HomeMy WebLinkAbout12-05-05 (2)
REV-1500 EX + (6-00)
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
HOOVER PAUL
DATE OF DEATH (MM-DD-Year)
F.
DATE OF BIRTH (MM-DD-Year)
09/14/2005 04/02/1925
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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lliJ 1. Original Return
o 4. Limited Estate
lliJ 6. Decedent Died Testate (AttachcopyofWi/I)
o 9. Litigation Proceeds Received
o 2. Supplemental Retum
o 4a. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy ofTrust)
o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
OFFICIAL USE ONLY
FILE NUMBER
21 -0 5 0 8 3 9
COUNTY CODE ---vEA~ - - NUMBEA- -
SOCIAL SECURITY NUMBER
1 6 2 - 2 2 - 0 734
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (date of death prior 10 12-13-82)
o 5. Federal Estate Tax Return Required
_ 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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THIS SECTION >MUSTBE COMf'LETEP, ALl.. COAAESPONPENCE5ANPCONFIPEN't'AL''tAXINFOA MATlON.SHOULD BE>DIRECTEI1TO:
NAME COMPLETE MAILING ADDRESS
ROGER B. IRWIN ESQUIRE 60 WEST POMFRET STREET
FIRM NAME (If Applicable)
IRWIN & McKNIGHT
TELEPHONE NUMBER
717 -249-2353 CARLISLE P A 17013
0.00 X _(15) 0.00
0.00 X _(16) 0.00
425,838.59 X .12 (17) 51,100.63
85,167.72 X .15 (18) 12,775.16
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1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
(11)
(12)
(13)
(8)
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)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
(14)
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
OFFICIAL USE ONLY
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105,638.89
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436,761.92
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542,400.81
25,396.63
5,997.87
31 ,394.50
511 ,006.31
511 ,006.31
19. Tax Due (19)
20. 0
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REV-1508 EX + (6-98)
.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
HOOVER PAUL
FILE NUMBER
F. 21 05
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
0839
ITEM
NUMBER
1.
DESCRIPTION
M& T BANK - Checking Account #509434
VALUE AT DATE
OF DEATH
11,152.72
2.
Sovereign Bank - Checking Account #1671001559
1,432.32
3.
Sovereign Bank - Checking Account #1671018575
46,330.74
4.
Sovereign Bank - Certificate of Deposit #1675302077
16,245.66
5.
Sovereign Bank - Certificate of Deposit #1675509192
11,903.09
6.
Sovereign Bank - Certificate of Deposit #3385021096
18,574.36
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
105 638.89
REV-1510 EX + (6-98)
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SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
HOOVER
PAUL
F.
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
FILE NUMBER
21 05
0839
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER. ATTACH ACOPY OFTHE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST VALUE
(IF APPLICABLE)
1. AIG Annuity - Policy XP220598 201,977.29 100. 201,977.29
2. M&T Bank - IRA #035004200307385 1,477.17 100. 1,477.17
3. M&T Bank - IRA #035004200348488 11,273.66 100. 11,273.66
4. Transamerica Life Insurance Company - Annuity 222,033.80 100. 222,033.80
#02PSL019665
TOTAL (Also enter on line 7 Recapitulation) $ 436761.92
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX + (12-99)
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
HOOVER
PAUL
F.
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21
05
0839
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Hoffman-Roth Funeral Home 7,711.60
2. Eby Granite Works, Inscripti80n 1,220.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s) Rick A. Hoover 2,600.00
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address 1190 Newville Road
City Carlisle State P A Zip 17013
Year(s) Commission Paid:
2. Attorney Fees Irwin & McKnight 10,350.00
3. Family Exemption: (If decedenfs address is not the same as c1aimanfs, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees 298.00
5. Accountant's Fees
6. Tax Return Preparer's Fees 350.00
7. Cumberland Law Journal, Estate Notice 75.00
8. The Sentinel - Estate Notice 137.03
9. Notary Fees 25.00
10. Register of Wills, Filing Fee 30.00
TOTAL (Also enter on line 9, Recapitulation) $ 25 396.63
(If more space is needed, insert additional sheets of the same size)
Continuation of REV-1500 Inheritance' Tax Return Resident Decedent
HOOVER
Decedent's Name
PAUL
F.
