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Home My WebLink About06-30-08Rev-isoo Ex + ts-a~l COMMONWEALTH OF REV-15 0 0 OFF{CIAL USE ONLY PENNSYLVANIA DEPARTMENT F REVE O NUE INHERITANCE TAX RETURN FILE NUMBER DEPT. 280601 G HARRISBURG, PA 17128-0601 RESIDENT DECEDENT 2 1 - 0 8 ~ ~ 1 - _ COUNN CODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER H Z GALLOWAY DARLENE D. 2 0 7- 3 0- 5 8 3 9 I 0 DATE OF DEATH (MM-DD-Year) DATE OF BIRTH (MM-DD-Year) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE C) 03/03/2008 04/19/1940 REGISTER OF WILLS Q (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER a ®1.Original Return ~ 2. Supplemental Retum ~ 3. RemainderRetum (date of death prior to l2-13-82) ~ a ~ ^ 4. Limited Estate ^ 4a. Future Interest Compromise (dace or death aver tz-t2-a21 ^ 5. Federal Estate Tax Return Required W ~ ~ a m ^ 6. Decedent Died Testate (Attach copy or win) ^ 7. Decedent Maintained a Living Trust (Attach copy or7rust) _ 8. Total Number of Safe Deposit Boxes a ^ 9. Litigation Proceeds Received ~ 10. SpoUSal POVerty Credlt (date ofdeath between 12-31-91 and 1-1-95) ~ 11. Election to tax under Sec. 9113(A) (Attach sch of ~ THIS SECTION MUST BE CQMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD $E DIRECTED TO: Z W NAME COMPLETE MAILING ADDRESS c ROGER B. IRWIN ESQUIRE 60 WEST POMFRET STREET a FIRM NAME (If Applicable) r ~ IRWIN & McKNIGHT p TELEPHONE NUMBER ~ 717 249-2353 CARLISLE PA 17013 1. Real Estate (Schedule A) (1) OFFICIAL USE ONLY 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) ~ '~ k ~ 4. Mortgages & Notes Receivable (Schedule D) (4) ~ > ~~ 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 0.00 ' ~ :. - ~ . "_ , c (Schedule E) ' c : Z .. ~ 6. Jointly Owned Property (Schedule F) (6) 47.94 -, ` I" ~~ Separate Billing Requested ~ ~ i - 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) 52,847.46 -_ ~~ -- H (Sclhedule G or L) ' - ' U-i Q 8. Total Gross Assets (total Lines 1-7) {g) 52,895.40 V ~ 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 6,980.00 10. Dents of Decedent, Mortgage Liabilities, & Liens {Schedule I) (10) 21,891.68 11. Total Deductions (total Lines 9 & 10) (11) 28,871.68 12. Net Value of Estate (Line 8 minus Line 11) (12) 24,023.72 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 24,023.72 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES Z 0 15. Amount of Line 14 taxable at the spousal tax 0 00 00 0 rate, or Vansfers under Sec. 9116 (a)(1.2) . X (15) . H ~ 16. Amcunt of Line 14 taxable at lineal rate 24,023.72 X .045 (1 g) 1, 081.07 ~ 17. Amount of Line 14 taxable at sibling rate 0.00 X .12 (17) 0.00 V 18. Amount of Line 14 taxable at collateral rate 0.00 X .15 (18) 0.00 19. Tax Due (19) 1,081.07 ~ ~ 20. • • rr • • ~ > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < Decedent's Complete Address: STREET ADDRESS 239 MIDDLE ROAD CITY STATE ZIP NEWVILLE PA 17241 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InterestlPenalty if applicable D. Interest E. Penalty 1.081.07 Total Credits (A + B + C) (2) 0.00 Total InterestlPenalty (D + E ) 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 5. If Line 1 + Lune 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the innterest on the tax due. (3) 0.00 (4) 0.00 (5) (5A) 1.081.07 B. Enter the total of Line 5 +SA. This is the BALANCE DUE. (5B) 1,081.07 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 : ........................................................................... ^ X^ b. retain the right to designate who shall use the property transferred or its income : ........................................ ^ X^ 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? ............................................................................................... ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ................. ^ 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. Under penalties of perjury, I 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 -~ ~-O AWKt55 39 BROAI~STREET G '' NEWVILLE PA 17241 SIGNATURE OF PREPARER OTHER THAN REPRESENTAT VE DATE ADDRESS EIO WEST POQ4(F~tET STREET CARLISLE 1701 ' 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. §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 0% [72 P.S. §9116 (a) (1.1) (ii)]. The statute doela 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 0% [72 P.S. §9116(a)(1.2j]. 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. §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 12% [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. ~~lU~ REV-1509 EX + (6-98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN ESTATE OF hlLt NUMtStK ~AI I nVIJAY DARLENE D 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. ADDRESS SURVIVING JOINT TENANT(S) NAME A. BRYAN GALLOWAY I39 BROAD STREET NEWVILLE, PA 17241 B C JOINTLY-OWNED PROPERTY: TIONSHIP TO DECEDENT SON ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET °1° OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. ADAMS COUNTY NATIONAL BANK 95.87 50. 