HomeMy WebLinkAbout03-27-07
~
~
~
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
Date of Birth
Decedent's Last Name Suffix
Decedent's First Name
MI
(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
<::)
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
c:::>
4. Limited Estate
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 <::) 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 Da ime Telephone Number
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
8. Total Number of Safe Deposit Boxes
c:::>
Firm Name (If Applicable)
REGISTEtf-o(JtILLS US~LY
~ ',; ~.:IJ
o
, " S::2
j]
../'.
N
-.J
(:) C-)
::c.-:!' 1
:0
,.., -"I
,,0.,
--r:J
f"':>
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, corre t and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
=;ISON . spa
ADDRESS ^ 1
It, S URR~ l~ .vb , V\cCl1I\N It ~ g ltJ(~
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
~
l,os;-o
DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056051047
15056051047
~~t
~
15056052048
REV-1500 EX
Decedent's Name:
M\C~L t. 0. f\f\Jt~MO
J
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) . . . . . . .. 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.
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 taxable
at lineal rate X.O_
17. Amount of Line 14 taxable
at sibling rate X .12
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
~~ ~V i! 0\
-,. ~\D (.\~.' 0' _l..-;
\Y '\~ /\.'\) ~~ ~\j'
~~ ,~. ~ ~\/~\~ "
~/~~ ~
Side 2
L
15056052048
--
...
Decedent's Social Security Number
15.
16.
17.
18.
c::>
15056052048
---I
REV-1500 EX Page 3
O'ecedent's Complete Address:
File Number
DECEDENT'S NAME I. _ D\A~*ON'O \dR.
{\\ ~<:t ,,^E l
STREET ADDRESS qlq ~ UMMel f\v~ \ f\$
\
---~
CITY LEM Q~ ~~ ! ST'P I ZIP
I A- i '10L{1
~
t2 \OCo.. O.3sg
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
OO.CXJ
Total Credits ( A + 8 + C ) (2)
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( D + E )
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.
(3)
(4)
(5) 00.00
(5A)
(58) 00.00
5. If Line 1 + line 3 is greater than line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
8. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
, ... .~-:.;:".._._"IIIj)JII"'.i.I'j!fJlr.ltl\.~
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. ~9116 (a) (1.1) (ii)]. The statute does not exemot 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 u~e 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. ~9116(1.2) (72 P.S. 99116(a)(1)].
The tax rate imposed on the net value oftransfers to odor the use of the decedent's siblings is twelve (12) percent [72 P.S. 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-1508 EX + (1-97)
ESTATE OF
~*
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
D \ 1\-",1-o,1J i 0 , ,jl\
M l e l\1\~l 1:
FILE NUMBER
.2. \ OlD ~ 0 ~S-8
, 3133'1.:~'q
'"
s.
~
t
~
,t.t It ;2-
~~s."Q
..2.~ L('
1. 2. ~.v~
(" ~ O.o~
COMMONWEALTH OF PENNSYLVANIA
INHERIT ANCE TAX RETURN
RESIDENT DECEDENT
L.
W Ac..tto\J \.1\ ~"r~ ~ , OD D c.l&.t-l ~06)..' ".. C.~~k("'~
S2.e l ~ ~~(/\I\. ~~ Rd... f\.1t;:;;"~~ \{\ ~v~ \ PA. "10~\
W~l-\~\f'c- &~\<..', ~Ol.'<\ 80<1 q15<>1- SA"" ~~
'5.2.01 S"l'\rS()~ Fe"/l'1 ~. Mee..lv'I",t\I1<t-, I PA- \'1o~~
RE.~ StC~ l\cpb\~t ~ A~~: q \ "\ \\\t~M~l A~ <\f~ \
~~ \ OAue' \?,\lJ~~ L.~Jvt",\~ Pit- '''lULl]
st~ t='1\~ ^~~ 1:~.s t, r~t\. ~ 4l. '5 ~ 4'-t~~ <t \~.. ~'CB
~c::~v,.,tt '* UN~!t...P~~lv,}--
1 G. B~ ~U\\.~+(. g~I-JNev~\G: v\~ \G-l H 2..5L.\c..4~~\,IJl.q4(.G~
~.
Lt,
s.
ta,
P~It~~( ~
TOTAL (Also enter on line 5, Recapitulation) $ 4 q l., o. 3 L
(If more space is needed, insert additional sheets of the same size)
.'
~~-.
ACHOVIA
'" , . .