Page 1
21 05 0839
File Number
Schedule H - Funeral Expenses & Administrative Costs - 81
ITEM
NUMBER DESCRIPTION AMOUNT
B. ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s) Kenneth E. Waqner 2,600.00
Social Security Number(s)/EIN Number of Personal Representative(s) 164280732
Street Address 60 Parker Street
City Carlisle State P A Zip 17013
Year(s) Commission Paid:
SUBTOTAL SCHEDULE H.B1 2,600.00
REV-1512 EX + (6-98)
.
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
HOOVER
FILE NUMBER
PAUL
F.
21
05
0839
Include unreimbursed medical expenses.
ITEM
NUMBER
1.
2.
3.
4.
5.
DESCRIPTION
VALUE AT DATE
OF DEATH
Continuing Care RX
697.17
Cumberland Crossings, Nursing
4,354.00
Philhaven, Medical
18.94
Mobilex, Medical
5.02
Carlisle Regional Medical Center
922.74
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
5 997.87
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FILE NUMBER
HOOVFR PAIH F. 21 05 n8~Q
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. Fay H. Sheaffer Sibling
410 S. Spring Garden Street 1/6th Remainder
Carlisle, PA 17013
2. Mary Jane Boldosser Sibling
47 Greenfield Drive 1/6th Remainder
Carlisle, PA 17013
3. Donald L. Hoover Sibling
1785 Buck Hollow Road 1/6th Remainder
Big Cove Tannery, PA 17212
4. Shirley H. Kingsborough Sibling
1801 Waggoners Gap Road 1/6th Remainder
Carlisle, PA 17013
5. John H. Wagner Sibling
60 Parker Street 1/6th Remainder
Carlisle, PA 17013
6. Lynn E. Hoover, Jr. Collateral
115 Woodshire Road 1 112th Remainder
Greenville, PA 16125
7. Rick A. Hoover Collateral
1190 Newville Road 1/12th Remainder
Carlisle, PA 17013
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV.1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
LAST WILL AND TESTAMENT
I, PAUL F. HOOVER, of North Middleton Township, Cumberland County,
Pennsylvania, declare this instrument to be my Last Will and Testament, hereby expressly
revoking all Wills and Codicils heretofore made by me.
1. I direct my Executors to pay all of my debts, funeral and administrative expenses as
soon as may be done conveniently after my decease.
2. I authorize and empower my Executors to sell any realty owned by me at my death,
and not specifically devised herein, at either public or private sale, and to give good and
sufficient deeds therefor, in fee simple, as I could do ifliving.
3. I devise and bequeath all of my estate of every nature and wherever situate as follows:
(a) 1/6th to Fay H. Sheaffer,
(b) 1/6th to Mary Jane Boldosser,
(c) 1/6th to Donald L. Hoover,
(d) 1I6th to Shirley H. Kingsborough
(e) 1/6th to Joan H. 'Wagner, fu1.d
(t) 1/6th to be divided between Lynn E. Hoover, Jr. and Rick A. Hoover,
share and share alike.
If any of the above are deceased at the time of my death, the child or children
shall recei ve the share of the deceased parent, share and share alike.
4. I nominate and appoint RICK A. HOOVER and KENNETH E. WAGNER to be the
Executors of this my Last Will and Testament; they are to serve as such without bond.
5. I hereby suggest that my personal representative retain the servIces of Irwin &
McKnight as attorneys in the settlement of my estate.
IN WITNESS \VHEREOF, I have hereunto set my hand and seal this U; day of
October, 2004.
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PAUL F. HOOVER
(SEAL)
Signed, sealed, published and declared by PAUL F. HOOVER, the above-named
Testator, as and for his Last Will and Testament, in the presence of us, who, at his request, in his
presence and in the presence of each other have subscribed our names as witnesses hereto.
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ACKNOWLEDGME1VT AND AFFIDA VIT
\VE, PAUL F. HOOVER, MARTHA L. NOEL and TRACI D. SMITH, the Testator
and witnesses respectively, whose names are signed to the foregoing instrument, being first duly
sworn, do hereby declare to the undersigned authority that the Testator signed and executed the
instrument as his Last Will and Testament, that he had signed willingly, that he executed it as his
free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the
presence and hearing of the Testator, signed the Will as a witness and that to the best of their
knowledge the Testator was, at that time, eighteen years of age or older, of sound mind and
under no constraint or undue influence.
