HomeMy WebLinkAbout06-04-08
'lEV-1500 EX + (6-00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
uJ
....
lo:~1Il
(,J D::lo:
wl1.(,J
J: 00
" D::..J
....l1.tIl
l1.
<l:
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
~
z
w
c
w
(.)
w
c
BELCHER
DATE OF DEATH (MM-DD-Year)
WALTER J.
DATE OF BIRTH (MM-DD-Year)
03/02/2008 04/17/1919
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST, AND MIDDLE INITIAL)
IX] 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Attach copy 01 Wi")
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (date 01 death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copyofTruSl)
o 10. Spousal Poverty Credit (date 01 death betwe6n 12-31-91 and 1-1-95)
OFFICIAL USE ONLY
FILE NUMBER 0
2-.L -.JL JL ...0. lo .l__
COUNTY CODE YEAR NUMBER
SOCIAL SECURITY NUMBER
1 99- 0 5 - 8 7 7 3
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (date 01 death prior to 12-13-82)
o 5. Federal Estate Tax Return Required
_ 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 01
....
z
uJ
C
Z
o
l1.
III
W
D::
D::
o
(,J
THIS SECTION M.OST' BE COMPLETED~ALLCORRESPONDENCEANDCONFIDENTIAL.TAX INFORMATION SHOUL.DBE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
ROGER B. IRWIN ESQUIRE 60 WEST POMFRET STREET
FIRM NAME (If Applicable)
IRWIN & McKNIGHT
TELEPHONE NUMBER
717 249-2353 CARLISLE 3
c_
:s::.
0.00 X _(15) 0.00
0.00 X .045 (16) 0.00
0.00 X .12 (17) 0.00
0.00 X .15 (18) 0.00
(19) 0.00
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
z
o
~
:J
~
a:
<(
(.)
w
0:::
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. ,Jointly Owned Property (Schedule F) (6)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Iotal Gross Assets (total Lines 1-7)
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)
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)
14. tlet Value Subject to Tax (line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
z
o
~
~
::;)
D.
:E
o
(.)
~
~
15. J\mount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
~~.~.;
- -)y
(:-J
_:!).
i:;~
CJ
('~')
-Tl ""1'1
~;~~
t.~:- 1_ I
u) (. )
-;i',
-0
I
I
I
...~ ~
-:::.i'"'
-
N
o
N
5,494.84
150.00
(8)
5,644.84
9,119.34
1 ,025.65
(11)
(12)
(13)
10,144.99
-4,500.15
(14)
-4,500.15
Decedent's Complete Address:
STREET ADDRESS
11 STALLION ROAD
CITY
CARLISLE
STATE
PA
I ZIP 17015
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Disc;Qunt
(1)
0.00
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits ( A + B + C)
(2)
0.00
T otall nterest/Penalty ( 0 + E ) (3)
4. If Line:2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If Line! + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B)
Make Check AGENT
0.00
0.00
0.00
0.00
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 !Xl
b. retain theright to designate who shall use the property transferred or its income; ........................................ 0 !Xl
c. retain a reversionary interest; or ...................................................................................................... 0 !Xl
d. receive the promise for life of either payments, benefits or care? ............................................................. 0 !Xl
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?............................................................................................... 0 !Xl
3. Did decedent own an 'in trust for' or payable upon death bank account or security at his or her death? ................. 0 !Xl
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ....................................................................................................... 0 !Xl
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of pe~ury.1 declare that I have examined this return, including accompanying schedules and statements. and to the best of my knowledge and belief, it is true, correct and complete.
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
A:J-l/1Qjdlr~o O. ~A.OA~
ADDRESS 11 STALLION ROAD
CARLISLE
SIGNATURE OF PRE PARER OTHER THAN REPRESENTATIVE
PA 17015
DATE
ADDRESS
60 WEST POMFRET STREET
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 3%
[72 P.S. 991'16 (a) (1.1) (ill.
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 0% [72 P.S. 39116 (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 steppare!nt of the child is 0% [72 P.S. 39116(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 4.5%, except as noted in 72 P.S. 39116(1.2) [72 P.S. 39116(a)(1)1.
