HomeMy WebLinkAbout07-07-06
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15056041046
REV-1500 EX (05-04)
PA Department of Revenue
Bureau of Individual Taxes
Dept. 280601
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
OFFICIAL USE ONLY
County Code Year
File Number
INHERITANCE TAX RETURN
RESIDENT DECEDENT
:,).... I
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(;dJi/
Date of Birth
I Z J
1.2. -35~~
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J j
19.1.
Decedent's Last Name
Suffix
Decedent's First Name
-r ./-J 0 (7'"\ P 5 c 1'-\
R.Ci.
MI
Q
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's First Name
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
_ 1. Original Return c:::> 2. Supplemental Return
c:::> 3. Remainder Return (date of death
prior to 12-13-82)
c:::> 5. Federal Estate Tax Return Required
c:::> 4. Limited Estate c:::> 4a. Future Interest Compromise (date of
death after 12-12-82)
c:::> 6. Decedent Died Testate c:::> 7. Decedent Maintained a Living Trust
(Attach Copy of Will) (Attach Copy of Trust)
c:::> 9. Litigation Proceeds Received c:::> 10. Spousal Poverty Credit (date of death
between 12-31-91 and 1-1-95)
o
8. Total Number of Safe Deposit Boxes
11. Election to tax under Sec. 9113(A)
(Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Telephone Number
c:::>
13/.:}~dA,z.H
Firm Name (If Applicable)
.6 E C:. k..
'7
I (:"7
REGISTE~ OF WILLS U~ONLY
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First line of address
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Second line of address
City or Post Office
State
ZIP Code
DATE FILED
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Correspondent's e-mail address:
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIG~ATU~E OF PERSON R5SPONSIBLE FOR FILING RETURN
i OJ..L~ ,J{' i3~
ADDRESS
.;.1.),/ 'I dv-k.) "~ r<-..t Q I.. .'(/ 1-4-/ II
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DAT
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IIC' I I
DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056041046
15056041046
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1---
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15056042047
REV-1500 EX
Decedent's Social Security Number
Decedent's Name:
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C:-
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RECAPITULATION
9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . .
1. Real estate (Schedule A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1.
2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2.
3'. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3.
4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5.
6. Jointly Owned Property (Schedule F) c;::) Separate Billing Requested . . . . . .. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) c;::) Separate Billing Requested.. . . 7.
.. 9.
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . .
. . 10.
11. Total Deductions (total Lines 9 & 10). . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 11.
oG
12. Net Value of Estate (Line 8 minus Line 11) . . . . .' .. .... .. .12.
13. Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13.
t1
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H ('1
TAX COMPUTATION - SEE INSTRUCTIONS
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0_
16. Amount of Line 14 taxable
at lineal rate X.O *S"
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
15.
).jC1 ~.. f
16.
17.
18.
19. TAX DUE. .
. . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
C=>
Side 2
L
15056042047
15056042047
--.J
REV-1500 EX Palle 3
File Number
Decedent's Complete Address:
DECEDENT'S NAME
f2.~ /..-J... Q7h,;., heJ<::'. 1
STREET ADDRESS
J. ). I "I ,.J '''' k...J I t.., 1-,: (: ,,-
CITY
(I t.Jl"'\ ,.;1 /...{ I r I
STAT~ '
I'~
ZIP . {
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Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payment?
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
). 2. ,J :J . (I 2
(1)
II \, r~
Total Credits ( A + B + C ) (2)
III '. S--~
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty ( 0 + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
.2. 1.J....j ~ I 1.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5)
(5A)
(5B)
A. Enter the interest on the tax due.
:).1.2~. /2
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; .......................................................................................... 0 ~
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 ~
c. retain a reversionary interest; or......................................................................................................................... 0 ~
d. receive the promise for life of either payments, benefits or care? ..................................................................... 0 ~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. ~ 0
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 ~
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ 0 ~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after JUly 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (3) percent [72 P.S. 99116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent
[72 P.S. 99116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is zero (0) percent [72 PS. 99116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in
72 PS. 99116(1.2) [72 P.S. 99116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 PS. 99116(a)(1.3)]. A sibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1502 EX+ (6-98)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF
FILE NUMBER
All real property owned solely or as a tenant in common must be reported at fair market value, Fair market value is defined as the price 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 property which is jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
/\J J H-
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV.l503 EX + (1-97)
ESTATE OF
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
VALUE AT DATE
OF DEATH
DESCRIPTION
/"JIM-
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
R~V-1504 E),(+ (1-97)
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a
sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
ITEM NUMBER
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
rJJf~
TOTAL (Also enter on line 3, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
~E)J-1505 ~X+ (6-9*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C-1
CLOSELY-HELD CORPORATE
STOCK INFORMATION REPORT
/ViA-
ESTATE OF
FILE NUMBER
City
State_ Zip Code
State on Incorporation
Date of Incorporation
Total Number of Shareholders
1. Name of Corporation
Address
2. Federal Employer I.D. Number
3. Type of Business
Business Reporting Year
Product/Service
4.
TYPE
VotingINon-Voting
TOTAL
SHARES
PAR VALUE
NUMBER OF SHARES
OWNED BY THE DECEDENT
VALUE OF THE
DECEDENT'S STOCK
Common
$
$
Preferred
Provide all rights and restrictions pretaining to each class of stock.
5. Was the decedent employed by the Corporation? ................................. 0 Yes 0 No
If yes, Position Annual Salary $ lime Devoted to Business
6. Was the Corporation indebted to the decedent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 Yes 0 No
If yes, provide amount of indebtedness $
7. Was there life insurance payable to the corporation upon the death of the decedent? ..... 0 Yes 0 No
If yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
8. Did the decedent sell or transfer an stock in this company within one year prior to death or within two years
if the date of death was prior to 12-31-82?
