HomeMy WebLinkAbout12-29-06
"
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15056051047
REV-1500 EX (06-05)
PA Department of Revenue .
Bureau of Individual Taxes
PO BOX 280601
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
County Code Year
File Number
Z/
()t;
00921
Date of Birth
/37/{'S//~
/()()$'2oafo
o '/-J. I / 9 / ~
Decedent's Last Name
Suffix
Decedent's First Name
MI
CLARI<
F L 0 I<EN c. E..
E'
(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::)
c:::>
4. Limited Estate
c::)
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
C=>
c::) 4a. Future Interest Compromise (date of
death after 12-12-82)
c::) 7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
c::) 10. Spousal Poverty Credit (date of death c::) 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
8. Total Number of Safe Deposit Boxes
C=>
LINbA
J NEUBAUM
7/1 ~52 /fc2/
Firm Name (If Applicable)
REGISTER OF WILLS USE ONLY
First line of address
If/Df
ELfV/E!<TDN
AVE
Second line of address
City or Post Office
State
ZIP Code
DATE FILED
HARRISBURG-
PA
/7/09
Correspondent's e-mail address:
/Jneubau~Aac(!. edu
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.
LE FOR FILING RETURN
I
DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056051047
15056051047
--.J
C-tJ
I "
--.J
15056052048
REV-1500 EX
Decedent's Name:
Decedent's Social Security Number
/ -3 7 / t,g// 6-
RECAPITULATION
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) . . . . . .
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.
8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8.
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)..... ... ... ...... ... ... ..... ....... 11.
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.
14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . . . . . . . 14.
TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES
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 tf~ble
at lineal rate X.O::t5
17. Amount of Line 14 taxable
at sibling rate X .12 .
18. Amount of Line 14 taxable
at collateral rate X .15 .
15.
16.
17.
18.
19. TAX DUE
. 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L
15056052048
.
/ / /22 .'l-tJ
.
5.
S.3 S / / 1 .s J
.
.
51f If, ;, 39 · 9.3
7 9 f i.59'
3S.,,0
g 0 71.0 9
SJ8/tS.SJj
SJ g /t,s.8'f
~ 1- ~/ 7. if to
.
c1.1 /{/ 7.Lffo
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15056052048
....J
.: 1>
REV-1500 EX Page 3
Decedent's Complete Address:
File Number c:2 / - tJ 6 - 0 09 Z ;/
DECEDENT'S NAME
Ff.-O/<.ENe E E. (il-AR.K
STREET ADDRESS I<OAh
g~Jf )..,/58 U~N
A pr :l~ r;,
Ce: I STATE f II I ZIP
'AfJljY III/...L 11C)j/
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
~
/2~ :2/1.410
l;,2,/P._gZ______
Total Credits ( A + 8 + C )
(2)
02/0,87
3. InteresUPenalty if applicable
D. Interest
E. Penalty
TotallnteresUPenalty ( D + E) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(5).$ ~3 rJo6.JJ9
"
A. Enter the interest on the tax due.
8. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5A)
(58) <1 2& tJ () t; , .~Fl
/
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;.......................................................................................... 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 care? ...................................................................... D ~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. D (gJ
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 181
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (3) percent [72 P.S. 99116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent
[72 P.S. 99116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. 99116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in
72 P.S. 99116(1.2) [72 P.S. ~9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
, ..
REV-1503 EX+ (6-98*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
F'Lo I<.. EN C E
E. CLAI<.K.
FILE NUMBER
,;t / - 0 (, - OcJ yat. 4-
All property jointly.owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
~.
DESCRIPTION
Se/L/ES .L 8rJ/'I)) - 5EI<./AL# ()tJOlt),f2 ?f'tJ9S
56e/E5 I f3rJNl> - SEI!./IJI--II-- otJ C2..tJd2. '8 () 9t
5Ej(/~S EE. ,BoN]) - SE/{//lL Ifl/g 9199~.6
VALUE AT DATE
OF DEATH
$ 5; tJ tJ () . tJZJ
..3.
