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Home My WebLink About08-28-06 REV-1S00 E\ 16-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 LU I- :.::~(/) <.)D::: :.:: UJ Q.. <.) :1:00 <.)0::: ...J Q..lD Q.. <t FILE NUMBER INHERITANCE TAX RETURN RESIDENT DECEDENT -2 L - Jl.. ~ 0-1 ----1l -.lL _ _ COUNTY CODE YEAR NUMBER t- :z: w c w <..) w o DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) Hiller, William A. DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) 02-10-2006 02-25-1921 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (lAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER 124 - 12 5801 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER KJ 1. Original Return o 4. Limited Estate [] 6. Decedent Died Testate (Attach copy of Will) o 9. Litigation Proceeds Received o 2. Supplemental Return o 4a. Future Interest Compromise (date of death after 12.12.821 o 7. Decedent Maintained a Living Trust (Attach copy ofTrust) o 10. Spousal Poverty Credit (date of death betveen 12.31.91 and 1.1.951 o 3. Remainder Return (date of death prior to 12.1).82) o 5. Federal Estate Tax Return Required ~ 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (Attach SchO) I- Z LU o Z o Q.. If) LU D::: 0::: o l) THIS SEGTIONMUSTBE COMPLETED,_ ALL CORRESPONDENCE ANOCONFIDEN-rIAl.tAJ( INFORI\IIATIONSHOUL.D ~E'OIRECTEPTO:" NAME COMPLETE MAILING ADDRESS Randall K. Miller FIRM NAME (If Applicable) 1255 S. Market Street Suite 102 Elizabethtown, p~ 17022 TELEPHONE NUMBER 717-361-8524 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) (1) (2) (3) (4) (5) 0.00 0.00 0.00 0.00 53,904.92 0.00 ,...... -.,...,,-.... .,.,~,...._.,'''''- c.~1:F;C-~,1\L t,l~?J:.: C!NL'Y 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) z: o ~ --I ::;:) !::: D.. <C <..> u.J c:::: 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) (7) (6) 0.00 (9) (10) (8) 4,528.77 71.69 53,904.9~2 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) (11) 4,600.46 (12) 49,304.46 (13) 0.00 (14) 49,304.46 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z: o ~ ~ ::;) D.. :!: o (.) x: ~ 15. Amount of Line 14 taxable at the spousal tax 0.00 0.00 rate, or transfers under Sec. 9116 (a)(1.2) x.O_ (15) 16. Amount of Line 14 taxable at lineal nate 49,304.46 x .O~ (16) 2,218.70 17. Amount of Line 14 taxable at sibling rate 0.00 x .12 (17) 0.00 18. Amount of Line 14 taxable at collateral rate 0.00 x .15 (18) 0.00 19. Tax Due (19) 2,218.70 CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 20.0 . , t'; :::o:;':,"J~~;t\..'" '.~1;;c',>:~?:'BE~U~ T9'AtiSv\IE~Atlr9UE$IIO~~:Q~~~E~R$~'~fD~;4t110 JiEC.IiE~>>l:(f~~:J~t~;<Cil\:~f.\1~;t~l?i'h:'f~~~,t~~~~~,t~~~ r Decedent's Complete Address: I STREET ADIlRESS Beth any Vi lii;g e 325 Wesley Drive CIIY . MechanlCsburq Tax Palyments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount I STATE ! PA (1) I ZlP17050 2,218.70 1,500.00 78.95 Total Credits ( A -+ B -+ C ) (2) 1,578.95 3. Interest/Penalty if applicable D.lnt'erest E. Penalty ToIallnterestiPenalty ( D -+ E ) (3) 4. If Lint! 2 is greater than Line 1 -+ Lioo 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Une 20 to request a refund (4) 0.00 5. If Linl! 1 + Lioo 3 is greater than Lioo 2, enter the difference. This is the TAX DUE. (51 639.75 A. Enter the interest on the tax due. (SA) S. Enter the total of Lioo 5 + SA. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT 639.75 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X. IN THE APPROPRIATE BLOCKS No ~ g; L8l !SJ 1. Did decedent make a transfer and: Yes a. retain the use or income of the properly transferred;.......................................................................................... D b. retain the right to designate who shall use the property transferred or its income;............................................ D c. retain a reversionary interest or.......................................................................................................................... D d. receive the promise for life of either payments, benefits or rae? ......m.....m..................................mmm...m.... 0 2. If death occurred after December 12, 1982, did decedent transfer property wiIhin one year of death without receiving adequate consideration? ...........m..................m......................................m.................................. D 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ...........m 0 4. Did decedent own an Individual RelirementAa:ount annuity, or other non-probate property which contains a beneficiary designation? ........................................................................m............................................. 0 El JSl ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPlETE SCHEDULE G AND ALE IT AS PART OF THE RETURN. Under penallies of peljury. I declare thai I have examined !his return. inciuding acrompanying sdIedules and sIaIemmls, and 1D l!le !Jest Ii my lu-'edge aOO beliei, it is Iir"", wrred and wrnpleIe, Declaration of preparer ather than the personal represer;lalNe is based 00 all information at whidl prepare.. has amy k~. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS DATE . 7-<2/7- (}'~ ~_._-,-'"._~--~~-- SIG~~t1R Orzq~~AT:~____________, ADDRESS 1255 S. Market Street, Suite 1~ Elizabethtown, PA 17022 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net vakle of lransfers to or fur \he use of the surviving spouse is 3% [72 P.S. ~9i116 (a) (1.1) (i)l 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 sUTvMng spouse is 0% [72 P.S. ~9116 (a) (1.1) (u}l. The slalub~ does not exemot a transfer to a surviving spouse from tax, and the sta1u!Dly requirements for disclosure of assets and ling a tax re1um are sliI applicable even if the sUlViving 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~e years of age or younger at death ID or fl: or a stepparent of the child is 0% [72 P.S. ~9116(a)(1.2)1. The tax rate imposed on the net value of transfers to or for the use of the decedenrs liooal beooficiaries is 4.5%, except as ooted The tax rate imposed on the oot value of transfers ID or for the use of the decedent's siblings is 12% [72 P.S. ~9116(al(1.3)] individual who has at least one parent in common with the decedent, whether by blood or adoption. . -) fpu -Cf 1 ! 7, C 'I~] ,r \ ~ "'_) l \........._J 11, an (\ C"') C'I") .... 1./ COMMmJWEAl TH 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 HILLER GARY 75 ROOSEVELT BLVD LANCASTER, PA 17601 _n_~~__ fold ESTATE INFORMATION: SSN: 124-12-5801 FILE NUMBER: 2106-0188 DECEDENT NAME: HILLER WILLIAM A DATE OF PAYMENT: 05/05/2006 POSTMARK DATE: 05/05/2006 COUNTY: CUMBERLAND DATE OF DEATH: 02/10/2006 NO. CD 006663 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $1,500.00 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: GARY HILLER CHECK# 0084 SEAL INITIALS: CM RECEIVED BY: TAXPAYER $1,500.00 GLENDA FARNER STRASBAUGH REGISTER OF WILLS __B-_ . COMMONWEALTH OFPENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY . ESTA'rE OF William A. Hiller FU.E NUMBER 21-06-0188 Include 1he proceeds of litigation and 1he date 1he proceeds were received by the eslale. All propeIfJ joinUy.owned with iIte right ofSUlVivOlShip must be disdosed on Schedule F mEM VAlUE AT DATE NUMBER DESCRIPTION OF DEATH 11. Bethany Village Retirement Center 325 Wesley Drive, Mechanicsburg, PA 47,040.00 2. PNC Bank checking Acct# 5140028884 4,876.07 '::' -' . Capital Blue Cross refund 115.60 4. Verizon refund 2.16 :; . Asbury Services, Inc. 4 Affiliates refund 1,839.09 6. Farmer's