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Home My WebLink About03-30-06 \ --.J 15056051058 OFFICIAL USE ~ (Q) t@ w Co~~ Co?e ~~~_mmm~ .~!.~~.~be~_.m_mm"m,,"" t REV-1500 EX (06-05) PA Department of Revenue '*' Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Number Date of Death INHERITANCE TAX RETURN RESIDENT DECEDENT 21 05 00741 Date of Birth 01/25/2005 07/19/1929 Decedent's Last Name Suffix Decedent's First Name MI WALSEN ALEXANDER v (If Applicable) Enter Surviving Spouse's Information Below Last Name Suffix First Name MI m~P~~~.~.~:.~.,,~~~~~L~:~~!~.~~'~?'~~-''''''.''.'''N' _._.'n...._..._.__.,..,"'"........_..~......,.....................................vNN"...,...........~.W.."'^^.,w..~'...-....a...-.....,.,....~.~-........-..-'".~..v............J THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW <a> 1. Original Return c=J 2. Supplemental Return c:t 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required C) c:::J 4a. Future Interest Compromise (date of death after 12-12-82) c::::> 7. Decedent Maintained a Living Trust (Attach Copy of Trust) c::> 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRE~T~D TO: Name ;.~~~!~.:m!~!:p~_~~.~~u~.~~_."..m_"~m.. 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes 4. Limited Estate c:) ca> C=> ; (717) 691-9809 I REGISTER OF WILLS USE Oft'LY I First line of address 1205 Manor Drive ......1 Second line of address (.:'1 -..J or Post Office State ZI P Code L___....PAT_~~~.!?._.__._.___._M._.......__..." 17055 Correspondent's e-mail address: Under penalti perjury, I de e that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is tru rrect and complete. D parer other than the personal representative is based on all information of which preparer has any knowledge; FILING RETURN ADDRESS 214 N. Addison Avenue, Elmhurst, IL 60125 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS Pecht & Associates, PC, 1205 Manor Drive, Suite 200, Mechanicsburg, PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051058 15056051058 -I ~ -~ ~ .-J 15056052059 REV-1500 EX Decedent's Name: ALEXANDER V WALSEN De~~dent'~_~~!~~ Security_~~~~~.^~__ : 076-32-7317 RECAPITULATION 1. Real estate (Schedule A). ............................................ 1. 0.00 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2. 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3. 0.00 4. Mortgages & Notes Receivable (Schedule D). . . . . . . . . . . . . . . . . . . . . . . . . . . ., 4. 0.00 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . ., 5. 14,648.04 0.00 6. Jointly Owned Property (Schedule F) C> Separate Billing Requested. . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) c:;:) Separate Billing Requested.. . . . . .. 7. 0.00 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. , 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . . . 9. 1,409.40 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . . . . . . . . . . . . . . . 10. 326.67 11. Total Deductions (total Lines 9 & 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 1 ,736.07 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 12,911.97 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13. 0.00 1464804 14. Net Value 12 minus Line 12,911.97 TAX COMPUTATION - SEE INSTRUCTIONS FOR 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 16. Amount of Line 14 taxable at lineal rate X.O_ 17. Amount of Line 14 taxable at sibling rate X .12 18. Amount of Line 14 taxable at collateral rate X .15 15. 581.04 16. 581.04 17. 18. 