DYes 0 No If yes, 0 Transfer 0 Sale
Transferee or Purchaser
Attach a separate sheet for additional transfers and/or sales.
Number of Shares
Consideration $
Date
9. Was there a written shareholder's agreement in effect at the time of the decedent's death? ....D Yes 0 No
If yes, provide a copy of the agreement.
10. Was the decedent's stock sold? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 Yes 0 No
If yes, provide a copy of the agreement of sale, etc.
11. Was the corporation dissolved or liquidated after the decedent's death? .................... 0 Yes 0 No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
12. Did the corporation have an interest in other corporations or partnerships? ............. 0 Yes 0 No
If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest.
THE FOLLOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
A. Detailed calculations used in the valuation of the decedent's stock.
B. Complete copies of financial statements or Federal Corporate Income Tax returns (Form 1120) for the year of death and 4 preceding years.
C. If the corporation owned real estate, submit a list showing the complete address/es and estimated fair market value/s. If real estate appraisals have
been secured, attach copies.
D. List of principal stockholders at the date of death, number of shares held and their relationship to the decedent.
E. List of officers, their salaries, bonuses and any other benefits received from the corporation.
F. Statement of dividends paid each year. List those declared and unpaid.
G. Any other information relating to the valuation of the decedent's stock.
(If more space is needed, insert additional sheets of the same size)
.RIlV.1506 ~~+ (9.0.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C-2
PARTNERSHIP
INFORMATION REPORT
f'JJt4
ESTATE OF
FILE NUMBER
1 . Name of Partnership
Address
Date Business Commenced
Business Reporting Year
State
Zip Code
City
2. Federal Employer I.D. Number
3. Type of Business
ProducVService
4. Decedent was a 0 General 0 Limited partner. If decedent was a limited partner, provide initial investment $
5.
A.
B.
c.
D.
6. Value of the decedent's interest $
7. Was the Partnership indebted to the decedent? ................................. 0 Yes 0 No
If yes, provide amount of indebtedness $
8. Was there life insurance payable to the partnership upon the death of the decedent? ..... 0 Yes 0 No
If yes, Cash Surrender Value $ Net proceeds payable $
Owner of the policy
9. Did the decedent sell or transfer an interest in this partnership within one year prior to death or within two years if the date of death was
prior to 12-31-82?
DYes 0 No
If yes, 0 Transfer 0 Sale
Percentage transferred/sold
Consideration $
Transferee or Purchaser
Attach a separate sheet for additional transfers and/or sales.
10. Was there a written partnership agreement in effect at the time of the decedent's death? 0 Yes 0 No
If yes, provide a copy of the agreement.
Date
11. Was the decedent's partnership interest sold? ....................................... 0 Yes 0 No
If yes, provide a copy of the agreement of sale, etc.
12. Was the partnership dissolved or liquidated after the decedent's death? ................... 0 Yes 0 No
If yes, provide a breakdown of distributions received by the estate, including dates and amounts received.
13. Was the decedent related to any of the partners? .................................... 0 Yes 0 No
If yes, explain
14. Did the partnership have an interest in other corporations or partnerships? . . . . . . . . . . . . .. 0 Yes 0 No
If yes, report the necessary information on a separate sheet, including a Schedule C-1 or C-2 for each interest.
THE FOllOWING INFORMATION MUST BE SUBMITTED WITH THIS SCHEDULE
A. Detailed calculations used in the valuation of the decedent's partnership interest.
B. Complete copies of financial statements or Federal Partnership Income Tax retums (Form 1065) for the year of death and 4 preceding years.
C. If the partnership owned real estate, submit a list showing the complete address/es and estimated fair market value/so If real estate appraisals have
been secured, attach copies.
D. Any other information relating to the valuation of the decedent's partnership interest.
REV-1507 EX+ (1-97)
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1.
rJl4-
TOTAL (Also enter on line 4, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
--~.'"'' ..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
FILE NUMBER
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 Schedute F.
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
rJJ4
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
REV-1509 ~x + (1-97)
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNS) ~VANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
iCu.\-h ~ -rhO\l'\p~,"'~
FILE NUMBER
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. '1xvlx..-- ~e....L
).).1l'1 Pt:,.-k...J ,'f4 t!.d.
tc...""'~ l.fl II a-1 /,,;;,,1
b tufjh k-
B.-~~ lj-d "-
50 f!-1.cJ..'1 ~l; ell j )..../4;"\<-
I-l. \,J,j bt;O ,0'1 1~4 I . 7 j J r.-l
D ".JJ.j h k.-
c.
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. Attach DATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. {(i(11 IY\ ~.,- L5 t'V"'\J.. - rss~).S" 7 tlIAf~. 3] Sb~.: Sf;J 4 J , I
J. A;J 1I1~ tV)~ T 6,",", L. - /500 J../ ).. I( 8"y 3 /! '"' I r. S"'l '), r 'j 33.31 c.,lell. ?~
TOTAL (Also enter on line 6, Recapitulation) $ JI,YJ.J.13
7
(If more space is needed, insert additional sheets of the same size)
~'~.~.""'.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
Ku.. J-h c.. -rtll),~Pj 0;;...,
FILE NUMBER
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.
ITEM
NUMBER
1.
DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER.
ATTACH A COPY OF THE DEED FOR REAL ESTATE.
;;t,
6cy b,~(A. "B-<d<.. -p tv-l J h k,- - / d"" J 0 J
Je~r"' ~ \k _ I)".M..}'''<..# - /I J~ J OJ
-- G,,--b,_l)~.~Lv- ,,)..J}c;5'"
..J t;. (-\. """ J "J
(W J..i.-. J Iw\f t-u-- - D t..v. J "'d...,,. - II J 1./ J 05""
3
Jf,
DATE OF DEATH
VALUE OF ASSET
11,000,
%OF
DECO'S
INTEREST
EXCLUSION
/IF APPLICABLE)
3oCO,
'l.oC,)
JC;.;.(:;.
lI,ll(..C
'3 c.W
"/~(C,
1 ~ u::..