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PAUL F. JlOOVER
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TRACI n. SMITH
COl\Il\'10N\VEAL TH OF PENNSYLVANIA
SS:
COUNTY OF CUMBERLAND
Subscribed, sworn to and acknowledged before me by PAUL F.HOOVER, the Testator
herein, and subscribed and sworn to before me by l\-1ARTHA L. NOEL and TRACI n.
SMITH, witnesses, this 7 i.:.:; day of October, 2004.
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Notafy Public
COMMONWEALiTH OF PENNSYLVANIA
_ Notarial Seal
Roger B. Irwin, Notarj Public
Carlisle Bera. Cumberland County
My Commission Expires Oct. 3, 2008
Member. Pennsylvania Association Of Notarres
3
m M&I'Bank
499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12
Phone (888) 502-4349
Fax (302) 934-2955
September 26, 2005
Irwin & McKnight
Attorneys At Law
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, Pennsylvania 17013-3222
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Re: Estate of Paul F Hoover
Social Securitv: 162-22-0734
Date of Death: September 14. 2005
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Dear Sir or Madam:
Per your inquiry dated September 22, 2005, please be advised that at the time of death, the above-named decedent had on
deposit with this bank the following:
I.
T}pe oj Account
Checking Account
A ccount Number
509434
Ownership (Names of)
Paul F Hoover *
Rick A Hoover, Kenneth E Wagner, POA 's
Opening Date
01/01/74 Closed 09/22/05
Balance on Date oj Death
$11,151. 65
Accrued Interest
$
un
Total
$11,152.72
Interest Paid YTD
$
7.72
2.
Tjpe oj Account
IRA
Account Number
035004200307385
Ownership (Names of)
Paul F Hoover *
Estate of Paul F Hoover, Beneficiary *
Opening Date
02/24/99
Balance on Date oj Death
$1,46793
Accrued Interest
$ 9.24
Total
$/,477.17
Interest Paid YTD
34.57 (Accrued interest is not included)
3.
Type of Account
IRA
Account Number
035004200348488
Ownership (Names of)
Paul F Hoover *
Estate of Paul F Hoover, Beneficiary *
Opening Date
02/24/99
Balance on Date of Death
$11,060.45
Accrued Interest
$ 213.21
Total
$11,273.66
Interest Paid YTD
$ 0. 00
Please be advised, there was no safe deposit box found for the above decedent.
*For further account information, regarding ownership and any changes, closures and/or reimbursement of funds,
etc., please call the High Street Carlisle Office # 717-240-4536.
Sincerely,
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Nancy Clagett
Records Management
11/15/2005 TUE 14:39 FAX
Sovereign Bank
ESTATE OF
SOCIAL SEClJRlTY #:
DATE OF DEATH:
Paul F. Hoover
162.22-0734
September 14, 2005
Accuunt #: 1671001559 Typt:
In the name of: Paul F. Hoover
D5Ite of DeaTh B~bmc(>:
Int.(YTD) from 1/1/2005 to
Acerued interest to dnte ot'deSlth:
Other Info; Clu~l;u 9/21/05 $1432.32
Accounr #~ 1 /)71 O1lt'i7~ Type:
In th~ name of: Paul F. Hoovcr
Date of Death Balance:
Iut.(YTD) IJ'ow 1/1/2005 io
Accrued interest to d3te of death:
Other Info: Closed 9/21/05 $46,330.74
Acrount #~ 1675302077
In the name of: Paul F. Hoover
Date of Death Balance:
Int.(YTD) from 1/1/2005
Accrucd interest to date of dcath:
Other Into: Clase.d 9/21/05 $16,271.12
Type~
to
Account #: Ib'/~4nlU:l 'l)'Pe:
I.. lhe ..alIn~ uf: Paul F. Huuver
Date of Death Balance: Closed prior
Int.(YTn) F'rnm I 1117.00,<; 10
Accrued interest to date of death;
other Info: Closed 8/30/05 $11,621.49
Account #: 1675173449 Type:
In the name of: Paul F. Hoover
Date ofDcath BaJan'cc: Closcd priOl'
