -" - : , ::: ,t - -. -: I .' " - -,"', /;, - " .(50) Clo~in~:~'9(/:~~S"J:)-'~~.,.~~.: ,: ',',': ~l'=-:,. ;I.":~ust~.~~f~i~~~t~;e;>(', 'fW&l=dd:\;t!t?h~ \5., ~o~et~~. n-ln est,,:,,"JI. W~lrdra",~I., ",.',' ; " " ': . '" . " : ' ,",. ': . ,:. .', . ~ " '. P dB F~. .,1 f _ '- ,_" 1- - '- 1..1 t IJ I' I I' repare . y , "L-, , , I' ' I . ,I " .. _ " ~. '.:.', '. ' I . _, I,!: 0 :3 ~ ~ ~.s 0 3 b I: ,_ ~o BOO b :1 ~ 5111. 1 -, 50 .il 0 0 ~ 0 0 58 b' 0 5.11 . ,,' I , 'I, I. I' I I I ..... ' ~,:>' ,8 'N 't'V -, ,!,~, \',) - \. I ()I;:I I OOJ:~OL '. ) 9 E 0 S I S. I. E 0 <: o '17 'Z' B. f, 0 0 O,~lj 0'_ ')10. 1\1 fi} 0 1. S ~ '8 0. SO -_~:r l ,"':2,0:. -...:I' ........f ..:" 0'- ' N .,. ;; ,'Co kFF-C12WLt.. ,- SC.H-EDu Lt: 'r:- / '1:L0"-'l 6: 1\ C(JG,\3o~14) / I ~ {\ (\ ORRSTO~N3/31/05 13~~~RY ACCOUNT ENCLOSURES Page 2 106211105 HELEN Y GROUP PAUL GROUP 23 CHURCH ROAD CARLISLE PA 17013 PRIME STATEMENT SAVINGS .'\CCOUNT NUMBER PREVIOUS BALANCE 1 DEPOSITS/CREDITS CHECKS/DEBITS SERVICE CHJI.RGE J N'l'EREST Pl'.ID ENDING BALANCE atement Dates 2/17/05 thru 3/ DAYS IN THE STATEMENT PERIOD AVERAGE LEDGER 100,5 AVERAGE COLLECTED 100,5 Interest Earned 3 Annual Percentage Yield Earned 2005 Interest Paid o 1/05 43 6.05 6.05 7.22 3.04% 3 7.22 / .00 \/100,586.05 .00 .00 / 347.22 V\00,933.27 REFERENCE 040093230 kfF"D2St0LE:' - SC\-\c t uLE F / :::L'TCM S- A ((Jb. iY O~ 14) ," .. ... IIiIIIII- ...- .-... "" HoIIin~er Funeral Home & Crematory. Inc. Eric L. HolIinQer. Supervisor June] O. 2005 Helen Group Yeingst 4228 Carlisle Road Gardners, PAl 7324 The Funeral Service for Helen Yeingst Group We sincerely appreciate the confidence YOll have placed in us and will continue to assist YOll in every waj' we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES. FACILITIES. AUTOMOTIVE EQUIPMENT. AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. I. Professional Services Funeral Director & Staff. . . . . . . . . . FUNERAL HOME SERVICE CHARGf:S SELECTED MERCHANDISE: l"iger Eye . . . . . . . . . . . . . . Oul<:r . . . . . . . . . . . . . . . 3620.00 3620.00 3000.00 1075.00 THE COST OF OUR SERVICES. EQUIPMENT, AND MERCHANDISE THA T VOl) HAVE SELECTED . . . . . . . . . . . . . 7695.00 Cash Advances Cemetery Charges. Newspaper Notice. Cerlilied Copies . Clergy Honorarium r:lowcrs. . . . TOTAL CASH ADVANCES AND SPECIAL CHARGES. 610.00 70.00 72.00 100.00 133.50 985.50 Total Total Cost . . . . . . . . . . . . . . . . . . . . . . . . . 8680.50 H1story 04/28/2005 Payment Forethought . TOTAL AMOUNT DUE -8400.00 280.50 ?~6~\5 \^ 19-\\O\~ 50] NORTH BALTIMORE AVENUE · MOUNT HOLLY SPRINGS. PENNSYLVANIA 17065 . (717) 486-3433. fAX (717) 486.321S www.hollinQerfuneralhome.com PAuL E. GROuP ANNA L. GROUP 23 CHURCH ROAD CARLISLE, PA 17013.Y332 1.\ \ ill 1'5/1,e 6 t1fc rt '71[' ~;~ "~Icl ;u</ 60-15036 313 000;,'25 11AIJ-Ll1dy d. f {/II? I ?'{; E. /1 'J ~.