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 39116(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-1509 EX + (6-98)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF
BELCHER
FILE NUMBER
WAL TER
J
21
08
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SUFMVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A. GERALDINE HOCKENBERRY
11 STALLION ROAD
CARLISLE, PA 17015
DAUGHTER
B
c
JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %01' DATE OF DEATH
ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF
NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1. A. M&T BANK - CHECKING ACCOUNT #402702 1,170.31 50. 585.16
2. A. FEDERATED - FUND NUMBER 2 7,336.60 50. 3,668.30
NASDAQ SYMBOL - LUGXX
LIBERTY U.S. GOV MONEY MARKET A
3. A. 5/2007 CORNERSTONE FEDERAL CREDIT UNION 30.20 50. 15.10
SAVINGS ACCOUNT #23769-01
4. A. 5/2007 CORNERSTONE FEDERAL CREDIT UNION 2,452.56 50. 1,226.28
MONEY MARKET ACCOUNT #23769-18
TOTAL (Also enter on line 6, Recapitulation) $ 5 494.84
(II more space is needed, insert additional sheets 01 the same size)
REV-1510 EX + (6-98)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
BELCHER WALTER
SCHEDULE G
INTER.VIVOS TRANSFERS &
MISC. NON.PROBA TE PROPERTY
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
J.
FILE NUMBER
21 08
DESCRIPTION OF PROPERTY
ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER. ATIACH A COPY OF THE DEED FOR REAl ESTATE. VALUE OF ASSET INTEREST VALUE
(IF APPliCABLE)
1. CUMBERLAND VALLEY COOPERATIVE ASSOCIATION 20.00 100. 20.00
CERTIFICATE NO. 6467-2 SHARES @ $10.00/SHARE
2. CUMBERLAND VALLEY COOPERATIVE ASSOCIATION 40.00 100. 40.00
CERTIFICATE NO. 8419-4 SHARES @ $10.00/SHARE
3. CUMBERLAND VALLEY COOP ERA TIVE ASSOCIATION 10.00 100. 10.00
CERTIFICATE NO. 3578-1 SHARE @ $10.00/SHARE
4. CUMBERLAND VALLEY COOPERATIVE ASSOCIATIONq 80.00 100. 80.00
CERTIFICATE NO. 10580-8 SHARES @ $10.00/SHARE
TOTAL (Also enter on line 7 Recapitulation) $ 150.00
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX + (12-99)
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
BELCHER
WALTER
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
Debts of decedent must be reported on Schedule I.
J.
FILE NUMBER
21
08
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. HOFFMAN-ROTH FUNERAL HOME 6,169.34
2. CUMBERLAND VALLEY MEMORIAL GARDENS 2,065.00
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 IRWIN & McKNIGHT 750.00
3. Family Exemption: (If decedent's address is not the same as claimanfs, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Prepare~s Fees PATRICIA A. ROSENDALE, CPA 110.00
7. REGISTER OF WILLS - FILING FEE 15.00
8. NOTARY FEES 10.00
TOTAL (Also enter on line 9, Recapitulation) $ 9.119.34
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX + (6-98)
*'
SCHEDULE.
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
BELCHER
FILE NUMBER
WAL TER
J.
21
08
Include unreimbursed medical expenses.
ITEM
NUMBEIR DESCRIPTION
1. WEST SHORE EMS - AMBULANCE
VALUE AT DATE
OF DEATH
835.80
2. CUMBERLAND COUNTY AGING & COMMUNITY SERVICES
132.30
3. PAMELA BURKHOLDER, TAX COLLECTOR - PERSONAL TAXES
9.80
4. CPARC - ADULT DAY CARE
47.75
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
1 025.65
REV~"" >X. "*,
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
BELCHE R
NUMBER
I.
II.
SCHEDULE J
BENEFICIARIES
WAL TFR
./.
1.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
GERALDINE A. HOCKENBERRY
11 STALLION ROAD
CARLISLE. PA 17015
FILE NUMBER
?1 OR
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
Lineal
AMOUNT OR SHARE
OF ESTATE
REMAINDER
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
n
c:
:;r:1 ~
trj !Xl
~ m
t't:1 :c
:;j r-
l>
ttj :2
Z
0 0
tl:I t't:1 <
t::l l>
l:'"l r-
0 r-
m
::I: -<
t::l n
~ 0
0000 0
t:zj U1 U1 U1 U1 -C
tI.l '--'-- t::J m
:c
1-3 0000 ;;po l>
". l-"l-"l-"l-" r-3 -t
1-3 '---- t''1 <:
t:zj 0000
0:>0:> 0:> CO m
0 l>
I'z:l (/)
(/)
~ Ultl.lUlUl tj :2
1-3 1-3 1-3 ~ ttj
l:'"l 0000 Cf.l
t-3 OOC10 C1
t::l ~~:;.:::;.:: :;r:1
~ H
"'cl"cPt1 '"lj "'d
~ C::C::C::C:: r-3
:::O~~~ H
OOOe) 0
::t::::I:::I::I: Z
>'>>>
Ultl.ltl.lUl
tJ:1t::lttjt::l
0
~
-l
'"'1
0000 <
-.J -..J -.J -.J 0
CO 0:> CO CO c::
l-" l-" l-" l-" 0 0
*'" *'" ~ *'" ::t:: U1
-.J 0'\ U1 ~ t:r:I -
:::0 0
CO
'-
...
