HomeMy WebLinkAbout06-18-07 (2)
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15056041147
. 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
".4t::-
OFFICIAL USE ONLY
County Code v_
INHERITANCE TAX RETURN
RESI[)ENT DECEDENT 2 1 0 7
FIle Number
~tf)
Date of Birth
147265750
11'292006
09191935
Decedent's Last Name
SuffIX
Decedent's First Name
MI
PURCELL
DOROTHY
(If Appllcable~ EnterSurvMng Spouse's Information I3eloW
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 INAPPROPRIATE OVALS BELoW
[!] 1. Original Return
4. Umlted Estate
o 2: SupPle~1 Return
o
o
o
4a. Fubn Interest CompromIse
(date.<1 death atIer 12-12-62)
o
o
3. Remainder Retum (date Of death
prior to 12-13~2) ..
5. Federal Estate Tax Retun'l Required
o
[j
o
6. Dacadanl DIad TaIlala
(Att8ch Copy <1 WII)
7 IleclecItn MaIrUIni.d a umg Trust
. (Attach Copy <1 Trust) .
8. Total Number of Safe DeposIt Boxes
9. LItigation Proceeds Received
10. =~~f::l~<1dealh
o
11.EIectlon to tax under Sec.li113(A)
(Attach Sch. 0)
~C)RRESPONDENT. THIS SEcnON MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENnAL TAXINFORMAnoN SHOULD BE DIRECTED. TO:
ame ; . Daytime Telephone Number
JAMES D. HUGHES ESQ. 7172496333
Firm Name (If Appflcable)
SALZMANN HUGHES PC
City or Post OffIce
CARLISLE
State
PA
ZIP Code
17015
REGISTER O.FWIl n N ~
~~ ~5~
~~~~~t1
~Vl~....OO
tjnOoo~~
ng~~~~
DATEFIL~ ~ '^~ ~ b
>~ ~
First line of address
354 ALEXANDER SPRING ROAD.
Second line of address
Correspondenfs &-mall address:
..... Under .......-- 01 Jl.lIIlu. I clecI8r8 th8t I have eXemIned 11II reIlili1. 1ncIudI. !1Y.!!1glChedillel and statemiInla Ind to the belt of . ~ iilc:I belief,
.ltis tn*."'~ e.ni:l~. Dec:Intk:ll\ ofprepanir other th8ri the ~ ~ is baaed on III klfonnallon' of whIch.piejl8rer Ii~ any 1<nc7.iiIedlie.
SIGNoJ; OF PERSON RESPONSIBLE FOR R6TUR DA:
Henry Thomas Purcell
nel Carll8lel PA 17013
OTHER THAN REPRESENTATIVE
James D. Hughes Esq.
xande.r Spring Road, Suite 1, Carlisle, PA 17015
Side 1
1505604:L:L47
1505b04:L147
--l .~
--.J
1505b042148
REV-1500 EX
DecedenfsName: Dorothy Purcell
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) 0 Separate Billing Requested............. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) 0 Separate Billing Requested............. 7.
8. Total Gross Assets (total Lines 1~7)....................................................................... 8.
.
Decedent's Social Security Number
147265750
743.94
21.863 83
22.607 77
5 . 928 00
18. 670 27
24. 598 27
-1.990 50
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 BequestslSec 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.
16.
Amount of Line 14 taxable
at the spousal tax rate, of
transfers under Sec. 9116
(a)(1.2) X ~ 0 00
Amount-of Line 14 taxable
at lineal rate X .045 0 00
Amount of Line 14 taxable
at sibling rate X .12 0 00
Amount of Line 14 taxable
at collateral rate X .15 0 00
18.
15.
16.
17.
17.
18.
19. Tax Due..................................................................................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
~U1
~\~~
Side 2
1505b042148
-1.990.50
o 00
o 00
o 00
o 00
o 00
D
15051:.042148
--.J
"':>;j:(:::i;j:n~;'
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-07-
DECEDENrs NAME
Dorothy Purcell
STREET ADDRESS
1122 Shannon lane
CITY I STATE IZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CreditsJPayments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
0.00
0.00
Total Credits (A + 8 + C)
(2)
0.00
3. InterestJPenalty if applicable
_ D. Interest
E. Penalty
Total Interest/Penalty (0 + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 2 Line 20 to request a refund
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. Thi$ is the 8ALANCE DUE.
(3)
(4)
(5) 0.00
(5A)
(58) 0.00
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:
a. retain the use or income of the property transferred;..................................................................................
b. retain the right to designate who shall use the property transferred or its income;....................................
c. retain a reversionary interest; or..................................................................................................................
d. receive the promise for life of either payments, benefits or care?..............................................................
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.
Yes No
~. ~
o ~
[!]
o
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) (1)].
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 exemDt 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 steppatent ofthe 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 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-1108 EX+ (6-91'
.
SCHEDULEE
CASH, BAN~ DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMOHWEALTH OF PENNSYlVANIA
HERlTAHCE TAX RElURN
RE8IDeN'r DECEDENT
ESTATE OF
Purcell, Dorothy
FILE NUMBER
21-07-
Include \he proceeds alllIg8tIon lnl \he date \he proceeds __ IlICeIved by \he .....,.
All property joInl1y-ownecl with \he rlght of 8Ul'VIvorsIdp mUJt be cIlsclosed on schedule F.
ITEM
NUMBER DESCRIPTION
1 E53 Federal Credit Union - $avlngs account
VALUE AT DATE
OF DEATH
743.94
TOTAL (Also enter on Line 6, Recapitulation).
743.94
(If more apace Is needed. additional pages of the ..mn~)
Copyright (c) 2002 fORn software only The Lackner GrouP. Inc.
FORn PA.1500 Schedule E (Rev. 6-98)
Rev-1810 EX+ (8-88)
.
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RES10ENT DECEDENT
ESTATE OF
Purcell, Dorothy
FILE NUMBER
21-07 -
This schedule must be completed end filed W the answer to any of questions 1lhrough 4 on the re_ side of the REV-1500 COVER SHEET Is yes.
ITEM I tUN OF n..... y DATE OF DEATH " OF DECO'S EXCLUSION TAXABLE
NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
THE DATE OF TRANSFER. ATTACH A COpy OF THE DEED FOR REAL ESTATE.
1 E53 Federal Credit Union -IRA account; 100% 21,863.83 21,863.83
beneficiary - Henry Purcell, son
TOTAL (Also enter on Line 7,Recapltulatlon) 21,863.83
(If more space Is needed, additional pages otthe same size)
Copyright (c) 2002 form software only The Lackner GrouP. Inc.
Form PA-1500 Schedule G (Rev. 6-98)
REV-1151 EX+ (12-89)
*'
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEAlTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTAfE OF
Purcell, Dorothy
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21-07.
ITEM
NUMBER
A. FUNERAL EXPENSES:
.
DESCRIPTION
AMOUNT
ewing Brothers FUneral Home Inc.
1,653.00
B. . ADMINISTRATIVE COSTS:
1. PersOnal Representative's Commissions
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Address
City
Year(s) Commission paid
State . Zip
2.
Attomey's Fees
SALZMANN HUGHES PC
750.00
3.
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant Henry Tho.mas Purcell .
Street Address 1122 Shannon Lane
City Carlisle
3,500.00
Relationship of Claimant to Decedent
State
Son
PA
Zip
17013
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
Other Administrative Costs
Register of Wl1Is . filing fee
25.00
TOTAL (Also enter on line 9, Recapitulation)
5,$28.00
Copyright (c) 2002 form .softwareonly The Lackner GrouP. Inc.
FormPA-1500 Schedule H (Rev. 6-98)
Rev.llI12 EX+ (8-98)
*'
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYlVANIA
INHERITANCE TAX RETURN
RESIlENT DECEDENT
ESTATE OF
Purcell, Dorothy
FILE NUMBER
21-07-
Include un...lmbursed medical ex~.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1
Capital One - credit card
1.099.22
2
Carlisle Regional Medical Center - patient #9344137
74.59
3
Carlisle Regional Medical Center - patient #7606970
1.896.38
4
Cltlbank - Citlbank (SO) N.AJSears Roebuck & Co.
1,700.27
5
CP02 Billing Center
92.98
6
Cumberland Goodwill Fire & Rescue
144.45
7
Discover Card
6,368.97
8
E53 Federal Credit Union - credit card
899.95
9
I-IADI+hctn..+h gAhDhili+D+lnn I-Inctnl+DI
42.40
10
Hershey Kidney SpeCialists Inc.