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 581.04 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT c::> 15056052059 Side 2 15056052059 -I L REV-1500 EX Page 3 ... Decedent's Complete Address: DECEDENT'S NAME ALEXANDER V WALSEN STREET ADDRESS File Number r~"~~~~~~:':~~=~~~:~:~~~mvN~~:~~~~~'V] DECEDENT'S SOCIAL SECURITY NUMBER 076-32-7317 CITY STATE ZIP Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1 ) 581 .04 Total Credits ( A + 8 + C ) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty 12.59 Total Interest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 12.59 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 8. Enter the total of Line 5 + SA. This is the BALANCE DUE. (SA) (58) 581 .04 12.59 593.63 A. Enter the interest on the tax due. Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN IIXII IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;.......................................................................................... D ~ b. retain the right to designate who shall use the property transferred or its income; ............................................ D ~ c. retain a reversionary interest; or........................................................................................................... ......... ...... D I)(f d. receive the promise for life of either payments, benefits or care? ...................................................................... D ~ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....... ............ ................ .................. ................... ..................... ........... ...... D ~ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D ~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ..... ....... ..... ................ ...... ............................. ...... ............................... .......... ..... D ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 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 three (3) percent [72 P.S. 99116 (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 or for the use of the surviving spouse is zero (0) percent [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 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 zero (0) percent [72 P.S. 99116(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 four and one-half (4.5) percent) except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. 99116(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-15D8 EX+ (6-98) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH/ BANK DEPOSITS/ & MISC. PERSONAL PROPERTY ESTATE OF ALEXANDER V. WALSEN FILE NUMBER 21-05-0741 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. . Fulton Bank Account #3622-24430 Social Security Benefit DESCRIPTION TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) VALUE AT DATE OF DEATH 13,636.84 1,011.20 14,648.04 10S7 0017 6139 Y Fulton Bank . LISTENING. STATEMENT OF ACCOUNTS 3622-24430 STATEMENT PERIOD FROM THROUGH 3-0 I-OS" 3-31-0S 0 PAGE 1 OF 1 x 1...111...111......11..11...1.1..1.1...111..1....11...11..11.1 ALEXANDER V WALSEN 411 W NORTH ST APT 1 CARLISLE PA 17013-2218 o ENCLOSURES o TRUE BLUE BANKING PREVIOUS .......... . DEPOSITS/ STATEMENT BALANCE CREDITS 13,636.84 CHECKS/ 1 DEBITS 13 .. 