HomeMy WebLinkAbout06-18-07
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15056041147
REV-1500 EX (06-05)
PA Department of Revenue
Bureau of Individual Taxes
Po. Bo.X.280601
Harrisburg, PA 17128-0601
ENTER DECEDENT INFo.RMATlo.N BELo.W
Social Security Number Date ~f Death
*'
o.FFICIAL USE o.NL Y
County Code Year
INHERITANCE TAX RETURN
RESIDENT DECEDENT 2 1 0 7
File Number
th?JV
Date of Birth
147265750
11292006
09191935
Decedent's Last Name
Suffix
Decedent's First Name
MI
PURCELL
DOROTHY
(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.lN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPRo.PRIATE OVALS BELo.W
[!J 1. OriglnalRetum
2~ Supplemental Retum
o
o
3. Remainder Return (date of death
prior to 12-13-e2) .
5. Federal Estate Tax Return Required
9. Litigation Proceeds Received
o
o
o
o
4a. Future Interest Compromise
(date.of death after 12-12~2)
o
c
o
4. Limited Estate
6. Decedent Died Testate
(Attach Copy of Will)
7 Deoedenl Maintained a Uving Trust
. (AttaCh Copy of Trust)
8. Total Number of Safe Deposit Boxes
10 Spousal Poverty Credit (date of death
. between 12-31-"91 and 1-1-95)
o
11. Election to tax under Sec. 9113(A)
(Attach Sch. 0)
~ORRESPONDENT. THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED.TO:
ame ; . Daytime Telephone Number
JAMES D. HUGHES ESQ. 7172496333
Firm Name (If Applicable)
SALZMANN HUGHES PC
City or Post OffIce State
CARLISLE PA
ZIP Code
17015
REGISTER OF WII Ci N:;l:l
c::: Q&;tIi
7'~ ::5c;;8
63'-d '-.....~
~~~~~~
ZCll~~OO
\jCiO '"I1'"I1
8g'"I1~~~
DATE FIL~ ~ . ~ ~ tIi
"d~.V'"\~ . (nO
>~ '"I1
First line of address
354 ALEXANDER SPRING ROAD.
Second line of address
Correspondent's e-mail address:
Under penalties of P.8rjury, I declare that I have e~mined this return, including accompanyjilg schedules and statements, and to the best of my knowledge and belief,
it Is true, C:ortect 8.00 complete. Declaration of prepater other than the personalrepresentatilie Is based on all Information Of which. pieparer has any kncNitedge.
SIGNA E OF PERSON RESPONSIBLE FOR NG RETUR DA.
Henry Thomas Purcell
ane, Carlisle, PA 17013
OTHER THAN REPRESENTATIVE
James D. Hughes Esq.
xander Spring Road, Suite 1, Carlisle, PA 17015
Side 1
15056041147
15056041147
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1SDSbD42148
REV-1500 EX
Decedenl'sName: 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.
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.
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 i4'iilX8ble
at sibling rate X .12 0 00
Amount of Line 14 taxable
at collateral rate X .15 0 00
17.
18.
19. Tax Due. ...... ..... ................ ...... ....................................................... ............. ............... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
~121
~\}\t~
Side 2
1SDSbD42148
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
-1,990.50
15.
o 00
o 00
o 00
o 00
16.
17.
18.
o 00
o
1SDSbD42148
.-J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-07-
DECEDENT'S NAME
Dorothy Purcell
STREET ADDRESS
1122 Shannon Lane
CITY I STATE !ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
0.00
0.00
Total Credits (A + B + C)
(2)
0.00
3. InterestlPenalty if applicable
_ D. Interest
E. Penalty
TotallnteresUPenalty (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.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(3)
(4)
(5) 0.00
(5A)
(5B) 0.00
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
No
o ~
D. ~
o ~
o ~
o ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... 0 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.
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?. .... .................................................................................................................
Yes
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the.
surviving spouse is three (3) percent [72 P .S. ~9116 (a) (1.1) (i)).
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero
(0) percent [72 P .S. ~9116 (a) (1.1) (Ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements
for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a
natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. ~9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent,
except as noted in 72 P.S. ~9116 1.2) [72 P.S. ~9116 (a) (1)].
The tax rate imposed on the net value of transfers to or for the use 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-1508 EX + (6-98)
.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
.
Purcell, Dorothy
FILE NUMBER
21-07-
ESTATE OF
Include the proceeds of Irrigation and the date the proceeds were received by the estafe._
All property Jolntly-owned wtth the right of survivorship mu$t be disclosed on sehedule F.
ITEM
NUMBER DESCRIPTION
1 E53 Federal Credit Union - savings account
VALUE AT DATE
OF DEATH
743.94
TOTAL (Also enter on Line 5, Recapitulation)
743.94
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA.1500 Schedule E (Rev. 6-98)
Rev-1510 EX+ (6-98)
.
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Purcell, Dorothy
FILE NUMBER
21-07-
ESTATE OF
This schedule must be completed and filed Wthe answer to any of questions 1 through 4 on the reverse side oflhe REV-1500 COVER SHEET is yes.
ITEM DESCRIPTION OF PROPERTY 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, Recapitulation) 21.863.83
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule G (Rev. 6-98)
REV-1151 EX+ (12-99)
.
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Purcell, Dorothy
Debts of decedent must be reported on Schedule I.
FILE NUMBER
21-07-
ESTATE OF
ITEM
NUMBER
A. FUNERAL EXPENSES:
DESCRIPTION
AMOUNT
Ewing Brothers Funeral Home Inc.
1,653.00
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
B.
Social Security Number(s) I EIN Number of Personal Representalive(s):
.
Street Address
City
Year(s) Commission paid
.
State
Zip
2.
Attorney'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 Thomas 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 Retum Preparer's Fees
7.
Other Administrative Costs
Register of Wills - filing fee
25.00
.
TOTAL (Also enter on line 9, Recapitulation)
5,928.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA.1500 Schedule H (Rev. 6-98)
Rev-1512 EX+ (5-98)
ESTATE OF
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Purcell, Dorothy
FILE NUMBER
21-07-
Include unrelmbursed medical expenses.
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
Citibank - Citibank (SO) N.A./Sears 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
42.40
J.I...:alth...nllth ~..h.:ahilit.:atinn J.ln...nit.:al
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
Internests 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 Memorial Home
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 form software only The Lackner Group, Inc.
Form PA-1500 Schedule I (Rev. 6-98)
Rev.1512 EX+ (6-98)
*'
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TN< RETURN
RESIDENT DECEDENT
Purcell, Dorothy
FILE NUMBER
21-07 -
ESTATE OF
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 form software only The Lackner Group, Inc.