5
C J J /1, u...c <
(,.0, "I i Cl,..v'\ n') _ -nI')O)."'t'j/.,)""i'"\ - J"" - II ~/CJ
jDW
TAXABLE VALUE
~CQO.
.r ~~ 0
:ro~G,
f'(;<.)O
?-o cc. .
TOTAL (Also enter on line 7, Recapitulation) $ J../ OJ 0 ~c. .
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX+ (12-99) _
, 'C}"-l~&
~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
P-u..\-h
FILE NUMBER
c.. -rh ~,,",,", ~Q J~.".
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
FUNERAL EXPENSES:
1.
C-I C> ~ J"." '" j .J.
~t"li-\I-.t VV',v-~.- J
j.. VI.,.... ch -€. ~ ,"
IAlk,'\ ")
5J~,
50
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
State _ Zip
Year(s) Commission Paid:
2. Attorney Fees
3. 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
4.
Probate Fees - 'F, k. 14. ~ r '"
I S_
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
f\,.'F I"'~"'\ (\JUr). '" j t~~ P-<.<) .
o Ph'Vr"kL'1 b..II- PhlV"~/c""
'70'-1.
1'5"4
TOTAL (Also enter on line 9, Recapitulation) $ ,11 ~ 7.
(If more space is needed, insert additional sheets of the same size)
REV-1512 !;OX+ ,(12-03)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
rJ)A-
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
Re:V-1513,EX+ (9-00)
'.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF
(Ll,lJ,-h c- 111':'l-"""l? .s~,",
FILE NUMBER
NUMBER
I
RELATIONSHIP TO DECEDENT
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s)
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1.
:.J~'-A ~<..lk_
50 jZ(,>c..k'l iJ,cri J f-s"ro...f(..
4 w.J lxt"^j f?4 I '133 ()
J-.
']Cyh:v-"13 <,J... .
):2.1 It -(Jerk,), cL.. ,U.
e~"""J H l " I ~1 II~ I (
jy\J4) h 1<-
)~JhJ.t',-
AMOUNT OR SHARE
OF ESTATE
,5DOjo
~ - (,
J U Ie
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
REV-1514 EX+ (12-03)
",*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE K
LIFE ESTATE, ANNUITY
& TERM CERTAIN
Check Box 4 on REV.1500 Cover Sheet
tJjA-
ESTATE OF
FILE NUMBER
This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89,
actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit.
Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99,
and in Aleph Volume for dates of death from 5-1-99 and thereafter.
Indicate the type of instrument which created the future interest below and attach a copy to the tax return.
o Will 0 Intervivos Deed of Trust 0 Other
o Life or 0 Term of Years
o Life or 0 Term of Years
o Life or 0 Term of Years
o Life or 0 Term of Years
o Life or 0 Term of Years
1. Value of fund from which life estate is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Actuarial factor per appropriate table .................................................
Interest table rate - 031/2% 06% 0 10% 0 Variable Rate %
3. Value of life estate (Line 1 multiplied by Line 2) ......................................$
o Life or 0 Term of Years
o Life or 0 Term of Years
o Life or 0 Term of Years
o Life or 0 Term of Years
1. Value of fund from which annuity is payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Check appropriate block below and enter corresponding (number) ..........................
Frequency of payout - 0 Weekly (52) 0 Bi-weekly (26) 0 Monthly (12)
o Quarterly (4) 0 Semi-annually (2) 0 Annually (1) 0 Other ( )
3. Amount of payout per period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
4. Aggregate annual payment, Line 2 multiplied by Line 3 ...................................
5. Annuity Factor (see instructions)
Interest table rate - 031/2% 06% 010% 0 Variable Rate %
6. Adjustment Factor (see instructions) ..................................................
7. Value of annuity - If using 31/2%, 6%, 10%, or if variable rate and period
payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . .$
If using variable rate and period payout is at beginning of period, calculation is:
(Line 4 x Line 5 x Line 6) + Line 3 ..................................................$
NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through
G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18.
(If more space is needed, insert additional sheets of the same size)
'REV-l64~ EX + (3-8.4) INHERITANCE TAX rJjH-
'*
SCHEDULE "l"
COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT OR INVASION
INHERITANCE TAX RETURN
RESIDENT DECEDENT OF TRUST PRINCIPAL FilE NUMBER
I. Estate of
(Last Name) (First Name) (Middle Initial)
This schedule is appropriate only for estates of decedents dying on or before December 12, 1982.
This schedule is to be used for all remainder returns when an election to prepay has been filed under the provisions
of Section 714 of the Inheritance and Estate Tax Act of 1961 or to report the invasion of trust principal.
II. Rttmainder Prepayment:
A. Election to prepay filed with the Register of Wills on (Date)
(attach copy of election)
B. Name(s) of life Tenant(s) Date of Birth Age on date Term of years income
or Annuitant(s) of election or annuity is payable
C. Assets: Complete Schedule L-l
1. Real Estate S
2. Stocks and Bonds S
3. Closely Held Stock/Partnership S
4. Mortgages and Notes S
5. Cash/Misc. Personal Property S
6. Total from Schedule L- 1 S
D. Credits: Complete Schedule L.2
1. Unpaid liabilities S
2. Unpaid Bequests S
3. Value of Unincludable Assets S
4. Total from Schedule L-2 S
E. Total value of trust assets (Line C-6 minus line 0-4) S
. '--s:'.