.6; /)~tJ, (}P
~ /22. fo
TOTAL (Also enter on line 2, Recapitulation) $ II; /.:L:Z. 1-0
(If more space is needed. insert additional sheets of the same size)
FLORENCE E. CLARK
7 CITADEL DRIVE
CAMP HILL, PA
137-16-5115
Redemption Date:
10/30/2006
17011-
Transaction Number:
6113300073
Serial Number Series Denom Issue Issue Price Interest Earned Redemption
Date Value
002028095 I $5,000.00 11 / 2003 $5,000.00 $566.00 $5,566.00
002028096 I $5,000.00 11 / 2003 $5,000.00 $566.00 $5,566.00
43849945 EE $1,000.00 02/1992 $500.00 $622.40 $1,122.40
Total number of bonds redeemed: 3
Highland Park Office
344 South 10th Street
Lemoyne, PA 17043
(717) 737-3322
REV-1508 EX+ (6-98) ..
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
F2.-0.REAlCE:.. E. (! L-A ,e~
ITEM
NUMBER
J.
1/
:1-.
FILE NUMBER
eZ / - CJ ro - tJ 0921
Include the proceeds of litigation and the dale the proceeds were received by the estale.
All property jolntly-owned wfth right of survivorship must be disclosed on Schedule F.
/.
DESCRIPTION
IYl Em gEi<S 1ST rEbEA/JL (!ICE])/"T UN/fJN
StNe) ~tJU;5c. j)/(/VE/ I? O. bax 10
/IlE-CIfAA//csl3u.eG) 1/1 11/J3'S
l1(!eOU/\[T #: Z3S7J/1 (//V(!.)...tI..!>ES SAVINGS) (J..j) ':5 ~
/i1~NEY ftlItNAGE/Y)ENT - STATEIJ1ENT ,ATTA(!.IIEIJ)
My- T J3ftNK
f1.6. .Box 1~7
f3VFFI1)"O) Ny 11fJ.f-o--O 7& 7
/I eCOUNT # ()cJtJtJooo A.~ 'If 11f3tJb (CIIECKI/IIG-)
# ()tJ()O()O0 98/11 /;{'/ (5AV/NcrS)
#-()/StJO~;l.13o~/~/f9 (/Jlt',1/EY fr!}//(KET)
#03ItJ() 39/3?2 t/bJf/ {d.b.)
-lit) ?J/tftJ3?/J/f}135~,t (e.o.)
if-.tJ3/t703'l1 /f-f~J.j77f (c.];>)
i1=cJ:J I t'O 3PI /f6-? 99 7t. (C.l:>-)
/'i< {/})E/V 71/11- j:JL.LI.4NCE /jeC:OU.Af7 SEI< \[ IC {;S
j7. o. bt X' 1/15?.2-
fJlIll-/-)bELfJ/lIA /fJA /y/1&-
llet!rJUN T -# 1/35 /cJ() /~3 l1.!J-t~ (5AV/NG-5)
CtJ/N etJ~j..ECII()N (l1fJfJ,~.1l/5I/L 1}7T)/e)/t;~)
---_.__.~-,-_._."., ---'_..,._-,.~.~----_.__._.__._---"'.._-----
s.
h'
lY/iSCELI-,I}NEtJ!.IS !JE;;ZStJN;fL Pl<tJPEI<. TY
(lASI/
VALUE AT DATE
OF DEATH
$.1.~7 76,8.91--
)
J,Jf5; ,260./9
j(()) <g~?9. 29
I; t>o/. j-o
/6,.j-'tfV
~?'0/
(If more space IS needed, msert additional sheets of the same size)
TOTAL (Also enter on line 5, Recapitulation) $ 5'35; / I 1. S ~
Send Inquires to:
5000 Louise Drive
PO Box 40
Mechanicsburg, PA 17055
www,members1st.org
Main Switchboard: (717) 697-1161 or (800) 283-2328
EZ Call: (717) 697-4372 or (800) 283-4372
TOO: (717) 697-5312 or (800) 283-2328 exl. 5312
TeleBranch: (717) 795-6049 or (800) 237-7288
MEMBERS 1st
FEDERAL CREDIT UNION
--=
-
-
4440 1 AV 0.293 15421-4440
1,1111111,111"",11111,1111111,11111,11111",11,1,,1,11,1,1,1
FLORENCE E CLARK
824 LIS BURN RD APT 226
CAMP HILL PA 17011
-
-
Statement of Accounts
Jun 25, 2006 thru~~;;~
Account Number: 235747
Account Balances at
Checking:
Savings:
Certificates:
Loans:
Money
a Glance:
0.00
8,813.98
151,534.87
0.00
Management: 106-.!~JJL75
~.;"~ ';'::' .C" :',:';
Page: 1 of 4
Your current Member Loyalty Reward level is Titanium
Give us your email address and you could win a $100 VISA Gift Card! See the
enclosed insert for more details.