Form PA-1500 Schedule I (Rev. 6-98)
REV 1513 EX+ (9-00)
*'
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
NUMBER
Purcell, Dorothy
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal
aistributions, and transfers
under Sec. 9116(a)(1.2)]
RELATIONSHIP TO
DECEDENT
Do Not List Trustee(s)
FILE NUMBER
21-07-
SHARE OF ESTATE AMOUNT OF ESTATE
(Words) ($$$)
ESTATE OF
I.
Karla Brown
F12 Farmhouse Lane
Morristown, NJ
Daughter
1/4
Henry T. Purcell
1122 Shannon Lane
Carlisle, PA 17013
Son
1/4
Patricia Purcell
112 Lincoln Street Apt 308
East Orange, NJ 07017
Daughter
1/4
Sharon G. Purcell
112 Lincoln Street Apt. 305
East Orange, NJ 07017
Daughter
1/4
Total
Enter dollar amounts for distributions shown above on lines 5 through 18, as appropriate, on Rev 1500 cover sheet
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PARTII- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
0.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule J (Rev. 6-98)
~. CUNA MUfUAL GROUP
April 3, 2007
CUID # : 22893
HENRY T PURCELL
63 ~R~OOjl Rq.
&(ST ,6RANGE, pfJ 07017
bl~fi~~~~n~R.t'Bi3
RE: INDIVIDUAL RETIREMENT ACCOUNT OF DOROTHY PURCELL
Dear HENRY PURCELL:
CUNA Mutual Group extend:> its sincere condoler.ces f~r the loss of DOROTHY PURCELL. We administer the IRA program for E 53
FCU. where DOROTHY PURCELL maintained this account. You have been identified as a beneficiary of the IRA owned by
DOROTHY PURCELL, and you are entitled to 100% of the funds in this account. The value of your share of this IRA as of the
owner's date of death is $21,863.83.
To receive these funds, complete and return the enclosed Benefit Selection Letter following the instructions below:
1: Complete the enclosed Benefit Selection Letter
. Select how you would like to receive the funds
. Select how you would like the payment made
Make a withholding election(s)
. Provide your Social Security number, date of birth, and your daytime telephone number
- Sign and date the letter
2. Return the letter in the envelope provided. If the letter 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 contact a tax advisor.
3. Keep this leller and the Additional Information Form for your records.
Once the Benefit Selection Letter is received, E 53 FeU will be authorized to disburse the IRA funds in the manner you elecl. If 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
Additionallnformalion Form
Boneficiary Payment Option Booklet. A
Return Envelope
cc: E 53 FeU
..
~: .';. . :. -;- ~"* .~
p~~~tipi&on of L_,j
,4. l>roperty
.~ ~/9 1/,[" vr IlJh I/O I.?
. Market Value at
Date. of Death
This Column For
Division Use
. {CC{AILA.4~
"
Name of Beneficiary
Relation to Decedent
n
son
Karla Brown
Patricia Purcell
dauqhter
If the decedent died testate, and the asset listed above do not pass by contract or survivorship, a comolete cony of the
IlIst will and testament. senarate writings and all codicils thereto must be submitted.
In the case of bank accounts be sure to list the name of the institution, title of the account and BALANCE as of the
DATE OF DEATH.
In the case of stocks be sure to include the name of the company, manner ofregistration and the number of shares.
Bonds should include the name of the issuer, manner of registration, date and face value.
A separate affidavit is required 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
1122 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 [S 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. . . .
3. AUTOMOTIVE EQUIPMENT
Vehicle to transfer remains to Funeral Home.
C. SPECIAL CHARGES
Direct Cremation. . . . . . . . .
FUNERAL HOME SERVICE CHARGES
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THA T YOU HAVE SELECTED . . . . . . . . . . . . .
Cash Advances
Cel1it1ed Copies ofthe Death Certificate .
Coroners Authorization Fee. . . . .
Newark Star Ledger Obit. . . . . .
TOTAL CASH ADVANCES AND SPECIAL CHARGES .
Total
Total Cost .
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
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 - 18.0000 % per annum.
~
$875.00
$225.00
$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 ID: 23-2298422
*
INSURANCE: MEDICARE B
147265750A
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
5757
CG0503743
11/05/2005
CCS
NONE
PATIENT NAME: DOROTHY PURCELL
CG0503743
Police/Fire/911
1122 SHANNON LN
TREATED @ SCENE NO TRANSPOR1
DOROTHY PURCELL
1122 SHANNON LN
CARLISLE, PA 17013
REASON(S)
FOR
TRANSPORT
Hypoglycemia
INVOICE
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
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
RECEIPT
PAYMENT DATE
AMOUNT
Bad Debt Write Off ''1/J C Z!~
t: / {'r..;.-> ,
(2 /1J $tJ j(, tJtJ550
NtlrMS bll 'J a 7ipt
1 '7 - (p J.- 0
04/24/2006
35.99
PLEASE PAY THIS AMOUNT ~
Total Credits - D -
- -99
35"
PATIENT NAME:
PATIENT NUMBER:
PURCELL, DOROTHY
5757
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE
AMOUNT $
ENCLOSED
g 5, 'ltj
CALL NUMBER
BILLING DATE:
CG0503743
01/29/2007
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
Police/Fire/911
1122 SHANNON LN
TREATED @ SCENE NO TRANSPORl
DOROTHY PURCELL
1122 SHANNON LN
CARLISLE, PA 17013
REASON(S)
FOR
TRANSPORT
DIABETES MELLlTIS
INVOICE
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE 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 Charges 108.46
DESCRIPTION OF PAYMENT
PAYMENT DATE
AMOUNT
Bad Debt Write Off
tlC/' (ifS
?tJ t3qK ~~SSD .
/ddfiFlSbu1J ~ 1&1/
fJ /1- (bS"d. - yo 2,0
11/21/2006
108.46
Total Credits - 0 -
PLEASE PAY THIS AMOUNT ~
I tJ g; y,G,
PATIENT NAME:
PATIENT NUMBER:
PU~CELL, DOROTHY
5757
.
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE
AMOUNT $
ENCLOSED
CALL NUMBER
BILLING. DATE:
CG0602071
01/29/2007
. /'\ P' li.,
1u:J " 7
Cumberland-Goodwill Fire Rescu GENERAL RECEIPTS PHilADELPHIA, PA 19101
LTD.
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 Mirarchi, D.O.
Wendy Schaenen, M.D.
Patrick Ratnasamy, M.D.
V. Martha Kapoor, M.D.
Shubha R. Acharya, M.D.
Pratheesh Viswanathan, M.D.