Mutual Insurance refund 32.00 TOTAL: 53,904.92 Bethany Villa 325 Wesley Dr (717) 591-8 e-mail: ww ement Center lrg, PA 17055 7) 766-0870 July 14,2006 Randall K. Miller Attorney at Law 1255 South Market Street, Suite 102 Elizabethtown, P A 17022 Dear Mr. Miller, I apologize for the delay in getting back to you with the information you had requested. The exact amount of the refund would be $47,040.00. This apartment has not been place behind other units in our marketing efforts. I am about to make that apartment our "Model" apartment with the hopes that it may speed up the process of finding an interested party for that particular apartment. Often times the "Model" apartment is the first to sell due to being set up and decorated attractively. The refund is issued upon us receiving an entrance fee from a new resident for that apartment. If you would like a copy of the Residency Agreement that explains the process I would be more than happy to send that to you. Sincerely, ~/i/~ i ./ I ( . !~>)AF!/J:___i/ /~: 'l-/75!'1- \ i t"V!~J . { ,/ -- / - Ii t.../ \ f _.- i' /i Stephanie Lightfoot v Director of Sales and Marketing. .--- -. '\ //-\.~\ 1:1.F. /~ ~f:~:EDlTATlON } PROGRAM @ eQUAL HOUSING OPPORTUNITY An Equal Opportunity Employer. An Equal Housing Opportunity Facility An Extended Afinistrv n{ H;;',~lpv A {f'j lintpr! ,\;prv;N'< Inr EFORM100472-0900 o PN'CBAN< Your account was DEBITED for the following reason: o Check"# posted on !XI Closed account 5J.40028884 o Branch adjustment (branch name) o Service charge error o Other: :J THE ESTATE OF WILLIAM A HILLER E C/O GARY HILLER B C/O GARY HILLER + 75 ROOSEVELT BLVD I LANCASTER, PA 17601-4039 encoding error _ posted to incorrect account Account Number File 10 AMOUNT $ 4,876.07 5140028884 040 0000106 PNC Bank, National Association FOR BANK USE ONLY / Date / 03/01/2006 of Charge Branch #/Dept. # Prepared By (PRINT Name) LAVONYA STILO + Capital BlucCross CHECK NUMBER: 30008651 ~ GROUP / SUBGROUP 10: 00900001 - 03/06/06 WILLlAIII1AHILLER c/o THE ESTATE OF WILLIAM A HILLER 75 ROOSEVELT BOULEVARD LANCASTER, PA 17601 u.. Explanation Of Refund ...... Refund IReason: Subscriber Deceased-William A Hiller-800306387 Total Refund Amount: $115.60 Capita! A,dvantage insurance Company" and Keystone Health Plan" Central. lndeperdent !icen~.,ees of t!lf-; 81',;~' and provider relations aii NF-49 (5/2005) THIS IS W "I ~:I i" "':I~.::t III :1~,~::t:15 IIell ~ [e) .1He5:t;::t:.il rIl.'!'J III: [ell. III ~[e) III ~[e-llII: 1::tIt;: ,~, I~ I ~ I~ I ~.'I'NIII::t :11', "':1 ~_ej: I:(~:": ,~l-..~.:I ~'J=I:Hej ~(tl :rellWI CHECK NUMBER: 6~4 30008651 ~ + S~pital,~~~~"~,;~~~ ~ ";om. "';~ '"'"' or behalf Capita! BlueCrass, and Keystore Health Plar:" Central 03/06/06 Independent Licensees of the 81~e Cross and Blue Shield Asscciation P.A Y TO THE ORDER OF: VOID AFTER 180 DAYS WILLIAM A HILLER C/O THE ESTATE OF WILLIAM A HILLER 75 ROOSEVELT BLVD 32-01 LANCASTER PA 17601-4039 1...111...1.11'1111"'1.11.1..111.....11.1.1..1...1.1.1.1...11 CHECK AMOUNT: u..u..u....$115.60 Mellon Bank, N.A., Philadelphia, PA Payable Through Mellon Bank (DE) N.A. Wilmington,DE a~~ II- jOOOB I; 5 ~II- 1:0 j ~ ~OOO'" 71: 211'111; 7 !; j!;lI- Asbury Services, Inc. & Affiliates 3/23/2006 Estate of William Hiller No. 106201 INVOICE DATE REFID DESCRIPTION TOTAL AMOUNT DISCOUNT AMOUNT APPLIED 3/20/2006 426516 < None > 1839.09 0.00 1839.09 CHECK AMOUNT $1,839.09 TOTALS $1, 839.09 $0.00 $1,839.09 1'AC{TIoIjCHAlS137B29fl.leJl,I."'EF2-<l1 3.73QlX160818 10108201 SI,IJ3e09 Asbury Services, Inc. & Affiliates 201 Russell A venue Gaithersburg, MD 20877 Bank 01 America North Carolina No. 106201 DATE 3/23/2006 CHECK NO. 106201 66.798 531 NC AMOUNT $1,839.09 PAY OnEl Thousand Eight Hundred Thirty-Nine Dollars and 09/100 Cents VOID IF NOT CASHED IN 120 DAYS TO THE ORDER OF Estate of William Hiller c/o Gary Hiller 75 Roosevelt Blvd. LANCASTER P A 17601 ~(lUL- 11-0 J.o I; 20 J.II- 1:0 5 ~ J.o 7 ~a ~I: 000 ~Bo J. I; 5 1;0 ~II- ~. 