24.69
11
Holy Spirit Hospital - patIent #28277549
1,026.67
12
Holy Spirit Hospital - patient #28532554
71.53
13
Intemests of Central PA Ltd
550.90
14
Lanc HMA Phys Mgmt
85.16
15
Mobile X-Ray Imaging Inc.
40.84
16
Pinker & Assoc.
62.19
17
Sarah A. Todd MemorlalHome
2.770.14
Total of Continuation Schedule
See attached page
TOTAL (Also enter on Line 10, Recapitulation)
18,670.27
(If more space Is needed, additional pages of the same size)
Copyright (c) 2002 fonn software only The Lackner Group, Inc.
Fonn PA-1500 Schedule I (Rev. 6-98)
Rev-1512 EX+ (8-88)
*'
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
continued
CClMMONWEAl TH Of' PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Purcell, Dorothy
FILE NUMBER
21-07-
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
18 Spirit Physician Services 140.53
19 The Bon Ton 15.00
20 Vascular Associates PC 566.30
21 West Shore EMS - patient #34446 966.80
22 West Shore Pathology 30.31
TOTAL (Also enter on Line 10, Recapitulation)
18,670.27
Copyright (c) 2002 fonn software only The Lackner Group, Inc.
Fonn PA-1500 Schedule I (Rev. 6-98)
REV-1513 EX+ (9-00)
*'
SCHEDULE ..
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
NUMBER
Purcell, Dorothy
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS ~nclude outright spousal
. ctistributions,{ and transfers
under Sec. lf116(a)(1.2)]
I.
Karla Brown
F12 Farmhouse Lane
Morristown, NJ
Henry T. Purcell
1122 Shannon Lane
Carlisle, PA 17013
Patricia. Purcell
112 Lincoln Street Apt 308
East Orange, NJ 07017
Sharon G. Purcell
112 Lincoln Street Apt. 305
East Orange, NJ 07017
RELATIONSHIP TO
DECEDENT
Do Not Li. Tnatee(sl
Daughter
Son
Daughter
Daughter
FILE NUMBER
21-07-
SHARE OF ESTATE AMOUNT OF ESTATE
(Words) ($$$)
1/4
1/4
1/4
1/4
Total
Enter dollar amounts for distributions shown above on lines 5 through 18, as appropnate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
Copyright (c) 2002 form software only The Lackner Group, Inc.
.
TOTAL OF PARnI - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
0.00
Form PA.1500 Schedule J (Rev. 6-98)
ft. CUNA MUIUAL GROUP
April 3. 2007
CUID ". : 22893
HENRY T PURCEll
63.Pt:RblWOOj1 R~ bUh~~#~n~i. r'OY3
~ST~RA~E. ~J 07017
RE: INDIVIDUAL RETIREMENT ACCOUNT OF DOROTHY PURCELL
Dear HENRY PURCELL:
CUi-.fA Mulual Group extend3 its sincere co.'1doIer..C8& f'Jf the Joss of DOROTHY PURCELl. We administer the IRA program for E 53
FCU. whete DOROTHY PURCEll maintained this account You have been Identified as a beneficiary of the IRA owned by
DOROTHY PURCELL, and you are entitled 10100% of the funds In this account. The value of your share of this IRA as of Ihe
owners dale of death Is 521,863.83.
To receive these funds, complele and return the enclosed Benefit Selection letter following the Instructions below:
1 ; Complete the enclosed Benefit Seledlon Letter
. Select how you would like to recelva the funds
. Select how you woulcllike the payment made
- Make a withholding etection(s) .
. Provide your Social Security number, dale of birth. and your daytime tolephonenumbet
. Sign and date the lettet
2. Return the letter In the envelope provided. If the latter is not returned by the deadline for receiving payments (see page 2). you
may be subject to an IRS penalty. If you have questions. please conlact a tax advisor.
3. Keap this letter and the Additjonallnformation Form for Y9Ur records.
Once the Benefit Selection Letter Is received, E 53 FCU win be authorized to disburse the IRA funds In the manner you elect. II you
have any questions, contact the IRA Representative at E 53 FCU at (908) 523-5729.
CUNA Mutual Group
IRA Services
Enclosures: Benefit Selection "letter
Additional Information Form
Boneficiary Payment Option Booklet. A
Return Envelope
cc: E 53 FeU
--
./
t. .~
This Column For
Division Use
:.-."~. ".
.:;: ,e /f
.".;,';
!:
.....".. .
. Name of Beneficiary
Karla ~.
Pa1;ricia Purcell
dauqhter.
. dauqht&
-H
:' '-;. C' . .... -"".:.~-'~,~~.:; ;:"1--', ".,..- !".:-.;,:.'~~~"....~.'t."
..... .,~l: " "~~,,...;~;:~.
. : j ; ,":", "". :', ! ,i"f \ . ~':. '.;'; ,"
If the decedent died testate, imd the asset listed above do not pass by contract or survivorship, a complete co'py dfthe
. Ia.'lt wilt and testament. separate writin~s and aU cod,cils thereto must be submi~.
In the case of bank accounts be sure to list the name of the institution, title of the account and. aAi.J\.NCE tiof the
DATE OF DEATH. .
In the case ofstodcsbe sure to include the name of the company, manner of registration and the number of shares.
Bondsshould,includethename of the issuer,manner of registration, date and face value. '
A separate affidavitisrequired for each institution releasing assets.
. . . ,
. ..
RIDERS MAY BE ATTACHED WHERE NECESSARY
Ewing Brothers Funeral Home, Inc.
630 South Hanover Street
Carlisle, PA 17013-
(717)243-2421
December 2, 2006
Henry Thomas Purcell
1 ) 22 Shannon Lane
Carlisle, PA 17013
The Funeral Service for Dorothy Purcell
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
1. PROFESSIONAL SERVICES
Services of Funeral Director/Staff. . . . $875.00
3. AUTOMOTIVE EQUIPMENT
Vehicle to transfer remains to Funeral Home. $225.00
C. SPECIAL CHARGES
Direct Cremation. . . . . . . .. .
FUNERAL HOME SERVICE CHARGES
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THA T YOU HAVE SELECTED . . . . . . . . . . . . . .
Cash Advances
Certified Copies of the Death Certificate.
Coroners Authorization Fee. . . . .
Newark Stat Ledger Obit. . . . . .
TOTAL CASH ADVANCES AND SPECIAL CHARGES .
Total
Total CQst. . . . . . . . . . . . . . . . . . .
SUB-TOTAL
INITIAL PAYMENT / DISCOUNT / CREDITS
TOTAL AMOUNT DUE
The unpaid balance over 30 days is subjected to a 1.50 % service charge per month. t 8.0000 % per an~
$245.00
$1345.00
$1345.00
$30.00
$25.00
$253.00
$308.00
$1653.00
$1653.00
0.00
$1653.00
Cumberland-Goodwill Fire Rescu
GENERAL RECEIPTS
PO BOX 12910
PHILADELPHIA, PA 19101
Phone #: (800) 367-0512. Federal Tax 10: 23-2298422
*
INSURANCE: MEDICARE B
147265750A
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
5757
CG0503743
11/0512005
CCS
NONE
PATIENT NAME: DOROTHY PURCELL
CG0503743
PolicelFire1911
1122 SHANNON LN
TREATED @ SCENE NO TRANSPORl
DOROTHY PURCELL
1122 SHANNON LN
CARLISLE, PA 17013
REASON(S)
FOR
TRANSPORT
Hypoglycemia
)
INVOICE
DESCRIPTION OF ~HARGE QUANTITY uNI'fPRleE . AM()uNT
. ...
1 CC SYRINGE A0394 1.0 1.46 1.46
10GTT TUBING A0394 1.0 7.58 7.58
ANGIOCATH (14-24) A0394 1.0 4.75 4.75
DEXTROSE 25GM A0394 1.0 8.19 8.19
GLUCOSE BLOOD A0394 2.0 5.54 11.08
NORMAL SALINE 500CC A0394 1.0 2.93 2.93
Total Charges 35.99
Bad Debt w":t! (!eS
(2;. /fJ /J" it. ~~55()
. f./dY/f'ti b"'J ~ 7iPC
7"/P ")..(}
04/2412006
35.99
. Total Credits
-D-
f'LEASE PAY THIS A~OUNT ~
Cumberland-Goodwill Fire Rescu GENERAL RECEIPTS PHILADELPHIA, PA 19101
Cumberland-Goodwill Fire Rescu
GENERAL RECEIPTS
PO BOX 12910
PHILADELPHIA, PA 19101
Phone#: (800) 367-0512 Federal Tax 10: 23-2298422
INSURANCE: MEDICARE B
147265750A
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
5757
CG0602071
06/03/2006
CCS
NONE
PATIENT NAME: DOROTHY PURCELL
CG0602071
PolicelFirel911
1122 SHANNON LN
TREATED @ SCENE NO TRANSPORl
DOROTHY PURCELL
1122 SHANNON LN
CARLISLE, PA 17013
REASON(S)
FOR
TRANSPORT
DIABETES MELLlTIS
INVOICE.