Free -Checking
01 1000674130321
752
40
18
659
--
'...111..."'....'.'."...'. ..11..1.11. ..11..... .11.1'. ..1.'.'
MICHAEL T D'ANTONIO JR
16 SURREY LN
MECHANICSIURG PA 17050
-
PI
Free Checking 4/27/2006 thru 5/25/2006
Account number: 1000674130321
Account owner(s): MICHAEL T D'ANTONIO JR
Account Summary
Opening balance 4127
Interest paid
Other withdrawals and service fees
Closing balance 5/25
$3,337.52t
0.07 +
3.200.00 .
5137.59.
Deposits and Other Credits
Date
5125
Total
Amount Description
0.07 INTEREST PAYMENT
$0.07
Interest
Number of days this statement period
Annual percentage yield earned
Interest earned this statement period
Interest paid this statement period
Interest paid this year
8
0.10%
$0.07
$0.07
$0.80
Other Withdrawals and Service Fees
Date Amount Description
5105 3.200.00 DEBIT MEMO
Total $3.200.00
.'
~~ ...
~CHOVIA
, ' ..
Unistatement Savings
01 3067980997503 752 60
o
18
569
00000272 01 MB 0.326 01 MAAD 2
1...111.. .11111..1.1.11.. .1...11. .1.11.. .11.... ..11.11. ..1.1.1
MICHAEL T D'ANTONIO JR
16 SURREY LH
MECHANICSIURG PA 17050
PI
U nistatement Savings
4/27/2006 thru 5/25/2006
Account number:
Account owner(s):
3067980997503
MICHAEL T D'ANTONIO JR
iii
--
;;;Ii
ii
Account Summary
Opening balance 4/27
Other withdrawals and service fees
Closing balance 5/25
$147.32 .
147.32" .
SO.OO
iii5
-
!!!!I!
-
iii
==
-
-
I!!!!!
..
iiiiiIi
-
==
..
-
Ii
==
!!!!!
Other Withdrawals and Service Fees
Dsts
5/05
Total
Amount Description
147.32' DEBIT TO CLOSE ACCOUNT
$147.32'
AS YOU REQUESTED YOUR ACCOUNT IS NOW CLOSED, AND THIS IS THE
FINAL STA TEMENT. IF YOU HA VE ANY QUESTIONS OR WISH TO REOPEN
THIS ACCOUNT, CALL US AT 800-WACHOVIA (800-922-4684), OR CONTACT
YOUR LOCAL FINANCIAL CENTER. WE APPRECIATE YOUR BUSINESS.
...
May 5, 2006
Dear Mr. and Mrs. Doban,
Enclosed please find a check for $535.00 as a refunded security deposit for the estate
of Michael D'Antonio. We were sorry to hear of his passing. He was a good person
and excellent tenant. If you have any questions regarding this, please contact us at
796-1090.
Thank you for preparing the apartment so well. We were able to rent it almost
immediately .
Sincerely,
1/4 j ~,// )("~~J\:r,. Ii
A,-';.)1A4< f i,./ l<./7'-'~, /
Barb and Dave Binkley
<;) . J7l~
'. ~-+t! -7"'/: .<<*" I.
"7"'-,____
\)~ ~-\\~
. I P\ .n
It.n 'A'. State Farm Mutual Automobile Insurance Company
A ' .
IN.UUNCft 'One State Farm Drive
Concordville PA 19339-0001
36701F381
D'ANTONIO, MICHAEL T JR
16 SURREY LN
MECHANICSBURG PA 17050-7800
1...111.. .111....1.1.11.. .1.. .II,.I.II.ullulI..II.II. ..1.1.1
MAY 02, 2006
RE: Account Number:
Refund Amount:
0379753613
*******25.41
AGENT
Dale Doban
717~737-4117
The attached refund is a result of your request to close your payment plan account.
If you have any questions, please contact your State Farm agent.
State Farm Payment Plan
134-4398 a.1 (o1b010ba) Rev. 02.24-2004
90M02
Pcp ,5- It--a l
\::~~ ,,~~\.