47.94 SAVINGS ACCOUNT #9111069 TOTAL (Also enter on line 6, Recapitulation) $ 47 94 (If more space is needed, insert additional sheets of the same size) REV-1510 EX + (6-98) COMMONYNEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY FILE NUMBER GALLOWAY DARLENE D. 1 08 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. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDETHENAMEOFTHEiRANSFEREE,7HEIRRELATIONSHIPTOOECEDENTAND THE DATE OF TRANSFER.ATTACHACOPYOFTHEDEEDFORREALESTATE. DATE OF DEATH VALUE OF ASSET %OFDECD'S INTEREST EXCLUSION (IFAPPLICABLE) TAXABLE VALUE 1. PERSONAL PROPERTY -TRANSFER-IN-KIND 10,418.00 100. 10,418.00 2. 1993 DOUBLE WIDE TRAILER -MARKET ANALYSIS 41,871,00 100. 3,000.00 38,871.00 ATTACHED -TRANSFER-IN-KIND TO BRYAN GALLOWAY WITI~IN ONE YEAR OF DATE OF DEATH 3. ADAMS COUNTY NATIONAL BANK -CHECKING ACCT 3,558.46 100. 3,558.46 BALANCE PAID TO HOLLINGER FUNERAL HOME TOTAL (Also enter on line 7 Recapitulation) I $ 52,847.46 (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 SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER GALLOWAY DARLENE D. 21 08 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOLLINGER FUNERAL HOME 4,555.00 B. 2 3 4. 5. 6. 7. 8 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State _ Year(s) Commission Paid: AttomeyFees IRWIN 8~ McKNIGHT Family Exemption: (If decedents address is not the same as claimants, attach explanation) Claimant Street Address City State Relationship of Claimant to Decedent Probate Fees Accountant's Fees Zip Tax Retum Preparers Fees PATRICIA A. ROSENDALE, CPA ~ 350.00 REGISTER OF WILLS -FILING FEE I 15.00 ROY D. GOTTSHALL -APPRAISAL ON PERSONAL PROPERTY 60.00 Zip 2,000.00 TOTAL (Also enter on line 9, Recapitulation) I $ 6,980.00 (If more space is needed, insert additional sheets of the same size) REV-1512 E)I; + (6-98) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN RESIDENT DECEDENT MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER GALLOWAY DARLENE D. 21 08 Include unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. BANK OF AMERICA -CREDIT CARD #4313 0702 4831 8039 6,429.42 2. AMERICAN EXPRESS -CREDIT CARD #3772 117535 91005 2,327.36 3. CHASE -CREDIT CARD #4246 3151 2968 0870 6,573.03 4. THE HELP CARD -ACCOUNT #4045430-0 2,367.24 5. APEX ASSET MANAGEMENT, INC. -CARLISLE ONCOLOGY -MEDICAL 92.50 6. WEST SHORE EMS -AMBULANCE 845.01 7. BRONSTEIN JEFFRIES, PA -MEDICAL 85.16 8. HARRISBURG PHARMACY -MEDICAL 6.50 9. ANDREWS & PATEL ASSOCIATES, P.C. -MEDICAL 15.00 10. JOHN HOPKINS UNIVERSITY -MEDICAL 1,148.50 11. MASLAND ASSOCIATES, INC. 8.16 12. ADAMS ELECTRIC COOPERATIVE, INC. -ELECTRIC 176.03 13. ADVANCED HEALTH SERVICES -MEDICAL 99.60 14. EMBARO -TELEPHONE 99.28 15. THREE SPRINGS FAMILY PRACTICE -MEDICAL 15.00 TOTAL (Also enter on line 10, Recapitulation) ( $ 21.785.71 (If more space is needed, insert additional sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent GALLOWAY DARLENE D. 21 08 Deceden~i's Name Page 2 File Number Schedule I -Debts of Decedent, Mortgage Liabilities, & Liens ITEM NUMBER DESCRIPTION 16. BURKHOLDERS MOBILE HOME PARK -LOT RENT 17. AERO ENERGY -FUEL 18. NATIONWIDE INSURANCE -HOMEOWNERS INSURANCE 19. NEWVILLE COMM. AMBULANCE -AMBULANCE 20. PENNS WOOD PHYSICAL THERAPY -MEDICAL 21. CHASE -CREDIT CARD -FINANCE CHARGE AMOUNT 555.00 294.00 386.00 50.00 212.92 105.97 SUBTOTAL SCHEDULE I 1,603.89 GRAND TOTAL SCHEDULE I $ 21,891.68 REV-1513 EX + (A._nni SCHEDULE J COMMON\NEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER A L Y E 1 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. BRYAN GALLOWAY Lineal 24,023.72 39 BROAD STREET REMAINDER tVEWVILLE, PA 17241 I 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 1. E3. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ (If more space is needed, insert additional sheets of the same size) MADAMS COiIN1Y NATIONAL BANK ,June 11, 2008 :[Twin & McKnight .Attn: Roger B Irwin 60 W Pomfret St Carlisle PA 17013 Re: Estate of Darlene D Galloway rear iillr. Irwin: 'Che following information is being provided as per your request: Acct. Type Account No. Account Accrued Ownership Date Principal on Interest to Opened D.O.D. D.O.D. Statement 911 l Ob9 $95.87 $0.00 Jt/w Bryan 6/20/01 Savings Galloway Account 1_;steem 2217465 $3,558.46 $0.02 Individual 10/7/05 Checking Account Enquiries concerning ACNB Corporation stock information should be directed to the Registrar and Transfer Company at 1-800-368-5948. If you need any additional information, please contact me at (717}339-5122. S~rely, ,„~ ~~%t7 ltr ~ UL i~ ~ -yt~, ~- Barbara JWar r Adams Coun ational Bank Lleposit Servi s Representative II _,, ~E~~ ~ r: - ~, ~ ~ ~ i, ~~/~,1 ~, ~: , ~= i i'i5%1 L~G~" `~' ~G, :~ rte,; ~! ~' ,c~~ ~~ r ~~ /+ . t - ~~ 1 v L-y 6' ~ ,-. ~, R ~ ,.i;~ ~~~~ ~~ ~ r ~ ~ y ~~,~,.. ,,.`^ " jD r f~ ,,,~ ~ _J~, ,, .~__ -~~. ,- y - ,~ ,J• } , r ,- / ~ P .-.y. r `--- / f f i~bja~.~r v J /^ ~J / -~ ,~ ~~-~ ~ ~~ , ~~ / /~+ .. f r.