F. Remainder factor (see Table I or Table II in Instruction Booklet)
G. Taxable Remainder value (Line E x Line F) S
(Also enter on line 7, Recapitulation)
III. Invasion of Corpus:
A. Invasion of corpus (Month, Day, Year)
B. Name(s) of life Tenant(s) Date of Birth Age on date Term of years income
or Annuitant(s) corpus consumed or annuity is payable
C. Corpus consumed S
D. Remainder factor (see Table I or Table II in Instruction Booklet) S
E. Taxable value of corpus consumed (Line C x Line D) S
(Also enter on Line 7, Recapitulation)
REV-1645 EX+ (7-85) INHERITANCE TAX {V j ,4-
SCHEDULE L-l
COMMONWEALTH OF PENNSYLVANIA REMAINDER PREPAYMENT ELECTION
INHERITANCE TAX RETURN
RESIDENT DECEDENT -ASSETS- FILE NUMBER
I. Estate of
(Last Name) (First Name) (Middle Initial)
II. Item No. Description Value
A. Real Estate (please describe)
Total value of real estate $
(include on Section II, Line C-1 on Schedule L)
B. Stocks and Bonds (please list)
Total value of stocks and bonds $
(include on Section II, Line C-2 on Schedule L)
C. Closely Held Stock/Partnership (attach Schedule C-1 and/or C-2)
(please list)
Total value of Closely Held/Partnership $
(include on Section II, Line C-3 on Schedule L)
D. Mortgages and Notes (please list)
Total value of Mortgages and Notes $
(include on Section II, Line C-4 on Schedule L)
E. Cash and Miscellaneous Personal Property (please list)
Total value of Cash/Misc. Pers. Property $
(include on Section II, Line C-5 on Schedule L)
III. TOTAL (Also enter on Section II, Line C-6 on Schedule L) $
(If more space is needed, attach additional 8Y2 x 11 sheets.)
REV-1646 EX+ (3-84)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
INHERITANCE TAX
SCHEDULE L..2
REMAINDER PREPAYMENT ELECTION
-CREDITS-
IV J fJr
FILE NUMBER
I. Estate of
(Last Name)
(First Name)
(Middle Initial)
Amount
II. Item No.
Description
A. Unpaid Liabilities Claimed against Original Estate, and payable from assets
reported on Schedule L- 1 (please list)
- -
Total unpaid liabilities S
(include on Section II, Line 0-1 on Schedule L)
B. Unpaid Bequests payable from assets reported on Schedule L-l (please list)
Total unpaid bequests S
(include on Section II, Line 0-2 on Schedule L)
C. Value of assets reported on Schedule L-l (other than unpaid bequests listed under
"B" above) that are not included for tax purposes or that do not form a part
of the trust.
Computation as follows:
Total unincludable assets S
(include on Section II, Line 0-3 on Schedule L)
III.
TOTAL (Also enter on Section II, Line 0-4 on Schedule L)
(If more space is needed, attach additional 8Y2 x 11 sheets.)
S
, ,
REV-164? EX+ (9-00)
SCHEDULE M
FUTURE INTEREST COMPROMISE
f\Jj~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Check Box 4a on Rev-1500 Cover Sheet
ESTATE OF
FiLE NUMBER
This Schedule is appropriate only for estates of decedents dying after December 12, 1982.
This schedule is to be used for all future interests where the rate of tax which will be applicable when the future interest vests in
possession and enjoyment cannot be established with certainty.
Indicate below the type of instrument which created the future interest and attach a copy to the tax return.
D Will D Trust D Other
I. Beneficiaries
NAME OF BENEFICIARY RELATIONSHIP DATE OF BIRTH AGE TO
NEAREST BIRTHDAY
1.
2.
3.
4.
5.
II. For decedents dying on or after July 1, 1994, if a surviving spouse exercised or intends to exercise a right of withdrawal within
9 months of the decedent's death, check the appropriate block and attach a copy of the document in which the surviving spouse
exercises such withdrawal right.
D Unlimited right of withdrawal D Limited right of withdrawal
III. Explanation of Compromise Offer:
IV. Summary of Compromise Offer:
1. Amount of Future Interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
2. Value of Line 1 exempt from tax as amount passing to charities, etc.
(also include as part of total shown on Line 13 of Cover Sheet) . .. . ..$
3. Value of Line 1 passing to spouse at appropriate tax rate
Check One o 6%, o 3%, o 0%......................$
(also include as part of total shown on Line 15 of Cover Sheet)
4. Value of Line 1 taxable at lineal rate
Check One o 6%, o 4.5% .......................... .$
(also include as part of total shown on Line 16 of Cover Sheet)
5. Value of Line 1 taxable at sibling rate (12%)
(also include as part of total shown on Line 17 of Cover Sheet) ..... .$
6. Value of Line 1 taxable at collateral rate (15%)
(also include as part of total shown on Line 18 of Cover Sheet) ..... .$
7. Total value of Future Interest (sum of Lines 2 thru 6 must equal Line 1) ..................... .$
(If more space is needed, insert additional sheets of the same size)
REV-1648 EX (11-99)
'*'
COMMONwEALTH OF PENNSYLVANIA
INHERITANCE TAX DIVISION
SCHEDULE N
SPOUSAL POVERTY CREDIT
(AVAILABLE FOR DATES OF DEATH 01101/92 TO 12/31/94)
f1J~
ESTATE OF
I ALE NUMBER
This schedule must be completed and filed if you checked the spousal poverty credit box on the cover sheet.
PART I - CALCULATION OF GROSS ESTATE
1. Taxable Assets total from line 8 (cover sheet) ............................................ 1.
2. Insurance Proceeds on Life of Decedent ................................................ 2.
3. Retirement Benefits ................................................................ 3.
4. Joint Assets with Spouse ............................................................ 4.
5. PA Lottery Winnings ............................................................... 5.
6b.