Alen J. Sweeney, M.D.
Roxana Vargas, M.D.
Dean L. Lehman, PA-C
Vinayshree Kumar, PA-C
Jody Searight, PA-C
Brent Calhoon, PA-C
. . .
01/25/07
. : .
44631
. . :.
550.90
. .. '.
550.90
PLEASE MAKE CHECK PAYABLE TO:
INTERNISTS
of Central Pa.
IRS# 23-2146427
HARRISVIEW PROFESSIONAL CENTER . 108 LOWTHER sT. . P.O. BOX 107. LEMOYNE, PA 17043-0107. (717) 774-1366 FAX (717) 774-4232
:1 ~"i :.I.]~l:n:IIl:l:1'1:'.~"~'~'i'jl
CHARGES OR PAYMENTS MADE
AFTER CLOSING DATE WILL
APPEAR ON NEXT STATEMENT.
DOROTHY PURCELL
1122 SHANNON LANE
CARLISLE PA 17013
L
J
~
. . ..
o PLEASE CHANGE ADDRESS IF INCORRECT
** Statement Due Upon Receipt * Thank You **
* Insurance Pending
CLOSING
DATE:
ACCOUNT
NUMBER
01/25/07 44631
INTERNISTS OF CENTRAL PA. . 108 LOWTHER ST. . P.O. BOX 107 · LEMOYNE, PA 17043-0107 . (717) 774-1366 FAX (717) 774-4232
,..... A "'1"'.... 'U. .... Ill. T
Vascular Associates P
816 Belvedere Street
Carlisle,PA 1712113
717--241'--51217121
/
Dorothy Purcell
1122 Shannon Lane
Carlisle,PA 1712113
Date Dr. Procedure Code
1216/15/715><x{
1217/24./715
1218/23/ 6
1219/19/ 5
1219/19/ 5
12161 15/716xx
1217/24/ 5
1217/2'+/ E,
1216/15/ 6xx'
1217/2'+/ 6
1217/24/ JEJ
1216/15/ 6xx
1217/24/ 6
1217/i:~4/ 6
1216/15/ EJx x (
1217/24/-6
1218/1214/ 6
0B/i:~3/ 5
Tax Id:
37205
35L~ 7 '+
36246
3721216
75961Z1
75710
Please remove and return this portion with your payment.
. .
. ... .
833.121121
el. 00
121.1210
~3~:19. 67-
258. bE.-.
12I.0iZl
0.00
7 1 LI', Il~li.)
0.121121
ill. 1211Z1
18L~. 11-"
483.86
550.12I1Z1
275. 12
2 1 '3. 10-'
389.121121
17L~.51
171. !,59-
154.1210
59. E.6
t=J7.47
107. i()0
0.0121
11217. 00-'
0.0121
fJ4. t-.J7
L~f). \'Z13
54.780
42.90
1 E,. 807
el.12.10
0\1
Phone: 7 7-241-5071Z
~56f,. 30
Endo-Stent Placement-1st 785.4
Plan Payment:10753
Plan Payment:10753
Adj:Medicare Write
Plan Payment:10751
Plan Payment:10761
Payment-Thank You
added 79mod per linda mcr re
Endo-Perc Trans Angio-Fe 785.4
79 modifier added
Plan Payment:10753
Plan Payment:10761
Plan Payment:10766
Adj:Medicare Write
Endo-Select Cath-aort,pe 785.4
Adj:Medicare Write
Plan Payment:10753
Endo-Stent Plac,Perc Add 7805.4
Adj:Medicare Write
Plan Payment:10753
Endo-Sup/lnter-Stent Pia 785.4
Adj:Medicare Write
Plan Payment:10753
Artefi~l-extremit~ Arter 7805.4
Plan Payment:10753
Adjustment PA MEDICARE
Plan Payment:10761
mcr rejects: 35474 C0971
Vascular Associates P
B16 Belvedere Street
Carlisle,PA 1712113
248. ~12
CONT'D
PATIENT t
BALANCE
AMOUNT DUE
D ot~ 0 thy Pun: e 11
1122 Shannon Lane
Carlisle~PA 1712113
Date Dr. Procedure Code
759t=J~:::~
1216/15/6xx"
07/24/ 6
('lJ7/24/ G
i:3392t:t
0G.l29.1Z1Gxx,{
07 /i:~4/ E,
07/24/ 6
09/ :l41 .f:,
OS/29/
07/24/
07/24/
07 /11/
08/08/
08/08/
10/13/
07/18/ 6j
08/08/ (;
08/08/ G
Tax Id:
93971
99;::~ 12
'-'., ~; .~:; 0 c. i a 1:.: e ~:. (:1
81f. Belvedey'e St:r'eet
Carlisle,PA 17013
71 7 '-c~L~ 1--~5121'71Z1
11/14/0(;
Pll?CiSe rem.oye and return this portion with y()ur payml?nt
. .. . ... .
COB15/
mcr rejects: 7571121
r~o-gf"
Endo-Ball Angio -Periph- 785.4
Adj:Medicare Write
plan Payment:liZl753
mcr rejects: 35474 C097/b
mcr rejects: 37205 C097/b
mcr rejects: 7571121 COB15!
included, not paid ssp
Non-Inv-LE Arterial Dupl 440.23
Adj:Medicare Write
Plan Payment: 1121753
Plan Payment:per e
policy not in effect
Non-Inv-Extremity-Venous 44121.23
Adj:Medicare Write
Plan Payment:1iZl753
Office Visit Straightfor 440.24
Adj:Medicare Write
Plan Payment:liZl755
Plan Payment:per e
coverage not in effect
Office Visit Expanded Pr
Adj:Medicare Write
Plan Payment:1iZl757
44121. 2L~
51.euLi
23. Lt~J.
~~2. el~:::~
;~56. 00
9f+. 1 ':j
lc~;31: 45
~~. 00
c~;~9. 00
79. 72.
11 '3. 42-
50.0121
.-.-:. t::::7
c....:;;.~(
29. 14-
0.00
75.00
;::5. 11.
39.91-'
5.51
"":.'-:' -;;- z::
"_IL...u -....Ib
29.85
7.29
9.98
ov
Phone: 717-241-507~
99213
5G6. 3121
Vascular Associates P
816 Belvedere Street
Carlisle,PA 17013
318. ;::~7
Il~. iZllZi
CONT'D
PATIENT t
BALANCE
AMOUNT DUE
Vascular Associates P
816 Belvedere Street
Carlisle,PA 17013
717"'-c:L~1--~)'~7Ilj
Do to. 0 thy P U'r' cell
1122 Shannon Lane
Carlisle,PA 17013
Please remove and return this portion with your payment.