--- ~r c:,,., fry _ '. ~ ~ _ ' ~G -~ r -- -' ~~ ~~ ~G ~, - r j d / c:-, r < ` r'~ _ ~ ~° ~ _~f G9~~~_ __<:~_.___. ~~: ~ .~__. ~~ /G ~ ~~~ :~ 4~" ;~ ~ f ~~ r,. ~ ~~ I ~~ ~ ~- _. ~Y~ !~ - -^ `,, r .~ ,.car ~!' T /,, ~, ;;,''= v i ~ ~ ~ ~ ~.''~d.~l y:f .~ r ~ - .,G ' :_.P 4` ~ ~ .. ..t` Vic' ,. _. ///I .... - ~~ / -- ; P~ ~ ~ // .el /, /) / !. `' / ~~~ / .' r f/ ~~ ~~ ? ~. ~~~~~ ~.. ~~:,~;~ fit n ~- , , ~~.,~ -- ;:~:l~..-,:o~-,_~ . / ~rt,,,~r~: r ,.. o • * ~'' r- ~~ l /~ ~/ ~rl C1' 4-. c:: ,_~ f~~ ~~~ ~„_- ~" r-.---- 396.00 + ,~ i ,~ ~s .~ ~ ~~, t'` -- v' ~'~s=~ tee,. ~/ C'. •~-..----305.00 + ~ -• ~r---9, 717.00 + = 10418• ~~~~`~j 0• * U~ P~u~ , "~ ~~Q ~ ~-lz-'D~ ~' <~ Irwin& McKnight ~, ~ Attn: Karen Noel ~ ~ 60 West Pomfret Street __: ~; Carlisle, PA 17013 ~~ A N Q A 5 S O C 1 AT E S _ '~~' Dear Karen, Apri129, 2008 Brian Galloway, the son of Darlene Galloway, has asked me to determine a fair market value for her property at 239 Middle Road, Newville, PA 17241. There are currently eight similar properties listed as active. The average of these (3 bedrooms, 2 bathrooms, 1978 or newer, on rented lots) is $47,062. The five sold properties in the past year average $36,680. The average of these two figures is $41,871 to indicate the fair market value of Darlene's property. This is a comparative market analysis and not a formal appraisal. My Best Regards, ary B. Davis REALTOR Dawn & Associates Realty 1156 Walnut Bottom Road, Carlisle, PA 17015 (0)717.258.8800 (F)717.258.8877 oared for DARLENE D GALLOWAY May 2008 Statement :oust Number: 4313 0702 4831 8039 Credit Line: $11,500.00 Cash or Credit Available: mmary of Transactions Billing Cycle and Payment Information :vious Balance $6,278.43 Days in Billing Cycle 30 yments and Credits - $0.00 Closing Date 05/03/08 rchases and Adjustments + $82.59 riodic Rate Flftance Charges + $68.40 Payment Due Date 05/28/08 -nsaction Fee FlnanCe Charges + __ $0.00 Current Payment Due $170.00 REV-1509 E)(+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ATE NUMBER GALLOWAY DARLENE D. 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. SURVIVING JOINT TENANT(S) NAME A. BRYAN GALLOWAY 39 BROAD STREET NEWVILLE, PA 17241 ADDRESS TIONSHIP TO DECEDENT C JOINTLY•OWNED PROPERTY: SON ITEM NUMBER LE-fTER FOR'. JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. ADAMS COUNTY NATIONAL BANK 95.87 50. 47.94 SAVINGS ACCOUNT #9111069 /' VISAA~GNATURE _ j:.~.: Forlnformayon on Your Account Vsit.• www. ban kofa m e rica. com Call toll-free 1-800-421-2110 TDD hearing-impaired 1-800-346-3176 Mail Payments to: BANK OF AMERICA P.O. BOX 15726 WILMINGTON, DE 19886-5726 Mad 8itlina lnauiries to: SCHEDULE F JOINTLY-OWNED PROPERTY ;., :=-_ -1 JIaI@tll@Ilt for account number: 4246 3151 296x10870 f StatF New Balance Payment Due Uate Past Due Amount Minimum Payment CHASE N,;w $6,573.03 04/11/08 $163.00 5317.00 W Make your check payable to Chase Card Services. Amount Enclosed $ New address or e-mail? Print at back. Amour "~-~.. 424631512968087D0003170000657303DOOD009 26346BEXZ07708C ItttIIItL,IttLlttl~tlL~tltl~tttllJJrttilttitltttllttlittl DARLENE D GALLOWAY T BUSINESS ACCOUNT CARDMEMBER SERVICE 239 MIDDLE RD PO BGX 15153 NEWVILLE PA 17241-9311 WILMINGTON DE 19886-5153 • Itttlll1111ttltl,111111111it{tt.tllttttlltrtiirtlltltittltittl ~: 5000 L60 28~: ~ 59 5 1 296808 70 711 OpeninglClosing Date: 02!18108 - 03!17108 CUSTOMER SERVICE B BUSINESS CARD STATEMENT Payment Due Date: Minimum Payment Due: 04/11/08 $317.00 In U.S. 1-800-346-5538 Espanol 1-888-795-0574 TDD 1-800-955-8060 Pay by phone 1-800-436-7958 • Outside U.S. call collect VISA ACCOUNT SUMMARY Account Number: 4246 3151 2J68 0870 1-480-350-7099 Previous Balance $6,362.50 Total Credit Line $7 200 ACCOUNT INQUIRIES Purchases. Cash, Debits +$56.95 Available Credit , $626 P.O. Box 15298 Finance Charges +$153.58 Cash Access Line $1,440 Wilmington, DE 19850-5298 New Balance $6,573.03 Available for Cash ~ PAYMENT ADDRESS P.O. Box 15153 Wilmington, DE 19886-5153 VISIT US AT: www,chase.com/businesscards PREMfER CASH REBATE POINT SUMMARY Previous Rebate Point Balance 9,132 Base Rebate Points on al{ Purchases 18 Rebate Earnings forfeited this month D pate ne~~,~,...._ - ,___ _.- i _e„ ~ utL ve at pion ur ~f r c c u OHC3N 004 E02276-1004557 OD Statement of Account '° THE ® Please write account number on all money orders, checks, and correspondence. • HELP e a ~ d Failure to return this payment stub with remittance could delay payment up to ~ days. Providing Unordinary Financing Options ~\~' Processing Center M f'.O. Box 829, Springdale, AR 72765 49 11260 Inrlllnrinltltlrrlnrlilrlnnllnulln~lltrlltltlnltlul Darlene Galloway 239 Middle Rd Newville, PA 17241-9311 ' Account Number ~ - ~ . ~ Minimum Payment 4045430-0 04/17/08 $ 136.00 ake Check Payable to C Processing Center .Delinquency Charge After 6:00 AM CT AN40UNT PAID ere will be a $25.00 fee for ndling returned payments. O4/ 18/O8 H a Th h ^ Check here if address or telephone number has