0
CO
l-" :> CJ
c..n 0:> *'" N l-" ;J:
0 0000 0 00
c:: N
0 0000 Z
0 0000 1-3 +:::a
W
N
~
CORNERSTONE
Federal Credit Union
p.o. Box 1181, 5 East Gate Drive, Carlisle, PA 17015
Telephone (717) 249-1661 FAX (717) 249-8208
www.comerstonefcu.coop
Member founded - Service based
March 27, 2008
RECEIVED
tMAR 2 8 2008
Irwin & McKnight
Roger B. Irwin
60 West Pomfret St.
Carlisle, PA 17013
IRWIN & McKNIGl-n
LAW OFFICES
RE: Estate of Walter J. Belcher
Roger,
At the time of his death, Walter J. Belcher was a joint owner of a savings and a money market
account Listed below is the information requested per your letter dated March 18, 2008:
Account Number 23769 (Savings and Money Market)
I. Register owner, Walter J. Belcher, joint owner Geraldine A. Hockenberry
2. Account opened May 14, 2007
3. N/A
4. N/A
5. 23769-0 I Savings $0.08, 23769-18 Money Market $29.61
6. 23769-0 I Savings $30.20, 23769-18 Money Market $2,452.56
If you require any additional information, please do not hesitate to contact me at 717-249- i 661
ext 240.
Sincerely,
,1WuIJ(1 JJ:~{~
Donna J. M~y (-- - d
Financial Services Administrator
MEI'1BER SAVINGS ACCOUNTS FEDERALLY INSURED To $100,000 By THE NATIONAL CREDIT UNION ADMINISTRATION
rlM&rBank
499 MitcheIl Road, Millsboro, DE 19966 Mail Code DE-MB-12
Phone (888) 502-4349
Fax (302) 934-2955
March 31, 2008
Law Offices
Irwin & McKnight
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, Pennsylvania 17013-3222
RECEIVED
APR 0 2 2008
mWII~ & McKNICH;
LAW OFF!CE~
Re: Estate of' Walter J Belcher
Social Security: 199-05-8773
Date of Death: March 02, 2008
Dear Sir or Madam:
Per your inquiry dated March 25, 2008, please be advised that at the time of death, the above-named decedent had on
deposit with this bank the following:
I.
Type of Account
Checking Account
Account Number
402702
Ownership (Names of)
Walter J Belcher *
Gerri Hockenberry *
Opening Date
09/01/67 Closed 03/31/08
Balance on Date of Death
$1,170.31
Accrued Interest
$ 0.00
Total
$1,170.31
Please be advised, there was no safe deposit box found for the above decedent
* If upon reviewing the information above, you believe there are additional accounts not referenced, please provide
us with an account number and/or name of any possible joint account holder. For any additional information on
the above accounts, including ownership and any changes, closures and/or reimbursement of funds, please call the
High Street Carlisle Office # 717-240-4536.
Sincerely,
.o?# h'C;7~a~/
Nancy Clagett
Records Management
~ d led PO Box 8600
re era Boston MA 02266-8600
MB 0100595281628 H 21 A
11,111111'1'11,11,,11"11111'1111111,1111,11111111111'111",1'11,
WALTER J BELCHER
GERALDINE A HOCKENBERRY JT TEN
11 STALLION RD
CARLISLE PA 17015-9530
Portfolio Overview
TOTAL. MARKET VALUE as of 0212912008
Investor News
~...... "~'..~
D' ill
..- )~
"...~.~,<,O
C'o...u",c.~
$7,336.60
For the source of Fund distributions according to Generally Accepted Accounting
Principles as required by federal securities laws. visit Federatedlnvestors.com.
Would you like to monitor your Federated Funds?
