HomeMy WebLinkAbout01-24-06
INVENTORY
Estate of JOHNSON, THOMAS W.
No.21
05
0950
, Deceased
Date of Death 5/26/2005
Social Security No. 204-26-7663
also known as
Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include all of the
personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation
placed opposite each item of said inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no
real estate outside the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I/We
verify that the statements made in this inventory are true and correct. I/We understand that false statements herein made are subject to the
penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities.
Name of
Attorney: HAROLD S. IRWIN III
I.D. No.: 29920
Address: 64 SOUTH PITT STREET
p'~o~al R",e,,:at'1 d~~
~OHNS~
Dated JANUARY ,2006
CARLISLE
PA 17013
Telephone: 717-243-6090
Description
Value
CASH
296.00
THE EPISCOPAL HOME, SHIPPENSBURG, PA: OVERPAYMENT
1,458.60
M& T BANK ACCOUNT 9830138450
3,638.95
EWING FUNERAL HOME, INC.: PREPAID FUNERAL EXPENSE
, 1,871.00.
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Total
(Attach Additional Sheets if necessary)
7,264.55
NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative,
include the value of each item, but such figures should not be extended into the total of the Inventory.
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REV-1500 EX + (&-00)
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)
JOHNSON, THOMAS W.
DATE OF DEATH (MM-DD-Year)
DATE OF BIRTH (MM-DD-Year)
OFFICIAL USE ONLY
FILE NUMBER
2 1 -0 5 0 9 5 0
COuNTY"CoiiE -VEAR- - - NuMBER- -
SOCIAL SECURITY NUMBER
2 04- 2 6 - 7 6 6 3
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (dale 01 death prior to 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)(Altach SchO}
THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AN[) CONFIDENTIAL TAX INFORMATlONSHOUI.. D BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
HAROLD S. IRWIN III 64 SOUTH PITT STREET
FIRM NAME (If Applicable)
IRWIN LAW OFFICE CARLISLE, PA 17013
TELEPHONE NUMBER
717-243-6090
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OS/26/2005 11/02/1931
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
[Xl 1. Original Return
D 4. Limited Estate
[Xl 6. Decedent Died Testate (Attach copy of Will)
D 9. Litigation Proceeds Received
D 2. Supplemental Return
D 4a. Future Interest Compromise (dale of death after 12.12-82)
D 7. Decedent Maintained a Living Trust (Attach copy ofTrusl)
D 10. Spousal Poverty Credit (dale of death between 12-31-91 and 1-1.95)
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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)
D 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)
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
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
0.00 X _(15)
0.00 X _(16)
0.00 X .12 (17)
0.00 X .15 (18)
(19)
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
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
>> BE SURETOANSWERALLQUESTIONS ON REVERSE SIDE AND RECHECKMATW < <
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(8)
(11)
(12)
(13)
(14)
OFFICIAL USE ONLY
7,264.55
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7,2134.55
3,830.23
8,363.17
12,193.40
-4,928.85
-4,928.85
0.00
0.00
0.00
0.00
0.00
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Add
ece ents omplete ress:
STREET ADDRESS
Shippensbura Health Care Center
121 Wallnut Bottom Road
CITY I STATE I ZIP
Shippensburg PA 17257
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
0.00
Total Credits (A + B + C)
(2)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (0 + E) (3)
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 (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58)
Make Check to: REGISTER OF WILLS, AGENT
0.00
0.00
0.00
0.00
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ........................................................................... 0 [gJ
b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 [gJ
c. retain a reversionary interest; or ...................................................................................................... 0 [gJ
d. receive the promise for life of either payments, benefits or care? ............................................................. 0 [gJ
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................. 0 [gJ
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ................. 0 [gJ
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ....................................................................................................... 0 [gJ
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
ADDRESS
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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 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 transfers to orfor the use of the surviving spouse is 0% [72 P .S. ~9116 (a) (1.1) (ii)].
The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if
the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent,
or a stepparent of the child is 0% [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 beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P .S. ~9116(a)(1)].
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. ~9116(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.
REV-1502 EX + (6-98)
*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
JOHNSON. THOMAS W. 21 05 0950
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price al which property would be
exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real properlY which is jointlv-owned with riaht of survivorship must be disclosed on Schedule F.
SCHEDULE A
REAL ESTATE
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
NONE
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1503 EX + (6-98)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
JOHNSON. THOMAS W.