changed. See reverse side. HC PROCESSING CENTER PO BOX 1309 LOWELL, AR 72745 Ilt~tlrrlrllrtrltlrrl~ltirrrrlltrllrll~trlrlrrll~rtlrltttrlltl 00000040454500 0013600 ACCOUNT NUMBER # ACCOUNT NAME STATEMENT DATE ~ ~ . °Delinquency Charge After 6:00 AM CT 4045430-0 Darlene Galiowa 03/28/08 04/17/08 04/18/08 Credit Limit Available Credit Previous Balance Payments /Credits New Charges New Balance 2470. U 22 .55 0.00 59.69 2 67 24 .DATE PROVIDER LQCATI4N QESCRIPTION AMOUNT 03/14/08 Delinquency Charge 39.00 Payment due on 03!13/08 of the last billing cycle is now PAST DUE! PLEASE PAY NOW! If your payment has been mailed, please disregard this notice. To pay by phone, call 800-935-3368 and press (1}for English or (2) for Spanish, then press (5). After entering your account number and t d 7423 t th 1 HC P i d f l i accoun access co e - press ( o au orize rocess ) ng to ra t an e ectron c payment from yyour checking account in compliance with U law overnin such transactions If ou wish to cancel this S a ment transaction ou u t d i di l b lli . , g y . . y p , y m s o so mme ate y y ca ng 888-750-6795. IMPORTANT NO"fICE ABOUT BILL PAY SERVICES: We accept electronic payments through Online Resources. However, if your bill pay service still mails checks, be sure they are mailed 6 - 8 days prior to the due date. Also, some banks deduct payments from their customers' bank accounts on the date the payments are "scheduled" with the bill pay service, but we may not receive the payments until a few days later. Ask your bill pay service about its procedures. We cannot credit your account until we receive the payment, and we are not responsible for ;payments not received by the due date. RETURNED PAYII4ENTS - I understand my returned check(s) may be collected electronically if the check is returned for insufficient or uncollected funds. Unless Promational Terms apply, Previous Balance must be zero and New Balance must be paid in full within 25 days of statement date to avoid additional finance char es. Daily Percentage Rate Average Daily Balance Days In Billing Cycle Current Due Pa§f Due Minirnum Payment Due 7 4° .074630° 2285.26 35 68.00 68.00 136. 0 rvvllct: sit KtVtKSt slut rUK iMYUK1ANl INf UKMAj1UN WWW.I1CCreCiIt.COnl MAIL PAYMENT TO: FOR OVERNIGHT MAIL: HC Processing Center HC Processing Center, IF YOU HAVE QUESTIONS, PO Box 1309 203 E Emma Ave, Suite A, PLEASE CALL.: 1-888-750-6794 Lowell, AR 72745 Springdale, AR 72764 ~i ~.e~.~~'~ ~a ' ~~, PO BOX 7044 ~: LANCASTER PA 17604-7044 ` ` ' 1891 SANTA BARBARA DR STE 204 ~~~ ~a LANCASTER PA 17604-7044 RETURN SERVICE REQUEST ^: %~ ,_,,___,_ _ ~ 1111111111111111 llln 11111 I IIII IIII I Iilll 11111 Iilli I III IIII CARL70 4399518 105 LAN 0 ooiso IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII APEX ASSET MANAGEMENT LLC PO BOX 7044 DARLENE D GALLOWAY LANCASTER PA 17604-7044 I~~~III~~~I~II~~II~~~~I~~II~~~III~~~~I~~I~I,~I~I~~ii 2.39 MIDDLE RD NEWVILLE PA 17241-9311 ~ SIGNATURE OF CARD EXP. ~~ ~ ~ CARDHOLDER: NUMBER: Amount DATE: SECURITY CODE (3 digits on back of card) ----------------------------------------------------------------------------- RETAIN LOWER PORTION FOR YOUR RECORDS. DETACH AND RETURN THIS PORTION WITH PAYMENT IN THE ENCLOSED ENVELOPE. ACCT FOR: CARLISLE ONCOLOGY RE: 607832 DATE: APR 05 2008 BALANCE DUE: $92.50 Dear DARLENE D GALLOWAY, We thank you for choosing CARLISLE ONCOLOGY for your health care needs. You should have received a bill for services provided by CARLISLE ONCOLOGY. The balance in full of $92.50 is now due for payment in full. We realize this could be an oversight and not a deliberate attempt to disregard your obligation. You may take care ofi this obligation today by returning a check, money order, or charge card infiormation with this letter. Please mail your payment in the enclosed envelope. VISA AND Mastercard are also accepted over the phone by calling {7'17} 519-1770 or toll fi ree {888) 592-2144. If' you need to make other payment arrangements, please contact our office. If full payment is not received in thirty days your account may be considered for collection activity. In the event full payment has been made or payment arrangement has been established, please accept our thanks and disregard this notice. This is an attempt to collect a debt. Any information obtained will be used for that purpose. Unless you notifiy this office within 30 days after receiving this notice that you dispute the validity of this debt or an;y portion thereof, this office will assume this debt is valid. If you notify this off ice in writing within 30 days after receiving this notice this off ice will obtain verification of the debt and mail you a copy of such verification. If you request from this office in writing within 30 days afiter receiving this notice, we will provide you with the name and address of the original creditor ifi different from the current creditor. This communication is from a debt collector. APEX ASSET MANAGEMENT LLC )9.3008040313901.00150 WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE STE#211 CAMP HILL, PA 17011 Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 PATIENT NAME: DARLENE GALLOWAY PATIENT NUMBER CALL NUMBER: INSURANCE: HIGHMARK -FREEDOM BI FER105102311001 DATE OF CALL: TIME OF CALL: CALLER: 3101678 FROM: TO: DARLENE GALLOWAY 239 MIDDLE RD REASON(S) NEWVILLE, PA 17241 FOR TRANSPORT INVOICE 70088 3101678 03/03/2008 ~~~~ ~~ '~t~?i?f7!