,. ~""'.".-..,.._----~".""....~. "..h.'._~'__u .... - -M'-"......'"~.~'..""'....____.,.._......__-H-'_....__...,"~_.~_~"<...,~_ ...." ._.,........._.. --""'"-"N'~'__~J"""''''''''~''~.' -"-,___I_..~,.....1..~""...,"c__"-".........,'..-'....._.__.....On,'_..,__~'-'
Receipt of Sale
John M. D'Antonio paid $225.00 cash for the purchase of one burgandy,
1989 Pontiac Bonneville, April 24, 2006. Condition: Fair to Poor.
VIN: IG2HZ54C4KW294694
Mileage:
f/53co
Signature of buyer:
J) O-t- ~,J)rl!ru-
Dale D. Dohan
V ~1c:~1 c)
John M. D'Antonio
(f;n fr.-OfL{/~ r .._
. 1'5 l'-1tdftu( r u.l!z",b-G/(]
Signature of seller:
REV-i511 EX+ (12-99) ,
, *'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
fVl (C-"Af:l T
a cANt~i 0 , 1t{
Debts of decedent must be reported on Schedule I.
FILE NUMBER
~ l 0 (. - 0 3$"8
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
!
FUNERAL EXPENSES:
M ~t::f{ '> hwel\ ~ ~ h'\ e: ~ ^
3, e~t ~N~. M~1\.1Vlt~&..\~,.4 \los"\
<;;-. \{J\.tlt~\~ ~Ek:\. eJtuv(~ ^
t Pa::h:1l DA, N\~1rM.t.\-(1U~ \ rA- ((\)~,
'v -F: W -, L llNJ"C'~ f\
I\'\'\~":>> <;~~. t1 CX\~~,... ~ M~ ~lt. 'i i1v~ \ ""It
1 S' (, Hl.C{ 0
~ 2.60_00
1.
'2..
\ 1oS"r'<< 1 q 1.. (JU
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
.00.0:>
Name of Personal Representative(s)
tw-~ ~~ ~rJ
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address \ t. S tA..Rt~ lJ,.J
City Ma:\\ANl('c.~\{l\ State PA- Zip \(O~-()
Year(s) Commission Paid: ~ l A.
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 'qt.{. 00
5.
Accountant's Fees
6. Tax Return Preparer's Fees
QO .~
00,(.)0
7.
TOTAL (Also enter on line 9, Recapitulation) $ (., ~ g3.'lO
(If more space is needed, insert additional sheets of the same size)
4- s-- 100<' w~'" S ltolt~ E'1V\.S - .l.cS (,AA-""~ v,~ ~ SVt\~~\l it ',' ~ 1-..4'"
~~ ~cl\. ~ nOLI
1.\ -H-2ob~ tNes\-" ~h.~ EM.S ~ .t Lj-l\.3~
4 - ~ _ ).00,," Sp vt.d.. P~'1 t \.et ^' kJ\ C;; eRv oe~-: ..t0S"~1J \QA l'\.Jc
~'-'-"~ ~lO \ ~r ~hU ,PA (7o~
REV-1512 EX + Jl-97)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
O'A-N~ -~
\
FILE NUMBER
d lot, - 0 :SS-B
"-
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
~\~"-~L -t.
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
1.
1.
3.
AMOUNT
f
OlD
l,~g
L(. 8" " "l.o~ : OM ,..r~ ~\c:( ~.cte t1:,..~ -t,Yl ~J..lkONl- 1l ~ 1(,5~. '3~
t\cco(,)AI+ ~ 54" Il()()'1o~L.{S 30'(<0
~.
5. '~..)c.)O l> r P.+-L', ~~v~JL .33<.:)50" ~ ~Olt
9-Ll HAv~",ftV ~ct M{~~ I ~A- \~\Oi
'5 .). \0 - L ->\:l l. \J ~ VI,.! ~ Ac echl '" \- ~ '111-=i It I-I q to) :ryu y
Q..\"""'VV':N\ I\f~ 4- Re.'v\""'~ "{ Pc:R"~ ~
~
\.
