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Home My WebLink About03-27-07 ..........,... ..J ~ 1505b051047 REV-1500 EX (06-05) PA Department of Revenue *' Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 Harrisbu ,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death ~ Suffix IjEJ Date of Birth (If Applicable) Enter Surviving Spouse's Infonnation Below Spouse's Last Name Suffix MI m MI o THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW _ 1. Original Retum C) 2. Supplemental Retum C) 3. Remainder Retum (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required C) 4. Limited Estate C) 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 Da ime Telephone Number 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 8. Total Number of Safe Deposit Boxes C) REGISTE&9Ol'1LLS USI!-9NLY ~l ;g ~: 1 ::r () ::u . :.'~; F;::; N : c~7) 3~ -...I _ C) 0 .." . ,--_).1 ?-~ ~a -'-'- N ::D --I N Correspondent's e-mail address: ~ llo~ DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505b051047 1505b051047 .....J"i ~ t" --l 15056052048 REV-1500 EX Decedent's Name: M~L t. Cl A"J't~MO ..:l 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) ~SeparateBilling Requested. . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ 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 Une 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X.O _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 20. FILL IN THE OVAL IF YOU ARE REQ\JESTINQ,.A ~EFUNP ()F.AN OVEt:lPAYN~T ~~. fV f!' ~ ~~. (\.~ ~~ ;; ~~~4/~~ ~ Side 2 L 15056052048 ,"-' Decedent's Social Seeurity Number ~ 15056052048 --1 REV-1500 E~ Page ~ Decedent's Complete Address: DECEDENT'S NAME \ (\\l~ M-El I. D AV\l-t\)N '0 -:iR. STREET ADDRESS II ^ 1\ q l~ ttC\N\MeL t\v~ ~ File Number ~ \0(,.. 03sg \ CITY L~MO ~ ST~ Pr Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount 00,00 (1) Total Credits ( A + B + C ) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( 0 + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) B. Enter the total of Line 5 + 5A. This is the BAlANCE DUE. (5) (SA) (5B) 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. 00.00 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;.......................................................................................... 0 ~ b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 ~ c. retain a reversionary interest; or.......................................................................................................................... 0 ~ d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [gj 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. ~9116 (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 surviving spouse is zero (0) percent [72 P.S. ~9116 (a) (1.1) (ii)l. 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~ne years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the ch~d 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 of the decedent's siblings is twelve (12) percent [72 P.S. ~9116(aX1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in convnon with the decedent, whether by blood or adoption. . . REV.l508 EX + (1-87) .w SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY D \ A-N~\fJ~ 0 . ,jl{ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (Vhe LV\El 1: FILE NUMBER l.