# cfC' ~ 6-t~- (i ~/<~ ...~.~ ~ ORRSIDWN RANK i /' oj r ,(,~~t) It.. \11'.1\ I I...-~If ou,? rL.._,....~"'4 R"A /1; I ,':(-Y\.~ '- I: 0 :) " :) " 5 0 :) b I: 0 0 0 ~ 0 5 a 2 5 III ,,5 a 7 I2e.ce-p-r: c>-. 1587 ~S- ")f~ x'.. $ ..]',..) ~ ---t .I\. Ii:, i,'- 5J f Ji M' .~ STEPHEN L. BLOOM ATTORNEY AND COUNSELLOR AT LAW WWW I'RACIICAI.COliNSEL COM 2100 LONc;SGAI'RnAIJ CARl.ISl.E. PEN;\iSYI.V/lNIA 1701."\ Sill (l () \,1 @ I' 1\\ (' T ,( /I I ( () I '\' S E I ( (l \1 Invoice submitted to: Group, Helen Y. c/o Paul E. Group, Executor 23 Church Road Carlisle PA 17013 June 08, 2005 In Reference To: Estate Administration Invoice #1589 Professional Services 4/29/2005 Preliminary administrative matters 5/11/2005 Preliminary administrative and estate matters; Conference with Executor; Preparation of Petition for Grant of Letters Testamentary, Oath of Personal Representative, proposed Grant of Letters. Estate Information Form and Exhibits; Document file re estate information; Preliminary Inheritance Tax matters 5/24/2005 Administrative and estate accounting matters; Prepare and file Federal Form SS-4 re Estate FEIN; Review correspondence from IRS re same; Telephone conference with client 6/1/2005 Administrative and estate accounting matters 6/2/2005 Administrative and estate matters; Review and file documents; Correspondence with PNC Bank, Orrstown Bank, M& T Bank, Sovereign Bank and Capital Blue Cross; Preparation of required Notice of Beneficial Interest in Estate and Certification of Notice under Rule 5,6(A); Preparation of required Legal Notices for publication; Correspondence with the Sentinel and the Cumberland Law Journal re same; Correspondence with Department of Public Welfare, Estate Recovery Section 6/3/2005 Appearance at Register of Wills Office to present Certification of Notice; File confirmation of same PRACTICAL COUNSEL + CHRISTIAN PERSPECTIVE TFLEPHn F:\CSr\1I1 TIll1 F/( I Hrs/Rate I I 0,50 I 200.00~hr 3.61. 200.00/hr 0.54 h 200.00/ r I I , i 0.17 i 200.00/br I 2.51 : 200.00/hr i 0,75 ' 200.00/~r 7[7-249-7~1.~ 7[7249,77:;-:- R 7 ... - .; 4 X q I) :: ~ Amount 100,00 721,61 107.44 33,33 502,22 150,00 Group, Helen Y. 6/8/2005 Consultation with client and miscellaneous matters; Review and file documents; Preliminary Inheritance Tax matters For professional services rendered Previous balance 7/23/2002 Payment - thank you Total payments and adjustments Balance due PAYABLE UPON RECEIPT - THANK YOU PRACTICAL COUNSEL 110 CHRISTIAN PERSPECTIVE Page 2 Hrs/Rate Amount 1.49, 297.17 200.00~hr 9.57', $1,911.77 $75.00 ($75.00) ($75.00) $1,911.77 STEPHEN L. BLOOM ATTORNEY AND COUNSELLOR AT LAW WWW I'RACTICALCOUNSEL COM 2100 Lo:-.;c;s GAP ROAD CARLISLE. PENNSYLVANIA 17013 SlJ LO() M@PRACTICA LC 0 \' N 5E L. C OM Invoice submitted to: Group, Helen Y. c/o Paul E. Group, Executor 23 Church Road Carlisle PA 17013 