FILE NUMBER
21 05
All property lointly-owned with right of survivorship must be disclosed on Schedule F.
0950
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
NONE
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1504 EX + (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSEL V-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
ESTATE OF
JOHNSON. THOMAS W.
FILE NUMBER
21 05
0950
Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a
sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
NONE
TOTAL (Also enter on line 3, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1507.EX + (6-98)
*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF
JOHNSON. THOMAS W.
FILE NUMBER
21 05
0950
All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
NONE
TOTAL (Also enter on line 4, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX + (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
JOHNSON. THOMAS W.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
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.
0950
ITEM
NUMBER
1.
2.
3.
4.
DESCRIPTION
CASH
Exhibit "B"
THE EPISCOPAL HOME,
SHIPPENSBURG, PA: OVERPAYMENT
Exhibit "C"
M&T BANK, CLOSE ACCOUNT # 9830138450
Exhibit "D"
EWING FUNERAL HOME, INC.: PREPAID FUNERAL EXPENSE
Exhibit "E"
VALUE AT DATE
OF DEATH
296.00
1 ,458.60
3,638.95
1 ,871.00
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
7,264.55
REV-1509 EX + (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
JOHNSON. THOMAS W.
FILE NUMBER
21
05
0950
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. NONE
B
c
JOINTL Y.OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER. A IT ACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. NONE
TOTAL (Also enter on line 6, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX + (6-9B)
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
JOHNSON. THOMAS W.
FILE NUMBER
21 05
0950
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.
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 A COPY OFTHE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST VALUE
(IF APPUCABLE)
1, NONE
TOTAL (Also enter on line 7 Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX + (12-99)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
JOHNSON. THOMAS W.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21
05
0950
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. EWING BROTHERS, CARLISLE, PA; CREMATION 1,871.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s) NORMAN G. JOHNSON 363.23
Social Security Number(s)/EIN Number of Personal Representative(s) 204-26-9874
Street Address 1350 LIBERTY STREET
City HARRISBURG State P A Zip 17103
Year(s) Commission Paid:
2. Attomey Fees IRWIN LAW OFFICE 1,500.00
3. Family Exemption: (If decedent's address is not the same as c1aimanfs, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees REGISTER OF WILLS 96.00
5. Accountanfs Fees
6. Tax Retum Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $ 3,830.23
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX + (6-98)
'*
SCHEDULE.
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
JOHNSON. THOMAS W.
FILE NUMBER
21
05
0950
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1. PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE: CIS # 250128615
Class 3 claim
VALUE AT DATE
OF DEATH
2,391.40
2. PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE: CIS # 250128615
Class 6 claim
4,491.16
3. SOCIAL SECURITY ADMINISTRATION # 204-26-7663
Overpayment
147.30
4. SHIPPENSBURG HEALTH CARE CENTER
Balance on account
1,333.31
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
8363.17
,,,,.,,,, ~. ".
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FILE NUMBER
.I0HNSC N THOMA~ W. 21 ()&; 0950
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 outritt spousal distributions, and transfers under
Sec. 9116 (a (1.2)]
1. NORMAN G. JOHNSON Sibling 100 PERCENT
1350 LIBERTY STREET
HARRISBURG, PA 17103
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. NONE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1. NONE
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)
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LAST WILL AND TESTAMENT
I, THOMAS W. JOHNSON, of 365 North Hanover Street, Carlisle, Cumberland
County, Pennsylvania 17013, do hereby make, publish and declare this to be my last
will and testament, hereby revoking all wills heretofore made by me.
1. I direct my personal representative to pay all of my debts, funeral and
administrative expenses as soon as convenient after my decease. I direct that all
inheritance taxes imposed or payable by reason of my death and interest and penalties
thereon with respect to all property, whether or not such property passes under this
Will, shall be paid by my personal representative out of my estate.
2. I authorize and empower my personal representative to sell any realty
and/or personalty owned by me at my death and not specifically devised or bequeathed
herein, at public or private sale or sales and to give good and sufficient deeds and/or
bills of sale therefor, in fee simple, as I could do if living. My representative is
authorized and empowered to engage in any business in which I may be engaged at
my death, for such period of time after my death as seems expedient to said
representative.
3. I give, devise and bequeath all of my estate of whatever nature and
wherever situate to my brother, Norman Johnson.