20 ACCOUNT: 3622-24430 SERVICE o FEE S .00 .00 ENDING BALANCE 13,6S0.04 INTEREST PAID THIS YEAR J\CCOIINT/INTEREST INFORMATION 42.63 DATE AGTIVITYDESCRIETIONREFERENCE 03-01 BEGINNING BALANCE 03-31. INTEREST CREDIT 03-31. ENDING.. BALANCE DEPOSITS/ CHECKSI CREDITS DEBITS 13..20 BALANCE 13,636.84 13,6S0.04 13,6S0.04 *** ANNUALPERCENTAGE....YIELDEARNEDDISCLQSURE>FROM 3-01-0S.......THROUGH 3-31-0S *** ANNUAL PERCENTAGE YIELpEARNED 1; 15% AVERAGEDAILYCOLLECTED>.BALANCE 13,636..84 INTERES T>EARNED 13.20 SERVICE FEE... BALANCE <INFORMATION..FROM 3-01~05THROUGH 3~31-05 AVERAGE LEDGER..BALANCE 13,636.84 AVERAGECOLLECTEDBALANGE MINIMUM LEDGER BALANCE 13,636.84 MINIMUM COLLEGTEDBALANCE 13,636.84 13,636.84 DIRECT INQUIRIES TO: FULTON BANK DIRECT BANKING CENTER P. O. BOX S04 EAST PETERSBURG, PA 17520-0S04 Member ED.I.e. fultonbank.com ..... ~i:.. ~'. -J ~ FORM SSA-1099 - SOCIAL SECURITY BENEFIT STATEMENT 2005 · PART OF YOUR SOCIAL SECURITY BENEFITS SHOWN IN BOX 5 MAY BE TAXABLE INCOME. · SEE THE REVERSE FOR MORE INFORMATION. Box 1. Name ALEXANDER V W ALSEN Box 3. Benefits Paid in 2005 Box 2. Beneficiary's Social Security Number 076-32-7317 Box 4. Benefits Repaid to SSA in 2005 Box 5. Net Benefits for 2005 (Box 3 minus Box 4) g ~ ... II) lD t n to) ~ U1 IS) ~ $1,011.20 DESCRIPTION OF AMOUNT IN..BOX 3 'SOCIAL SECURITY ADMINISTRATION NORTHEASTERN PROGRAM SERVICE CENTER 1 JAMAICA CENTER PLZ JAMAICA NY 11432-3898 OFACIAL BUSINESS PENALTY FOR PRIVATE USE, $300 Paid by check or direct deposit Medicare premiums deducted from your benefit Total Additions Benefits for 2005 Form SSA-1099-SM (1-2006) aJ :J I- UJ U. U. o II: <( W I- ~ o ...J o u.. NONE $1,011.20 DESCRIPTION OF AMOUNT IN BOX 4 $933.00 $78.20 $1,011.20 -$1,011.20 NONE Box 6. Voluntary Federal Income Tax Withheld NONE Box 7. Address ALEXANDER VWALSEN 411 W NORTH STREET APT 1 CARLISLE PA 17013-2218 Box 8. Claim Number (Use this number if you need to contact SSA.) 076-32- 7317 A DO NOT RETURN THIS FORM TO SSA OR IRS Tl M09 1 PRESORTED FIRS"f-CLASS MAIL POSTAGE AND FE-:J PAID SOCIAL SECURITY ADMINISTRATION PERMIT NO. G:-11 ~es44897-11C3as4S0S7 0481-256-06 _,************** AUT6CR ** C-OOB ALEXANDER V WALSEN 411 W NORTH pr.t'f.DT.'IT."Tn ._. - --. APT! 'WALS'fo.1..1 .170.133015 1..1.0:S Joe 01/.1.7/06 NOTIFY SENDER OF NEW ADDRE5S CARLISLE.PA ] ~fhS~NADDISON AVE 111I11I11I11111111111..111 ELMJ-fUFlS T rL 60.1..26 - 27.2.1. )0. B IS) ~ ~ CD LD '" ,!. n II) m ~ U1 IS) U1 "'" 't::~ ._ + "11 o r o 120 -{ m l> :JJ o " " en -i c CD +' REV-1~511 EX+ (12-99) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF ALEXANDER V. WALSEN FILE NUMBER 21-05-0741 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. DESCRIPTION AMOUNT 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions TOTAL (Also enter on line 9, Recapitulation) (If more space is needed, insert additional sheets of the same size) State Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City Year(s) Commission Paid: 2. Attorney Fees 750.00 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 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Appointment ot out-ot-state executor 8. Cumberland Law Journal (Notice) 9... ..The Patriot-News (Notice) 10 Family Settlement Agreement filing tee " ~ RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 WALSEN ALEXANDER V Estate File No.: Paid By Remarks: 2005-00741 JA ------------------------ Receipt Distribution ------------------------ Fee/Tax Description PETITION LTRS TEST WILL AUTOMATION FEE COMMISSION TO TAKE SHORT CERTIFICATE JCP FEE Check# 1731 Check# 1840 Total Received.... ..... Payment Amount 60.00 15.00 5.00 20.00 20.00 10.00 ---------------- $100.00 $30.00 $130.00 Receipt Date: Receipt Time: Receipt No. : 8/19/2005 11:11:45 1041652 Payee Name CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D .. ~ CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, P A 17013 August 26, 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: Wayne M. Pecht, ESQUIRE RE: j Alexander V. Walsen, 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: August 12, 19, 26, 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 August 9.. 