August23,2005 In Reference To: Estate Administration -Interim Invoice 6/9/05-8/23/05 Invoice #1624 Professional Services 6/28/2005 Telephone consultation with client 7/6/2005 Review correspondence from Department of Public Welfare, Estate Recovery Program 7/27/2005 Administrative and estate matters; Review Proofs of Publication of Legal Notice; Review correspondence from Knouse Foods; Review documentation of expenses and assets; Preliminary Pennsylvania Inheritance Tax and Discount Calculation; Telephone consultation with client 8/3/2005 Telephone consultations with client and PNC Bank; Correspondence 8/23/2005 Administrative and estate accounting matters; Review and file Pennsylvania Inheritance and Estate Tax Official Receipt; Correspondence with M& T Bank and Orrstown Bank; Correspondence with client; Preliminary Preparation of Inheritance Tax Return Schedules For professional services rendered Additional Charges: 7/19/2005 Publishing Fee - Legal Notice - The Sentinel Total costs TEl. F P lION F 7 1 7 - 2 4 9 - 7 7 1 7 FACSIMILE 717-249-775'" TOLLFRFF 877-548-9602 Hrs/Rate Amount 0.08 16.67 200.00/hir 0.08 16.67 200.00/h!r 1.11 221.89 200.00/hl" 0.25 200.00/hr 2.17 200.00/ht 50.00 433.83 3.69 $739.06 137.03 $137.03 PRACTICAL COUNSEL + CHRISTIAN PERSPECTIVE Group, Helen Y. Total amount of this bill Previous balance 6/8/2005 Payment - thank you 7/30/2005 Payment - thank you Total payments and adjustments Balance due PAYABLE UPON RECEIPT - THANK YOU PRACTICAL COUNSEL + CHRISTIAN PERSPECTIVE Page 2 Amount $876.09 $1,911.77 ($1,911.77) ($137.03) ($2,048.80) $739.06 STEPHEN L. BLOOM ATTORNEY AND COUNSELLOR AT LAW WWW PRACTICAl.COUNSEL COM 2 100 L () N (; S GAP R 0 A 0 CARLISLE, PENNSYLVANIA 1701.~ SflLO()M@PRACTICAlCOI'NSEl. COM Invoice submitted to: Group, Helen Y. c/o Paul E. Group, Executor 23 Church Road Carlisle PA 17013 October 14, 2005 In Reference To: Estate Administration Invoice #1651 Professional Services 8/24/2005 Telephone consultation with client 9/7/2005 Administrative and estate matters; Research re joint account Inheritance Tax requirements; Review correspondence from M&T Bank and Orrstown Bank; Office consultation with clients; Review and file documents 10/5/2005 Administrative and estate matters; Evaluation of joint bank account history documents and research re Pennsylvania Revenue Department Regulations re application of Inheritance Tax to same 10/13/2005 Preparation and finalization of Pennsylvania Inheritance Tax Return, Tax Calculation, Schedules and Exhibits for filing; Preparation of required estate Inventory for filing; Preparation of Status Report of Administration under Rule 6.12; Confirmation of applicable Register of Wills filing fees; Administrative matters 10/14/2005 Conference with clients for review and execution of Inheritance Tax Return and Inventory; Final matters of