1- .. .....
Date Dr. Procedure Code
- .
0.00
Plan Payment:per e
policy not in effect
10/13/716
147B.00
7LI'1. 01-..
589. 59-'
5121. QH2I
0.00
147.4121
Amputation Above Knee 440.24
Adj:Medicare Write
Plan Payment:10760
Hospital-Visit-Focused-B 440.24
Plan Payment:i0760
mcr rejects: 99231 C097/t
Adjustment PA MEDICARE
2759Q1
1217 /;:~QI/ If:,j
08/1.7/216
e18! 17/ 71f:,
07/19/716j
08/ :l7 / 716
0..00
99;:::31
5el. tZHt)-.
tL~9/06/ Zl6
1183.00
t;,39.75
L~34. f..:.0-
0. 0Q)
1.08.65
Amputation Finger/thumb 785.4
Adj:Medicare Write
Plan Payment:10765
Plan Payment:per e
policy not in effect
i:~G951
08/16/716j
Ql9/12/16
09/12/216
11/13/lfJ
Vascular Associates P
816 Belvedere Street
Carlisle,PA 17013
ov
Phone: 7 7-241-50712
Tc.~x Id:
5EfJ. 3121
PATIENT t
BALANCE
AMOUNT DUE
5GE... 3121
See reverse side for explanation of columns.
CP02 BILLING CENTER
151 NORTH 5TH ST.
MIFFLlNBURG, PA 17844
DOROTHY PURCELL
0094-0078993-000003-MC
05/31/2007
MIXED AADC 085
DOROTHY PURCELL
C/O SALZMAN HUGHS,P.C.
354 ALEV ANDER SPRING RD SUITEA
CARLISLE, PA 17015
1...111...111..1.1.11.111.1
CP02 BILLING CENTER
151 NORTH 5TH ST.
MIFFLlNBURG, PA 17844
Detach and return 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
CP02 BILLING CENTER
151 NORTH 5TH ST.
MIFFLlNBURG, PA 17844
(866) 227-9229
9478993
Total
'Balance reflects the charges assigned to the patient as of this statement date. BALANCE is SUBJECT to CHANGE.
Page: of
Date of Description of Service Amount Patient
Service Billed Activity
10/11/2006 R-02 PORT ABLE UNIT 64.00 6.41
31.93-
10/11/2006 R-02 CONCENTRATOR 85 PE 410.00 40.08
209.59-
11/11/2006 R-02 PORTABLE UNIT 64.00 6.41
31.93-
11/11/2006 R-02 CONCENTRATOR 85 PE 410.00 40.08
209.59-
Please remit balance d 7-9229 ext 28
WEST SHORE EMS - CARLISLE
205 GRANOVIEW AVE
SUITE 211
CAMP Hill, PA 17011
Phone #: (800) 367-0512 Federal Tax 10: 23-2463002
INSURANCE: MEDICARE B
CEL TIC
147265750A
0000170733
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
34446
3053953
11/15/2005
CCS
NONE
PATIENT NAME: DOROTHY PURCELL
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
DESCRIPTION OF CHARGE
QUANTITY
UNIT PRICE
AMOUNT
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
)1ucil~ ~ III~D
~ ~[) '/U4Dfo'
J~
Total Charges
629.37
RECEIPT
PAYMENT DATE
, AMOUNT
Bad Debt Write Off
03/24/2006
629.37
dJ
J &AU(};I ~a~~
629.37
PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT ~
RETURNED CHECK FEE - $32.00
$0.00
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE 0.00
CALL NUMBER 3053953 AMOUNT $
BILLING DATE: 01/26/2007 ENCLOSED
~ VISA I.]
~ AND ~Q'
MASTER CARD
ACCEPTED
W~C:::T C:::J.ln~~ I=MC::: _ ~4~11C:::1 1= ?n~ ~~4NnVII=W 4VI= ~4MP J.l1I1 P417n11
WESTSHOREEMS-BLS
205 GRANOVIEW AVE
SUITE 211
CAMP HILL, PA 17011
Phone #: (SOO) 367-0512 Federal Tax 10: 23-2463002 WEST SHORE
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
DESCRIPTION.OF CHARGE
QUANTITY
UNIT PRICE
AMOUNT
Wheelchair One Way Transport
Transport Van Mileage
A0130
A0999
1.0
5.0
53.92
3.24
53.92
16.20
,
'--.
(/) l/Vl
Total Charges
70.12
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Bad Debt Write Off 10/13/2006 70.12
Total Credits 70.12
PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT -.- $0.00
RETURNED CHECK FEE - $32.00
PURCELL, DOROTHY
34446
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE
AMOUNT $
ENCLOSED
0.00
CALL NUMBER
BILLING DATE:
145408W
01/26/2007
== ::: [.1
MASTER CARD
ACCEPTED
WF~T ~1-40RE 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
INSURANCE:
MEDICARE B
CELTIC
147265750A
0000170733
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
34446
0604209
11/06/2006
IBAL
IBAL
PATIENT NAME:
DOROTHY PURCELL
0604209
FMC DIALYSIS
CARLISLE REGIONAL MEDICAL CTR
DOROTHY PURCELL
SALZMANN HUGHES PC
354 ALEXANDER SPG RD STE 1
CARLISLE, PA 17015
REASON(S)
FOR
TRANSPORT
Hypertension
RENAL FAILURE -ACUTE
INVOICE
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
ALS EMERGENCY LEVEL 1 A0427 1.0 1015.98 1015.98
ALS MILEAGE A0425 5.0 11.32 56.60
EKG ELECTRODES A0396 1.0 4.70 4.70
Oxygen Administration A0422 1.0 56.15 56.15
Total Charges 1133.43
DESCRIPTION OF PAYMENT RECEIPT. PAYMENT DATE AMOUNT
Medicare Assignment Adjustment 12/15/2006 762.12
Medicare Part B Payment 107845439 12/15/2006 297.05
Total Credits 1059.17
PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT ...... $74.26
RETURNED CHECK FEE - $32.00
PATIENT NAME:
PATIENT NUMBER:
PURCELL, DOROTHY
34446
DETACH ALONG PERFORMATIQN AND RETURN STUB WITH PAYMENT
AMOUNT DUE
AMOUNT $
ENCLOSED
74.26
CALL NUMBER
BILLING DATE:
0604209
03/06/2007
This account is now PAST DUE!! Payment must be received
WITHIN 10 DAYS. Collection process will begin.