`:`It'Y" ~iFi)U:',Al. JE{tbICF:S REJ NONE 239 MIDDLE RD CARLISLE REGIONAL MEDICAL CTR UNCONSCIOUSNESS CANCER DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT PARAiMEDIC INTERCEPT A0999 1.0 797.87 797.87 INF CONTROL GLOVES (PR) A0382 1.0 3.65 3.65 GLUCOSE BLOOD A0394 1.0 6.74 6.74 PERIPHERAL IV A0394 1.0 36.75 36.75 Total Charges 845.01 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Total C. edits C.00 PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -~. $845.01 RETURNED CHECK FEE - $31.00 DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT AMOUNT DUE 845.01 PATIENT NAME: GALLOWAY, DARLENE CALL NUMBER 3101678 AMOUNT $ PATIENT NUMBER: 70088 BILLING DATE: 03/21/2008 ENCLOSED A claim for this invoice amount was denied by your insurance ~ VISA carrier. Balance is your responsibi{ity -please remit. v~ AND '~ ~ + r , MASTER CARD ACCEPTED WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE STE#211 CAMP HILL, PA 17011 /'~ Statement Make Checks Payable To: Bronstein Jeffries, PA 4-830 Londonderry Road Harrisburg, PA 17109 I~~~III~~~~l~~l~lrl~~l~,~il~l~l~l - Darlene D. Galloway - 239 Middle Road Newville, PA 17241 1 Account Statement Date Due Date Total Due 41995 Apr 3, 2008 Apr 28, 2008 85.16 Amount Enclosed $ lu~llln~lu~lllln~i~inul~ll Bronstein Jeffries, PA 4830 Londonderry Road Harrisburg, PA 17109 Please Check box and indicate any change in address on reverse side. Detach at pertoration and return above portion with payment. Service Date Service Provider Description Charges Payments / Adjustments Patient Account: 41995 -Darlene D. Gallowa Previous Balance: 85.16 .Patient Balance: 85.16 IF YOU HAVE RECENTLY MADE A PAYMENT, PLEASE DISREGARD THIS STATEMENT. BALANCES UNPAID AFTER 30 DAYS MAY BE ASSESSED A $10 BILL CHARGE. QUESTIONS REGARDING YOUR BILL, PLEASE CALL 657-2599. Statement Date 1-30 Days 31-60 Days 61-90 Days 91-120 Days 121-150 Days Over i50 Days Due Date Total Due Apr 3, 2008 0.00 85.16 0.00 0.00 0.00 0.00 ;Apr 28, 2008 85.16 l Bronstein Jeffries, PA • 4830 Londonderry Road • Karrisburg, PA 17/9 • (7/ 7) 657-2599 Account Number, 41995 ris3.o N0000-BEAZ20080403-000~~685-00~OnnF5_n ANDREWS 8~ PATEL ASSOCIATES, P.C. 3912 TRINDLE RD. CAMP HILL, PA 17011 PHOi~IE: (717) 761-8740 TOTAL DUE I CURRENT I 31 - 60 DAYS 61 - 90 DAYS 91 -120 DAYS OVER 120 DAYS • ~ ~ 15.00 0.00' `15.00 0.00 0.00 0.00 15.0 Please pay this amount! DARLENE D. GALLOWAY (ESTATE) 239 MIDDLE RD NEWVILLE PA 17241 Y ~• ~ • ~ DARLENE D. GALLOWAY (ESTATE) (27479.0) 27479.0) 02/05/08 OFFICE CONSULTATION 275.00 02/08/0$ Adjustment 0.00 $15.00 was applied to your deductible $15 .-0 0 COPAY 02/13/08 Ins Pmt-FREEDOM BLUE PPO 197.9'7 02/13/OS Adjustment 62.03 15.00 02/05/08 TOTAL FOR DARLENE D._GALLOWAY-(ESTATE) 15.00 WE ACCEPT VISA AND MASTER CARD-JUST GIVE US A CALL! • •. • ANDREWS 8 PATEL ASSOCIATES, P.• 3912 TRINDLE RD. CAMP HILL, PA 17011 ~ ~ 03/21/08 03/21/08 • ~ 27479 (1) 27479 Detach this stub and return with pa ment. CLINICAL PRACTICE ASSOCIATION BiUinglnquisies: Call (410) 933-1200 or 1-800- .7-0066 or contact us via e~rnail at jbupbs®jbmi.ed (p sole account number, patient name, address, and phone number) ^ VISA ^ MASTERCARD ^ AMERICAN EXPRESS ^ DISCOVER CARD NUMBER: DISCOVER CARD USERS: INCLUDE LAST 3-DIGITS ON SIGNATURE STRIP EXP DATE: SIGNATURE: O/j`ice Hours: Monday-Friday, gam-4pm PAYMENT DUE DATE ACCT # PAY THIS AMOUNT AMOUNT ENCLOSED PATIENT: DARLENE GALLOWAY UPON RECEIPT 30-9356504 $114$•50 RESPONSIBLE PARTY: MAIL PAYMENT T0: I~~~III~~~I~~I~I~I~~I~~~III~I~~~~il~~~~ll~~~ll~~ll~l~l~~l~l~~l THE JOHNS HOPKINS UNIVERSITY DARLENE GALLOWAY CLINICAL PRACTICE ASSOCIATION 239 MIDiDLE RD 13263 AB 0.341 AMECH p0 BOX 64896 NEWVILLE, PA 11241-9311 BALTIMORE, MD 21264-4896 ^ CHECK BOX ][F YOUR ADDRESS/INSURANCE HAS CHANGED (SEE REVERSE SIDE). 303122678032420080011485048963 PLEASE DETACH AND RETURN THE TOP PORTION WITH YOUR PAYMENT. STATEMENT OF PHYSICIAN SERVICES ~ (AS OF MARCH 24, 2008) ACCOUNT NUMBER: 30-9356504 PATIENT NAME: DARLENE GALLOWAY PAGE 1 THE FOLLOWING INVOICES DESCRIBE OUTSTANDING CHARGES FOR SERVICES PROVIDED BY PHYSICIANS AT THE JOHNS HOPIQNS UNIVERSITY. THE LEFT SIDE DESCRIBES THE SERVICES PROVIDED AND THE CHARGES FOR EACH SERVICE. THE RIGHT SIDE DESCRIBES ACCOUNT ACTIVITY AND THE AMOUNT YOU OWE. PLEASE NOTE THAT THIS IS A PHYSICIAN BILL AND NOT A HOSPITAL BILL. CALL (410) 550-7370 OR 1-800-425-7100 FOR QUESTIONS CONCERNING YOUR JOHNS HOPKINS HOSPITAL BILL. CALL (410) 550-0750 FOR QUESTIONS CONCERNING YOUR BAYVIEW HOSPITAL BILI. INVOICE NUMBER: 30-43113921 CHARGES PROVIDER: REF LAB /MCCARTHY MD,EDWARD JHU REFERENCE LABORATORY 12/28/07 88323-CONSULT ON OUTSIDE MTRL.: FROM CARLISL... $250.00 12/28/07 88313-GRP 2 SPECIAL STAIN : .......................... $88:50 12/28/07 88342/59-IMMUNOCYTOCHEMISTRY: 6 UNIT(S) ............. $810.00 TOTAL: X1148.50 PAYMENT ACTIVITY 01/17/08 BLUE SHIELD CLAIM FILED 02!15/08 BLUE SHIELD PAYMENT PAYMENT ..................... 