HomeMy WebLinkAbout10-17-07
.-J
15056051058
REV-1500 EX (06-05)
PA Department of Revenue
Bureau of Individual Taxes
PO BOX 280601
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
County Code Year
File Number
j, 07
Oq2~
Date of Birth
195-32-4744
06/14/2007
09/12/1942
Decedent's Last Name
Suffix
Decedent's First Name
MI
Painter
Dorothy
L
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's First Name
MI
Painter
Rodney
w
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
. 1. Original Return
2. Supplemental Return
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate T;~x Return Required
4. Limited Estate
4a. Future Interest Compromise (date of
death after 12-12-82)
7. Decedent Maintained a Living Trust
(Attach Copy of Tnust)
10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
8. Total Number of Safe Deposit Boxes
Mark W. Allshouse, Esq.
Firm Name (If Applicable)
Christian Lawyer Sol.
(717) 582-4006
REGISTER OFW!~.LS USE om..'!
r~'
First line of address
4833 Spring Road
-J
Second line of address
i',,)
City or Post Office
Shermans Dale
Slate
ZIP Code
DATE FILf!:O
C,)
v'
PA
17090
Correspondent's e-
DATE ,-.
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15056051058
Side 1
15056051058
...J
~
--.J
15056052059
REV-1500 EX
Decedent's Social Security Number
Decedent's Name:
Dorothy
L Painter
195-32-4744
RECAPITULATION
1. Real estate (Schedule A).
1.
0.00
2. Stocks and Bonds (Schedule B) . . . . . . .
2.
0.00
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) . . . .. 3.
0.00
4. Mortgages & Notes Receivable (Schedule D) . . . .
.............. 4.
0.00
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . . 5.
12,240.00
0.00
6. Jointly Owned Property (Schedule F) Separate Billing Requested. . . . . .. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) Separate Billing Requested 7.
0.00
8. Total Gross Assets (total Lines 1-7). . . . .
8.
12,240.00
2,552.50
5,563.54
8,116.04
4,123.96
0.00
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)
13. Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J)
. . . . . . . 12.
.......13.
14. Net Value Subject to Tax (Line 12 minus Line 13)
. . . . . . 14.
4,123.96
TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0JL 4,123.96
16. Amount of Line 14 taxable
at hneal rate X 0
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
15. 0.00
16. 0.00
17. 0.00
18. 0.00
. . . . 19. 0.00
19. TAX DUE.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
L
15056052059
Side 2
15056052059
--.J
REV-1500 EX Page 3
Decedent's Complete Address:
DECEDENT'S NAME
Dorothy L Painter
STREET ADDRESS
680 Creek Road
File Number
DECEDENT'S SOCIAL SECURITY NUMBER
195-32-4744
CITY
Carlisle
I STATE
PA
ZIP
17013
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits ( A + 8 + C ) (2)
0.00
Total Interest/Penalty ( 0 + E ) (3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4)
8. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5A)
(58)
0.00
0.00
0.00
0.00
0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due.
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;.......................................................................................... 0 [KJ
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 [KJ
c. retain a reversionary interest; or.......................................................................................................................... 0 [KJ
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 [KJ
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0 [KJ
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 [KJ
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ....................................................................................................................... 0 [KJ
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (3) percent [72 PS. S9116 (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 survivinq spouse is zero (0) percent
[72 P.S. S9116 (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 PS. s9116(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 PS. S9116(1.2) [72 PS. s9116(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. s9116(a)(1 J)]. 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
ESTATE OF
Painter, Dorothy L.
FILE NUMBER
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1. 2000 Buick Regal LS Sedan 40 automobile
5,910.00
6,330.00
2. 1998 Dodge Durango Sport Utility 40 automobile
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
12,240.00
REV-1511 EX+ (12-99)W
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Painter, Dorothy L.
FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
Hoffman-Roth Funeral Home & Crematory, Inc.
Cremation Service Package
Obituary Notice
Death Certificates
Coroner authorization cremation fee
1,790.00
114.50
60.00
25.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
. State
Zip
Year(s) Commission Paid:
2.
Attorney Fees
563.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
State
Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
2,552.50
REV-1512 EX+ (12-03)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Painter, Dorothy L.
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
FILE NUMBER
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Praxair Healthcare Services medical bill 12.25
2. Carlisle HMA Physician MGMT medical bills 1,280.12
3. Kinetic Imaging, Inc. medical bill 43.58
4. Carlisle Regional Medical Center medical bills 3,784.30
5. Bronstein Jeffries PAID avid P. Chernicoff, DO medical bill 13.88
6. Philip Carey, MD medical bill 20.00
7. Cumberland Pathology Associates medical bill 373.50
8. Blue Mountain Anesthesia Associates 35.91
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
5,563.54
REV-1513 EX+ (9-00)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Painter, Dorothy L.
FILE NUMBER
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. Rodney W. Painter spouse 100%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 12,240.00
(If more space is needed, insert additional sheets of the same size)
I, DOROTHY L. PAINTER, of North Middleton Township, Cumberland County,
Pennsylvania, declare this to be my last will and revoke all wills which I have
previously made.
T I give, devise and bequeath my entire estate, real and personal,
to my husband, Rodney W. Painter, if living, and if he shall fail to survive me,
then to my daughter, Tanyia La Painter, if living, and if she shall fail to
survive me, then to her surviving issue, per stirpes, absolutely and in fee
simple.
II If neither my husband, my daughter, nor any of my daughter's issue
shall survive me, I give and bequeath five percent (5%) of my net distributable
estate, before payment of any inheritance or similar taxes, unto St. John's
Episcopal Church of Carlisle; all the rest, residue and remainder of my estate I
give, devise and bequeath in equal shares to my husband's sister, Judy Kern, and to my
niece, Tracey Lynn Eppley, if living, and if either of them shall be deceased,
all to the survivor of the two of them, absolutely and in fee simple. If none
of the foregoing shall survive me, I give and bequeath my entire estate unto St.
John's Episcopal Church of Carlisle.
III Any share of my estate which shall become distributable to a
minor may be held in a savings account, certificate of deposit or similar
security, in a federally insured banking or savings institution in the name of
the minor and marked not to be withdrawn until the minor attains the age of 18
years.
IV I appoint my husband, Rodney W. Painter, as Executor of this
will, and if for any reason he shall fail to qualify or cease to act as such
during the administration of my estate, I appoint my daughter, Tanyia La
Painter, as substituted Executrix, and if for any reason she shall fail to
qualify or cease to act as such during the administration of my estate, I
appoint my husband's brother-in-law, Gary Kern, as alternate Executor of this
will. I direct that no bond shall be required of any fiduciary named in this
will.
IN WITNESS WHEREOf, I have hereunto set my hand and seal this ,/C~day
of May, 1983.