QESCftIPTION OF CHARGE QuANTITY UNITPAlc& . AMOUNt'
BLS RESPONSE AND TREATMENT A0998 1~0 75.00 75.00
10GTT TUBING A0394 1.0 7.58 7.58
ANGIOCATH (14-24) A0394 1.0 4.75 4.75
DEXTROSE 25GM A0394 1.0 8.19 8.19
GLUCOSE BLOOD A0394 1.0 5.54 5.54
NORMAL SALINE 500CC A0394 1.0 2.93 2.93
OP SITE A0394 1.0 4.47 4.47
Total Chal"g8S 1 08.46
.
O&S~PTION OF PAYMENT
p.,..titDll:. .
11/21/2006
Bad Debt Write Off
pC 4' (if S .
I ~tJ /3?K fRtPSSO ~
;jarrJSb"'~ f) /7/
" J 1- to.n. - f'O "J.,o
108.46
Total Credits
-0-
PLEASE PAY THIS AMOUNT -.....
Cumberland-GoOdwlll Fire Rescu GENERAL RECEIPTS PHILADELPHIA, PA 19101
PLEASE MAKE CHECK PAYABLETO:
.
. .
IRS# 23-2146427
Peter M. Brier, M.D.
Michael L. Gluck, M.D.
James A. Tyndall. M.D.
Ira J. Packman, M.D.
Richard Schreiber, M.D., F.A.C.P.
Lawrence B. Zimmerman, M.D.
Michael A. DeMichele, M.D.
Carla J. Dente, M.D.
Dominic Miran:hJ, D.O.
Wendy Schaenen, M.D.
Pabick Ratnasamy, M.D.
V. Martha I<apoo~ M.D.
Shubha R Acharya, M.D.
Pratheesh VlBwanathan, M.D.
A1en 1: Sweeney, M.D.
Roxana Vargas, M.D.
Dean L. Lehman, PA-C
Vmayshree Kumar, PA-C
Jody Searight, PA-C
Brent Calhoon, PA-C
01/25/07
INTERNISTS
of Central Pa.
LTO.
.
44631
.
.. .
550.90
.. ..
HARRISVIEW PROFESSIONAL CENTER . 108 LOWTHER ST. . P.O. BOX 107 . LEMOYNE, PA 17043-0107 . (717) 774-1366 FAX (717) 774-4232
:.:Gtu.."I:'II:'..U.J:.....IJr..JlfJl
550.90
DOROTHY PURCELL
1122 SHANNON LANE
CARLISLE PA 17013
CHARGES OR PAYMENTS MADE
AFTER CLOSING DATE WILL
APPEAR ON NEXT STATEMENT.
L
J
~
D PLEASE CHANGE ADDRESS IF INCORRECT
.. Statement Due Upon Receipt * Thank You **
* Insurance Pending
CLOSING
DATE:
ACCOUNT
01/25/07 NUMBER 44631
INTERNISTS OF CENI'RAL PA. · 108 LOwrHER sr. · P.O. BOX 107 · LEMOYNE, PA 17043-0107 · (717) 774-1366 FAX (717) 774-4232
STATEMENT
Ref. No; G 01962H
Vascular Associates P
816 Belvedere Street
Cat~lisle,PA 17013
717--241-5070
./
Dorothy. Purcell
1122 Shannon Lane
Carlisle,PA 17013
Date Dr. I Procedlll e Code Description
Please remove and return this portion with your payment.
.
06/15/
07/24/
07 /i:~4/
08/23/
08/23/
08/23/
09/07/
06/15/
07/24/
08/23/
09/19/
09/19./
06/15/
07/24/
07/24/
06/15/
07/24/
07/24/
06/15/
07/24/
07 /i:~4/
06/15/
01/24/
08/04/
08/i.~3/
Tax Id:
37205
35474
36246
37206
75960
75710
Endo-Stent Placement-1st 785.4
Plan Payment:10753
Plan Payment:10753
Adj:Medicare Write
Plan Payment:10761
Plan Payment:10761
Payment-Thank You
added 79mod per linda mcr r
Endo-Perc Trans Angio-Fe 7B5.4
79 modifier added
Plan Payment:10753
Plan Payment:10761
Plan Pay~ent:10766
Adj:Medicat~e Wt~ite
Endo-Select Cath-aort,pe 785.4
Adj:Medicare Write
Plan Payment:10753
Endo-Stent Plac,Perc Add 785.4
Adj:Medicare Write
Plan Payment:10753
Endo-Sup/Inter-Stent PIa 785.4
Adj:Medicare Write
Plan Paym~nt:10753
Arte~i~l-e~t~i~it~ Aft~r 785.4
Plan Payment:10753
Adjus~ment PA MEDICARE
Plan Payment:10761
mcr rejects: 35474 C097/
Vascular Associates P
816 Belvedere Street
Carlisle,PA 17013
:
B33.00
0.00
0.00
5~19. 67
258.66
0.00
0.00
64.67
714.00
46.03
0.00
0.00
18'+.11
483.86
550.00
276.12
219. 10
38':).00
174.51
171.59
154.00
69.66
67.47
107.00
0.0121
107. 00-
0.00
54.7B
42.90
16.87
0.00
ov
Phone: 7 7-241-507
566.30
566.30
CONT'D
PATIENT t
BALANCE
AMOUNT DUE
""'ssociates P
816 Belvedere Street
Cat~lisle,PA 17013
717-241-512170
Dorothy Purcell
1122 Shannon Lane
Carlisle,PA 17013
.
.
. .
P!~~~~ rernov~8Ild return thisp<>rtion with o.ur a ,ment.
.
DILlgnosls Chrgs./Ctedlts
:
mcr rejects: 75710 COB15!
co-97
06/15/ 6xx 75962 Endo-Ball Angio -Pet-.i ph- 785.4 51.00 5.51
07/24/ 6 Adj : Med i cat~e Wt~ it e 23.47
07/24/ 6 P.1an Payment: 10753 22.02
mct~ t~ejects: 35474 C097/b
mcr t~ej ect s: 37205 C097/b
mCt~ t~ejects: 75710 COB15/
included, not paid sep
06/29/ 93926 Non-Inv-LE Artet~ial Dupl 440.23 256.121121 32.36
07 /L~4/ Adj :Medicat~e Wt~ i t e 94. 19
07/24/ Plan Payment: 1075.3 129.45
09/ :l4/ Plan Payment : pet~ e 0.00
policy not in effect
06/29/ 93971 Non-Inv-Extremity-Venous 440.23 229.00 29.86
07/24/ Adj : Med icat~e Wt~ i t e 79.72
07/24/ Plan Payment: 10753 119. 42
07/11/ 99212 Office Visit Stt~ai ght fot- 440.24 60.00 7.29
08/08/ Adj :Medicat~e Wt~ i t e 23.57
08/08/ Plan Payment:10755 29. 14-
10/13/ Plan Payment: pet~ e 0.00
covet~age not in effect
07/18/ 6j 99213 Office Visit Expanded Pt~ 440. 2'+ 75.121121 9.98
08/08/ 6 Adj :Medicat~e Wt~ i t e 25. 11
08/08/ 6 Plan Payment:10757 39.91
Vasculat~ Associates P
816 Belvedet~e Stt~e et ov
Tax Id: Carlisle,PA 17013 Phone: 7 7-241-507
PLEASE RETAIN THIS PORTION OF
STATEMENT FOR YOUR RECORDS
CONT'D
PATIENT t
BALANCE
AMOUNT DUE
566.:30
Vascular Associates P
816 Belvedere Street
Carlisle,PA 1712113
717.....241-51217121
Dorothy Purcell
1122 Shannon Lane
Carlisle,PA 1712113
Please remove and return this portion with your payment.
. . .