~
~
'3 2....~ SD
3~.(,Y
$
~l{..ot>
TOTAL (Also enter on line 10, Recapitulation) $ 48 8 (o!-~
(If mo,'e space IS needed. Insert additional sheets of the same size)
vvc.~ I ~nu"c CIVI~ - C.IVI~
205 GRANDVIEW AVE
SUITE 211
CAMP HILL, PA 17011
Phone #: (800) 367..0512 Federal Tax 10: 23-2463002 'JVF~ST SH ().Illi
PATIENT NAME: MICHAEL DANTONIO
3061940E
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL
CALLER:
FROM:
TO:
49544 PRIV
3061940E NONE
04/05/2006
INSURANCE:
914 HUMMEL AVE APT 1
HOLY SPIRIT HOSPITAL
MICHAEL DANTONIO
914 HUMMEL AVE APT 1
LEMOYNE, PA 11043
REASON(S)
FOR
TRANSPORT
ALTERED LEVEL OF CONSCIOU
Hypoglycemia
INVOICE
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
ALS EMERGENCY LEVEL 1 A0427 1.0 967.60 967.60
ALS MILEAGE A0425 3.0 10.78 32.34
Oxygen Administration A0422 1.0 53.48 53.48
10GTT TUBING A0394 1.0 8.36 8.36
3CC SYRINGE A0394 1.0 1.62 1.62
ANGIOCATH (14-24) A0394 5.0 5.24 26.20
EKG ELECTRODES A0396 1.0 4.44 4.44
GLUCAGON A0394 1.0 60.4 7 60.4 7
GLUCOSE BLOOD A0394 2.0 6.11 12.22
NARCAN 2MG A0394 1.0 22.59 22.59
NORMAL SALINE 500Ce A0394 1.0 3.14 3.14
Total Charges 1192.46
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THiS AMOUNT - lNVOICE DUE UPON RECEIPT ~ $1192.46
RETURNED CHECK. FEE - .00
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE
AMOUNT $
ENCLOSED
1192.46
)ATIENT NAME: DANTONIO, MICHAEL
)ATIENT NUMBER: 49544
CALL NUMBER
BILLING DATE:
3061940E
04/11/2006
THIS INVOICE IS YOUR RESPONSIBILITY. Please forward this
itemized statement to your Ins Carrier and MAKE PAYMENT
DIRECTLY TO US. Please include Invoice Numbers on your
check.
AND
MASTER CARD
ACCEPTED
WEST SHORE EMS - EMS 205 GRANDVIEW AVE CAMP HILL, PA 17011
VISA
vvt:~ I ~MUt(t: t:M~ · tsL~
205 GRANDVIEW AVE
SUITE 211
CAMP HILL, PA 17011
Phone #: (800) 367-0512 Federal Tax 10: 23-2463002
..JIL..
~~.
WEST SHt1RE
141624W
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
49544 WCS
141624W NONE
04/11/2006
12:30 PM
HOLY SPIRIT HOSPITAL
HOLY SPIRIT HOSPITAL
LEBANON VA HOSPITAL
PATIENT NAME: MICHAEL DANTONIO
INSURANCE:
MICHAEL DANTONIO
914 HUMMEL AVE APT 1
lEMOYNE, PA 17043
REASON(S)
FOR
TRANSPORT
CANCER
INVOICE
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
STRETCHER One Way Transport A0999 1.0 93.94 93.94
Transport Van Mileage A0999 33.0 3.09 101.97
Oxygen Administration A0422 1.0 53.48 53.48
Total Charges 249.39
DESCRIPTION OF PAYMENT
RECEIPT
PAYMENT DATE
AMOUNT
Total Credits
0.00
PLEASE PAY THIS AMOUNT - INVOiCE DUE UPON RECEIPT ~
$249.39
)ATIENT NAME: DANTONIO, MICHAEL
)ATIENT NUMBER: 49544
DETACH ALONG PERFORMAT\ON AND RETURN STUB W\TH PAYMENT
AMOUNT DUE
AMOUNT $
ENCLOSED
249.39
CALL NUMBER
BILLING DATE:
141624W
04/18/2006
THIS SERVICE IS NOT COVERED BY MEDICARE OR MEDICAL
ASSISTANCE.
