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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128~601
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Criss, Nancy A.
DATE OF DEATH (MM-DD-YEAR)
03/21/05
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
DATE OF BIRTH (MM-DD-YEAR)
06/01/22
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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[!] 1. Original Retum
o 4. Limned Estate
~ 6. Decedent Died Testate (Attach copy of Wil)
o 9. Litigation Proceeds Received
o 2. Supplemental Retum
o 4a. Future Interest Compromise (dale of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy ofTrus!)
o 10. Spousal Poverty Credit (date of death belween 12-31-91 and 1-1-95)
FILE NUMBER
21 05
0279
-- --
COUNTY CODE YEAR
NUMBER
SOCIAL SECURITY NUMBER
187-16-6747
THIS 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 Retum Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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NAME
Marvin Beshore
FIRM NAME (If Applicable)
Law Offices of Marvin Beshore
TELEPHONE NUMBER
(717) 236-0781
COMPLETE MAILING ADDRESS
PO Box 946
130 State Street
Harrisburg, PA 17108-0946
13,570.82
(8)
29,367.30
39,284.00
(11)
(12)
(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)
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
0.00 x.O _ (15)
120,720.29 X.o 45 (16)
0.00 x .12 (17)
0.00 x .15 (18)
(19)
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
0.00
0.00
0.00
5,800.77
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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 Govemmental 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)
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0.00
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189,371.59
68,651.30
120,720.29
0.00
(14)
120,720.29
0.00
5,432.41
0.00
0.00
5.432.41
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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 II
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 I
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116(a:
individual who has at least one parent in common with the decedent, whether by blood or adoption.
r-.r{\ U\ '~lJicJ"\7 five parent
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uJ 1,fiJ. ___ _102, as an
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REV.1502 EX. (6-'.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF
Nancy A. Criss
FILE NUMBER
21-05-0279
All real properly owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at 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 jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
Real property at 2202 Parkside Rd., Lot 92, Country Club Manor,
Camp Hill Borough, Cumberland County, PA.
Please see attached description and HUD-1 settlement sheet.
Conveyed on July 21,2005.
Value shown is the contract sales price.
VALUE AT DATE
OF DEATH
170,000.00
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
170,000.00
. -
Estate of Nancy A. Criss
File Number: 21-05-0279
Legal Description for Schedule A
ALL THAT CERTAIN tract or parcel of land situate at 2202 Parkside Road, in the Borough of
Camp Hill, Cumberland County, Pennsylvania, more particularly bounded and described as
follows, to wit:
BEGINNING at a point on the northerly line of Parks ide Road, which point is 110.09 feet west
of the northwesterly corner of Apple Tree Road and Parkside Road; thence along the northerly
line of Parks ide Road south 73032' west 21.75 feet to a point; thence in an arc having a radius
of 84.89 feet in a westerly direction 131.73 feet to a point; thence north 72044' east 110. 06 feet
to a point; thence south 140 11' east 80.31 feet to a point, the place of BEGINNING.
BEING the premises which Ralph E. Lamison, and Odette D. Lamison, his wife, by deed dated
November 4, 1968, and recorded November 18, 1968 in the Cumberland County Recorder of
Deeds Office in Record Book Z22, Page 1018, conveyed unto John D. Criss and Nancy A. Criss,
husband and wife.
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U. S. DEPARTMENT OF HOUSING and I '~BAN DEVELOPMENT OMB No. 2502-0265
SETTLEMENT STATE. .JT .'itlepro for Windows no
~ ASSURED LAND TRANSFERS, INC.
301 Market Street B. TYPE OF LOAN
Lemoyne, P A 17043-0109 o 1, FHA 02. FMHA o 3. CONV.UNINS.
(717) 761-4720 04.VA o 5. CONV. INS.
6. FILE NUMBER: r LOAN NUMBER:
5022
MORT. INS. CASE NO.:
14112-1
C. NOTE: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown.
Items marked "(p.o.c.)" were paid outside the closing; they are shown here for information purposes and are not included in the totals.
D. NAME AND ADDRESS OF BORROWER: E NAME AND ADDRESS OF SELLER: F. NAME AND ADDRESS OF LENDER
Guillermo Soyos, Lisa Horowitz Soyos Estate of Nancy A. Criss CASH SALE
G. PROPERTY LOCATION: H. SETTLEMENT AGENT: Assured Land Transfers, Inc. I. SETTLEMENT DATE:
2202 Parkside Road Jul 21 2005
Lot 92, Country Club Manor Thursday
Camp Hill Borou9h PLACE OF SETTLEMENT: 301 Market Street. Lemoyne. PA 04:00 PM
Cumberland County, PA
J. SUMMARY OF BORROWER'S TRANSACTION K. SUMMARY OF SELLER'S TRANSACTION
100. Gross Amount Due From Borrower 400. Gross Amount Due to Seller
101- Contract sales price 170,000.00 401. Contract sales price 170,000.00
102. Personal Property 402. Personal Property
103. Settlement Charges (line 1400) 3,439.25 403.
104. 404.
105. 405.
Adjustments for items paid in advance by seller(s) Adjustments for Items paid in advance by seller(s)
106. Cityrrown tax 406. CityfTown tax
107. County/City tax 07/21/05 to 12/31/05 244.32 407. County/City tax 07/21/05 to 12/31/05 244.32
108. Assessments 408. Assessments
109. School Tax 07/21/05 to 06/30/06 1,494.67 409. School Tax 07/21/05 to 06130/06 1,494.67
110, 410.
111. 411-
112. 412.
120. Gross Amount Due from Borrower 175,178.24 420. Gross Amount Due to Seller 171,738.99
00, Amounts Paid By Or In Behalf Of Borrower 500. Reductions In Amount Oue To Seller
201. Deposit or earnest money 1,500.00 501. Excess deposit (see Instructions)
702. Principal Amount of new loan(s) 502. Settlement charges to seller (line 1400) 8.418.91
203. Existing loan(s) taken subject to 503. Existing loan(s) taken subject to
204. 504.-Payoff of First Mortgage Loan
Soverei9n Bank 30.722.72
205. 505. Payoff of Second Mortgage Loan
206. 506.
1207. 507.
1208. 508.
209. 509.
Adjustments for items unpaid by seller Adjustments for items unpaid by seller
10. CitylTown tax 510. CityfTown tax
11. County/City tax 511. County/City tax
12. Assessments 512. Assessments
213. School Tax 513. School Tax
214. 514.
'15. Sewer 07/01105 to 07/21/05 6.52 515. Sewer 07/01/05 to 07/21/05 6.52
216. 516.
217. 517.
218. 518.
~19. 519.
220. Total Paid By/For Borrower 1,506.52 520. Total Reductl9!l Amount Due Seller ;$9,148.15
1300. CASH AT SETTLEMENT FromlTo BORROWER 600. CASH AT SETTLEMENT To/From SELLER
1301. Gross AmI. due from borrower (line 120) . 175.178.24 601. Gross Amount due Seller (line 420) 171,738.99
1302. Less AmI. paid bylfor borrower (line 220) 1,506.52 602. Less reduction in Amt.due Seller (line 520) 39.148.15
303. Cash t8I FROM DTO Borrower 173,671.72 603. Cash t8I TO o FROM Seller 132,590.84
- "
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Buyer or Borrower's Signature
Seller's Signature
-"..~._---_.~ Paid Froml
L. SETTLEMENT CHARGES Case # 50. Paid From
700. Total Sales Commission based on Prictr. $ % Borrower's Seiler's
Division of Commission at: $ 5,100.00 Total Funds At Funds At t
701 5,100.00 ERA-NRT, Inc. Settlement Settlement
702.
703. Commission paid at Settlement I 5,100.00
704. Transaction Fee to ERA-NRT, Inc. I 125.00
800. Items Payable In Connection With Loan
80l. Loan Origination Fee
802. Loan Discount
803. Appraisal Fee to
804. Credit Report to
805. Inspection Fee to
806. Mortgage Insurance to
807. Assumption Fee to
808.
809.
810.
811.
900. Ilems Required By Lender To Be Paid In Advance
901. Interest from 0.0000 IDay
902. Mortgage Ins. Premium 0 Months to
903. Hazard Ins. Premium 0 Years to
904. 0 Years to
905. 0 Years to
1000. Reserves Deposited With Lender For
100L Hazard Insurance 0 Months @ $ IMonth
1002. Mortgage Insurance 0 Months @ $ IMonth
1003. CitylTown Taxes 0 Months @ $ IMonth
1004. County Taxes 0 Months @ $ 45.60 /Month
1005. Assessments 0 Months @ $ /Month
1006. School Taxes 0 Months @ $ 132.17 /Month
1007. 0 Months @ $ /Month
1008. 0 Months @ $ 10.00 /Month
1100. TItle Charges
1101- Setllement or closing fee
1102. Abstract or title search
1103. Title Examination
1104. Title Insurance Binder
1105. Document preparation
1106. Notary fees Assured Land Transfers, Inc. 5.00 10.00
1107. Attorney's fees
(includes above items No.:)
1108. Tille Insurance Assured Land Transfers, Inc. ~
(includes above items No.:) 1101 thru 11.04 and 1108
1109. Lender's coverage $
1110. Owner's coverage $ 170,000.00
111l.
1112. I I
1113. I
1200. Government Recording and Transfer Charges
1201. Recording Fees: Deed $ 40.50 Mortgage $ Release $ 40.50
1202. City/County tax/stamps: Deed $1,700.00 Mortgage $ 1,700.00
1203. State tax/stamps: Deed $1,700.00 Mortgage $ 1,700.00
1204. Recorder of Deeds
1205.
1300. Additional Settlement Charges
1301. Home Inspection, Termite & Radon to BIS Home Inspection Service 360.00
1302. Overnight Courier Fee (payoff) to Assured Land Transfers, Inc. 18.00
1303. 2005/2006 School District Real Estate Taxes to Janet L. Miller, Tax Collector 1,585.91
1304. Tax Certification Fe to Assured Land Transfers, Inc. 5.00
1305.
1400. Total Settlement Charges (enter on lines 103 & 502, Sections J & K) 3,439.25 8,418.91
Parties agree that no liability is assumed by Settlement Agent ror the accuracy of Information fumlshed by others as shown on the HUD-1 Settlement Statement.
Buyer's Address & Phone:
The HUD-l SetUement Statement.whlch I have prepared Is a true and accurate account of this transaction. I have caused or will cause the funds to be disbursed in accordance with this
stateme~ ~~
Settlement Agent
Y/3(~r
Date
~
REV-1508 EX+ (6-98> ..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
Nancy A. Criss
FILE NUMBER
21-05-0279
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.
ITEM
NUMBER DESCRIPTION
1. Checking Account - Sovereign Bank - # 0571128513. Please see attached DaD letter.
2. Savings Account - Sovereign Bank - # 2334026735. Please see attached DaD letter.
3. Personalty: Please see attached Appraisal by Claude C. Wolfe & Associates.
4. Four burial plots in Prospect Hill Cemetery. Acquired in 1955. Please see Indenture
January 5, 1955 attached.
5. Benefit under the Last Will and Testament of Lynn H. McCord: Dauphin County
Register of Wills Number 1070-2004.
Please see attached copy of Last Will and Testament; Account of M& T Bank; and
investment statements.
VALUE AT DATE
OF DEATH
816.46
302.07
2644.00
400.00
1500.00
6. Refunds from cancelled subscriptions
138.24
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
5,800.77
!'
Sovereign Bank
ESTATE OF
SOCIAL SECURITY #:
DATE OF DEATH:
Nancy A. Criss
187-16-6747
March 21, 2005
Account #: 0571128513 Type:
In the name of: Nancy A. Criss
Date of Death Balance:
Int.(YTD) from 1/1/2005 to
Accrued interest to date of death:
Other Info:
Checking
Open date: 1/30/1997
$816.46
3/14/2005
$0.00
$0.45
Account #: 0574111928 Type:
In the name of: Nancya. Criss
Date of Death Balance: Closed prior
Int.(YTD) from 1/1/2005 to
Accrued interest to date of death:
Other Info: closed 2/14/05
Club Account
Open date: 12/31/1980
2/14/2005
$0.00
$0.00
Account #: 2334026735 Type:
In the name of: Nancy A. Criss
Date of Death Balance:
Int.(YTD) from 1/1/2005 to
Accrued interest to date of death:
Other Info:
Savings
Open date: 7/6/2001
$302.07
2/13/2005
$0.18
$0.18
Account #: N-6819166206 Type: Home Equity Credit Line Open date: 1/6/2005
In the name of: Nancy A. Criss or James D. Criss
Date of Death Balance: $29,953.80 (dod payoff$30,062.51)
Int.(YTD) from to
Accrued interest to date of death:
Other Info:
Page 1 of 1
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CLAUDE C. WOLFE & ASSOCIATES
AUCTIONEERS & APPRAISERS
FAMILY OWNED SINCE 1910
2009 LINCOLN STREET · CAMP HILL, PA 17011
717-737-0734
Appraisal for the Estate of Nancy A. Criss
2202 Parkside Drive, Camp Hill, PA 17011
LIVING ROOM
Empire, hand made grandfather's clock
Pair of end tables
Coffee table
Table lamp
Floor lamp
Misc. books
Misc. bears, Beanie Babies, etc.
Misc. knick-knacks on mantle
Misc. beer cans, mugs, etc.
Flat iron
Live plant
Upholstered chair
3-Drawer chest - refinished
Upholstered rocking chair
Wooden card table
Firkin
Jug - chipped
Painting
Scales
Misc. contents of living room
DINING ROOM
Table and 6 chairs - worn
Stereo - old
Stereo cabinet
CD's & 45 rpm records
Clock
April 6, 2005
250.00
50.00
20.00
2.00
5.00
5.00
10.00
5.00
2.00
3.00
2.00
8.00
150.00
25.00
125.00
15.00
2.00
10.00
3.00
25.00
60.00
40.00
10.00
45.00
1.00
~
CLAUDE C. WOLFE & ASSOCIATES
AUCTIONEERS & APPRAISERS
FAMILY OWNED SINCE 1910
2009 LINCOLN STREET · CAMP HILL, PA 17011
717-737-0734
Criss appraisal
Page 2 of 6
DINING ROOM - continued
Wall shelf
Misc. Beanie Babies
Bell collection
R. S. Germany cream pitcher
Chester cup
8.00
2.00
5.00
20.00
20.00
Majolica Com pitcher - rough condition
Misc. Masonic souvenirs
Bavarian china
Misc. crystal
Crock pot
25.00
5.00
35.00
4.00
2.00
Noritake platter
Misc. vases
Misc. contents of built-in china cabinet
Misc. contents of dining room
7.00
5.00
25.00
10.00
KITCHEN
Table & 2 chairs
Kenmore refrigerator
Electric can opener
Toaster oven
Pfaltzgraff dinnerware
35.00
60.00
1.00
2.00
15.00
Misc. glassware
Misc. cookware
Flatware
Trash can
Misc. contents of kitchen
4.00
3.00
4.00
1.00
15.00
CLAUDE C. WOLFE & ASSOCIATES
AUCTIONEERS & APPRAISERS
FAMILY OWNED SINCE 1910
2009 LINCOLN STREET · CAMP HILL, PA 17011
717-737.0734
Criss appraisal
Page 3 of 6
4-Drawer serpentine chest - worn
Misc. games
Hoover upright vacuum cleaner - old
RCA 17" TV
Toshiba VCR
Misc. VCR tapes
TV stand
Upholstered chair
Sofa and matching chair
Floor lamp
TV trays
Telephone
Answering machine
Bank
(2)Yard chairs
Misc. contents of bedroom
Pair of twin beds
4-Drawer chest
Table lamp
Kneehole desk & chair - worn
Hamper
Small file cabinet
Hat/coat tree - broken
6-Drawer Empire chest
DustBuster
(2)Small diamond rings
REAR BEDROOM
FRONT BEDROOM
35.00
3.00
3.00
25.00
15.00
10.00
1.00
2.00
15.00
5.00
1.00
1.00
2.00
1.00
4.00
10.00
10.00
20.00
2.00
10.00
1.00
3.00
1.00
225.00
1.00
150.00
~
CLAUDE C. WOLFE & ASSOCIATES
AUCTIONEERS & APPRAISERS
FAMILY OWNED SINCE 1910
2009 LINCOLN STREET · CAMP HILL, PA 17011
717-737-0734
Criss appraisal
Page 4 of 6
FRONT BEDROOM - continued
Misc. sterling silver jewelry
Misc. gold rings
Masonic ring
Misc. costume jewelry
Misc. linens
Misc. contents of bedroom
UPSTAIRS WEST BEDROOM
4-Drawer chest
Trash can
(2)Twin beds - old
4-Drawer black painted chest
Doll bunk bed
Misc. doll, etc.
Sterling silver flatware - partial service for 6
Holmes & Edwards flatware - silver inlaid service for 12
Misc. contents of bedroom
LANDING
Cedar chest
Card table & chair
UPSTAIRS EAST BEDROOM
Misc. flowers and planters
Misc. Christmas decorations
Pair of lamps
Ironing board
(2)Old quilts - poor condition
75.00
50.00
65.00
25.00
10.00
25.00
20.00
1.00
10.00
5.00
10.00
3.00
200.00
50.00
20.00
30.00
5.00
5.00
3.00
1.00
1.. 00
5.00
~
ClAUDE C. WOLFE & ASSOCIATES
AUCTIONEERS & APPRAISERS
FAMILY OWNED SINCE 1910
2009 LINCOLN STREET · CAMP HILL, PA 17011
717-737-0734
Criss appraisal
Page 5 of 6
BASEMENT
Exercise bicycle 1.00
Metal shelving 5.00
Craftsman bench grinder 20.00
Misc. hand tools 35.00
Hardware 10.00
Kitchen Aid mixer - 10 years old 60.00
RCA clothes dryer 35.00
Sleeping bags 5.00
Dehumidifier - old 10.00
Misc. old tools 10.00
Misc. contents of basement 25.00
REAR PORCH
Small refrigerator 30.00
Picnic table & benches 5.00
Misc. patio furniture 10.00
SHED
Propane grill- old 5.00
Wooden step ladder 4.00
Battery charger 1.00
Circular saw - old 2.00
Misc. contents of shed 10.00
'f
CLAUDE C. WOLFE & ASSOCIATES
AUCTIONEERS & APPRAISERS
FAMILY OWNED SINCE 1910
2009 LINCOLN STREET · CAMP HILL, PA 17011
717-737-0734
Criss appraisal
Page 6 of 6
APPRAISAL TOTAL $ 2,644.00
This Fair Market Value appraisal is true and correct to the best of my ability as an
auctioneer and appraiser with 35 years experience.