1121/13/ 6 Plan Payment: pet~ e 121.121121
po licy not in effect
1217/2121/ 6j 2759121 Ampl..ltat ion Above Knee 44121.24 1478.121121
08/17/ 6 Adj :Medicat~e Wt' i t e 741. 1211
1218/17/ 6 Plan Payment: 112176121 589. 59-
1217/19/ 6j 99231 Hospital-Visit-Focused-B 44121.24 5121.121121
1218/ :l7 / 6 Plan Payment: i12l76121 121.0121
mct' t~ejects: 99231 C097/
1219/06/ 6 Adjustment PA MEDICARE 50.121121
1218/16/ 6j 26951 Amputation Fin 9 et~/t humb 785.4 1183.121121
1219/12/ 6 Adj : Med i cat~e Wt~ i t e 639.75
1219/12/ 6 Plan Payment: 1121765 434.6121
11/:l3/ 6 Plan Payment: pet~ e 121.1210
policy not in effect
Item Balance
147.4121
0.121121
108.65
Tax Id:
Vascular Associates P
816 Belvedere Street
Carlisle,PA 1712113
ov
Phone: 7 7-241-51217
566.3121
PATIENT. t
BALANCE
AMOUNT DUE
566.3121
S~e reverse side for explanation of columns.
CP02 BILLING CENTER
151 NORTH 5TH ST.
MIFFLlNBURG, PA 17844
DORotHY PURCELL
oo94-oo78993-000oo3-MC
05/31/2007
MIXED AADC 085
DOROTHY PURCELL
C/O SALZMAN HUGHS,P.C.
354 ALEV ANDER SPRING RD SUITEA
CARLISLE, PA 17015
111.111...11111111.11.1.1.1
CP02 BILLING CENTER
151 NORTH 5TH ST.
MIFFLlNBURG, PA 17844
Detach and retum with payment.
Patient Statement
Our statements have been changed to better serve you. Please see the back for details.
Service Provider Statement Date
05/31/2007
Date of
Service
10/11/2006
10/11/2006
11/11/2006
11/11/2006
9478993
CP02 BILLING CENTER
151 NORTH 5TH ST.
MIFFLlNBURG, PA 17844
(866) 227-9229
Page: of
Description of Service
Amount
Billed
64.00
31.93-
R-02 PORTABLE UNIT
R-02 CONCENTRATOR 85 PE
R-02 PORTABLE UNIT
R-D2 CONCENTRATOR 85 PE
Please remit balance d
WEST SHORE EMS - CARLISLE
205 GRANOVIEW AVE
SUITE 211
CAMP HILL, PA 17011
Phone #: (800) 367-0512 Federal Tax 10:23-2463002
III
WEST SHORE
E]'\'1ERC;FNC.~/ fvIr';D!C~/..L. Stf,'.\:fCL
PATIENT NAME: DOROTHY PURCELL
INSURANCE: MEDICARE B
CELTIC
147265750A
0000170733
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
34446
3053953
11/15/2005
CCS
NONE
3053953
1122 SHANNON LN
CARLISLE REGIONAL MEDICAL CTR
DOROTHY PURCELL
SALZMANN HUGHES PC
354 ALEXANDER SPG RD STE 1
CARLISLE, PA 17015
REASON(S)
FOR
TRANSPORT
HYPOCOLEMIC SHOCK-NON TR
INVOICE
PARAMEDIC INTERCEPT
10GTT TUBING
ANGIOCATH (14-24)
DEXTROSE 25GM
EKG ELECTRODES
GLUCOSE BLOOD
OP SITE
NORMAL SALINE 500CC
A0999
A0394
A0394
A0394
A0396
A0394
A0394
A0394
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
588.11
8.36
5.24
9.03
4.44
6.11
4.94
3.14
588.11
8.36
5.24
9.03
4.44
6.11
4.94
3.14
~VJ~
~""- rnocbecw~
()'n. -
J~
Total Charges
629.37
Bad Debt Write Off
629.37
~~~/f/~o
~ ~[) IIJ~/O~
PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT ~
RETURNED CHECK FEE - $32.00
~ VISA [.1
... AND
MASTER CARD
ACCEPTED
WEST SHORE EMS - CARLISLE 205 GRANDVIEW AVE CAMP Hill, PA 17011
WESTSHOREEMS-BLS
205 GRANOVIEW AVE
SUITE 211
CAMP Hill, PA 17011
Phone #: (800) 367-0512 Federal Tax 10: 23..2463002
&II
WEST SHORE
E!vlERC;F.J.Jcv':\,[ e.DICAL, SEH\i!C'F~,':'~
INSURANCE: MEDICARE B
CELTIC
147265750A
0000170733
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
34446 CRED
145408W NONE
07/31/2006
06:10 PM
HOLY SPIRIT HOSPITAL
HOLY SPIRIT HOSPITAL
HEAL THSOUTH REGIONAL SPEC HO:
PATIENT NAME: DOROTHY PURCEll
145408W
DOROTHY PURCELL
SALZMANN HUGHES PC
354 ALEXANDER SPG RD STE 1
CARLISLE, PA 17015
REASON(S)
FOR
TRANSPORT
AMPUTATION
INVOICE
Wheelchair One Way Transport
Transport Van Mileage
, ---4.
A0130
A0999
1.0
5.0
53.92
3.24
53.92
16.20
~~~. OO~- 1W=
a~~
~~C/Y1
(r\.QJ,. @fJI/UL 6L-
,
"'-
Total Charges 70.12
Bad Debt Write Off
1 0/13/2006
70.12
Total Credits 70.12
PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT -.
RETURNED CHECK FEE - $32.00
~ VISA le1
... AND
MASTER CARD
ACCEPTED
WEST SHORE EMS.. BLS 205 GRANDVIEW AVE CAMP HILL, PA 17011
WEST SHORE EMS - CARLISLE
205 GRANOVIEW AVE
SUITE 211
CAMP HILL, PA 17011
Phone #: (800) 367-0512 Federal Tax 10: 23-2463002
PATIENT NAME:
DOROTHY PURCELL
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
INSURANCE:
MEDICARE B
CELTIC
147265750A
0000170733
0604209
DOROTHY PURCELL
SALZMANN HUGHES PC
354 ALEXANDER SPG RD STE 1
CARLISLE, PA 17015
REASON(S)
FOR
TRANSPORT
INVOICE
ALS EMERGENCY LEVEL 1
ALS MILEAGE
EKG ELECTRODES
Oxygen Administration
A0427
A0425
A0396
A0422
1.0
5.0
1.0
1.0
Medicare Assignment Adjustment
Medicare Part B Payment
107845439
12/15/2006
12/15/2006
PLEASE PAY THIS A,.OUNT - INVOICE DUE UPON RECEIPT
RETURNED CHECK FEE - $32.00
411
WEST SHORE
Fi~\:IFR(~r~~.J(--' \':\'1E'DIC /\ L SER'/ICES
34446
0604209
11/0612006
IBAL
IBAL
FMC DIALYSIS
CARLISLE REGIONAL MEDICAL CTR
Hypertension
RENAL FAILURE -ACUTE
1015.98
11.32
4.70
56.15
1015.98
56.60
4.70
56.15
Total Charges
1133.43
762.12
297.05
Total Credits
1059.17
-..
This account is now PAST DUEll Payment must be received
WITHIN 10 DAYS. Collection process will begin.
WEST SHORE EMS - CARLISLE 205 GRANDVIEW AVE
I VIS{ .1 ~:: lel
MASTER CARD
ACCEPTED
CAMP Hill, PA 17011
WEST SHORE EMS - CARLISLE
205 GRANOVIEW AVE
SUITE 211
CAMP HILL, PA 17011
Phone #: (800) 367-0512 Federal Tax 10: 23-2463002
ill
WEST SHORE
EMERGENC\' MEDICAL SEJ<\'!CE:<
INSURANCE: MEDICARE B
CELTIC
147265750A
0000170733
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
34446 CDIS
148831W NONE
11/17/2006
09:27 AM
THE SARAH TODD HOME
SARA A TODD MEMORIAL HOME
FMC DIALYSIS
PATIENT NAME: DOROTHY PURCELL
148831W
DOROTHY PURCELL
SALZMANN HUGHES PC
354 ALEXANDER SPG RD STE 1
CARLISLE, PA 17015
REASON(S)
FOR
TRANSPORT
RENAL FAILURE -ACUTE
INVOICE
~.
,~s~w
\
61.-. c:t. fhRcli. ~lVUL
~~~
t
Total Charges 60.00
. Total Credits 0.00
PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT ......
RETURNED CHECK FEE - $32.00
=c ~=: .
MASTER CARD
ACCEPTED.