Visit Feideratedlnvestors.com and select MyPortfolios within the
Products tab to create a customized portfolio of your Federated
holdin~ls. Total returns. price history and much more can be
tracked with this easy to use tool!
04643 1/1
Monthly Statement
For the period ending February 29, 2008
Page 1 of 2
~ The funds' Senior Officer. who manages the
process by which the funds' Board
considers the funds' advisory fees. prepares
an analysis to assist the Board in this
regard. which is summarized in the
"Evaluation and Approval of Advisory
Contract" for each fund that is available at
Federatedlnvestors.com.
~ Important note: .
Please review the information contained in
this statement and promptly report
inaccuracies or discrepancies in writing.
This statement is not for tax purposes. but it
should be retained for your records.
Account Information
Fund number 2
Account number 9903193
JJ For account questions, balances. yields, etc.
. call 1-800-245-4770. For automated phone
access call anytime 1-800-245-2999. TTY-
Service for the deaf and hearing impaired is
available at 1-800-358-6930- TTY phone
needed
rtj Access to fund information is available at
~ Federatedlnvestors.com.
Federated Securities Corp., Distributor
,/
/
./
-.."..............
.........................................'.......
...............................,...............
~;tt*iM.*~~::;:,~~,i:.~'W~t\
CPARC
Accounting Office
71 Ashland Avenue
Carlisle, PA 17013
Telephone (717) 249-2611
CPARC is an equal opportunity, affirmative action employer.
~
Sold To: Walter Belcher & Gerri Hockenberry
11 Stallion Road
Carlisle, PA 17015
Invoice # 1225
Date: March 4, 2008
Your Order No.
Terms:Gross Cash 30 Days
I.R.S. #23-1489837
Description Unit Price Total
February 2008 Adult Day Care
Walter Belcher- 1 day@ $47.75 $47.75
February 08 - 1
location - Carlisle
Total Due $47.75
Hoffman-Roth Funeral Home & Crematory, Inc.
219 North Hanover Street
Carlisle, P A 17013
(717)243-4511
March 19, 2008
Geraldine Hockenberry
11 Stallion Road
Carlisle, P A 17015
The Funeral Service for Walter J. Belcher
15269-62
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
OUR SERVICE:
Traditional Funeral Service Package . . . . . .
FUNERAL HOME SERVICE CHARGES
$4150.00
$4150.00
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THAT YOU HAVE SELECTED . . . . .. ......
, $4150.00
Cash Advances
Opening Grave. . . . . . . . .
Newspaper Obituary Notice- Sentinel. .
Newspaper Obituary Notice - Patriot News
Clergy Offering . . . . . . .
Certified Copies of Death Certificates. .
Flowers. . , . . . . . . . .
$1270.00
$146.52
$283.82
$100.00
$60.00
$159.00
TOTAL CASH ADVANCES AND SPECIAL CHARGES.
$2019.34
Total
Total Cost .
$6169.34
HistOlj'
03/19/2008 White Circle Club .
$-200.00
TOTAL AMOUNT DUE
$5969.?4
This statement is net and payable in full within 30 days of receipt.
Please return this portion with your Remittance
$
Amount Enclosed
Service ID # 15269-62
Walter J. Belcher
" *
:>
~9
",n
3r
",r
~n
~,~
~c..
~. ::T
:>n
:!In
~~
r"'g
r::l
(j'<
~.~
'"
:1-=
"'n
(j'"
og-
3 iil
g3
~ 2!.
<:7'::1
~.:~;
g'g
0::>
srla"
0::1.
fi' .:<'
e:~
::I,C"
l<l07
1>>' .;.0.'
l<lO .
3:.,::f'
cn'n
~qO
~~'"
o),~:;
i.~
:",\'",
::T
n
'"
'"
07
'"
o
....
n'
:3
'"
,~ .
P-
;,.:nu,
. n'
"3 .'
-,'::0',
:',',~J~ "'I
"Cl
"'.""1
_~;o
..:S.
. p-'
'0
P-
" c-
. '-< .'.
.0
::I'
n
~
'0'
,g.
',,:,,:(1
,.".:......-
."'"Cl
'~"
,."
jOl
a
8"
"Er-,
(ii'"
r"l
!'-' ~ c:l " Vl -<'
:s: :s: > co ~. N
~ '" ~ -0
0 0 ;:l': !' !'
0. 0.