51-44 . . lIer;*'n.... 119 ~ . NO. 5179250 COM~ISSION<REFUND ACCOUNT FEB2S, 2006 TWO. AND 16/100 *************************"'*********DOLLARS TO THE.ORDER OF PAY $*******2.16*.... WILLIAM<j. HILLER C...O<GARY ..HILLE}i. 75 ROOSEVELT..BLVD LANCASTERPA CB VERIZON .PA 17601 /1--1.. . ..... ... iJtd ~ ~ignature - ,'. '. - '-'" VHFC-VERlZONPENNSYlVANIA p;AY ABLE TH~OUGHBAHKOFAMERICA HARTFORD, .CDNN !"5 H<J2 5&"" "'{Cl',~ ~"lOOI, I, 5~ OOOOOOOb 71, "bU" fu ,----- FARMERS' MUTUAL INSURANCE COMPANY SUSQUEHANNA BANK 54219 60-912/313 4/21/2006 561'0rtl> Mukel Street . Post Office Box 221 E.iiL1bcthtown, PA 17022.0228 PAY TO THE ORDER OF ESTATE OF WILLIAM HILLER $ **32.00 Thirty-T\YoandOO/100************************************************************************************************** DOLLARS ESTATE OF WILLIAM HILLER C/O GARY HILLER 75 ROOSEVELT CIRCLE MINNETONKO MN 55345 5040 ~SA~ 6 il& -'" ~ .....,~ ~ _t,....,. - AUTHORIZED SIGNATURE MEMO RE\VRlTE OF CHECK #53688 II- 0 5 ~ 2 ~ Ii II- I: 0 ~ l ~ 0 Ii l 2 ~ I: ~ ~ 0 2 5 b ~ 5 0 1.11- FARMERS' MIlJTUAL INSURANCE COMPANY 54219 ESTA TE OF WILLIAM HILLER 4/21/2006 REFUND FROM CANCELLA nON OF POLICY HO 144644 32.00 145-00 Cash Checking-FF REWRITE OF CHECK #53688 32.00 REV-'1511 EX+ (12-99) _ .~~~. ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF William A. Hiller ALE NUMBER 21-06-0188 Debts of decedent must be reported on Schedule I. I1EM NUMBER A. DESCRIPTION AMOUNi 1. FUNERAL EXPENSES: Nissley Funeral Home, LTD 228 East Main Street Mount Joy, PA 17552 1,616.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representatille(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City Sta1e _ Zip Year(s) Commission Paid: 2. AttomeyFees Randall K. Miller 2,500.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach El)I!lIanation) Claimant Street Address City Stlle _Zip Relationship of Claimant to Decedent 4. ProbmeFees Cumberland County ROW 193.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 8 . .. 9. ITR tax filing fee Cumberland Law Journal The Sentinel - advertise estate 101.64 + 28.13 15.00 75.00 129.77 TOTAL (AI$) enteron line 9, Recapitulation) $ 4 ,528 .77 NISSLEY FUNERAL HOME,LTD. 228 EAST MAIN STREET MOUNT JOY, PENNSYLVANIA 17552 (717) 653-1151 ST A TEMENT MARCH 4, 2006 RE: WILLIAM A. HILLER, DECEASED PERSONAL AND PROFFESIONAL SERVICES DIRECT CREMA nON CERTIFIED COPIES OF THE DEATH CERTIFICATE CORONER'S OFFICE CHARGE STONE LETTERING OBITUARY NOTICE (HBG NIP) $ 995.00 395.00 36.00 25.00 125.00 40.00 BALANCE DUE $1,616.00 :-. !i ,j " ~~ERS I NO, 0080 L FIRST~lli A SUSQUEHANNA BANe 60-912/313 wwwJfb,com y - ;; tJ- () r:. 13 (J . . . ' " DATE ' to PAYTOTHE T. "AAIIl/VS.. / I' fL Jl7J/'!/J ~~~I .' , ORDEI3 OF~-L-~_-~n&~~---~-H-/7~-JA~--_---- .___.J $ // & / ~ i OJ __~'Vlltd~ /ltJ~Lz(i!z_l' ti 4.~-t_~____ _________ __________ ~OLLARS 6J f FOR ________ f t /<-"T1u /1'1/1/ \ "--./ C</;j /-tz.J!..1!y~, V M') EXECUTORI ~ ADMINISTRATOR M' ~ PERSONAL REPRESENTATIVE M' TRUSTEE ESTATEOF {Vil/IGln f1-/-/;/ler' I:Ojl.jOQI.2jl: 1000'5S~~91 RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17~13 HILLER WILLIAM A Estate File No. : Paid By Remarks: 2006-00188 MILLER RANDALL K MG Receipt Date: Receipt Time: Receipt No. : 3/01/2006 10:44:23 1043514 ------------------------ Receipt Distribution ------------------______ Fee/Tax Description PETITION LTRS TEST WILL SHORT CERTIFICATE JCP FEE AUTOMATION FEE Check# 7877 Total Received......... Payment Amount 135.00 15.00 28.00 10.00 5.00 ---------------- $193.00 $193.00 Payee Name CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN BUREAU OF