WEST SHORE EMS - CARLISLE 205 GRANDVIEW AVE
~ VISA lel
~ AND Ie, ..,
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
INSURANCE: MEDICARE B
CEL TIC
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
DESCRIPTION OF CHARGE
QUANTITY
UNIT PRICE
AMOUNT
WHEELCHAIR VAN TWO WAY
A0130
1.0
60.00
60.00
~'s~~
LfL ~ fh.R cU (! (}.I\JL
i
)/rUJ..U
~-~~ (
(J (!
('
Total Charges
60.00
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT ...... $60.00
RETURNED CHECK FEE - $32.00
PATIENT NAME: PURCELL, DOROTHY
PATIENT NUMBER: 34446
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE
AMOUNT $
ENCLOSED
60.00
CALL NUMBER
BILLING DATE:
148831W
01/26/2007
I VIM I ~:: \.1
MASTER CARD
ACCEPTED
\AICC::T C::l.lnDJ: J:M~ _ r.ARII~LE 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
l.J~
\~J
WE\.......,. S' . iT: . 'S' Hi' '0'. ,'REi '. i'
\ -', ,I '"c, ',i : _ :'; ',,';; ", -
f"C,_.~ .0... _, ..-' , . ,_' d" .0__,.0. .
INSURANCE: MEDICARE B
CEL TIC
147265750A
0000170733
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
34446 WCS
148848W REVW
11/20/2006
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
DESCRIPTION OF CHARGE
QUANTITY
UNIT PRICE
AMOUNT
WHEELCHAIR VAN TWO WAY
---
A0130
1.0
60.00
60.00
~s T- ~
~.&.t \~~ OL &t ~
&
a-
Total Charges
60.00
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
.
PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT ~ $60.00
RETURNED CHECK FEE - $32.00
PATIENT NAME: PURCELL, DOROTHY
PATIENT NUMBER: 34446
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE
AMOUNT $
ENCLOSED
60.00
CALL NUMBER
BILLING DATE:
148848W
01/26/2007
I V~ I ~:: l.~l
MASTER CARD
ACCEPTED
'AIC~T ~unl:)!: !:I\JI~ _ RI ~ ?n5 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
/~\
~~....<::'
\.......... ,.1
WES' ""'iT "SH' O,"'R'" 'E'."
\, :\ 'i-,'" ,.I. l'-, ,,: " J .: '-'_ '. "
f':\'l;:,? ~ :;'":
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
PATIENT NAME: DOROTHY PURCELL
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
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
ALSEMERGENCYLEVEL1 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
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Medicare Assignment Adjustment 01/16/2007 727.60
Medicare Part B Payment 107900790 01/16/2007 292.21
Total Credits 1019.81
PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT ~ $73.05
RETURNED CHECK FEE - $32.00
PATIENT NAME: PURCELL, DOROTHY
PATIENT NUMBER: 34446
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE
AMOUNT $
ENCLOSED
73.05
CALL NUMBER
BILLING DATE:
3075145
03/22/2007
This is the amount due after your Insurance Carrier's
payment.
\An::~T ~unDt: t:uC:: _ rd~1 I~I F 205 GRANDVIEW AVE
I VISA' I ~:: \.1
MASTER CARD
ACCEPTED
CAMP HILL. PA 17011
Statement
United Church of Christ Homes
Sarah A. Todd Memorial Horne
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
____________________________________________________J___________________________
BALANCE FORWARD
05/31/07 Finance Charge
, ~, ?'
" ,,~ ~'f
2:'j~39. 83
'fJ5.50
2,839.83
2,875.33
lHff~CJJ If rIDUD rn
THIS Jl,CCOmH ''It.S NO DOUBT
ESCAPED YOUR NOTICE. Wilt you
PLEASE SttiO US A REMITTAIKE.
NOTE: ***** PAYMENT IS DUE UPON RECEIPT ***** BUr NO LATER THAN
THE 25TH OF THE MONTH ***** Please remit the LA~t AMOUNT printed on
your statement. Include the ACCT# from the state~~nt on the MEMO LINE
of your check. PaYments after 6/6/07 do not refleCt on statement.
NOTE: ** LATE PAYMENTS ARE SUBJECT TO A 1.25% LATE CHARGE PER MONTH **
A $10.00 FEE WILL BE CHARGED for RETURNED CHECKS **
MOBILE X-RAY IMAGING, INC
945 EASTPARK DR SUITE 102
HARRISBURG, PA 1711 I
Ifpaying by credit card: VI, MC, DISC or AM EXP-acct#
3 digit# on back of card _, name on card address
STATEMENT
1-800-420-X-RA Y (9729)
WE ACCEPT MAJOR CREDIT CARDS
expiration date
I
I
SALZMANN HUGHES, P.c.
ATTORNEYS & COUNSELORS AT LA W
354 ALEXANDER SPRING ROAD, STE I
CARLISLE PA 17015
L
--3
--..
OFFICE USE ONLY
RP35582 04/23/07
XACTl
-
BERFECT
CARE @
DESCRIPTION
.... PLEASE DETACH HERE AND RETURN TOP STUB WITH YOUR PAYMENT ....
:. .
I' . DiBI!miEIIR_et:r.":(C1=--'~~"i~(f:kl(I!I~."'JlI'''''''Ill'J'::I~I..:T.i"'I::I~..:I"I'.
@COPYRIGHT 2002. sri COMPUTER SERVICES, INC
71010 Chest Xray Single View TEGX 1.00
Patiel1t:DOROTHY PURCELL - 173412
11/27/2006 Highmark Medicare Services
73030 SHOULDER 2 VIEWS PROFES TEGX 1.00
Patient: DOROTHY PURCELL - 173412
Medicare Services
Q0092 TEGX 1.00
PURCELL - 173412
Highmark Medicare Services
R0070 Xray Equipment TEGX 1.00
PURCELL - 173412
Medicare Services
27.00
7.34 17.82
27.00
7.34 17.82
28.60
8.99 17.36
160.00
123.06 6.17
72.60
16.57 51.89
1.84
1.84
2.25
30.77
4.14
Please call or write with your other
insurance information. If you have
no other insurance, please remit
payment immediatley. Thank you
MESSAGE: SEE REVERSE SIDE IF AN INSURANCE MESSAGE APPEARS......
. NEW INS. PMT.
SINCE LAST BILL
NEW PAYMENTS
SINCE LAST BILL
PLEASE PAY
SALZMANN HUGHES, P.c.
40.84
CURRENT DUE
PAST DUE
FINANCE CHARGE
Mobile X Ray Imaging Inc. 945 EAST PARK DR. SUITE 102 . HARRISBURG, PA 17111
,.................., .
................. .'