!!.. ~ rrl
-l
~
~ ~ ~
~ ~ ><
C),C)
l>> III
C ."
lJO (JQ
~ ~
."tj '"Cl .."
.. --.
.~;;..;....,-'..:-.. .-. ,,-. ~
~e~\ N --l
~ :!1.i2 0 c:l?= ~i ~
S'g..a80 ~ " lit -
.,.25'~ a:;;l. ~"".;:;~.
::s..~'ti:I- :> g- ::I e;.;:J
';'g;/Q'l>>,;I;:l~" :r,,' "tI 1:1"0
,;;Q;:~:I>>"'.';;':~?,t~-"R '" 1>> ~~
tb~5"'~ s '3 ~'o
"~ig;~ a g n ~
.n .' ....o.s.. Z a ==
~ . ..'tl..... g p 0 rrl
'+ .'. ~....;:. el >-
. '-li>. :::1: ~ ::I" s::
......" li + ~o:: g
'::: N Q\. z
.,S if'-l
.N ~. ....
9 ~.
>
z
~
rrl
t:'
>-
:l!!j
.0
n
3
~,g
..:'~-
"ir
....~.
;R
.<
..',(D.
,...-....
."
"~ ",
'~~
.:.:;~.
.'~.,
::.~'
. . cs.
. <:;i:/'g.
>g-
.:2
.5.
[.
";':"'0
~
.X
::r'
~""
c.
S!l
::' ("'l
3: r' c:l :s: 3:
0 a
0 (") (") t""l
Z ~ :> 3 :::
0 N g.
c: n 0
::: ::I Vl ~ ::c
t""l en N' " ;;
Z n <>
!:l F 0 r
-l '"
o' tiQ.
Z -=' ? Z
"%l '" "%l
0 n- O
::c -:.... - ::c
::: .~I s::
~ >< .\ ~
0 F 0
z z
!"
ll:l ~ (j 0 :::
'"
c: ~ 3 () t""l
;l:l '" ::r ::c
0- r.> ~
:z c: (")
~ :::; '< "'" :c
"" ::r >
~ ~ Z
Z ...,
co !2
3 ....,
'U: 'U: 'U: :: !' 3 Vl
!'-' !'-' ~ ~
0 " " " (")
::r
'" '" " <> '"
'" '" '" '" ::I
~ (") (") (") c-
., .., :::l. v;'
~. ~' ~. ~ '"
o' o' 0 o' in'
::I ::I ::I :> c:r
"
5'
O<l
-0
c
..,
(")
::I"
'"
'"
...,
0.
0'
..,
1;;
n
~
~
0
9-
n
.,
(")
n
3
a
0
..,
';<
.' '.
Q
0'
:-1
N
Cf.':i \V'J
N
><
~
"'~
-<
t-z~
I I'
',,-j
f'-
d.8:9 3. ~ :p l5 :3 8 g 9 3 Jij.:g 1) g ~
....:j Vl' ~ ." '>ii...... 0 S' C). ~ ~,c -< CIl r "l:l o:l
~ OC n ~ [ ~:.~ E ~3'~.a~ 8 ~.a 5. ::;
~ ~,o-t:.:,.,',~ :s :;;}^,:a .[ ff': 8:-'i.,~"Y'E 5. Q e ~'~
~ ~ g t;a' o' (Xj.~g ;>::l ::1 e:. ~. 25
..... ;;:, ::3 ""'0'.. ;:l . l>>. ;:;"'" _. _. QQ',...,
.... __ :j '" ";so. ;:> O<l ::ll 0 ::>".'~
_ _ "'...." O. !!.'o .... ....~ n E! .... )-
~ ..~ ~ a ~..~ ~ a g, ~ CD ~ 8
~ ~ ~ ~.. ~ ~g. S' ~ ~ Z
~ ~~a a~ t;(") ~o
CIl"'<:7' () 3~ ""..",
rrl i3~ ~.... ga:::~
"l:l ~ ;:l er ==
~ ~$ ." "'?:;
~ 5' g ~ ,..,
rrl ~3 0 ~~
~ ;;:3 .fVl
-l g
== "r1
~ '"
c:: '"
"l:l
"-'
11t-1-11
""
""
""
""
""""""""""
l
"" "" ""
~ ~ ~, vq' b'" (;Il'"t
r rfr
Vlr'CIlCl
-g~a~
.a o' ~
~ ='::s
Vl
'0
co
(")
A
~
rCllCl
sa ~.... '"
a..
g' g
.~
rZVl
~ 9 ~
~3 g,
;:l
II
rZVl
('tI 0 n
< ;-.. g.,
~ ~ o'
::I
t'""
t'""
~
...
n
o
3
.",
'"
::I
'<
..