4. I nominate and appoint Joyce S. Cope to be the personal representative
of my estate, to serve without bond. If she cannot or does not serve, then I appoint
Norman Johnson to be the substitute personal representative, also without bond.
'. .
5. I appoint Joyce S. Cope to be the guardian of my son, Thomas W.
Johnson, Jr., if he is under the age of eighteen at my death.
6. I suggest that my personal representative retain the services of Harold S.
Irwin, III, Carlisle, Pennsylvania in the settlement of my estate.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this 18th day of
January, 2000.
/)lvo-?~ 7YJ/ ~~~
THOMAS W. JOHNSON
(SEAL)
Signed, sealed, published and declared by the above-named person as and for a
last will and testament, in our presence, who at said person's request, in said person's
presence and in the presence of each other have hereunto set our names as
subscribing witnesses.
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ACKNOWLEDGMENT AND AFFIDA VIT
WE, THOMAS W. JOHNSON, GAY L. IRWIN and HEATHER A. BARBOUR,
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 that he had signed
willingly, and 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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THOMAS W. JOHNSON
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HEATHER A. BA BOUR
COMMONWEALTH OF PENNSYLVANIA
:55:
COUNTY OF CUMBERLAND
Subscribed, sworn to and acknowledged before me by THOMAS W. JOHNSON,
the testator herein, and subscribed and sworn to before me by GAY L. IRWIN and
HEATHER A. BARBOUR, witnesses, this 18TH day of January, 2000.
NOTARIAL llAL
!lONNII L. COYLE. NOTARV PUBUC
"0 Q' OARUlLI, CUMBERLAND COUNTV
\4MIIIION IIXPIRES OCTOBER 17 2002
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Notary Public
. .
EXHIBIT 'B'
Attachment B
Carlisle Regional Medical Center
Patient Valuables Log Sheet Patient Demographics
A. Receipt of Valuables: Describe valuables (i.e. ring: yellow band with white stone).
BAG NUMBER 24- Z lP4-) .
#
Items
I
Date
J ,
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<-(1'-: !!) <.,
I i
Item
Description
Monev (list amount)
Checl<s (Traveler's
Checks)
Rina (s)
Necklace (5)
Watch
Earrina (s)
Wallet
Kevs
CheckbookJ8ank Book
Other:
'1 .J(~11 /) 00
I
I
I /
I /
Valuables to. PYXIS v
Safe Transported by:
.. ~ . .
Employee's Signature: 1),j)4\. v1~ 01'1 DC{ 111' \' r~i\. j
Patient's Signature: t~,d<f;' /J..;J'1...vfc~
. r
b 8 0 ed N R
8. Valua les ee )oen : BAG UMBE : ,....
Date Opened Items Removed Items Placed Patient's Employee's
Sionature Sicmature
I
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NEW BAG NUMBER:
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FOR
ACCOUNT
AMT. OF
ACCOUNT
AMT. PAlO
BALANCE
DUE
CHECK .
MONEY
ORDER
. .
EXHIBIT 'c'
"- -
THE EPISCOPAL HeME
206 EApT SURD $TREET
. ."pHI.PPENp!3,UIlG. PA 17257
;~b~~6~~l .. .'. '. . 1$**1,458.60
One THousand Four Hundred Fifty-Eight and 60/100****************************************** DOLLfl..RS 6J ~'fff
Mr. Tom Johnson
CIO Irwin Law Office
64 South Pitt St.
Carlisle, P A 17013
./
lEMO Mr. Johnson reimbursed to estate
11-0 ~880 711- -:0 :11;0 71; ~ 50-: I; ~0009:15 2211-
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lIIP
DEPOSIT TICKET
)A Int on Lawyer Trust Acct Boar
-larold S Irwin III
OL T A Account
CURRENCY
COIN
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l\J,S
lATE to (5/()~
hecks and other items are received for deposit
Jbject to the terms and conditions of this
nancial institution's account agreement. Deposits
lay not be available for immediate withdrawal.
)rrstown Bank
ihippensburg, PA 17257
TOT OTHER SIDE
LESS CASH REC'D
TOTAL
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l.0800 280 l.1I-
THE EPISCOPAL HOME
Mr. Tom Johnson
Jan. and Feb.
