HomeMy WebLinkAbout10-28-05
REV - 1500 EX + (11..00)
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REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21 05
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
00502
NUMBER
g1. Original R~~- 0 2. Supplemental Return
o 4. Limited Estate 0 4a. Future Interest Compromise (date of death after
, 1~1~8~
\ ~ 6. Decedent Died Testate (Attach copy 0 7. Decedent Maintained a Living Trust (Attach
01 Will) copy of Trusl)
I,Oc9 ,.Liti~~tionpro~e:~:;e..cei~:.d.........> .....>>.....0.... <>.......>.1.0. Spousal Poverty Credit (date of death between
THIS SI:':CTION' MUSTi:JeCQMI?I..ISTED.AI..I..CQFlA
NAME
! Stephen L. Bloom
,.
COMMONWEAlTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
-- '--I DECEDENT'S NAME (LAST, 'FIRST, AND MIDDLE INITIAL)
Bosler, Martha J.
...
! ;;~;;~;A~~;M:D-YEAR)~~- "--l:~'~ ~~~I~~H ;~M-DD-YEAA)'----'
o APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL)
....
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IRM NAME <If applicable)
Stephen L. Bloom, Esquire
rELEPHONE NUMBER
~=~17117~::~~::::(SChedUle A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
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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)
174-05-0664
_ _~HIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
-- --------
SOCIAL SECURITY NUMBER
o 3. Remainder Retum (date of death prior to 12-13-82)'--
o 5. Federal Estate Tax Return Required
o 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
COMPLETE MAILING ADDRESS
2100 Longs Gap Road
Carlisle, PA 17013
(1 ) None
(2) None
(3) None
(4) None
(5) 52,519.09
(6) None
(7) None
(9) 11,721.99
(10) 418.04
--------L:::~:)
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10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
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(8) 52,519.09
(11 )
12,140.03
(12)
40,379.06
(13)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(14)
40,379.06
---_.__._.._._...._._~----~-_._._._..~_._-----_._-------
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
i 15.Amount of Une 14 taxable at the spousal tax rate,
or transfers under Sec. 9116(a)(1.2)
x .00
(15)
x .045
(16)
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16. Amount of Line 14 taxable at lineal rate
I 17.Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
x .12
(17)
19. Tax Due
40,379.06 x .15
(18) 6,056.86
(19)
6,056.86
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
20. 0
>> BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH << , i
Copyright 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00)
1\
>I
Decedent's Complete Address:
STREET ADDRESS
18 Cedar Street
CITY
Mt. Holly Springs
STATE PA
ZIP 17065
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
6,056.86
Total Credits (A + B + C)
(2)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
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.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3)
(4)
(5)
(5A)
(5B)
0.00
6,056.86
6,056.86
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? ............................. ............................... ............... ............................................
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?.. ............................... .................... ...................... ..........................................
y~ i
D 181
D 181
D 181
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of pe~ury, I declare that I have examined this return. including accompanying schedules and statements. and to the best of my knowledge and belief. it is true, correct and complete. Declaration of
~~pare!_2~~~~_~~an the personal rep~esentatilJe is based on at! information of which preparer has any knowledge. - ---.-...------ --
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS DATE
Merle W. Barclay
~ ~E~J6NSIBLE FOR FILING RETURN
18 Cedar Street
MI. Holly Springs, P A 17065
ItJ -27 -05-
ADDRESS
6~-
ADDRESS
DATE
2100 Longs Gaj) Road
Carlisle, ITA 17013
/0 :2/ 05
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 the
surviving spouse is 3% [72 P .S. ~9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of trans
[72 P.S. ~9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse fn
of assets and filing a tax return are still applicable even if the surviving spouse is the only be
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 I
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. ~9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal
1.2) [72 P.S. ~9116 (a) (1)].
~-t'-
Po.
f:\PD
-.. - -""';.';na SDouse is 0%
I 3S. 0 D disclosure
C(o 00
t-/ S" 00 e of a natural
~ LL~~
72 P.S. ~9116
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblil1
under Section 9102, as an individual who has at least one parent in common with the deceu,,"<, ....--
Iling is defined,
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF I FILE NUMBER
_ _~osIeI", M~~~a~_________________________1__~~_0~~0502 __ ___
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorshIp must be disclosed on schedule F.
ITEM
NUMBER
1 M&T Bank - Checking Account # 1183141
DESCRIPTION
VALUE AT DATE OF
DEATH
41,370.14
2
M&T Bank - Certificate of Deposit #031003911151600
11,148.95
TOTAL (Also enter on line 5, Recapitulation)
52,519.09
.