2005 by Becky H. MorgenthallExecutive Director .. ~ PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVAl'TIA SSe COUNTY OF CUl\1BERLAND Lisa Marie Coyne, Esquire, Editor of the CU1nberland Law Journal, of the County and State aforesaid, being duly S\V01l1, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in th~ said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, V1Z: August 12,19,26,2005 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodjcal of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisen1ent, and that all allegations in the foregoing statements as to tilne, place and character of publication are true. Walsen, Alexander V., dec'd. Late of 411 West North Street, Carlisle. Executor: Paul J. Walsen, c/o Wayne M. Pecht, Esquire, Pecht & Associates, PC, 1205 Manor Drive, Suite 200, Mechanics- burg, PA 17055-4894. Attorneys: Wayne M. Pecht, Es- quire, Pecht & Associates, PC, 1205 Manor Drive, Suite 200, Mechanicsburg, PA 17055-4894. ..".- SWORN TO AND SUBSCRIBED before me this 26 day of August. 2005 NOT ARI SEAL LOIS E. SNYDER. Notary Public CarHsle Boro, Cumberland County My Commission Expires March 5, 2009 .' / ;f' ~~~~\ ~ .... ~ ------ ~ / ~~<<tit patriot-News " Now you k'now Order Confirmation Order Source 0001359081 rholton rholton Fax customE!r PECHT & ASSOCIATES, PC Orderer Account Number 73761 Ad Order Payer Paver Account Number 73761 Sales Order Taker Special PricinQ None PECHT & ASSOCIATES, PC SUITE 200,1205 MANOR DRIVE PO Number ESTATE OF WALSEN WAYNE PECHT Mechanicsburg PA 17055-4917 USA Ordered Bv Customer Fax Customer EMail Customer Phone 717 -691-9810 Paver Phone 717 -691-9810 Tear Sheets o Proofs o Affidavits 1 Blind Box Promo Tvpe <NONE> Invoice Text Materials Total Ad Cost $100.95 Payment Amount $0.00 Payment Method $100.95 Amount- Due Ad Number Ad Type 0001359081-0' Legal Liners Ad Size :1.0X15Li Color <NONE> Production Method Production Notes Ad Booker Product Information Class ificati on # Inserts" Run Dates PNCO: :Full Run 846-Estate Notices-West 3 8/9/2005, 8/16/2005, 8/23/2005 Run Schedule Invoice Text ESTATE NOTICEEstate of Alexander V. Walsen, deceased, late of 41 8/23/2005 9:29:51AM 1 ..PECHT & ASSOCIATEt , . OPERATING ACCOUNT 1205 MANOR DR SUITE 200 MECHANICSBURG, PA 17055 . c. 1840 DATE O~t 2aJ~ ( 60-1878/313 . BRANCH 1 .,. : b~J~~OF _~1lSkr of h!r Ifs of c~ Gzrwt:; I . . ~ {~ . ~~~f . FOR ~~"I1J~ e~ 1/,$, 60, -: "lJ DOLLARS f[j S.curi!y . Feature. Details on Back. w II. 0 0 . 8 L. 0 II. I: 0 3 . 3. ij '7 8 '7 I: APPOINTMENT OF OUT-OF-STATE EXECUTOR / ~ R~V-1~2 EX+ (12-03) .. '* SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21-05-0741 ESTATE OF Walsen, Alexander V. Report debts Incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 110.00 Andorra Radiology Associates 33.00 2. 326.67 Lancaster HMA Physician Mangement 3. Earthlink 23.95 4. Sprint 49.72 5. Apex Asset Management 110.00 TOTAL (Also enter on line 10, Recapitulation) (If more space is needed, insert additional sheets of the same size) c . c MAKE CHEC~S PAYABLE TO: . -. ANDORRA RADIOLOGY ASSOC PC PG BOX 892 'CONCORDVILLE, PA 19331 ADDRESS SERVICE REQUESTED .. For all billing questions, please call 800 -7 4 8 - 2413 Responsible Party: ALEXANDER v WALSEN Tax 10 #: 233016413 PAGE: 1 03/22/05 9280727 SEr,JtJ REM!T TO: ALEXANDER V WALSEN 411 W NORTH ST APT 1 CARLISLE, PA 17013 ANDORRA RADIOLOGY ASSOC PC PO BOX 892 CONCORDVILLE, PA 19331 D Please check box if above address is incorrect or insurance information has