,"'7 " "
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---- --~~-.----..-~-_=:J~---~~~~J~---.L-~,--~--~
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse)
STATE FILE NUMBER
H105.143 REV 1112006
TYPE I PRINT IN
P~RMANENT
BLACK INK
8b. Counlyol Death
8d Facilrty Name (Il not ins1ilulion, give street and number)
Carlisle,
6. Dale of Birth (Month, day, year)
64
Yo
Sept. 12, 1942
/i [. Cumberland
N. Middleton Twp, 680 Creek Rd.
10. Race: American Indian. Black, White, ete
(S",."" Whi te
11. Deceden1's UsuallXcvDalion (KirK! 01 woo. done dUor! most 01 WQrt.in life. Do no! stale retired
Kind of Work Kind o( Business { Industry
Tire builder Rubber Co,.
, 2 Was Decedent ever in the
U,S. Armed forces?
DVes []No
13. Df!cedent's Education (Specrty only highest grade completed)
Elementary! secon1?20.12) College (1-4 or 5+)
14, Marilal Stalus: Married. Naver Married
WiOowed, Divotct!d (Specffyl
Married
15. Decedent's Marlin\! Address (Sreel. City Ilown, s1al~, rip code)
680 Creek Rd.
Carlisle, FA 17013
1B. Father's Name (Firs!, middle, lasi, suffix) Frank Sherman
Decedenfs
ActualReside~ 17a.Slale
17b. Counly
PA
Cumberland
Did Decedeni
U'Jf!ine
Townsrnp?
17c. f9 Yes, Deceden1 Lived ill
17d. 0 No, Deceden1 Lived w~hif1
AClual Limits of
Middleton
Twp
CiIy:Boro
19. Mottler'sName (First, middle, maiden sumame) Leona Stingfel:Low
20a. tnlor.nanl's Name (Type f Print)
Rodney W. Painter
2680C;~i~kddrRsdS1:~I,cic/~7:ti~ll;:PA 17013
21 a, Melhod of Disposition
2k Place 01 Disposition (Name of ~melery, allmalqry o,c:,plher p1ace)&
Hoffman-Rothcruneral nome
rematory
21d Locahof'l (Ci:y (town, stale, zip code)
Carlisle, PA 17013
Iter1'.s 2.i'26 musl be completed by person
whooronouncesdeath
22'Nam"ndAdd'''''''''ili~ Hoffjljan-Roth Fuoera] Home [I" Crematory
219 N. Hanover ~t., carllsle, FA 1/u13
23~,.,.icegeNUrT!b.e.5
.K/l/,;</.::> '/:2 7 ~
25. Was Case Referred to Medical Examiner! Olroner lor a Reason Other than Gremalion 0' Donation?
DYes ~o
ApprOXimilleinlerval: Pa~ It: Enlerothersionilicanl~~..I2..l!u.l1:!, 2~TobaCCO Use ContriDule 10 Death?
Onset 10 Dea~h ' .put no! resolting in lhe underlying cause given in Part Yes 0 PrntJably
n,.." 1111"...,.........
! 29'11 r;::~:- ~ -..,...-....
~olpr!!gnan1withinpas;year
o Pal;;~.a:":: a: time 01 dea:~
o Notpregnant.l>ulpregnanlwilhlll.<l2days
oldealh
o NOlpregnal'li,bu'IP'egnant43ctaystol)'~ar
b~lore d!!::!th
o Unknown if pregnanf within the o.asl vea'
JI
~I
I
~~
~
<::l
~l
!
CAUSE OF DEATH (See instructions an exam les)
Item 27. Part I: Enterlhe ~ - diS€ases, lnjlJries. 01 romplicalions -that diredlycaused the dealh. DO NOT enter !erminal events such as cardiac arrest.
respiraloryarrast,orventricularrrbrillationwrthoLltShowinglheeliology. Usl only one cause on each line
I'MM.I:D1ATE..C..'AUSEI.Fi.nal.disease.or ---r _" ~ f-'A/1 ~
COOOIUon resUllIngln Ol!'aln) --.- ~"" j-- ./'f.-./Jr'V'''''''
Due to (orasa consequence oQ. {J
Sequen1ialtyltstcondillOns,il any,
~~:~o 0~D'E~:'~~~~ a Due 10 (or as a consequence 01):
. rtflseaseorlOlury:tlafmrtialedlhe
.. events resullillg In oealh) LAST.
Due 10 (eras a conSEQlIeoce 00:
DYes ~NO
:IDb. Were AUlopsy FlI1dings
Available Prior 10 Completien
of Cause of Oeath?
DYes 7No
31, Manner of Deatll
~atural 0 Homicide
o Accident DPendll1glnvI?sIIga1ion
o Suicide 0 Coule! Nol ~ Determinecj
32c, Place of Ini\Jrr Horne, Farm, Sl.reei. Factory.
Office Building. elc, (Spet:ily)
302. WasanALltopsy
Perlormed?
32d. Tllneor Iniury
M
33a Cerlifler(checkonIllOlle) 33b SlgnalUreand~ertiflf!r f)
, Certltvrng phYSICIan (phySICian certllving cause of deatn when anathe' phYSlClar'l has pronounced dealh and comQkled lIem 23) 'f.o,( 110- --/--;::;.-- V-J
To the best 01 my knowledge death occurreCl due 10 lhe cause(s) and man~r as staled... - - - - - - - - - - - - - - - - - - - - - - - - - - - - - _ _ _ )6'
Prol1Ouncmg and certdVlng phvslClan (physIC an bo'h pronounclf1Q death and c€"rtllymo 10 C<luse 0 dealh) 33c LIcense Number
Tolhebeslolmvknowledoe deathoceurredatlhetr~ dale ;ndplace andduelothecause(s)<lndmarmerasslated__________________ 0 mD 0/9 79 dE
~~~~a~:~"::;:~~;~~~I~~ and I or investigation. in my opinior" cieath occurred at lne time, dale, and place. anu due to tlte causers) and manner as slated_ 0
~::c::.~-;,
. , .;p ~>?F--o 7
i
I
I
I.
I
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: R"~'d~"::~~~-t"~
v I~II 1,)1 i
10
3' ",m, ,"'A"',,", "P,"oc W1w Com'."i:2 ,: D"" ""m 27) T""'I~U[fS /.- G jJ/.)
3R&kqt@er~nng 1Ffa'j 17013
'"
, Kelley Blue Book - Private Party Pricing Report - Buick, Regal
Page I of2
Kelley Blue Book
THETRUSTEO RESOtJRCE
"""""'~ItlIlt,QlII
Send to Printer
z:~(l ve:t[s~-:rn(:ni
2000 Buick Regal lS Sedan 40
BLUE BOOK' PRIVATE PARTY VALUE
Condition
Value
Excel!errt
$6,390
..I Good
$5,910
(Selected)
fair
$5,305
Average Consumer Rating (6 Reviews)
Read Reviews
4.2 out of 5
Review This Vehicle
Vehicle Highlights
Mileage:
Engine:
Transmission:
Drivetrain:
40,358
V6 3.8 Liter
Automatic
FWD
Selected Equipment
Standard
Air Conditioning
Power Steering
Power Windows
Power Door Locks
Tilt Wheel
Cr'uise Control
AM/FM Stereo
Cassette
Dual Front Air Bags
ABS (4-Wheel)
Traction Control
Blue Book Private Party Value
Close Window
Private Party Value is what a buyer can expect to pay wilen buying a used car from a
private party. The Private Party Value assumes the vehicle is sold "As Is" and carries
no warranty (other than the continuing factory warranty). The final sale price may
vary depending on the vehicle's actual condition and local market conditions. Thrs
value may also be used to derive Fair Market Value for insurance and vehicle
donation purposes.