*i
COMMONWEALTH OF PENNSYLVANIA II
INHERITANCE TAX RETURN
RESIDENT DECEDENT
___ _____ _____~_l_
SCHEDULEH
FUNERAL EXPENSES &
ADIVIINIS1RA11VE COSTS
--
__ ~__ ___ n__ _____ _
ESTATE OF
Bosler, Martha J.
I FILE NUMBER .--------
___~~__L__~~___25 - 00502___ __ ___
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER I
-i-rFUNERALEXPENSES:
1 i Ewing Brothers Funeral Home
DESCRIPTION
I
i
B. I ADMINISTRATIVE COSTS:
1. I Personal Representative's Commissions
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Address
City State _ Zip
Year(s) Commission paid
2. Attorney's Fees Stephen L. Bloom, Attorney and Counsellor at Law
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
5. I Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
I Publication of Legal Notice - Cumberland Law Journal
I
2 I Publication of Legal Notice - The Sentinel
I
I
\
I
Ju
TOTAL (Also enter on line 9, Recapitulation)
I AMOUNT
+~~-------- ---
i 8,366.70
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
3,000.00
136.00
75.00
144.29
I
-----1----~-_.-- - - - -
11,721.99
1
.
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
L
,
I FILE NUMBER
______~__~~~5~050?___
ESTATE OF
Bosler, Martha J.
Include unreimbursed medical expenses.
ITEM
NUMBER
---.-.-
1
DESCRIPTION
AMOUNT
-~---~--~~--
103.00
Ambulance/Medical- West Shore EMS-BLS
2
Medications - NeighborCare Pharmacy Services
80.79
3
Nursing Care - HCR ManorCare
173.50
4
Medical Care - Horizon Eye Care
60.75
____ _ n__ ______
TOTAL (Also enter on Line 10, Recapitulation)
418.04
REV-1513 EX+ (9-00)
ESTATE OF
NUMBER
I.
II.
.
I SCHEDULEJ
~_~____ BENEFICIARIES
I
\
~
I FILE NUMBER
, 21 - 05 - 00502
I
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Bosler, Martha J.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
RELATIONSHIP TO
DECEDENT
I
+ AMOUNT OR SHARE
OF ESTATE
-----.--.----.--------
TAXABLE DISTRIBUTIONS (include outright spousal distributions)
Earl Rowe
I Big Spring Terrace
Newville, P A 17241
Other
1,000.00
2
Melissa (Rowe) Lesher
50 Bonnybrook Road, Lot #5
Carlisle, P A 17013
Other
1,000.00
3
Merle W. Barclay
18 Cedar Street
Mt. Holly Springs, P A 17065
50% of residue as
tenant by entireties
4
Donna Barclay
18 Cedar Street
Mt. Holly Springs, P A 17065
Other
50% of residue as
tenant by entireties
Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet
I NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
lB. CHAAIT ABLE AND GOVEANMENT AL OISTAIBUTIONS
I
i
I
I
I
I
I
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REv-1500 COVER SHEET]
I
.
......-----
I, MARTHA J. BOSLER, of North M~ddleton Township, Cumberland County,
Pennsylvania, declare th~s to be my last will and testament, and revoke all wills
and codicils which I have previously made.
I After the payment of all of my just debts, administrative expenses an
A. To Kelly and Joe Barclay each the sum of One Thousand Dollars
inheritance and similar taxes, I give and bequeath the following legacies:
($1,000.00) to be used for their college education and to be paid to them i
I should die before they graduate from high school and I have not previousl
pa~d the sum oe One Thousand Dollars ($1,000.00) to each of them.
B. To Earl and Melissa Rowe each the sum of One Thousand Dollars
($1,000.00) to be held in trust and invested by my Executor until each is
ready to go to college, and then to be applied toward his or her college
expenses, and if either of them shall fail to go to college, to be held in
further trust until the beneeiciary attains the age of 21 years, at which
time the trust shall be paid over to the beneficiary.
II All the rest, residue and remainder of my estate, real and personal,
I give, devise and bequeath unto Merle W. and Donna Barclay as tenants by the
entiret~es, and if both of them shall fail to survive me, I give, dev~se and bequeat
III
I appoint Merle W. Barclay Executor of this w~ll.
If for any reaso
the same in equal shares to their four children, Debbie Barclay, Lynn Barclay, Joe
Barclay and Kelly Barclay.
he shall fa~l to qualify or cease to act as such during the administration of my
estate, I appoint Donna Barclay as alternate Executrix, with the same powers and
duties as if originally appointed.
I direct that no bond shall be required of any
fiduciary named in this will.
IN WITNESS WHEREOF, I have hereunto set my hand and Beal this ~~ day of
July, 1986.