administration: Appearance at Register of Wills for filing of Inheritance Tax Return and Inventory; Official Reciept; Review of Notice of Appraisement from Department of Revenue; Appearance at Register of Wills for filing of final Status Report of Administration under Rule 6.12; Final correspondence For professional services rendered Previous balance PRACTICAL COUNSEL + CHRISTIAN PERSPECTIVE TELEPIION 717-249-7717 FAcSIMrLE 717-249-7757 TOLLFREF R77-'i4R.9602 H rs/Rate i Amount 0.08 ' 16.67 200.00/~r 1.14 227.33 200.00/~r 0.70 139.39 200.00/hr 3.41 682.44 200.00/~r 1.42 283.33 200.00/lir 6.75 $1,349.16 $739.06 Group, Helen Y. Balance due PAYABLE UPON RECEIPT - THANK YOU PRACTICAL COUNSEL + CHRISTIAN PERSPECTIVE Page 2 Amount $2,088.22 RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17G13 Rece~pt Date: Rece+pt Time: Recelpt No.: 5/11/2005 15:00:21 1040616 GROUP HELEN Estate File No. : Paid By Remarks: 2005-00435 PAUL GROUP JA -_______________________ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST WILL AUTOMATION FEE SHORT CERTIFICATE JCP FEE Cash Total Received......... 135.00 15.00 5.00 32.00 10.00 ---------------- $197.00 $197.00 CUMBERLAND COUNTY GE~RAL CUMBERLAND COUNTY GEN RAL CUMBERLAND COUNTY GEN RAL CUMBERLAND COUNTY GEN RAL BUREAU OF RECEIPTS & CNTR FUN FUN FUN FUN M.D CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, P A 17013 July 1, 2005 Cumberland Law Journal is published every Friday by the Cumberland County Baxr Association and is designated by the Court of Common Pleas as the official legal publicatipn for Cumberland County and the legal newspaper for publication of legal notices. TO: Stephen L. Bloom, ESQUIRE RE: Helen Group aka Helen Y. Group ESTATE Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. ===============================================================~==== Advertisement inserted on following dates: June 17,24, July 1,2005 Advertising Cost $ 75.00 $ 0.00 Proof of Publication Second Proof Request $ 0.00 Payment Received $ 75.00 Total Amount Due $ 0.00 -------- -------- Payment received June 14.2005 by Becky H. Morgenthal/Executive Director t<1:' AIN 'H'~ ....Ut< "UN rUt< yuut< t<l:l.ut<u~ PA 17013 BILL TO ATTORNEY AT LAW STEPHEN BILLlN DATE 06/22/05 TART DATE 06/08/05 RATE NET AMOUNT LGL 130.68 130.68 M PUBLIC NOTICES LINE 36 * 2 ST P DA . 06/2~/05 GROSS AMOUNT 3 PROOF OF PUBLICATION 01PRF 6.35 DAYS RUN PURCHASE ORDER Est.HelenGroup PAY THIS AMOUNT · AFTER 0 1-'lq~t) cl~ 3(PDI Deadlines for in-column legal advertisements: Monday is Friday at 11 a.m.; Tuesday is Friday at 4 p.m.; Wednesday is Monday at 12 Noon; Thursday is Tuesday at 12 Noon; Friday is Wednesday at 12 Noon; SU*day is Thursday at 12 Noon. MESSAGE: Thank you for advertising with The Sentinel. If you have any questions regarding your Legal bill please call Tammy Shoemaker 243-2611, ext 203. Fax your legals to 243-3754, attention Tammy Shoemaker You can also EMAIL yourlegaltoClassifiedads:classified@curnberlink.com Please send a cover letter including your name and address as an a~tachment rl- --.. v Sprint. 