Member: Certified Appraisers Guild of America
CLAUDE C. WOLFE & ASSOCIATES
('... -
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W. K. Dusty Chapman, CAGA
DEED 1/1286
.
m4is Jubruturr
Made the:. :-:-.:: .~~.~.. .~~.~,... ~.~~ ~.day .of.. ~.~:-:-.~.~ :':'.~.~ ~.~~. ~.:: ~.. .~~?~~.~!. ..':-:.~~.-:::':'.~.-:-:~.-::.~~.~ :":'.~.~~,-A. D. 19. .~~..
between PROSPECT HILL CEMETERY CORP., a corporation, duly organized under the laws of the Com-
monwealth of Pennsylvania, and having its principal place of business in the City of Harrisburg, Dauphin
County, Pennsylvania, of the one part, hereinafter referred to as the Grantor; and..............................................
....... .John.. .n... .Cr.l.s.8... and.! or.. .N.aney.. .A..... .c.r.1..~ ~ .J... b"'.~.. .w.t.f.~.... ..W:~J1~. ..tA~... .r.'=-.IA~... .t:?f.......................
survivorship.
.... ....18-44... P-ar.k.. .S.tl1set................................................ .......... ......................................... ................. ..... ............................
Harri sburg, Pennsy1 vania. .
of ................................. .. . .. .. . .. . . .. . .. .. .. . . . .. . . . .. . . . . . .. . . . .. . . . . . . . . .. . . . .. . ... .. .. .. .. . .. .. .. .. .. . .. . .. .. . .. . .. .. . .. .. . . . . .. .. . .. .. . .. .. . .. .. .. . .. .. .. . . . . . .. .. . . . . . .. .. . . . .. . ..
of the other part, hereinafter referred to as the Grantee.
WITNESSETH, That the said Grantor for and in consideration of the sum of..............................................
....... Two... Hundr.e.d.. Po.lla..~.s....~ ~.":":.~~. ":"::~. ":":.~ :-:.~.~ :":".~.~~. ~.7: :":".~~. ~.~ .-:. :":'.:-: :7.7:'.7.:':".:-:::'. 7:'.7. -::. ~.':'::-:-. ::::-::-:-.::.~ ~.~.7. Dollars
to it in hand paid by the said Grantee, at and before the ensealing and delivery hereof, the receipt whereof it
doth hereby acknowledge, hath granted, bargained, sold, aliened, released and confirmed, and by these pres-
ents doth grant, bargain, sell, alien, release and confirm unto the said Grantee, his heirs and assigns, the ex-
clusive and entire right of interment or sepulture in all that certain burial lot designated as..............................
... ... ..LOT... NO.... .ll2.. Unit... .Se. c.t i.on... ~~ 13. ~~... C. qXH;I.".~:t.ln&.. .Qt....;f. m~~...g,:r.~.!~. ~.,...............................................
n IN THE GARDEN OF MEMORIES."
....................................... ~.. -................................ ...................... . .......... ........... ~"".'.. ......... ~.............. ~............................... ~..,....,......
Section........ MEM'P.nr.At.......in PROSPECT HILL CEMETERY in Susquehanna Township, Dauphin County,
Pennsylvania, as shown on a Plat filed in the office of the PROSPECT HILL CEMETERY CORP., at Har-
risburg, Pa., together with all and singular the ways, avenues, passages, rights, liberties, privileges, im-
provements, hereditaments and appurtenances whatsoever and thereunto belonging, or in any wise apper-
taining, and the reversions and remainders thereof, and the right of participation in the statutory fund set
apart for the perpetual care and preservation of the within described lots, the grounds and renewal of the build-
ings and property of the said Cemetery Corporation as provided in its charter.
TO HA VE AND TO HOLD the same, with the appurtenances, unto the said Grantee, his heirs and assigns,
to and for the only proper use and behoof of the said Grantee, his heirs and assigns, forever, for the uses and
purposes of sepulture only, and to and for no other use, intent or purpose whatsoever, subject to all the rules,
regulations, conditions and instructions made and adopted, or which may hereafter be made and adopted by
the Corporation Grantor for the government of lot owners, or visitors to the. cemetery and the burial of the
dead, and in and by any By-Laws made and adopted or which may hereinafter be made and adopted by the said
Corporation Grantor, its successors and assigns.
.
THE PROSPECT HILL CEMETERY CORP. doth hereby constitute and appoint..........................................
....... W..... .A.... .~~1:~.~.1:p,g~....................................................................... .................................. ...................... ..,..... to be
its Attomey, for it and in its name, and as and for its corporate act and deed, to acknowledge this Inden-
ture before any person having authority under the laws of the Commonwealth of Pennsylvanil\, to take such
acknowledgllleIlts, to the intent that the SIMIle ll1.~y be dw-y :reeord~.
IN WITNESS WHEREOF, The said Grantor
tested by the hands of its President and Secretary
"
L. S.
1
LAST WILL AND TESTAMENT
OF
LYNN H. McCORD
I, LYNN H. McCORD, of Hampden Township, Cumberland
County, Pennsylvania, being of sound and disposing mind and
memory, do make, publish and declare this to be my Last will and
Testament; hereby revoking all wills and Codicils by me at any
time previously made.
ITEM I: I request that my body be
cremated.
ITEM II: All inheritance, estate and
similar taxes becoming due by reason of my death ("Death Taxesn),
whether such Death Taxes shall be payable by my estate or by any
recipient of any property, shall be paid by my Executor out of
the property passing under ITEM VI of this will as an expense and
cost of administration of my estate. My Executor shall have no
duty or obligation to obtain reimbursement for any Death Taxes
paid by my Executor, even though paid with respect to proceeds of
insurance or other property not passing under this Will.
ITEM III: I hereby exercise all powers
of appointment which I may have at the time of my death in favor
of my Executor, and all property subject to all such powers of
appointment shall be included in my estate and be governed by the
provisions of this will.
Page 1 of 10 pages
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ITEM IV: I give and bequeath all of my
household furniture and furnishings, automobiles, books,
pictures, jewelry, china, crystal, appliances, silverware,
wearing apparel and all other like articles of household or
personal use or adornment to the then living members of the
following group: CONDE SPAULDING HACKBARTH, MARYAN NORDBY DAILY,
CHARLES B. SPAULDING, II,and JUDITH DULANEY CRUNKILTON, to be
divided among them in as nearly equal shares as possible. Any
items not selected by the aforementioned beneficiaries shall be
distributed in accordance with a list which I shall maintain.
Any articles remaining after selection by the aforementioned
beneficiaries and distribution in accordance with the list which
I shall maintain shall be offered to the then living children of
MRS. MILFORD PAT~ERSON, COL. and MRS. CHARLES G. BRITTON, JR.,
COL. and MRS. THOMAS STONE and MR. and MRS. JOHN HAVAS. All
items remaining thereafter shall be sold at a private auction
house and the proceeds thereof shall pass as part of my residuary
estate.
ITEM V: I give and bequeath all of the
cash located in my safe deposit box at the time of my death to
the then living members of the following group: CONDE SPAULDING
HACKBARTH, MARYAN NORDBY DAILY, CHARLES B. SPAULDING, II and
JUDITH DULANEY CRUNKILTON, to be divided among them in equal
shares.
ITEM VI: I give, devise and bequeath
all the rest and residue of my property, real, personal and
Page 2 of 10 pages
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mixed, not disposed of in the preceding portions of this Will, as
follows:
(a) Sixty-five (65%) percent thereof to be
divided and distributed as follows:
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(1) One-fourth (1/4) thereof to PHILIP
HACKBARTH and CONDE SPAULDING HACKBARTH, or
the survivor of them living at my death. If
Philip Hackbarth and Conde Spaulding
Hackbarth both predecease me, then to their
respective children then living, per capita..
If Philip Hackbarth and Conde Spaulding
Hackbarth both predecease me leaving no
children who survive me, then said share
shall be divided in equal shares among the
remaining subparagraphs 'of this ITEM VI(a)
and distributed to the beneficiaries
thereunder in accordance with the provisions
thereof.
(2) One-fourth (1/4) thereof to CHARLES
B. SPAULDING, II and BARBARA SPAULDING, or
the survivor of them living at my death. If
Charles B. Spaulding, II and Barbara
Spaulding both predecease me, then to the
children of Charles B. Spaulding, II)then
living, per capita. If Charles B. Spaulding,
II and Barbara Spaulding both predecease me
leaving no children who survive me, then said
share shall .be divided in equal shares among
the remaining subparagraphs of this ITEM
VI(a) and distributed to the beneficiaries
thereunder in accordance with the provisions
thereof.
(3) One-fourth (1/4) thereof to DR.
JOHN DAILY and MARYAN NORDBY DAILY, or the
survivor of them living at my death. If Dr.
John Daily and Maryan Nordby Daily both
predecease me, then to their children then
living, per capita. If Dr. John Daily ~nd
Maryan Nordby Daily both predecease me
leaving no children who survive me, then said
share shall be divided in equal shares among
the remaining subparagraphs of this ITEM
VI(a) and distributed to the beneficiaries
thereunder in accordance with the provisions
thereof.
Page 3 of 10 pages
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(4) One-fourth (1/4) thereof to JUDITH
DULANEY CRUNKILTON, if she survives me. If
Judith Dulaney crunkilton does not survive
me, then to her children then living, per
capita. If Judith Dulaney Crunkilton does
not survive me and leaves no children who
survive me, then said share shall be divided
in equal shares among the remaining
subparagraphs of this ITEM VI(a) and
distributed to the beneficiaries thereunder
in accordance with the provisions thereof.
It is my request, but not my direction, that a
portion of the foregoing bequest of my residuary estate
be paid as soon after my death as possible to assist
the beneficiaries with the expenses that they may incur
in connection with the bequests made to them under ITEM
IV of this Will.
(b) Twenty (20%) percent thereof to be divided and
distributed in equal shares among the then living members of
the following group: the children of CONDE SPAULDING
HACKBARTH; the children of PHILIP HACKBARTH; the children of
MARYAN NORDBY DAILY; the children of CHARLES B. SPAULDING,
IIi and the children of JUDITH DULANEY CRUNKILTON.
(c) Five (5%) percent thereof to be divided and
distributed as follows:
(1) One-eighth (1/8) thereof to CLYDE
WINER and ZELMA WINER, or the survivor of
them living at my death. In the event Clyde
Winer and Zelma Winer both predecease me,
said share shall be divided in equal shares
among the remaining subparagraphs of this
ITEM VICe) and distributed to the
beneficiaries thereunder in accordance with
the provisions thereof.
(2) One-eighth (1/8) thereof to HELEN
HALLOWELL, if she survives me. If Helen
Page 4 of 10 pages
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Ha1.1owe11, predeceil~tis"iDe,-;~~sa:L
di vided in equal shares among the remairiinq': ,'. ,
subparagraphs of this ITEM VI(c) and
distributed. to the beneficiaries thereunder
in accordance with the provisions thereof.
(3) one-eighth (1/8) thereof to MRS.
DOROTHY HANDEYSIDE COOMBES, if she survives
me. If Mrs. Dorothy Handeyside Coombes
predeceases me, then to her children then
living, per capita. If Mrs. Dorothy
Handeyside Coombes predeceases me leaving no
children who survive me, said share shall be
divided in equal shares among the remaining
subparagraphs of this ITEM VI(c) and
distributed to the beneficiaries thereunder
in accordance with the provisions thereof.
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(4) One-eighth (1/8) thereof to be
divided equally among LINDA GODDARD, CATHY
COLLINS and CHARLES G. BRITTON, JR. If any
of the foregoing beneficiaries shall
predecease me, I give and devise the share
otherwise payable to such deceased
beneficiary to the then living children of
such deceased beneficiary, per capita. If
any of the foregoing beneficiaries predecease
me and do not leave children who survive me,
the share otherwise payable to such deceased
beneficiary shall be divided equally among
the then living beneficiaries of this ITEM
VICc) (4). If all of said beneficiaries are
not living at the time of my death and do not
leave any children who survive me, said share
shall be divided in equal shares among the
remaining subparagraphs of this ITEM VI(c)
and distributed to the beneficiaries
thereunder in accordance with the provisions
thereof.
(5) One-eighth (1/8) thereof to
HARRISON ZIEGLER, IV, if he survives me. If
Harrison Ziegler, IV predeceases me, then to
his children then living, per capita. If
Harrison Ziegler, IV predeceases me leaving
no children who survive me, said share shall
be divided in equal shares among the
remaining subparagraphs of this ITEM VI(c)
and distributed to the beneficiaries
thereunder in accordance with the provisions
thereof.
Page 5 of 10 pages
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(6) one-eighth (1/8) thereof
CHESTER CRISS, if she survives me.
Chester Criss predeceases me, then
children then living, per capita. If Nancy
Chester Criss predeceases me leaving no
children who survive me, said share shall be
divided in equal shares among the remaining
subparagraphs of this ITEM VICc} and
distributed to the beneficiaries thereunder
in accordance with the provisions thereof.
(7) one-eighth (1/8) thereof to MRS.
JACK L. THORNS LEY , if she survives me. If
Mrs. Jack L. Thornsley predeceases me, then
to her children then living, per capita. If
Mrs. Jack L. Thornsley predeceases me leaving
no children who survive me, said share shall
be divided in equal shares among the
remaining subparagraphs of this ITEM VI(c)
and distributed to the beneficiaries
thereunder in accordance with the provisions
thereof. .
(8) One-eighth (1/8) thereof to DR. and
MRS. ROBERT SHERMAN, or the survivor of them
living at my death. In the event Dr. and
Mrs. Robert Sherman both predecease me, then
to their children then living, per capita.
If both Dr. and Mrs. Robert Sherman
predecease me leaving no children who survive
me, said share shall be divided in equal
shares among the remaining subparagraphs of
this ITEM VI(c) and distributed to the
beneficiaries thereunder in accordance with
the provisions thereof.
(d) Ten (10%) percent thereof to the FIRST CHURCH
OF CHRIST SCIENTIST, Front and Woodbine streets,
Harrisburg, Pennsylvania.
If all of the gifts made under anyone of the foregoing
subparagraphs of this ITEM VI lapse, the share otherwise passing
under that subparagraph shall be distributed among the remaining
residuary beneficiaries in the same proportion they now bear to
each other.
Page 6 of 10 pages
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ITEM VII:
No interest in income or
principal of my estate shall be subject to attachment, levy or
seizure by any creditor, spouse, assignee or receiver in
bankruptcy of any benericiary of my estate prior to the
beneficiary's actual receipt thereof. My Executor shall pay over
the net income and the principal to the beneficiaries herein
designated, as their interests may appear, without regard to any
attempted anticipation (except as may be specifically provided
herein), pledging or assignment by any beneficiary of my estate
and without regard to any claim thereto or attempted levy,
attachment, seizure or other process against said beneficiary.
ITEM VIII:
Any person, who shall
have died at the same time as I or under such circumstances that
it is difficult or impossible to determine who shall have died
first, shall be deemed to have predeceased me.
ITEM IX:
In the settlement of my estate, my
Executor shall possess, among others, the following powers to be
exercised for the best interests of the beneficiaries:
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(a) To retain any investments I may have at my
death so long as my Executor may deem it advisable to
my estate so to do.
(b) To vary investments, when deemed desirable by
my Executor, and to invest in such bonds, stocks,
notes, real estate mortgages or other securities or in
such other real or personal property as my Executor
shall deem wise, without being restricted to so-called
"legal investments."
(c) In order to effect a division of the
principal of my estate or for any other purpose,
including any final distribution of my estate, my
Executor is authorized to make said divisions or
distributions of the personalty and realty partly or
Page 7 of 10 pages
! .
wholly in kind. If such division or distribution is
made in kind, said assets shall be divided or
distributed at their respective values on the date or
dates of their division or distribution. In making any
division or distribution in kind, my Executor shall
divide or distribute said assets in a manner which will
fairly allocate any unrealized appreciation among the
beneficiaries.
(d) To sell either at public or private sale and
upon such terms and conditions as my Executor may deem
advantageous to my estate, any or all real or personal
estate or interest therein owned by my estate severally
or in conjunction with other persons or acquired after
my death by my Executor, and to consummate said sale or
sales by sufficient deeds or other instruments to the
purchaser or purchasers, conveying a fee simple title,
free and clear of all trust and without obligation or
liability of the purchaser or purchasers to see to the
application of the purchase money or to make inquiry
into the validity of said sale or sales; also, to make,
execute, acknowledge and deliver any and all deeds,
assignments, options or other writings which may be
necessary or desirable in carrying out any of the
powers conferred upon my Executor in this paragraph or
elsewhere in this Will.
(e) To mortgage real estate and to make leases of
real estate for any term.
(f) To borrow money from any party, including my
Executor, to pay indebtedness of mine or of my estate,
expenses of administration, Death Taxes or other taxes.
(g) To pay all costs, Death Taxes or other taxes,
expenses and charges in connection with the administra-
tion of my estate, and my Executor shall pay the
expenses of my last illness and funeral expenses.
(h) To vote any shares of stock which form a part
of my estate and to otherwise exercise all the powers
incident to the ownership of such stock and to actively
manage and operate any unincorporated business,
including any joint ventures and partnerships, with all
the rights and powers of any owner thereof.
(i) In the discretion of my Executor to unite
with any other owners of similar property in carrying
out any plans for the reorganization of any corporation
or company whose securities form a part of my estate.
Page 8 of 10 pages
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(j) To assign to and hold in my estate an
undivided portion of any asset.
(k) To hold investments in the name of a nominee.
(1) To compromise controversies.
ITEM X:
If at any time any minor shall
be entitled to receive any assets free of trust by reason of my
death, whether payable hereunder, by operation of law or
otherwise, I appoint the then surviving parent of such minor as
Guardian of such assets authorized by law payable to such minor.