~t?1A/fi,A J-~ (SEAL)
Signed, sealed, publiShed and declared ' ; ~
by Martha J. Bosler, testatrix above named, ~ J3~ ~ ~
as and for her last will and testament, i~ . _
written on one sheet of paper, in our /"pOl) ~ 1'Yl...-) .I!!Jjg'g "7n!)-..8,
presence, who in her presence, at her
request, and in the presence of each
other have hereunto subscribed our
names as attesting witnesses:
.
rlI M&fBank
499 Mitchell Road, MiIIsboro, DE 19966 Mail Code DE-MB-12
Phone (888) 502-4349
Fax (302) 934-2955
June 16,2005
Stephen L Bloom
Attorney and Counsellor at Law
2100 Longs Gap Road
Carlisle, Pennsylvania 17013
Re: Estate of Martha J Bosler
Social Security: 174-05-0664* chanJ!ed to 206-56-1064
Date of Death: Mav 30, 2005
Dear Sir or Madam:
Per your inquiry dated June 07, 2005, please be advised that at the time of death, the above-named decedent had on deposit
with this bank the following:
1.
Type of Account
Checking Account
Account Number
1183141
Ownership (Names of)
Martha J Bosler ·
Merle W Barclay, POA
Opening Date
01/24/94
Balance on Date of Death
$41,370.14
Accrued Interest
$
0.00
Total
$41,370.14
2.
Type of Account
Certificate of Deposit
Account Number
031003911151600
Ownership (Names of)
Martha J Bosler ·
Merle W Barclay, POA
Opening Date
04/20/91 Closed 06/02/05
Balance on Date of Death
$11,014.90
$ 134.05
Accrued Interest
Total
$1l,148.95
Please be advised, there was no safe deposit box found for the above decedent. * For further account information,
regarding ownership, closures and/or reimbursement of funds, etc., please call the North Middleton Office # 717-
240-4521.
Sincerely,
~(J~r-
Nancy Clagett
Records Management
.
Ewing Brothers Funeral Home, Inc.
630 South Hanover Street
Carlisle, P A 170 I 3-
(717)243-2421
June 4, 2005
Merle W. Barclay
18 Cedar St.
Mount Holly Springs, PA 17065
The Funeral Service for Martha Jane Bosler
11
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, F ACIUTIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
\. PROFESSIONAL SERVICES
Services of Funeral Director/Staff . . . . . .
FUNERAL HOME SERVICE CHARGES
SELECTED MERCHANDISE:
18G Praying Hands Gask. Casket. . . . . . .
#5 American OBC. . . . . . . . . . . .
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THA l' YOU HA VE SELECTED . . . . . . . . . . . . .
Cash Advances
Opening Grave. . . . . . . . .
Clergy/Mass Offering. . . . . . .
Certified Copies of the Death Certificate.
Flowers (All Rose Spray) . . . . .
Sentinel Obit. . . . . . . . .
TOTAL CASH ADVANCES AND SPECIAL CHARGES.
Total
Total Cost.
. . . . . . . . . . . . . . . . . . . . . . . . .
SUB-TOTAL
INITIAL PAYMENT / DISCOUNT / CREDITS
TOTAL AMOUNT DUE
The unpaid balance over 45 days is subjected to a 1.00 % service charge per month - 12.0000 % per annum.
b/~~~
(?~r~ /~
~.