1 of 6 Monthly statement: April 25, 2005 Customer number 717-960-9410-962 Customer service 1-S00-S2S.S009 Internet address sprint.com/loc81 Summary of Current Charges Monthly Service Charges Other Charges and Usage Taxes and Surcharges Total 2269 .07 6.43 ---, 529;191 ._.,----~ TotatCurremChargu. Previous charges Payment April 13 - Thank you: Balance 28.70 -28.70 .00 TotaIDue:> DsteDue:. . fJ S-/If /O~- ;I I s'-f .) P6~ $29.19 @ Please recycle ............/;II\IIIlY<18.'2C)05 . -------------------------------------_._------------~------ NNNNNNYV 6 Please return this portion with payment. ..... ..... Sprint~ Customer service 1-800-829-8009 1111111, ,,1111, 1111/1111111,1"111111111. 111.1111.1'111.,11'11 AUTOCR" * R-005 - - 011877 PAUL GROUP % HELEN GROUP 23 CHURCH RD CARLISLE PA 17013-9332 = - !!!!!!!!! Internet address sprint.com/local Customer number 717-960-9410-962 Date due: May 18,2005 Total amount due: $29." ",.,,.J""" ""r.r May 25. Amount enclosed: , 529.1!l Wnte your 13-dlglt custorrWe{ nurno~r un chec"'- Make checks payable to: Sprint PO Box 7 40463 Cincinnati OH 45274-0463 1.1,.1,1,11111.11" .1.1..111'1' j/ 111.11"1 .1/ ,,1.1, I 12 71796094109621 00000000002919 000029193 0517409 \ I CUSTOMER: HELEN GROUP DA TE: 04/30/05 FACILITY: THORNWALD HOME ACCOUNT: 5702-01-(17574 PHARMERICA (::1:> 4'JI.,\ BU'l: I:^(;).J.\ VI', II^RRISIll'J{(;. I'^ 1-;112 PRIMARY PAYOR: INSURANCE SEl~0090027 POLlCY#: PREVIOUS BALANCE: PAYMENTS RECEIVED: -$173.91 CREDITS: S 1 73.91 I RX NUMBER I IBalance Forward: 04/15/05 PAYMENT - THANK YOU COPAY OR DEDUCTIBLE PER MEMBER'S INSURANCE 04/18/05 1171263.00 FUROSEMIDE 20 MG TABLET 04/26/05 1177372.00 DOXEPIN 50 MG CAPSULE 04/26/05 1178205.00 METOCLOPRAMIDE 5 MG TABLE 04/26/05 1179519.00 MORPHINE 10 MG/ML VIAL 04/27/05 1063848.05 METOCLOPRAMIDE 5 MG TABLE 04/27/05 1128262.02 DOXEPIN 50 MG CAPSULE 04/27/05 1171979.00 FUROSEMIDE 20 MG TABLET 04/27/05 1178890.00 AMOX TR-K CLV 875-125 MG 04/28/05 1102021.04 CARBIDOPA/LEVO 25/250 TAB DATE DESCRIPTION DENIED B' CUSTOMER'~ INSURANCE FOR NDC NOT 04/01/05 1089436.04 CITRUCEL POWDER 04/18/05 1147719.01 NATURE'S TEARS DROPS 04/19/05 1089436.05 CITRUCEL POWDER 04/26/05 1177501.00 EAR DROPS 6.5% 04/27/05 1102022.03 ASPIRIN 81MG TABLET EC 04/27/05 1128263.02 SENNA-GEN NF TABLET 04/27/05 1128264.02 PRILOSEC OTC 20 MG TABLET 04/27/05 1128265.02 OCUVITE TABLET PAGE: lof2 EFFECTIVE DATES: 05101/03 NEW CHARGES: BALANCE S112.X4 DUE' r SII2.X4 I I I I QTY BILLED DUE FROM INSUR~NCE CHARGES/ AMT INSURANCE ADJU T CREDITS I I I I I 173.91 -173.91 27.000 30.00 2.14 2~ .41 I 1. 45 1.000 30.00 1. 59 2(.65 .76 1.000 30.00 1. 