Vehicle Condition Ratings
Exce!lent
"Excellent" condition means that. the vehicle looks new, is in excellent
http://www.kbb.com/KBB/U sedCarslPricingReport.aspx?ManufacturerId=7 & Yearld=200... 7/17/2007
Kelley Blue Book - Private Party Pricing Report - Buick, Regal
Page 2 of2
mechanical condition and needs no reconditioning. This vehicle has never had
any paint or body work and is free of rust. The vehicle has a clean title history
and will pass a smog and safety inspection. The engine compartment is clean,
wit.h no fluid leaks and is free of any wear or visible defects. The vehicle also
11as complete and verifiable service records. Less than 5% of all used vehicles
fall into thiS cat.egory.
..I Good (Selected)
$5,910
"Good" condition means that the vellicle is free of any major defects. This
vehicle has a clean title history, the paint, body and interior have only minor (if
any) blemishes, and there are no major mechanical problems. There should be
little or no rust on this vehicle. The tires match and have substantial tread wear
left. A "good" vehicle will need some reconditioning to be sold at retail. Most
consumer owned vehicles fall into this category.
fai.
$0,305
"Fair" condition means that tile vehicle has some mectlanical or cosmetic
defects and needs servicing but is still in reasonable running condition. This
vehicle has a clean title history, the paint, body and/or interior need work
performed by a profeSSional. The tires may need to be replaced. There may be
some repairable rust damage.
P f.HH'
N/A
"Poor" condition means that the vehicle has severe mechanical and/or cosmetic
defects and IS in poor running condition. The vehicle may have problems that
cannot be readily fixed such as a damage(j frame or a rusted-through body. A
vehicle with a branded title (salvage, flood, etc.) or unsubstantiated mileage is
conSidered "poor." A vellicle in poor condition may require an independent
appraisal to determine its value. Kelley Blue Book does not attempt to report a
value on a "poor" vehicle because the value of cars in this category varies
greatly.
. Pennsylvania 7/17/2007
http://www.kbb.comlKBB/U sedCars/PricingReport.aspx?ManufacturerId=7 & Y earId=200...
7/17/2007
, Kelley Blue Book - Private Party Pricing Report - Dodge, Durango
Page 1 of2
Kelley Blue Book
THEnUSltO RfSOURCE
bb.c_
IF''!;ii Send to Pnnter
ON SELECT MOllELS ~
o~ OR $3,500
rtI'lAlfCll<IGj; t:a.SUMfl\ (ASJ!
_ 60 MalI'O!s AlWW4.lJtf;
- pws-
$1,000 BONUSCASH
1998 Dodge Durango Sport Utility 40
BLUE BOOK PF~IVATE PARTY VAlliE
- --':'1if1
Condition
Value
Excellent
'" Good
$6,330
(Selected)
F@ir'
Average Consumer Rating (11 Reviews)
Read Reviews
3.9 out of 5
Review This Vehicle
Vehicle Highlights
Mileage:
Engine:
Transmission:
Drivetrain:
40,306
V8 5.2 Liter
.i\utornatic
4WD
Selected Equipment
Standard
SLT
Air Conditioning
Power Steering
Powe'r Wlf1dows
Power Door Locks
Tilt Wheel
Cruise Control
AM/FM Stereo
Cassette
Dual Front Air Bags
Third Seat
Roof Rack
Alloy Wheels
Blue Book Private Party Value
Close Window
Pl'lvate Party Value is what a 11uyer can expect to pay when buying a used car from a
pl'lvate party. The Pnvate Party Value assumes the vehicle IS sold "As Is" and carries
no warranty (other than the continuing factory warranty). The final sale price may
vary clepending on tile vellicle's actual condition ami local market conditions. TI1is
value may also be used to derive Fair Market Value for insurance and vehicle
donation purposes.
Vehicle Condition Ratings
ExccHcnr:
$6,820
httn'//UTUTUT khh rn1'1'1/KRR/T kprir~r<:/Pririno-Rpnnrt ~'mv?V phirlprl~<:<::=T T<::prlr~rRrl\;f~nnf~
7117/')nn7
PRAXAIR HEALTHCARE SERVICES
UNIT G
4667 SOMERTON ROAD
TREVOSE, PA 19053
215 436-1366
215 436-1377
fifjffiflPRAXAIR
6211-1/1:6224
5T A TEMENT
05/31/07 I
15157XXXXXXXXXX I
12.~
I
I
HEALTHCARE SERVICES
DOROTHY L. PAINTER
680 CREEK ROAD
CARLISLE PA 17013-9646
PLEASE REMIT TO:
PRAXAIR HEALTHCARE SERVICES
UNIT G
4667 SOMERTON ROAD
TREVOSE PA 19053-6754
11111111111111111111111111111111111111,1111111111I111111111111
1'11111111111111111111111,1.11111111I1111,111111,11111111111,1
PLEASE REMOVE AND RETURN THIS PORTION WITH YOUR PAYMENT
OS/22/07 W238460
OXREFD
D-TANK 02 COMPRESSED GAS
12.25
PRAXAIR HEALTHCARE SERVICES
UNIT G
4667 SOMERTON ROAD
TREVOSE, PA 19053
215 436-1366 215 436-1377
I--.q..........- mOlAt: ..-.u.-.-.....-.._.Li
Q!$;)
u
12.25
000540 533165
c::;.q.oLL....c:rE fMI. PHYSICI.PN ill-1I' IN
P 0 Err{ 5J6
EAST J:-1::;.L/::..,.cl:{.JFG, PA 17sax>.:D6
PAYMENT OPTIONS
Check # Amt;$
FEJJJFN SERvICE FaJ]ES1E)
V1.201.Q 070
s5392M
TH21.
IIM 001.
0540 L
Please Include Securlt Code From Back Of Card
CHECK CARD USING 1:0Il PAYMENT
IIIl8.ST~RCARD
CARD NUMBER
I VISA I ~SA
EXP. DATE
CARDHOLDER NAME
SECURITY CODE
SIGNATURE
AMOUNT
RE~\!j:"T ~C:
CARLISLE HMA PHYSICIAN MGMT IN
POBOX 506
EAST PE.TERSBUR, PA 17520-0506
I." III" ,1,1,1, ,,1,1 II,,, II,,, ,1,1.11,,, ,II" 11,,,.11,, I" 1,1
DOROTHY L PAINTER
680 CREEK RD
CARLISLE, PA 17013-9646
I." III" ,III." 11,11"11,1,111111,, ,1,.1,11 "1,,1.11,,, .1,1.1
,~
,:)F:ce P!-:c:~:s ~\JunilJei
"\, Statement Date \1
! i
: 06/20/07 !