WEST SHORE EMS - CARLISLE 205 GRANDVIEW AVE CAMP HILL, PA 17011
WEST SHORE EMS - BLS
205 GRANOVIEW AVE
SUITE 211
CAMP HILL, PA 17011
Phone #: (800) 367-0512 Federal Tax 10: 23-2463002
.
WEST -SHORE
EMERGENCY Iv! [':D1C';L SERViCE:.>
INSURANCE: MEDICARE B
CELTIC
147265750A
0000170733
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
34446 WCS
148848W REVW
11120/2006
09:48 AM
THE SARAH TODD HOME
SARA A TODD MEMORIAL HOME
FMC DIALYSIS
PATIENT NAME: DOROTHY PURCELL
148848W
DOROTHY PURCELL
SALZMANN HUGHES PC
354 ALEXANDER SPG RD STE 1
CARLISLE, PA 17015
REASON(S)
FOR
TRANSPORT
RENAL FAILURE -ACUTE
INVOICE
~s~~
~&.t~~ 6L~ ~
~
a--
Total Charges 60.00
Total Credits 0.00
PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT .....
RETURNED CHECK FEE - $32.00
~ ~:: [el
MASTER CARD
ACCEPTED
WEST SHORE EMS - BLS 205 GRANDVIEW AVE CAMP HILL, PA 17011
WEST SHORE EMS - CARLISLE
205 GRANOVIEW AVE
SUITE 211
CAMP Hill, PA 17011
Phone #: (800) 367-0512 Federal Tax 10: 23-2463002
.
WEST SHORE
EMERGENCY MEDICAL SERVICE,
PATIENT NAME: DOROTHY PURCELL
INSURANCE: MEDICARE B
CELTIC
147265750A
0000170733
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
34446
3075145
11/29/2006
IBAL
NONE
3075145
SARA A TODD MEMORIAL HOME
CARLISLE REGIONAL MEDICAL CTR
DOROTHY PURCELL
SALZMANN HUGHES PC
354 ALEXANDER SPG RD STE 1
CARLISLE, PA 17015
REASON(S)
FOR
TRANSPORT
ALTERED LEVEL OF CONSCIOU
Hypotension
INVOICE
........, ./ .~_JU'Y ~frF'RIC$ M4<$Jt:1
:::".,,:>.< ..... ....
ALS EMERGENCY LEVEL 1 A0427 1.0 1015.98 1015.98
ALS MILEAGE A0425 4.0 11.32 45.28
10GTT TUBING A0394 1.0 8.78 8.78
ANGIOCATH (14-24) A0394 1.0 5.50 5.50
EKG ELECTRODES A0396 1.0 4.70 4.70
GLUCOSE BLOOD A0394 1.0 6.42 6.42
NORMAL SALINE 500CC A0394 1.0 3.30 3.30
VERSED 5mg/ml VIAL A0394 1.0 2.90 2.90
Total Charges 1092.86
" Fl-=~IPT ~t,.ltTi>~tE AMOUN'T
<. .. ".,<: i . ....
Medicare Assignment Adjustment 01/16/2007 727.60
Medicare Part B Payment 107900790 01116/2007 292.21
Total Credits 1019.81
,." "."
PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT ....... .'t$~05
RETURNED CHECK FEE - 32.00 " .',.
$
This Is the amount due after your Insurance Carrier's
payment.
WEST SHORE EMS - CARLISLE 205 GRANDVIEW AVE
~ VISA [_I
liliiii AND
MASTER CARD
ACCEPTED
CAMP HILL, PA 17011
Statement
United Church of Christ Homes
Sarah A. Todd Memorial Home
1000 West South Street
Carlisle, PA 17013
Statement Date: 06/11/2007
James Hughes, Esq.
Salzmann Hughes, P.C.
354 Alexander Sprg Rd, Suite 1
Carlisle, PA 17013
Due Date: 06/25/2007
Re: Dorothy Purcell
Account Nr: 101818
Date
Description
Days
Quant
Rate
Charges
PaYments
Balance
----------------------------------------------------~---------------------------
,
BALANCE FORWARD
05/31/07 Finance Charge
:u
2.'i;il'3 9 8 3
.+~. . .
'!'~35. 50
itl
2,839.83
2,875.33
~~~IJ lIDlUJrn
THIS ACCOUNT HAS NO DOUBT
ESCAPED YOUR NOTICE. WILL you
PUASES~DUSARUMnANct
NOTE: ***** PAYMENT IS DUE UPON RECEIPT ***** BI'" NO LATER THAN
THE 25TH OF THE MONTH***** Please remit the ~'::AMOONT pr:j.nted on
your statement. Include the ACCT# from the stat~,' .nt on the MEMO LINE
of your check. Payments after 6/6/07 do not refleq~ on statement.
NOTE: ** LATE PAYMENTS ARE SUBJECT TO A 1.25% LATS:CHARGE PER MONTH **
A $10.00 FEE WILL BE CHARGED for RETURNED CHECKS **
STATEMENT
Ifpaying by credit card: VI, MC, DISC or AM EXP-acct#
3 digit# on back of card _, name on card address
expiration date
I
I
SALZMANN HUGHES, P.C.
ATTORNEYS & COUNSELORS AT LAW
354 ALEXANDER SPRING ROAD, STE 1
CARLISLE PA 17015
-
. . t.
L
-.J
Please call or write with your other
insurance information. If you have
no other insurance, please remit
payment immediatley. Thank. you
BERFECT
QRE@
.. PLEASE DETACH HERE AND RETURN TOP STUB WITH YOUR PAYMENT ..
\.'iew
PURCELL - 173
Medicare Servi
...S PROFES
PURCELL - 173
KMedicare Servi
PURCELL - 173
Medicare Servi
quipment
URCELL - 173
Medicare Servi
View
PURCELL - 173
<Medicare Servi
MESSAGE: SEE REVERSE SIDE IF AN INSURANCE MESSAGE APPEARS'"
PLEASE PAY
SALZMANN HUGHES, P.C.
Mobile X Ray Imaging Inc' 945 EAST PARK DR . SUITE 102 . HARRISBURG, P A 17111
.PORC~~L, DOHOTHY ~~~11~4Y - U~/lb/~UUb U~TAIL U~/~lILUUb 1 pg
QUARANTftR
.,1I.IoIF.
AIID
ADDRESS
DOROTH'{ PURCELL
1122 SHANNON LANE
CARLISLE PA 17013
DETA L OF CURRENT CHARGES, PAY
08/16 PUMP SET 3Y TYP0116139313
08/16 SECONDARY SET 0116139339
08/16 CEFAZOLIN 500MG0244080364
08/16 CEFAZOLIN 500MG0244080364
08/16 MIDAZOLAM 1MG/M0144140242
08/16 MIDAZOLAM 1MG/M0144140242
08/16 BUPIVICAINE 0.20244720019
08/16 LIDOCA 1% 30ML 0144720118
08/16 TOES-AMPUTATION0110092633
08/16 HAND DRAPE 0110230118
08/lE KERLIX 4" 0110242451
08/16 GELSKIN PREP TR0110243814
08/16 SKIN STAPLER CA0110244069
08/16 UNIV EXT DRAPE 0110265676
08/1E HSC MINOR KIT 0110500767
08/16 ELECT PEN W/HOL0110507531
08/16 GROUND PAD ADUL0114103147
08/lE BAND ELAS FP. 4 "0114122139
G8/16 IV START KIT 0114123152
08/16 BANDAGE ELAS 4"0114124713
08/1f IV CATH 20X1-1/0114126239
08/16 IV CATH 22X1 0114606248
08/16 IV CATH 22X1 0114606248
08/16 NACL 0.9 1000 0116130635
08/16 DECALCIFICATION0125501305
08/16 TISSUE GRS&MIC-0125505306
08/16 OR-1ST 1/2 HR 10110103000
08/16 OR-ADD TIME II 0110103018
08/16 BASE UNITS 0349102320
Q8/16 CRNA TIME UNITS4449103021
08/16 MAC I SUPPLIES 0149111040
08/16 OPS LEVEL I 0211101250
BALA CE FORWARL>
ENTS AN
58.00
24.00
28.00
28.00
11.00
11.00
22.00
13.00
84.00
52.50
3.50
9.50
30.00
25.00
24.75
9.25
9.00
12.00
7.73
3.00
6.00
7.00
7.00
23.00
180.00
251.00
1161.00
633.00
330.00
440.00
5'13 .00
440.00
0.00
P?LIC'l NUMBER
1<;7265-:5:;,
JOHN G
ADJUSTME
58.00
24.00
28.00
28.00
11.00
11.00-
22.00
13.00
84.00
52.50
3.50
9.50
30.00
25.00
24.75
9.25
9.00
12.00
7.73
3.00
6.00
7.00
7.00-
23.00
180.00
251.00
1161.00
633.00
330.00
440.00
513.00
440.00
PATlon" _IER PLEAlIE UUR TO PATIDlT
'!:;~TIi:;~i;ii!;: (i if.":~i:;~:~~:n!!,: =~~R:S~~=IRlES
.. .... .. ..... .. ....