The Guardian may receive, administer and shall have full
authority to use such assets, both principal and income, in any
manner the Guardian shall deem advisable for the best interests
of the minor, including college, university, graduate or other
education, without securing a court order. The Guardian shall
have all the rights and privileges in its capacity as Guardian as
are herein granted to my Executor as to my estate.
ITEM XI:
All references in this will to
"child", "children" or "issue" shall apply only to such as are
born of the blood and born of the body. It shall specifically
exclude step-children and their issue, but shall specifically
include such as are legally adopted.
ITEM XII:
I hereby appoint DAUPHIN
DEPOSIT BANK AND TRUST COMPANY as Executor of this Will.
ITEM XIII:
Any Guardian or Executor shall
qualify and serve without the duty or obligation of filing any
bond or other security. Any corporate fiduciary shall be
entitled to compensation for services in accordance with the
Page 9 of 10 pages
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standard schedu~e of fees in effect when the services are
rendered.
IN WITNESS WHEREOF, I have set my hand and seal to
preceding nine (9) pages, this
this, my Last will and Testament, consisting of this and the
. -fh
~:.- day of
JYT_7lA."..A..41 ..J.
,
1992.
Page 10 of 10 pages
L/' /1', e.-p It
"lthtn"'.... IV' )1}. - C'.h-J!--- ( SEAL)
Lynn H I McCord
We, the undersigned, hereby certify that the foregoing
will was signed, sealed, published and declared by the above-
named Testatrix as and for her Last will and Testament, in the
presence of us, who, at her request and in her presence and in
the presence of each other, have hereunto set our hands and seals
the day and year above written, and we certify that at the time
of the execution thereof, the said Testatrix was of sound and
disposing mind and memory.
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CJ..bi1A\J~ 4. '?#~
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( SEAL)
Residing at:4)'SVA€t~ ~
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Residing at: 65'S Si'~7'I...j Fl26JJT ST:
(SEAL)
I-lRf2lZI)" f!1./{2G, ,?r1- 17/(} 4.
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(SEAL)
Residing at:
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Register of Wills of
DAUPHIN
County, Pennsylvania
INVENTORY
Estate of Lynn H. McCord
No. 1070-2004
Date of Death 12/06/2004
also known as
,Deceased Social Security No.
159-38-3060
, Manufacturers and Traders Trust Company
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 of 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
are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities.
Name of
Attorney:
Rhoads & Sinon, LLP
Joanne E. Book, Esquire
1.0. No.:
82028
Signature:
Tr,ade s Trust Company
DL YlCE PRES'I)"
....tRUST OMQI
Address:
One South Market Square 12th Fl
Address:
213 Market Street
Harrisburg~ PA 17108-1146
Harrisburg, PA 17101
Telephone: 717/233 -5731
Telephone: 717/255-2109 /
Dated <if.] I /P 5.-
Description
Value
(See continuation page(s) attached)
, (Attach additional sheets if necessary)
Total:
360,642.03
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.
Prepared by the Pennsylvania Bar Association
Copyright (c) 1996 form software only CPSystems, Inc.
Form .RW-7 (1992)
.
Estate of:
Date of Death:
County:
INVENTORY
Lynn H. McCord
12/06/2004
Dauphin
CASH:
GE Capital Assurance - Final
Benefit Check to Date of
Death
1,000.00
Mass Mutual - Final Monthly
Annuity on Policy #0901655
154.19
MTB Money Market-Inst I Fund
#420 - Principal Balance as
of Date of Death - Received
from Lynn McCord Trust
12,231.94
MTB Money Market-Inst I Fund
#420 - Income Balance as of
Date of Death - Received
from Lynn McCord Trust
Accrued Interest
26,224.61
10.62
New England Financial -
Replacement Check for
Uncashed Check
13.89
New York Life Insurance
Company - Pro-rata share of
Benefit due Estate
84.75
PA Treasury Department -
Annuitant Retirement Benefit
739.11
Received from GE Capital
Assurance - Payment on
Nursing Home Insurance from
10/27/04 thru 11/26/04
3,100.00
Received from PNC Advisors -
Income to Date of Death from
Frank Handyside Trust
553.59
44,112.70
1
fI
Estate of:
Date of Death:
County:
Lynn H. McCord
12/06/2004
Dauphin
Received from Lynn H. McCord
Trust:
STOCKS/LISTED:
350 shares Bac Cap Tr 11
350 shares Citigroup Cap VIII Pfd
6.95% 1/14/05
1,500 shares Exxon Mobil Corporation
Accrued Dividend
350 shares Georgia Power Co. Pfd
6% 1/14/05
350 shares Merrill Lynch Pfd Cap
Tr III 7% 1/05
500 shares SBC Communications Inc
500 shares Verizon Communications
350 shares Wells Fargo Cap 7%
1/14/05
350 shares Wells Fargo Cap Tr Pfd
6.95% 1/14/05
1,270.325 shares MTB Short Term
Corporation Bd-Inst 1-#518
Accrued Interest
Received from Lynn H. McCord
Trust:
BONDS:
$15,000 U.S. Treasury Savings
Bonds Series HH 4% due
7/01/11
$25,000 Federal Home Loan Bank
2.375% due 2/15/07
Accrued Interest
$25,000 Federal Home Loan Mtg
2.75% due 3/15/08
Accrued Interest
2
9,278.50
9,304.75
75,292.50
405.00
8,897.00
9,436.00
12,815.00
20,945.00
9,152.50
9,411.50
12,512.70
5.52
15,000.00
24,597.66
183.07
24,496.09
154.69
177,455.97
.
Estate of:
Date of Death:
County:
Lynn H. McCord
12/06/2004
Dauphin
$25,000 Federal Home Loan Bank
Disc Nt due 4/15/05
$25,000 Federal Home Loan
Banks 2.375% due 8/15/06
Accrued Interest
$25,000 Federal National
Mortgage 2.05% due 10/28/05
Accrued Interest
24,787.50
24,746.09
183.07
24,871.09
54.10
TOTAL RECEIPTS OF PRINCIPAL...............
3
139,073.36
360,642.03
rm M&T Investment Group
. P.O. Box 1377
Buffalo, NY 14240-9828
Account Summary Section
Statement of Value and Activity
January 1, 2006 - March 31, 2006
This Pel'iod 1/1/06 to 3/31/06
$317,680.88 $317,680.88
$0.00 $0.00
-$1,115.02 -$1,115.02
$2,966.89 $2,966.89
$0.00 $0.00
$319,532.75 $319,532.75
$0.00 $0.00
Beginning Market Value
Cash Additions
Cash Disbursements
Income
Change in Market Value
Ending Market Value
Realized Gains/Losses
(Included in Total Above)
Investment Objective: Preservation of Principal: Minimize volatility and produce income through a
portfolio of investment grade fixed income securities. M&T's Investment Policy committee set the
current percentage as 100% in Cash & Cash equivalents.
Asset Class Balance
II 1000/0 Cash & Equivalents $319,532.75
Mccord, Lynn H Ex - Account # 2001489
1000/0 Total Assets Value
$319,532.75
Page 1 of 8
350 -0100060
.
Asset Detail
Statement of Value and Activity
January 1, 2006 - March 31, 2006
Shares/Par Value Market Value Tax Cost Est. Ann. Income
Description Current Pries Unrealized G/L Current Yield
Cash & Equivalents
MTB Money MId-lnst I-Fd #420 309,102.26 $309,102.26 $309,102.26 $12,920.47
TICKER: AKMXX 1.00 $0.00 4.18%
MTB Money Mid-lost I-Fd #420 10,430.49 $10,430.49 $10,430.49 $435.9Qi)
TICKER: AKMXX 1.00 $0.00 4.18%
----
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-
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:':~:~:~;.;~:>\~:;~~:;~/r;!:n~~t\t:;>.; ..::..:.." :.:....... ,", ....,.. . ~::Y:{{j:kfi)(}}))
, ::::::~::::::::::::::::::::::::::::::::;:::':,:,: ..,:::'::::::::::::::::,::...:~:j:!::~~~~;~::::::::::.:':::::;::::::':::'::::;'i:/~~:~'~:T:~~:::~:::"::,',.;::: :"':'{::' :'::::~~!'~;~~~m!'~
Total All Assets
$319,532.75
$319,532.75
$0.00
$13,356.46
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-
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~
Mccord, Lynn H Ex - Account # 2001489
Page 2 of 8
.
OFFICIAL USE ONLY
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
REV-1Soo EX + (6-00)
FILE NUMBER
c P
o 0
R N
R D
E E
S N
T
c
o
M
P
T U
A T
X A
T
I
o
N
D
E
C
E
D
E
N
T
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
McCord L n H.
DATE OF DEATH (MM-DD- YEAR)
SOCIAL SECURITY NUMBER
159-38-3060
THIS RETURN MUST BE FILED IN DUPUCATEWlTH THE
1070-2004
COUNTY CODE
YEAR
NUMBER
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
1. Original Return
4. Limited Estate
6. Decedent Died Testate
Supplemental Return
Future Interest Compromise (date of death after 12-12-82)
Decedent Maintained a Living Trust 0
3 date of death
. Remainder Return prior to 12-13-82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
(Attach copy of Will) (Attach copy of Trust)
o 9. litigation Proceeds Received 010. Spousal Poverty Credit
D 11. Election to tax under Sec. 9113(A)
(Attach Sch 0)
NAME
Ruth Ann McMillen, Trust Officer
FI RM NAME (If Applicable)
Manufacturers and Traders Trust Com an
TELEPHONE NUMBER
COMPLETE MAILING ADDRESS
213 Market Street
Harrisburg, PA 17101
R
E
C
A
P
I
T
U
L
A
T
I
o
N
1 255-2109
1. Real Estate (Schedule A)
Z. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or
Sole - Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash. Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
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)
1Z. Net Value of Estate (Line 8 minus Line 11)
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)
(8) 360,642.03
(11) 40,484.66
(12) 320,157.37
(13) 32,015.74
(14) 288,141.63
(1)
(2)
(3)
None
316,529.33
None
OFFICIAL USE ONLY
(4)
(5)
None
44,112.70
(6)
None
-0-
37,231.17
3,253.49
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
0.00
0.00
0.00
288,141.63
.0 0
.0 45
.12
.15
(15)
(16)
(17)
(18)
(19)
0.00
0.00
0.00
43 ,221. 24
43 ,221. 24
x
X
X
X
::fWi!Wt~i+::
Copyright (c) 2000 form software only The Lack:ner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
,
Decedent's Complete Address:
STREET ADDRESS
1901 North Fifth Street
CITY I STATE I ZIP
Harrisburg PA 17102
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
43 ,221. 24
0.00
39,900.00
2,100.00
Total Credits ( A + B + C) (2)
42,000.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
TotallnterestlPenalty ( D + 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) 0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 1,221.24
A. Enter the interest on the tax due. (SA) 0 . 00
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B) 1,221.24
Make Check. Pa)fabl~~o: '" .... .~I:~I.S,.e:R.. ~F. .~.I~l~~ ..~~~~~................ .. .. . ..... .. .. .. .. .. .. .
!11111!!IIII!III!lll!III!!II!l!!!I!I!I!!llll!!I!I!!!l!i!ll!i!!!!iiilllll!!I!IIIIIII!lliilliililIIIIIIIIIWi!!i!ilillillllllllllllllllll!ll!illll!lllllllillmmmmmmmmmmmmmmmmmmmmmmlllillllllllllllllilliililiiilllllll!llll!liillllillilll!!I!!IIIII!i!lllllliIWlilllllllllllli!IWlllllllllillllll!lllilllmmililiiiii!illiWllllii
" '" '.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; . . . . . . . . . . . . . ~i ~
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? . . . . . . . . . . . . . . . . . . . . . . . . . . . ., 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.
0.00
~
~
~
Manufacturers and Traders Trust Company
213 Market Street
-----------------------------------------------------
Harrisbur , PA 17101
Manufacturers and Traders Trust Company
213 Market Street
-----------------------------------------------------
mmmillllWillllll!llllllllllllllllmiilllllliiliimillllillliiiilllllliililiiliiili!!lillmmmmm:lllilli!llll:!ii!:iil!ii!!ili!i!i~ffil~lliIlilllmlmlllii~@llil!!mm:~mlllmmlm!mlillimmmmmmmmmmmmmmmmmmmmlmmlillllillllillliiillllilil!llllliilIlli!illliiilmmlliiliIWllilillllll!i
For dates of death on or atter 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 atter January 1, 1995, the tax rate imposed on the net value of transfers to or for 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 atter 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(aX1)].
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.
Copyright (c) 2000 form software only The Lackner Group, Inc.
Form REV-1500 EX (Rev. 6-00)
11
REV-1503 EX + (1-97)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
SSff 159- 38- 3060
12/06/2004
1070-2004
Lynn H. McCord
ITEM
NUMBER
14
15
16
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
DESCRIPTION
Received from Lynn H. McCord Trust:
UNIT VALUE
VALUE AT DATE
OF DEATH
1
350 shares Bac Cap Tr 11
9,278.50
2
350 shares Citigroup Cap VIII Pfd 6.95% 1/14/05
9,304.75
3
1,500 shares Exxon Mobil Corporation
Accrued Dividend
75,292.50
405.00
4
350 shares Georgia Power Co. Pfd 6% 1/14/05
8,897.00
5
350 shares Merrill Lynch Pfd Cap Tr III 7% 1/05
9,436.00
6
500 shares SBC Communications Inc
12,815.00
7
500 shares Verizon Communications
20,945.00
8
350 shares Wells Fargo Cap 7% 1/14/05
9,152.50
9
350 shares Wells Fargo Cap Tr Pfd 6.95% 1/14/05
9,411.50
10
$15,000 U.S. Treasury Savings Bonds Series HH 4% due
7/01/11
15,000.00
11
$25,000 Federal Home Loan Bank 2.375% due 2/15/07
Accrued Interest
24,597.66
183.07
12
$25,000 Federal Home Loan Mtg 2.75% due 3/15/08
Accrued Interest
$25,000 Federal Home Loan Bank Disc Nt due 4/15/05
$25,000 Federal Home Loan Banks 2.375% due 8/15/06
Accrued Interest
24,746.09
183.07
24,496.09
154.69
13
24,787.50
$25,000 Federal National Mortgage 2.05% due 10/28/05
Accrued Interest
24,871. 09
54.10
1,270.325 shares MTB Short Term Corporation Bd-Inst
1-#518
Accrued Interest
12,512.70
5.52
TOTAL (Also enter on line 2, Recapitulation)
316,529.33
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems,lnc.
Form REV-1503 EX (Rev. 1-97)
,
REV-1S08 EX + (1-97)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Lynn H. McCord SS# 159-38-3060 12/06/2004 1070-2004
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
DESCRIPTION
GE Capital Assurance - Final Benefit Check
VALUE AT DATE
OF DEATH
1,000.00
2
Mass Mutual - Final Monthly Annuity on Policy #0901655
154.19
3
MTB Money Market-Inst I Fund #420 - Principal Balance as of Date
of Death - Received from Lynn McCord Trust
12,231. 94
4
MTB Money Market-Inst I Fund #420 - Income Balance as of Date of
Death - Received from Lynn McCord Trust
Accrued Interest
10.62
26,224.61
5
New England Financial - Replacement Check for Uncashed Check
13.89
6
New York Life Insurance Company - Pro-rata share of Benefit
due Estate
84.75
7
PA Treasury Department - Annuitant Retirement Benefit
739.11
8
Received from GE Capital Assurance - Payment on Nursing Home
Insurance from 10/27/04 thru 11/26/04
3,100.00
9
Received from PNC Advisors - Income to Date of Death from
Frank Handyside Trust
553.59
TOTAL (Also enter on line 5, Recapitulation) $ 44,112. 70
(If more space is needed, insert additional sheets of the same size)
Copyright (e) 1996 form software only CPSystems, Inc. Form REV-1508 EX (Rev. 1-97)
REV-1510 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Lynn H. McCord
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
.
SStf 159 - 38 - 3060
12/06/2004
FILE NUMBER
1070-2004
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
DESCRIPTION OF PROPERlY % OF
ITEM RELAW8~M{tI~ t~1>~~~6~~l~~J~~~1ffr~EJF t~~~SFER. DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE ..
NUMBER ATTACH A COpy OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE)
1 Manufacturers and Traders Trust
Company, Successor to Dauphin
Deposit Bank and Trust Company,
Trustee under Revocable Trust
Agreement dated 9/5/89 with
Lynn H. McCord, Settlor. Upon
Death of Settlor, Trust
Terminated and Assets were
Distributed to the Personal
Representative of the Estate.
See Schedule B - Item 1 thru 16
See Schedule E - Item 3 and 4
TOTAL (Also enter on line 7, Recapitulation) $ 0.00
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc.
Form REV-1510 EX (Rev. 1-97)
REV-1S11 EX +(1-97)
't
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Lynn H. McCord
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
B.
SS4f 159-38-3060
12/06/2004
FILE NUMBER
1070-2004
DESCRIPTION
AMOUNT
1
FUNERAL EXPENSES:
W. Orville Kimmel Funeral Home, Inc. - Funeral Expense
1,809.80
2
W. Orville Kimmel Funeral Home, Inc. - Grave Opening
1,200.00
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s) Manufacturers and Traders Trust Company
Social Security Number(s) I EIN Number of Personal Representative(s) 16 - 0538020
Street Address 213 Market Street
City Harr i sburg State PA Zip 17101
16,425.68 .
Year(s) Commission Paid:
2.
3.
Attorney's Fees Rhoads & Sinon, LLP
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
15,000.00
4.
Register of Wills
520.00
Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
1
Other Administrative Costs
Dauphin County Register of Wills - Four Short Certificates
24.00
2
Internal Revenue Service - 2004 Federal Income Tax - Balance due
for the Trust
5.00
3
PA Department of Revenue - 2004 State Income Tax - Balance due
for the Trust
22.00
4
Rhoads & Sinon, LLP - Reimbursement for Cost of Advertising and
Proof of Publication in the Dauphin County Reporter $65.00
and the Patriot-News $170.58
235.58
Total of Continuation Schedule(s)
1,989.11
TOTAL (Also enter on line 9, Recapitulation) $ 37 ,231.17
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1511 EX (Rev. 1-97)
~
Estate of: Lynn H. McCord
Soc Sec #: 159-38-3060
Date of Death: 12/06/2004
Continuation of Schedule H-B4
(Probate Fees)
Item
11
Description
Amount
1
Dauphin County Register of Wills - Probate Fees
520.00
520.00
.,
.