-
~
:-~- ~
~ 21.\ )~
0:1 CIl ~ ~:, ::I
C () CIl ,o, c-
.,;l:l , ()
!.: :;~<; 0
.., ::r: .. . ~
~O:2 ~
;a-Z> ~
;. ~ ~ t" ~
~ g. ~
':C e: 3'
$:~ ~
t'"" '" L ;;
_0.:<:1 .,.... r;>
:::::" ...... =l
c;') fh "; ::5.
:Co- _
Cil 0'" 0
. ~ t<'"' 8
;j~ -\) ~
n ~... ~
c:l r" <'
5.h .,.....,z
~ ~ \: 5'
~Q' [-
IAS
8"2
< ;:l
"''<
a.~
~~
1fo
>lI.l
~~
3~
g ~
;[
:;: .Q
5~
~ g:
'"
~o.
9- g.
"'~
i[
z+
rn: g, [
=- fa) ~:_g,
~S; ::1"(")
~~$
a ~ E?'
.. ~ co
00 s.13
-a
99 ~!!l
~~~()
~~ 0 '"
-- ~~.
00 ;:>9-
C') C') :i' ~
D)-,c>> t":!..
a a 1fti
g g o~
o Ell ::I"
o @ Q
s-;;;lg,2
" O<l;:l 9- .-'
~;:>~",9-
~ 03 g &
;~~~~
;:;: -0 P- tT1 Jg
,.. '" n ~;:;"
I""" a."Cr ............0
'0 g ~ ~a
i-o~~o
~??o~!
~ ~ ~ ~
0::1-05:
~~co8..
c- '" 3-. 0
00 g ..,
.."",""5i::r
~ ',~ ~ 2..~
n "("g; c.. ~'!].
0- n-::t
::I 0 ~ 9- '"
~.~ :J. n ~
~P-[g-g
o' 0 c:r < =
::I3'!l...~8.
-.,.0::;_
~ ~2ir
o ""'.
~ ~;P
2 ~ (i
~ ~. [
o' 0 (l)
::3 ?-'::
()
::r
o
~.
...
II
rc;')
.. .,
~ ~
...
~Vl
~.",
"CI ..
~ ::::
003
~"
::I 0
CI<l C
;:>2:
'"
00
o-B
~ g.
'"
.go
'" Vl
P-s;
to.> 0<:'
li 4'-r
("'l~~
::roo.
o ;:l '"
~. ~
l" c
!:l
o'
::I
>
:: ~
'"
3
n
a
\ I
o:l
5.
a:
5'
(JQ
+
~
i
"
11
i:l
.......
=t' it
~~
::r1l
s.~
,., -.
ftt ~
"
~
o:l
5.
a:
5'
QQ
...
;:l
0.
()
::r
o
n'
...
nop\\
c: '" ""
-.1-3 -'-".
::i~lfa'iil'
':"-::!.::I:::I:
~~~ 9..8. '.-
.:.,50.9:9:
VlO -<;:l "
""," aClCl OQ
-::1:_00
_.("D .....,~
OQ '< .." "tl .
~s:gg
I>> n ::s ::s
'1'3~~
nO--
~ ~j ~
[C'lii:i';;;'
Oe!tnt'"
. d. C t'"
~g[(j
_ ~ ~'"1
-.I . e! t'"
o rS'-C t'"
t;;ot"'n
~ t"'..J
"n
~--:
..JQ
3
-0
~
J
e:
(ij'
~
g.
"[/6
~~:
!!=
....c
de;
e>::s
.atrQ
Sg.
~,.c'"
,~:r;
~..,=
5.'i
'~"$.
fTl.'i!!
~ . D).
!i.i'.
~~,
>=
trQJ,
[J..'~
~::"~~~e
-;-,~~J.~, B
~ z ~ '~~' ....
;E~ !!: ~~,
S~QQQ
-0,,333
::tlono
~l~a
n"~b
~Q~n
~~e;--:
--E!t'"
S'~'-Cr
::';':t"'<l
""'-'l''''''';
:::i (j
8 '"
t..> rS
o
3
'0
~
J
o
~~~.