6a. Other Nontaxable Assets: List (Attach schedule if necessary).. 6a.
6c.
6d.
6.
SUBTOTAL (Lines 6a, b, c, d)
6.
7. Total Gross Assets (Add lines 1 thru 6) ................................................. 7.
8. Total Actual Liabilities .............................................................. 8.
9. Net Value of Estate (Subtract line 8 from line 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9.
If line 9 is greater than $200,000 - STOP. The estate is not eligible to claim the credit. If not, continue to Part II.
PART II - CALCULATION OF JOINT EXEMPTION INCOME - (Attach copies of Federal Individual Income
Tax Return for decedent and spouse.)
Income: 1. TAX YEAR: 19 2. TAX YEAR: 19 3. TAX YEAR: 19
a. Spouse .......... . 1a. 2a. 3a.
b. Decedent . . . . . . . . . . 1b. 2b. 3b.
c. Joint ............ . 1c. 2c. 3c.
d. Tax Exempt Income . . 1d. 2d. 3d.
e Other Income not
listed above . . . . . . . . 1e. 2e. 3e.
f. Total ............ . 11. 2f. 3f.
4. Average Joint Exemption Income Calculation
4a. Add Joint Exemption Income from above:
(1 f)
+ (2f)
+ (3f)
(+3)
1. Insert amount of taxable transfers to spouse or $100,000, whichever is less ..................... 1.
4.
Multiply by credit percentage (see instructions) ........................................... 2.
This is the amount of the Resident Spousal Poverty Credit. Include this figure
in the calculation of total credits on line 18 of the cover sheet. ............................... 3.
For Nonresidents, enter the ratio of the decedent's gross estate in PA to the value of the
decedent's gross estate ............................................................. 4.
Multiply line 3 by line 4 and enter the total here. This is the amount of the Nonresident Spousal
Poverty Credit. Include this figure in the calculation of total credits on line 18 of the cover sheet. . . . . .. 5.
2.
3.
5.
REV.1649 EX. (1.97) ,
SCHEDULE 0
ELECTION UNDER SEC. 9113(A)
SPOUSAL DISTRIBUTIONS
NJ~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Do not complete this schedule unless the estate is making the election to tax assets under Section 9113(A) of the Inheritance & Estate Tax Act.
If the election applies to more than one trust or similar arrangement, a separate form must be filed for each trust.
This election applies to the Trust (marital, residual A, B, By-pass, Unified Credit, etc.).
If a trust or similar arrangement meets the requirements of Section 9113(A), and:
a. The trust or similar arrangement is listed on Schedule 0, and
b. The value of the trust or similar arrangement is entered in whole or in part as an asset on Schedule 0,
then the transferor's personal representative may specifically identify the trust (all or a fractional portion or percentage) to be included in the election to have such trust or
similar property treated as a taxable transfer in this estate. If less than the entire value of the trust or similar property is included as a taxable transfer on Schedule 0, the
personal representative shall be considered to have made the election only as to a fraction of the trust or similar arrangement. The numerator of this fraction is equal to
the amount of the trust or similar arrangement included as a taxable asset on Schedule O. The denominator is equal to the total value of the trust or similar arrangement.
PART A: Enter the description and value of all interests, both taxable and non-taxable, regardless of location, which pass to the decedent's
survivin souse under a Section 9113 A trust or similar arran ement.
DESCRIPTION VALUE
Part A Total $
PART B: Enter the descri tion and value of all interests included in Part A for which the Section 9113 A election to tax is bein made.
DESCRIPTION VALUE
Part B Total
(If more space is needed, insert additional sheets of the same size)
Page: 1 Document Name: untitled
~-_._~_.:-l---------------~-_._-----~--~--
STMT
ACTION
PROD CODE DDA
CURR CODE
ACTN POST EFFECTIVE
TRACE ID
06/22
CO
STFD 1 THF
96 OP EBRN
COlD
ACCT
TRANSACTION STMT FORMAT 06/06/28 10.06.39
MS 50861 LAST PAGE OF TRANSACTIONS
~542849~SHORT NAME THOMPSONRUT
~ ~~SEARCH FROM 106/04/25 THRU
CHECK NUMBER TRAN AMOUNT D/C
DESCRIPTION
4896
5290006495 CHECK NUMBER 4896
106/06/28
BALANCE
745.64
D
10,613.80
06/28
I-GENI06062800000001 INTEREST
06/28 179612399
MQWBKP99 CLOSEOUT
.33
C
10,614.13
PAYMENT
10,614.13
D
.00
PF: I-HELP 3-PLVL 6-INQ 7-SB 8-SF 9-ASUM ll-CUTO -STSM
n~~~. h/?R/?OOh ~imp, 10,07,OQ ~M
,Page: 1 Document Name: untitled
---------------;-----~-~~---_._~_.-.~--_..._--_._-
STMT
ACTION
PROD CODE DDA
CURR CODE
ACTN POST EFFECTIVE
TRACE ID
* OS/22
CO
STFD 1
96 OP EBRN
COlD
ACCT
THF TRANSACTION STMT FORMAT 06/06/28 10.06.44
MS 50852 ACTION COMPLETE
;
* 06/01
85542849 SHORT NAME THOMPSONRUT
PAGE 2 SEARCH FROM 106/04/25 THRU 106/06/28
CHECK NUMBER TRAN AMOUNT D/C BALANCE
DESCRIPTION
4893 6,690.63
1500626768 CHECK NUMBER 4893
1,315.83
020061455915700 US TREASURY 303 RR RET
4894 40.00
5286689898 CHECK NUMBER 4894
4895
5306922719 CHECK NUMBER 4895
4897
6620948068 CHECK NUMBER 4897
D
11,324.33
C
12,640.16
* 06/07
D
12,600.16
* 06/09
447.54
D
12,152.62
* 06/15
794.28
D
11,358.34
* 06/16 1.10 C 11,359.44
I-GEN106061600037665 INTEREST PAYMENT
* 06/16 10.00 D 11,349.44
I-GEN106061600037666 MONTHLY SERVICE CHARGE
* 06/16 10.00 C 11,359.44
I-GEN106061600037667 SERVICE CHG WAlVE- RELATIONSHIP PRICING
PF: 1-HELP 3-PLVL 6-INQ 7-SB 8-SF 9-ASUM 11-CUTO -STSM
n~ro. ~/?R/?nn~ ~;mo' 1n.n7.1~ ~M
. m1 M&rBank
ACCOUNT. NO.. .