0.00 (p) ADJUSTMENT .................. 0.00 AMOUNT DUE NOW ........................... 51148.50 (A) SEE EXPLANATION OF BENEFITS (E06) FROM YOUR INSURER YOUR ACCOUNT IS NOW PAST DUE. TO AVOID COLLECTION ACTION, PLEASE PAY THE AMOUNT INDICATED ABOVE UPON RECEIPT OF THIS STATEMENT. PATIENT PAYMENTS RECEIVED SINCE 02/24/08... $0.00 INSURANCE PAYMENTS RECEIVED SINCE 02/24/08. $0.00 ACCOUNT BALANCE INSURANCE PENDING PATI NT OW S $1148.50 $0.00 $114$.50 THANK YOU FOR CHOOSING THE JOHNS HOPKINS UNIVERSITY CLINICAL PRACTICE ASSOCIATION! THE JONNS HOPKINS UNIVERSITY CLINICAL PRACTICE ASSOCIATION PO BOX 64896, BALTIMORE, MD 21264-4896 (410)933-1200 1-800-657-0066 013263 001 001 014946 Opt ppi MASLAND ASSOCIATES INC 220 WILSON STREET SUITE 109 CAF?LiSLE, PA 17013 Please pay promptly, thank you. PAGE 1 / 1 ADDRESSEE QSS0507A AUTO MIXED AADC 923 7000010155 01.0038.0014 1O155f1 ~nt~~~u~~u~t~t~u~tn~~~t~nu~~uu~~nt~~n~~f~i{n~t~n, DARLENE D GALLOWAY ' ' 239 MIDDLE RD NEWVILLE PA 17241-9311 ^ Please check box if address is incorrect or insurance information has changed, and indicate changels) on reverse side. PLEASE OET/\CH AND RETURN TOP PORTION WITH YOUR PAYMENT STATEMENT DATE DESCRIPTION OF SERVICE AMOUNT INS. BAL PAT. BAL LINE ITEM BAL 02!02/08 ENCOUNTER 170227 FOR DARLENE WITH TAYLOR MD, DEBRA D 02/02108 93010 -Electrocardiogram report $38.00 $8.16 03/27/08 Freedom Blue Payment (1' (Applied To Deductible)) $0.00 03/27/08 Freedom Blue Adjustment (1 (Applied To Deductible) ) -$29.84 ENCOUNTER TOTAL $8.16 $0.00 $8.16 $8.16 Balance is your responsibility. CURRENT 30-60 DAYS 60-90 DAYS 90-120 DAYS OVER 120 DAYS TOTAL ACCOUNT BALANCE DUE FROM PATIENT $0.00 $8.16 $0.00 $0.00 $0.00 $8.16 $•'~ 6 If your insurance contract requires you to pay a co-pay, it is your responsibility to pay the co-pay the day of your visit. If not paid that day, an additional $7 charge will be added to your account. Aiso, we do accept VISA/MASTERCARD payments. 249-8871 STATEMENT DATE PAY THIS AMOUNT ACCOUNT NUMBER 05/07/08 8.16 8729 SHOW AMOUNT PAID HERE ~iu~~~nt~~~unn~~n,{nt{~u~~n~i~n~nt~u~~n~n~~~~n~ MASLAND ASSOCIATES INC 220 WILSON STREET SUITE 109 CARLISLE PA 17013-3697 MASLAND ASSOCIATES INC 220 WILSON STREET SUITE 104 CARLISLE, PA 17013 2044810306 Group: 4410 '}' DATE BILLED METER NUMBER ACCOUNT NUMBER J--'-~~ 05/02/2008 33118857 2044810306 -~- .r-~' PAYMENT 05/22/2008 176.03 DUE BURKHOLDERS LT 3 Cycle 1 3095 1 AV 0.312 4 3095 DARLENE D GALLOWAY EST C-10 P-18 239 MIDDLE RD NEWVILLE PA 17241-9311 BILLING DETAILS + I~nlil~~~lul~l~lul~nlllrln~~N„~JI~~JL~IIJ~L~I~I,~I ~" - - - - - - - - - - - - - - - - - - - - - - - - Detach here Please detach the above portion and return with your payment. ,. _e_~.._..___.__~. .___...._w_.~..-_.~..~.u.. --_.__..,..__._.._.4_..__ _._ ... .._ ~..~...~,. w ~__..._.,,. _._~ .._. _ . _.._w.. _._._ __ . . Account #• 2044810306 .Meter Type Previous Present Multiplier KWH Reading Reading Reading Used Type Name: DARLENE D GALLOWAY EST ~--- -- ° -° _., ___ .,. .. . ~ . ~ .__.____ ._ _t..___,_ .. _ _ KWH 18740 18956 1 216 Actual Reading Dates: 03/30/2008 TO 04/30/2008 Rate: RES01 RESIDENTIAL ': Service Loc: BURKHOLDERS LT3 BASIC CHARGES ' Energy supply prices and charges are set by your electric generation supplier. - Adams Electric Cooperative Inc. 1338 Biglerville Road Gettysburg, PA 17325-1055 ENERGY SUPPLY: Energy charge 216kwh @ TOTAL ENERGY SUPPLY DISTRIBUTION: Access charge Distribution charge 216kwh @ r TOTAL DISTRIBUTION TOTAL BASIC CHARGES (888) 232-6732 COOPERATIVE READ NON-BASIC CHARGES COM .057 12.31 Round-Up donation 0.84 12.31 TOTAL NONBASIC CHARGES 0 84 21 75 . .019 4.10 25.85 38.16 ,.,.....-.- _ w~. w....--~,,.~__~...~-M.-~, _.. .~.,-.~.e_~._..~ _..... ~.._ ,_,..m ACCOUNT SUMMARY _. ..._ _ __ ~._~ .~._~_.a __.___., ....._~..,.....~,...~.w..m ,~_x._Y .~,, Rev Manth ~ APR 2008 Previous Balance: 135.00 _. x ._ ..___. __ . ,, _ Payments Received: 0.00 Total yearly} Late Penalty: 2.03 KWH for 9978 past 12 Balance Forward: 137.03 months Total Basic: 38.16 Average '. Total Non-Basic: 0.84 monthly 831 '`' Sales Tax: 0.00 KWH ACCOUNT BALANCE for past 12 176.03 months _ _ _ _ ..k PAYMENT DUE 05/22/2008 176.03 0 • (1 C1 :: ADVANCED HEALTH SERVICES '7407 STA;~~LINE ROAD `~~~ I'O BOX 85 ORANGEVILLE OH 44453-0000 ,j ~ ~~ Bill To ~ ~ AHSGALLD00 GALLOWAY DARLENE 239 MIDDLE ROAD NEWVILLE, PA 17241-0000 1 h • U ~_l /, 1 . i1 i./ {' ~,,.~~.