You~. p\CCOU:1! Number
....f
T
PaQe ;...]0.
~_/
?LC,L\SE RETURi\J THiS PClRT1CH\! \.r\n:~ PP,\if'~/IEf'r
Patieilt BCii&;iC2 ~'f;lC:\JV /:\:\11,:]:...;[\;7
-------------.---------------------------------------------.-----------------.---------.-------'.---...---.---..-.-..----.--------.-
717 519-0753
533165 !
1
CONTINUED
~P,L;i[: H=Rc
CH,L\RGES. APPEARING ON THIS STATEh/lENT ARE NOT INCLuDED O!'J .pJ\lY HC)SPiTAL ~q~L OR STt~\Tt:t\A=;<T
_::,; ~ A ;;..r: ,-'" ~~ 1 ,. ~O}/~A~.~"'.~".i.{"'~~~~~-~!l~~~~}~;L:~ ~l~
,,..;;".,. ._' _ .' , :EXPLANATJONJP1:AC])JV,a~;:.;f.,::~;;'<_: '_:~:,,,;"
;t-~, ; ~ ~ - , ,.. ~'~". ....'" .p""__t~r> ~.:!.:;!t"":--!~7';"~~~~%~~~~~l;;:..,,.
...~"'0Jr.
~:" j i
)52207 LONGTON 110 THERAPEUTIC RADIO INV#:PAINTER,DOROTHY
AMOUNT TO BE PAID BY CO INS $96.39
INSURANCE PAYMENT
INSURANCE ADJUSTMENT
Insurance Balance: 0.00
489.00
061507
061507
-224.91
-167.70
Patient Balance:
96.39
052407 LONGTON 110 XF.AY
AMOUNT TO BE PAID BY CO
INSURANCE PAYMENT
INSURANCE ADJUSTMENT
lrisurance Balance~ O~~O
INV#:B PAINTER,DOROTHY
INS $17 .85
133.00
061507
061507
-41.64
-73.51
Patient Balance:
17.85
061507
061507
THERAPEUTIC RADIO INV#:9.......Pf>.INTER,DOROTHY
AMOUNT APPLIED TO DEDUCTIBLE $100>00
AMOUNT TO BE PAID BY COINS $6E;.3!:i
INSURANCE PAYMENT
INSURANCE ADJUSTMENT
Insurance Balance: 0.00
4B9.00
053007 MALCOM MD
-154.91
-167.70
Patient Balance:
166.39
061507
061507
XF.AY
AMOUNT TO BE PAID BY CO
INSURANCE PAYMENT
INSURANCE ADJUSTMENT
Insurance Balance: 0.00
INV#: 10 PAINTER, DOROTHY
INS $16.93
107.00
053007 MALCOMMD
-39.52
-50.55
Patient Balance:
16.93
053007 MALCOM MD
RADIATION INV#:11 PAINTER,DOROTHY
FIVE FRACTIONS FROM 05232007 TO 05302007
504.00
"';~t.o'
06/20/07
PLEASE !NDICATE YOUR .ACCOUNT r\!Ui\ii5E~i \IV:-1t:[\j CALU1.~3 O:_JFi C)Ff;C=::
533165
S"laisfllent
?A7iENi 6ALAN~
PAY THiS A.!v10UI
CONTINUED
5:=:1",,}:; ;;~QU;RlES: ?,t,'{~\r;EN;S TO:
CARLISLE HMA PHYSICIAN MGM'l' IN
POBOX 506
EAST PETERSBURG, PA 175200506
717 519-0753
533165
c::7J.."RLISIE HFi FBYSIr::::IlW MMI' IN
P 0 RJ>( 5J6
EA.....c:r .lli~r PA 175ZXJ5J6
PAYMENT OPTIONS
Check # Amt$
ffiIUIN SERvICE R:J;J1ESIED
V1201.Q 070
B5392M
TH21.
IIM 001
0541. L
Please Include Securlt Code From Bacl< Of Card
CHECK CARD USING FOR PA YMENT
[n) 8STERCARD
CARD NUMBER
IWSA 10
VlSA
EXP. DATE
CARDHOLDER NAME
SECURITY CODE
SIGNATURE
AMOUNT
RE:hfJiT -C:
CARLISLE HMA PHYSICIAN MGMT IN
POBOX 506
EAST PETERSBUR, PA 17520-0506
111I111",1,1,',"1.111,"11,",1.1.11,",11"11,".11"1"1.1
DOROTHY L PAINTER
717 519-0753
06/20/07 :
'{GUi Account \\1;(1;)81' ....;' Pags r\:o. "Y
533165 i 2
PL.EP"SE ;:-1ETU~~\1 ;~i~S PC~?Ti():\} \!\'T;~ ~.t\"!'I~;\;
Patient Balanc;e ---\ r-
~ .3;-)<:.\\/ ,.L,fv'!C;U~'<:
~, .~' ~:.:0:-:S !',<;:T1::'~,' ~-....,y.-- S';-,;~s:Tlen: D&.te ..'\(
448.76 ,05:D"-:=::;,;:: ".
-~~
CHARGES A~'PE;\RfNG Ohl-HiS STATEfviEf\;T ARE NOT INCLUDED O~~ i~.!'-.JY HCSPlTf\L Bl~L e)M S.T,L,;;::;vH::f",:;
AMOUNT TO BE PAID BY CO INS
061507 INSURANCE PAYMENT
Insurance Balance: 0.00
$151.20
-352.80
Patient Balance: 151.20
-,- - .
::;:.':.2.1s:'";-':ern
06/20/07
PLEA.SE lNDjC.4,TE YOUR ACCQUf\JT !'JUI\f!BER VYHEf\! CP~LLIl\tG CHJF; ()t=:=iC>=:
533165
Je.~s:
448.76
31-60 Days
0.00
61-90 Days
0.00
>90 Days
0.00
Total
Ins Pending
P.'; 1 lEi\!: BALANCE
p,A,....i THiS ,Aj;j:OUI'T
Current
448.76
0.00
448.76
3~i~D ih~G;jiR;ES:' F_;,Yi',,~E.i<~S -1-2:
CARLISLE HMA PHYSICIAN MGMT IN
POBOX 506
EAST PETERSBURG, PA 175200506
717 519-0753
533165
"rnRI:rsIE H-a PHYSICIAN MMr IN
P 0 B7X 8J6
FAST J:1!j~, PA 175ZXJ5J6
PAYMENT OPTIONS
Check # Amt $
mIfJfN SERYICE FS;JJESIID
VJ.20J.Q 070
B5392M
TU2J.