\OU~ O~S-8 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jolntly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. 2... ~. l{. s. l.... W Ac..ttov \.1\ fYt4 ~ , 000 C. 1"l1 ?:.O~).., .. e.~~k\"'~ 52.0' ~\~~ Fc:-R~ Rd.. 1\1-=-~\Ci av~ ,PA. "loS-\" WAc.l.'<);;I\~ P.lflWo.l\<.... "'10l."1C\ 8oC\Q1S01- SAvi~! iS~\ S"IV\P$()~ Fe:"1l-1 Rd.. Me~(.V'''''I~~'''' ~k 11o~~ RE~ S~ C\~':rt.~A~~:ql'i \\~~Me.lA~~+\ ~~'. ()A\oJe ~\~~ l-~-Nl~~ P,\. \'1ul.l3 st~ ~l\~ J\.J~ -:t~~.. r\')h~4\. 15 ~4"{~.<t\{,.5<o8 ((c:::~c(. r* \.1.N ~ P~~l \..V-. 'Cl81 ~d~:h~ g~J-JNeV~\G: v~~ \G-l ~ 2..5,",c.l{k\.Ul.q4<.G~ Pt:tt~\M~l ~ , 3.53i.5tt 'il\ ,1.4(, ;2... ~ ~~s.oo - ..l~L.( , ~ z.. 2 ~+\Jg ~ (, 9 O.O~ TOTAL (Also enter on line 5, Recapnulation) $ 4 qi,O. !2.. (If more space is needed, insert additional sheets of the same size) _ ~L._"~."~...iIIiIIi::,. - -<t__~__ __........:_~~:-.~~~_ ___~ .' ~~.. AcHOVIA r . ,'.. . Free 'Checking 01 1000674130321 752 40 1 18 659 -- I.. .111.. .111.. ..1.1.11.. .1.. .11..1.11.. .11..... .11.11.. .1.1.1 MICHAEL T D'ANTONIO JR l' SURREY LN MECHANICSIURG PA Il0S0 - PI Free Checking 4/27/2008 thru 5/25/2008 Account number: 1000674130321 Account owner(s): MICHAEL T D'ANTONIO JR Account Summary Opening balance 4/27 Interest paid Other withdrawals and service fees Closing balance 5/1.5 $3,337.52- 0.07+ 3,200.00 . 513759, Deposits and Other Credits Date Amount Description 5125 0.07 INTEREST PAYMENT Total $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 DBIs Amount Description 5/05 3,200.00 DEBIT MEMO 'rotal $3,200.00 '.. ...~ .. ..- ,.., . . tJ nistatement Savings 01 3067980997503 752 60 o 18 589 WHOVIA 00000272 0' MB 0.326 0' MAAD 2 1...111,"111", f 1.1.11...1...11..1.11...11.. f .1111 f 11...1.1.1 MICHAEL T D'ANTONIO JR 16 SURREY LN MECHANICSIURQ PA 17050 PI U nistatement Savings 4/27/2006 thru 5/25/2006 Account number: Account owner(s): 3067980997503 MICHAEL T D'ANTONIO JR Account Summary Opening balance 4/27 Other withdrawals and service fees Closing balance 5/25 $147.32 ' 147.32' . 50.00 II - . . - - II - . . - iiiiiIiII . - . ii .. Other Withdrawals and Service Fees Da" 5/05 T~'I Amount DHcrlption 147.32' DEBIT TO CLOSE ACCOUNT mrn. AS YOU REOUESTED YOUR ACCOUNT IS NOW CLOSED, AND THIS IS THE FINAL STATEMENT. IF YOU HA VE ANY OUEST IONS 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, ~ ' ~ 11/ .f1~ ceJfltj Barb and Dave Binkley / ~ "'5-\\4).., 1\ . " "au ..... . State Farm Mutual Automobile Insurance Company A" an:,~teF~ Drive INI....NC~ ConCOl'dllflle PA 19339-0001 36701F381 D'ANTONIO, MICHAEL T JR 16 SURREY LN MECHANICSBURG PA 17050-7800 1...11I...11I....1.1.11.. .I...II..I.IIIIIII......II.II...I.L I MAY 02, 2006 RE: Account Number: Refund Amount: 0379753613 *******25.41 AGENT Dale Doban 717-737-4117 The attached refund is a resuh of your request to close your payment plan account. If you have any questions, please contact your State Farm agent. State Fann Payment Plan 134-4398 a.1 (o1b010ba) Rev. 02-24-2004 9OM02 Dcp 5-\r-o<. \::S~ J\t~\. 