Member of National Funeral Directors Association
$2995.00
$2995.00
$2795.00
$1175.00
$6965.00
$1045.00
$100.00
$36.00
$159.00
$61. 70
$1401.70
$8366.70
$8366.70
11150.16
$-2783.46
p1.r-r &' #~ ;:;~~
- ~/J/~
-- Paf~
~ (3~~~
STEPHEN L. BLOOM
ATTORNEY l\ND COliNSELLOR AT LAW
w w W 1'1< ^ (' T I (' A I. C () I J N S I.: l. (" () M
2 I 0 0 L ( ) \i (; S GAl' R () :\ D
c: ,\ R I I S IE, P /. !'.; '.; S Y 1 V:\ 0: I A 1 7 0 1 J
, B I (l( 1\;1 (i~ I' 1< :\ ( TI ( ,\ I <. (ll "S E I. . C (l ~I
Invoice submitted to:
Bosler, Martha J. Estate
c/o 18 Cedar Street
Mt. Holly Springs, PA 17065
Merle W. Barclay, Executor
October 27,2005
In Reference To: Estate Administration - Final Billing Statement
Invoice #1655
Professional Services
7/6/2005 Correspondence; Review and file information from M&T Bank
7/13/2005 Review and file information from Department of Public Welfare, Estate
Recovery Program
7/26/2005 Administrative and estate matters; Review documentation re estate
expenses
8/24/2005 Correspondence
10/14/2005 Administrative and estate matters; Correspondence
10/19/2005 Administrative matters
10/26/2005 Administrative and estate matters; Preliminary preparation of
Inheritance Tax Return and Schedules; Correspondence
Reserve for final administrative and estate matters, including: Finalize
and Assemble Inheritance Tax Return, Schedules and Exhibits for
Filing; Finalize Inventory for Filing; Conference with Executor for
Review and Execution of Inventory and Inheritance Tax Return;
Appearance at Register of Wills for Presentation of same; Review and
Filing of Notice of Appraisement from Department of Revenue;
Preparation and Execution of Release, Receipt and Refunding
Agreements; Preparation of Notice of Status of Administration;
T f' l. E l' 11 ();\i E 7 I 7 - 2 4 9 - 7 7 1 7
FACSIMIlE 717-249.7757
T () l. I I; I( F I. R 7 7 - 5 4 R - 9 (, J .:
Hrs/Rate Amount
0.17 33.72
200.00/hr
0.09 1722
200.00/hr
0.25 50.78
200.00/hr
0.04 7.11
200.00/hr
0.17 34.78
200.00/hr
017 3383
20000/hr
1.95 390 17
200.00/hr
4.71 941.06
200.00/hr
PRACTICAl. COUNSEL + CHRISTIAN PERSPECTIVE
Bosler, Martha J. Estate
Appearance at Register of Wills for Presentation of same; related
Correspondence
For professional services rendered
Previous balance
6/7/2005 Payment - thank you
Total payments and adjustments
Balance due
PAYABLE UPON RECEIPT - THANK YOU
PRACTICAL COUNSEL + CHRISTIAN PERSPECTIVE
Hrs/Rate
7.55
l'
Page
2
Amount
$1,50867
$1,49134
($1,491.34)
($1,491.34)
$1,50867
STEPHEN L. BLOOM
A T TOR N E Y ;\ N D C 0 l' N S ELL 0 R :\ T L /\ \\
w W \V I' r~ ACT I C A /. C I ) r I I' S I: /. C () M
2100 L()~(;sC.\I'RI),\J1
C .\ J( /. 1 S I 1:. P / .,'< S Y r \' .\ ~ I A I 7J I .\
S II I () n \1 @ I' 1\ :\ C T II A /. C ( ) 1 . :'.: S F I. (' () \.,
Invoice submitted to:
Bosler. Martha J. Estate
c/o 18 Cedar Street
Mt. Holly Springs. P A 17065
Merle W. Barclay, Executor
June 03, 2005
In Reference To: Estate Administration - Initial Interim Billing Statement
Invoice #1588
Professional Services
5/31/2005 Preliminary administrative and estate accounting matters
6/2/2005 Preliminary preparations for probate/administration
6/3/2005 Administrative and estate matters; Research re effect of interlineation
on probate of original Last Will and Testament; Preparation of Petition
for Probate and Grant of Letters and Exhibits, Oath of Personal
Representative, Oath of Non-Subscribing Witnesses, proposed Decree
of Probate and Grant of Letters Testamentary, and Estate Information
Document; Preparation of IRS Form SS-4 and correspondence with
IRS re same and FEIN granted; Appearance at Office of Register of
Wills for presentation of Petition and supporting documentation;
Conference with Executor
Initial reserve for administrative and estate matters: Review of Grant of
Letters Testamentary/Short Certificates; Preparation and service of
required Notices of Beneficial Interest in Estate/Correspondence re
same; Preparation and filing of required Certfication of Notice at
Register of Wills Office; Preparation of required Legal Notices for
publication/Correspondence re same with Sentinel and Cumberland
Law Journal/Review Proofs of Publication; Correspondence with
Financial Institutions, Department of Public Welfare. etc. re
documentation of date of death Valuation/Liabilities/Review of same
For professional services rendered
T /. I (. I' II ( ) "F 7 1 7 . ! .\ <) . 7 ., I ;-
I" A I S I \1 r I r 7 1 7 !.\ l) ;' - ~ 7
TOI.l FREE R77.:;4R.<)(,:2
Hrs/Rate Amount
0.53 106.17
200.00/hr
025 4967
200.00/hr
2.76 552.17
200.00/hr
3.92 783.33
200.00/hr
7.46 $1.491.34
PR/\CTICAJ. COliNSI-:1. + CHRISTIAN PERSPECTIVE
, .