... ..... . .............
Page 1 of 2
ADDITIOIlAI. PATlD1T IILLIRlJ IIAT IE IIECESSARY
lOR AllY CIlAIIIJES IIOT POSTED WIIEII lllI1i STATE-
IIEIJT WAS PHPAUD. OR If IIJSURAIJCE CAIIRIElU!
DO ROT PAY AllY PART or TIll! AKOUIItS IHOWII
UHDEIl Esrnu.TED IIISUIWICE COVEIIAlIE.
PURCELL, UUKUTtly
L~~~LJJq - U~/LIILVUV U~~~~~ ~V/V.'~~~~
- r-"
OUAJWlTOR
NAIIE
MID
ADDRESS
DOROTHY PURCELL
1122 SHANNON LANE
CARLISLE PA 17013
147265750A
PAn ENT
AMOUNT
DETA L OF CURRENT CHARGES, PAY
09/27 AVELOX 400MG TA0144083020
09/27 APAP 325MG TAB 0344280014
09/27 ALARIS EXTENSIOOl14128169 5.81 5.81
09/27 VENIPUNCTURE 0117111030 15.00 15.00
09/27 BBGT 0125109125 48.00 48.00
09/27 METABOLIC PANEL0125201070 118.00 118.00
09/27 CPK (CREAT. PHOO125204108 48.00 48.00
09/27 CKMB 0125204165 47.00 47.00
09/27 PRO BNP 0125205162 182.00 182.00
09/27 CBC,AUTO DIFF 0125301201 81.00 81.00
09/27 MANUAL DIFFEREN0125301805 37.00 37.00
09/27 BLOOD CULTURE 0125402801 220.00 220.00
09/27 BLOOD CULTURE 0125402801 220.00 220.00
09/27 BLOOD BANK/HOLD0125800004
09/27 TROPONIN T 0125205071 68.00 68.00
09/27 CHEST PORT 0136501070 358.00 358.00
09/27 IV PUSH 0117100033 155.00 155.00
09/27 LEVEL IV 1-4 HR0117105917 823.00 823.00
09/27 EKG 0173111007 135.00 135.00
09/27 EKG PC-INTERPRE0173131005 29.00 29.00
BALA CE FORWARD 0.00
SUMM RY OF CURRENT CHARGES
PHARMACY 250 21.05 21.05
M/S SUPPLIES 270 5.81 5.81
LABORATORY 300 1084.00 1084.00
OX X-RAY 320 358.00 358.00
EMERGENCY ROOM .450 978.00 978.00
EKG/ECG 730 164.00 164.00
HOLY SPIRIT HOSPITAL
CAMP HILL, PA
ADDITIOIIAL .ATIEIJI BILLING NAY BE .I/ECUlWIY
FOR AllY CHAIIlJES NOT POSTED WIIDl nlls snn:-
NDlT WAS 'IlEPARED. OR IF INSUIWICE CARIIIERS
DO I/OT PAY ANY PARr OF ntE ANOwrs SHIIW
IlIIDER EsrINATED IJlllUlWlCE COVERAGE.
P;:IOP 1 of :i.
BROOKLYN HTS, OH
216.739.5100
BURLINGTON, NJ
609.914.0437
CHICAGO, IL
312.782.9676
CINCINNATI, OH
513.723.2200
CLEVELAND,OH
216.685.1000
WELTMAN, WEINBERG & REfS CO., L.P.A.
AttorDeys at Law
175 South 3rd St., Suite 900
Columbus, OH 43215
(614) 801-2710 (800) 893-5041
(614) 801-2604 (fax)
MOD-Thurs 8am-9pm, Fri 8am-5pm, & Sat 8am-12pm EST
www.weltman.com
COLUMBUS,OH
614.228.7272
DEERFIELD, IL
847.940.9812
DETROIT, MI
248.362.6100
GROVE CITY, OH
614.801.2600
PHILADELPHIA, PA
215.599.1500
PITTSBURGH, PA
412.434.7955
March 14,2007
JAMES HUGHES, Esquire
354 ALEXANDER SPRING RD SUITE 1
CARLISLE, P A 17015
Re: The Estate of DOROTHY PURCELL
Creditor: DISCOVER FINANCIAL SERVICES LLC.
Client Account No.: 6011001082523467
Our File No.: 5778442
Dear JAMES HUGHES:
As you are aware, this firm represents DISCOVER FINANCIAL SERVICES LLC.. Please be advised, the current
balance on the above referenced account is in the amount of$6,368.97.
Please forward payment to PO Box 163428, Columbus, OR 43212 with check made payable to DISCOVER
FINANCIAL SERVICES LLC.. Please include our seven-digit ftle number listed above.
Thank you for your assistance in this matter. If you have any questions, please feel free to contact our office at
1-800-893-5041.
ie L. Hance
Probate Specialist
Ext.22777
This law firm isa,~bt collector attempting' to collect this debt for. oW' client and any information obtained will be. .
used forthat'purp6se~
"
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.,
65015230906
.' ~
~..,... ~;',.
~NN~~TA OffiCE:
lIMES . ALOGH - MN
GAfrfW. BecKER- DC, FL IL MN, WI.
.CREDlTOR'S RIGHTS SPfCIAUST
AMERICAN BoARD OF CEI1TIFlCATION
BALOGH BECKER, LTD.
ATTORNEYS AT LAW
FLORIDA OffiCE:
2900 UNIVERSITY DR
SUITE 54
CORAL SPRINGS, FL 33065
ANTHONY J. MANISCALCO- FL
CHELSEA A. WHITlEY - AZ, KY, MI, MN, WI
ANGELA M. HORN - MN
MARY EuEN WEEMAN - KS, MN, MO
STEVEN M. TOMS - MN
MEAGAN M. PROeST - MN
MICHAel J. DoUGHEI1TY -IN, MN
Jill M. GEMLO - MN
ANDREW S. MILLER - MN
MATTHEW R. EICHENLAUB - MN
JENIFER C. MELBY - NJ, TX
ROBIN R. LEDoNNE - CA, MN
JACK ATNIP III - CA, MN
JASON R. ASTRUP - MN, ND
TY RIHA - MN
KIMBERLY J. MAKI- MN, OR
MAI1THA J. BALDWIN - MN
SEND ALL WRmEN REPUES TO:
4150 OLSON MEMORIAL HIGHWAY, SUITE 200
MINNEAPOLIS, MINNESOTA 55422-4811
TELEPHONE 763-852-8449
FAX 866-234-0503
TOLL-FREE 871-768-4494
Of COUNSEL:
lITow LAw OFFICES, P.C.
[IOWA)
LUSTIG, GLASER & WILSON, P .C.
(MASSACHUSETTS)
February 23, 2007
Account Number
************3903
Balance
$1700.27
Reference Number
3615144
Dear JIM HUGHES:
I am writing to inform you that our law firm now represents Citibank (South Dakota) N.A. Sears Roebuck
& Co in the Estate of DOROTHY PURCELL. This letter confirms an unpaid balance of $1700.27 on this
account.
Please call this office toll free at 1-877-768-4494 to resolve this matter.
Cordially,
Salogh Secker Ltd.
Attorneys at Law
This firm is a debt collector. We are attempting to collect a debt and any information obtained will be
used for that purpose.
GONBALOOl7103
111111111111..11.111111.11
I.... II I
LAW FIRM OF BALOGH BECKER, LTD
41 so Olson Memorial Highway, Suite 200
Minneapolis. MN 55422-4811
ADDRESS SERVICE REQUESTED
Account #: ************3903
Balance: $1700.27
Client ID: SEARSO
February 23, 2007
111111.1111111.........11
1111.. I .
BALOGH BECKER, LTD
4150 Olson Memorial Highway Suite 200
Minneapolis MN 55422-4811
1.1.1..1.1111..1..1.1..1.1.11111..1....11...11.1.1.11"11'11.1
************3903-7103 354513 35462
1...11111.111""1111.1.1.111.1.1..1.1.1.... UII.II.II U 1111.1
JIM HUGHES
354 Alexander Spring Rd Ste 1
Carlisle PA 17015-7451
Undeliverable Mail Only:
P.O. Box 1954
Southgate, MI 48195-0954
I ~II~ 1111mlllllllll~ 11111111111111111111111111
Mlliedlnterstate.