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SAVINGS ACCOUNTS
00 - REGULAR SAVINGS
Date Transaction Description
Jun 25 Balance Forward
Jun 30 Deposit Dividend 1.000%
Annual Percentage Yield Eamed 1.00(/% from 06/01/2006 through 06/30/2006
Jun 30 Withdrawal IRS Withholding FEDERAL
Jun 30 Deposit Transfer From Share 40
Jun 30 Deposit Transfer From Share 41
Jun 30 Deposit Transfer From Share 44
Jun 30 Deposit Transfer From Share 45
Jul 31 Deposit Dividend 1.000%
Annual Percentage Yield Eamed 1.00(/% from 01/01/.2006 through 01/31/20Dq
Jul 31 Withdrawal IRS Withholding FEDERA'i ~
Jul 31 Deposit Transfer From Share 40 :~
Jul 31 Deposit Transfer From Share 41 ~_"':'.:_l...'
Jul 31 Deposit Transfer From Share 44 ~:;
Jul 31 Deposit Transfer From Share 45 ~ ,~.t ~
Aug 31 Deposit Dividend 1. 000% ~ ..~_ .i' :~
Annual Percentage Yield Eamed 1.01(/% from OS!P1/2006 fh/pugh OS/31/20oq
Aug 31 Withdrawal IRS Withholding FED~RALjl ~
Aug 31 Deposit Transfer From Share 40 "~ - :1
Aug 31 Deposit Transfer From Share 41 ,,!
Aug 31 Deposit Transfer From Share 44
Aug 31 Deposit Transfer From
Sep 20 Deposit Transfer From
Sep 24 Ending Balance
05 - MONEY MANAGEMENT
} ~,~.;
Additions Subtractions Balance
8,221.69
6.76 8,228.45
1.89- 8,226.56
23,97 8,250.53
43.12 8,293,65
30.66 8,324,31
82.96 8,407.27
7.14 8,414.41
1.99- 8,412.42
24.77 8,437.19
44.55 8,481.74
31.68 8,513.42
89.55 8,602.97
7.31 8,610.28
2.04- 8,608.24
24.77 8,633.01
44.55 8,677.56
31.68 8,709.24
89.55 8,798.79
15.19 8,813.98
8,813.98
Date Transaction Description
Jun 25 Balance Forward
Jun 30 Deposit Dividend Tiered Rate
Annual Percentage Yield Eamed 2.5(}{J% from 06/01/2006 through 06/30/2006
Jun 30 Withdrawal IRS Withholding FEDERAL
Jun 30 Deposit Transfer From Share 43
Additions Subtractions Balance
105,720.46
214.63 105,935.09
60.09- 105,875.00
60.40 105,935.40
- - - Continued on following page - - -
1\"1
l\11Ef\.tBERS 15t
tf.lJEj( ,\ I. (;j:i Ji;mft'NIU:<
'1
\
.