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: ''7'S3co Signature of seller: J) o..t. J, riJroa-.- (f;rr ft:-()- n Y-I1o/--e r / i_ f) l'.rt(-d~a2i r ()/Iu~/O Dale D. Doban Signature of buyer: ~ P ~~(O John M. D'Antonio REV-1'511 EX+ (12-99) . " '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF (\It (t".A6:L T: ITEM NUMBER A. B. 1. FILE NUMBER cl , 0 (, - 0 35""8 () t A I\rh,~{ () . i ({ Debts of decedent must be reported on Schedule I. DESCRIPTION AMOUNT 1. FUNERAL EXPENSES: t\'\ ~~'> hw~ ~ K ~ e: too:.. ^ 3, e~t ~N~, M~W\c..V:!i,o\~, ,4. qos\ <1>;-, \{J\.-\4~ Ak ~ek::\. ~\I< ~ 1\ t Pe::kll DA, lv\~1tM.Q.~u~ ,rA- n\)~~ V.f: 11J', L.~~c~ (\ M'\ tt-J ~~ ~ t-\ OC\ ~~J-I ReA.. M~ A-vl t ~ i1v ~ \.....~ .. l01(1b l1oS"t"" ~ ~" 2.. .. S" t 91.C{o . 2.80,00 ! ADMINISTRATIVE COSTS: Personal Representative's Commissions ,oo.(.P Name of Personal Representative(s) ~ h~ ~tJ Social Security Number(s)/EIN Number of Personal Representative(s) Street Address \ (.,. S ~~ lJ.,J City Ma:\\AN(c..~\t~ State PA- Zip \'(OS""() Year(s) Commission Paid: tJ l ~ 2. Attomey Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant 4. 5. Street Address City State _ Zip Relationship of Claimant to Decedent Probate Fees ~ 'q.4. \)0 Accountant's Fees 7. 6, Tax Retum Preparer's Fees 00,00 00.00 TOTAL (Also enter on line 9, Recapitulation) $ "~3 3.to (If more space is needed, insert additional sheets of the same size) REV.1512 EX. p-911 SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS DjA-N~ ~ , FILE NUMBER ~I~- 0 $S"B COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF M\ l!"-~L 1'. Include unreimbursed medical expenses. ITEM NUMBER 1. 2.. DESCRIPTION AMOUNT 4- 5.. loo(. W~t S \to4~ ~S' - ..toS (,M-f.Jd. V\o.,a ~ S~l~~\ it , I , q L.4: '- (\~ 'ahl\~ ~ nOli 4 - H... 2ob(. tNe3 t- 'i k.J~ EtIf\s ~ .t 4'\. .3 ~ 4 -~....lOO<'" SplM..+ P~c:\.et.\lv\ SeRv~~~.tos~\Ht:~ Aut: ~~ :uc.. ~r ~l\ ,PA (7o~ L(. :3 - ,., -l.o~ ; OM l"Jt~ ~l( lu~dc t~""<:" {\Yl ~~kON\.. <Jl ~ ,(,5~. '3S Ae.co'-'.vf.tt; 54(,lloc'1o<o'-lS' 3oq,(o 3. ~. L. .,. s. ,~-)uo l1 r P,+-L ~ f\UoJ~=:lL 330'5"0-4 ~ ~Oll 9.1., HA:<.Ib~^", ~ ct I\U~ IoJ I f)..,fo 'CO lOi V~u,J ~ AceChl~\- ~"t\1~~l-t<.1l"JS"3-(Uy f\r~ .&- R~vwc...l '""{ Pc(t.~~ n 1 -'< s .). ~ -2.~(;)(" Q..l....~ \'v~N\ f l,~g 01> ~ ~ '3 L,1 ~ 3~.(,Y .. ~~yt> TOTAL (Also enteron line 10, Recapitulation) $ 488l.o!-). (If m~ space is needed, insert additional sheets of the same size) VVC., 1 .,nuR.C CIII., - cm., 205 GRANOVIEW AVE SUITE 211 CAMP Hill, PA 17011 Phone #: (800) 367-0512 Federal Tax 10: 23-2463002 WEST SHORE PATIENT NAME: MICHAEL DANTONIO 3061940E PATIENT NUMBER: CALL NUMBER: DATE OF CALL: TIME OF CALL: CALLER: FROM: TO: 49544 PR/V 3061940E NONE 0410512006 INSURANCE: 914 HUMMEL AVE APT 1 HOLY SPIRIT HOSPITAL MICHAEL DANTONIO 914 HUMMEL AVE APT 1 LEMOYNE, PA 17043 REASON(S) FOR TRANSPORT ALTERED LEVEL OF CONSCIOU Hypogtycemia INVOICE DESCRIPTION OF CHARGE QUANTITY UNIT PRICE I AMOUNT ALSEMERGENCYLEVEL1 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 60.47 60.47 GLUCOSE BLOOD A0394 2.0 