changed, and indicate change(s) on reverse side. STATEMENT PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT IN ENCLOSED ENVELOPE Tax ID #: 233016413 STATEMENT 11111111111111111111111111111111111111111111111111111111111I SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION 2556 - 0002 DATA 201 CR2-K 056263 355379 IAN: . JMi\ PHYS ~ CJINT PEN EO BJX 619 ~ b~, PA 1752fXJ619 STATEMENT PAno:IENT OPTIONS Check # Amt $ ArCRESS SERlICE RB;J.JESIlID V1252 041 B5392M TH31 BNS 011 0632 L Please Include Securitv Code From Back Of Card CHECK CARD USJN~ FOR PA YMENT [II) ~9TERCARD , VISA ~ ~SA CARD NUMBER EXP.DATE CARDHOLDER NAME SECURITY CODE SIGNATURE AMOUNT of ALEXANDER 'WALSEN 214 N ADDISON AVE ELMHURST, IL 60126-2721 1.111111.11.1111111.1.1111111.1111.1111.111.1111.11.1..11111.1 REMIT TO: LANC HMA PHYS ~ CENT PEN PO BOX 619 EAST PETERSBUR, PA 17520-0619 '11.11111.1.1.1.111.111.1111.11 .111111.111.11111.111.1111.1111 Office Phone Number 717 519-0753 Statement Date 03/29/05 Your Account Number 355379 PLEASE RETURN THIS PORTION WITH PAYMENT New Balance' SHOW AMOUNT 110.00 PAID HERE $ ----------- ---------------------------------."-------------- --~-------------------------_._- -------"------.;.--- -------.;.. ----------------------------------- CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT itatement >ate: 03/29/05 PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE: 355379 NOTE: Charges and payments not appearing on tbis statement will appear on next month's statement._ INVOICE PAGE: Attn: Accounts Receivable fJ .. PO Box 7645 Atlanta GA 30357-7645 (888) EARTHLlNK M-F 7am-12am EST http://myaccount.earth link. net Account No: 0000-000011987491-7 Invoice No: 000000214453862 Billing Date:03/14/05 Due Date: . 04/04/05 Previous Balance: New Charges: 23.95 .00 EarthLink" Amount Due: Total Due: ACCOUNT SUMMARY FOR: Alexander Walsen .00 23.95 Previous Balance 23.95 Balance Due: 23.95 Please pay upon receipt and be sure to include your account number 11987491 with your payment. Any previous balance is now past due. Questions about this * http://www.earthlink. * http://support. with a friendly Live * Send email to invoice Please remember: You common billing questions , instant messages to above address date to dispute a charge this invoice before , arrange a one-time service plan and more at: to $100) : Please 8end payment8 to: EarthLink Inc., PO Box 530530, Atlanta GA 30353-0530 Please 8em writtencorre8pondence to EarthLiDkInc. PO Box 7645 Atlanta GA 30357-7645 -- ------..-- --. .u___... .... ...... u______ - noon -- noon --.--. ...... .-. .....~~~.~~~~.~~!!__~~~~~:._ ~~~.~~.~~~_~~~~.~~~_~~<?~ .~~.~~~.:~~:~~~:...... .u...u_..____.u.u........ u.um....... ....m...._u_____..... ......_.. ................. 'm 10: MEIN33 R: OS/19/04 Keep top portion foryourrecoros. fJ EarthLink Inc. Attn: Accounts Receivable PO Box 7645 Atlanta GA 30357-7645 Account No: Location No: Invoice No: 0000-000011987491-7 0001 000000214453862 PAYMENT COUPON Due Date: Total Due: 04/04/05 23.95 EarthLink" To make a one-time credit card payment, please visit your "My Account" Web page at: http://myaccount.earthlink.net or call1-BBB-EARTHLINK. RETURN SERVICE REQUESTED Amount Enclosed: 00000000119874917000180000002144538621040405700000239583 1931 III1I1I11III 1111111/1111111 11111111 Remit To: EARTHLINK INC PO BOX 530530 ATLANTA GA 30353-0530 1..11. II 111..11..1,',,111,"11,1'1'1..11,"11,',1' . , ALEXANDER WALSEN 214 N ADDISON AVE ELMHURST IL 60126-2721 18188.2005030826302.01931 Mov:illK1_ Take EarthLink with you! Find out how at httD:llsuDDOrt_earthlinLnetlmmri~ ~ Snrinte 't. . * Please recycle ..... T Sprinlc~ Monthly statement: May 13, 2005 Customer service 1-800-829-8009 Previous cha rges Payment Past due balance 1 of 4 Internet address sprint.com/local Customer number 717-249-7894-397 49.72 .00 49.72 nn...............................................................................................................u............................................................................................................ ilil~iIJ'l~II!li!