Rossmoyne
5000 Louise Drive
Mechanicsburg PA 17055
Inquiries Call:
Acct XXXXXXX747
Eff: 10/27/06
T1r: 0443
717-795-5100
CLARK,FLORENCE E
Date: 10/27/06
Time: 2:19pm
Withdrw1 from
Prev Bal:
Amount:
New Bal:
Seq:
Withdrwl from
Prev Bal:
Maturity date:
Amount:
New Bal:
Seq:
Withdrwl from
Prev Bal:
Maturity date:
Amount:
New Bal:
Seq:
Withdrwl from
Prev Bal:
Maturity date:
Amount:
New Bal:
Seq:
Withdrwl from
Prev Bal:
Maturity date:
Amount:
New Bal:
Seq:
Withdrwl from
Prev Bal:
Maturity date:
Amount:
New Bal:
Seq:
Withdrwl from
Prev Bal:
Maturity date:
Amount:
New Bal:
Seq:
Depcsit to
Prev Bal:
Amount:
New Bal:
Seq:
MONEY MANAGEMENT 05
106,805.06
106,805.06
0.00
#676980
6 MONTH CERTIFICATE 40
11,432.88
03/21/07
11,432.88
0.00
#676981
6 MONTH CERTIFICATE 41
20,025.39
04/19/07
20,025.39
0.00
#676982
6 MONTH CERTIFICATE 43
30,076.08
02/05/07
30,076.08
0.00
#676983
18 MONTH CERTIFICATE
44
15,044.04
05/07/07
15,044.04
0.00
#676984
24 MONTH PRIME RATE
CERT 45
25,106.76
02/12/07
25,106.76
0.00
#676985
30 MONTH CERTIFICATE
46;
21,565.34
05/09/08
21,565.34
0.00
#676986
REGULAR SAVINGS 00
9,019.64
230,055.55
239,075.19
#676987
: ',drwl from 6 HONTH
'l'J Bal:
'';''d.:t:ri ty date:
: 'CD unt :
New Bal:
Seq:
Deposit to REGULAR
Prev Bal:
Amount:
New Bal:
Seq:
III]
fl;1 M&tB
STATEMENT PERIOD
/'" -"",
SEP.02-0CT.04,2006 )
, ,.,,"""
PAGE==:]
10F~
00 0 06113H NH 017
17009
FLORENCE E CLARK
824 LISBURN RD APT 226
CAMP HILL PA 17011
1/
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'J ,",
l" .'
f ;ii11' .t(~ ~
i l' f
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SELECTED "'ACCOUNT . SUMMARY .'.
ACCOUNT
TYPE
ACCOUNT
NUMBER
INTEREST EARNED
YEAR-TO-DATE
HATURITY
DATE
HIT SELECT WITH INTEREST~
HIT PREHIUH INTEREST
HIT HARKET ADVANTAGE
REGULAR TIHE DEPOSIT
REGULAR TIHE DEPOSIT
REGULAR TIHE DEPOSIT
REGULAR TIHE DEPOSIT
000000022874305)
0000000981111241
015004213061879v
031003913820641//
031003914573562,1
0310039144647791
031003914569876 V
3.87
39.75
1,568.03
700.52
591.41
1,303.71
632.98
02-08-07
04-18-07
06-26-07
03-19-07
TOTAL DEPOSITS
* INTEREST EARNED IS INCLUDED IN YOUR TIHE DEPOSIT ENDING BALANCE
ONLY IF IT HAS BEEN PAID TO YOUR ACCOUNT.
B~NlDAX:CGE lo/~.~ht~
..........:.......,-;"........'
6,586.96 </0:- ./0
1,106.42 l,'It' .... 'i<, ~
10l,568. 03rbn'l/ r;l
29,815 . 62lE0l~ i; (V 41
27,261. 05* ~'I' "!'!~ :"y' 'r
..,.. .....,. ....' ~. .;,;
52, 107 .46lE~ ;/;,i fil
28 477 59*"" ... r
, . ,;1"7 ';<:j!o 0' '"
.d,....."'.Jr l .cL
246,923.13
~-.,~:/~, H;";': ""Iii'
I~' T..,,'< (0), .7.
---___1 -'_'no . "..-'~
M&T SELECT WITH INTEREST
IA~~TI FLORENCE E CLARK
HIGHLAND PARK
ACCOUNT NO.
22874305
ACCOUNT SUMMARY
, "BEGINNING, OEpOsITs&. ",' ,.,OTHER' '.., . ','," · · CURRENT .:ENDING ",
, , 'aALANCE" "... . OTHER .ADOtTIONS ,. tHECKSI'AtD'" 'StJlTRACTtONS' · INTEftEST PD .......... ... 'BALANCE'
NO. I AHOUNT NO. I AHOUNT NO I AHOUNT
3,395.99 41 7,739. 18 141 4,378.40 5 I 170 06 0 .25 6,586 .96
POSTING " .'
DATE'.