6.11 12.22 NARCAN 2MG A0394 1.0 22.59 22.59 NORMAL SAlINE 500CC 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 - INVOICE DUE UPON RECEIPT ~ $1192.46 RETURNED CHECK FEE - $31.00 DETACH ALONG PERFORMATJON AND RETURN STUB WITH PAYMENT AMOUNT DUE AMOUNT $ ENCLOSED 1192.46 'ATlENT NAME: DANTONIO, MICHAEL 'AnENT NUMBER: 49544 CALL NUMBER BILLING DATE: 3061940E 04111/2006 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. WEST SHORE EMS - EMS 205 GRANDVIEW AVE t--;;] ~:: MASTER CARD ACCEPTED CAMP HILL. PA 17011 vvt:~ I ~MUt(t: t:M~ - tsL~ 205 GRANOVIEW AVE SUITE 211 CAMP HILL, PA 17011 Phone #: (800) 367-0512 Federal Tax 10: 23-2463002 PATIENT NAME: MICHAEL DANTONIO PATIENT NUMBER: CALL NUMBER: DATE OF CALL: TIME OF CALL: CALLER: FROM: TO: INSURANCE: 141624W MICHAEL DANTONIO 914 HUMMEL AVE APT 1 LEMOYNE, PA 17043 REASON(S) FOR TRANSPORT INVOICE WEST SHORE 1',:\("\' \jl:1J!( \1'<1 ,I<\-!{ 49544 WCS 141624W NONE 04/11/2006 12:30 PM HOLY SPIRIT HOSPITAL HOLY SPIRIT HOSPITAL LEBANON VA HOSPITAL CANCER 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 O~OO PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT ...... $249.39 RETURNED CHECK FEE - $31.00 JATlENT NAME: DANTONIO. MICHAEL JATlENT NUMBER: 49544 141624W 04/1812006 DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT AMOUNT DUE AMOUNT $ ENCLOSED CALL NUMBER BILLING DATE: 249.39 THIS SERVICE IS NOT COVERED BY MEDICARE OR MEDICAL ASSISTANCE. WEST SHORE EMS - BLS 205 GRANDVJEW AVE r--------l VISA .. [' ViSA I t'....di ---------~ AND MASTER CARD ACCEPTED CAMP HILL. PA 17011 "...... CMCft. ur rn '''.vlAft "Cft y IVCO>> )IRIT PHYSICIAN SERVICES IS GRANDVIEW AVE STE 210 'MP HILL PA 11011 MICHAEL DANTONIO 914 HUMMEL AVE APT 1 LEMOYNE PA 1~1788 1 of 2 ACCOUNT # 1283128 STATEMENT DATE: 04122106 LAST STATEMENT DATE: ~ IF AllY QUESTIONS, Pl.EASE CONTACT: SPIRIT PHYSICIAN SERVICES ~~...........;;~ .......;,i;q~~r[!,~";{.;_... ""il >> PAtmlr: IIICHAEL DJtinlmJi2l3126 . PEIfIIIED IY: RICHARD __ II) II) PUCE Of sw:: 21 PElFllllED AT: lIS INITIAL IIJSP CME LEVEl I 717-17J.44IIO FED TAX 10 ## 25178U71 ....... ..... . .CtiARG.,;,.t.c1. 'P4vYa1TlCUA.p.1l1Olt ADotUSTIIEftT. ~ ';..c"'<" WII&I06 99223 ~ 162.9 1".10 1".10 PERfl8ED AT: lIS WD6I06 99233 162.9 S1_ENr IIJSP, LEVEL II IM/D6ID6 PERfI8ED AT: lIS WD71D6 99232 162.9 ~ IIJSP, LEVEL II WD71D6 PEIfo'GM:D AT: lIS IM/aID6 99232 162.9 ~ IIJSP, LEVEL II M/IIIID6 PEIlfl8lED IY: DIlIUtII tlBLEY II) II) PEIFIRED AT: lIS W891D6 99Z32 162.9 51__ IIJSP, LEVEL II IMI09ID6 PERRIIEDlT:1IS DVlDID6 99231 162.9 _BfI' IIJSP, LEVEL I 04I1D1D6 PERRllED AT: lIS MIlVD6 99231 162.9 IIISPITAL DISCIIAISE <3D HI OVlJlO6 IALKE: MICHAEL DINIlIGD .661.10 DmClTES _ fINKIAL M:TMTY SINCE LAST IILl. 102.10 102 .10 73.10 73.10 73.10 73.10 73.10 73.10 49.10 49.10 110.10 110.10 PATIENI' IlLKE .... CIf THIS srlTBENT D lIE ,... YIIJ. PLEASE REMIT RILL IIIIIfI' PIIItPI1.Y. PlYMENr D lIE UPCIf RECEIPT Of THIS srlTBENT . TIESE SEIYICES tEE PllWIDED IV SPIRIT PII'ISICI. __ .....RYICES _ ME SEPARATE ,... lilt IIISPITAL FEES- ---.EASE CALL n7-97Z-4490 NITH lilt U!STDIIS - QKEIIOIC TIESE CIURSES. __ ....."