Estate of: Lynn H. McCord
Soc See #: 159-38-3060
Date of Death: 12/06/2004
Continuation of Schedule H-B7
(Other Administrative Costs)
Item Description
11
Amount
5 PSERS - Refund of Overpayment of Monthly Annuity
739.11
6 Reserve for Filing Fees
500.00
7 Reserve Rhoads & Sinon - Out of Pocket Expense
750.00
1,989.11
,
, REV-1S1ZEX+(1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Lynn H. McCord
SCHEDULE I
DEBTS OF DECEDENT,
MOR TGAGE LIABILITIES, AND LIENS
55=11 159- 38 - 3060
12/06/2004
FILE NUMBER
1070-2004
Include unreimbursed medical expenses.
ITEM
NUMBER
1
DESCRIPTION
Homeland Nursing Home - Nursing Home Expense
AMOUNT
1,259.54
2
Internal Revenue Service - 2004 Federal Income Tax - Balance due
964.00
3
PA Department of Revenue - 2004 State Personal Tax
120.00
4
PA Department of Revenue - 2004 State Income Tax - Balance due
342.00
5
Rhoads Pharmacy - Prescription Drug Expense
67.95
6
Waggoner, Frutiger and Daub - 2004 Tax Preparation Fee
500.00
TOTAL (Also enter on line 10, Recapitulation) $ 3,253.49
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996farmsaftwareonlyCPSystems, Inc. Form REV-1512 EX (Rev. 1-97)
J
'" REV-1513 EX + (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Lynn H. McCord SS# 159-38-3060 12/06/2004
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I. TAXABLE DISTRIBUTIONS [Include outright spousal dIstributions, and
transfers under See, 9116(a)(1.2)]
1 Conde Spaulding Hackbarth
Philip Hackbarth
1500 Sheridan Road #7K
Wilmette, IL 60091
SCHEDULE J
BENEFICIARIES
FILE NUMBER
1070-2004
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
Niece 1/4th of 65%
share of
Residue per
Item VI (a)(l)
of the Will
2
Charles B. Spaulding, II
Barbara Spaulding
1738 West Chase Avenue
Chicago, IL 60626
Niece
1/4th of 65%
share of
Residue per
Item VI (a) (2)
of the Will
ENTER DOLLAR AMTS, FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET
II. NON- TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
First Church of Christ Scientist
2147 North Front Street
Harrisburg, PA 17110
10% share of
Residue per
Item VI (d) of'
the Will
32,015.74
TOTAL OF PART" - 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)
Copyright (c) 2000 form software only The Lackner Group, Inc.
32,015.74
Form REV-1513 EX (Rev. 9-00)
:
..
~state of: Lynn H. McCord
Sac Sec #: 159-38-3060
Date of Death: 12/06/2004
Item
If
Continuation of Schedule J, Part I
(Taxable Bequests)
Name and Address of Beneficiary
Relationship
Amount or
Share of Estate
3
Dr. John Daily (Deceased)
Maryann Nordby Daily
143B E1mcrest Drive
Dallas, PA 18612
Niece
4
Judith Delaney Crunkilton
12828 SW 69 Way, Unit 110
New Castle, WA 98056
Niece
5
Elizabeth Sears Smith
1543 Upshur Street, NW
Washington, DC 20011
Great-Niece
6
Christopher A. Sears
2161 West Wilson Avenue
Chicago, IL 60025
Great-Nephew
7
Rory Hackbarth
1317 West Henderson
Chicago, IL 60657
Great-Nephew
8
Philip Hackbarth
1608 Apache Trail
Colorado Springs, CO 80906
Great-Nephew
9
John N. Daily
54 Norton Avenue
Dallas, PA 18612
Great-Nephew
1/4th of 65%
share of
Residue per
Item VI (a)(3)
of the Will
1/4th of 65%
share of
Residue per
Item VI (a)(4)
of the Will
1/11th of 20%
share of
Residue per
Item VI (b) of
the Will
1/11th of 20%
share of
Residue per
Item VI (b) of
the Will
1/11 th of 20%..
share of
Residue per
Item VI (b) of
the Will
l/llth of 20%
share of
Residue per
Item VI (b) of
the Will
l/llth of 20%
share of
Residue per
Item VI (b) of
the Will
!
Estate of: Lynn H. McCord
Soc Sec #: 159-38-3060
Date of Death: 12/06/2004
Item
II
Continuation of Schedule J, Part I
(Taxable Bequests)
Name and Address of Beneficiary
Relationship
Amount or
Share of Estate
10
Arlene E. Daily
10 Country Club Estates
Thornhurst, PA 18424
Great-Niece
11
Donald Daily
414 Beth Avenue
Brick, NJ 08724
Great-Nephew
12
Charles B. Spaulding, III
3617 East Seneca
Tucson, AZ 85716-2925
Great-Nephew
13
Elizabeth McCord Spaulding
c/o Charles B. Spaulding, II
Parent and Natural Guardian
1738 West Chase Avenue
Chicago, IL 60626
Great-Niece
14
Joseph E. Crunkilton
10526 43rd Street, Court E
Edgewood, WA 98372
Great-Nephew
15
Janet Crunki1ton Teegarden
12728 SE 25th Place
Bellevue, WA 98005
Great-Niece
Clyde Winer (Deceased 12/21/97)
Zelma Winer (Deceased 3/18/01)
Helen Hallowell (Deceased 6/1/03)
l/llth of 20%
share of
Residue per
Item VI (b) of
the Will
l/llth of 20%
share of
Residue per
Item VI (b) of
the Will
l/llth of 20%"
share of
Residue per
Item VI (b) of
the Will
l/llth of 20%
share of
Residue per
Item VI (b) of
the Will
l/llth of 20%
share of
Residue per
Item VI (b) of
the Will
l/llth of 20%
share of
Residue per
Item VI (b) of
the Will
."
Estate of: Lynn H. McCord
Soc Sec #: 159-38-3060
Date of Death: 12/06/2004
Item
If
Continuation of Schedule J, Part I
(Taxable Bequests)
Name and Address of Beneficiary
Relationship
Amount or
Share of Estate
Dorothy Handeyside Coombes (Deceased 3/9/05)
16
Estate of Dorothy Handeyside Coombes
Cousin
Cathy Collins (Deceased)
Children:
17
Michael Garret Collins
48 Sparrow Circle
Newton, NJ 07860
Friend
18
John David Collins
19 Hadowonitz Drive
Ogdensburg, NJ 07439
Friend
19
Amy Marie Brand
67 Springbrook Trail
Sparta, NJ 07871
Friend
20
Linda Goddard
503 Russet Leaf Terrace
Woodsboro, MD 21798
Friend
21
Charles G. Britton, III
92 Logan Road
Dillsburg, PA 17019-9143
Friend
1/6th of 5%
share of
Residue per
Item VI (c)(3)
of the Will
1/9th of 1/6th
of 5% share of
Residue per
Item VI (c) (4)
of the Will
1/9th of 1/6th
of 5% share of
Residue per
Item VI (c) (4)
of the Will
1/9th of 1/6th
of 5% share of
Residue per
Item VI (c)(4)
of the Will
1/3rd of 1/6th
of 5% share of
Residue per
Item VI (c)(4)
of the Will
1/3rd of 1/6th
of 5% share of
Residue per
Item VI (c)(4)
of the Will
REV-151 0 EX + (6-98)
*'
COMMONVVEAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
Nancy A. Criss
FILE NUMBER
21-05-0279
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 lliE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
NUMBER lliE DATE OF TRANSFER. ATTACH A copy OF THE DEED FOR REAl ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1. Balance of Trust FBO Nancy A. Criss established under the 13570.82 100 13570.8
Last Will and Testament of John D. Criss.
Please see attached Declaration of Trust dated September 20,
2001.
TOTAL (Also enter on line 7 Recapitulation) $ 13,570.8
2
2
(If more space is needed, insert additional sheets of the same size)
".
James D. Criss, Jeffrey D. Criss, Barbara Ann Criss and Mary Criss Breen.
B. TECHNICAL DIRECTIONS AND DEFINITIONS.
The words "gross estate," "taxable estate," "marital deduction," "pass,"
"qualified terminable interest property," "unified credit," and "state death tax credit" , if used
herein, shall have the same meaning as these words have in the Internal Revenue Code of 1986,
as amended.
C. USE OF TRUST.
The Trustees shall hold and dispose of the trust property as follows:
(1) The net income of the Trust shall be paid to Nancy A. Criss in
quarterly or more frequent installments, or used for her benefit if she is disabled.
(2) The Trustees are authorized at any time and from time to time to
distribute to Nancy A. Criss or apply to her benefit from the principal of this Trust (even to the
point of completely exhausting the same) such amounts as the Trustees deem necessary to
provide for her reasonable health, maintenance, and support. In determining the amounts of
principal to be so disbursed, the Trustees may take into consideration any other income which
Nancy A. Criss may have from any other source, and also her capital resources other than
household goods, residence, and personal effects.
(3) During the lifetime of Nancy A. Criss, she shall have the right in any
calendar year (including the year of my death) to withdraw from the principal of this Trust an
amount or specific assets which are not in excess of the greater of the following: Five Thousand
Dollars ($5,000) or five percent (5%) of the market value of the principal of the trust on the last
-2-
'.
day of the calendar year in which such withdrawal is requested. Such right of withdrawal shall
be exercised in each case by Nancy A. Criss notifying the Trustees in writing to that effect,
specifying the cash or assets at current market value which she desires to withdraw; and
promptly thereafter the Trustees shall make such distribution to her. Such right of withdrawal
shall be noncumulative.
(4) Upon the death of Nancy A. Criss, the remaining trust funds shall
be distributed, in equal shares, per stirpes, in trust or otherwise, among the children of
John D. Criss, who are named, James D. Criss, Jeffrey D. Criss, Barbara Ann Criss and
Mary Criss Breen.
(5) If any beneficiary to whom the Trustees are directed under this
Subparagraph C to distribute any share of trust principal is under the age of twenty-one
years when the distribution is made and if no other trust is then to be held under this
instrument for such beneficiary's primary benefit, such beneficiary's share shall vest in
interest in such beneficiary indefeasibly, but the Trustees may, in the Trustees' sole
discretion, withhold possession of it under the provisions of this instrument for such
beneficiary's benefit until such beneficiary attains the age of twenty-one years (or dies
prior thereto), at which time such beneficiary's portion shall be distributed to such
beneficiary (or to such beneficiary's Personal Representative as the case may be). In the
meantime, the Trustees shall disburse so much of the net income and principal of such
beneficiary's portion as, in the Trustees's sole discretion, may be necessary to provide
for the support, comfort, and education of such beneficiary. For all sums so disbursed
-3-
~
the Trustees shall have full acquittance. Any net income not so disbursed shall be
annually accumulated by the Trustees and added to the portion from which it was
derived.
D. MAXIMUM DURATION OF TRUST.
Notwithstanding anything herein to the contrary, the trusts under this instrument
shall terminate not later than twenty-one years after the death of the last survivor of Nancy A.
Criss, and the descendants of John D. Criss living on the date of his death, at the end of which
period the Trustees shall distribute each remaining portion of the trust property to the
beneficiary or beneficiaries, at that time, of the current income thereof, and if there is more than
one beneficiary, in the proportions in which there are beneficiaries.
E. POWERS OF TRUSTEES.
With reference to the trust estate created herein and every part thereof, the
Trustees shall have the following rights and powers, acting together, without limitation and in
addition to powers conferred by law:
(1) The Trustees may sell publicly or privately, without an order of court,
upon such terms and conditions as they shall deem best, any property of the trust estates;
and no person dealing with the Trustees shall have any obligation to look to the
application of the purchase money therefor.
(2) The Trustees may invest and reinvest all or any part of the principal of
the trust estate in any stocks, bonds, mortgages, shares or interests in common trust
funds, mutual funds, or other securities or property, real, personal or mixed, and of any
-4-
.,
kind or nature whatsoever, as the Trustees may deem advisable, and without
diversification if the Trustees deem it advisable, irrespective of whether or not such
securities or property are eligible for trust investment under state or any other law, and
may change any investment received or made by the Trustees, and may hold cash if the
Trustees deem it advisable.
(3) The Trustees may exercise broad discretion as to diversification of trust
property, and shall not be required to reduce any concentrated holdings merely because
of such concentration, and shall have full discretion as to the percentage to be invested
in fixed income securities, and is specifically relieved from any requirements, legal or
otherwise, as to the percentage of the trust estate to be invested in fixed income
securities, and may invest and retain invested any trust estate wholly in common stocks.
(4) The Trustees shall have full power to sell, convey, lease or mortgage,
repair and improve, and take any and all other steps with regard to any real estate that
may at any time be a part of the principal of the trust estate; and any lease of such real
property or contract with regard thereto made by the Trustees shall be binding for the
full period of the lease or contract, though said period shall extend beyond the
termination of the trust.
(5) The Trustees shall have the power to vote shares of stock held in the trust
estate at stockholders' meetings in person or by special, limited, or general proxy, with
or without power of substitution, as the Trustees shall deem best.
(6) The Trustees shall have the power to participate in the liquidation,
-5-
':.
reorganization, consolidation, incorporation and reincorporation, or any other financial
readjustment of any corporation or business in which the trust estate is or shall be
financially interested.
(7) The Trustees shall have full power to borrow money from any source for
any purpose connected with the protection, preservation, improvement or development
of the trust hereunder, whenever in the Trustees' judgment the Trustees deem it
advisable, and as security to mortgage or pledge any real estate or personal property
forming a part of the trust estate upon such terms and conditions as the Trustees may
deem advisable.
(8) The Trustees shall have authority to hold any and all securities in bearer
form, in the Trustees' own name, or the name of some other person, partnership or
corporation, or in the name of a duly appointed nominee, with or without disclosing the
fiduciary ownership thereof.
(9) Whenever the Trustees are required pursuant to a provision hereof, to
divide the principal of the trust estate into parts or shares and to distribute or allot same,
the Trustees are authorized to make such division in cash or in kind or both; and for the
purpose of such division or allotment, the judgment of the Trustees concerning the
propriety thereof an~ relative value of property so distributed or allotted shall be binding
and conclusive with respect to all persons interested herein.
(10) During the minority or incapacity of any beneficiary to whom income is
herein directed to be paid, or for whose benefit income and principal may be expended,
-6-
..
the Trustees may pay such income and principal in anyone or more of the following
ways: (l) directly to said beneficiary; (2) to the legal guardian or committee of said
beneficiary; (3) to a relative of said beneficiary to be expended by such relative for the
maintenance, health and education of said beneficiary; (4) by expending the same
directly for the maintenance, health and education of said beneficiary. The Trustees
shall not be obliged to see to the application of the funds so paid, but the receipt of such
person shall be full acquittance to the Trustees.
(11) In general, the Trustees shall have the same powers, authorities, and
discretions in the management of the trust estate as I would have in the management and
control of my own personal estate. The Trustees may continue to exercise any powers
and discretions hereunder for a reasonable period after the termination of any trust estate
or estates, but only for so long as no rule of law relating to perpetuities would be
violated.
F. APPOINTMENT AND COMPENSATION OF TRUSTEES.
Jeffrey D. Criss and James D. Criss shall be the Trustees of this trust. If either
fails to qualify as Trustee, or having qualified, dies, resigns, or declines to serve, then and in
such event the remaining Trustee shall continue alone. Neither of the named Trustees, shall be
required to furnish any surety upon their bond as such fiduciaries. The Trustees shall be
entitled to receive reasonable compensation for their services hereunder.
G. SPENDTHRIFT RESTRICTION.
This trust and the benefits hereunder, both income and principal, which are
-7-
~
payable to any beneficiary shall not be subject to assignment, alienation, pledge, attachment or
the claims of creditors.
WHEREFORE, intending to be legally bound hereby the Grantors and the Trustees have set
their hands and seals hereto the day and year first above written.
~ss:.~ _
///ftlA/~~
. ~~~7
WITNESS:
..
ESTA~FJOHND.C~S .
, QL~
By:
James D. Criss, Co-Executor
~iJ ·
WITNESS:
WITNESS:
~
James D. Criss, Co-Trustee
-8-
REV-1511 EX' (12-991.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Nancy A. Criss
FILE NUMBER
21-05-0279
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A. FUNERAL EXPENSES:
B.
1.
DESCRIPTION
AMOUNT
1.
Memorial service
Wake meal
Auer Memorial Home: obituary
Funeral luncheon
150.00
71.00
245.00
500.00
Funeral was pre-paid
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s) Jeffrey D. Criss, Executor
Social Security Number(s)/EIN Number of Personal Representative(s) 163-58-8497
Street Address 2018 Dickinson Avenue
6,500.00
City
Camp Hill
State ~Zlp
17011
Year{s) Commission Paid: 2006
2.
Attorney Fees
5,000.00
3.
Family Exemption: (If decedent's address Is not the same as claimant's, attach explanation)
0.00
Claimant
NONE
Street Address
City
State _Zip
Relationship of Claimant to Decedent
4.
Probate Fees
302.00
5.
Accountant's Fees
0.00
6.
Tax Return Preparer's Fees
0.00
7.
Expenses associated with sale of real property:
Pest control service
Tree removal
Roof repair
Gas furnace service
Utility bills before sale
Painting
SUB.TOTAL THIS PAGE
SUB-TOTAL ATTACHED PAGE
185.00
225.00
1000.00
128.00
909.83
1050.00
16265.83
10101.47
26,367.30
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
..
.
Rev. 1511
Schedule H: continued
Funeral Expenses and Administrative Costs
Estate of Nancy A. Criss
B.
7.
8.
9.
10.
11.
12.
13.
14.
Continued
Carpet cleaning
Plumbing
Additional plumbing and repairs
Materials for property sale
Telephone reimbursement
Furnace repair
Joe Tresco: additional plumbing
Postage for executors
Cost of title search
Realtor's commission
Realty transfer taxes
School real estate tax paid less proration to settlement date (1585.91-1494.67)
County real estate tax proration to settlement date
Sewer proration to settlement date
Tax certification and courier and notary fees
Invoice for appraisal of personalty
Payments made on home equity line of credit during estate administration
File Number:21-05-0279
Additional costs after DOD on payoff of home equity line of credit Account # 6819166206
Postage, copy and fax expense
Legal notices of administration
Fee to File Inventory
Fee to File Inheritance Tax Return
SUB-TOTAL
183.38
80.00
488.00
154.48
90.00
138.00
100.00
37.00
28.00
5,100.00
1,700.00
91.24
(244.32)
(6.52)
33.00
225.00
1,012.37
660.21
55.00
146.63
15.00
15.00
$10,101.47
..