59 21.66 .75 1.000 30.00 1. 86 21'.19 .95 42.000 30.00 2.47 2~.87 3.66 28.000 30.00 2.26 24.80 2.94 84.000 30.00 3.34 2:3.58 3.08 14 . 000 78.30 20.72 3:1.84 21.74 70.000 78.95 4.09 4Q.65 25.21 cm ~RED 454.000 15.000 454.000 15.000 28.000 56.000 28.000 28.000 : 7.75 4.35 7.75 3.00 .60 1. 45 21.70 3.85 7.75 4.35 7.75 3.00 .60 1.45 21.70 3.B5 BILLING QUESTIONS: OX:30 AM - 05:00 PM PHONE XOO-352-9161 MEDICATION QUESTIONS: 09:00 AM - 04:00 PM PHONE 7\7 -651-9996 PAYMENT A~DRESS: P.O BOX 6413 i CAROL STRE.AJM. IL 60197 -6413 PHARMERICA 491-A BLUE EAGLE AVE HARRISBURG. PA 17112 ru .11 ru [):> .11 W ..c b-' CJ CJ [):> [):> b-' rr- CJ ru CJ ru 31111-UB17 RETURN SERVICE REQUESTED CUSTOMER NAME: HELEN GROUP n Please check box if address is incorrect or insurance U information has changed, and Indicate change(s) on reverse side. 1...11111.111'11111111,11.1,1111111",11,..1,1..1,1..11,,111.1 HELEN GROUP C/O PAUL GROUP 23 CHURCH ROAD CARLISLE. PA 17013-9332 31111.UB 17 '1ICONQNP300BBB9 lICOPG2BY: 1.2 1l1li111111111111111111111111.... lllllU.. I : dlL ~ERICA ('Ij~ IF PAYING BY MASTERCARD. DISCOVER. VISA OR AMERICAN EXPRES$. FILL OUT BELOW CH~CK C^,1f) USIN(i ~()lIll^YMI-N r I ;~D .0 ~D ~IO i"""" MAsrH~CMH) f):SGOVPH _ VISA ~i AtJi-IlIC,o\ /-X.Jllt-I.~S "^HIl "1I1.<1lI H ^"'OIJI'IT SIGN^! ullL I 'XI' I)~II : ,ACCT.' DUE DATE PAY THIS AMOUNT 05/30/05 I 570~-Ol-07574 $112.84 1111,11111111111111111111111111111,111.11,1111111111,,11,1,1111 PHARMERICA P.O. BOX 6413 CAROL STREAM, IL 60197-6413 5702010007050704000112840 PAGE: 20f2 PREV10\JS $173.91 PAYMENTS -$173.91 CREDITS: NEW $ 112.X4 ~~~~NCE $112.X4 BALANCE: RECEIVED: CHARGES: DATE I RX NUMBER DESCRIPTION QTY I BILLED !DUE FROM I INSURANCE I CHARGES AMT INSURANCE ADJUST CREDITS 04/27/05 1150015.01 DOCUSATE SODIUM 100 MG CA 56.000 1. 85 1. 85 Amount Due: 112.84 ru ..0 ru 0> ..0 w .r= b' CJ CJ 0> 0> b' lr CJ b' CJ ru CUSTOMER: HELEN GROUP FACILITY: THORNW ALD HOME DATE: 04/30/05 ACCOUNT: 5702-01-07574 PHARMERICA c:~I~ THANK YOU FOR YOUR BUSINESS. WE APPRECIATE THE OPPORTUNITY TO SERVE YOU. 11111111 III. m 11111111111111111,. '111111101,t1Innllnllnnnnnnnn .......all Ii ... STATEMENT OF ACCOUNT Smith Radiology, INC 1515 Bridge Street New Cumberland, Pa. 17070 IRS NO. 251698194 PLEASE MAKE YOUR CHECK PAYABLE TO: Smith Radiology, INC. (717) 774-7351 Helen Group T Il 0 r n w aid H 0 m e 442 Walnut Bottom Road Carlisle,PA 17013 AMO NT PAID $ P~EffREil.)RN. OHlS .g>~R"IJCH\l WHH YOUR PAYMENT TO: DATE DR. PATIENT PROCEDURE CODE DESCRIPTION . AMOUNT PREVIOUS BALANCE > 0.00 22.00 0.00 02/17/05 ncs Helen 71010 03/21/05 Applied to Deductible 03/21/05 Mad applied 9.21 to Deductible 03/21/05 Chest 1V Plan Payment:. Adjustment Capital 12.79- Plan Payment:. Bill Balance--)\ I 0.00 9.21 CP~ 7/0)0;; tI- I () if ..~..,.