BNS 002
3520 L
Please Include Securit Code From Back Of Card
CHECK CARD US/NIl FOR PAYMENT
f~l] 8.STERCARD
CARD NUMBER
I "/SA 10
VISA
EXP. DATE
CARDHOLDER NAME
SECURITY CODE
;';",";"::
.....,:..:.!.t;
tl' ril:';':
. :yr,
SIGNATURE
AMOUNT
;-:' .~-~~. "
0024151 0003/0003 00000 OB2D2DD7
DOROTHY L PAINTER
CARLISLE HMA PHYSICIAN MGMT IN
POBOX 506
EAST PETERSBUR, PA 17520-0506
1...11111.1.1.1.,.1,111,"11,".1.1.11,".11..11,".11..1.,1,1
533165
P~i::/:\,SE F'~E'T:d;':,:\~
'[ '<.;'
717 519-0753
08/20/07
",....... .._.-'_._.~--._,.~'~-~-~-...,
3
831.36
.. ':':-..:,'\'::-:-{
:'.;~.:- ,=:..~ - -'~. ~~~/ "-=
?-e:;Crr
'~/i..'-..J ,....._ '_.
'--!;.........'2IC-..:
;:'j:
. ':.,', .',. ,',j~]'~1'~.~~,~.,:g,'.''. ,~~ .:.,'.:;',
072407 INSURANCE ADJUSTMENT
Insurance Balance: 0.00
-15.00
Patient Balalnce:
52.20
152207 MALCOM MD XRAY
AMOUNT TO BE PAID BY CO
072407 INSURANCE PAYMENT
Insurance Balance: 0.00
INV#:3 PAINTER,DOROTHY
INS $208.20
694.00
-485.80
Patient Balcllnce:
208.20
)52207 MALCOM MD
072407
072407
XRAY INV#: 4 PAINTER,DOROTHY
AMOUNT TO BE PAID BY CO INS $46.56
INSURANCE PAYMENT
INSURANCE ADJUSTMENT
Insurance Balance: 0.00
190.00
-108.64
-34.80
Patient Balance:
46.56
)52307 MALCOM MD XRAY INV#: 20
$16.93 COPAY
080607 INSURANCE PAYMENT
080607 INSURANCE ADJUSTMENT
Insurance Balance: 0.00
PAINTER, DOROTHY
107.00
-39.52
-50.55
Patient Balance:
16.93
397.39
31-60 Days
151. 20
PAINTER, DOROTHY
319.00
152307 MALCOM MD
080607
080607
XRAY
$37.59 COPAY
INSURANCE PAYMENT
INSURANCE ADJUSTMENT
Insurance Balance: 0.00
r1
(] ,
'1{/ '11
!" . il'l/'
11..' I., v
t. .i..
/.,( d.l
/.Y' II
-87.72
-193.69
Patient Balance:
37.59
08/20/07
533165
Current
61-90 Days
282.77
>90 Days
0.00
Total
Ins Pending
831.36
0.00
831.36
-----.. _.....- '....,- .'~'.<~.._~- - .n~__'~'"_,,____,~_<~~_~,,,__~ ~,,~,..'._,.-....._-~._.~~..,.....,. ""~'''_'__'~_.. "_'~'__'~_~_'_''''''._'_'''~_'',_" ~~~~~._ ___~~~~~_~__,~__..,.'____~'~'_____'~_",_"_,_~____,_.,,, U'"'~"'__..'.__w,..""___""
CARLISLE HMA PHYSICIAN MGMT IN
POBOX 506
EAST PETERSBURG, PA 175200506
717 519-0753
Patients will be responsible for
all collection fees including
3rd party collection agency
and attorney charges.
S,T' "rE Er\~T
Kinetic Imagingl Inc.
4520 Union Deposit Road
Harrisburg P A 17111
CHECK CREDIT CARD USING FOR P A YM:E:)\.o'T ~ F1LL O'IJ1' BELOW.
of. O[V/SA) old o:'~~J
CARD NU1'vfBER PfN AMOlJ!\j
NAME ON CARD (pLEASE PRINT)
EXP. DATE
SIGNATURE
Office Hours: 8:00 AM - 5:00 PM
Phone: 717/652-6105
STA TE1\lENT DA TE ACCOUI"-IJ #
06/20/2007 7700411
Patient: DOROTHY L PAINTER
PAY TIns AMOUi'l'j
CONTINUED
------
;:'.:.h!:::):~;i~; ;:-.~_:::-
~1I1111111111 11111111111111 11111/1111111
I nil 11111 1111 111/1111111111 1111
.----.---
---.- -,-'. ". --. - ~ -.
',..,,':"';' . ~- -..' , .-'"'' --' ~
37191 AT 0.334 *12 03719
1...11/...11111 ",./1.. 1/ ,1.1'1111,..1,.1.11..1,,1." II .,1,1,1
Dorothy L Painter
680 Creek Road
Carlisle PAl 70 13-9646
I.. ,I 1/'11 I.. .11.. .11.,.1" ,1.,1
Kinetic Imaging, Inc.
4520 Union Deposit Road
Harrisburg PAl 7111
~ P....=L',S~ C;..,:=C:< ~,c:): ::= ,L--,3C",:,.:: ;.2S=:ES2. !S ;:\;,::>::::RRECT ?r~C j:\:0iGP.TF:.:::-:ANG=:S' 0;\ 5.4Ci,.
TRIST AN1-o 138140-0003719-0864290-00 1-00 1940-#004340
f'~ ~~'=---/.\C;r-. ~;E;=:,E:",,;
,. \.
,i-,;\L :-',=
--" ,',~. -",--' -- ,", "'. '-'~"j .
-..,.. -'~-
1.'--' ....., .