- 0.....11::1111:... ur ""'~'''''''''N ~I:KV""c:t PIRrr PHYSICIAN SERVICES )5 GRANDVIEW AVE STE 210 AMP HILL PA 17011 MICHAEL DANTONIO 914 HUMMEL AVE APT 1 LEMOYNE PA 17043-1781 2 of 2 ACCOUNT # F- IF AJIY QUESTIO_. PLEASE co.,-ACT: SPlRrr PHYSICIAN SERVICES o,41E'.'......'.:<c.Q1Y.. .~~"...'... 1283121 STATEMENT DATE: 04122106 LAST STATEMENT DATE: 717-87J.4480 FED TAX ID # 2517887't ........ ........;;'A'fIlINTlQ~ """tiS, C~~_......,... ~ 'IIPORTMIT: "LEASE ..,ACII MID RETUII. 80nOl( "1}Ifr1JPl9l.rAT'''fIfT W(TH 'fOUltP6Y11EfIT STATEMENT DATe GUAIIANTOA UllPONSI..UTY: MINIMUM MYMDI 812 04122108 $ 888.00 $ 688.00 8P1Rn' PHYSICIAN SERVICES 205 ORANDVlEW AVE (HP) !.1,.~t~ILL PA 17011 1...111...111......11...11...111...111...1..1..1...11...1..1.1 ~~O: SPIRIT PHYSICIAN SERVICES " 205 &RANDVIEW AVE STE 210 CAMP HILL PA 17011 DODDi!l:ali! MICHAEL DANTONIO 914 HUMMEL AVE APT 1 lEMOVNE PA 17043-1769 02 rcEfI. GIlLY CKIlCK CHE I'OIl4;:RSHT CARD MYIIIIIT. PLIFASE PW. .. IIIfORIIATIOII 8a.ow -, --- '.... - ~ :' ,.:.-_"'-~-_-::."?_~*:.~.. ------~-----_._- ----_._------ ~ -_.. _,_~.L:aL_x_"_::.'.:..._...uf .['0 K",L,"j_ EXP DATE :::f_\'&~: t -'...:~""- 1281128 _Mle _VISA - ':.._ _-__:.. .~-__:.:__-..::;""..--...~;"-O.:..::.-::--"';-'- - .:: -- --~- _. ..=..~;.'" ._--~...;;:~.-..:'"--:::::._. $ 888.00 '. IISO CARDHOLDER NAME (PRINT) - '._--",_.-.._-, ----.,---,,--."-..., -- ......-----... ......-.......---..-,...- CREDIT CARD SIGNATURE d!1 ~ .. '-. .4 FORM 93 - O. C. DIVISION IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION OF } } } } } } No. 21-06-0358 of 2006 IN RE: 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. P A 17050 (personal representative. if any. or counsel). August 17 .2006 L /~: (Claimant) OMNIUM WORLDWIDE. INC. 7171 MERCY RD. SUITE 400 PO BOX 6618 OMAHA. NE 68106 800-999-3778 (Claimant's Address) US-lRRC 2S RECOVERY MAIN'l'BNlNCE ... .' ........ CLIENf: CHASE BANK'USA, N.A. -BANK ONE STANDARD CLI REFt: 5467100306453096 S!lTOS: ACTIVE STATUS REASON: 42-CLAIM FILED RECDSP 15:30:04 8/16/2006 ACXXXDr.r: 126049512 PACKET: More... ADDUSS IlOUII.!IC* I I PIm INFOltlWClI PHCItB TYPE: AREA COO!: PREFIX: camcr IlU'(RfM'IClI I LINGUIGI: ADDRESS mE: PRMHOM RESP: PRMRSP STREET: 914 IItHIL AVE APT 1 I CXIlDC'l mE: PRMCON PREFIX: FIRST _: is! MIDDLE lIME: LAS! lWI: DAHfCtfIO mElU)II): MICHAEL SSN: 183361478 CUI: LEMOYNE S'l'A'l'B: PA ZIP COOl: n043 1769 CCXIft'RY: us- -Mm COO!: DNMUND lDIIR: Bl'l'BNSICI : AN_ COOE: CALL COO!: SUWIX: \ ZVIlftS I I CURRIlf1' BlLAla: 2659.38000 PROOSED PADlN'rs: 0.00000 DLIaS I I lDJUS'Hlft'S I I IDJUS'lID JW.DCI: O. 00000 PRnCPlL PA!DlS: 0.00000 PmMS I I 1CCXDft S'1'A!1mcs I LIS21JIG ~: 2659.38000 WClL LIsmG BU.: 0.00000 More... ACTIVI'l'Y : S42 CLAIM FILED LGLCHG PROB FILNG FEES:$10.00000 CLM EXCUTR-FILE CLAIM WITH PROBATE:PROBATE CLAIM FORM 7392 08/16/2006 15:30:04 7392 OB/16/2006 15:30:00 7392 OB/16/2006 15:29:40 roLLaf UP ACmI'lY: REVIEW FOLUlf UP DAD: 8/23/2006 fOLUM UP !IMB: More... I ICCOOH'l mRIBtJ'l'BS I P2=CCI'nHUI SDJa F3=Im P4=PlOG'! FWDD amAC! I'7=PRlVIOOS <nmcT P8=Hm CDr1IC'r I'9=BIS!ORI !'24G1 KEYS Do Hot Mail CoDdiuon bisb Por Contact Address