VISA
AND
MASTER CARD
ACCEPTED
WEST SHORE EMS.. BLS 205 GRANDVIEW AVE CAMP HilL. PA 17011
'"' ..,....1;..1;... ur rn'''.''...... "CR." I"~
)IRIT PHYSICIAN SERVICES
S GRANDVIEW AVE STE 210
'MP HILL PA 17011
MICHAEL DANTONIO
114 HUMMEL AVE APT 1
LEMOYNE PA 17OQ..1789
1 of 2
~ IF ANY QUESTIONS, PLEASE CONTACT: SPIRIT PHYSICIAN SERVICES 717-972-4490
DATE PROCEDUIIE ....0IAf; Q1'Y DESCRIPTION
CODE CODE '
>> PATIENT: NICHAEL DHlED 1283126
PERfl8ED 8Y: RICHARD IDINS114 MD tI)
PLACE OF SYC: 21
PERFDIIED AT: lIS
DVIIiI06 99223 162.9 INITIAL IaSP CARE LEVEl I
....11&I06
IJIt/D6lO6 99233
D4ID6ID6
OVD7106 99232
"107106
DVaII06 99232
M/IIII06
1MID91D6 99232
1MI09/D6
MIlDlD6 99231
M/10106
1JIt1l1lD6 99238
1JIt/1l/06
ACCOUNT #
1283126
STATEMENT
DATE: 04122106
LAST STATEMEIIT
DATE:
FED TAX ID # 251766971
PAYMENTI. .GUARAM1OR
INS. CHARGE ADJUSTMENT' BALANCE
1..DO
1".00
162.9
PERfDIItED AT: lIS
SlBSNJENT IIISP, LEVEL II
lot.OO
102.00
162.9
PERFDIIED AT: lIS
Sl8SBilUENT IIJSP, LEVEL II
73.00
73.00
162.9
PERfIIIED AT: lIS
SlBSBIJENT IIISP, LEVEL II
73.00
73.00
162.9
PERfl8ED IV: DlAH.- tlJSLEY MD NO
PERFIRIED AT: lIS
SlItSElilUENT ImP, LEVEL II
73.00
73.00
162.9
PERfIIItED AT: lIS
SlItSBilI JENr 1aSP, LEVEL I
49.00
49.00
162.9
PERFDIIED AT: lIS
IDSPIT At DISCHARGE <3D HI
100.00
100.00
BlLKE: MICHAEL DINIlImJ
t668.00
Dl)ICATES HEN FINKIlL ACTIVITY SItl:E LAST BILL.
PATIENI' BALKE SIIII4 114 THIS STATBENr IS lIE FIIIt YCIJ. PLEASE
REMIT FULL MIIMI' PlDPTLY. PAYMENT IS lIE ~ RECEIPI' OF THIS
STATBENr .
WJIB'I'IESE SERVICES MERE PllJYIDED 8Y SPIRIT PHYSICI" ...
.....RVICES .. ARE SEPARATE Flat ItIf I12SPITAL FEES ...
.....EASE CALL 717-972-4490 NITH JNf USTIIIfS --
BIIICIKEIImC THESE CHAISES. ...
., .ft . CMCn. ur ,..n 1 i:t1"'IIlN i:tl:rt Y 1"-'1:3
PIRIT PHYSICIAN SERVICES
)5 GRANDVIEW AVE STE 210
AMP HILL PA 1'1011
MICHAEL DANTONIO
914 HUMMEL AVE APT 1
LEMOYNE PA 17043-1789
2 of 2
ACCOUNT #
r IF Aft QUESTIONS. PLEASE COIITACT: SPIRIT PHYSICIAN SERVICES
DA1'E ~RE =.i' Q1YDESCRIP'I'ION
1283126
STATEMENT
DATE: 04122106
LAST STATEMENT
DATE:
717.972-4490 FED TAX ID # 251788971
INS CHARGE. ~=~Q~
____________---UlPJJIfTAN7: P4fA'E "fJ:ACH 4110 Ul!lJULIRUJ!..PO~TION QF STATomtIT !IlIH VOIjAP.MJIflI..I-________________
512
SPIRIT PHYSICIAN SERVICES
20S GRANDVlEW AVE (HP)
S1E 210
CAMP HILL PA 17011
STATEMENT DATE:
04/22/06
GUARANTOR RESPONSIBILITY: MINIMUII PAY"EN
S &68.00 S 668.00
1,"111,"111. .....11.. .11,"111,"111.. .11111111..11...1111.1
.- SPIRIT PHYSICIAN SERVICES
To: 205 GRANDVIEW AVE STE 210
CAMP HIll PA 17011
OOOOC!blC!
MICHAEL DANTONIO
914 HUMMEL AVE APT 1
LEMOVNE PA 17043-1769
02
lCE U.E ONLY
CH&:K OIlE
FOR c;REDIT CARD PAy.err. PLEASE flU-IN INfORMATION BElDW
~ ._,______ ..._n___~___
- ----_.-.~--...~..-.,...
___.___.. __..._.... '"-' ._.e_,
_._...~....__.._ .____..r.__
-_._-~." ---_.- "'-."