85542849 RELATIONSHIP CHECKING WITH INTEREST
MAY.17-JUN.16,2006
1 OF 1
00
o 06123M NM 017
59476
RUTH C THOMPSON
OR BARBARA l BECK
2219 PARKSIDE RD
CAMP HIll PA 17011-2131
INTEREST PAID YEAR TO DATE
5.86
WEST SHORE PLAZA
18,224.28
.. .. ... .... <CHECKs PAID . .
NO. AMOUNT
5 8,181.77
1.10
11,359.44
. POSTING ............. .DEPOS;r;rs~IHrERESr. .........CHECl(S...&..OrHER..... ............OAIl.y........
· DAtE . .fRANSACUON>DEsCRIPUON.. .. . . & otHER ADDttlONS IsOBtRACUONs .... .... .BAi.ANtE. . . . . ...... ...
05-17-06 BEGINNING BALANCE $18,224.28
05-19-06 CHECK NUMBER 4892 209.32 18,014.96
05-22-06 CHECK NUMBER 4893 6,690.63 11,324.33
06-01-06 US TREASURY 303 RR RET 1,315.83 12,640.16
06-07-06 CHECK NUMBER 4894 40.00 12,600.16
06-09-06 CHECK NUMBER 4895 447.54 12,152.62
06-15-06 CHECK NUMBER 4897 794.28 11,358.34
06-16-06 INTEREST PAYMENT 1.10 11,359.44
ENDING BALANCE $11,359.44
ACCOUNT ACTIVITY
..CHECI($I'AIO .$l,.I"I'IARY
I
4892 05-19-06
4895 06-09-06
209.32
447.54
4893 05-22-06
4897* 06-15-06
6,690.63
794.28
4894 06-07-06
40.00
ANNUAL PERCENTAGE YIELD EARNED = 0.10 %
. _ ~oLJ
Y u\f
A $1,000 FOR YOUR THOUGHTS?
CONDUCT A TRANSACTION AT YOUR LOCAL BRANCH BETWEEN JUNE 13 AND JULY 21, 2006 TO
RECEIVE AN INVITATION TO PARTICIPATE IN OUR CUSTOMER SERVICE SATISFACTION
SURVEY. COMPLETE THE SURVEY FOR A CHANce TO WIN A GRAND PRIZE OF $1,000 OR ONE
OF FIVE $100 PRIZES!
I nnA..4/11n~\
. .
ACCOUNT.NO.
85542849 RELATIONSHIP CHECKING WITH INTEREST
APR.15-HAY.16,2006
1 OF 1
00
o 06123H NH 017
22957
RUTH C THOMPSON
OR BARBARA L BECK
2219 PARKSIDE RD
CAMP HILL PA 17011-2131
INTEREST PAID YEAR TO DATE
4.76
WEST SHORE PLAZA
ACTIVITY
DEPOSUS" INTEREST .CHECKS&OTHER
&OfHERADDtrIONS .SU&TRACfIONS
04-15-06 BEGINNING BALANCE
04-25-06 CHECK NUI1BER 4890
05-01-06 US TREASURY 303 RR RET
05-01-06 CHECK NUHBER 4891
05-16-06 TELLER TRANSFER CREDIT
05-16-06 INTEREST PAYHENT
6,447.13
$8,527.13
2,080.00
1,315.83
172.00
3,223.83
15,000.00
0.45
18,224.28
ENDING BALANCE
$18,224.28
CHECKSPAIO.SUHHARY
I
4890 04-25-06
6,447.13
4891 05-01-06
172.00
ANNUAL PERCENTAGE YIELD EARNED = 0.09 %
FOR QUESTIONS ABOUT YOUR ACCOUNT CALL 1-800-724-2440.
NEED A HORTGAGE? H&T CAN HAKE IT HAPPEN. WE OFFER HORTGAGES FOR CUSTOHERS WITH:
- LITTLE HONEY FOR A DOWNPAYHENT OR CLOSING COSTS
- THE NEED TO HAXIHIZE THEIR LOAN AHOUNT
- DIFFICULTIES DOCUHENTING THEIR INCOHE OR ASSETS
TO FIND OUT HORE CALL 1-800-557-0535 OR VISIT H&T AT WWW.HANDTHORTGAGE.COH.