.
1Iome= PEST CONTROL SPECIAL SERVICE AGREEMENT
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1. GENERAL INFORMATION. Thll Agreement by and between: .
.j, ry, {! (" I \J'
Customer Name ("CUSTOMER")
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1, 2-:')'2.- ~ {' k J" ,. ,'?l...( It.,:;<
Billing Address
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Grid it.
'7'57- 1-&&9
Telephone (Day)
(Evening)
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City
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State
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Service Address of Subject Property
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Description ofstr'Uchm:(s) &Overed/Comments
AND Home Paramount Pest Control Companies, Inc. S IS '5 E. '7--"; .....j ! ~ Ie',.)( PU c p:, /., /7 L~' ~/ / f:;'l. G}:7
"HOME PARAMOUNT" / Address , ,. Telephone
is entered into on t..,I ~ l S' D') (date). CUSTOMER declares bimself7herselfto be the Owner and/or Authorized Agent of the Subject Property.
This AGREEMENT is not a General Pest Control agreement and therefore ONL V covers the pest specifically marked below. This AGREEMENT is for a ninety
(90) day term. Thereafter this AGREEMENT will expire.
City
State
Zip
2. TREATMENT INFORMATION. CUSTOMER agrees that ONL V the pelt marked below are eovered under this AGREEMENT. It is
eXDrealv undentood that anv other DeltLlndndln2 TERMI~S. are NOT eovered under this AGREEMENT. This Agreement provides for the
treatment of:
A. Check ONL v'One:
[J Bat Exclusion [J Carpet Beetles [J Flies
[J Bed Bugs [J Clothes Moths [J Squiml Exclusion
[J BeeslWaspslHornets [J Fleas (Indoor) ~ Al'l t;- (f;,;' ,:,' /,.~". 1'7 J
B. The C;USTOMER herby acknowledges receipt of the Customer Pesticide Information ~onn. *- '1(.,\ ;', A'? trtj4 " r .. r. <3
C. Inspector ~ents: UIt..l.. -/ I ~ -IT -e' 4../ Mo..; n'; 10 r ~. ,/ ~M ,'1.,{ ...' J-,.!: ;t.l;.-, / J" -
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3. PAYMENT. Upon condition of receipt of payment as requited herein, HOME PARAMOUNT agrees to provide services as described in.this' AGREEMENT.
Sebedule of Fees: Payment Type: Sorry, no cash accepted.
Service $ /75<!:!? a MasterCard' CJ Discover Cl Visa Amount $
Tax $ / D :0' Acct #. Exp. Date:
Deposit $ CUSTOMER Signature:
Balance Due $ I t ~ Y"D CJ Money Order Cl Check Check No, Amount $
Please moke check/ money order poyable to Home PQ1'll1tIOIlnt Pes.f.Conl~ ComptlllW, Inc.
Serviee Frequency: As Required During Warranty Period
A. A finance charge of 1 ~% per mouth, 18% annually, is applied to delinquent accounts. CUSTOMER. shall pay all costs associated with collections
including, but not limited to, court costs and attorney's fees.
B. OPTIONAL PROVISION. In the event CUSTOMER does not provide HOME PARAMOUNT access to the Subject Property or Premises on.the
scheduled service date. CUSTOMER hereby authorizes HOME PARAMOUNT to perform an uterior service of the Subject Property and
invoice/charge CUSTOMER at the regular service rate.
CUSTOMER Aeeeptance of Optional Provision 3D (signature)
BUYERS RIGHT TO CANCEL. YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF
THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. REFER TO THE A'ITACHED NOTICE OF
CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT. TM U"unignetJ ave,..,d IIIId henby agJW both to the above IInd to
the .l~ua1 tmllS ""d co~ditio~~ .n the reverse side of this Agre8IMt. Tlte Undersigne}lJt~~~ " the lUJtlce,~f cllncWllltion form.
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OMERSIGNATURE' .....-'. DATE . .. .... "'- -:. ,HOME.r4\RAMOl: TREPRESENTATIVE .,'
...his AGREEMENT is contingent upon Management approval. HOME PARAMOOO reserves the right to amend or re~ AGREEMENT ifnot acc:epteCl within 30 days.
WHITE - BranchIYElLOW-8ervice DepartmentIPINK - Customer
C2004 Home Paramount Pest Control Companies, Inc.
Previnull F.ditinnll Obsolete
HP332 (3/04)
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CHARGES
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ALPINE TREE EXPERTS, INC.
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INVOICE
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ADDRESS
CITY, STATE, ZIP
SOLD BY
TERMS
F.O.B.
PRICE
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PAY LAST AMOUNT
IN THIS COWMN
794536
DATE
UNIT
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EQUIPMENT SERVICIE REPAIR AND EVALUATION FORM
Date
1-800-322-6013
Customer Name
(I"/~;:c!..;Y .:2:G/..,.; /?;i~
Customer Request:
Equipment Type
House Heater
Central NC
Water Heater
Room Heater
Replace
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* NG=Natural Gas, LP=Propane, E=Electric, 0= Oil, W=Wood, C=Coal
Time Arrived: ~:'/r Time Left: 13:~r
COST FOR SERVICE CALL
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Expiration Date _ _1_ _1_ _ _ _
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CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, P A 17013
; {, APR 2 6 2005
.Jbr~,H':r"'1:-,wJrl' ,
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April 22, 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:
Marvin Beshore, ESQUIRE
RE:
Nancy A. Criss, 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:
April 8, 15,22,2005
Second Proof Request
$ 75.00
$ 0.00
$ 0.00
$ 75.00
-------------
$ 0.00
----
Advertising Cost
Proof of Publication
Payment Received
Total Amount Due
Payment received April 5. 2005
by Beckv H. Morgenthal/Executive Director
...
.
trbe patriot-News
Now you knOw
Order Confirmation
Order Source
0001286761
rholton
rholton
Fax
Paver
Paver Account Number
53450
Ad Order
Sales
Order Taker
Customer
MARVIN BESHORE
Orderer Account Number
53450
Soecial Pricina None
MARVIN BESHORE
ATTORNEY AT LAW, 130 STATE STREET,P.O. BOX
946
Harrisburg PA 17108-0946 USA
PO Number
Ordered Bv
Customer Fax
ESTA TE OF CRISS
MARVIN BESHORE
Customer EMail
Customer Phone 717-236-0781
Paver Phone 717-236-0781
Tear Sheets
o
Proofs
o
Affidavits
1
Blind Box
Promo Tvoe
<NONE>
Invoice Text
Materials
Payment Amount
$71.63
$0.00
$71.63
Payment Method
Total Ad Cost
Amount Due
Ad Number Ad Tvoe
0001286761-0' Legal Liners
Ad Size
:1.0X11Li
Color
<NONE>
Production Method Production Notes
Ad Booker
Product Information
Classification
# Inserts
Run Dates
PNCO: :Full Run
846-Estate Notices-West
3
4/5/2005, 4/12/2005, 4/19/2005
Run Schedule Invoice Text
NOTICE IS HEREBY GIVEN that Letters Testamentary in the estate 0
4/19/200510:35:21AM
1
...
REV-1512 EX+ (6-98)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
.
COMMONW~THOFPENNSYlVAN~
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Nancy A. Criss
FILE NUMBER
21-05-0279
Include unrelmbursed medical expenses_
ITEM
NUMBER DESCRIPTION
1. Home Equity Credit Line - Sovereign Bank - #N6819166206: DOD payoff
2. Linda Beates (personal care provider)
VALUE AT DATE
OF DEATH
30,062.51
399.76
619.13
3. Linda Goodhart (personal care provider)
4. Louise Breski (personal care provider)
5. Myra Pifer (personal care provider)
331.50
97.50
6. Cathy DeHaven (personal care provider)
7. Special Care (Office charge for personal care payable at date of death - check number
154 paid 3/21/2005): see attached invoices
97.50
6482.50
8. Pinnacle Health Infusion: medical bill
60.60
5.00
9. Janet Miller, Tax Collector: local tax
10. Reimbursement for roof repair in 2002 to Ann Criss
1128.00
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
39,284.00
...
.
Sovereign Bank
Nancy A. Criss
187-16-6747
March 21, 2005
ESTATE OF
SOCIAL SECURITY #:
DATE OF DEATH:
Account #: 0571128513 Type:
In the name of: Nancy A. Criss
Date of Death Balance:
Int.(YTD) from 1/1/2005 to
Accrued interest to date of death:
Other Info:
Checking
Open date: 1/30/1997
$816.46
3/14/2005
$0.00
$0.45
Account #: 0574111928 Type:
In the name of: Nancya. Criss
Date of Death Balance: Closed prior
Int.(YTD) from 1/1/2005 to
Accrued interest to date of death:
Other Info: closed 2/14/05
Club Account
Open date: 12/31/1980
2/14/2005
$0.00
$0.00
Account #: 2334026735 Type:
In the name of: Nancy A. Criss
Date of Death Balance:
Int.(YTD) from 1/1/2005 to
Accrued interest to date of death:
Other Info:
Savings
Open date: 7/6/2001
$302.07
2/13/2005
$0.18
$0.18
Account #: N-6819166206 Type: Home Equity Credit Line Open date: 1/6/2005
In the name of: Nancy A. Criss or James D. Criss
Date of Death Balance: $29,953.80 (dad payoff $30,062.5 1)
Int.(YTD) from to
Accrued interest to date of death:
Other Info:
Page 1 of 1
GRISWOLD SPECIAL CARE
Cumberland County
r'/. " )
Client Name;:;:;;; Ilt"".,,' 1'" . tk~4J~'/J..-'"
Signature: / ",f . .
ec' 1'1]'
Caregiver Name~_~ -?~.1 ~.,: ~{;,V
'--
Signature:
.
ii
.r: ! ._
'W'k
;. ~.1'-
'117-975-0540
,,"c.'h"e'
~(~~~:L,:~
Social Security #:
Address:
Rates
Hourly
Overnight w/sleep
Live-in
Date Hours
M.
Tu.
w/1-/ .'
Th. ';!.
Fr. '1 / Z-
Sa.
Suo
.# Miles
'4,
r"'
.I '.
...._.-'o'-~
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
GRISWOLD SPECIAL CARE
Cumberland County
Client Name:
Signature:
Address:
717-975-0540
,(I jJ.<' /.$ ~ ('-
~ JI ..,.# _.(:0'
l~~~ ,t-..,~
Rates
Hourly $
Overnight w/sleep $
Live-in
Date Hours
M.
Tu.
W.
Th.
Fr.
x
X
X
X
X
X:
Xrl. _
TOTAL $
'5.?-'i,) vX Cf" 7-5" =
<;:' - "j,;: )Vt X:7.. '7.1;- =
I X .35
Effective 01/01/03 TOTAL $ ~? (/, ? .
Additional charges ifmore than one person. Time-and-a-halffor Holidays,
Please mail WHITE copy with Office fee to:
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
f
GRISWOLD SPECIAL CARE
Cumberland County
Client Name:
Signature:
Caregiver Name:
~r;'~~
717-975-0540
- P
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Signature: ~.
Social Security #:
Address:
,/ .
---:;,; CZ c::J ff
, ", J
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Care iver
$ 9.75
$ 76.00, '
$ HO.OOt
x Rate = Pa
X
X
X
X
h X X
k X X
Suo X X 0'"
# Miles X .35 TOTAL $'-'.11
Effective 01/01/03 TOTAL $ '/ ~ . . ._"'" '
Additional charges if more than one person.' Time-and-a-half for Holidays,
Please mail WHITE copy with Office fee to:
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
Rates
Hourly
Overnight w/sleep
Live-in
Date
M.
Hours
Tu.
'4,
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
U'~~ rrVL.IJ~.c ~\,..~.(:lL \"'.I'1..n~
Cumberland.County /'
Client Name: IV ~l,.t..t.'"'t:I
Signature:
C~~giver N~e: iJ'/t!t!A s[:-;7cJY.ttJll4 U"
sigI1atur~~''-':L/1'. "i';,.. 1i,:;:: /',:"/~Z;:,:f~;,1' .
Social Security #:
717-975-0540
/1
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I Address:
I Rates Caregiver
I ~oW;ly I $ 9.75
LZ;~~~~~~/Sl::~,._._.,.~~li~:~~
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IM/::J).-fT~~j "'(r~, I. X /1t_J
I Tu': ;J,;) 1 ?~ rI '1 x'" ~
LWi,r'~ i/ Ix';"
L~1,' ]'T-I1-" rx~
L . . '.,!., ' .". I j X,r) "'? <.: =1/'7 ~"X
FI'. L.lL3,"> _ II V'~ / ,') "' /-'- 1 . ~~1J_~~
I Sa:'l) ;\i] IL.. rXlJ, 1s~ =/1 1: #-4' X =~ c:t:
I J I/fl"-J- -~ ,,,',# -- , 1 ' 1 X ')') ,
Su nil "';~"71 X(i,/ > =/1 , rt.1 =~U:.~..:r
# 'i1es . >''j X .35 = I/,..;,;"',h: TOTAL $~~
Effective 01/01/03 TOTAL $~<jf f, 71 ~J7)
Additional charges if more than one pePSOn." ime- -a-half for HoUdU%,' "
Pleasemail WHITE copy with Office fee to:
L Offic~ 8.~.
I $ 2.50 rd 1t'l1J~
$.1..4..0. .0. 1;l?
$ 20.00 \'Z\'\'iP"
= Pay I ~ Rat~~:=)~.~~~:c
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. Copies .
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GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
J-.~
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/I
GRISWOLD SPECIAL CARE
Cumberland County
Client Name'. f..v' {."~ (v"1I (.f rrg
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717-975-0540
Address:
I
f
L
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Rates
Hourly
Overnight w/sleep
Live-in
Date
M. t~" ~
Tu.G'), "1
w. j} :i
Th.l). f-j
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Sa.
Suo
# Miles
$
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$
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.,
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
GRISWOLD SPECIAL CARE
Cumberland County
Client Name:
Signature:
Caregiver Name:
Signature:
Social Security #:
Address:
717 -97 5-0540
Rates Care Iver
Hourly $ 9.75
Overnight w/sleep $ 76.00
Live-in $ 110.00
Date Hours x Rate = Pa
M. X
Tu. X
W. X /d
;ijk7. 7- Ul ,-V, X 0; /) =/, /'
Fr. X
Sa. X
Suo X
# Miles X .35
Effective 01101/03 TOTAL $
Additional charges if more than one person. Time-and-a-halffor Holidays.
Please mail WHITE copy with Office fee to:
. Copies.
White - Office
Yellow - Client
Pink - Caregiver
$
.,
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
J
l
'1
GRISWOLD SPECIAL CARE
Cumberland Coun /
Client Name: l/d~.1~~;-t:J
S. tur I
Igna e: .'
Caregiver Name: 1 j It f 1\.t1
'1~:r ~
Signature:
Social Security #:
Address:
1tJ.
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(~#l' ,., _) .>
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GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
Care iver
$ 9.75
$ 76.00
$ 110.00
x Rate = Pa
-X =/Ir,
X "'"1/1: f ~
Xi d-"
X
X
X
X
X .35
Effective 01101103 TOTAL $ 3Si.<))
Additional charges if more than one person. Time-and-a-half for Holidays.
Please mail WHITE copy with Office fee to:
. Copies .
White - Office
Yellow - Client
Pi~. - ~.~:~!~.:r..
GRISWOLD SPECIAL CARE
Cumberland County
Client Name: .t),
Signature:
Caregiver Name={ !nvC{t.-
Signature:n;;/', .(./~.<
"
Social Security #:
Address:
~\
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'j
X
X
X
X
X
TOTAL $
(ft.... I'
.717-975-0540
Rates
Hourly
Overnight w/sleep
Live-in
Date
Care . ver
$ 9.75
$ 76.00
$ 110.00
x Rate = Pa
Fr.
Sal :l-/ D
Su.iJ. e I
# Miles
Effective 0 I/O 1103 TOTAL $ -, (0 IJ
Additional charges ifmore ~an one person. Time-~d-a-halffor Holidays.
Please mall WHITE copy WIth Oftke fee to:
. Copies.
White - Office
Yellow - Clien1
Pink - Caregiver
M.;,1/,jl/ , .;)
Tut0,',//- ~/~
~,
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
Offi~...., 11\/'"
$ 2.50-'-'4"\"'~
$ 14.00 (~J-:P':
$ 20.00 \'2.\~~
x Rate - Fee
X;,~' .)
X).
X
X
X
- 1
--,..,~~.
Signature:
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GRISWOLD SPECIAL aARE
Cumberland County ,/f
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Signature: ./
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717-975-0540
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GJtiSWOLD SPECIjiL CARE
Cumberland County I'
Cli N 1.-0"7.
ent ame: r~ /t.:f/C:..
Signature:
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Social Security #:
Address:
Signature:
Social Security #:
Address:
Rates Care lver Offic Rates Care iver Off' e .1"1' .,
Hourly $ 9.75 $ 2.50 Hourly $ 9.75 $ 2.50 ~~
Overnight w/sleep $ 76.00 $ 14.00 Overnight w/sleep $ 76.00 $ 14.00 ,tp
Live-in $ 110.00 $ 20.00 Live-in $ 110.00 20.00 ~\~
= Feel ---j----
Date Hours x Rate =Pa x Rate Date Hours x Rate =Pa x Rate
M. X X M. X X
Tu. X X Tu. X X
X =1 X X X
,
X X X X
X Xli ..,.>.~ ,) r
Fr. X r.. "
Sa. X X X X
Suo X X X X
# Miles X .35 TOTAL $ # Miles X.35 .TOTAL $
TOTAL $ //...."1'. " - -"-- --~---
Effective 01/01/03 TOTAL / '1 Effective 01/01/03
Additional charges if more than one pe on. Ime-and-a-halffor Holidays. Additional charges if more than one person. Time-and-a-half for Holidays.