'-f::3:J.l.:E.L2J_rQ;;-~:1l:-;r1"- 01. ~n '-o1r
Mle
VISA
128312&
EXP OA TE
.-, - ..'_. ..'"--....- -.-'.' ._...~-"..-. _..~
... _...._.~. ~_ "..u._"" _.-... '....... _. ,
.. ..~..__..~.. _.._~_.- ....~--..-.-.".--_..- . .-
__.___.. ___ '" ...._ .,,"u._....~__~.__..,_....___.._..___.
...... __ _....__...___.....n......_.~_.~_._'"._..__..__.. ...
S 668.00
. . 1250
CARDHOLDER NAME (PRINT)
~~lDZiJc~
-._-....-.. ....-.. - ~.-.,,-_...-~_._,,-
_nO. .... ...~.__... ...~_ _ '.''''4
. ---.......,-_.. ._..-.~..._.
..r ...__...._..._.._____..
....-... ......~". _...
.. . '''. ... ~.. . - .--
CREDIT CARD SIGNATURE
SPIRrr PHYSICIAN SERVICES
. ...
-....
FORM 93 - O. C. DIVISION
IN THE COURT OF COMMON PLEAS
OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
OF
}
}
}
}
}
}
No. 21-06-035R of 2006
INRE: ESTATE
EST DANTONIO
(Deceased)
CLAIM
To the Clerk of Orphans court Division:
Index and make proper entry in your official records of the claim of OMNIUM
WORLDWIDE, INC. for BANK ONE (Claimant), account # 5467100306453096, in the
amount of $2,659.38 against the estate of the above named decedent.
This claim is filed under Section 732 (b) (2) of the Fiduciaries Act of 1949 as amended.
The said decedent, who resided at 914 HUMMEL AVE APT 1, LEMOYNE, PA
17043-1769, died on April 13,2006.
Written notice of this claim was given to DALE DOBAN, 16 SURRY LN,
MECHANICSBURG, PA 17050 (Personal representative, if any, or counsel).
August 17
,2006
~~~:
(Claimant)
OMNIUM WORLDWIDE, INC.
7171 MERCY RD, SUITE 400
PO BOX 6618
OMAHA, NE 68106
800-999-3778
(Claimant's Address)
~
(--~c.-..-
ARS-ARRC 2~
RECOVERY MAINTENANCE
RECDSP 15:30:04 8/16/2006
~: 126049512
PACDT :
. ... ....-.....
CLIENT: CHASE BANK USA, N.A. -BM~K ONE STANDARD CLI REF': 5467100306453096
STlTUS: ACTIV1 STATUS REASON: 42-CLAIM FILED
More.. .
PHONE :nm)~TI~ I
PHONE TYPE:
AREA CODE:
PlW'IX:
NUMBER :
m'ENSION :
ANSWER CODE:
CALL CODE:
CON'l'ACT INFORMATI~ I I ADDRZSS INroHGTI~ I I
LANGUAGE: ADDRESS TYPE: PRMHOH
RESP: PRMRSP STREET: 914 HtItIL AVE APT 1
I
CONTACT TYPE: PRt4CON
PREFIX:
FIRS'l' _: EST
MIDDLE H>>IE:
LAST NH: DANTONIO
mENDED: ti\ICH~.EL
SUFnX:
SSN: 183361478
CITY: LEMOYNE
STATE: PA
ZIP CODE: 17043 1769
COUNTRY: us- -MAIL COOE: DNMUND
m>>aS I I ADJUS'lMENTS \ I
ADJUSTED BALANCE: 0 . 00000
PRINCIPAL PAYHEN'lS: 0 . 00000
!VENTS I I
CORRBNT BALANCE: 2659.38000
PROOSED PAYMENTS: 0 . 00000
PmIBlftS I I ACCOUN'f STAnS'rlCS I
LISTING BALANCE: 2659.38000
LOCAL LISTING HAL: 0.00000
More. ..
ACTMTY:
842 CLAIM FILED
LGLCHG FROB FILNG FEES:$10.00000
CLM EXCUTR-FILE CLAIM WITH PROBATE:PROBATE CLAIM FORM
fOLLCM UP AC'l'MTY: REVIE~i
FOLLaf UP DATE: 8/2312006
FOLLaf UP TIME:
7392 08/16/2006 15:30:04
i392 08/16/2006 15:30:00
7392 08/16/2006 15:29:40
More.. .
I ACcotJN'l' AmIBU'l'ES I
r2=CCmINOI SEARCH F3=UIT F4=PRCWr F6=ADD CONTACT F7=PRMOUS CCImCT F8=Nm C<IITACT F9=IlISTORY F24=lGB KiYS
Do Not Mail Condition Exists For Contact Address