H&T IS AN EQUAL HOUSING LENDER.
t
~~1t
Page: 1 Document Name: untitled
---.- -------------r; .----.-,.-.---~-----,.------~---.----,------.--~-
STFD 1 THF TRANSACTION STMT FORMAT 06/06/28 10.07.56
STMT CO 96 OP EBRN MS 50861 LAST PAGE OF TRANSACTIONS
ACTION COID
PROD CODE DDA ACCT (fSOO42118831~SHORT NAME THOMPSON RUTH C
CURR CODE PAGE SEARCH FROM 106/04/14 THRU 106/06/28
ACTN POST EFFECTIVE CHECK NUMBER TRAN AMOUNT D/C BALANCE
TRACE ID DESCRIPTION
* 04/14 54.46 C 33,492.25
I-GEN106041400034098 INTEREST PAYMENT
* 05/15 56.37 C 33,548.62
I-GEN106051500013950 INTEREST
05/16 D - 18,548.62
6016997901
C
18,575.89
06/15
I-GEN106061500012119 INTEREST PAYMENT
06/28
I-GEN106062800000001 INTEREST PAYMENT
06/28 179612398 18,586.46
MQWBKP99 CLOSEOUT
C
18,586.46
.00
-r ~) 4r~ j...
PF: 1-HELP 3-PLVL 6-INQ 7-SB 8-SF 9-ASUM 11-CUTO -STSM <:./....i c-_LI "")
n~~=. ~/~Q/~nn~ ~~mQ. 1n.nQ.?~ nM
. .m! M&I'Bank.
ACCOUNTHO.
15004211883184
MIT MARKET ADVANTAGE
MAR.16-MAY.15,2006
1 OF 1
00
o 06123M NM 017
17839
RUTH C THOMPSON
JEAN A YELK
BARBARA L BECK
2219 PARKSIDE RD
CAMP HILL PA 17011-2131
INTEREST EARNED FOR STATEMENT PERIOD
INTEREST PAID YEAR TO DATE 328.96
110.92
WEST SHORE PLAZA
ACCOUNT SUMMARY
WITHDRAW LSIOTHER<<
. .SUlTRACTtONS.. .
AMOUNT
.CURRENT
XNTEREstPAID · ..
0.00
0.00
110.83
POSTING
DATE
ACCOUNT ACTIVITY
DEPOSITS:,INTERESTW/ORAWALSIOTHER
. &.OTtiERADDnXot$ .<Sti&TRACtIONS ..
03-16-06 BEGINNING BALANCE
04-14~06 INTEREST PAYMENT
05-15-06 INTEREST PAYMENT
54.46
56.37
$33,437.79
33,492.25
33,548.62
ENDING BALANCE
$33,548.62
ANNUAL PERCENTAGE YIELD EARNED = 1.99 %
FOR QUESTIONS ABOUT YOUR ACCOUNT CALL 1-800-724-2440.
NEED A MORTGAGE? MIT CAN MAKE IT HAPPEN. WE OFFER MORTGAGES FOR CUSTOMERS WITH:
- LITTLE MONEY FOR A DOWNPAYMENT OR CLOSING COSTS
- THE NEED TO MAXIMIZE THEIR LOAN AMOUNT
- DIFFICULTIES DOCUMENTING THEIR INCOME OR ASSETS
TO FIND OUT MORE CALL 1-800-557-0535 OR VISIT MIT AT WWW.MANDTMORTGAGE.COM.
MIT IS AN EQUAL HOUSING LENDER.
I OOAA 111m'
Statement
United Church of Christ Homes
Sarah A. Todd Memorial Home
1000 West South Street
Carlisle, PA 17013
Statement Date: 06/09/2006
Barbara Beck
2219 Park Side Rd.
Camp Hill, PA 17011
Due Date: 06/25/2006
Re: Ruth C Thompson
Account Nr: 101597
Date
Description
Days
Quant
Rate
Charges
PaYments
Balance
BALANCE FORWARD
05/17/06 PAYMENT
05/31/06 Medical Supplies
05/31/06 Incontinence Suppli
05/31/06 Personal Laundry Se
06/01/06 Room & Board - Semi
7,279.15
6,690.63
7,279.15
588.52
639.90
725.40
749.80
1,382.80
1. 00
1. 00
1. 00
3
51.38
85.50
24.40
211.00
51.38
85.50
24.40
633.00
(Y\Q)l
d-d-\.5,'
) ~ ~. &5
114.2>i
5g~. 5~
dns (1,~
~
- 5gg5~
Lv~~lut .~ ~
~
,J-tb
7q~.J~
~ c.('\ u
~~~\\\)\o
NOTE: ***** PAYMENT IS DUE UPON RECEIPT ***** BUT NO LATER THAN
THE- 25TH OF THE MONTH ***** Please remit the LAST AMOUNT printed on
your statement. Include the ACCT# from the statement on the MEMO LINE
of your check. PaYments after 6/2/06 do not reflect on statement.
NOTE: ** LATE PAYMENTS ARE SUBJECT TO A 1.25% LATE CHARGE PER MONTH **
A $10.00 FEE WILL BE CHARGED for RETURNED CHECKS **
MONTHLY MED CHARGES
MAY 2006
Thompson, Ruth
Room 50a
Resident #
101597
date item # cost date item # cost date item # cost
1-31 Gluco Strip 56 28.56
Syrinqe TB 1 0.29
Lancet 56 10.64
Syringe Insulin 41 11.89
OXYGEN BRIEFS EQUIPMENT
Large 9 85.50
BRIEFS
SUPPLIES
02
TOTAL
910000
200000
209000
85.50
51.38
0.00
136.88
--- I I iA. J" 4...J'-e~. '\
~/'\ -t..-.... J-i
Banquet
Mechanicsburg
61 Gettysburg Pike
t~echanicsburg, PA 17055
717--697-2214
W~M . hosss. corn
6/8/2006
Server: Ashley A.