Please mail WHITE copy with Office fee to: Please mail WHITE copy with Office fee to:
~, . Copies . GRISWOLD SPECIAL CARE . Copies .
GRISWOLD SPECIAL CARE White - Office White - Office
6 West Main Street Yellow - Client 6 West Main Street Yellow - Client
Shiremanstown, PA 17011 Pink - Caregiver Shiremanstown, PA 17011 Pink - Caregiver
GRISWOLD SPECIAL CARE
Cumberland C
Client N
717-~5-0540
d
GRISWOLD SPECIAL CARE
Cumberland County
Client Name: -;/1/ I!/ C
Signature:
Caregiver Name:
Signature:
717-975-0540
'./ -
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Address:
,-----
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Address:
Rates
Hourly
Overnight w/sleep
Live-in
Date Hours
M.
Care
$ 9.75
$ 76.00
$ 11 0.00
x Rate = Pa
X
X
Date
Hours
I}L
W
Th.
Care lver
$ 9.75
$ 76.00
$ 110.00
x Rate = Pa
X
X
X
X
Fr. X
Sa. X
Suo X
# Miles X .35
Effective 01/01/03 TOTAL $
Additional charges if more than one person. Time-and-a-ha If for Holidays.
Please mail WHITE copy with Office fee to:
Rates
Hourly
Overnight w/sleep
Live-in
$
M.
Tu.
Tu.
Fr.f X
Sa. f X
Suo X
# Miles X.35 ~_
Effective 01/01/03 TOTAL $ ....~- ~.,....'
Additional charges if more than one person. Ime-and-a-half for Holidays.
Please mail WHITE copy with Office fee to:
. Copies .
White - Office
Yellow - Client
Pink - Care iver
'/
- b
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GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
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GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
. Copies.
White - Office
Yellow - Client
Pink - Caregiver
6
~--~~~~~f!::"'~,-:.~--------~-"rf'!"J"~':"~:~':<~;:-:;-~--'Q:'.~~.;v~.1\::
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GRISWOLD SPECIAL CARE
Cumberland County
Client Name:
717-975-0540
Signature:
;r,j.
'I S"S
Caregiver Name' ''In 7
Signature' /j -H
" 1
Social Security #: (I
Address: 3.:/ y L <:) ~ u. s7" s: 7~ ,f: _<:.. ;-; r:
Fa.5 T f?e' /;
Rates Care
Hourly $ 9.75
Overnight w/sleep $ 76.00
Live-in $ 110.00
Date Hours x Rate = Pa
M. X
Tu. X
W X
Tho X
Fr. X
X/J- + O\'J =
X 9.
X .35
Effective 01/01/03 TOTAL $ -.: '10 0
Additional charges ifmore than one person. Time-and-a-halffor Holidays.
Please mail WHITE copy with Office fee to:
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
~ ....~_. .....
.,
GRISWOLD SPECIAL CARE
6 West Main Street
Sbiremanstown, PA 17011
GRISWOLD SPECIAL C4JfE
Cumberland County "
Client Name~ d4/!_~(!
Signature:
717-975-0540
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Caregiver N~:"'''V/:>. cO "...;' /~"l J
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Signature: '~
Social Security #:
Address:
Rates
Hourly
Overnight w/sleep
Live-in
Care iver
$ 9.75
$ 76.00
$ 110.00
x Rate = Pa
X~1
~.
Off'
$ 2.50
$ 14.00
20.00
x Rate = Fee
-X ':;.;;}-
X
X X
X -jJ7v,X
X)!'X
X X
suo ._X X
# Miles X .35 TOTAL $1 J "I , .'>
Effective 01/01/03 TOTAL r /11 0
ry).. di.' tioIlij1 QharRes if more than one pers n. ~ r d::-half for Holida'ys.
/....;,.[..1.i-' ,~ ~~Pleasemail WHITE copy witll Officeree1O:'-"--~ .
I ..... . Copies .
mB" GRISWOLD SPECIAL CARE White - Office
~ . 6 West Main Street Yellow _ Client
...... Sbuemanstown, PA 17011 Pink C .
- aregIver
Date
Mo/:1:/
Hours
./ ~:;
Tu.
717-975-0540
/1
( ~.../'S..s.
(~O'LO /l1t'~
Caregiver
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$ 110.00
I Off~.m.",...:
$ 2.50 ,~" \ G-' .
$ 14;00 \ \\'L';U
$ 20.00 ~~
x .35
Effective: 01/01/03 TOTAL $. . 52 __
dditional charges if more than one person, Time-and-a=t;aJ(fc)rHolidaY5.
Please mail WHITE copy with Office Fee to:
. Copies.
White - Office
Yellow - Client
Pink - Care iver
GRISWOLD SPECIAL CARE
o 6 West Main Street
Shiremanstown, PA 17011
I
GRISWOLD SPECIAL CARE
Cumberland County
Client Name: ~/'~-r~''-r-
Signature:
717-975-0540
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6 West Main Street
Shiremanstown, PA 170J J
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GRISWOLD SPECIAL CARE
Cumberland County
Client Name: A, j1 /1 ,~ C
I \i,/"~ j\J ".\
Signature:
Caregiver Name: 1 ~ l J ,.1'\ n t -<O~;J ,e:.".' C' '
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Date Hours
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f.. ,::.,-'.,
x
X
X
X
X
TOTAL $, :: \. '
.,
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
. Copies .
White - Office
YeIloVl' - Client
Pink - Caregiver
, -
GJtISWOLD SPECIAL CARE
Cumberland Coun
Client Name:
Signature:
AJ~,I
/
$ l 1',1) /r,. ,," : t., A.--:--
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Social Security #;
Address:
Rates
Hourly
Overnight w/Sleep
Live-In
Date !
Care iver
$ 9.75
$ 76.00
$ 110.00
x Rate
Tu.
W,
Th.
Fr.
Sa,
x
x t, _ ..
x :35"
Effective: 01/01/03 TOTAL $
Additi~nal charges if more than one petSon. ;Time-and-a-half for Holida
Please mail WHITE copy with Office Fee to: ys.
. Copies.
White - Office
Yellow - Client
Pink Care iver
Suo
",
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
--
GRISWOLD SPECIAL CARE
Cumberland County
Client Name: VI CJ.......'v \J" .A.jl
I
Signature: I
Caregiver Name:
Signature:
Social Security #: DO ~:s - 22. .-:: ..2 '-I /,
Address: ? 3 / 5r ~~ cLe~ (J. c<l.
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Rates I I Caregiver L _Of&:~ WI\
Hourl~ $ 9.75 $ 2.50 ~~ \1.110'\
O."e~ght w/sleep $ 76.00 $ 14.00 ~-
LIve-m n $ 110.00 $ 20,00 \ z." ,}
Date ,I Hours I x Rate = Pay lx ~~ - F~e ..
M, I IX Ix
Tu. I I X ~X
I I X I X
X LX
X X
X J./ I X '7 ~' - " .J L
X T X-
# Miles X .35 TOTAL $ /
Effec.t~ve 01/01/03 TOTAL $/:~, _ _ inn .
Addlttonal charges if more ~an one person. Time-and-a-ha]ffor Holidavs~'
Please mall WHITE copy with Office fee to: '
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GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
. Copies .
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717-975-0540
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GRISWOLD SPECIAL CAR{
Cumberland County
Client Name.;.<?'}
Signature:
Caregiver Name:
',.> Care iyer L. Offi~ A.:.I~
$ '9.75 $ 2.50 ll! 1\ \t-
$ 76.00 $ 14.00 ~ '\1
$ 110.00 $ 20.00 _-
x Rate = Pa x Rate - Fee '
X Ix
X X
X X
Xl X
X ~ X
X !.,.. / n ? ~X
X = - - - Ix
# Miles X.35 TOTAL $
Effe~ve 01101103, TOTAL $1 j~ r .. .
Addittonal charges If more ~han one person. Time~lf for HolidllYs.
Please mall WHITE copy witliOffice fee to:---' , . -
. Copies.
While - Office
Yellow u Client
Pink - Caregiver
Signature: _,1:.~,::/
..",'..;,c k",,"''',j.':l...
Social Secrtrity #:
Address:
Rates
Hourly
Overnight w/sleep
Live- in
Date
M.
Hours
.,
717-975-0540
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GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
.
GRISWOLD SPECIAL CARE
Cumberland County
Client Name:
Signature:
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717-975-0540
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GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
GRISWOLD SPECIAL CARE
Cumberland County
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Signature:
Caregiver Name:
Signature:
Social SecurIty #:
717-975-0540
( ;~*
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Address:
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Care iver
$ 9.75
$ 76.00
$ 11 0.00
x Rate - Pa
X
X
X
-' o.{, /7-. X
Fr. X
Sa. X
Su, X
# Miles X .35 ()".)
Effective 01/01/03 TOTAL ~. .
Additional charges if more than one person. !ime-and-a-halffor Holulays.
Please mail WHITE copy WIth OffIce fee to: .
. Caples.
.... GRISWOLD SPECIAL CARE White _ Office
'lira 6 West Main Street Yellow - Client
~JIII'" Shiremanstown, PA 17011 Pink - Caregiver
Rates
Hourly
Overnight w/sleep
Live-in
$
Date
M.
Hours
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GRISWOLD SPECIAL CARE 717-975-0540
Cumberland County
Client Name: Ail" W C c' t S j
Signature:
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Address:
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Rates ;
Hourly
Overnight w/sleep
Live-in
Care iver.
$ 9.75
$ 76.00
$ 110.00
x Rate = Pa
X
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GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
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Cumberland Coun
Client Name:
717-975-0540
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Address: ,0 OX
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$ 2.50fd....lt..~
$ 14.00 t " ,~
$ 20.00 . .....~
- Pa x Rate Fee
x
x
x
Rates
Hourly $
Overnight w/Sleep
Live-In
Date Hours
M.
x
Tu.
W.
Th.
x
I
1
1
x
x
x .35
Effective: 01/01/03 TOTAL $ :J~' .' . . ...
Additional charges if more than one person. Time-ancl-a-half lor Holidays.
Please mail WHITE copy with Office Fee to:
. Copies.
White - Office
Yellow - Client
Pink - Care iver
'"
GRISWOLD SPECIAL CARE
6 West Main Street
Shireo:aanstown, PA 17011
r-
GRISWOLD SPECIAL CARE
Cumberland Coun (
Client Name:
Signature:
Caregiver Name: L/ #...
Signature:
Social Security #:
Address:
r
Rates
Hourly $
Overnight w/sleep $
Live-in
!
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.~
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
# Miles x ,35
Effective: 01/01/03 TOTAL $
Additional charges if mo~ than one rs ime-and-a-half for Holidays.
Please mail WHITE copy with Office Fee to:
. Copies.
White - Office
Yellow - Client
Pink Care iver
GRISWOLD SPECIAL
CumberlandCoun
Client Name:
Signature:
Social Security #:
Address:
Rates
Hourly
Overnight w/Sleep
Live-In
Date
W.
Th.
Fr.
Sa.
717-975-0540
/ X
Care iver
$ 9.75
$ 76.00
$ 110.00
x Rate
x
x
x
x
x
x
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
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Cumberland County
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nename. P7..--1ip-):.U'M e....'t-tt_<t.A,./
[Signature:.. . ~. ... j' I
I CaregiverName6}~--t:..t'~~-t.//5~~i"~4ti.-t~l'
[ Signature: \.,./ T.--
l Social Security #:
I Address:
I Rates 1 Caregiver I Off'~--'Ce
I ~~:n.l~ght w/sleep I i6:g0 --.ll rl~:~rr t)~
I Live-in ! 110.00 $ 20.00 I\~I~
L Date ,.1I<>UfS r x Rate = Pa~_ n _Lx Rate = F;;---
I M. I I X = I X ;;;,__n
I Tu. . .n. . I... . . .1 X . = .1 X .. .... =
L~... .//->h_oCn./;L.1 X q..7s- = ,1/7. ~x L-o':;' i/ ~- ~'tJ./
I ;:"7Jtlnl~/ / :/1~ j :1
I sa.rnt ~x . =' I X -
Suo I I X = =:J X nn =
I # Miles I I X.35 = ... .... .I TOTALS; cJ>;/-t
I Effec?ve 01/01/03. ~ TOTAL$..! .,..5/ q.=== ..n ... .'
AddltJonal charges If more than one person. Time-and-a-halffor Holidavs.
Please mail WHITE copy with Office fee to: .
",
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
GJUSWOLD SPECIAL CARE
Cumberland County
Client Name: JJ f-} IJ ~. lL
Signature:
717-975-0540
/,f ~~, 1;" ~
1...__ ! C _) ,..,;).
Signature:
Social SecuritY,#:
[ Address:
I Rates
Hourly
o.Vernight w/sleep
Live-in
[ Date I Hours
I-M {, , ,~ I ,,' ''\
. .~, I.? Jif""
1-- TUll~ :::.-::/ I _l_c1'
W." . ~
I Thj! (0 In"-/
Fr. .
ISa.flfr --
S
#
Caregiver
9.75
76.00
1 OffilAi_~
$ 2,50 r 4 ...,.-
- $ 14.,.0. O. '''AJ~~
$ 20.QQ_~
.1 x Rat.~~:~!,~__~
j_ X:\ 5 ,) _=:,\t,\
4~ tt;:' 'i'~ = 2.,~ :,.:,.~-
I XL-c"u/ ""~?'-_n
j )(~. 5''':='''''-
Ix - ~--~
1 X ::.. = ;'1. -
,~~.;; ,,=". .....~ -
..g......"
TOTAL $
= }>a.Yn _
= ~ ,j-',
j ~. --.!i_
- ~-),-';"-"I
-~
=grl
"..
......~
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
.j.!If7-:;-.....-~~-_.:-~..~:-..:
'\
GRISWOLD SPECIAL CARE
Cumberland Coun I
Client Name: I~
Signature: j
Caregiver Name:
Signature:
Social Security #:
Address:
717-975-0540
~';at/
x
x
x .35
Effective: 01/01/03 TOTAL $.J>
Additional charges if more than one perso . '~i6mWalf for Holidays.
Please mail WHITE copy~ht)tf~elFee to:
... . Copies.
_, GRISWOLD SPECIAL CARE White - Office
~ . 6 West Main Street Y 11 Cl
""'lIIIII . Shiremansto-Tn, P'A 17011 e ow - ient
no Pink Care iver
qRISWOLD SPECIAL CARE
Cumberland County
Client Name:
717 -975-0540
Signature:
Caregiver Name:
. /--,
Signature: ,"
Social Security #:
.,"~._.."":
Tu.
W. x
Th. x
Fr. X
Sa. X
x
X
X
X
X
X
X
,TOTAL $t O,O(
Suo
X
# Miles X .35
Effective: 01/01/03 TOTAL $ ~J 4' ri'
Additional charges if mo~ than one rson. Time-and-a-half for Holidays.
Please mail WHITE copy with Office Fee to:
..., GRISWOLD SPECIAL CARE · Copies ·
!mil White - Office
~ 6 West Main Street II
""'lIIIII Shiremanstown, PA 17011 Ye ow - Client
Pink Care iver
"-:-"l-"~~"';'" -~:"':'
.,o,~
G diD SPECIAL CARE
Cumberland County I
Client Nam~/1A
Signature:
717-975-0540
l
j';
~ .
~.
t;.
I'
i'
.
Caregiver Nan;1e:-
I /
Signature: \../
Social Security #:
Address:
Rates
Hourly
Overnight w/sleep
Live-in
Date
M.
OffiCN.. \\..M
$ 2.50
$ 14.00
$ 20.00
x Rate = Fee
X
X
t'
~~
I
Care iver
$ 9.75
$ 76.00
$ 110.00
x Rate = Pa
X
X
XCI
XI
X
X
Suo X
# Miles X .35
Effective 01101/03 TOTAL $ ~ 1. J <:
Ad itional charges if more than one persd . Ti -and-a-half for Holidays.
Please mail WHITE copy with Office fee to:
. Copies .
White - Office
Yellow - Client
Pink" Caregiver
......
\ '
~~
Hours
",
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
GRISWOLD SPECIAL CARE
Cumberland County
Client Name: v?);~ A~t:/j
I
Signature: ,I
Caregiver Name:
Signature:
Social Security #:
Address:
717-975-0540
-j
() /.\
Rates
Hourly
Overnight w/sleep
Live-in
Date
M.
Off~ Jl. ,.
$ 2.50 !
$ 14.00 r~!
$ 20.00 '\\1\l
x Rate - Fee
X
X
X
X
X
'-' X;:!'
X
TOTAL $ . "i ; I
t
I
I'
Ii
Care iver
$ 9.75
$ 76.00
$ 110.00
x Rate = Pa
X
X
X
X
,X
....X
X
X .35
Effective 01/01103 TOTAL $ I~ '10
Additional charges if more than one person. Time-and-a-halffor Holidays.
Please mail WHITE copy with Office fee to:
. Copies .
White - Office
Yellow - Client
Pink - Caregivel
Hours
Tu.
W.
Th.
It
,fF
- "'"
.j
",
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
p:::,;:,------ ._--.
,
GRISWOLD SPECIAL CARE
Cumberland County
Client Name:
Signature:
Caregiver Name: II.....J nit;! (Jl
Signature: ,! it'
Social Security #:
Address:
Rates
Hourly
Overnight w/sleep
Live-in
Date
M.
Th.
W.
Th.
Fr.
Sa.
.,
[
fi
r'
l:
r;
(
GRISWOLD SPECIAL CARE
6 We~t Main Street
Shiremanstown, PA 17011
C~b;;l~dC~~;;",afUJ 7n~
Client Name:"17.A
or
Signature:
r
Caregiver Name: ;:-::.::
r _,~
Signature:
Social Security #:
Address:
Rates
Hourly
Overnight w/sleep
Live-in
Date
Hours
M.
Iu.
w.
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
-.--....-- -..----
; '1;: ~'_
-~~.' --~"'4~::?~;-::~~>:~~7,->:'t..--;-;:7~_y;;.,~~::-"';~-':-<-1r-'C,~.>j,T",~::'-.-~~~-:"~7:;;s:::~::,;~,}:?:~,-,';~'-::~';2!t-:~::.~.;,~:.c;:'~.
717..975':'0540
.