,-'~_::::\~, .,----'::: :::::-- -;\
I DATE CODE DIAGNOSIS DESCRlPTION OF SERVICES
05/17/07 74160 V1O.11 CT ABD W CONT
05/17/07 72193 VlO.11 CT PELVIS W CaNT
05/17/07 70470 V10.11 CT HEAD BRAIN WO W CaNT
05/17/07 72070 724.1 XR T -SPINE 2 VIEWS
05/17/07 72114 724.2 XR L-SPINE CaMP W BENDING
05/18/07 78306 VlO.11 NM BONE SCAN WHOLE BODY
OS/21/07 73010 786.6 XR SCAPULA CaMP
OS/21/07 73060 793.7 XR HUMERUS 2 OR MORE VIEWS
OS/21/07 71020 786.6 XR CHEST 2 VIEWS
OS/22/07 77014 198.5 CT FOR RT PLANNING
05/31/07 FILED MAIL HANDLERS
06/01/07 FILED MAIL HANDLERS
06/04/07 FILED MAIL HANDLERS
06/12/07 198.5 MAIL HANDLERS PAYMENT
06/12/07 198.5 MAIL HANDLERS AD]
06/12/07 198.5 FR 05-17-07 TO 05-18-07
06/12/07 198.5 CO-INS 27.42
06/19/07 198.5 MAIL HANDLERS PAYMENT
06/19/07 198.5 MAIL H.A]\ll)LERS AD]
06/19/07 198.5 FR 05-21-07 TO 05-21-07
voiiS/O; 198.5 MAIL HANDLERS PAYMENT
06/19/07 198.5 MAIL HANDLERS AD]
06/19/07 198.5 FR 05-21-07 TO 05-22-07
061l9/07 198.5 CO PAY 16.16
AMOUNT
$275.00
$275.00
$272.00
$50.00
$80.00
$200.00
$40.00
$40.00
$50.00
$250.00
$246.76-
$877.82-
$16.68-
$63.32-
$l45.46-
$138.38-
ACCOUNT CONDITION: Current: $43.58
Patient: DOROTHY L PAINTER
Location of Service
Cft..RLISE REG MED CTR INP AT
30 Days: $0.00 60 Days: $0.00
Account Number: 7700411
Referring Physician
PHILIP D CAREY MD
CONTINUED
90 Days: $0.00 120 Days: $0.00
Statement Date: 06/20/2007
Performing Physician
KINETIC IMAGING
Kinetic Imaging, Inc.
4520 Union Deposit Road
Harrisburg PAl 7111
TRIST AN1-0138140-o003719-o864290.001-o01940-#O04340
Phone: 717/652-6105 IRS# 20-4912847
Sf TE~vrEr~T
~CREDITC~FORPAYMEl-<~!'f.LOtJTBEL~
D~ D~ D~ D~
CARD "J'.'UMBER PIN AMO~I
J
~
Kinetic Imaging, Inc.
4520 Union Deposit Road
Harrisburg PAl 7111
NA),{E ON CARD (PLEASE PRINT)
EXP. DATE
SIGNA TURE
Office Hours: 8:00 AM - 5:00 PM
Phone: 717/652-6105
STATEMENT DATE ACCOGNT#
. 06/20/2007 7700411
...-/
Patient: DOROTHY L PAINTER
PAY THIS AJi-tOLi\J
$43.58
_L.l\~:;':....;_r~:' ?:...:.:;
IIIIIIIIIIIIIIII~IIIII~ ~I~ 11II1 ~IIIIII
1111111111I 1111 ~IIIIIIIIIIIIIIII
,,' ..... ~-, ,- "..
O"d",,_ ......'. .._.<,,_'..
37191 AT 0.334 *12
1.,.111,"111""1.11"11.1,1,"11...1..1.11,.1.,1.11,..,1.1.1
Dorothy L Painter
680 Creek Road
Carlisle P A 17013-9646
1",111,"1",11",11".111.1,,1
Kinetic Imaging, Inc.
4520 Union Deposit Road
Harrisburg P A 17111
TRIST AN1-0138140-0003719-0864290-001-001940-#O04341
/,;C, ;::':::-;-,::':,_:=-,:,"': ._:::':_,::=,
~::- ~~
.- -,.. ,.--
_".1\, ._.'\ .:.......' ~
:~,: ~:..E':,2:: C---~=Ct< Be,>: iF P,E>:-'::= :t.::::DFESS!S 1NCG,=;RECT ,-".NS ;;'J01C/;T::: ':-;M",'\f\'3ES OJ\1 B.02,Ct-(.
DATE
06/20/07
CODE
DIAGNOSIS
198.5
DESCRIPTION OF SERVICES
CYCLE STATEMENT - 606
AMOUNT
ACCOUNT CONDITION- Current: $43.58
Patient: DOROTHY L PAINTER
Location of Service
CARLISE REG MED CTR INP AT
30 Days: $0.00 60 Days: $0.00
Account Number: 7700411
Referring Physician
PHILIP D CAREY MD
BALANCE DUE: $43.58
90 Days: $0.00 120 Days: $0.00
Statement Date: 0612012007
Performing Physician
KINETIC IMAGING
Kinetic Imaging, Inc.
4520 Union Deposit Road
Harrisburg PAl 7111
TRIST AN1-0138140-0003719-0864290-001-001940-#004341
Phone: 717/652-6105 IRS# 20-4912847
-------~,.~'--_._----_._---~_._-_._-----
~~~"~~~,3]ll!""~'~~
'::~......:;, ....' ;JJ~j ,A~!;<,1!;' .. .,.. .'. .~,. .~~~~~~ 007852 858HNA 000097R
,.-.,
tAR I '!"l f=
p'-'l.! ..L, -.)'-'~
i -EC!ONi\L
v E S , C ,.;.:.. C c N T E R
UPON RECEIPT
Ilr: PA.\,']NG BY C~ED1T Ct>,RD, FILL Cl..}";- BE~:::>/i Ai\J:J SE~. REVERSE SIDE
I 8'-i:::CK C/',~-C, I ,~, ~_- -'=~',''(r\.1EN'"
I
l
I ACCOUNT NO.
I
I
45 Sp~Ir,: Drive
Carlisie ,D~ ~ 7e,'<:)
ADDRESS SERVICE REQUESTED
~~,S--EYC,':~S fa ~s~::,\...:::=, ~- ;:5..:\ ~'~~~iCAh ::XPRESS !
STATEMENT DATE I EALANGE DUE F'~';).~
i I :
06/18/20071 $3,072.431 i
. I
7700411
MAKE CHECKS PAYABLE TO:
PAINTER, DOROTHY L
680 CREEK RD
~ CARLISLE
""
PA 17013
CARLISLE REGIONAL MEDICAL CENTER
361 ALEXANDER SPRING ROAD
CARLISLE PA 17015-9129
1"1111",111"""11,1,1,1,1"",11111,11,1",11",,,111,,1,1
1"IIIIII.III"IIIIIII.II.lllllilll,IIIII.II,.I,II,II",,1,1,1
LJ Please checl, if abovE: accress is incor;-ect ailG indi(;ate change on i8VerSE: sicis.
TO jf'iSuR~ PROPER CREDiT, Oi::Ti\CH At'.JD RETLIRI\! li1iS :::J~;i'!ON I;"'; THE Ej\jCL()S~=' :::!\i\/t:,-O;::~.
PATIENT NAME
PATIENT ACCOUNT NO. DATE OF SERVICE TYPE OF SERVICE
7700411 05/17 n007
TOTAL CHARGES
23,371.10
PAINTER,
DATE
PAYMENT/ADJUSTMENTS
05/17/07
06/13/07
06/13/07
06/14/07
06/14/tl7
515.00-
4,544.22-
15,109.45-
4,544.22
4,674.22-
$3,072.431
MESSAGES
The amount shown on this statement is outstanding at
this time. Your prompt payment will be greatly
appreclated.
FOR BILLING QUESTIONS, PLEASE CALL:
(717) 960-1680
...