LheCK 10 11 b~
Seat 1
1 Adult Salad Bar
Decaf Coffee
Sen i or 10%
Seat 1
1 : 46 : 02 PM
laD 1 e lUG
5.99
1.29
- 0.73
total: [ 6.94]
Seat 2
1 Salad Bar w/Sand 5.99
1/3 Pound Burg Sal 0.99
Add Provolone 0.29
Add Bacon 0.49
Sierra Mist 1.59
Seat 2 tota I : [ 9.91]
Seat 3
1 Adult Salad Bar 5.99
Pepsi 1.59
Seat 3 total:[ 8.03]
Seat 4
1 Adult Salad Bar 5.98
Sierra Mist 1.59
Seat 4 totol:[ 8.03]
Seat 5
1 Adult salad Bar 5.89
Pepsi 1.59
Seat 5 tota 1:[ 8.03]
Seat 6
1 Steak and Shrimp
Pepsi
Stat 6
14.99
1.59
total:[ 17.57]
Seat 7
1 Adult Salad 'Bar 5.99
Water
Sf<at 7 total:[ 6.35]
Seat 8
1 Crab Cake
~~ate r
Seat 8
Seat 9
1 Sirloin Tips
Hawa i i an Punch
Seat 9
Seat 10
10.99
total:[ ),1.65J
7.99
1.59
total: [ 10.15]
Seat 10
1 Pork Chop 8.99
Unsweetened Iced Tea 1.59
Seat 10 tota'l:[ 11.21]
Seat 11
1 Ham Steak Reg.
Pepsi
Seat 11
Seat 12
1 Sirloin Tips
Diet Pepsi
Senior 10%
Seat 12
Seat 13
1 Shrimp (br!scampi)
Pepsi
Senior 10%
_Seat 13
Seat 14
1 Chicken Filet
Raspberry Tea
Seat 14
Seat 15
1 Chicken Filet Reg.
Mt. Dew
Seat 15
10.99
1.59
total:[ 13.33]
7.99
1. 59
- 0.96
total: [ 9.14]
10.99
1.59
- 1.26
total:[ 12.00J
7.99
1. 59
total:[ 10.15]
10.98
1.59
total:[ 13.33]
Seat 16
1 Chicken Filet 7.98
Unsweetened Iced Tea 1.59
Seat 16 total:[ 10.15]
Seat 17
1 Flat Iron Steak 11.99
Sweetened Iced Tea 1.59
Seat 17 total:[ 14.39]
Seat 18
1 Sirloin Tips
Pepsi
Seat 18
Seat 19
1 Ground Beef
Raspberry Tea
Seat 19
7.99
1.59
total:[ 10.15]
7.89
1.59
tota 1: [ 10 .15]
Seat 20
1 Chicken Filet Sandwich
Diet Pepsi
Seat 20
5.48
0.99
tota1:[ 6.87]
Seat 21
1 Salad Bar w/Sand 5.99
Chicken Fi let Sal1.49
, Unsweetened Iced Tea 1,59
Seat 21 total:[ 9.61]
I HUU I L ~d I dLl Oct r
Unsweetened Iced Tea
Senior 10%
Seat 22
~l. ~j
1.59
-- 0.76
total: [ 7.23]
Seat 23
1 Chicken Filet
Decaf Coffee
Senior 10%
Seat 23
7.99
1.29
- 0.93
total:[ 8.85]
Seat 24
1 Adult Salad Bar
Unsweetened Iced Tea
Senior 10%
Seat 24 total:[
5.99
1.59
- 0.76
7.23]
Seat 25
1 Filet Mignon 15.99
Unsweetened Iced Tea 1.59
1 Mushrooms 99 cent 0.99
Seat 25 total:[ 19.68]
Seat 26
1 Adult Salad Bar
Unsweetened Iced Tea
Sen i or 10%
Seat 26 total:[
5.99
1.59
- 0.76
7.23]
Seat 27
1 F i let Mignon 15 . 89
Unsweetened Iced Tea 1.58
1 Mushrooms 99 cent 0.99
Seat 27 total:[ 19.68]
Seat 28
1 Tips-Smothered BBQ 10.98
Unsweetened Iced Tea 1.59
Seat 28 total: [ 13.33]
Seat 29
1 Kid's Cheeseburger
Sierra Mist
Seat 29
3.99
0.99
total:!: 5.28]
I! Seat 30
I 1 Kid's Pizza
. Sierra Mist
I( Seat 30
3.99
0.99
total: [ 5.28]
Seat 31
1 Salad Bar w/Sand
1/3 Pound Burg Sal
Add Ame ri can
Unsweetened Iced Tea
Seat 31 total:[
5.99
0.99
0.29
1.59
9.39]
Seat 32
1 T i ps-Smothe red BBQ 10.99
Unsweetened Iced Tea 1.59
Seat 32 total:[ 13.33]
Seat 33
. 1 Adult Salad Bar
Sweetened Iced Tea
5.99
1.59
1 Adult Salad Bar 5.99
Sweetened Iced Tea 1.59
Seat 33 tota 1 : [ 8.03]
Seat 34
1 Adult Salad Bar
Sweetened Iced Tea
Seat 34 tota I : [
Seat 35
1 Sirloin T1PS
Water
Seat 35
5.99
1.59
8.03]
7.99
total:[ 8.47]
Seat 36
1 Little Hoss
Mt. Dew
Seat 36
8.99
1.59
total: [ 11.21]
Seat 37
1 Chicken Filet 7.99
Water
Seat 37 total:[ 8.47]
II
J
! 'I
I I
i'
I
Seat 38
1 Stuffed Steak
Sierra Mist
Seat 38
8.99
1.59
total:[ 11.21]
SubTotal
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Gratuity
lotal
Cash
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Seat 20
1 Chicken Filet Sandwich
Diet Pepsi
Seat 20
367.14
22.03
58.37
441.04
447.54
5.49
0.99
total:[ 6.87]
Seat 21
1 Sa lad Bar w/Sand p. 99
Chicken Fi let Sal 1.49
Unsweetened Iced Tea 1 .59
Seat 21 total:[ 9.61J
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