)
$
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
Signature:
717-975-0540
/-""\
'~~[J
i _,..r-',~
Caregiver Na~e: ;(/ Ii/V-f .('2!.7(g'/~4~7
Signatur ;/~t~ c~':;-L
Social Secunty #:
Address:
x
x
x'/.1.s
'l" x .35
Effective: 01/01/03 TOTAL $ J;{:, 5' ... .....un L.___H.__
Additional charges if more than one person. Time-and~a-half for Holidays.
Please mail WHITE copy with Office Fee to:
. Copies.
White - Office
Yellow - Client
Pink - Caregiver
.,-!
":(j
;.~
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
{J'.l(l,:) rYULV ,:)rnl.-1AL l.-Al(J:!,
Cumberland County " i
Client Name: .!ll{;;.~-yl.CAA
.~r
Signature:
717-975-0540
//
v1 /...~~~
/1
1/ C;~ .
Caregiver Na.tl?:Et-6?:::; (~/Vv';~ /! -'a-
- Signature: /~..~ ,:S ~l--EI'.. ),'lcd~'~-:':'c;>i ,<
I Caregiver I Off~e.L tII'1.<;'
$ 9.75 I $ 2.50 YA,'%r v-~
$ 76.00 $ 14.00 1Ly''Zr
$ 110.00 $ 20.00 1\'lA-\O~
x Rate =P~ IxRate = Fee . .
X X
X X
. ""1 t/)' //1,./ X ---7 (~ -Ix
0' X /i JX
X X
X IX.
X X
X.35 TOTAL $
- .-
Effective 01/01/03 TOTAL $; c=-~-
Additional chiu-ges if more than one person. T1nle-and-a-haIf for Holidays_
Please mail WHITE copy with Office fee to:
-
Social Sec.urity.#:
Address:
Rates
Hourly
Overnight w/sleep
Live- in
Date
M.
Hours
Tu.
Fr.
Sa.
Su.
# Miles
.~C__J
/ /-,~-_/
GRISWOLD SPECIAL CARE
6 West Main Street
ShiremanstowD, PA 17011
. Copies .
White - Office
Yellow - Client
___Pink - Caregiver
Care iver
$ 9.75
$ 76.00
$ 110.00
Bours. x Rate = Pa
X'
X
X
X
X
X
X'I.1S- =/11-
X .35
Effective 01/01/03 TOTAL $/1 .-
Additional charges if more than one person. Time-and-a-half for Holidays.
Please mail WHITE copy with Office fee to:
. Copies .
White - Office
Yellow ~ Client
Pink - Caregiver
Care lver
$ 9.75
$ 76.00
$ 110.00
x Rate = Pa
X
X
X /;} -F~>
)(I-
Fr. ,/ 1- X
Sa. X
Suo X
# Miles X .35
Effective 01/01/03 TOTAL $ :~.- th,
Additional charges ifmore ~an one person. T e-~d-a-halffor Holidays.
Please mad WHITE copy WIth Office fee to:
..
GRISWOLD SPECIAL CARE
Cumberland County
Client Name:
717-975-0540
Signature:
/7 r' (
"'--
,-.
....)
M.
Tu.
W.
Th.
Fr.
Sa.
Suo J-....-=?
# Miles
Effective: 01/01/03 TOTAL $
Additional charges if more than one perso. ime-and-a-half for Holidays.
Please mail WHITE copy with Office Fee to:
. Copies.
White - Office
Yellow - Client
Pink - Care iver
"
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremans~.PA 17011
Client Name:
S!gnature:
IS~
Signature:
Social SecuritY #:
Address:
~-J.
.l:~t~.t1~;;e;;~~
Rates
Hourly
Overnight w/Sleep
Live-In
Date Hours
M.
Care iver
$ 9.75
$ 76.00
$ 110.00
x Rate = Pa
x
Offic
$ 2.50
" '$ 14.00
$ 20.00
x Rate
x
x~ ~,~:s {; - l:'~e;~
.~:}- ~r-~; ~';':"~"':--".~;':
Th.
x
x
x
x
Fr.
Sa. X X
Suo X X
# Miles x .35 TOTAL $~-
Effective: 01/01/03 TOTAL , 3t? 0cJ
Additional charges if more than one person. ime-and-a-half for Holidays.
.,. Please mail WHITE copy with Office Fee to:
. Copies.
White - Office
Yellow - Client
Pink - Care iver
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
-....r', -.~
GRISWOLD SPECIAL CARE
Cumberland County
Client Name: ,\ l~n(?Cl
Signature:
Caregiver Name: l- 'f
Signature: ~'}",lt{
Social Securit)! #:
Address:
717-975-0540
;1 ,,-I <' r
.. r J -> ,-",)
Il
Caregiver Offic~ "'"-_. ~
$ 9.75 $ 2.50 ~""V~.
$ 76.00 $ 14.00 :;c;\.~
$ 110.00 $ 20.00 ... \\~\~
x Rate = Pay x Rate - Fee
X ..1) -I ft. X:;,S:o ~3fJ
Xq. '{ S''' -1(1. -. X,). S,') ')
X - 1 X
X X
X X
...:xq r:::; --\'=- -11""1 'X
,*~.,.:;Y~---rr-t.... X
X.35 . TOTAL
Effective 01/01/03 TOTAL $..;2.. 3 8 u. .
Additional charges ifmore than one person. . ime-an -a-half for Holidays.
Please mail WHITE copy WIth OffIce fee to:
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
Rates
Hourly
Overnight w/sleep
Live-in
Date
M.I I '1
Tu.,
W.
Th.
i
JI
j
~
1
I'
j
n
it
II
\..I
~
'1
1
",
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
,/I.J V.J&V
Client Name: .
Signature:
Caregiver Name:
Signatut~~i'-
: I .
Social Security #:
Address:
I
)
I j I}ll 6 (j LtJlllll~/r
rZT/I!l,/,=~J--'
r+,:r-~~'r" _1'".1 ..~-. ,",
".>>" ~'"'~--""'- -~~-".., ~...-
Rates
Hourly
Overnight w /Sleep
Live-In
Dat~
M.
$
iver Off~q
$ 250 1'4 ~~ 1~
$ 14.00 ~. " -
$ 20.00 ~~
x Rate '= Pee'
X,.Li l;';-:/l _ "7~.{i':{
~~~~~~j ---~~'-~1. J_ ~
>7
x
= 1/4j.;'1X:7~'$ f"'/O'...',.
/--.$ / #' .;'.... '_~_ '" _J~_____
X =
:!,
X
I x-t~.~--;') ~~~f, __
x .35 r- ~ fOTAi-$-,J~ ,_~1 j ..<
------~T-T--y----.:----
Effective: 01/01/03 TOTAL $ ""'1'"".""; ~t7_
Additional charges if more than one persd'n.' Time-and-a-half for Holidays.
Please mail WHITE copy with Office Fee to:
. Copies.
White - Office
Yellow - Client
P~~"~e.&"er_
Suo
#
-,
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
~~
~.
!
~
81iISWOLD SPECL
Cumberland County
Client Nam&.---:1'l
Signature:
Signature:
Social Security #:
Address:
Rates
Hourly
Overnight w/sleep
Live-in
Date
I
r
t., .4M. ~{ ~'"
r Tu.
t wi 2.t?
I Th. 2.7
~ ::. 1 D
Hours
;.r-
Suo
j~-''':,
$
$
# Miles
Effective 01/01/03
Additional charges if more than one pe .
Please mail WHITE copy wit
.,
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
~7~*~~z..~399 .1S
CiRlSWOLD SPECIAL CARE 717-975-0540
Cumberland County ,
Client Name: ,J (l\,.Cc_ !~ C' ( (S~ ('"
Signature:
Caregiver Name:
Signature:
Social Security #:
t.
Care
$ 9.75
$ 76.00
$ 110.00
x Rate = Pa
X
X
X
X
X
X (I 1'1('
suo X '
# Miles X .35 -- 't::
Effective 01101103 TOTAL $ ~...;:..\,.., . i
Additional charges ifmore than one person. Time- - .halffor Holidays.
Please mail WHITE copy with Office fee to:
. Copies .
White - Office
Yellow - Client
Pink ~ Caregiver
Rates
Hourly
Overnight w/sleep
Live-in
Date
Hours
M.
Tu.
W.
Th.
Fr.
.,
f~\
$
r
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA.ll011
GRISWOLD SPECIAL CARE
Cumberland Coun
Client Name:
717-975-0540
Address:
Rates
Hourly
Overnight w /Sleep
Live-In
Date Hours
M.
Car~give1"
$ 9.75
$ 76.00
$ 110.00
x Rate
fx
Off)fet'\, ,\ I
--~-I T-2.50 l'Q ':tt"1 I'
$ 14.00 i -;'?\.~
$ 20.00 ..,l~\~s
x Rate - ee
Ix
= Pay
Tu.
x
9.... -z5"=JJ2liJ x
- =~/()C
=~/) I.t>c
~~~tr
",
GRISWOW SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
GRISWOLD SPECIAL CARE
Cumberland County
Client Name:
Signature:
Caregiver Name:
717-975-0540
i
'f
.,
f
,I
L
Address:
Date
M.
L.c.~~VV\..iv '~(._.Q.Q
\ Care
$ 9.75
$ 76.00
$ 110.00
x Rate = Pa
X
X
X
X
X
Rates
Hourly
Overnight w/sleep
Live-in
Hours
Tu.
W.
Th.
Fr.
Sa.
Suo
.,
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
GRISWOLD SPECIAL CARE
Cumberland County
Client Name: I, Y.~J:l0 \/
\
717-975-0540
\. ,r\ '~) ! \:'
\'
Signature:
Caregiver Name:
i i
t)i~"')'--
Signature:
Social Security #:
(1
Address: '-1 <.? i
'j ).
Rates
Hourly
Overnight w/sleep
Live-in
'-r:. . -t" 1
&-;..~ I .
Office
$ 2.50
$ 14.00
$ 20.00
x Rate
Care
$ 9.75
$ 76.00
$ 11 0.00
x Rate = Pa
X
X
X
X
X
X
X 1:::,
X .35
Effective 01/01/03 TOTAL $ "'. <'r:
Additional charges if more than one person. Time-and-a-half for Holidays.
Please mail WHITE copy with Office fee to:
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
Date
Hours
M.
Tu.
W.
Th.
Fr."'
",
GRiSWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
." , -ill --..;;;J. -."--
Client Name:
Signature:
Caregiver Name: l,,-
J.I:/
Signature:
Social Security #:
Address:
Rates
Hourly
Overnight w /Sleep
Live-In
Date f
M.
iver
om e
$ 2.50
$ 14.00
$ 20.00
x Rate
$
x .35
Effective: 01/Oli03 TOTAL
Additional charges if more tpan one fSerson. nne-and-a-h:llf for Holidays.
Please mail WHITE copy with Office Fee 10:
. Copies.
White - Office
Yellow - Client
Pink - Care iver
-,
GRISWOLD SPECIAL CARE
6 West Mairi. Street
Shiremanstown, PA 17011
~"
. 1 if"
1~
..f.~--",I,...... .y" ,-~'~ s-P
v1ir"'~r 4i:-~-~p'4{~
GRISWOLD SPECIAL. '1RE
Cumberland County I f
[ J,!
Client Name:1~1lt/"'Yti.f!/ J -{:;"/f~U/
- ~l
I Signature: . I) .1. 'u' ....~ ---.L- .~.
I Caregiver N~tY;~:;.~.:,.l-;,r2"'~ /(j~~l~~~?i.A!."/
I Signature: -C../"
I Social Security #:
I Address:
I
, 717-975-0540
II
t
'~
it
If
r
~
r
r
t
[
r
I
~,
t
1 Caregiver I . Office .ILllI.
$ 9.75 l $ 2.5OT(i"Wflp
$ 76.09 $ 14.00 t ~ 1)
$ 11 0.00... ...$ 2Q.QO n_~ ~p
1 x Rate .~ r x R.ate- = Fee' .~.
X Z~- -] ., .... .S v- ~:2.()>
XI -./l?~ Jx ~3a,t."
X = 1/ X =3!~~'-
X .. X - ':s../'
X X
xLx
suo X X
# Miles <) z. X .35 TOTAL $
Effective o I/O 1 103 TOTAL $ -~"'(J k
Additional charges if more than one person. Time-and-a-half for Holidays.
Please mail WHITE copy with Office fee to:
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
W.
Th.
Fr.
-,..c.1:k
Sa.
",
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
J
'J
I
j
l
I
i
I
U-A.lJ WVLLI JC .c~Ll1L ~
_~,!~~e.rI~_~~~C!~~~~~..__~
I ciie~t Name~L1..kLCH\l
I --... /'
Signature:
I /1 --'r!
Caregiver Name: I .,. ,..-. /.......... i/
-. \~ c~-{! t' \. .~
sign~ture{ j.,?~~/:'-y ____ ;S"
-.-(" /'"
717-975-0540
/1 .'
lLf- ; .5 ~.
Social Security #:
Address:
Rates
Hourly
Overnight w/Sleep
Live- In
Date Hours
Care iver Of\iH~~jl
$ 9.75 $ . 2.50 '4i~
$ 76.00 $ 14.00 .r
$ 110.00 $ 20.00 :1 t15
x Rate = p~. I x~_at~.. =' Fee
x 7 7 -) ~.~; ,odx . ==_,,2 v, I:A
..' l..](
?x =~3;0(,'jt.
x
M. /'p)'!
Tu.
SU,
=L$t.~5k~
=/Iz.nbx
-- Jx
TOTAL $ /l,;;'"'(l
- 31;~
=.1~.J'bL
# Miles x .35
Effective: 01/01/03 TOTAL $jI!lJi.,)
Additional charges if more lhan one person." Time-and-a-half for Holidays.
Please mail WHITRcopy with Office Fee 10,
. Copies.
White - Office
Yellow - Client
Pink - Caregiver
-,
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
GRISWOLD SPECIAL CARE
Cumberland County
Client Name: lJ :) ~1
Signature: I
Caregiver Name: L\ n~
Signature:
717-975-0540
(~
.. r< ".).
Rates
Hourly
Overnight w/sleep
Live-in
Date
Hours
Care
$ 9.75
$ 76.00
$ 110.00
x Rate
X
X
X
X
X
lver
M.
Tu.
W.
Th.
Fr. <<
Sa..... ,.,';
Su,J; t,
# Miles
Effective 01/01103 TOTAL $' illS'. . .t'; ."
Additional charges ifmore!lum one person.' e-and~.halffor lloliday~ '.
Please mad WHITE copy with Office fee to: : .'
",., GRISWOLD SPECIAL CARE · Copies ·
... .' 6 West Main Street White - Office
"""II1II Shiremanstown, PA 170 II Yellow - Client
Pink. - CaI'llgiver
GRISWOLD SPECIAL CARE
Cumberland Coun
Client Name:
Signature:
717-975-0540
./ t
( ~/ r--. .
Signature:<'i~...,
Social Security #:
Address:
Ra~s
Hourly $
Overnight w/Sleep
Live-In
Date
M. 'f
Fee
1'/( /1/
.;'~...:
~ t
~
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x
...~~. O.A. xt(: "1r5
x .35
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Additional charges if mo~ than one rson. Time-and-a-half for Holidays.
please mail WHITE copyt:?Jh gffi~t:) to:
...., GRlSWOW SPEcf'ifl~ , · .Copies ~
_ CARE White - OffiCe
~ S~west Main Street Yellow - Client
town. PA 17011 Pink Care iver
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Signature:
Caregiver Name: "'1lT V''+ r'{"''\'! 1\ S I
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Social Security #:
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iver
Rates
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Overnight w/sleep
Live-in
Date
M.
$
t,
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$ 2.50 'l'l K
$ .14.00. Zl!(~~
$ 20.00 n\2tb-
x Rate = Fee
X_-~ ~ --
X
X
~
X~ -r--
X
X
TOTAL $ .
GRISWOLD SPECIAL CARE · Copies ·
White - Office
6 West Main Street...k
Shiremanstown, PA 17011 .....Yellow - Client
"pink - C ~egiver
I
,
GRISWOLD SPECIAL CARE
Cumberland County
Client Name: 7)0v11f-.1./j
Signature:
Caregiver Name: 1.
Signature: i~:>"'''''t.~.!
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Address:
717-975-0540
11 ~St
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$ 110.00 $ 20.00 t\~\l6+:
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Effective 01/01/03 TOTAL $. ~(.". . ^ "c
Additional charges if more than one perso~. tim::and-a-hlllf for Hbli~s ~'t 0
Please mall WHITE copy with Office fee to: .
ItJ GRISWOLD SPECIAL CARE · Copies ·
. .' 6 West 1\1 ain Street White - Office
Shiremanstown, PA 17011 Yellow - Client
Pink - Car~giver
I
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LDate
[ ~~\ /(,.-
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GRISWOLD SPECIAL CARE
Cumberland County
Client Name:
Signature:
Caregiver Name:
Signature:
Social Security #:
Address:~ c;<,g-.
Rates
Hourly
Overnight w/sleep
Live-in
Date, Hours
M.
$
$
Fr.
Sa.
Suo
# Miles
Effective 01/01/03 <
Additional charges if more than one person. . ime-~d-a-half for Holidays.
Please mail WHITE copy WIth Office fee to:
lei.
. 'llIlIII1I"'"
. Copies .
White - Office
Yellow - Client
Pink - Caregiv~r
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
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GRISWOLD SPECIAL CARE 717-975-0540
Cumberland County
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Client Name: ~ 'I Dc L..tL.AAAJ
Signature:
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Signature:
Social Security #: .~
Address:
Rates
.Hourly
Overnight w/sleep
Live-in
Date Hours
M.
Tu.
W.
Th.
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
. Copies.
White - Office
Yellow-Client
Pink - Caregiver
GRISWOW SPECIAL CARE
Cumberland Coun
Client Name:
717-975-0540
(!r fS 5
/.J:~{j'_<2-~_
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Address:
Rates
Hourly $
Overnight w/Sleep
Live In
Date
, Offj<;,e. __.
$ 2.50 ~
$14.00 ~?'~~
$ 20.00 zhii~
Pay x Rate 'Fe~
?CJJtoa x2. 5" () ;;()~Ot
x /
~117.{)IJ x StJ.1L
x
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-1'l.tJO x
9..2..~3 x
x x, n...-
# Miles x .35 TOTAL $ Q :: .15
Effective: 01/01/03 TOTAL $,3'? (,1 _
Additional charges if more than one person'. Time and-a-half for Holidays.