Inc.
~
800 Interchange West
435 Ford Road
Minneapolis, MN 55426-1096
Toll Free: 800-790-0278
MM1/83245312JXCB 00812954064 000542410016
1...111...111......11..11....111...11..1...11...1.1..1.1.1.1.1
Dorothy Purcell
1122 Shannon Ln
Carlisle, PA 17013-1783
Nov. 15,2006
DATE OF SERVICE: July 12, 2006
ACCOUNT #: 83245312
REFERENCE #: 9344137
CLIENT: CARLISLE REGIONAL MEDICAL CTR
TOTAL DUE: $74.59
Dear Dorothy Purcell:
At this time, your account has become seriously delinquent and has been referred to this office for collection.
In order to avoid further activity to recover the money owed, please remit the ba~nce in full to the address provided 6n the
remittance coupon below. For your security, please make your Ilayment payable to Allied Interstate, Inc., or your provider.
If you have questions regarding this matter, please contact our office at the number listed above and speak to a representative.
Please be advised that if you fail to resolve this issue your account will be reported to a national credit bureau and your credit
record may be negatively affected.
To pay your balance online, please visit h~:lIalliedinterstate.caIliPav .com and use the following information:
User Name: U 14 Password: 8324531217013
Unless you notify this office within 30 d~s after receiving this notice that you dispute the validity of this debt or any portion
thereof, this office will assume this debt IS valid. If you notify this office in writing within 30 days from receiving this notice that
you dispute the validity of this debt or any portion thereof, tfiis office will obtain verification of the debt or obtain a copy of a
Judgment and mail you a copy of such juClgment or verification. If you request this office in writing within 30 days after receiving
lhis notice, this office will provide you with the name and address of the original creditor, if different from the current creditor.
We are a debt collector attempting to collect a debt and any information obtained will be used for that purpose. Please note
that if your financial institution rejects and returns your payments for any reason, a service fee - the maximum permitted by
applicable law - may be added to your balance.
Sincerely,
Allied Interstate, Inc.
Sincerely,
Account Representative
800-790-0278
Allied Interstate, Inc.
Detach and return with payment
Date:
Client Ref Number:
Client
Amount Due:
Amount Remitted:
Nov. 15,2006
9344137
CARLISLE REGIONAL MEDICAL CTR
$74.59
$
Payment and Correspondence Address:
MM1/832453121858
Allied Interstate, Inc.
Healthcare Division
P.O. Box 361533
Columbus, OH 43236-1533
1.1..1..111111.11111..111111.11,1.111.11.1111,11'111
)(r.R
Date: 11/06/2006
WEST SHORE PATHOLOGY
PO BOX 750
SCRANTON PA 18501
Amount Due: $19.63
$19.63
L/'/
Address Service Requested
PHL4*26*28114536
iiiiiiii
!!!!!!!!!!!
iiiiiiii
-
!!!!!!!
.
iiiiiiii
iiiiiiii
!!!!!!!!!!!
MBD571.A1R8FC000043.A12~.001023 001021
Mail Paymentto:
DOROTHY PURCELL
1122 SHANNON LN
CARLISLE PA 17013-1783
WEST SHORE PATHOLOGY
PO BOX 750
SCRANTON PA 18501-0750
1,"11I"1111.1.11'11I1111I1,"111I1.1.1.11'11I1.1.11,"1"1.1
MED571
Patient Name
Account Number
Account Balance
- DOROTHY PURCELL
- 26*28114536
- $19.63
Place of Service: HOLY SPIRIT HOSP IP
Referring Doctor: JOHN CALAITGES
Date of Service: 07/20/2006
Dear DOROTHY PURCELL:
This is a reminder that payment on your account is now due.
As a courtesy to you, our business office has assisted you by
billing your insurance. Insurance paid their portion.
YoU are now responsible for this account. please submit payment
in full today.
Mail your payment to the address shown above. To insure proper
credit, enclose this letter and write your account number on the
check.
If payment in full has been made, please disregard this notice.
sincerely,
BILLING OFFICE
1-800-238-3614
..
For questions call, 800/238-3614 and when prompted enter your identification number as follows 2129*28114536
1.10-1''''''''....... "....,....... '-'I __...........___,
PO BOX 517
HAZLETON, PA 18201
800-450-6208 EXT 212
STATEMENT
11-14-06 1~
a2-09-06 57 MEDICARE PAYMENT RECON 107108356 198.06 -198.06
212-09-06 57 MEDICARE ADJUSTMENT RECON 1071'08356 .00 -198.06
a3-03-06 57 INSURANCE CO PAYMENT 022006 -49.52 -247.58
218-09-06 57 INSURANCE CO REFUND CK#5579 198.06 -49.52
217-01-06 110 HEMODIALYSIS MCP DOROTHY JRD 400.00 350.48
thru 07-3 -06
218-31'""06 110 MEDICARE PAYMENT RECON 107628355 195.33 155.15
218-31-06 110 MEDICARE ADJUSTMENTRECON 107628355 155.34 -.19
10-05-06 110 INSURANCE CO PAYMENT 092606 .00 -.19
10-05-06 110 POLICY NOTIN EFFECT AT TOS
217-30-06 121 SUBSEQUENT HOSPITAL CARE DOROTHY SJH 116.00 115.81
219-21-06 121 MEDICARE PAYMENT RECON 107673004 -43.23 72.58
219-21-06 121 MEDICARE ADJUSTMENT RECON 107673004 -61. 96 10.62
11-02-06 121 INSURANCE CO PAYMENT' 102306 .00 10.62
11-02-06 121 POLICY NOT IN EFFECT AT TOS
07-31-06 122 HEMODIALYSIS DOROTHY DHM 247.00 257.62
09-21-06 122 MEDICARE PAYMENT RECON 107673004 -56.29 201. 33
Z19-21-06 122 MEDICARE ADJUSTMENT RECON 107673004 176.64 24.69
11-02-06 122 INSURANCE CO PAYMENT 102306 .00 24.69
11-02-06 122 POLICY NOT IN EFFECT AT TOS
PLEASE MAKE CHECKS PAYABLE TO:
HERSHEY KIDNEY SPECIALISTS, INC
-PAYMENT DUE:
NOV 2 8 2006
Please Return This Portion With Your Remittance
001070
DOROTHY PURCELL
1122 SHANNON LANE
CARLISLE PA 17013
~
2
~
\,
-,-
HEAL THSOUTH Rehabilitation Hospital
Of Mechanicsburg
175 Lancaster Blvd.
Mechanicsburg, PA 17055
(717) 691-3700
'----
PATIENT NAME: Dorothy Purcell
PATIENT NUMBER: 714122
BILLING DATE: November 15, 2006
BILL TO: Dorothy Purcell
1122 Shannon Lane
Carlisle, PA 17013
SECON"O NOTICE
.<,..,:....
~, ".
.....
TELEVISION: ($1.00 PER DAY)
DATE:
TAX ON TELE;VISION: (PA SALES TAX 6%)
PAST DUE AMOUNT: $ 42.40
DATE: Original bill sent on 10/15/06
DATE:
PREVIOUS PAYMENTS RECEIVED:
$
$
$ 42.40
(For proper credit, please return the bottom portion with your remittance)
--------------------------------------------------------------------~--------------------------------------------------------------------------------
PATIENT NAME: Dorothy Purcell
PATIENT NUMBER: 714122
MAKE CHECK PAYBLE TO: HEALTHSOUTH
**VISAlMASTERCARD ACCEPTED
RETURN THIS PORTION WITH PAYMENT TO:
HEAL THSOUTH Rehabilitation Hospital
of Mechanicsburg
175 Lancaster Blvd.
Mechanicsburg, PA 17055
(717) 691-3700
COMPLETED BY: toi TV BILL
HEAL THSOUTH Rehabilitation Hospital
Of Mechanicsburg
P.O. Box 140065
Nashville, TN 37214
111~lllllmlllm~11
00143
o
CAPITALAccOUNTS
~
P.o. Box 140065
Nashville, TN 37214
800.282.3214. 800.296.3317 (fax)
7234-14
Dorothy Purcell
1122 Shannon Ln
Carlisle P A 17013-1783
111111111111111.11.111111111111111111..1.1111.111.1111.1.1.1.1
Date: 11/14/2006
Account: 198282
Client: Pinker & Assoc
Balance: $62.19
Dear Dorothy Purcell:
You have not made satisfactory payment arrangements to pay this seriously delinquent debt. Be advised, Capital Accounts
reports unpaid collection accounts to the national credit bureaus monthly.