HBCI
PJRCELL, DOHO~HY ~~~//~4~ - U~/lb/~UUb U~~AIL U~/~l/LUUb 1 pg
~..... o:;~
TYPE Of
BIll
DATE OF
BILL
OlJARAmol'IR
t:fAMf
Aim
ADORES;)
DOROTrL. prJRCELL
1122 SfiAl',lNON Ll\NE
CARLISLE FA 17013
DESCRIl'TlOlJ (jf
HOSPITAL SERVICES
DETA L OF CURRENT CHARGES, PAY~ENTS AN
08/16 PUMP SET 3Y TYPOl16139313 58.00
08/16 SECONDARY SET 0116139339 24.00
08/16 CEFAZOLIN 500MG0244080364 28.00
08/16 CEFAZOLIN 500MG0244080364 28.00
08/16 MIDAZOLAM 1MG/M0144140242 11.00
08/16 MIDAZOLAM 1MG/M0144140242 11.00
08/16 BUPIVICAINE 0.20244720019 22.00
08/16 LIDOCA 1% 30ML 0144720118 13.00
08/16 TOES-AMPUTATION0110092633 84.00
08/16 HAND DRAPE 0110230118 52.50
08/lE I<EELIX 4" 0110242451 3.50
08/16 GELSKIN PREP TR0110243814 9.50
08/16 SKIN STAPLER CA0110244069 30.00
08/16 UNIV EXT DRAPE 0110265676 25.00
C8/1E HSC MINOR KIT 0110500767 24.75
08/16 ELECT PEN W/HOL0110507531 9.25
C8/1E GROUND PAD ADUL011410J147 9.00
08/1E BAND ELAS FE 4"0114122139 12.00
G8/16 IV START KIT 0114123152 7.73
08/16 BANDAGE ELAS 4"0114124713 3.00
08/1f IV CATH 20X1-1/0114126239 6.00
08/16 IV CATH 22X1 0114606248 7.00
08/16 IV CATH 22Xl 0114606248 7.00
08/16 NACL 0.9 1000 0116130635 23.00
08/16 DECALCIFICATION0125501305 180.00
08/16 TISSUE GRS&MIC-0125505306 251.00
08/16 OR-1ST 1/2 HR 10110103000 1161.00
08/16 OR-ADD TIME II 0110103018 633.00
08/16 BASE UNITS 0349102320 330.00
08/16 CRNA TIME UNITS4449103021 440.00
08/16 MAC I SUPPLIES 0149111040 S13.00
08/16 OPS LEVEL I 0211101250 440.00
GROUP tR1HIll-:R
1~1265-;:),~~_
JOHN S
L
I
-,-!
E~;T. COVE;U\(;[ P,'oT I r~trr
IUS. co. }oj.). -I A'.tO-JrfJ"
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
ADDITION"AL PATIENT BILLING MA;( BE NECESSARY
FOR ANY CHARGES NOT POSTED WHEN nns STATE-
MENT WAS PREPARED ~ OR IF INSURANCE CARRIERS
DO NOT PAY ANY PART OF nIE AMOUNTS SHOWN
UNDER ESTIMATED INSURANCE COVERAGE.
PUECELL, UUKUTJiX Lb:J.5L:J::J'l - V':JILIILVVV '-'~~,..,~~ ~v'v.,_vvv
GUARAtrrOR
NI\ME
AND
ADDRESS
DOROTHY PURCELL
1122 SHANNON LANE
CARLISLE PA 17013
DETA L OF CURRENT CHARGES,
09/27 AVELOX 400MG TA0144083020
09/27 APAP 325MG TAB 0344280014
09/27 ALARIS EXTENSI00114128169
09/27 VENIPUNCTURE 0117111030
09/27 BBGT 0125109125
09/27 METABOLIC PANEL0125201070
09/27 CPK (CREAT. PH00125204108
09/27 CKMB 0125204165
09/27 PRO BNP 0125205162
09/27 CBC,AUTO DIFF 0125301201
09/27 MANUAL DIFFEREN0125301805
09/27 BLOOD CULTURE 0125402801
09/27 BLOOD CULTURE 0125402801
09/27 BLOOD BANK/HOLD0125800004
09/27 TROPONIN T 0125205071
09/27 CHEST PORT 0136501070
09/27 IV PUSH 0117100033
09/27 LEVEL IV 1-4 HROl17105917
09/27 EKG 0173111007
09/27 EKG PC-INTERPRE0173131005
BALA CE FORWARD
SUMM RY OF CURRENT CHARGES
PHARMACY 250
M/S SUPPLIES 270
LABORATORY 300
OX X-RAY 320
EMERGENCY ROOM 450
EKG/ECG 730
HOLY SPIRIT HOSPITAL
CAMP HILL, PA
n.................... 1 r..-F ?
5.81
15.00
48.00
118.00
48.00
47.00
182.00
81.00
37 .00
220.00
220.00
68.00
358.00
155.00
823.00
135.00
29.00
0.00
21.05
5.81
1084.00
358.00
978.00
164.00
NUIlBER
147265750A
ETI. COVERAOE PATIENT
HIS. CO . NO.4' AHOUHT
5.81
15.00
48.00
118.00
48.00
47.00
182.00
81.00
37.00
220.00
220.00
68.00
358.00
155.00
823.00
135.00
29.00
21.05
5.81
1084.00
358.00
978.00
164.00
2610.86 2610.86
;;\:JJL6::l:o.:U:a:6.:: :m:2:61:o.::~::g6.::::
....................................n.. ...............-.............................
ADDITIONAL PATIENT BILLING MAY BE .NECESSARY
FOR ANY CHARGES NOT POSTED WHEN TIllS STATE-
MENt WAS PREPARED~ OR IF INSURANCE CARRIERS
DO NOT PAY ANY PART OF TIlE AMOUNTS SHOWN
UNDER ESTIMATED INSURANCE- COVERAGE.
Attorneys at Law
175 South 3rd St., Suite 900
Columbus, OH 43215
(614) 801-2710 (800) 893-5041
(614) 801-2604 (fax)
Mon-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
BROOKLYN HTS, OH
216.739.5100
BURLINGTON, NJ
609.914.0437
CHICAGO, IL
312.782.9676
CINCINNA n, OH
513.723.2200
CLEVELAND, OH
216.685.1 000
WELTMAN, WEINBERG & REIS CO., L.P.A.
March 14,2007
JAMES HUGHES, Esquire
354 ALEXANDER SPRING RD SUITE 1
CARLISLE, PA 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 43272 with check made payable to DISCOVER
FINANCIAL SERVICES LLC.. Please include our seven-digit file 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.
nkie L. Hance
Probate Specialist
Ext. 22777
This la,y firm is a .dcbt collector attempting to collect this debt for our client and any information obtained will be
used for that purpose.