~ T Invoice Date Invoice # ~~•~o :. ?5/08 009529 /~ ~ 'O Number: ~~ V~~ 239 MIUULE kuHU , NEWVILLE, PA 17241-0000 EMBARQ" Payment Options & Contact Info Current Cha es At-A-Glance Retail Store in Your Area ~ CARLISLE EMBARQ Services ~ 346 York Road Total In the Embarq Building ~ EMBARQ Basic Home Phone I -Page 3 32.70 Pay Online EMBARQ.com/myaccount Pay by Phone 1-E377-813-7604 Customer Service 1-800-829-8009 Repair Service 1-800-788-3600 Internet Address EMBARQ.com/residential Local and Optional Services -Page 3 .67 Long Distance -Page 3 2.00 Taxes and Surcharges -Page 4 10.10 ~:, _ _., Iota[ Current Charges ~ 4• _ _. ., .... _ 4 545.#T. Savings & Benefits s You saved $11.25 this month by combining Embarq services! See Savings and Benefits section for details. `~/ Page 1 of 8 Monthly Statement Account Number April 4, 2008 717-776-4822-418 Previous Balance Payments & Adjustments Past Due, Please Pay Now 53.81 I .00 I 53.81 I EMBARQ" 36 Please return this portion with payment ® Please Recycle Customer Service Internet Address Account Number 1-800-829-8009 EMBARQ.com/residential 717-776-4822-418 Please pay past due amount of 553.81 immediately Total Amount Due: $100.51 if received after May 4 AV 01 026241 681456 97 A**5DGT ~n~~~~nr~n~i~~~n~u~~~~~~nn~~nn~~n~~~n~~i~i~n~i~n DARLENE GALLOWAY UNIT3 239 MIDDLE RD NEWVILLE PA 17241-9311 Amount Enclosed: Write your 13t1igit account number on check Make checks payable to: Embarq PO Box 96064 Charlotte NC 28296-0064 ~u~~~~n~ui~~~~i~u~~~n~~m~~uu~~n~~n~n~~~~ Total Current Charges Total Amount Due .45.47 I $99.2$ J Current Charges Due By: 04/28/08 H received after May 4: 5100.51 599.28 12 71777648224184 00000000004547 000099284 0812406 THREE SPRINGS FAMILY PRACTICE 303 NORTI[ BALTIMORE AVE MT. HOLLY' SPRINGS, PA 17065 05/05/08 1 724 15. b0-~ Forwarding Service Requested 29135 ESTATE OF DARLENE D GALLOWAY 239 MIDDLE ROAD NEWVILLE PA 17241-9311 _MC _VISA Card~~ Sign THREE SPRINGS FAMILY PRACTICE 303 NORTH BALTIMORE AVE MT. HOLLY SPRINGS, PA 17065 Security Code _ Exp _/_ •. .•. • • AESSAGES EXPLAINED ~ BELOW *** Y 4 Y~ ~ Your Ac ~ 4 ~~ ~ 9 ~ t count Balance is Overdue! Please make ~ ' S Yk4 ' ' ~ ' ~ ~ ~ Y~ ' ' ' ' Patent Immediately!! ' ' ' ' ' *'ti~~ ~ c c ~ c c c C c c ~ c~ c C~ c~ c~ c~c c~ cic c c c~ e~Y~c~ c~cic~ c~c~cYc~ c~t~c~ c~c~c~C~c~c~t~Y ~ c~c~c4t~ cYc~t~Y~ c~ e~c~:4c~c~c~ c9c~c~ c9c9c9c~c~t ~c4c~Y9c9cx~'c4c~c~c Insurance Charges pending to Prv: 168.00 . Ins Pay/Adj against Ins pending 143.89 -24.11 0.00 01/25/08 1 1 L OFFICE VISIT EST LEVEL 4 99214 197.0 90.00 02/06/08 02 Acce t Assign Adj. -3.70 /06/08 BS PENNSYLVA Payment 71.30 15.00* 02/08/08 1 1 OFFICE VISIT EST LEVEL 4 99214 197.0 90.00 02/08/08 Check-Personal Payment 15.00 02/21/08 Acceppt Assi gn Adj. -3.70 02/21/08 BS PENNSYLVA Payment 71.30 0.00 02/27-/08 1 1 OFFICE VISIT EST LEVEL 4 99214 941.20 95.00 02/27/08 Check-Personal Payment 15.00 03/13/08 BS PENNSYLVA Payment 71.30 03/13/08 Accept Assign Adj. -8.70 0.00 L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make payment. SATE LAST PAID ~ AMOUNT • - ~ • - . ~ 02/27/08 15.00 0.00 0.00 15.00 'CHREE SPRINGS FAMILY PRACTICE AECK ~ X303 NORTH BALTIMORE AVE :YABLE TO: ___ _ MT. HOLLY SPRINGS, PA 17065 0.00 I 0.00 PAT~~ 1-DARLENE D GALLOWAY PRV/~ 1-DANIELS, MICHAEL 0, M.D. 0.00 I 0.00 , 15.00 ' ~ •~ ~ 15.00' Ph:(717)-486-8550 Acct~~: 724 Date: 05/05/08 Page 1 of 1 NEWVILLE COMM. AMBULANCE C/0 PROMED SERVICES, INC. 4 W. MAIN STREET SHIf~EMANSTOWN, PA 17011 1-866-678-6855 DARLENE GALLOWAY 239 MIDDLE RD NEWVILLE, PA 17241 Patient Bill DOB: 04/19/1940 Line Date Range Prov Procedure DxRef POS Charge Unt Apprv'd Pt Pd lns Pd Adjusted Pt Due Balance! - • ~ ~ r ~ • 1 ~ . , ~ Claim Number: 4780018IDiagnosis 1} 780.01 Ins: 1) FRE/Non FERiC?5t02311001i01998217 01 03/03-03/03/08 010 A0429RH 1 A 500.00 1 500.00 Procedure: BLS EMERGENCY SERVICE Dates first billed: 04/08/08 Over 30 Patient Totals: 500.00 500.00 Page: 1 Printed: 05!19108 08:21 ID: Newv-2278 253.80 196.20 50.00 0.00 253.80 196.20 50.00 50.00 50.00 Total Amount Due By Guarantor: 50.00 ~~ ~~~~V~a~~~ pCC e~~tP ay a tP m P~oac \\fOC aQ vv`rwv DETACH HERE www ---------------------------- PLEASE MAKE CHECKS PAYABLE TO NEWVILLE COMM AMBULANCE Prov Codes: 010=Newville Ambulance - - - - - - - - - - To insure proper credit, please clip and mail the bottom section for each page and include with payment - - - - - - - - - Guar: GALLOWAY, DARLENE #: Newv-2278 Clms: 47800188 Total Due (all pages); 50.00 Page 1 ~~ PENNS WOOD PHYSICAL THERAPY 419 VILLAGE DR STE 3 CARLISLE, PA 17015 (717) 240-0330 ~, FED T.AX ID# 76-0430771 RONALD D. GREENWAY, P.T. DARLENE D. GALLOWAX 239 MIDDLE ROAD NEWVILLE PA 17241 STATEMENT PATIENT: INJURED: PHYSICIAN: ID N0: EMPLOYER: DATE: 04/23/2008 DARLENE D. GALLOWAY 03/06/2007 DELL, DAVID M.D. FER105102311001 ACCT 1131.24 11 BZ RG DIAGNOSIS: LUMBAGO (LOW BACK PAIN) - 724.2 SPINAL STENOSIS, LUMBAR REGION - 724.02 INSURANCE PATIENT DATE -------- DESCRIPTION --------------------------------------------------- CHARGES --- PAID ADJUSTS PAID BALANCE FORWARD 198.84 ------- -------- ------------------ 04/02/07 *HOT/COLD PACK ~ 30.00 ~ -30.00 04/02/07 *ELECTRIC STIMULATION; UNATTENDED ~ 27.00 9.80 -14.75 04/02/07 *ULTRASOUND ~ 48.00 8.74 -37.07 04/04/07 *MANUAL THERAPY TECHNIQUES-EA 15 MIN.. ~ 55.00 19.19 -31.011 04/04/07 *ULTRASOUND I 48.00 8.74 -37.071 04/04/07 *ELECTRIC STIMULATION; UNATTENDED ~ 27.001 9.80 -14.75 04/04/07 *HOT/COLD PACK ~ 30.00 , -30.001 04/30/07 3iIGHMARK BLU billed 1202.00 for 03/06-03/28/7 04/30/07 iiIGHMARK BLU billed 1202.00 for 03/06-03/28/7 04/30/07 IiIGHMARK BLU billed 265.00 for 04/02-04/04/7 06/18/07 FiIGHMARK BLU billed 1467.00 for 03/06-04/04/7 07/09/07 I)ARLENE D. GAL Billed 135.00 for 03/06-06/18/7 07/18/07 FiIGHMARK BLU billed 1202.00 for 03/06-03/28/7 09/12/07 FiIGHMARK BLU billed 1467.00 for 03/06-04/04/7 10/04/07 E3LUE SHIELD pd.