This account will be reported as a seriously delinquent collection account if payment in full is not received within 14 days of
date above.
As you have been previously advised, all information reported to the National Credit Bureaus will remain on your credit file
for up to seven (7) years. .
You can still avoid this action by sending the balance in full. Be govemedaccordingly.
This letter is an attempt to collect a debt. All information obtained will be used for that purpose.
Credit Bureau Notification
Pay by phone at 800.282.3214
*** Ask for Dan Stevens ***
Direct all payments to Capital Accounts
RETURN BOlTOM PORTION WHEN PAYING BY MAIL
Dorothy Purcell
1122 Shannon Ln
Carlisle PA 17013
111111111111
Visa [ ] MasterCard [ ] AMEX [ ] Discover [ ]
Card Holder Name:
Card Holder Signature:
CREDIT CARD NO.:
DDDDDDDDDDDDDDDD
EXPIRATION DATE: PAYMENT AMOUNT:
DDDD $
Capital Accounts
PO Box 140065
Nashville TN 37214-0065
III 1I.11II1..I.IIIIII.IIIIIIIIIIIIII.lIu.I.I..III1.I.I.1II1I1
Account Number: 198282
Amount Due Now: $62.19
DL2-04
~5~FEDERAl
~ ~ CREDIT UNION
PARK AND BRUNSWICK AVE. · P.O. BOX 23 · LINDEN, NEW JERSEY 07036
Tel.: 908-523-5860 . Fax: 908-523-6119
www.e53fcu.org
February 21,2.0.07
Salzmann Hughes, P.C.
Attorneys & Counselors at Law
354 Alexander Spring Rd, Suite A
Chambersbmg, PA.17015
RE: Estate of Dorothv Purcell
Dear Sir or Madam:
In reply to your later dated December 27,2.0.09 regarding the Estate of Dorothy Purcell,
the following information is included:
1: The registered owner or owners: Dorothy Purcell
2: The date on which the account was established: September 1, 1988.
3: The date of death balance (principle plus accrued interest): $889.6.0 plus $1.0.35 in accrued interest.
4: If there is any credit life insurance on the account. Yes, we pay up to $15,.0.0.0..0.0 for all combined
loans with our Credit Union. Once we receive a copy of the original death certificate, a claim for this
loan will be submitted to our insurance company.
Please contact our credit union should.you have additional questions regarding Mrs. Purcell's
accounts.
Yours truly,
rm Patton
E53 Federal Credit Union
(9.08) 523-5729
/
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CREDIT UNIONS"
Wh.... people .re WOIIh more INn mon.y."
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FEDERAL CREDIT UNION
Account Number: 4820994331106777
Closing Date: 06f21/06
Credit limit: $3,500 Available Credit: $2,426
Cash limit: $3,500 Available Cash: $2,426
U\.I",V 1 n, rU","'I:LL
~'~~l~t\ 71J'fi~ ~~ iv' V.
(j)
Customer Service:
(800) 299-9842
To Report a Card Lost or Stolen:
(727) 57C)..4881 LOCAL
(~)~381TOL~FREE
Please Direct Written Inquiries to:
CUSTOMER SERVICE
PO BOX 30495
TAMPA, FL 33630
To view or pay your account on-line:
. www.eZCardlnfo.com
Previous Balance $ 1,035.17
Purchases + 25.90
qRsO + 0.00
Credits 0.00
Payments 0.00
Insurance + 0.00
other Debits + 0.00
Finance Charges + 12.36
NEW BALANCE $ 1,073A3
.
"
'-::t- . ...., -
VISA
~
~
Bonus Points
Available
9,734
-~lJt;.'~ ~ l ~. \ ~r ~ ~ ~, ~ l ~~t~ I 1'( '~' l. -~:,~' "':A~ :<;~.> .:,,~ ,~. ~ :. >; /," ~ r'l~ 5:( -: 'J::i}~' ':;\~ '{~ ~~ i:.: ~~ . :~ i~ ~ . if 1j.~~.' '-f {,:~! J.~ <l~~~~.ll';: ~~~~~?fr:f~;~'":!rJ 'r;~!r; .,
Id.;'.:'" Total Minimum Payment Due ...$65.00:
~
. . . , Payment Due Date NOW DUE
Mail Payments to: VISA PO BOX 31279 TAMPA FL 33631-3279
.,
IBmtm ..
Minimum Payment
Past Due Ainount
Over limit I Fees
33.00
32.00
0.00
.~.'(( 1~.~.J, ....1. .'~\'~'.~~' :,~;~"!>'''''",:.;. .:. 'I \: ~ ,,:::io :": ".~...~..\l,:".. ."~',il,,..\<.'~~..,
$
$
$
_RJ~_.~
. PLEASE NOTE MINIMUM PAYMENT DUE. WE MAY REPORT INFORMATION ABOUT YOUR ACCOUNT TO CREDIT
BUREAUS. LATE PA YMENTS, MISSED PAYMENTS, OR OTHER DEFAULTS MA Y BE REFLECTED IN YOUR CREDIT
REPORT.
. PHONE BILL. CABLE BILL. GYM DUES. PA Y THOSE MONTHL Y BILLS WITH VISA. SA Y GOODBYE TO WRITING CHECKS,
BUYING STAMPS AND WORRIES ABOUT GETTING BILLS IN THE MAIL ON TIME TO AVOID LATE PA YMENTS. AND VISA'S
ZERO UABlUTY POUCY PROVIDES YOU WITH MAXIMUM PROTECTION AGAINST FRAUD. FOR MORE DETAILS, GO TO
WWW.EZCARDlNFO.COM AND CUCK ON THE -PAY BILLS WITH VISA- UNK/
. .
.. . . .
TfIfIS Date Post Date MCC Code Refe/'ence Number AmOlllt
05130 05131 4816 2469216615000095<<)18719 TWX"AOL SERVICE 0506 $ 25.90
800-827~NY
': :'~';~" ':J.~1 '.;; l ~!. ( ,: i ~~.. t;:,: (.. ~t .',,: :~~:; :;-..;~~~ (.~j~' ~ ~~'?'i~. J'.~~: v~!;~ };li.; ~ >If,,4'f., ,:. ';;: . ',~ ;.~.~: {~I' ~'.~~' '~~~'}~:~;4' ~1~~ ,~~:~r~~~'~~~T}:'\~-.'~:: ': :w.:.:~~7~:: ~t
Beginning
BaIMce
',708
Ending
Balance
',734
PoInts
Earned
28
PoInts
Adjusted
o
PoInts
Redeemed
o
. EFFECTIVE JUNE 1,2001 TRAVEL RESERVATIONS AND TICKEnNG MUST BE MADE 30 DAYS IN ADVANCE OF
ACTUAL DEPARTURE DATES. THIS CHANGES FROM THE CURRENT REQUIRED 21 DAY ADVANCE NOTICE.
PI.EASE DETACH COUPON AND RETURN PAYIIENT USING THE EM:LosEDENVELOPE -ALLOW SDAYS FOR IIAIl. DEUVERY 01IlZ fi25Q
E53 FEDERAL CREDIT UNION ~5'S ~4820"r.9. 941Ji13" --311'0 6'7'!U77. .
POBOX23PARK&BRUNSWICKAV ,,;;J
LINDEN NJ 07036 - 0023 FBlEIAl CIBlIT UNION
--
Check box lo indica.
IlIIrneIaddrwa cMnge D
on b8ckaflhla ~pon
t: ~~....::-t r.~~:~~~:.:'
't.""! {"';\ ., . ~ . ~!....,....,\~~
AMOUNT OF PAYMENT ENCLOSED
\';,~ (~t~~"; ~1'~"", ~~~....
"'d't"':':'''~il~' .~r;)
. 'i ~ J. r: _ ~ _,'
$
06f21/06
$1,073.43
$65.00
NOW DUE
DOROTHY PURCEU
1122 SHANNON LANE
CARLISLE PA 17013 .1783
-
=-
--
-
-
11111111111111111111111111111111111111111111111111111111111111
MAKE CHECK PAYABLE TO:
11111111111111111111111111111111111111111111111111111111111111
VISA
PO BOX 31279
TAMPA FL 33631 - 3279
79 4820 9943 3110 6777 00006500 00107343 3