· TRANSACTION DESCRIPTION "
ACTIVITY
OEPOSITS~ INTEREsT CHECKS & OTHER
10THERADDITIONS ."'. .StJaTRACTIONS"
09-02-06 BEGINNING BALANCE
09-06-06 CHECK NUHBER 3321
09-08-06 CHECK NUMBER 3322
09-08-06 CHECK NUHBER 3324
09-11-06 CHECK NUHBER 3319
09-12-06 WFCB CREDITCARD CHECK PYHT 000000000003323
09-12-06 CHECK NUHBER 3327
09-14-06 CHECK NUHBER 3326
09-14-06 SUNOCO SVC STATION HARRISBURG
40.00
160.67
30.84
50.00
84.41
40.00
2,610.00
37.02
".DAILY..
bALANCE
$3,395.99
3,355.99
3,164.48
3,114.48
2,990.07
343.05
3389
Prudential Alliance Account Services
PO. Box 41582
Philadelphia, PA 19176
Prudential ~ Financial
FLORENCE CLARK
824 L1SBURN RD APT 226
CAMP HILL PA 17011-7110
Page 1
435100123B562
PRIMARY
ACCOUNT NUMBER
9/30/2006
STATEMENT
CLOSING DATE
111.111,"111".".11".111".1".11".1111""1.1111.11.1.1.1
TAX ID NO:
ALLIANCE ACCOUNT
BALANCE
LAST STATEMENT
20,770.50
NO. 4351001238562
CREDITS
NC. i TOTAL AHCUNT
1 I 64. B7
CHECKS AND DEBITS
NO.; TOTAL A:40t,~~T
o I 0.00
BALANCE
THIS STA'!'E~-~!~T
ACCOUNT TRANSACTIONS /ojpG
DATE........... AMOUNT............ .BALANCE... DESCRIPTION
09/30 64.B7 20,B35.37 CREDIT-INTEREST
.~ -2El,835.J7
~(J) <t91.:l9
****** CURRENT INTEREST RATE
****** INTEREST CREDITED YEAR-TO-DATE
3.BOO% ******
492.53 ******
********** END OF STATEMENT **********
NOTICE: See reverse side for reconciliation of this statement and important information. 803-1
.,
CLAIR E. SHA TTO, JR.
3910 Mark Ave.
Harrisburg, PA 17110
717-545-7002
COINS
CARDS
COLLECTIBLES
BOUGHT -- SOLD -- APPRAISED
November 6, 2006
Mrs. Linda Neubaum
4104 Elmerton A venue
Harrisburg, PA 17109
Thank you for giving me the opportunity to appraise the coins in the estate of
your late mother, Florence E. Clark. My appraisal has determined the fair market value
of the coins on November 5th, 2006 to be $ 1,001.50. A breakdown by type is attached.
Sincerely,
Cf2a.-( ~ (
Clair E. Shatto, Jr.
..' ..
ESTATE OF FLORENCE E. CLARK
DENOMINATION DATE QUANTITY GRADE UNIT VALUE TOTAL VALUE
$1.00 7 VG 10.00 70.00
$1.00 18 VF-XF 12.00 216.00
$1.00 1903 XF 35.00
$1.00 1894-0 F-VF 40.00
1~ 1836 10.00
50~ 1893 VF 5.00
1t 1859 AG 2.00
$1.00 bill 1899 G 20.00
$2.00 bill 1899 VG 40.00
Baa of foreign 3.00
Wheat 1 ~ 0.25
5t V's 3 0.25
10t silver 15.00
Clad 50t 11 15.00
Silver 5~ 4 1.00
1~ 1905 AU 10.00
1~ 1879 G 5.00
1t 1881 XF 10.00
Baa of 1t 5.00
Book of 25t 35 62.00
Book of 50t 25 87.50
Book of 50t 29 101.50
Book of 25~ 12 21.00
Book of 25~ 34 59.50
Book of 1 O~ 65 45.50
Book of 10t 60 42.00
$11.35 silver 80.00
TOTAL VALUE OF APPRAISAL 1,001.50
REV-1511 EX+ (12-99).
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
FJ..(}tfE-NC-E- E. eL-/t/!..,/G
Debts of decedent must be reported on Schedule I.
FILE NUMBER
02..1-1) ~ -Ot/9:<',f
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
;vi y E~ $- II IM.A! E,.e. F (/ N c:. t<?A L ;-Ie; ME
;(iTA {}-..w:.,mAtV Fr1A... FO/IJEf.?.AL J...tJNCflEOtJ
IEAi.E~ 'S ;=/..-{)uJE~S
5; 9?j. "~
dtJ b. .~ (p
.J,1/./3
~.