Inr.(YTD) from 1/112005 10
Accrued intel'est to date of death:
Other Info: Closed 8/30/05 $14,459.05
Checking
$1,432.32
9n/2005
$0.01
C.hecking
$46,330.74
8/3 1/2005
$31\.'19
CD
$16,245.66
8/31/2005
$19.09
CD
R/,OJ700'i
$0.00
CD
8/30/2005
$0.00
Psge 1 of2
~ 003/006
Open date: 1/17/2002
$6.11
Open elate: fi/ll'll?.OO,
$555.18
Open date: 12/12/2001
Upen date:
$306.03
313J:l004
$1 fi::Un
Open date: 3/18/2004
$202.57
11/15/2005 TUE 14:39 FAX
Sovereign Bank
ESTATE OF
SOCIAL SECURITY #:
DATE OF DEATH:
Paul F. Hoover
162-22-0734
September 14, 2005
Account #: 1675474090 Type:
In the name of: . Paul F. Hoover
Date of Death Balance: Closed prior
Int.(YTD) from 111/2005 to
Accrued interest to date of death:
Otherlnfa: Closed 8/30/05 $18,394.13
CD
8/30/2005
$0.00
Account #: 1675509192 Type:
In the name of: Paul F. Hoover
Date of Death Balance:
Int.(YTD) from 1/1/2005 to
Accrued interest to date of death:
Other Info: Closed 9/21/05 $11,921.75
CD
$11,903.09
8/31/2005
$13.99
Account #: 3385021096 Type:
Tn the name of: Paul F. Hoover
Date of Death Balance:
Int.(YTD) from 1/1/2005 to
Accrued interest to date of death:
Other Info: Closed 9/21/05 $18,574.36
CD
$18,574.36
8/31/2005
$22.91
Account #: 3385088038 Type:
In the name of: Paul F. Hoover
Date of Death Balance: Closed prior
Int.(YTD) from 1/1/2005 to
Accrued interest to date of death:
Other Info: Closed 4/15/05 $16,703.17
CD
4/15/2005
$0.00
@004/006
Open date: 3/2612004
$245.70
Opcn date: 8/1 0/2004
$224.23
Open date: 3/20/2000
Open date:
$415.43
1/5/2000
$102.39
DEC-02-2005 10:58AM
FROM-M " T BANK
+7172404518
T-803 P.002/002 F-867
i.~~
TP......""~~ Li:fl:: ~ CCIIWlIID'
....333 ~od ll.o&ll :NP.
JIC IIaIf 5183
~ hpIds. Janrl !2<4M-311l
November 30, 2005
Irwin & McKnight
Attn: Roger B Irwin
Wes-t Pomf.ret Frofel'iaional BUilding
60 West Pomfret Street
Carlisle PA 17013-3222
0: ADn1Uty Humber(s) 02PSLD19665
Dcar Rogcr B Irwin:
Thank you for the recent inquiry on ~he above listed non-qualified
annuity for Paul F Hoover (Deceased}.
As of SepLember 14, 2005, ~he full-accumulated value was
$222,033.80.
Our recorda indicate this annuity was processed ~s a death claim to
the primary heneficiaries on November 3, 200S.
TXilnsilID.ericil. Life Insurance Company is i1. member of t.he Insurance
!1~Ikecpl~ce Standdrds Association (LMSA), an organization committed
to high ethical marketp~ace standards in the sale and service of
individual ~ife ~nsurance and annuities.
If you have any questions or concerns, you may call our customer
service line. Our toll free customer service line, 1-800-553-5957,
is avai.Latl.Le Central Time :t.t'om ',: DO AM to ~: 30 :E'M Monday-Thursday
and Friday 7:00 AM to 4:30 PM.
Sincerely,
CustoMer Care Group/pjj
Transamerica Life Insuranc~ Company
~af_ eEGON.Clq
.
m
AIG Annuity Insurance Company
P.O. Box ~71
Amari 110. Texas 79 I (J5-(J~71
X(J0.42.+.49'i(j
~.D ~~~uw~~
lfi ~
! ? 2006
September 30,2005
Irwin and McKnight
60 Pomfret Street
Carlisle, PA 17013
'1,!J "I>,!
y Y L 1. ~
\f ki' N' I T" r I rI"
Vl C -"~.l ,! l.J Cl
Policy Number:
Deceased:
XP220598
Paul Hoover
Dear Roger Irwin:
The Internal Revenue Service requires reporting of all death benefits for federal estate tax purposes. Form
712 is prepared for regular life insurance contracts only. Since this contract was an annuity, the Form 712 is
not applicable.
Listed below is the death benefit information for the above-referenced annuity contact.