::J!UPON RECEIPT I
~
,-., Lf.RlJSLE
i--! 'r'rv 'AL
L \~,--,}(,-,,'~~ ;,
v ~~: := ,.\ LeE ~ T E R
~~~~etl!J~~~11iT~' 007852 858HMA 000123R
45 Spr:nt Dcive
Carlisle. PA. 17D-: 3
i IF PAYING BY CREDIT Ct,RD, FILL OUT BELOW AND SEE: REVERSE SIDE
I ''"'HcC'' rA':'"l~ II<::.!\',.... ce'-' -'^Vl~-,.,I..,..
I -", L ~ ,--" ,:ol.J vu;;;\.::), '-: ....., Vlt:.r'.,
I :kS7S":,,'1C .. ;SCO\lE~-~~~< :~SA
1~..i,1ES:CAN ::XPRES5
ADDRESS SERVICE REQUESTED
UPON RECEIPT
7702459
06/25/20071
BALANCE DUE ~~~~fjll.ii:E\i;.
$nl.87! ;
ACCOUNT NO,
STATEMENT DATE I
MAKE CHECKS PAYABLE TO:
PAINTER, DOROTHY L
680 CREEK RD
::; CARLISLE
.....
PA 17013
CARLISLE REGIONAL MEDICAL CENTER
361 ALEXANDER SPRING ROAD
CARLISLE PA 17015-9129
1..,111...111..,...11.1.1.1.1..".11.,1.11,1,..11..,.,1II 1.1,1
1,1.111...11111..,.11..11.1.1...11,1.1,,1,11..1..1.11....1.1,1
CJ Please check iT sbo;,-e aod;-ess is j:lC;)rrec'~ am': jndicaJe changE: ~r~ reverse side.
70 H~SUFE ~R0P~~ C:REDiT, DETACh Ai'4D fiE.TlH~;I\ -iH!S f:':)HTiQi,: IN T;-{E Ef\j':;LOSE;";: EN\ftLOPE.
PATIENT NAME
PAINTER, DOROTHYl
PATIENT ACCOUNT NO. DATE OF SERVICE
7702459
DESCRIPTION.
TYPEOFSERVICE
TOTAL CHARGES
DATE
8,898.38
PAYMENT/AQJUSTMENTS
CHEMO/RADIATION THERAPY
06/22/07
06/22/07
HMO/PPO. INSURANCE DISCOUNT..
INSURANCE PAYMENT
1,779.68-
6,406.83-
I PAYMENTS AND CHARGES RECEIVED AFTER THE STATEMENT DATE WILL BE REFLECTED ON iHE NEAl STATEMENT.
MESSAGES
The amount shown on this statement is outstanding at
this time. Your prompt payment will be.greatly
appreciated.
.....=........."".",."."'...-=."" .J"="""';.u<.1l~~~.,..=~.......~"""",
ACCOUNT- BALANCE aUf:
$711.87'
FOR BILLING QUESTIONS, PLEASE CALL:
(717) 960-1680
--
~UPON RECEIPT
Statement
Make Checks Payable To:
Bronstein Jeffries, PA
4830 Londonderry Road
Harrisburg, PA 17109
Account
39490
Statement Date
Ju18,2007
Due Date Total Due
Jul :11, 2007 13.88
Amount Enclosed $
1111111111111'1111.11..11.1..1.1
Dorothy L Painter
680 Creek Road
Carlisle, PA 17013
1,11111,1.1...111111.1.1,,111.11
Bronstein Jeffries, PA
4830 Londonderry Road
Harrisburg, PA 17109
r
..- _ -. -. _ .--.-..-_ _ _ _ _ __. _ _ ______... _ ___..... __... _ _ ..__ __...._. ....._ __.... _.. ___....____n.__..........._ ..... .g.~~~~~.: ~~~~~ .~~:<.~~~ !~_~i.~~: _~~~_~~~~?_:!~. ~.~~~~~.~ ~~ .~:~~:~:'~!?_:.__
Detach at perforation and return above portion with payment.
-1
Service Date
Description
Charges
Previous Balance:
Payments I
Adjustments
Patient Account: 39490 - Doroth L. Painter
OS/21/2007 MEMO: 061207 PT OWES $13.88 COPA Y
ChemicoffDO, David P. Consult IP Initial new/est L4
FILED: MaiIhandJers 14
ADJ: Health America/Assurance Adjustment
PAY: MailhandIers 14
0.00
05/30/2007
06/02/2007
06/12/2007
200.00
PlrtJentBalance:
-61.16
-124.96
13.88
r
-1
IF YOU HAVE RECENTLY MADE A PAYMENT, PLEASE DISREGARD THIS STATEMENT. BALANCES UNPAID AFTER
30 DAYS MAY BE ASSESSED A $10 BILL CHARGE. QUESTIONS REGARDING YOUR BILL, PLEASE CALL 657-2599.
Jul 8, 2007 13.88 0.00 0.00 0.00 0.00
Bronstein Jeffries, PA . 4830 Londonderry Road. Harrisburg, PA 17109' (717) 657-2599
0.00
Statement Date
1-30 Days
3 1-60 Days
61-90 Days
91-120 Days 121-150 Days Over 150 Days
PHILI~ D. CAREY, MD
360 ALEXANDER SPRING ROAD
CARLISLE, PA 17015
~i8ce .O~ S.en,r~ce
STATEMENT fOR PROFi2SS~QNA1.. SERV~CES
CARLISLE REG MED CENTER I
PT-0006
Page No.
1
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DOROTHY L PAINTER
680 CREEK ROAD
CARLISLE PA 17013
3;:; ~8
PAINTER
'( C,~--;:ECK ::iERF ar:c See Reverse Fe! Cb8t";(;e of Pvj6!"ess 2nd/c-; rnSiJ::-ance ~nto?mat~0G_
A"lY ~aY;T:ents 0:- Chaig9s A5ie:- ',re f~bo''/e 8;\;;ng Date \/\fiii Appear On You;- Next Stateme~t.
t~~~~N:t3il ~~E~i~
Patient: D PAINTER
Doctor: PHILIP D CAREY
99213 OFFICE/OUTPATIENT VISIT, EST, EX
DX: 786.2
MAIL HANDLERS
PMT MAIL HANDLERS
W/O MAIL HANDLERS
D PAINTER
PHILIP D CAREY
BRONCHOSCOPY W/BIOPSY
239.1
MAIL HANDLERS
D PAINTER
PHILIP D CAREY
SUBSEQUENT HOSPITAL CARE, MOD CO
162.9
SUBSEQUENT HOSPITAL CARE, MOD CO
162.9
SUBSEQUENT HOSPITAL CARE, MOD CO
162.9
HOSPITAL DISCHARGE DAY MGMT, <30
162.9
MAIL HANDLERS
05/10/07
05/14/07
06/07/07
06/07/07
05/17/07
Patient:
Doctor:
31625
DX:
06/14/07
05/18/07
Patient:
Doctor:
99232
DX:
99232
DX:
99232
DX:
99238
DX:
05/19/07
OS/21/07
OS/22/07
J6/14/07
2_~ !\j~)""""je:-
s
JV '-' :-::-e-....iics
07/10/07
. AmouV"'l+ (\, <0
i '"' '"''-'vv 20.00
OS/22/07
DOROTHY
! Amount t::-:cfosed
i(t'
:~
)
Chart No.