Bosler, Martha J. Estate
Balance due
PAYABLE UPON RECEIPT - THANK YOU
P R :\ cr I c: :\ LeO UN S I': L + C 11 R 1ST 11\ N PER S PEe T I V E
--
Page
2
Amount
$1,491.34
, I 4 ,
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17G13
Receipt Date:
Receipt Time:
Receipt No. :
6/03/2005
13:14:00
1040860
BOSLER MARTHA J
Estate File No. :
Paid By Remarks:
2005-00502
MERLE W BARCLAY
JA
------------------------ Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST
WILL
AUTOMATION FEE
SHORT CERTIFICATE
JCP FEE
Check# 3300
Total Received...... ...
90.00
15.00
5.00
16.00
10.00
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
BUREAU OF RECEIPTS & CNTR M.D
$136.00
$136.00
. t I "
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 Bar
Association and is designated by the Court of Common Pleas as the official legal publication for
Cumberland County and the legal newspaper for publication of legal notices.
TO:
Stephen L. Bloom, ESQUIRE
RE:
Martha J. Bosler aka Martha Jane Bosler, 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.
---------------------------------------------------------------------
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Advertisement inserted on following dates:
June 17, 24, July 1, 2005
Advertising Cost
$ 75.00
Proof of Publication
$ 0.00
Second Proof Request
$ 0.00
Payment Received
$ 75.00
Total Amount Due
$
0.00
---------
---------
Payment received June 14,2005
by Becky H. MorgenthallExecutive Director
. .' "
I'L; 11"'\11" I I II"'" r VI' I IVI" I VI' I vvn. .,.......'-'.''''''''''''
REMITTANCE ADDRESS I BILL TO
THE SENTINEL - LEGAL ATTORNEY AT LAW STEPHEN L. BLC:):
P.O. BOX 130, CARLISLE, PA 17013
AD NUMBER I CLASS SALESPERSoN BilliNG DATE LINES
287849 10 PUBLIC NOTICES c30 06/29/05 38 * 2
AD DESCRIPTION START DATE STOP DATE
NOTICE LETTERS TESTAMENTARY ON THE 06/09/05 06/23/05
PUBLICATION INSERTIONS RATE NET AMOUNT GROSS AMOUNT
3 THE SENTINEL - LEGAL 3 LGL 137.94
TOTAL AD CHARGE 137.94
3 PROOF OF PUBLICATION 01PRF 6.35
DAYS RUN
PURCHASE ORDER PAY THIS AMOUNT 144.29 173.15*
martha j . hosler · AFTER 07/29/05
M
MESSAGE:
Thank you for advertising with The Sentinel.
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; Sunday
is Thursday at 12 Noon.
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@cumberlink.com
Please send a cover letter including your name and address as an attachment
DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT
THE SENTINEL - LEGAL .
POBOX 130 CARLISLE PA 17013 martha J. hosler
. . I.
AD NUM-eI:R CLASSO START DATE STOP DATE
287849 PUBLIC NOTICES 06/09/05 06/23/05
AD DEsCRIPTION BILLlf'.m-DAiE TELEPHONE NUMBER
NOTICE LETTERS TESTAMENTARY ON THE 06/29/05 717-249-7717
GROSS AMOUNT OF
173.15
DUE AFTER 07/29/05
TOTAL AMOUNT DUE
144.29
ENTER AMOUNT ENCLOSED
ATTORNEY AT LAW STEPHEN L. BLOOM
2100 LONGS GAP ROAD
CARLISLE, PA 17013
1...11111.111'1111.111111.1111.1
20200000002878490000000000000001731500000144298
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WEST SHORE EMS - BLS
205 GRANDVIEW AVE
SUITE 211
CAMP HILL, PA 17011
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
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INSURANCE:
MEDICARE B
AARP
174050664A
174050664
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
28455 WCS
131301W NONE
OS/25/2005
11 :24 AM
CARLISLE HOSPITAL
CARLISLE REGIONAL MEDICAL CTR
MANORCARE HEALTH SVCS - CARLI:
PATIENT NAME:
MARTHA BOSLER
131301W
MERLE BARCLAY
18 CEDAR ST
MOUNT HOLLY SPRINGS, PA 17065
REASON(S)
FOR
TRANSPORT
AL TERED MENTAL STATUS
INVOICE
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
STRETCHER VAN ONE WAY A0999 1.0 63.00 63.00
OXYGEN ADMINISTRATION A0422 1.0 40.00 40.00
Total Charaes 103.00
DESCRIPTION OF PAYMENT
RECEIPT
PAYMENT DATE
AMOUNT
PLEASE PAY THIS AMOUNT -!~ #/0'/ ,.-
~-l'l-()j
$103.00
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE
PATIENT NAME: BOSLER, MARTHA J CALL NUMBER 131301 W AMOUNT $
PATIENT NUMBER: 28455 BILLING DATE: 06/27/2005 ENCLOSED
103.00
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THIS SERVICE IS NOT COVERED BY MEDICARE OR MEDICAL
ASSISTANCE.