Type of Annuity Contract:
Date ofIssue:
Contract Owner's Name(s):
Original Investment:
Cost Basis
Cash Value as of Date of Death on 09/14/05:
Proceeds made payable to:
NQ
08/30/05
Paul Hoover
$201,474.67
$201,474.67
$201,977 .29
Bene name
If you have any questions please contact our customer service representatives, at 1-800-424-4990. We
appreciate this opportunity to serve you.
Sincerely,
Julie Gallob
Claims Examiner
AIG Annuity
A/G AI/Ill/in' Inwrlll1,e Compony
i\1t'mher (~/\I1/('ri(,{/1l [nfenurtional (;rou/), !nc
RESIDENT STATEMENT from
CUMBERLAND CROSSINGS
1 LONGSDORF WAY
CARLISLE, PA 17013
717 -240-2100
Statement Date
Due Date
ACCOUNT NUMBER
SCOOO 173
09/30/2005
Upon Receipt
$4,354.00
AMOUNT PAID $
Please make check payable to CUMBERLAND CROSSINGS
PAUL F HOOVER
clo RICK HOOVER
1190 NEWVILLE ROAD
CARLISLE, PA 17013
Remit To:
Diakon Lutheran Social Ministries
P.O. Box 8500-1131
Phialdelphia, PA 19178-1131
Please d(jtac~ and return thi3 porti,)n v,'it~. your rcrnittanG0 to the address Gbavc.
Comments
Pre B ill 0 - 30 31 - 60 61 - 90 > 90 BALANCE DUE
$0.00
$4,354.00 II
.____. ...._________....J..
$0.00 IL'
- ------- ----- --~ .
$0.00 :1
_______ _____It
$0.00
$4,354.00
Balance Forward $6,979.67 $6,979.67
09/01/05 - 09/14/05 Oxygen Therapy 14 $3.53 $49.42 $7,029.09
09/09/05 - 09/09/05 LEG BAG MED 2 $3.02 $6.04 $7,035.13
09/09/05 - 09/09/05 02 NASAL CANNULA 1 $1.28 $1.28 $7,036.41
09/09/05 - 09/09/05 EZ WRAP FOAM TUBE 1 $1.41 $1.41 $7,037.82
09/09/05 - 09/09/05 Oxygen Tank - Small 3 $21.00 $63.00 $7,100.82
09/09/05 - 09/09/05 HUMIDIFIER BTL, DISP. 1 $2.88 $2.88 $7,103.70
09/09/05 - 09/09/05 UD BAG W/ VALVE & PORT 2 $3.50 $7.00 $7,110.70
09/09/05 - 09/09/05 CATHETER FOLEY 18FR X 5CC 1 $2.10 $2.10 $7,112.80
09/09/05 - 09/09/05 Triangular Graduate 1 M CC 1 $0.46 $0.46 $7,113.26
09/09/05 - 09/09/05 LEG STRAP ELASTIC CATH TUBE 1 $7.50 $7.50 $7,120.76
09/12/05 - 09/12105 Oxygen Tank - Small 2 $21.00 $42.00 $7,162.76
09/12/05 - 09/13/05 EZ WRAP FOAM TUBE 2 $1.41 $2.82 $7,165.58
09/13/05 - 09/13/05 02 NASAL CANNULA 1 $1.28 $1.28 $7,166.86
09/13/05 - 09/13105 INJECTION KIT 26 $8.00 $208.00 $7,374.86
09/13/05 - 09/13/05 Incontinence Charge 15 $2.35 $35.25 $7,410.11
09/13/05 - 09/13/05 Oxygen concentrator 13 $3.53 $45.89 $7,456.00
09/13/05 - 09/13/05 Blood Glucose Finger Stick 2 $4.50 $9.00 $7,465.00
09/13/05 - 09/30/05 R&B Private Pay (17) $183.00 $(3,111.00) $4,354.00
TOTAL BALANCE DUE: $4,354.00
r---
r..... \
II '1
[: ,-", ,~"
J. 'I .~j',) h',.,:...L.'__'
PlBH sum
FACILITY NAME
I CUMBERLAND CROSSINGS
RESIDENT NAME
~AUL F HOOVER
ACCOUNT NUMBER
SC000173
RESIDENT STATEMENT from
CUMBERLAND CROSSINGS
1 LONGSDORF WAY
CARLISLE, PA 17013
717 -240-2100
Statement Date
Due Date
ACCOUNT NUMBER
SC000173
09/30/2005
Upon Receipt
$4,354.00
AMOUNT PAID $
Please make check payable to CUMBERLAND CROSSINGS
PAUL F HOOVER
c/o RICK HOOVER
1190 NEWVILLE ROAD
CARLISLE, PA 17013
Remit To:
Diakon Lutheran Social Ministries
P.O. Box 8500-1131
Phialdelphia, PA 19178-1131
Please detach and return this portion with your remittance to the address above.