10/3/2005
18807
1,458.60
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BAl"'JK
Operating Cash
iO
Teller #/Transaction #
Time/Date
Amount
Account #
003#00:36 DEF'
08080i~41PMI0-05-05
H,458.60
fi.1.08002801
BR-36A IU3H
Plecbt' be sure to enter this transaction in your records.
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ACCOUtlr NO.
9830138450
BEGINNING
BALANCE
3,638.95
POSTING
DATE
ACCOUNT TYPE
M & T FIRST
THOMAS W JOHNSON JR
C/O HAROLD IRWIN
64 SOUTH PITT ST
CARLISLE PA 17013
DEPOSITS &
OTHER ADDITIONS
NO . I AMOUNT
01 0.00
STATEMENT PERIOD
OCT.15-NOV.15,2005
00
o 04319M NM 017
18456
HIGH STREET-CARLISLE
ACCOUNT SUMMARY
CHECKS PAID
NO . I AMOUNT
oT 0.00
OTHER
SUBTRACTIONS
NO . I AMOUNT
1 I 3,638.95
0.00
CURRENT
INTEREST PD
ACCOUNT ACTIVITY
DEPQSITS,INTEREST
TRANSACTION DESCRIPTION & OTHER ADDITIONS
10-15-05 BEGINNING BALANCE
11-01-05 CLOSEOUT
ENDING BALANCE
L JE:'l, /O~i'i" c,,'l
CHECKS & OTHER
SUBTRACTIONS
3,638.95
IT'S EASIER TO BANK AND INVEST IN ONE PLACE. WE'RE THAT PLACE. VISIT US AT
WWW.MANDTBANK.COM.
INVESTMENTS: * ARE NOT FDIC-INSURED * HAVE NO BANK GUARANTEE * MAY LOSE VALUE
BROKERAGE SERVICES ARE OFFERED BY M&T SECURITIES, INC. (MEMBER NASD/SIPCl, NOT
BY M&T BANK.
PAGE
1 OF 1
ENDING
BALANCE
0.00
DAIL Y
BALANCE
$3,638.95
0.00
$0.00
. '.
EXHIBIT 'E'
..
DISCLOSlJRE-DISCLAIMER FORM
the h:lkr~1i Irade (\lllllnl,sioll's hIIlLT,illnduslr) I'ractlcc.\ Rl if T rcqlllrc\ ccrtain disclosurcs and prohihit-; misrcprcscntations.
1 Ills I )",c!osurcs'l JiscLlllnLT hmn I-; ~I chcd;list lie; ask tllI>:;e; IIC se;nc to read and sign if during the fune;ral arrangcmcnts ow' linn complicd with
the'I{,llllI\ill).:
)\;ame of 1 kce,lse;d:
(,'lbn~OIl
Date of Dcath
'.' 1\/
() :=,
I ),Ile or t'l111l'LtI ~111d:or final dislhlSition or hod).
\. \h: umkrsigncd rccclve;d a (icne'rall'ricc LIsI ctleT\i\<: on ,
mcrd1allllisc
N c:, \' \-:.:'.mr) (::"
2DC
prior {(I disellssing prict,s, services, or
) lire ulldcrsl).'llcd n;ccl\l,d a (,I-;ke't !'ricc List dlCctile Oil. ii:: J",':Td',.',r ;. '), /UU4
prior to liclling or di\cussing price'S or caskcts
3. fhc ul1lkrsigncd I'e,'cllcd an Olilcr Buri,1i (\,nlaine;r PrlCC (,ist e;ftl.:ctiIe; Iln tlC)V (:clbe r >~ J, ,) 'J U 4
of ouln hurial cOI1l<uncrs.
prior to li<:llin).' o!" discllssing pri
4 lhc 1I11dcrsigncd I\crc not told thlltemhlllming is rcqlllrcd h) 1<1\\ and werc told that thc lall docs /lot requirc cmbalming exccpt in c<:rtain case~;. If
e;lllb,t1millg 11,1-; provldcd, it 11<1, donc Ilith thc pcrmission of Ihe; llndersigned,
'; thc 1I111kr.sigIlCd Ilcre nllllllld tlrat all,l hl\ requlrc:, c:mhalming Elr dir<:C\ cremations, immediate hurial. or if reli'i.l'cr<ililln i\ al,lilabk and thc funer,1
1\ II ithout I ICII ill12 Dl 1I-;I(;I(I!)n
IJ. rhe; ulllkrsl)ln<:d IICrL' inltHlncd thai the {;lI\ dOl'S nol lequire' a easketllll' dirL'ct crcmatiun,
7 rhc ulllkr:;iglled IICle' mfonned thill thc I<lI\ docs nol rcqlJJrc thc purchase of all ()lller burial container.
