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HomeMy WebLinkAbout12-07-06 -.J 15056051058 REV-1500 EX (06-05) PA Department of Revenue . Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-0601 ENTER DECEDENT INFORMATION BELOW Social Number Date of Death OFFICIAL USE ONLY County Code Year File Number INHERITANCE TAX RETURN RESIDENT DECEDENT 21 06 0515 Date of Birth 12/28/2005 05/14/1935 Decedent's Last Name Suffix Decedent's First Name Thomas (If Applicable) Enter Surviving Spouse's Information Below Last Name Suffix First Name ~p()u!le'sSocial Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW <8J 1. Original Return 2. Supplemental Return c:::l c:::l 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required c:::l 4. Limited Estate C::> 4a. Future Interest Compromise (date of death after 12-12-82) c:::l 7. Decedent Maintained a Living Trust (Attach Copy of Trust) c:::l 10. Spousal Poverty Credit (date of death c:::l 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 DaytilllEll"ElIElphoneNumbElr c:::l c:::l . ...Qm 8. Total Number of Safe Deposit Boxes c:::l 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received Nathan C. Wolf (717) 241-4436 I"';,,) ......REGisTERO~iLLSUSEO~ '7- 0 0'"' <c; :n 0 :' -12:J rr, ;::;:':,:~ <oJ ,-~E~~ ~ ~:,~3~~ ~ =0 J:;- .1)~~El)m .C) co Firm Name Wolf & Wolf First line of address 10 West High Street Second line of address or Post Office I L. State ZIP Code Carlisle PA 17013 Correspondent's e-mail address: Under penalties of pe~ury, I declare that I have examined this retum, including accompanying schedules and statements, and to the best of my knowledge and belief, it is corn ct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. ADDRE 77 Partridge Circle, Carlisle, PA 17013 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS 10 West High Street, Carlisle, PA 17013-2922 PLEASE USE ORIGINAL FORM ONLY Side 1 L 15056051058 15056051058 MI o MI ri-l C) (-'J FS r"h Cj o ---,-, -Tl (--) , c::;:~~ , ,"I .....J ~ -.J 15056052059 REV-1500 EX Decedent's Name: Thomas o Raffensperger RECAPITULATION 1. Real estate (Schedule A). ....................................."..... 2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . . . 4. Mortgages & Notes Receivable (Schedule D). . . . . . . . . . . . , . . . . . . . . . . . . . . . . 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . , . . . . 6. Jointly Owned Property (Schedule F) c:::l Separate Billing Requested . . . . . . . 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) c:::l Separate Billing Requested.. . . . . . . 8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . , . . . . . . . . . . 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 taxable at lineal rate X.O_ 17. Amount of Line 14 taxable at sibling rate X .12 0.00 18. Amount of Line 14 taxable at collateral rate X .15 19. TAX DUE. . . . . . . . . , . . . . . . . , . . . . . . , . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 15056052059 Side 2 177-26-6812 1. 0.00 2. 5,107.00 3. 0.00 4. 0.00 5. 3,439.00 6. 0.00 7. 0.00 8. 8,546.00 9. 10,909.00 0.00 -3,161.00 15. 0.00 16. 17. 18. 0.00 15056052059 .....J REV-1500 EX Page 3 Decedent's Complete Address: DECEDENTS NAME Thomas 0 Raffensperger STREET ADDRESS 3437 Market Street F' 0515 DECEDENTS SOCIAL SECURITY NUMBER 177-26-6812 CITY Camp Hill STATE PA ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 0.00 Total Credits (A + B + C ) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (58) 0.00 0.00 0.00 0.00 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. 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 [iJ b. retain the right to designate who shall use the property transferred or its income; ............................................ D [iJ c. retain a reversionary interest; or.......................................................................................................................... D [iJ d. receive the promise for life of either payments, benefits or care? ...................................................................... D [iJ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. D [iJ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. D [iJ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ D [iJ 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. ~9116 (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. ~9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or 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. ~9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use ofthe 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* COMMONV\lEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF THOMAS D. RAFFENSPERGER FILE NUMBER 21-06-0515 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. 2 DESCRIPTION Marriott Int'llnc Class A Common Stock (Acct No. 01565157376) 36 Shares/$67.02 per Share Met Life Inc Stock (Account No. 8062 82934555) 39 Shares/$48.87 per Share Van Kampen Funds Equity & Inc. Fund Class A (Acct 25-33442) 90.444 Shares/$8.72 per Share VALUE AT DATE OF DEATH 3 2,412.72 1,905.93 788.67 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 5,107.32 R~V-1508 EX+ (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF THOMAS D. RAFFENSPERGER FILE NUMBER 21-06-0515 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jolntlyo()wned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH PNC Bank - Account No. 51-3009-0527 3,439.19 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 3,439.19 RE'v-1511 EX+ (12099* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF THOMAS D. RAFFENSPERGER FILE NUMBER 21-06-0515 Debts of decedent must be reported on Schedule L ITEM NUMBER A. AMOUNT B. 1. DESCRIPTION 1. FUNERAL EXPENSES: Monahan Funeral Home, Inc. Evergreen Cemetery, Gettysburg, PA 6,291.50 925.00 2 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Carol L. Vignapiano Social Security Number(s)/EIN Number of Personal Representative(s) Street Address 77 Partridge Circle City Carlisle 430.00 State PA Zip 17013 Year(s) Commission Paid: 2. Attomey Fees 2,700.00 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 89.00 5. Accountant's Fees 0.00 6. Tax Return Preparer's Fees 7. Cumberland Law Journal - Legal Advertising The Sentinel - Legal Advertising Final Apartment cleaning expense - Milton Stackfield 75.00 173.33 225.00 8 9 10,908.83 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) RE\t-1512 EX+ (12-03) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF THOMAS D. RAFFENSPERGER FILE NUMBER 21-06-0515 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. Camp Hill Fire Company NO.1 - Un reimbursed Medical Expenses 673.00 2 Milton Stacktield (Rent Payment for Apartment) 125.00 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 798.00 REv-1513 EX+ (9-00) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES FILE NUMBER 21-06-0515 ESTATE OF THOMAS D. RAFFENSPERGER RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS ~nclude outright spousal distributions, and transfers under See, 9116 (a) (1.2)] 1 John Raffensperger Brother 0.00 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) . t?omputershare POBox 43069 Providence, RI 02940-3069 TEL: 800-311-4816 FAX: 201-222-4842 INTERNET: www.computershare.comlequiserve RECEIVED SEP 2 5 2006 September 21, 2006 Nathan C. Wolf Attorney At Law 10 West High St. Carlisle, PA 17013 MARRIOTT INTERNATIONAL, INC. CLASS A COMMON Thomas D. Raffensperger Account Number: 01565157376 Dear Mr. Wolf: Thank you for your inquiry. The following list provides the information requested for the above account, as of the close of business on December 28, 2005. Share Balance: 36.000 Value Per Share: $67.02 Total Market Value: $2,412.72 Thank you for the opportunity to be of service. Please contact us at 800-311-4816, should you have any questions. Sincerely, J\ Clt'U_lJ fY) '-V, d-V\cL..~ Nancy Miranda Shareholder Services CS-0019 Rev 1/06 THOMt\S D RAFFENSPERGER ~-Acco~nt Market Value Stock pnc.e as of Total Market 11/07/2005 Value [ <50200 ---1 "960" Investor ID~ 8062 8293 4555 ;~;u .~ 1....*.... .'.1......1. ".'.' .....'...."...~....... ....~.... '.'I..........r ........ ll.t :j, .oJ .. .. .J, , If' I" ".I.' q. L!lli!! "X!L'~' ;~,1' . ~~!!llihlii . '~,'~ 1'1, ! i~ i ~ .,. ,~r' I .IL iifii/:.'_,_~l, ii (LOS" 2005 Dividend Summary Record Date Total Number of Dividend per Current Shares Share Dividend 11/07/2005 39.0000 $0.52 $20.28 Payable Date Tax Withheld Net Dividend Class of Stock 12/15/2005 $0.00 $20.28 COMMON 'I~ ....._1::....... .I..,!.,..., ....1., 1."..'..1.'. . ..!. ............. .......~!'..... '.-'...,..' : i!:'I...t... ~' '. " ~I .'. ; . 1.. Ilt:t' ..! '. l lil:ll, ! I ~ r !ll ; i !~ , :jt~ t J I q! .~j, ;! \I: ,. -, h filiiJ:,: \ .. 'J'l_1\. f~ ,( : '-I nfLo v S #q 0.67/ SJ+~ o..-l: 51 )hoft,5 , ..,.. ..,:: 1 '~ ; :. '> ,~;' For inquiries about your acoount or discrepancies on this statement, contact information is listed below: Internet: www.melloninvestor.com/isd Emall: metlife@meUoninvestor.com Phone: 1-800-649-3593 General Mall: MetLife, Inc, c/o Mellon Investor Services P.O, Box 4447 South Hackensack, NJ 07606-2047 0024189 Please Note: Important 2005 Tax Information ~~~EW8~i~~TRIBUTlONS U.S. TAX INFORMATION FOR 2005 MetUfe OMB NO. 1545-0110 COpy B FOR RECIPIENT RECIPIENT'S IDENTIFICATION NUMBER 177-26-6812 II BOX lA TOTAL ORDINARY DIVIDENDS $20,28 QUAUFIED DIVIDENDS II BOX lB $20.28 FEDERAL INCOME TAX WITHHELD II BOX 4 $0.00 I PAYER'S FEDERAL IDENTIFICATION NUMBER 13-4075851 I TO WHOM PAID THOMAS D RAFFENSPERGER 3437 MARKET ST CAMP HILL PA 17011-4428 REPORTED BY MELLON INVESTOR SERVICES 480 WASHINGTON BLVD, JERSEY CITY, NJ 07310 IMPORTANT 2005 TAX INFORMATION FOR INFORMATION REGARDING THE ABOVE, CALL 1-800-649-3593 This Is Important tax Information and is being furnished to the Internal Revenue Service, If you are required to file a return, a negligence penalty or other sanction may be imposed on you If this Income Is taxable and the IRS determines that it has not been reported, Box 4 - Shows backup withholding, For example. a payer must backup withhold on certain pay- ments at a 28% rate jf you did not give your taxpayer identification number to the payer. See form W.9, Request for Taxpayer Identification Number and Certification, for information on backup withholding, Include this amount on your income tax return as tax withheld, Oox 1 A - Shows ordinary dividends that are taxable. Include this amount on line 9a of Form 10,10 or 1040A Also, report it on Schedule B (Form 1040) or Schedule 1 (Form 1040AI, if reouired. The amount shown may be a distribution from an employee stock ownership plan ([SOP), Report it as a dividend on your income tax retum, but treat it as a plan distribution, nol as investment income for any other purpose. Nominees. If this form includes amounts belonging to another person, you are considered a nominee recipient. You must file Form 1099.DIV with the IRS for each of the other owners to show their share 01 the income, and you must lurnish a Form 1099-DIV to each, A husband or wife is not required to file a nominee return to show amounts owned by the other. See the 2005 General Instructions for Forms 1099, 1098, 5498, and W-2G. Box 1 B - Shows the portion of the amount in box 1 A that may be eligible for the 15% or 5% capi- tal gains rates, See the Form 1040J1040A instructions for how to determine this amount Report the eligible amount on line 9b, Form 1040 or 1040A, I::U I' I ' 'I' "I I' , I I' I ,I I' i"I I ,I, a~e iPep~sit ,he' ~d .. . - FIRST FINANCIAL GROUP, INC. Financial Advisors RECEIVED SEP 072006 .. September 6, 2006 Nathan C. Wolf, Esq. Wolf & Wolf 10 'Nest High Street Carlisle, PA 17013 RE: Thomas D. Raffensperger Estate Dear Mr. Wolf: Per your request, the date of death value (12/28/05) of the mutual fund holdings is set forth below: Account Tile Thomas D. Raffensperger Shares 90.444 Value for Share $8.72 Value as of 12/28/05 $788.67 Please call if you have any questions or concerns. GKRlmeb 134 Sipe Avenue, Suite 101 · Hummelstown, PA 17036 · Telephone (717) 533-8960 . Fax (717) 533-6932 Securities and Investment Advisory Services offered through NATIONAL PLANNING CORPORATION (NPC). Member NASD/SIPC, a Registered Investment Adviser. First Financial Group, Inc. and NPC are separate and unrelated companies. "., , . ,,,td, .., \. '-,.6" ;,,,,-,;.,_<t',,,,,.,J..cr:~,,,,, '.'''':--'' . :'/i'; ';r;--~':;,:,,~, '.1;-"\~_~,,,,, :. .;(0, ,.,.