Comments
PreBi/I 0 - 30 31 - 60 61 - 90 > 90 BALANCE DUE
L
$0.00
r
i
$4,354.00
$0.00 ~
$0.00
$0.00
-,
$4,354.00
I
I
,
~
Balance Forward $6.979.67 $6,979.67
09/01/05 - 09/14/05 Oxygen Therapy 14 $3.53 $49.42 $7,029.09
09/09/05 - 09/09/05 LEG BAG MED 2 $3.02 $6.04 $7,035.13
09/09/05 - 09/09/05 02 NASAL CANNULA 1 $1.28 $1.28 $7,036.41
09/09/05 - 09/09/05 EZ WRAP FOAM TUBE 1 $1.41 $1.41 $7,037.82
09/09/05 - 09/09/05 Oxygen Tank - Small 3 $21.00 $63.00 $7,100.82
09/09/05 - 09/09/05 HUMIDiFIER BTL, DISP. 1 $2.88 $2.88 $7.103.70
09/09/05 - 09/09/05 UD BAG W/ VALVE & PORT 2 $3.50 $7.00 $7,110.70
09/09/05 - 09/09/05 CATHETER FOLEY 18FR X 5CC 1 $2.10 $2.10 $7,112.80
09/09/05 - 09/09/05 Triangular Graduate 1 M CC 1 $0.46 $0.46 $7,113.26
09/09/05 - 09/09/05 LEG STRAP ELASTIC CATH TUBE 1 $7.50 $7.50 $7.120.76
09/12/05 - 09/12/05 Oxygen Tank - Small 2 $21.00 $42.00 $7,162.76
09/12/05 - 09/13/05 EZ WRAP FOAM TUBE 2 $1.41 $2.82 $7,165.58
09/13/05 - 09/13/05 02 NASAL CANNULA 1 $1.28 $1.28 $7,166.86
09/13/05 - 09/13/05 INJECTION KIT 26 $8.00 $208.00 $7,374.86
09/13/05 - 09/13/05 Incontinence Charge 15 $2.35 $35.25 $7,410.11
09/13/05 - 09/13/05 Oxygen concentrator 13 $3.53 $45.89 $7,456.00
09/13/05 - 09/13/05 Blood Glucose Finger Stick 2 $4.50 $9.00 $7,465.00
09/13/05 - 09/30/05 R&B Private Pay (17) $183.00 $(3,111.00) $4,354.00
TOTAL BALANCE DUE: $4,354.00
FACILITY NAME
CUMBERLAND CROSSINGS
fnl r;:\ WIT r-----1r" n n i?
. 0 .' 11'\ \\~. I' I.' '.' '..' 1',-,
1 Lw;, \ , '!! Ii! : r'
I,' I\,\\J, L ,_J, \u' ,0.--,
~ ' ..J ._/ i 0-.'4_' '_"" ,-.~I
t' TlJl' A-rOII...~r Lf!,~ !!n 'F,!'P'
on." ~lt. ...r~. Hk_ It,-, L'"...YI
ESCflPHi Vi}!))! NDliCE
L!PUASE mm PAYAAHH IMMEDIATELY
ACCOUNT NUMBER
SC000173
--- ---'"
/-
Hoffman-Roth Funeral Home, Inc.
219 North Hanover Street
Carlisle, P A 17013
(717)243-4511
October 5,2005
Roger Irwin
Attorney at Law
60 West Pomfret St.
Carlisle, P A 17013-
The Funeral Service for Paul F. Hoover
~...,- .- ,." '\ "'" -.. '-"'fl
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14602-153
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
OUR SERVICE:
Traditional Funeral Service Package . . . . . .
FUNERAL HOME SERVICE CHARGES
SELECTED MERCHANDISE:
Stanford Casket . . . . . . . . . . . . . . . . . . . . . .
Monticello Interment Receptacle. . . . . . . . . . . . . . . . .