RECEIPTS & CNTR M.D CUMBERLAND COUNTY GENERAL FUN CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, P A 17013 March 24, 2006 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: Randall K. Miller, ESQUIRE William A. Hiller, ESTATE RE: 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: March 10, 17, 24, 2006 Total Amount Due 75.00 $ 0.00 $ 0.00 $ 0.00 ------------- $ 75.00 Advertising Cost Proof of Publication Second Proof Request Payment received ---;;- I i I II """Ii,, j ( --:1 ~~II'~m\ A susaUEHANNA BANe /! ,r / www.ffb.com/DA TE ././ - ::/- {: (c' . /)l ; ,/'14 L,' , PAYTOTHE / './ L 0,~ I,,?)-, !i", '.' A ,'--::{ /. '/ .;--..1;0/ L J7/l / ORD~R of.6i{LI~.L''t..Y(/f:{ l(C,,,"-- .j I U~~.L&."'~L.LLL~~--~-----.. / ' /, ~/ l"=::~_lLLSj- - :::;(",--'lLLc'. _~__---=~_.. ----~n _._nn__~__n' DOLLARS ID / f ESTATEOF u)iJrr(tr)~ 4. r+-i/!c..r- NO. 0081 6(}-9121313 13 $ 75, (;'(/ FOR ~ t ell ;J Ii '. /~~:; t{lOS0 M') EXECUTOR! ~ ADMINISTRATOR M' ~ PERSONAL REPRESENTATIVE M' TRUSTEE 1:0 ~ . ~o g . 2 ~I: J 000 1552... C;;q / 9landall J{. Mif&t ATTORNEY AT LAW 1255 South Market Street, Suite 102 Elizabethtown, Pennsylvania 17022 (717) 361-8524 - FAX (717) 361-9071 March 6, 2006 Jolene Anderson The Sentinel 457 E. North Street PO Box 130 Carlisle, P A 17013 RE: Estate Notice for William A. Hiller AD# 302734 Dear Jolene: Enclosed herewith is a check in the amount of$101.64 in payment of the remaining amount due for the Estate Notice referenced above. Kindly forward a receipt for payment made along with proof of publication to our office after the Estate has been published. Thank you for your kind attention to this matter. Very truly yours, "', i~i(C(2l r 1_( J' " ,- 1 \ / i ! I I '. Joanne M. Miller Legal Secretary to Randall K. Miller ,'C il I' i I - -;-;--h;1 WARMERS I L FIRST~[K{ NO, 0079 A SUSQUEHA.NNA BANe www.ffb.com ::L (/- /'! C: DATE ,-j c/ > 60-912/313 13 PAY TO THE lilL !> J ,1 -{ _' ,,{ ~.~?~~,O~___j _/~~~':!--~:~1~~:-;~//----Z;-~ 47,--,----~------==_~--- _, i 1/ ~_j2{l__I\.(J;:.t-6{L f/~_{ J, f-0 Ikcl """--~~. - - . - .. - -'--'-'--~-----'--~'~"------"'~------~--"-'-~---- $ I '" . _ - L! It /9(( t __ DOLLARS 6J 1:031. 301:1 I. 231: ~ { 1000'55';( <2>9 \ Il,lJ/) Uci} /~ M') EXECUTOR! ~ ADMINISTRATOR M' ~ PERSONAL REPRESENTATIVE M' TRUSTEE ESTATE OF I Ii -Ift>l _ {-; 'I" I vC-( l(fll n'/-ller FOR ___________________________ ---------- 9landaft J{. ~ ATTORNEY AT LAW 1255 South Market Street, Suite 102 Elizabethtown, Pennsylvania 17022 (717) 361-8524 - FAX (717) 361-9071 March 6, 2006 Jolene Anderson The Sentinel 457 E. North Street PO Box 130 Carlisle, P A 17013 RE: Estate Notice for William A. Hiller AD# 302734 Dear Ms. Anderson: Enclosed herewith is a check in the amount of $28.13 in payment of the Estate Notice referenced above. Kindly forward a receipt for payment made along with proof of publication to our office after the Estate has been published. Thank you for your kind attention to this matter. Very truly yours, . '~~l ,. ILG~)}I.f)2?dU i - Joanne M. MIller Legal Secretary to Randall K. Miller - ,$l.w-;,.....-:-.:;"".,::"~~-:",;!.!..;"~--:~---,,. .~?7ill~:; CUll! " .'I I ::. t',' -I, II .. ~ ,1 1- II i 1 rFARMERS I L FIRST~lli A SUSQUEHANNA BANe www.ffb.com NO. 0078 -'I 7 ~ ~/' I ~ PAY TO THE. 'I /1} " \V'/,'/ /)'" if "..1 L 1/ __~ __ _~ $ ,1,. g: / 3 O'~ER OF ~'-~---;7~~ ~7J; v ~ - - /-: / J-};:- ~..,,--~ _.______ v ,J~'-C~~-<~d {daLA I~O:__~ ~~.~tlli-- __..DOLLARS ~ ESTATE OF L lj'ill d -11 N. Ii .1 Ie ,- ( L/6Z./~ /-fv~ M' t ~6~19~IW~~TOR '. , -<I- '7 M' ~ PERSONAL FOR ~~2dc.."-"-L~l!_.J:21-,,-w J. ,,:. j __~_~__ ) REPRESENTATIVE ~ M' TRUSTEE I:O~ .~Og. 2~1: 1000 155~C091 :; / -{J / DATE \.)