650 /5230906
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 ELLEN WEEMAN - KS, MN, MO
STEVEN M. TOMS - MN
MEAGAN M. PROBST - MN
MICHAEL J. DOUGHERTY-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
MARTHA J. BALDWIN - MN
SEND ALL WRlnEN REPLIES TO:
4150 OLSON MEMORIAL HIGHWAY, SUITE 200
MINNEAPOLIS, MINNESOTA 55422-4811
TELEPHONE 763-852-8449
FAX 866-234-0503
TOll-FREE 877-768-4494
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,
Balogh Becker Ltd.
A ttorneys 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.
GONBAL0017103
111111111111111111111111111111111111111111111111111111111111111111111I111111111I111111111111111I1111111111111111111
1111111111111111111I1111111111111111111111111
LAW FIRM OF BALOGH BECKER, LTD
4150 Olson Memorial Highway, Suite 200
Minneapolis, MN 55422-4811
ADDRESS SERVICE REQUESTED
Account #: ............3903
Balance: $1700.27
Client 10: SEAR50
February 23. 2007
11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111I1111111111111111111
1111111111111111I11111111I111111111
BALOGH BECKER, LTD
4150 Olson Memorial Highway Suite 200
Minneapolis MN 55422-4811
1,1,1"1.1,, 1,,1,. I. 1,.1,1,1,,11,,1.,. ,11",11,1,1. II"". 11.1
............3903-7103 354513 35462
I.. ,III" .111".,,, 11.1,1. I" .1,1. ,1,1. 1,.,.1111...". III" I. I
JIM HUGHES
354 Alexander Spring Rd Ste 1
Carlisle PA 17015-7451
Undeliverable Mail Only:
~/;edlnterstate
Inc.
~
800 Interchange West
435 Ford Road
Minneapolis, MN 55426-1096
P.O. Box 1954
Southgate, MI 48195-0954
111111111111111111111111\1111111111111111111111111\111111111\111111111
Toll Free: 800-790-0278
MM1/83245312/XCB 008 12954064 0005424/0016
1..1111...111.111.111.1111.11111...111.1.1.11.1.1.1.11.1.111.1
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 balance in full to the address provided on the
remittance coupon below. For your security, please make your payment 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 http://alliedinterstate.callipav.com and use the following information:
User Name: UD14 Password: 8324531217013
Unless you notify this office within 30 days 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, this office will obtain verification of the debt or obtain a copy of a
Judgment and mail you a copy of such judgment or verification. If you request this office in writing within 30 days after receiving
this 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.
-,,-'-'-'.......;._.~..;...;.;.,;..:...:..:.~.;;..._......:..:..:..........--..:..;.--_..;.---_.._~'_-..:..'-'...:_-----.................---------.....:,..........--.........-................-".-..;:---.............................................---_...--------.........;.;.;..-_...---_............_..._'_........;..--_..-------_...__....._~......._-_...-~_..._..._--_.__.._-;.-'----------_......_......_....._...
Detach and return with payment
Sincerely,
Account Representative
800-790-0278
Allied Interstate, Inc.
Date:
Client Ref Number:
Client:
Amount Due:
Amount Remitted:
Nov. 15,2006
9344137
CARLISLE REGIONAL MEDICAL CTR
$74.59
$
Payment and Correspondence Address:
MM1/83245312/858
Allied Interstate, Inc.
Healthcare Division
P.O. Box 361533
Columbus, OH 43236-1533
1.1..1..11'111.1..11..1111...11.1.1".1111.11111'111
Yr'R
Date: 11/06/2006
WEST SHORE PATHOLOGY
PO BOX 750
SCRANTON PA 18501
Amount Due: $19.63
v
$19.63
Address Service Requested
PHL4*26*28114536
iiiiiiiiiiiiii
!!!!!!!!!!!
iiiiiiiiiiiiii
-
!!!!!!!!!!!
iiiiiiiiiiiiii
iiiiiiiiiiiiii
!!!!!!!!!!!
MED571.A1R8FC000043.A12PKW.001023 001021
Mail Payment to:
DOROTHY PURCELL
1122 SHANNON LN
CARLISLE PA 17013-1783
WEST SHORE PATHOLOGY
PO BOX 750
SCRANTON PA 18501-0750
11111111111.1.1.111'11111111'1111111.1.1.11111.1.1.111..1'11.1
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
PO BOX 517
HAZLETON, PA 18201
800-450-6208 EXT 212
STATEMENT
. IL-.'''\.oJ1 ,t-, .,...A.JI-'_' '-'I _.....,....__............_,
11-14-06
1~
212-09-06 57 trlED I CARE PAYMENT RECON 107108356 198.06 -198.06
212-09-06 57 MEDICARE ADJUSTMENT RECON 10710835E.; .0121 --198.06
213-03-06 57 INSURANCE CO PAYMENT 022006 -49.52 -247.58
08-09-06 57 INSURANCE CO REFUND CK#5~579 198.06 -49.52
07-01-06 110 HEMODIALYSIS trlCP DOROTHY JRD 400.00 350.48
tht-'ll 07-3 -06
218-31-06 110 MEDICARE Pi=WMENT RECON 1076283~5 195.33 155. 15
08-31-06 110 MEDICARE ADJUSTtrlENT RECON 107628355 155.34 -. 19
10-05-06 110 INSURANCE CO PAYtr1ENT 092606 .00 -. 19
10-05-06 110 POLICY NOTIN EFFECT AT TOS
07-30-06 121 SUBSEQUENT HOSPITAL CARE DOROTHY SJH 116.00 115.81
09-21-06 121 MEDICARE PAYtr1ENT RECON 10767300Lt -43.23 72.58
219-21-06 121 MEDICARE ADJUSTMENT RECON 107673004 -61.96 10.62
11-02-06 121 INSURANCE CO P'WMENT 102306 .00 10.62
11-02-06 121 POLICY NOT IN EFFECT AT TOS
217-31-06 122 HEMODIALYSIS DOROTHY DHM 247.00 257.62
219-21-06 122 MEDICARE PAYMENT RECON 10767301214 -56.29 201.33
09-21-06 122 MEDICARE ADJUSTtrlENT RECON 107673004 176.64 24.69
11-02-06 1 --.0-' INSURANCE CO PAYMENT 102306 .0121 24.69
CoCo
11-02-06 122 POLICY NOT IN EFFECT AT TOS
PLEASE MAKE CHECKS PAYABLE TO:
HERSHEY KIDNEY SPECIALISTS, INC
PA.Ylv!EJ.1T DUE:
Nav 282006
Please Return This Portion With Your Remittance
001070
DOROTHY PURCELL
1122 SHANNON LANE
CARLISLE PA 1712113
c~
\
-'-
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
SECOND NOTICE
t
"'-""-"'-""-"'-',
....c..... . ...._..'___.c..........:..'........
mE:S,~~lPf:rON '
l
AMQWNT
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 PA YBLE TO: HEAL THSOUTH
**VISA/MASTERCARD ACCEPTED
RETURN THIS PORTION WITH PAYMENT TO:
HEAL THSOUTH Rehabilitation Hospital
of Mechanicsburg
175 Lancaster Blvd.
Mechanicsburg, PA 17055
(717) 691-3700
COMPLETED BY: tqj TV BILL
HEAL THSOUTH Rehabilitation Hospital
Of Mechanicsburg
P.O. Box 140065
Nashville, TN 37214
1111111111111111111111111111111111111111
00143
CAPITALAccOUNTS
~.