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VISA
aster.€arci,
AND
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ACCEPTED i
WEST SHORE EMS - BLS 205 GRANDVIEW AVE CAMP HILL, PA 17011
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THANK/YOU FO~ ALLOWI G NEIGHBO CARE frO PROVIDE YOUR PHARMACY NEEDS. HE TOTA
RESPONSIBILITY AND M BE PAID BY PERS,NAL CHECK, MONEY ORDER, VISA. MA ERCARD,
OR AMERICAN EXPRESS. THE FAVOR FA P OMPT PAYMENT IS APPRECIATED.
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Our rJm2ttant addre s has changed. I you include the tear-off stub w th your
changJ 2S reL ected n the stub and nq> additional action on your parr: _s necess
a~d~:j12ne c eck ser ice and/or no stub is returned with your payment, please c
L-a s ~ . $tiAO 0",701" 'T'h;:,nk vn1J
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@ NeighborCare'"
~ Phoemo,y SP,~i,,,
.. 3419 CONCORD RD.
. YORK. PA 17403
, NCPDP# 3972634
. PHONE 888.565-6708
HOURS M.F 830 AM . 500 PM
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OS/21/05 R5859502 (OPAY 50458030201 RX
OS/25/05 R5861933 COPAY 51079075657 RX
OS/25/05 R5863386 COPAY 24208075006 RX
OS/25/05 R5863391 COPAY 58177088601 RX
05/31/05 R5865351 COPAY 50458030101 RX
BILL FOR SERVICES PAGE: 2 of 2
BILLING DATE ACCOUN~- -----.-
05/31/05 21-24156
PRIMARY PHYSICIAN ---~
#21 I GUISTWITE, DARRYL
~-USTOMER NAME
i MARTHA J. BOSLER
rFACILITY~--'
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lJv1CHS CARLISLE
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RISPERDAL 0.5MG TABLET
DAYS SUPPLY; 30
(ARBIDOPA & LEVODOPA 25HG/100MG TABLET
(RP; SINEMET)
DAYS SUPPLY: 30
ATROPINE SULFATE OPTHALMIC 11. SOLUTION
DAYS SUPPLY: 10
MORPHINE SULFATE 20MG/1HL ORAL CONC.
(RP: ROXANOL)
2iPPLY: 3
RISPERDAL 0.25MG TABLET
DAYS SUPPLY: 30
GUISHJITE
30
9.00
GUISTlHTE
90
6.00
GUISTWlTE I
GUISTl.JlTE i
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j DAYS OUTSTANDING
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,~~. 3419 ::::~~~v;~
YORK. PA 17403
. NCPDP# 3972634
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PHONE 888-565-6708
HOURS M-F 830 AM - 5:00 PM
,-~ PleaSi~ crwck box It lleio\';, address IS Incorrect or insurance
'n 'i1:(lr:~l"tl(!11 11"S cl,al1gcd and IIldlcatc changels) on reverse sloe.
ADDRESSEE:
I, .,111,1, III. 1"11,, ,1,1,. 1.11.1,,1,,1, 11,1, "" 111,,1,,11. ,I
MARTHA J. BOSLER
C/O MERLE BARCLAY
18 CEDAR STREET
MOUNT HOLLY SPRINGS, PA 17065-1429
'TAX "
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$89.74
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0.00
i_IF P!-Y~I>I_c;J:l..Y MAST~~I\'3.D, DISCOVEFl.. VISA OR AMER~AN EXPRESS, FILL OUT BELOW'-~
! CHECK CARD USING FOR PAYMENT ..._._-~
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I ,-~,--_____ MASTERCARD DISCOVER __ _ ___ _ VIS,!;, t;;.~~a AMERICA'" EXPRf:SS
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!c:.AFm NUM8fH -'TAMC)UNT--~--~--:
iSIGNATURE
-- I EXP DATE -..----j
r
CARDHOLDER NAME I CUSTOMER NAME ",'IIJ::I'Hj
i I MARTHA J. BOSLER
~CCOUNT NO. BilLING DATE _~MOUNT DUE
l___?1-24156 05/31/05 $89.74
30713 liE; 1 3693CDU056E PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT
MAKE CHECKS PAYABLE TO: 6S?S~6"
11"111,1"",111",1,1,1.1.,1,1,1"11,,,11,,.1111,1111,11,"I
NEIGHBORCARE PHARMACY SERVICES INC
BOX 8900 .