-~j(P 60-912/313 13 REV-15'12 EX+ 11-93} SCHEDULE i DEBTS OF DECEDENT, MORTGAGE LIABILITIES AND LIENS COMMONWEAlJH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT EST.aJE OF William A. Hiller Please Print or Type FilE NUMBER 21-06-0188 AMOUNT l'rEM I DESCRIPTION NU~1 1. Holy Spiri t Hospital 12.00 2. Conner Rich Associates 3. Bonnie K. Miller, Treasurer personal tax TnTA' IA'<e,.. 4............ _.. 1:....& 1n D__....:...I_..:--' Ll,9.89 9.80 I /.. ...,., en BHOLY ~IWJ: The Spirit of Caring Holy Spirit Hospital 503 N 21ST STREET CAMP HILL PA 17011 # 717-763-2138 For Account Information, Please CalI717-763-2138 $- Statement of Account 06/16/06 11/011'05 Description PREVIOUS BALANCE HGB AND HCT Amount Transaction Date .00 .00 ;, I I FARMERS I FIRST~m NO. 0085 U ill ESTATE OF GU 1'1 J ((1: 11)1 fl HI'/I-Pr M>) EXECUTOR! ~ ADMINISTRATOR M> ~ PERSONAL REPRESENTATIVE M> TRUSTEE FOR __~__~_______ 1:0 ~ . ~O Ii . 2 ~I: I CoO I Estimated Insurance Due: .UU Total PatIent l.:redIts: YOUR INSUF!ANCE HAS BEEN BILLED.THIS IS YOUR CURRENT BALANCE. YOUR PAYMENT IS DUE UPON RECEIPT. THANK YOU. B09 361 .00 PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID. Account nlllance: .L....uu ___________________________________________________________________~~~_~~~~~~~~~~_f"Y_me~______________________________________________________________ For Hospital Use Only Account Number: 26577064 HILLER ,WILLIAM A O~ 011] Card Number: o HOLY SPIRIT HOSPITAL 503 N 2~ST STREET CAMP HILL PA 17011 # ADM DT: 110105 DSH DT: "NONE" SB: 21022 717-766-0279 Patient Name: ADDRESS SERVICE REQUESTED HR: 285.9 HSG Signature: o Check box if ~ address or insurance inl'ormation has changecl. Please make changes on back. Make Check Payable To HOLY SPIRIT HOSPITAL . The C\<"V2 Number is the last 3 digits on the back of your credit card, by your signature /d'CO 00008485 01 001 1...111.1111..111..1...1.1..1.11..111..1...11.1..1...11..1..11 HOLY SPIRIT HOSPITAL P.O. BOX 822183 PHILADELPHIA,PA 19182-2183 26577064 WILLIAM A HILLER 5225 WILSON LN HECHANICSBURG PA 17055-6663 0000265770640010000000120000100735000000011308 \_/;~~Heritage Medical Group, LLP ,.-", CONNER RICH ASSOCIATES 207 House Avenue Suite 101 Camp Hill, PA 17011 ~~j Cheok C"" ",.d ond F;n in ."ow to .oy by c",d;t CO.... VISA 6;:,c\.; 0 MasterCard 0 Visa I card Number Amount Signature Exp, Date Statement Date Pay This Amount Account # 04/07/06 $49.89 297944 Payment Due Date SHOW AMOUNT $ +7, >}<j 04/28/06 PAID HERE 1...111...111"1.1.1..1.1...11..1.1....11...111.1..1.1...1..11 000;;;"********** 3-DIGIT 170 WILLIAM A HILLER 325 WESLEY DR MECHANICSBURG PA 17055-3511 CONNER RICH ASSOCIATES PO Box 12942 Philadelphia PA 19101-0942 [J Please check If address or Insurance information IS Incorrect and complete form on back. PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT Account #: 297944 Please Pay: $49.89 i III (II Ii II d <' ( /I II,' (' TJ t h--,I" ,- ,I,'! ,I I Due Date: 04/28/06 Insurance Patient Charges Balance Balance 65.00 65.00 0.00 0.00 0.00 -15.11 0.00 0.00 0.00 -49.89 49.89 0.00 0.00 .00 49.89 I NO 0083 Date WILLIAM A HILLER ID# 297944/JAMES R HARTY MD 01/25/2006 OFFICE / OUTPATIENT VISIT ESTABLISHED PATIENT EXP PROBL 02/22/2006 PAYMENT FROM MEDICARE 03/07/2006 SYSTEM CONTRACTUAL ADJUSTMENT FROM MEDICARE 03/07/2006 PAYMENT FROM MEDICARE 04/03/2006 PATIENT RESPONSIBILITY 03/29/2006 PAYMENT FROM CAPITAL BLUE CROSS BALANCE TICKET #BVC001813 I FARMERS I FIRST~[K{ A SUSQUEHANNA BANe , / 60-912/313 PAY TO THE L .::c/o~ ., S /~~ l I' ~~) 1 ,J /! ,I' / /1 J.... / J' DATE~:/! -dO $~L~.l:--'-J ,I:'.