Please mail WHITE copy with Office Fee to: .
. Copies.
..., GRISWOW SPECIAL CARE White - Office
_ ' 6 West Main Street Yellow - Client
..... Shiremanstown, PA 17011 Pink:-c::aregiver
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I GRISWOW SPECIAL CARE
Cumberland County
Client Name: ,/1\)0.. V\tfi i
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Signature:
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Address:
Rates
Hourly
Overnight w /Sleep
Live-In
Date
- Pay
Offj!;~.1 ___
I $ 2.50 ~t:l1t l\.,e
$ 14.00 \\ ~
$ 20.00 1.1\ c;{6.
I x Rate = t<eev
Ix
IX-
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M.
x
Tu.
. li
x
x
x
~ q "7"- ~xi~.If;L)~.JA
x c</",',' -1'1 r 061 x :/_ I iL) J3~'M
x .35'\ - TOTAL ~e,jf;
Effective: 01/01/03 TOTAL $' ~i IX .:~. __~
Additional charges if more than one person. TiIne-and-a-haIf for Holidays.
Please mail WHITE copy with Office Fee to: ,
. Copies.
GRISWOW SPECIAL CARE White - Office
, 6 West'MainStreet Yellow - Client
ShireOIaIUliown, PA 17011 Pink" Giiregiver
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Cumberland Coun
Client Name:
717-975-0540
Signature:
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Address:
Rates
Hourly $
Overnight w /Sleep
Live-In
Date
Suo .~
# Miles Xc .35
Effective: 01/01/03" TOTAL $5
Additional charges if more than one person. Time-and-a-half for Holidays.
Please mail WHITE copy with Office Fee to:
. Copies.
White - Office
Yellow - Client
Pink - Care iver
'"
GRISWOLD SPECIAL CARE
6 West Main Street
Shi1'emanstown, PA 17011
-~_'';';;.L...:;;p...::';..2.'-
GRISWOLD SPECIAL CARE
Cumberland County
Client Name:
Signature:
Caregiver Name: 0-9A.JJ (,Ii (Ji .ir;
Signature:
717-975-0540
{ 1/. , . ;:,...5(//yl
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Address: 2>:
Rates
Hourly
Overnight w/sleep
Live-in
Date Hours
M.
Care iver
$ 9.75
$ 76.00
$ 110.00
x Rate = Pa
X
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Sa.
suo
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GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
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# Miles .
Effective 01/01/03 TOTAL $ I )'1.
Additional charges if more than one person. Time-and.a-halffor Holidays.
Please mail WHITE copy with Office fee to:
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
~,
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown. PA 17011
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GRISWOLD SPECIAL CARE
Cumberland County
Client Name: ()A r(!~1 t.-.J.I" J S",<;
717-975-0540
Signature:
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Rates
Hourly
Overnight w/sleep
Live-in
Date Hours
M.
Tu.
W.
Th,
iver
$
$
SaJ-J I d(
{)
iles
Effective 01/01/03 TOTAL ..~3('/
Additional charges if more ~ one person. Tiflle-and-a-half for Holidavs.
Please mall WHITE copy with Ofhce fee to: .
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown. PA 17011
717-975-0540
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Cumberland Coun
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Social Security #:
Address:
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Overnight w/Sleep
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ate
717-975-0540
GRISWOLD SPECIAL CARE
Cumberland Coun
Client Name: 1\/ .
Signature:
Caregiver Name: Co.... ,j.,
Signature: /l ,;' ,
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Social Security #:
Address:
$
x .35
Effective: 01101/03 TOTAL $i 1-
Additional charges if more than one person. Time-and-a-half for Holidays.
Please mail WHITE c~w' _Offi e to'
" . Copies.
GRISWOLD SP White - Office
6 West Main Street Yellow - Client
Shiremanstown, PA 17011 , Pink - Care iver
GRISWOLD SPECIAL CARE'
Cumberland County
Client Name: -YJ
Signature:
Caregiver Name:
,...~ "~". -7'1'" C-' .
717-975-0540.
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Signature: l:S....;
Social Security #:
Address:
Rates
Hourly
Overnight w/sleep
Live-in
Date Hours
M.
Tu.
Sa.
suo
# Miles
.,
Care iver
$ 9.75
$ 76.00
$ 110.00
x Rate = Pa
X
X
$
Rates
Hourly
Overnight w/Sleep
Live-In
Date
M. .., _
GRISWOLD SPECIAL CARE
6 West Main street
Shiremanstown, PA 17011
. Copies .
White - Office
Yellow - Client
Pink .. Caregiver
Care iver
$ 9.75
$ 76.00
$ 110.00
x Rate
x
xtf.1S -
x.35
Effective: 01/01103 TOTAL $
Additional charges if more than one person. Time-and-a-half for Holidays.
Please mail WHITE copy with Office Fee to:
. Copies.
White - Office
Yellow - Client
Pink - Caregiver
",
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
GRISWOLD SPECIAL CARE
Cumberland County
Client Name: CI2I3 ~.. Na AI (l( /'
Signature: /' . 7
CaregiverName: /6J2,[/11_,(t>,d~ U OV:Y)C7'L..
Signature:
Social Security #:
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Address:
Rates
Hourly
Overnight w/sleep
Live-in
mate / I Hours
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717-975-0540
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$.' 9.75
$ 76.00
$ 110.00
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
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GRISWOLD SPECIAL CARE
Cumberland County
Client Name=j( j~/i/~l (11 /l {!1Z15&-"'~
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Signature: (J
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CaregIver Name: ,\dI!! )l4' -'fHA A~f,t>"
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Signature:
Social Security #:
Address:
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717-975-0540
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GRISWOLD SPECIAL CARE
Cumberland County I
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Client Name: /11/r,V'l,/'.-/
Signature:
Caregiver Name: /
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Signaturc?':<;:Z";. 'I
Social security #:
Address:
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717-975-0540
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Rates Caregiv~r Office .
Hourly $ 9.75 $ 2.50 IQ....'~
Overnight w/sleep'$ 76.001 l- $ 14.00 .f6n~
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Date Hours x Rate = Pay x Rate = Fee
M X = X
fu X = X
w X.~ X
Th X = X
Fr. X::;.... X
k i Xn =,; X
su;J:J7 ~- Yif 75 ~7(f75- X ..~ = ",1.(.
# Miles X .35 = / TOTAL $
Effective 01/01103 TOTAL $ ~/)7~ tri6t)
Additional charges ifmore than one person. Timll-and-a-half for Holidays.
Please mail WHITE copy with Office fee to:
X
X
X
X
X
X
X.35
Effective 01101103 TOTAL $ ;\ C~ S
Additional charges if more than one person. Time-and-a-halffor Ho Idays.
Please mail WHITE copy with Office fee to:
. Copies .
White - Office
Yellow - Client
Pink- Caregiver
~,
GRISWOLD SPECIAL CARE
6 West Mai~ Street
Shiremanstown, PA 17011
f:..:..........
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GRISWOLD SPECIAL CARE
Cumberland Coun .
Client Name:r;1 /
i/ l J
Signature:
Social Security #:
Address:
Rates
Hourly
Overnight w/sleep
Live-in
iver
$
$
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
717-975-0540
C-_....
'0
Oft..
$ 2.50
$ 14.00
20.00
x Rate
X ,~~
X
X
X
X
X
X
TOTAL $
Care iver
$ 9.75
$ 76.00
$ 110.00
x Rate = Pay
X /\ '<"
X
X
X
.X
X
X
# Miles X .35
Effective 01/01/03 TOTAL $
Additiona charges ifmore than one person. Ime-and-a-halffor Holidays.
Please mail WHITE copy with Office fee to:
~,
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
Signature:
Social Security #;
Address:
Rates
Hourly
Overnight w/sleep
Live-in
~,
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
\,
Off~ ~I..n
$ 2.50 r d -n- \-=>1
$.14.00 (P"'.~.~ ~
$ 20.00 . ~\1r~
X Rate = Fee
.X .
~ e x-/ l. .
='.~. 7
. Copies.
White - Office
Yellow - Client
Pink - Caregiver
GRISWOLD SPECIAL CARE
Cumberland County
Client Name:unO...I)r~ l' "l.A
Signature: C)
Caregiver Name! ~lj/,..J .
Signature:
Social Security #:
Address: I !;6~ "::->--\1... .'{vl. e.y:}.i,,{'1
L:.:i;"~" /7fli.., ."e2.,:: f/cL.--
Rates Care iver
Hourly $ 9.75
Overnight w/sleep $ 76.00
Live-in $ 110.00
Hours x Rate = Pa
X
X
X
X
Fr. X
Sa. X
Suo X
# Miles X.35 \.I = I .Y <f
Effective 01/01/03 TOTAL; t::)/c;_
Additional charges if more than one person. Time-and-a-half for Holidays.
Please mail WHITE copy with Office fee to:
717-975-0540
GRISWOLD SPECIAL CARE
Cumberland Coun
Client Name:
.
717-975-0540
t
"
~
':j40
l ,~4-
'3ib5
= Fee'
M.
Tu.
W.
Th.
Fr.
x
x
Suo X
# Miles x .35
Effective: 01/01/03 TOTAL $ ,
Additional charges if more than one pers . . T e-and-a-half for Holidays.
Please mail WHITE copy with Office Fee to:
. Copies.
White - Office
Yellow - Client
Pink - Care iver
X
X
TOTAL $'A7,llQ.
!
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j GRISWOLD SPECIAL CARE
, CumberlaIl~CollntLm_n .
[Cli~ntName: jJ 1~ n (~~C- 171" $ <~ ,,'
I Signatur~ f '-~. ,}'..;~"J
r Caregiver Name: Li<
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
",
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
Ita,
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GRISWOW SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
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Cumberland County
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717-975-0540
717-975-0540
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SIgnature: '
Signature:~,;':'.
'1 ,".,1- !i\
Social SecuritY #:
Address:
Social Security #:
Address:
L_ __ j)ffiG~ "
II 2.50 rd 11 \QD
$ 14.00. ~~tt;i"
$ 20.00 ~,
1 x Rate = Fee
X
Ix
U<_
Ix
Ix
,-o.+" Xc~. -e S- -I r 0 I X) S I
xq.l ~ =(Jn~5ol x;,'-.0 .
X .35 J TOTAL $_~:l
Effective 01/Oll03 TOTAL $jl"" ~K() .. .._~_.....
AdditIOnal charges if more than one person. Time-and~a-hal f for Holidays.
Please mail WHITE copy with Office fee to:
. Copies .
\\'hite - Office
Yellow - Client
Pink - Caregiver
Rates
Hourly
Overnight w/sleep
Live-in
Rates
Hourly
Overnight w/sleep
Live-in
Care
$ 9.75
$ 76.00
$ 110.00
x Rate = Pa
X
X
X
X
X
Care iver
$ 9.75
$ 76.00
'$ 110.00
x Rate = Pa
X
X
X
XI'i.......
X ~ II
X
suo X
# Miles X .35
Effective 0 lIO lI03 TOTAL ./ ~
Additional charges if more !han one pe n. T' e-"and-a-halffor Holidays.
Please maIl WHITE copy with Office fee to:
$
Hours
Date
M.
Date
M
Hours
Tu,
Tu.
W
Th.
. Copies .
White - Office
Yellow - Client
Pink - Caregiver
",
",
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
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Cumberland County "
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. Signature: t' /
Caregiver Name: /.. p,' , : () /j
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Signatul)}:~A~'" ~j(A"","--
Social ~c~ #: -
Address:
Rates
Hourly
Overnight w/sleep
Live-in
$
$
(~==I *.P .I vi- ....X ~~ ~ ~-Z,'"
"'.rd jA d.. X 4" -)'.
Tu.
W X
Th. X
IT X
k X
k X
# Miles X .3 5 TOTAL $ {".~r.-;: Pi
Effective 0 1/0 1/03 TOTAL $ : :J( t... 0-.)
Additional charges if more than one person. Time-and-a-half for Holidays.
Please mail WmTE copy with Office fee to:
. Copies.
White - Office
Yellow- Client
Pink - Caregiver
-.,
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 17011
G1usw(Jrn~'PhrJALCARE -
Cumberland County t
Client Name: '. / () () (JLA
Signature:
717-975-0540
; 'k."'/CC
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.~;.
Signature:
Social Security #:
Address:
Rates
Hourly
Overnight w/sleep
Live-in
Date Hours
M:f
Care . ver
$ 9.75
$ 76.00
$ 110.00
x Rate = Pa
$
X'~f
X
Xl~
XCi- '1 ~
X.35
Effective 01101/03 . TOTAL $.5',/1! c-~-
Additional charg~s if more than one i>~on.' Time-and-a-half for Holidays.
Please mail WHITE copy with Office fee to:
. Copies.
White - Office
Yellow - Client
Pink - Caregiver
-,
GRISWOLD SPECIAL CARE
6 West Main Street
Shiremanstown, PA 170J I
..."",~
--.-.., '-:.~r ..,....
=:'~.
717-975-0540
<<-_/
Address:
Rates
Hourly
Overnight w/sleep
Live-in
Date
Caregiver Offi
$ 9.75 $ 2.50
$ 76.00 $ 14.00
$ 110.00 $ 20.00
x Rate - Pa x Rate
X X
X 2C
-7' t'" _ 1/~'J' .:f> :z
X '~1~ /; .h. .
X. J I'/L X
X /11. :Ix
k X X
suo X X
# Miles X .35 TOTAL $ ;' /: "
Effective 01101103 TOTAL $Jf I. ?. .
Additional charges if more than one person. !ime-and-a-halffor Holulays.
Please mail WHITE copy WIth OffIce fee to:
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.
. REV.1513 ""(9-<)0) ..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DeCEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
Nancy A. Criss
FILE NUMBER
21-05-0279
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)]
James D. Criss Son 1/4
102 Fetrow Lane
New Cumberland, PA 17070
Barbara Ann Criss Daughter 1/4
914 E. Water St.
Lock Haven, PA 17745
Mary C. Breen Daughter
39 Oxford Court 1/4
Pittsburgh, PA 15237
Jeffrey D. Criss Son 1/4
2018 Dickinson Avenue
Camp Hill PA 17011
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
n 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 11- 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)
MARVIN BESHORE
Attorney at Law
130 STATE STREET, P.O. BOX 946
HARRISBURG, PA 17108-0946
Email: mbeshore(a).mblawfmn.com
Telephone: (717) 236-0781
Fax: (717) 236-0791
June 8, 2006
Hand Delivered
Glenda Farner Strasbaugh
Register of Wills
Cumberland County Courthouse
1 Courthouse Square
Carlisle, PAl 7013
Re: Estate of Nancy A. Criss - File No. 21-05-0279
Dear Ms. Strasbaugh:
Enclosed for filing are one original and one copy of the Rev 1500 P A Inheritance Tax
Return for this estate and my escrow check for tax in the amount of$737.50.
Please date stamp the second copy and return it to my legal assistant.
I also enclose the original and one copy of the Inventory for this Estate and my check for
$30.00 for the filing fees - $15.00 for the inheritance Tax Return and $15.00 for the Inventory
Please return a stamped copy of the Inventory.
Thank you for your assistance.
MB:amb
Enclosures
cc: Jeffrey D. Criss and James D. Criss
Co-Executors of the Estate of Nancy A. Criss
(w/o enclosure)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
BESHORE MARVIN
130 STATE ST
PO BOX 946
HARRISBURG, PA 17108-0946
nU____ fold
ESTATE INFORMATION: SSN: 187-16-6747
FILE NUMBER: 2105-0279
DECEDENT NAME: CRISS NANCY A
DA TE OF PAYMENT: 06/09/2006
POSTMARK DATE: 06/08/2006
COUNTY: CUMBERLAND
DATE OF DEATH: 03/21/2005
NO. CD 006816
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $737.50
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$737.50
REMARKS: MARVIN BESHORE
CHECK# 005037
SEAL
INITIALS: CM
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
(Rev. 10/04)
Before the Register of Wills of Cumberland County, Pennsylvania
Estate of Nancy A. Criss
also known as
: No. 21-05-0279
, deceased
Inventorv
We, James D Criss and Jeffrey D. Criss, personal representatives of the estate of the above
named decedent, verify that the items appearing in the following inventory include all of the
personal estate of the decedent wherever situate and all of the real estate of the decedent in the
Commonwealth of Pennsylvania, that the valuation placed opposite each item of the inventory
represents its fair value as of the date of the decedent's death, and that the decedent owned no
real estate outside of the Commonwealth of Pennsylvania except that which appears in a
memorandum at the end of the inventory. We understand that falseBtEtate nts made in this
invent?1!' are subject to the penalties of 18 Pa.C.S. 9 49~lating t rn.. fal~ification to
authontles.
Date: April 18. 2006 .
Signature of Individual Personal Representative
Typed N e: James D. Criss
,~
ividual Personal Representative
Jeffrey D. Criss
Si at e of Attorney
Typed Name: Marvin Beshore, Esquire
Supreme Court J.D. No.: 31979
Office Address:
Telephone Number: 717-236-0781
9 i :01 HrJ 6 - lirnr 9UOZ
i '~l I ~ j 1 I (..., ("" !t<T 1 ,....\ t'~\ -, ~ ~
:JU JJujU JJ\JdUJJC
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Description
Real property situate in Cumberland County, Pennsylvania at
2202 Parkside R., Lot 92, Country Club Manor, Camp Hill
Borough. Value shown is the contract sale price.
Checking Account - Sovereign Bank - #0571128513
Savings Account - Sovereign Bank - #2334026735
Personalty appraised by Claude C. Wolfe & Associates
Burial plots in Prospect Hill Cemetery. See attached
"Indenture"
Value
170,000.00
816.46
302.07
2644.00
Benefit under the Last Will and Testament ofLynn McCord
Balance of Trust FBa Nancy A. Criss
Refunds from cancelled subscriptions
400.00
1500.00
13570.82
138.24
Total
$ 189,371.59
Note: The memorandum of real estate outside of the Commonwealth of Pennsylvania may, at the
election of the personal representative(s), indicate the value of each item included in the
memorandum, but the value of such real estate should not be included in the total value of the
inventory.