PHILADELPHIA. PA 19175.8900
45100000021-2415600000003214170000000000089748
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~. .~ NeighborCare™
. ~"... J..... Pharmacy Services
.. 3419 CONCORD RD.
'_ YORK, PA 17403
NCPDP# 3972634
. PHONE. 888-565-6708
HOURS M-F 830 AM - 500 PM
I" - ~----" --
1 CUSTOMER NAME
I
I MARTHA J. BOSLER
I FACILITY
I MCHS CARLISLE
BILL FOR SERVICES PAGE: 1 of 2
BILLING DATEJi,CC~D"ij"iiT-NO.~"
05/31/05 21-24156
PRIMARY PHYSICIAN
#21 GU!STWITE, DARRYL
'~TEi~ ~,$X"" : ~ANS 'd "t.lDC' '.CAT. . , ,".""...;. . 1)ESCRIPTION ' ,. " . " PHYSICIAN 'OTY. $AMOUNT
PAYMENT. THANK YOU!
CARBIDOPA & LEVODOPA 25MG/100MG TABLET
(RP: SINEMET)
DAYS SUPPLY: 30
RISPERDAL 0.25MG TABLET
DAYS SUPPLY: 30
LEVOTHYROXINE SODIUM ** 0.075MG TABLET
(RP:LEVOTHROID (75MCG))
DAYS SUPPLY: 30
ALLEGRA ** 180MG TABLET
DAYS SUPPLY: 30
OMEPRAZOLE ** 10MG CAPSULE SA (RP:PRILOSEC)
DAYS SUPPLY: 30
ATENOLOL 25MG TABLET (RP:TENORMIN)
DAYS SUPPLY: 30
FLUOXETINE ** 20MG CAPSULE (RP:PROZAC ****)
DAYS SUPPLY: 30
LORAZEPAM ** 0.5MG TABLET (RP:LORAZEPAM
****)
I DAYS SUPPLY: 3
I
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THANKiYOU FOIR ALLOW I G NEIGHBO CARE 0 PROVIDE YOUR PHARMACY NEEDS. HE TOTA
RESPONSIBILITY AND M~ BE PAID BY PERS ,NAL CHECK, MONEY ORDER, VISA. MAS1 ERCARD
OR AM~RICAN iXPRESS'ITHE FAVOR F A PROMPT PAYMENT IS APPRECIATED j
Our rdmittanqe addre~s has chan ed. I you include ~he tear-off stub w th your
change is re~lected n the stub and n additional action on your part Is necess
an on~line c eck ser ice and/or no st b is returned wi~h your payment, please c
addJ:.eds to the :10; one ref1 ~&;'tub belo,.r Th.::mk- yn))
05/17/05 CK2039 GP
04/25/05 R5845033 COPAY 51079075657 RX
! 05/01/05 R5848824 COPAY 50458030101 RX
05/09/05 R5853222 COPAY 00378180501 RX
05/13/05 R5855866 COPAY 00088110947 RX
05/13/05 R5856471 COPAY 00378521193 RX
05/17/05; R5842412 CO PAY 51079075920 RX
05/18/05 R5858129 COPAY 49884073301 RX
05/18/05 R5859130 COPAY 00228205750 RX
-77.42
GU I S T\-IITE 90 6.00
GUIST\-IITE 30 9.00
GUIST\.JlTE 30 6.00
GUIST\-IITE 30 9.00
GUIST\-IITE 30 6.00
GUIST\-IITE 30 5.93
GUIST\-JITE 30 6.00
GUIST\-IITE 15 5.81
YOUR
ER,
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PREVIOUS'BAlANCE :'l'-.:1iPAYMENTS ',-.' ;~:."'J1ETURNS" 'ADJUSTMENTS, RNANCECHARGE .":NEWCHARGES . TAX ''i'OTALDUE,
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3419 CONCORD RD,
YORK, PA 17403
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.- rnlorl1c;;t,o:ollaS chanllfcj. and Indicate cllangelsl on reverse srde
ADDRESSEE:
1",11/",111",.11",1,1""11,1"1,.1,11,1",,,111,,1,,11,,1
MARTHA J BOSLER
C/O MERl.E BARCLAY
18 CEDAR STREET
MOUNT HOllY SPRINGS, PA 17065-1429
1IIIIIIIII!IIIII!IIIIIIIIIII~!lnlllllllllllllilllllllllll!111I11! Ilill 1111I 1111 II'
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: IF PAYING BY MASTERCARD. DISCOVER, VISA OR AMERICAN EXPFlESS. FILL OUT BELOW.