~j 13 O/~ OF~ -'-~-~"-~~~,-~~~u-,i_JJ:'-li-~_,___ -~ _ _ _ -7';, kef '~L"~-:_/)L{lU:>'jaaLLLQ /j/c}u_____ __ _ ',. DOLLARS ~ ~::A:EOF_0dll~O~~~HI/~~~=- ~ ~, ~ ~? ~ :) 1:0:' ~ :.o~ ~ 2 :'1: 1000/55:1. IMPORTANT MESSAGE. ABOUT YOUR ACCOUNT PROMPT PAYMENT WOULD BE GREATLY APPRECIATED. Total Balance -Insurance Pending Amount Due 49.89 .00 49.89 Make Checks; Payable To: CONNER RICH ASSOCIATES For Billing Questions Call (717)-7618331 PLEASE DO NOT SEND CASH THROUGH THE MAIL E(:d521-32 PAGE 1 OF 1 4043 ** TAXPAYER COPY ** BILL DATE 3/01/2006 BILL NO 4043 BONNIE K. MILLER. TREASURER 1993 HUMMEL AVENUE CAMP HILL. PA 17011-5938 JOB TITLE FULLY RETI RED CTL 13 2118 2006 PERSONAL TAX NOTICE COUNTY OF CUMBERLAND TOWNSHIP OF LOWER ALLEN UNPAID TAXES SUBMITTED TO DELINQUENT COLL 11/30106 VALUE O. 1~~"LLI~~l?~:oi~Bm1H~~:;J.'"U!L~1.?J1z~TIEik~~i CNTY PIC MUN PIC 5.00000 5.00000 4.90 4.90 5.00 5.00 5.50 5.50 HILLER WILLIAM A 325 WESLEY DRIVE #106 CAMP HILL PA 17011 ~~~~:J~=-""3' .. 9.8Om.---- CNTY pic 2.0% 10.0% DISCOUNT MUN piC 2.0% 10.0% 3/01/2006 TO 4/30/2006 10.00 FACE 5/01/2006 TO 6/30/2006 11.00 PENALTY AFTER 6/30/200E MON,TUES & THURS 9-4 OR BY APPT CLOSED WEDNESDAYS. FRIDAYS & HOLIDAYS PHONE (717) 975-7575 EXT 1701 DEADLINE TO APPEAL OR CHANGE JOB TITLE IS 90 DAYS FROM BILL DATE 240-6365 OR 697-0371 EXT 6365 OR 532-7286 EXT 6365 S (' l Ii! If I' II Ii il ( .J /. d { IFARflI.~[d A SUSQUEHANNA BANe www.ffb.com NO. 0082 ~I /(1 :J -t/! (.'-' 1 "-- __, DATE ~ v; . I.j.. /) '~( / I'!'~' r," ,;;7, ' /-, _ PAYTOTHE 1<A.J''-'1J, ,! k . l, t}{ !) /~ !~l. 1 '( ~ ,~l... $ C( i/' ORDER OF_~U jL-l~~ \ .! J /11....--:... ! ~j (.lA/,- \L_i_',-_t.L~___ i' ,j C 1(1lU / ,j)" :dc' 6l;/ it;(; c _:==~---:~=--~-:==~~-----:___--~~-LLAR s Iil ESTATE OF ).) t' 'i l' {l 1'1(1 ~ '/~1/ I j lie',. V"" ~ / '77./1 - j' / ./ I~ ~ l)J V I ! \ r U (.{.?'V" ~ AI' EXECUTOR' ADMINISTRATOR ?"l) ( /. ) <)1 ,/( .t;i ,/., ,/ AI' ( PERSONAL ~OR.~~ ___L ~_~~~,. _ \. ~_____ _===~ { AI') ~:::~::NTATIVE 60-912/313 13 1:0 ~ . ~O ~ . 2 ~I: JOOO/55:t S"CII COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX AEnJRN RESIDENT OECEDENT SCHEDULE J BENEFICIARIES = ES1ATE OF William A. Hiller FILE NUMBER 21-06-0188 NU RElATIONSHIP TO DECEDENT AMOUNT OR SHARE IMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not UstTrustee(s) OF ESTAlE I TAXABLE DISTRIBUTIONS [mdude outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)} 1. Gary Hiller 75 Roosevelt Boulevard Lancaster, PA 17601 Son 50% 2. Thomas Hiller 606 Mallard Road Camp Hill, PA 17011 Son 50% 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 aECTION 10 TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. = TOTAL OF PART n - ENTER TOTAl NON-TAXAB1.E DISTRIBUTIONS ON UNE 13 OF REV-1500 COVER SHEET $ 11f__:-_~'" ~-_....... -......... .. - -- 1Easl Dill aub W~slam~ul I, WILLIAM A. HILLER, Lower Allen Township, CUmberland County, Pennsylvania being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament, hereby revoking all other Wills and Codicils heretofore made by me. ARTICLE I. I direct the payment of all my just debts and the expenses of my last illness and funeral from my Estate as soon after my death as conveniently may be done. I authorize my Executor to expend funds from my Estate for the purchase, erection and inscription for a suitable gravemarker. All the foregoing shall be considered expenses of the administration of my Estate. All transfer, succession and other death taxes which shall become payable by reason of my death in respect of property owned by me and passing under this Will shall be paid from my residuary estate as a part of the cost of the administration of my Estate. ARTICLE II. I give and bequeath unto my sons, GARY HILLER, Dover, Pennsylvania and THOMAS HILLER, West Fairview, Pennsylvania, if both survive me, all of my household goods, my automobile, and other tangible personalty of like nature (not including cash or securities), together with any insurance thereon, in equal shares, to be divided between them as they shall agree, and in the event of disagreement as to any item, such