#4-~...,_____ - ~- We Have Not Been Paid oi1Tl1TSClalm~ \ -~. Because Your Insurance Company: C1Sentpa~emtoyou rM Applied these charges to your deductible o Does not cover this service o Has not yet received the Information requested from you o Terminated your coverage on o Other Please remit In full or call to arrange a payment schedule. , IF FULL PAYMENT IS NOT RECEIVED A MONTHLY SERVICE CHARGE WILL BE ADDED TO YOUR BALANCE. PAYTHISAMOUNT ~ \ I Statement United Church of Christ Homes Thornwald Home 442 Walnut Bottom Road Carlisle, Pa. 17013 Statement Date: 06/09/05 I Helen Group Re: Helen Group Date Description Days Charges Balance 04/05 Supplies 58.59 $58.59 I'm sorry these charges were in her chart. Thanks Apr-05. Briefs reg Suction Cath Gloves Toothettes Wipes Cleansing foam Prefilled Humidifier E Nasal Cannula Water soluable bag T8 safety syringe Lube jelly 100ml sterile water Oxygen tubing . THORNWALD HOME . Helen Group 4.99 0.46 4.22 0.99 6.12 6.67 3.4 0.56 0.77 0.53 0.06 0.56 1 3 2 1 1 3 1 2 1 1 3 1 3' 1 14.97 92 4.22' 0.99 18.36 6.67 6.8' 0.56 0.77 1.59 0.06 1.68 1 58.59 KNOUSE FOODS Stephen L. Bloom Attorney and Counsellor at Law 2100 Longs Gap Rd. Carlisle, P A 17013 RE: Estate of Helen Group SS# 180-09-0027 NC #: 5140185193 Dear Mr. Bloom: Knouse Foods Cooperative. Inc. 800 Peach Glen - Idaville Road Peach Glen. Pennsylvania 17375-0001 Tel: (717) 677-8181 Fax: (717) 677-7069 Web Site: www.knouse.com July 25, 2005 M&T Investment Group forwarded to me the letter you sent to them on June 2, 2005 regar~ing the death of Helen Group. Thank you for informing us of her death. Helen was a member ~fthe Knouse Foods Bargaining Unit Employees Retirement Plan. At the time of her retirement ~elen elected the 60 Month Certain and Continuous form of payment. Under the terms of the 60 *,onth Certain and Continuous form of payment a monthly benefit is paid to the retiree for their lif~time with a guarantee of sixty (60) monthly payments. Helen retired from Knouse Foods on Octpber 1, 1982. As a result there are no additional benefits due or payable. Please extend our sympathy to Helen's family. The copy of the death certificate you provided stated that Helen died on April 27, 2005. He~en had elected to have her monthly benefit ($101.42) deposited directly to her checking account ~t PNC Bank. M&T Investment Group attempted to recall the May 2005 and June 2005 payments th~t were deposited in Helen's checking account following her date of death. M&T Investment Gro~p was informed that the account has been closed. As the attorney representing Helen's Estate we!would appreciate you reimbursing Knouse Foods Cooperative $202.84 for the two payments made tq Helen in May and June. If you have any questions you are welcome to contact me at 717-677-81 & 1 Ext. 1330. Thank you for your attention to this situation. . Sincerely, KNOUSE FOODS COOPERATIVE, INC. .' r;;z~ ohn H. Eisele Pension Administration