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, ~.....: MASTERCARD
icARD NUMBFR '
,
ISIGNATURE
I
I CARDHOLDER NAME
1
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CHECK CARD USING FOR PAYMENT i
.. 0 . VISA' ,0 ~ 0 ,
, DISCOVER VISA ~ AMERICAN EXPRESS j
i AMOUNT
I
I EXP DATE
~
I CUSTOMER NAME
I MARTHA J. BOSLER
ACCOUNT NO. , BILLING DATE I AMOUNT DUE
i '
L 21-24156 I 05/31/05! See LastPag~
30713'1,1313693C000563 PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT
MAKE CHECKS PAYABLE TO: 6525461;
'lIJ=I.,.'ti
06/20/05
" .
1",111,1.".,111",1,1,1,1"1,1,1"11",11,,,11,,,11,"11,,,1
NEIGHBORCARE PHARMACY SERVICES. INC
BOX 8900
PHilADELPHIA, PA 19175-8900
45100000021-2415600000003214170000000000089748
.........
HCR.ManorCare
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE. PA 171313
(717)-2t19-00BS
PRIVATE
I~ERLE BARCLAY
FOR MARTHA BOSLER
18 CEDAR STREET
MOUNT HOLLY SPRINGS. PA
ROO/~ 218 -f'-\
1713 6!:,
BOSLER, MARTHA .J
24156
11/18/04 05/30/05 05/31/05
eI5/01/0'6 BP,Lr\NCE FORWARD 5.728.00
05/113/135 PAnlENT 5,234.00
0f,/10/05 PAYMENT 2113.00
05/30/05 51801 TOTAL INCONT-OLY FEE QTY 30 ) 2113.00
e'5/04/05 1110(1 WASH AND SET QTY 1 ) 9.00
05/04/05 111ei0 HAIR CUT QTY 1 ) 8.50
(')5/01/05 REV LASi MO RC 5,518.013
05/01-05/30/05 ROOM CHARGE 5,340.00
03/31/05 AD,] REV R & B 1.602.0(1
03/31/05 ADJ R & B 1,566.00
04/30/0S ADJ REV R & B 5.518.00
04/30/05 AD,] R & B 5,394.00
PAYMENi DUE UPON RECEIPT
~-
173.50
E.4;(:itX; -#-/01
d'-//-OS
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___~~ 071516MJB
rLRf2J::N EYE CARE GUlP, P. C.
aJ7 MDICi'lL AR15 HJLUJI1G
22f) WIL9CN S.il<N::1.'
CARLISlE PA 17013
C: ..,.. f ~'T'< ~ (, r::;. f r-r-
\,. ,/',!, l\il[.~ '\ I
~. SERVICE REJ;!JESIED
11796
135372
"l'TE14
13HF 002
1751 L
AMOUNT
;-~: ::'_ ! 0"1 1-
HORIZON EYE CARE GROUP, P
207 MEDICAL ARTS BUILDING
220 WILSON STREET
CARLISLE, PA 17013-3697
111,111".111,","11..11,"11,.11"1.1..1..,11.1..1.1,
CREDIT CARD
CARD NUMBER
CARDHOLDER NAME
MARTHA J. BOSLER
SIGNA TURE
MERLE BARCLAY
18 CEDAR STREET
MOUNT HOLLY SPRING, PA 17065-1429
111I111".111,".11..,1.1....11.1..1..1.11.111,"111"1..11..1
1.1,1
60.7!
717 243 2331
071516MJB
01
PLEASE RETURN THIS PORTIO WITH PAYMENl
Patient Balance
SHOW AIVIO T /0 7 e-
60.75 PAID HERE $ It' I ..)
OffiCE: Phonr- !;Jumbei
YOllC Accoun: Number
P:}CJ€ !\Jc
---------------------~,----------------------------------------- -------------
CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL Bill OR STATEMENT
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,04 CPT: 76519 -LT A-SCAN WITH IOL CALCUL M BOSLER
366,17
104 HGSADMINISTRATORS FILED
:04 AARP HEALTH CARE OPTIONS FILED
243.00
-182.2
60.7!
0.00
0.00
FOR YOUR CONVENIENCE WE ACCEPT VISA OR MASTERCARD
09/13/05
PLEASE INDICATE YOUR ACCOUNT NUMBER WHE\J CALLING OUR OFFICE:
071516MJB
tIDING
PATIENT HAL
60.75
TOTAL HAL
60.75
CURRENT HAL
PAST DUE
60.75
PATIENT LANCE
PAY THI MOUNT
liES I PAyMENTS TO
ON EYE CARE GROUP, P.C.
EDICAL ARTS BUILDING
ILSON STREET
SLE PA 17013
(717) 243-2331
41100
q--I'1-0
---