3.
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
Cl/f./lt;BII-L \L W 15 €
1 j,/'J.o-o
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
j- / () , (j-()
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
:L2. 0', trO
TOTAL (Also enter on line 9, Recapitulation) $ ''0 988. 59
(If more space is needed, insert addttional sheets of the same size)
REV-1512 EX. (12-03)
'*
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
F'i-O/(EAlCE E. CJ-,4,eK. dl-()fo - ooy~'I
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.
!lE/l,(//-! Svt!T/! - T V J3 /L.L
..1-; ~1 0
~.
WEST S}/OIC~ Ems - 7/?IlNSfJ~R. T 7~ )/EA-i-TI-/ Sourfl
VEl<lZoAi - FINAL TE~jJ/kJNE ~/~L-
7(). /;t
j.
/0. t?8'
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
F!)' .6-0
HEAL THSOUTH Rehabilitation Hospital
Of Mechanicsburg
175 Lancaster Blvd.
Mechanicsburg, PA 17055
(717) 691-3700
BILLING DATE:
PATIENT NAME: Florence E Clark
PATIENT NUMBER: 714658
BILL TO: Florence E Clark
824 Lindham Rd. Apt. #226
Camp Hill, Pa. 17011
DESCRIPTION
TELEVISION: ($1.00 PER DAY)
DATE: 9/26/06 - 9/30/06
TAX ON TELEVISION: (PA SALES TAX 6%)
PAST DUE AMOUNT: $
DATE:
DATE:
PREVIOUS PAYMENTS RECEIVED:
TOTAL:....(PL.IS~$lSiPAYj"HI$AI\II~
(For proper credit, please return the bottom portion with your remittance)
AMOUNT
$
5.00
$ .30
$
$ 5.30
~. /'1.;?.yl?b
(!f :H:- / tJ {; ::L
-----------------------------------------------------------------------------------------------------------------------------------------------------
WESTSHOREEMS-BLS
205 GRANOVIEW AVE
SUITE 211
CAMP HILL, PA 17011
Phone #: (800) 367-0512 Federal Tax 10: 23-2463002
t.r.~\
(...~,
('~~')
{ . '
WEST SHORE
F-\1;_::?{-_:;',~~\!('~!-' ;\/;I-~r'!C'i\j ~~FR', lCL::<:
INSURANCE: MEDICARE B
FEP
137165115A
R01938193
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
31339 WCS
147137W NONE
09/25/2006
12:45 PM
HOLY SPIRIT HOSPITAL
HOLY SPIRIT HOSPITAL
ACUTE REHAB HOSPITAL
PATIENT NAME: FLORENCE CLARK
147137W
FLORENCE CLARK
824 L1SBURN RD APT 226
CAMP HILL, PA 17011
REASON(S)
FOR
TRANSPORT
Pneumonia
INVOICE
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
Wheelchair One Way Transport A0130 1.0 53.92 53.92
Transport Van Mileage A0999 5.0 3.24 16.20
Total Charges 70.12
DESCRIPTION OF PAYMENT
RECEIPT
PAYMENT DATE
AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT ......
RETURNED CHECK FEE - $31.00
..
~#~
verizRo
We never stop working for you.
Billing Date: 10/24/06 Page 1 of 4
Telephone Number: 717 737-0130
Account Number: 717737-0130302 27Y
MRS FLORENCE CLARK
Account Summary
**
Previous Charges
No Payment Received
Past Due Charges (please pay now)
$ 19.11
.00
$19.11
Convenience! Access Your Ver/zon
Account Online, Day or Night!
Enjoy the benefits of managing your
Verizon account online. View and pay
your bill, order services, request
repair, and more. Visit us today at
verizon.com/se/fservice to register.
New Charges
Verizon (page 3)
Total New Charges Due
~tal Due: (Past Due + New)
- $ 9.03
- $ 9.03
$ 10.OS-j
~
fl- /0/30/0 (;
p~e~:::ay ,upon receipt . ck 1f /005'
(fINAL 8"1.:\
This1=marsHlmay have already been referred to an outside collection
agency.
Questions about your bill? Call 1800660-2215
See page 2 for all other Verizon contact information.
Change of billing address?
Go to verizon.com/billingaddress or see page 2.
.... Detach & return payment slip with your check, payable to Verizon.