P. 0. Box 140065
Nashville, TN 37214
800.282.3214.800.296.3317 (fax)
7234-14
Dorothy Purcell
1122 Shannon Ln
Carlisle P A 17013-1783
111I11I11I11I11I11I111111'11I11111I11111'111111I1.1111.1.1.1.1
Date: 11/14/2006
Account: 198282
Client: Pinker & Assoc
Balance: $62.19
Credit Bureau Notification
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 governed accordingly.
This letter is an attempt to collect a debt. All information obtained will be used for that purpose.
Pay by phone at 800.282.3214
*** Ask for Dan Stevens ***
Direct all payments to Capital Accounts
RETURN BOTTOM PORTION WHEN PAYING BY MAIL
Dorothy Purcell
1122 Shannon Ln
Carlisle P A 17013
1111111111111111111111111111111111111111
Visa [ ] MasterCard [ ] AMEX [ ] Discover [ ]
Card Holder Name:
Card Holder Signature:
CREDIT CARD NO.:
0000000000000000
EXPIRATION DATE: PAYMENT AMOUNT:
DODD $
Capital Accounts
PO Box 140065
Nashville TN 37214-0065
11111.1...1111.111.11.1..111...11....11...1.1..1111.1.1'11.111
Account Number: 198282
Amount Due Now: $62.19
DL2-04
~5~FEDERAl
~ I~ 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 21,2007
Salzmann Hughes, P.C.
Attorneys & Counselors at Law
354 Alexander Spring Rd, Suite A
ChambersburK. pA.n015
RE: Estate of Dorothv Purcell
Dear Sir or Madam:
In reply to your later dated December 27,2009 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): $889.60 plus $10.35 in accrued interest.
4: If there is any credit life insurance on the account. Yes, we pay up to $15,000.00 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,
1m Patton
E53 Federal Credit Union
(908) 523-5729
fJ
AM E R I C A'S
CREDIT UNIONS'.
Where people are worth more than money.7V
t:l~
FEDERAL CREDIT UNION
U~J"V 1 n, ru""'t:LL.
Account Number: 4820994331106777
Closing Date: 06/21/06
Credit Limit: $3,500 Available Credit: $2,426
Cash Limit: $3.500 Available Cash: $2,426
~
Customer Service:
(800) 299-9842
To Report a Card Lost or Stolen:
(727) 570-4881 LOCAL
(866) 604-0381 TOLL-FREE
Please Direct Written Inquiries to:
CUSTOMER SERVICE
PO BOX 30495
TAMPA, FL 33630
To view or pay your account on-line:
WVIIW.eZCardlnfo.com
~".'
~
Previous Balance $ 1,035.17
Purchases + 25.90
CRS/:1 + 0.00
Credits 0.00
Paym~nts 0.00
Insurance + 0.00
Other Debits + 0.00
Finance Charges ~ 12.36
NEW BALANCE $ 1,073.43
. -:0" . -. -
VISA
/
~
Bonus Points
Available
9,734
~.'."..-'-'.'
~
Total Minimum Payment Due $65.00
Payment Due Date NOW DUE
Mail Payments to: VISA PO BOX 31279 TAMPA FL 33631-3279
. PLEASE NOTE MINIMUM PA YMENT DUE. WE MA Y REPORT INFORMA TION ABOUT YOUR ACCOUNT TO CREDIT
BUREAUS. LA TE PA YMENTS, MISSED PA YMENTS, OR OTHER DEFAUL TS MA Y BE REFLECTED IN YOUR CREDIT
REPORT.
. PHONE BILL. CABLE BILL. GYM DUES. PAY 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 PAYMENTS. AND VISA'S
ZERO LIABILITY POLICY PROVIDES YOU WITH MAXIMUM PROTECTION AGAINST FRAUD. FOR MORE DETAILS, GO TO
WWW.EZCARDINFO.COM AND CLICK ON THE "PA Y BILLS WITH VISA" LINK!
I Trans Date I Post Date I MCC Code I Reference Number [ Description I Amount I
05130 05131 4816 24692166150000954018719 TWX'AOL SERVICE 0506 S 25.90
800-827-6364 NY
9,708
26
o
9,734
. EFFECTIVE JUNE 1,2006 TRAVEL RESERVATIONS AND TICKETING MUST BE MADE 30 DAYS IN ADVANCE OF
ACTUAL DEPARTURE DATES. THIS CHANGES FROM THE CURRENT REQUIRED 21 DAY ADVANCE NOTICE.
E53 FEDERAL CREDIT UNION
PO BOX 23 PARK& BRUNSWICKAV
LINDEN NJ 07036 - 0023
PLEASE DETACH COUPON AND RETURN PAYMENT USING THE ENCLOSED ENVELOPE - ALLOW 5 DA ~'S FOR MAIL DELIVERY 0102 G25V
E5~ ''<'''''' ,,,",-. ' > N",'t''il"'~~''''''j;''
i~:;;%:i-~QO!Jll "t,i.!i.~.~r;li~
4820 9943 3110 6777
FEDERAL CREDIT UNION
06/21/06
$1.073.43
$65.00
DOROTHY PURCELL
1122 SHANNON LANE
CARLISLE PA 17013 -1783
111111111111111111111111111111111111111111111111111,11111111II
Check box to indicate D
name/address change
on back of this coupon
AMOUNT OF PAYMENT ENCLOSED
NOW DUE
$
MAKE CHECK PAYABLE TO:
---
~o
~-fB
-co
===~
-
===
1111111111111111111111111111111111.1111.111111111.111111111111
VISA
PO BOX 31279
TAMPA FL 33631 - 3279
79 4820 9943 3110 6777 00006500 00107343 3