HomeMy WebLinkAbout02-28-08
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 2B0601
HARRISBURG, PA 17128-0601
*'
INFORMATION NOTICE
AND
TAXPAYER RESPONSE
FILE
ACN
DATE
NO. 21 -Drt,-22S
07113361
03-28-2007
REV~15ii3 E~ !$P ..(99..00)
[' ',':-- 0.'~~ ,,,", 8
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TYPE OF ACCOUNT
o SAVINGS
!iJ CHECKING
o TRUST
o CERTIF.
[.l; i
!: ? ,.EST. OF PAUL E MYERS
. - CS . S. NO. 177 - 42- 1161
DATE OF DEATH 02-16-2007
COUNTY CUMBERLAND
('I
ABRAM 0 MYERS ~l
984 GREENSPRING RD
NEWVILLE PA 17241
REMIT PAYMENT AND FORMS TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
.2 c (.
ORRSTOWN BANK has provided the Department with the information listed below which has been used in
calculating the potential tax due. Their records indicate that at the death of the above decedent, YOU were a joint owner/beneficiary of
this account. If yOU feel this information is incorrect, please obtain written correction from the financial institution, attach a copy
to this form and return it to the above address. This account is taxable in accordance with the Inheritance Tax Laws of the Commonwealth
of PennsYlvania. Cluestio'ls ..ay he ~nswered by c311;'1'! (717) 787-8~77.
COMPLETE PART 1 BELOW * * * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS
Account No. 815942
Account Balance
Percent Taxable
Amount SUbject to Tax
Tax Rate
Potential Tax Due
PART
[!]
Date 01-30-2001
Established
To insure proper credit to YOUr account, two
(2) copies of this notice must accompany Your
payment to the Register of Wills. Make check
payable to: "Register of Wills, Agent".
2,061.91
X 16.667
343.66
X .15
51.55
TAXPAYER RESPONSE
NOTE: If tax payments are made within three
(3) months of the decedent's date of death,
YOU may deduct a 5% discount of the tax due.
Any inheritance tax due will become delinquent
nine (9) months after the date of death.
[CHECK]
ONE
BLOCK
ONLY
A. [] The above information and tax due is correct.
1. You may choose to remit payment to the Register of Wills with two copies of this notice to obtain
a discount or avoid interest, or you may check box "A" and return this notice to the Register of
Wills and an official assessment will be issued by the PA Department of Revenue.
B. [] The above asset has been or will be reported and tax paid with the PennSYlvania Inheritance Tax return
to be filed by the decedent's representative.
C. ~ The above information is incorrect and/or debts and deductions were paid by you.
You must complete PART ~ and/or PART ~ below.
PART
~
TAX RETURN - COMPUTATION
LINE 1. Date Established
If YOU indicate a different tax rate, please state YOUI'
relationship to decedent:
2. Account Balance
3. Percent Taxable
4. Amount SUbject to Tax
5. Debts and Deductions
6. Amount Taxable
7. Tax Rate
8. Tax Due
PART
[!J
OF TAX ON JOINT/TRUST ACCOUNTS
1
2
: J~n:1f5"
6. 0
7 X
8 (l)
DEBTS AND DEDUCTIONS CLAIMED
PAID
TOTAL (Enter on Line 5 of Tax Computation)
perjury, I deClare that the facts
my knOWledge and belief.
have reported
HOME (
WORK (
TELEPHONE
r.1
\)
~
CHAMBERSBURG GASTROENTEROLOGY ASSOCIATES, LTD.
835 FIFTH AVENUE
CHAMBERSBURG, PA 17201
PHONE:
(717) 263.0629
JOHN G. ENDERS. M.D.
MARK P. DOBISH, M.D.
WAYNE C. HOOVER, M.D.
M. FAROOQ KHOKHAR, M.D.
CHAD E. POTTEIGER, D.O.
I
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.~'$TArfMf:'NT OAT,!;
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;6t*' '_ . ~" ~ J l: ''''''''f(,,~ r';:' ::;;::V:],
,~:; ENO'PAYM.eN'rTQ:,:~iti' .