6291
75.00
75.00
#
55271
55271
55271
Filed
c#
c#
29.89-
25.11-
45.11
20.00
500.00*
520.00
#
58711
Filed
80.00*
600.00
80.00*
680.00
8a.00*
760.00
125.00*
885.00
#=
58721
Filed
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P'L,0.Ce; Of 8thV. CDv~:
ReJ:err-ing PhYS~Cja.0
.' Of~ice
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\ 22 ~ 00~:J3;i9"! Hos~;t2.:
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3~ : Ski;:ec ~ac;;ity
32 \LFSi:-:~
, 5 -; ,i;-:c::eps0ce:t: LabJ:"'a~G:;'
-.--J\~ :),"er U~"st8d Faci".v
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- . ,-~.-~
crJMBERLAND PIJ.THOLOGY ASSOC S
PO BOX 188
LANDISVILLE PA 17538
BI LLI NG I NQTJI RI ES: MONDAY THRU FRI Dl>,Y
8: 00 AM TO 5: 00 PM (EST)
TOLL FREE PHONE: 1-888-22.3-5649
RETURN SERVICE REQUESTED
STl;iEMENT DATE
07-25-07
P ATI ENT: DOROTHY L. PAINTER
LOCATION CARLISLE REGIONAL
PIN#: 024802014844
12 IP
0030 DUN
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P,4Y 7H1S f:\I'.WJUf'.)"T ,f:.,CCT. ;:
$373. 50 A248-0013769-01
i"'H""r ,[,-..,,- .
I~' vv:.;::v~..Jt..j;'-:;! ;;:
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DOROTHY L. PAINTER
680 CREEK RD
CARLISLE, PA 17013-9646
I, , , III, , , III, , " " II" ILl, I " , II " I I " 1.11, , II , III. II I, I, 1.1
CUMBERLAND PATHOLOGY ASSOC S
PO BOX 188
LANDISVILLE PA 17538
I " ,III " ,I, 1,1" , 11,1 t ,I,ll t , , II , III, ,I,!, , 1,1, , 1,1. , I, " II, I
Cl Please check box if above address is incorrect or insurance
information has changed, and indicate change(s) on reverse side.
.~~.:.~i~
KEEP THIS PORTION FOR YOUR RECORDS
PLEASE DETACH PJ~D RET!JRr~ TOP PORTION WiiH YOUR PAYMENi
Your insurance company has not paid the total amount of these services.
Please remit your prompt payment for this outstanding balance.
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fNStiR.ANcE
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PLAN: ......
SECONDARY INS ORANCE
PHONE:
PRIVATE PAY
POL:
PLAN:
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GRP:
. DATE ..
CODE'
THIS IS ~I BILL FOR P OFESSIONAL LAB SERVICES, SUPERVISED
P~:~~OGI~rT' IFT:::Ef::'::::.:~~Q::::::.E:~:::: :::E
05-17-07 88112 CYTOPATHOLOGY WjSELECTIVE
I CELLULAR ENHANCEMENT
05-17-07 I 88305 I LEVEL IV - SURG PATHOLOGY
GROSS AND MICROSCOPIC
EXAM
05-17-07 88305 LE\~L IV - SLTRG PP~HOLOGY
GROSS AND MICROSCOPIC
EXAM
06-12-07 PAYMENT MAILHANDLERS
CO- I NS YOUR INS. COMPANY' S EOB
I NDI CATED A CO- I NS u'RANCE
AMOUNT OF $12. 30 FOR
S ERVI CES PROVI DED.
CO-PP_Y YOUR INS. COMPANY'S EOB
INDICATED A CO-PAY
AMOUNT OF $31.20 FOR
SERVI CES PROVI DED.
PIN#: 024802014844
CUMBERLAND PATHOLOGY P~SOC' S
PO BOX 188
LA-NDISVILLE PA 17538
IRS#: 30-0317755
5
BY A BOARD CERTIFIED
~I NG PHYSI I A,..~~
GARD THIS ]OTICE.
175.00 1
I
150. 00
175.00
325. 00
150. 00
475.00
101. 50
373. 50
I
PLEASE PAY THiS AMOUNT ~ I
DOROTHY L. P 1'J. NTER
ACCT NO: A248-0013769-01
.
!
I
i
i
~.:1
$3/3.50
.~
srLt TEfllfENT
FROM: BLUE MOUNTAIN ANESTHESIA ASSOCIA
PO BOX 947
CHAMBERSBURG, PA 17201
7/27/07
PAINTER, DOROTHY L
814-G
35.91
AMOUNT
REMITTED
TO:
02546/T13 P1
PAINTER, DOROTHY L
680 CREEK RD
CARLISLE, PA 17013-9646
MAKE CHECK PAYABLE TO:
BLUE MOUNTAIN ANESTHESIA ASSOCIA
PO BOX 947
CHAMBERSBURG, PA 17201-0947
1",111",111"""11,,11,1,1,,,11,"1"1,11"1.,1,11,",1,1.1
1."111",1"1,111,,,,,,11 11",1,111.1.,1111,1,1"11,,,11,,1,1
- ~
We also accept: [J LI'7S'I i 0 ~
Please detach iOO ooriion .3nd return wah
VOUr ,remittance In the enclosed envelooe.
CARD NO.
EXP. DATE
SECURI1Y CODE'
"Security code can be
found on the back of the c:1rd
AMT. AUTHORIZED
~URE
RetaIn this oortion of statement for your tax records.
DATE
DESCRIPTIONOFSEORVICES
j . AMOUNT I BALANCE
PHYSICiAN! LOCATION
**Services For PAINTER, DOROTHY L*
Account#
679
OS/21/07 21
06/23/07
06/23/071
99253 1ST INPT CONSLTJ 55 MIN
Payment MAILHANDLERS
MEDICARE HMO AJUSTMENT
325.00
83.78
205.31
35.91 JULIO SOLA
261 ALEXANDER SPRING RD
'PLACE OF SERVICE
11 . OFFICE
112. HOME
21. INPAT HOSP
/22. OUTPAT HOSP
23. EMERG ROOM
31. SNF
I 32. NURSING FAC.
33. CUST CARE FC
FOR BILLING QUESTIONS CALL
CUSTOMER>CARE
800-827-345S.>.
EXT.407
SAM-4PM
IRS NUMBER
PROVIIJERSBILLlNGADDRESS
BLUE MOUNTAIN ANESTHESIA ASSO
35.91 PO BOX 947
CHAMBERSBURG, PA 17201
251690800
MESSAGE.