~~hh~
-.10000
-b~ggg
~':i -< '?-<.
t..>Q.S:S:S:
~~~33
r: ::I. g.8.
::tlaaa
2C'lC'lC'l
p.~ae:
\;'/i'o~
~ a a a'
C;;'~CI}~
IfrSg.r-<
~o3 f!l.)3
. n Q. .
~"$F
....~: r-'11
;:i-'r;"";
t..> n
-0 '"
r5
o
3
'0
~
J
vi
~
0'
.:J
e:
o
o
~
~
'"
'"
::I
c-
o
-0
'"
.,
'"
o
..,
'"
o
-.
5-
n
n
o
3
n
"
.;1
:I!
Ci'i
>
Cl
rn
~
~
-l
3
co
0.
n
~
~
P-
er
'"
~
g
CIl
!l..
if
'"
::I
P-
()
o
%.
iil
!l
'lj,
WESTSHOREEMS-ALS
205 GRANDVIEW AVE
SUITE 211
CAMP HilL, PA 17011
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
PATIENT NAME: WALTER BELCHER
PATIENT NUMBER:
CALL NUMBER:
DATE OF CALL:
TIME OF CALL:
CALLER:
FROM:
TO:
INSURANCE: MEDICARE B 199058773A
CAPITAL BLUE CROSS YWM80033215900
3101441A
WALTER BELCHER
11 STALLION RD
CARLISLE, PA 17015-9530
REASON(S)
FOR
TRANSPORT
INVOICE
t:;"
,
WEST SHORE
, ,<
70054
3101441A
02/29/2008
MOEN
B
YEAGE~SPERSONALCAREHOME
HOLY SPIRIT HOSPITAL
DISORIENTATION
Hypothermia
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
PARAMEDIC INTERCEPT A0999 1.0 797.87 797.87
EKG ELECTRODES (4PK) A0396 1.0 4.94 4.94
GLUCOSE BLOOD A0394 1.0 6.74 6.74
SAUNELOCK A0394 1.0 26.25 26.25
Total Charges 835.80
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT - INVOICE DUE UPON RECEIPT -+- $835.80
E K FEE - 31.00
RETURNED CH C $
835.80
PATIENT NAME:
PATIENT NUMBER:
BELCHER, WALTER
70054
3101441A
05/15/2008
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE
AMOUNT $
ENCLOSED
CALL NUMBER
BILLING DATE:
THIS ACCOUNT IS NOW 40 DAYS PAST DUE!! Please send your
payment now. PROTECT YOUR CREDIT!
~I VISA : ,~. .
~ AND ..'Mliitr'
MASTER CARD
ACCEPTED
PA 17n11
WEST SHORE EMS - ALS 205 GRANDVIEW AVE CAMP I.m I
CUMBERLAND COUNTY
AGING & COMMUNITY SERVICES
16 Wrs]' HIGH S'mEET, SUITE 100 CARLISLE, PA 17013
(717) 240-6110 OR 1-1388-697-0371 EX!' 6110
HX: (717) 240-6118
One Team. . , One MiJJion
Gary Eichelberger
Chairman
Bruce Barclay
Vice Chairman
I INVOICE FOR SERVicES
Richard L. Rovegllo
Secre(a1~v
Terry C Barley
Director
Walter Belcher
11 Stallion Rd.
Carlisle, PA 17015
Invoice Number: January-08-12
Invoice Date: March 4, 2008
SERVICE PROVIDED: ADC-Full Day
MONTH OF SERVICE: January, 2008.
ACTUAL COST PER Full Day I
YOUR REDUCED SLIDING FEE SCALE RATE PER Full Day I
TOTAL Full Day(s) OF SERVICE YOU RECEIVED \
43.951
9.451
14.00 I
PLEASE PAY THIS AMOUNT I 132.30 I
Payment Due Upon Receipt of Invoice. Payment Is Delinquent if not paid by March 29,
2008. Contact CCOA if any issues.
Make Checks Payable To: CUMBERLAND COUNTY OFFICE OF AGING
Please ke~p_this cC?Py ~or your records
/..i... -". ,
~ ~ (c. i! -Cc'-
-:. :'/' .
'--'-'1 I
'" -t:,~. ..
j 'j" '/-.
-t /
..
I '
, '
h
Lb-iCL
l
C!l/# lu" ~/- G ,/ -t't"kd J I
' "- u I "C..CU::. 3 :2 Lt (;?