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CHAMBERSBLJRG GASTROENTEROLOGY
ASSOCIATES
1335 f'IFTH AVENUE
CHAMBEf,SBURG, PA 17201
(717) 263-0629
~
ESTATE OF PAUL E MYERS
DAYS PERSONAL CARE HOME
202 S SECOND ST
CHAMBERSBURG PA 17201
-/
~A.49~iJN~(~I;IM~'
03/13/07 03/13/07
~
33181 (1) 33181
-, . Q~TE ~,/- '," D~SCRIPT'ON-"~~,:- -. '..;', <r~,~~~E"" ~ C~~t.~.:.', --;'~~
01/05/07
01/31/07
01/31/07
01/06/07
01/31/07
01/31/07
'i ,I
I
ESTATE OF PAUL E MYERS (13181.0)
I
LEVi
I
LEVE
I
TOTAL FOR I ESTATE
I
I
I
'I I'
I
I
I
I
CONSULT, INITIAL HOSP,
Ins Pmt-MEDICARE
Adjustment
120.0
110.56
61.80
E MYERS
DETACH THIS STUB AND
RETURN WITH PAYMENT
':~':,BAi;;~.NeE, :,: -. "OA'TE<;-":~
~~t-<':; .... .,J:,. '4,'..J.lti'; ~4i :;;:~$J, 'r-~!i H 'y)"~'~'''\1'''~'\l:'\:1 ~
(33181.0)
21.06 01/05/07 I
27.64 01/06/07
48.70
84.22
14.72
HOSPITAL, SUBSEQUENT,
Ins Pmt-MEDICARE
Adjustment
200.0
OF
I
"
! )
, l
PAYMENT IS DUE WITHIN 30 DAYS
L___
;J)JffiUAno". r ITHn 11':11 HllOl'\ I rW.:rnll[1'iIU~
. All PAY
~THIS ,
48.70 AMOUNT I
STATEMENT
SHIPPENSBURG HEAL TH CARE CTR Facility Phone: 717-530-8300
121 WALNUT BOTTOM RD
SHIPPENSBURG, PA 17257
Resident: PAUL E MYERS
Statement Date: 02/04/08
Abram & Sandra Myers
984GREEN SPRING ROAD
Newville, PA 17241
Date Service Through Qty Description Amount
Sub Total as of 12/31/06 379.00
Charges
02/01/07 01/30/07 01/31/07 2 Co-Insurance 248.00
02/06101 . 02/0_llQ7_____l>2LQ6/07 6 Co-Insurance 744.00
(3)6/01/07------12/01/06 02/08/~7 ~lla~ ~ 9g3~
Sub Total 1,955.00
Balance 2,334.00
Cash Receipts/Adiustments
01/03/07 11/10/06 11/30/06 Payment -362.50
06/22/07 11/10/06 02/08/07 Payment -552.00
02/08/07 12/01/06 12/01/06 Payment -16.50
06/01/07 01/30/07 01/30/07 Payment -32.00
06/01/07 11/10/06 11/10/06 1 ADJ. Co-Pay- 97001- PHYSICAL THERAPY -14.61
EVA
06/01/07 11/10/06 11/10/06 1 ADJ. Co-Pay- 97003- OCCUPATIONAL -15.57
THERAPY
06/01/07 11/13/06 i i /30/06 10 ADJ. Co-Pay- 97110.. PT THERAPEUTiC -54.10
EXERC
06/01/07 11/13/06 11/30/06 16 ADJ. Co-Pay- 971100T-THERAPEUTIC -86.56
EXCERIS
06/01/07 11/13/06 11/28/06 9 ADJ. Co-Pay- 97112- PT NEUROMUSCULAR -50.58
RE-
06/01/07 11/27/06 11/27/06 1 ADJ. Co-Pay- 97116- PT GAIT TRAINING -4.76
06/01/07 11/10/06 11/30/06 24 ADJ. Co-Pay- 975300T- THERAPEUTIC OT -136.32
ACT
06/01/07 12/01/06 12/01/06 1 ADJ. Co-Pay- 97110- PT THERAPEUTIC -5.41
EXERC
Page 1
.
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Cumberland Valley Memorial Gardens
A DIVISION OF STONEMORPARTNERS, L.P.
1921 Ritner Highway
Carlisle, PA 17013
Phone (717) 243-3541 Fax (717) 243-4495
Invoice No. 3886
INVOICE ~
Customer
Name Abram O. Myers
Address 984 Greenspring Road
City Newville State PA
Phone
ZIP 17241
Date
Order No.
Ref#
FOB
2/15/2008
#27-4-0045.7
P!W----
DeSC!iPt~_________4_ _~rl.!! Pri~_~-+_____!<:lIA.~_1
24x12 Individual Bronze Memorial on 28x16 Granite Base
(with vase assembly)
$1,551.00
$1,551.00
Original date of purchase: 2/24/2007
Payment Details
o Cash
@ Check
o Money Order
Name
SubTotal
Processing Fee
$1,551.00
-~-~------~~-
$75.00
TOTAL
$1,626.00
~_ -- -_ m~_ -=
PAID IN FULL
Osiris Holding of Pennsylvania, Inc.
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