~I~iit~'i~:~~~'~~ll:~!I\\iji~I~~ij~i\~iij~.I~II~ .... n........ n.............. ow.......... o. o. n 0... 0... o. o. o' o. ow 0... _ ,... _.. 0... o. o. ow.. o. .... n o. '. .on ,_.. _... 0..... o' o' 0... o. 0..... o. 0..... o. o' 0... o. '... o. 0... 0......... o. o' _. ow 0... o. o' .... o. .... o. o. o. 0... _... ow.. o. 0" .___._.__..__...._.__.____...__._._n_.______..________.~_.____.._..___...__..__________..__._.._______..________.._.._...._._____n_.u.__n_.._____.__ jllfmllt.k'!jJllll:e~!l~~~~ll~I!lliitllli!.II~!.!~I~~t.tt. Please return this portion with payment. NNNNNNNY 4 Customer service 1-800-829-8009 1.11..11......11..1.1.11'11.1.11...1..1.1...11...11.1..11..1.1 ~ ~ + 010667 ALEXANDER WALSEN 214 N ADDISON AVE ELMHURST IL 60126-2721 - - Internet address Customer number sprint.comjlocal 717-249-7894-397 Please pay past due amount of $49.72 immediately. Total amount due: $49.72 Amount enclosed: I Write your 13-digit customer number on check. Make checks payable to: Sprint PO Box 740463 Cincinnati OH 45274-0463 1.1..1.1.1'111111'111.111111111.1..1.11"11111.1.1.1 12 71724978943975 00000000000000 000049720 0519208 .. ~~~ 1891 Santa Barbara Drive, #204 Lancaster, E4 17601 Telephone: 717-519-1770 Toll Free: 888-592-2144 4- MAY 17 2005 Account For: Alexander Walsen 214 N Addison Ave Elmhurst IL 60126-2721 CARLISLE HOSPITALISTS Client Account #: 355379 Balance Due: $110.00 Your account(s) with CARLISLE HOSPITALISTS has been placed for collection. List of accounts: Name WALSEN ALEXANDER 355379 C1ient Reference CARLISLE HOSPITALISTS Visit Date Ba1ance Due 01/01/05 110.00 Please contact this office at 717-519-1770 or 888-592-2144 to make suitable arrangements to pay this outstanding balance. This is an attempt to collect a debt and any infonnation obtained will be used for that purpose. Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will assume this debt is valid. If you notify this office in writing within 30 days after receiving this notice, this office will obtain verification of the debt and mail you a copy of such verification. If you request from this office in writing within 30 days after receiving this notice, we will provide you with the name and address of the original creditor, if different from the current creditor. This communication is from a debt collector. Please refer to our account number 1510457 when calling or writing about this account. 004563-APEX12415517488361 I11111I1I11II11I1I "III " 11111111111111111111111 " 111/1111 PO Box 7044 Lancaster PA 17604-7044 RETURN SERVICE REQUESTED *** Please detach below and return in the enclosed envelope with your payment *** If you wish to pay by credit card, please enter the requested infonnation in spaces provided ZD~D.DED Date: MAY 17 2005 Amount: $110.00 Account: 355379 Card#:________________ Expiration Date: Amount Authorized: S Signature: 3 Digit Security Code (back of card) ___ Billing Address: CPMC41 1510457 1241 LAN Alexander Walsen 214 N Addison Ave Elmhurst IL 60126-2721 1.11..11......11..1.1.11....1.11...1..1.111.11...11.1..11..1.1 Send Payment To: APEX Asset Management, LLC PO Box 7044 Lancaster PA 17604-7044 1111111.111.11..11.11.1111111.111.11.1..1.1..1.1..1.11111.1..1 .;. ... .:rv-1513 EX+ (9-00) '* SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER NUMBER I 1. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under ,Sec: u~t1~. (a) (1))] u Paul J. Walsen, 214 North Addison, Elmhurst, IL 60126 RELATIONSHIP TO DECEDENT Do Not List Trustee(s) AMOUNT OR SHARE OF ESTATE 12,931.87 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 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 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) 0.00 e- - t. .1fr ... \ ..- # LAST WILL AND TESTAMENT OF ALEXANDER V. W ALSEN '- I, ALEXANDER V;. W ALSEN, . of the County of Cumberland, State of Pennsylvania, being of sound and disposing. mind and memory, do make, publish, ordain and dec~are this to be my LAST WILL AND, TESTAMENT, hereby revoking any and all former Wills and Codicils by me at any time heretofore made. ARTICLE ONE I direct my Executor hereinafter named, to pay all of my funeral expenses; the - - - - - - - - -- ~ - - - - _. - - . - --- - ~ administration expenses of my estate, including inheritance, estate and succession taxes, state or federal; and all other proper and just debts and charges against by estate. ARTICLE TWO All the rest, residue and remainder of my estate, both real and personal, of whatever kind or character and wheresoever situated which I may own at my death, or to which I may be .entitled at my death I give, devise and bequeath to my son PAUL J. W ALSE~ to be his exclusively, absolutely and forever. ARTICLE THREE In the event that PAUL J. W ALSEN, identified in ARTICLE TWO, does not survive me, it is my intention that that my estate pass to his spouse and children, or estate. ARTICLE FOUR I hereby nominate and appoint my son PAUL J. W ALSEN, currently residing in the State oflllinois, as EXECUTOR of this my LAST WILL AND TESTAMENT. I give my Executor power, without need for authorization of any Court, to invest in bonds, stocks, notes or other property, "lease, borrow, sell or exchange all or any part of my ~state for such p~ces and upon such' terms as my Executor deems p~oper; to compro~se, contest~ prosecute or abandon claims in favor of or against, my estate; to make divisions or ~ <:'~ ~ ~ ~ .- distribution of my estate in individual mterest or wholly or partly in~~; and to execute and deliver necessary instruments and give full receipts and discharge. No s"ecurity shall be required on the bond bfmy executor whenever or wherever acting. My Executor is authorized, in the performance of his duties, to retain the services of whatever experts he, in his sole discretion, deems appropriate for the orderly and expe4ient management of my estate. My Executor shall be reimbursed for all expenses incurred in connection with the administration and distribution of my estate but shall not be entitled to any additional compensation for his services unless the administration and distribution becomes a matter of judicial contest. " IN WITNESS WHEREOF, I have signed this my LAST WILL AND TESTAMENT, consisting of two pages, this page included, and for the purpose of identification have placed my initials at the foot of each preceding page, this lif day of V~ b~ 2004. Certification of the witnesses is on page 3. iJl1, ~J~. I~ .... (seal) ALEXANDER V. WALSEN 1 COMMONWEALTH OF PENNS"L VANIA Notarial Seal Marian~e G. Manion, Notary Public SBver Spn~ ~Vv'p., Cumbertand County My CommISSIon Expires Mar. 8, 2008 Mem~r. Pennsylvania Association Of Notari s ct~/f~~ @\..'Y'~/\,t(V~ 390386JE11 2