~"~,~:,,;:;:;~ t 't, );,;:t;\'-"i';.',1"'_,,"~\ ..:,~)"1 ,;;..;_,,,::':'..,'i'~~' ,.i.1";.\~_;;":,")]);:>r..')~i,~~"~i;;:',,;:,,,_ <.;:/I.~:J.~;'.':t~ ::;.'</fr' P;ss'book SaVings Account Statenlcnt l)NC: Bank. ,-;'.J" ;'-"'j'::;~:.-" " . -.._~ "''','- r~ ~'....,\: ~'d,,~$,-: ,..,..,,,...,..... (:'.,,};.:,. ,~",~ ~~:-:c ~~\;; ..,d~~'~ ';:'; ~':;" ""~~ For the period 12/01/2005 to 12/31/2005 Primary account number: 51-3009.0537 Page 1 of 1 Number of enclosures: 0 THOMAS D RAFFENSPERGER 3437 MARKET ST CAMP HILL PA 17011-4428 .!Sa. For 24-hour banking, and transaction or -.-- interest rate information, sign-on to 'D' Account Link<~ by Web on pncbank,com. For customer service call '1-888-PNC-BAI\IK between the hours of 6 AM and Midnight ET. Para servicio en espanol, 1-866-HOLA-PI\IC Moving? Please contact us at 1-888-PNC-BANK ~ Write to: Customer Service PO Box 609 Pittsburgh PA 15230-9738 II:J Visit liS at pncbankcom ~ ~ ~ TDD terminal: 1-800-531-1648 For hearing irnpair ed clients only >>assbook Savings Account Summary Iccount Number: 51-3009-0537 lalance Summary Thomas D Raffensperger Average Monthly balance 2,771.SI Average collected balance 2,771.81 Charges and fees Please see Activity Detail section for additional information. .00 Beginning balance 3,150.85 Deposits and other additions 7:38.34 Other deductions 450.00 Ending balance 3,439.19 ~ctivity Detail ~eposits and Other Additions ~// ~~ ] 3.34 Description Direct Deposit - Soc See US Treasury g03 XX,x...XX6SI2A Interest Payment There were 2 deposits and other additions to this account totaling $738.34. lle ~/21 Amount 735.00 ther Deductions Ite ~/05 Amount 450.00 Description \Vithdrawal There was 1 other deduction totaling $450.00. Tel 0400010601 0063 :terest Summary terest paid this year terest withheld this year Iterest Rate Schedule 5.24 0,00 tes 101 to 12/3] I nterest rate .25 % FOHM9SJR-fM05 Robert J. Monahan RECEIVED PAYMENT MONAHAN FUNERAL HOME, INC. 125 CARLISLE STREET, GETTYSBURG, PENNSYLVANIA 17325 717-334-2414 27 EAST MAIN STREET, FAIRFIELD, PENNSYLVANIA 17320 717-642-8266 TO Carol Vignapiano 77 ?artridge Circle Carlisle, Pa. 17013 FOR THE FUNERAL EXPENSES OF Thomas Donald Raffensperger December 28, 20 06 20 TOTAL ITEMIZED ACCOUNT ON INSIDE PAGE - EVER6RE,EN CEMETERY' 799 BALTIMORE STREET. GETTYSBURG, P A 17325 717-334-4121 February 13, 2006 To: Carol Vignapiano 77 Partridge Circle Carlisle, PA 17013 ,J-- ~r ~~ QUANTITY DESCRIPTION LOCATION AMOUNT 1 Burial of Thomas D. Raffensperger 165 T 4 $925.00 TOTAL $925.00 PAYMENT TOTAL DUE $925.00 Make all checks payable to: Evergreen Cemetery If you have any questions concerning this invoice, call Brian Kennell, Supt. THANK YOUI :::~' ~::: -'-,--\. ~8 [II] lVISA r 1 Local TEL: (717) 214-6018 Toll Free TEL: (877) 214-6018 FAX: (717) 214-6020 email: info@ambulancebillingoffice.com TIN: 23-6266703 ';ffi;i MASTERCARD DISCOVER I~VISA CARD NUMBER EXP DATE SIGNATURE AMOUNT INVOICE DATE RUN NUMBER 4/19/2006 05-69856 $673.00 Camp Hill Fire Company No 1 Billing Office P.O. Box 726 New Cumberland, PA 17070 CAROL VIGNAPIANO 77 PARTRIDGE CIRCLE CARLISLE, PA 17013 Patient Name: RAFFENSBERGER, THOMAS Patient SSN: XXX-XX-6812 Date of Service: 12/21/2005 14:19 IIIIIIII~IIII~II"II ~IIIIIIIII ~IIIIIII ~III~IIIII Fr~:; ~~I~I~~~tCHEosPital Primary Payor: Bill Patient Secondary Payor: PLEASE MAKE ANY CORFIECTIONS TO ADDRESS ABOVE. IIIIIIIIIIIII~IIIIIIIIIII 11/111111 DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT. I Date 12/21/05 12/21/05 12/21/05 Description Basic Life Support/Emergency Mileage Oxygen Total Procedure Code A0429 A0425 A0422 Qty 1 2 1 Unit Price 555.00 14.00 90.00 Total Charge 555.00 28.00 90.00 673.00 Discounts / Adjustments Payments 0.00 0.00 Medicare denied your claim stating you did not have Part B coverage on this date. Please send payment. Payment in full is your responsibility. Camp Hill Fire Company No 1, 877 214-6018 RAFFENSBERGER, THOMAS 05-69856 PAY THIS AMOUNT III..