item shall pass as a part of my residuary estate. ARTICLE III. All the rest, residue and remainder of my Estate, of whatever nature and wherever situate, I give, devise and bequeath unto my sons, GARY HILLER and THOiV1AS HILLER, share and share alike, provided that should either of my sons pr1edecease me, I direct that such deceased son's share shall pass to his issue per stiirpes by representation. ARTICLE IV. I appoint CCNB Bank, N.A., Camp Hill, Pennsylvania, guardian of any property which passes, either under this Will or otherwise, to a minor and with respect to which I am authorized to appoint a guardian and have not otherwise specifically done so, provided that this appointment of a guardian shall not supersede the right of any fiduciary in its discretion to distribute a share wherever possible to the minor or to another for the minor's benefit. Such guardian shall have the power to use principal and well as income from time to time for the minor's support and education (including college education, both graduate and undergraduate) without regard to his or her parent's ability to provide for such support and education, or to make payment for these purposes without further responsibility to the minor or the minor's parent or to any person taking care of the minor. ARTICLE V. I name, constitute and appoint my son, GARY HILLER, Executor of this my Last Will and Testament. Should he fail to qualify or cease to so act, I name, constitute and appoint my son, THONIAS HILLER, Alternate Executor to complete administration of my Estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal, this da.y of. .-, , 1986. . .j7:/ /4;' William A. Hiller Signed, sealed, published and declared by the above-named Testator, as and for his Last Will and Testament, in the presence of us, who at his request, in his pr,esence and in the presence of each other, have hereunto subscribed our names as witnesses. /',/ , .~. ,.' I ,. f, of/.F: . t,":' f -: / J -,' I ;( /i:.:~t>c.,[..' )2~ f ,_OJ; C t ~ /" "f-t'I:./~ ,--<_.._. (SEAL) /fi~ ~:'-\t ',~ "' ,. .f'....." -r ". . ,I, /; , 1 '.,/-V' Y.!';''< " .--........ ~- -...,.... :,..... t,<""- -\ \.. ../. 7) . 7... / i / l.{./L l....t ,r' ';'1 /',,/ ACKNOWLEDGl'.iENT COMMONWEALTH OF PENNSYLVANIA ss: COUNTY OF CUMBERLAND I, WILLIAM A. HILLER, whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. ,/1//;," _ /. .//~./1 //~,~t-t.~~j., .;-,.~ i-{ ~ ' n.L---t.:t- i William A. Hiller Sworn or affirmed to and acknowledged before me,by WILLIAMA. HILLER;. this ".\ \ day of f" '. , 1986. "<:::::::-:._t../.",_ . _. "',..:'-, )' ....<. ' Notary';Public') DIANNE LENIG. NOTARY PUBLIC My Com"lission Expires Dl!cember 21. 1989 l.tmoyne, Pill Cumbtrland County AFFIDAVIT COl\IlVIONWEALTH OF PENNSYLVANIA ss: COUNTY OF CUMBERLAND We, and, the witnesses whose names are signed to the foregoing instrument, being duly' qualified according Ito law, do depose and say that we were present and saw the Testator sign and lexecute the foregoing instrument as his Last Will and Testament; that he signed I I 1 willingly and that he executed it as his free and voluntary act for the purposes I therein expressed; that each of us in the hearing and sight of the Testator signed I Ithe Will as witnesses; and that to the best of our knowledge, the Testator was at Ithat time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. '~ /; ../.>/j tflt? -:,? ~JI~ V\_ ,_ (., \.~ . /_ ,_4 T /7; /( // .'.""i' ///I~(b /.4' //" -- Y,)' ;' 'dvti .-/..... r 1..:" ';'.I/-f.:. "'r..;:~~ _~ r Sworn or affirmed to and subscribed to before me by and _,_ . __ , witnesses, this ..,\ day of 1 B86. '~".'.,..\.. Notary' ful:>lic f'H ~".'-: 1 DOG. NOT AR'{ PUBLIC .' - ." ~ " ',.',1"-' c.. "'I! sS9 ~.,'>,' : lefr,_:;;,!,r~~ u~ C ...;;;~ije'i;c~H} (odHi