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THAT YOU IL\ VE SELECTED . . . . . . . . . . . . .
Cash Advances
Opening Grave. . . . . . . .
Newspaper Obituary Notice-Sentinel.
Clergy Offering . . . . . . .
Certified Copies of Death Certificates.
Flowers. . . . . . .
Organist. . . . . . . . . .
Luncheon - Bethany Guild. . . .
TOTAL CASH ADVANCES AND SPECIAL CHARGES.
Total
Total Cost
.. . . .. . .. .. .. .. .. .. .. .. .. . .. .. . .. . .. .. . .. .
History
09/19/2005 Fraternal Order of Eagles.
TOT AL AMOUNT DUE .
This statement is net and payable in full within 30 days of receipt.
$3690.00
$3690.00
$2090.00
$1170.00
$6950.00
$500.00
$107.10
$100.00
$12.00
$132.50
$100.00
$250.00
$1261.60
$82] 1.60
$-500.00
$7711.60
- - - - - - - - - - - - - - - - - - - - - - - - - - -.. - -. - - --- - - - - - - - - - - - - - - - - - - -. - - - - - - - -..-
Please return this portion wi'th your Remittance
$
Amount Enclosed
Service 10 # 14602-153
Eby Granite Works
P. O. Box 18kNewville, Pa. 17241-0187
Phone: (717) 776-5118
I,~~el
Name ~~ ~4) ~'~~; .~ '
t '-""', [/../ v...---, -1::""'"7 _
Address -) I ." '. ','. .~.) ( J /1 /(
Phone c9s ~ - /7 ~7
Monument J - i:, il) - t.) 'I J - <)
Slant
Base d- ;; Y () - <;. Y- () - fc,
Bevel '__ j.' .
.. . Grass Marker
"ODesign
i? .. I
L v.6i.. /':,.
f-d
,
Corner Post 0
Flower Vases 0
Date if) ~ (j- ()~
I
Zip / 7i)/ :3
_.:.,-...,~.
Kind of Granite,y0 h, .' Q-.!' ./J l']0uJ
Cemetery fJt2o-d IfN ~ t II.'..€. ()
f' .--, <
Name on back FOUNDATION
IYesl IINo~ I WARRANTY
1~
'\
;-100 Ue.r
-/-/// f (J' F.
/(..A0.
fl7 IJ /--; 1 2- / q ;) ~ ___
I .' cf ~ I)D S
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take full responsibility for the accuracy
GRO.
P.G. #
PGS
GRA
VAS
POSTS
GARS
COM
B&J
o
o Check How to Letter
Letter this way - opposite
Unit Price $ / d, ~ {) Flower Vase $
- $ Total $/~<<D Deposit $/6?~().
(lll:(:l /6:1&?::r:;,
I agree that said memorial. with title thereto and nght 01 possession imfreof. shaiT remain your personal property until I have paid lor it in
Corner Post $
Misc. $
Balance $ ---G--
full. In default of any payment hereunder, I license you to repossess and remove the said memorial, without guilt or trespass or other wron9;
land authorize and empower you, in my namE! and on my behalf, to apply to the management of said cemetery or other.premises lor a permit
. for its removal and to take any other steps you may deem necessary or expedient and lurther agree to sllve you harmless 'rom any entry,
repossession and removal; you may retain said memorial or dispose of it at your own discretion without being answerable to me lor it or any
proceeds therelrom.
Orders subject to cancellation. All contracts contingent upon strikes, accidents, and other causes beyond our controi.
I understandthat30 days after placement of the memorial a FINANCE CHARGE will be entered on the billing date. It is computed by a periodic
rate 011 Y2 % per monlh which is an annual percentage rate 0118 % applied 10 the previous balance before deducting credits, payments or adding
purchases appearing on this statement. To avoid FINANCE CHARGE pay the "New balance' before the billing date next month.
I AGREE THAT ALL LETTERING AND DATES GIVEN ON ABOVE ORDER ARE CORRECT. '
I ALSO HAVE BEEN INFORMED AND UNDERSTAND THAT THERE WILL BE A CHARGE FOR ANY LETTERING OONE AFTER THE
ME~~~; ~~::O~E~R:;~~~~~ ~~~;~~i:~ENt/FOUNDATION GUAR~NTEE. IF APPLICA~LE.
/.1 .~
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Grave Marked
# of Grave
Cremation
.',\.