X Thc funeral home; nlillk 110 l'cprL'scntaliolls ID thc lnHkrsigncd e:rnballllil1g or the us<: oLIll~ nll:rclwlldisc mailabk Illr the run<:ral hOlllc IlmrlJ del,l)
lkcolllp<lSr!lOn of Ihc rL'lllalnS for a long timc or inddinit<: tilTle,
lJ, rlre lIIJdnslgncd undcrst:lnds that lile' 1(lncral hOlllc has disclaimcd all Ilarrallti<:s with regard to caskct\, outer burial conlaim:rs, ,1Ild olhL'r Illerehand
sold by the Illneral hOIllL'.1 hL' undL'rsigJlcd furthcr undcrstands that thL' llnly warranties, express or ill1rhed. granted in <:onncetion with the goods Sl
by (h<: funeral homc arc thc cxpre;ss l\Titkll l\illTantics, if any, <::\tcndL'd by the manufacturers orth<: goods, No othL'r warranties. including the imrh
\\,IIT;illlic\ Dllh,' 11I\.'I\h:llll:r!,ilil\ I'l i:lnl'.\' 1;,1' ,11'"nicuLII' purpose cUT cxkl1lkd h: the rUl1el:iI hOlllc
Done: this 27
day or
Mav
20 ~_~
W itllcsscd
~...~~
Funeral Din:ctor/Ful1eral Firm Provie License Ii
PerSOlJ(s) making final arrange-ments
.~ /2~~A" ..'
''?''---Z-----~~--
Relatior
Date signed
Signature or Purchaser
Rl'latiOl
Si,l.'.nature of Purchaser
Rc!atio
jU9-\OIAL OF AUTOMOTIVE EQUIPMENT
A3 $
225 00
- '"
. TOTAL OF PROFESSIONAL SERVICES,
FACILITIES AND AUTOMOTIVE
EQUIPMENT
A S
1,37500
SUMMARY OF CHARGES:
A Professional Services, Facilities and
Equipment and Automotive
Equipment
8, Merchandise
C Special Charges,
D Cash Advances,
$
$
$
$
1,37500
-0-
220,00
276,00
9, CHARGES FOR MERCHANDISE
Casket
(DeSCription) Casket
$
-0-
Outer Receptacle S -0-
(Descnptlon)_Q..uts:.LCnnta~__,___,_,,___
,0,
TOTAL OF ALL SELECTIONS
PAID AT TIME OF OR PRIOR TO
ARRANGEMENTS,
BALANCE DUE
REASON FOR EMBALMING
None
,$
1871C
Outer bunal container
(Descnptlon) Alternate Container
Acknowledgement cards $ -0-
Register Book(s)$ -0-
Memonal folders $ -0-
Prayer cards $ -0-
Temporary grave marker $ -0-
Buna! clothing S -0-
I agree that I have examined the terms of goods and services selected above and found them to be correct and according to the arrangements I have
requested and I acknowledge a copy of this Statement of Funeral Goods and Services selected I represent that I have sufficient funds available for
payment of total price for goods and services selected, I also agree to make payment of S 1,87100 wlthin..-1.Ldays, I agree to be JOintly and
severally liable With anyone who signs below A late charge of 1 % per month amounting to 12% per year will be applied to the unpaid balanc
beglnnlng~days from the date of this agreement I Will also pay to the Funeral Director all reasonable costs paid by the Funeral Director to collect amount
I owe under thiS agreement. Those costs may include attorney's fees, court costs and other costs. Any additional services or merchandise ordered or
requested a~er th:d~~e oUbisagreement ~l'IslderedPart of thi,~,agreement and the cost thereO~1/ be ,reflected n the final bill or statement
(Seal) 0. ~ ~~-~- .5 2/} cr.r-
I ,/ /:f' , ./ (Purchaser) (Date)
(Seal}
s
$
S
oc
1 871 0
If any ,Iaw,cemetcry or cremalory rcquircmcnts havcrcqlllfcd thc purchasc 01
any 01 thc Items hstcd abovc thc law or rcqulrcmcnt is c\plallll:d hchlll
(Purchaser)
Crematorium requires container
-
--