$222.22 FOR 03/12-04/04/7 10/04/07 Portion of claim # 6 pd. 10/04/07 Portion of ins. claim 7 also pd. 10/04/07 CONTRACTUAL WRITE- cr.$1031.86 FOR 03/06-04/04/7 11/20/07 -------- L~ARLENE D. GAL Billed 212.92 for 03/06-10/04/7~ --------------------------------------------------- ' ---------- -------- ------------------ TOTALS CURRENT OVER 30 OVER 60 OVER 90 OVER 120 0.00 0.00 0.00 0.00 212.92 PLEASE PAY YOUR PORTION BY THE 9TH OF MAY. 1467.00 222.22 -1031.86 0.00 PLEASE PAY '...,212.92 ~ THANK YOU r ,IaI@fil@flt tOr account nurnper-. ~-coo o~. r~ ~~~~ . ,-~., New Balance Payment Due Date Past Due Amount Minimum Payment $105.97 06/13/08 $0.00 $10.00 Make your check payable to Chase Card Services. Amount Enclosed $ ~,~ New address or e-mail? Print on back. ~~ 4266841036087748000010D000010597D000003 16145 BEX Z 14508 D DARILENE D GALLOWAY 239 MIDDLE RD NEWVILLE PA 17241-9311 I,,, I N I,,, I„I, I, I„I.,, I I I, I,,,, I I,,,, 11,,,11„I I, I, i„I, I„I CHASE ! i I,,,III,I„I„1,1„I„II,,,I,1,,,,11,1,1,,,11„1,1,,,11„II„I CARDMEMBER SERVICE PO BOX 15153 WILMINGTON DE 19886-5153 ~: 5000 L 60 281: 20 3 LO 3 608 7 748911• Opening/Closing Date: 04/25/08 - 05/24/08 CUSTOMER SERVICE CHASE ~ in D 0 M imum Paym ent Due: $10.00 Espanol 1-888-446-3308 TDD 1-800-955-8060 Pay by phone 1-800-436-7958 Outside U.S. call collect 1-302-594-8200 VISA ACCOUNT SUMMARY Account Number: 4286 8410 3608 7748 Previous Balance $2,207.02 Total Credit Line $2,000 ACCOUNT INQUIRIES P.O. Box 15298 Payment, Credit:a -$2,101.05 AvailableCredii $1,894 Wilmington, DE 19850-5298 New Balance Cash Access Line $105.97 ~ 000 ~ ayment Available for Cash $1,894 PAYMENT ADDRESS P.O. Box 15153 Wilmington, DE 19886-5153 above VISIT US AT: °ritS the www.chase.com/creditcards rvice. If ;riience, TRANSACTIONS Benefit Trans ~ Amount Date References Number Merchant Name or Transaction Description Credit Debit Benefit Activation Department (888) 314-4371 Monday -Friday 8:00 a.m. - 8:00 p.m. Eastern Time ICI otoo oared for. DARLENE D GALLOWAY May 2008 Statement :ount Number: 4313 0702 4831 8039 Credit Line: $11,500.00 Cash or Credit Available: mmary of Transactions Billing C t~cle and Payment Information evious Balance $6,278.43 Days in Billing Cycle 30 yments and Credits - $0,00 Closing Date 05/03/08 rchases and Adjustments + $82.59 riodic Rate Finance Charges + $68.40 ,nsaction Fee Finance Charaes + -- $0.00 w Balance Total $6,429.42 Payment Due Date Current Payment Due Past Due Amouri4 Total Minimum Payment Due 05/28/08 $170.00 + $151.00 i~ VISA~GNATURE ,_ ..;~ Forlnformation on Your Account /sit.• www. bankofa merica.com Call toll-free 1-800-421-2110 TDD hearing-impaired 1-800-346-3178 Mail Payments to: BANK OF AMERICA P.O. BOX 15726 WILMINGTON, DE 19886-5726 Mail Billing Inquiries to: I _ BANK OF AMERICA P.O. BOX 15026 WILMINGTON, DE 198$0-5026 ~ ~ ~ ~ ~._ r_-.:., - _. _._~ . _._ __ _ __ .. a _. _ _ _~_ ~..., - Pro~~,~.ob~onal Post~na Transaction Reference Account rchases and Adjustments _ _______Offer_ID_ _ DateV_,. _Date __Number Nu__m_be_r__T Amount TEFEE FOR;PAYM<=NT DUE 04/28 04!28 04/28 6278 39,00 iEDIT PROTECT PLAN 1.800.942.1083 05/03 05/03 900A 43.59 WOR.LDPOINTS 0 MONTHLY EARNINGS 0 BONUS POINTS THIS MONTH " 0 POINTS AVAILABLE -- .. ~, YOUR PAYMENT WAS NOT RECEIVED BY THE DUE DATE. TO AVOID FUTURE FEES OR RATE INCREASES, PLEASE MAKE YOUR PAYMENTS ON TIME AND REMAIN UNDER YOUR CREDIT LIMIT. REMEMBER, IF TWICE IN 12 MONTHS YOUR PAYMENT IS RECEIVED AFTER THE DUE DATE AND/OR YOUR CREDIT LIMIT"IS EXCEEDED; YOUR INTEREST RATES MAY fNCREASE. NEED A VACATION? REDEEM YOUR WORLDPOINTS REWARDS FOR EXCLUSIVE RESORT ACCOMMODATIONS OR USE YOUR POINTS TO DISCOUNT THE PRICE. CALL 1-877-738-2845! DID YOU KNOW THE AUTOMATED SYSTEM PROVIDES THE ABILITY TO HEAR YOUR ACCOUNT BALANCE, MAKE PAYMENTS, SELECT PINS, ORDER STATEMENTS AND DISPUTE CHARGES? Obi 00642942000321~00~0200000004313~70248318039 BANK OF AMERICA P.O. BOX 15726 WILMINGTON, DE 19886-5726 In,Ill,lulu!,Inlnlln~l~l,ln,inl~l,llninl~l Check here for a change of mailing address or phone number(s). Please provide all corrections on the reverse side. ACCOUNT NUMBER: 4313 0702 4831 8039 1 00(11843 08673 0400000001 USE211 00005-06N DARLENE D GALLOWAY 239 MIDDLE RD NEWVILLE PA 17241-9311-399 NEW BALANCE TOTAL: $6,429.42 PAYMENT DUE DATE: 05/28/08 - - -" ~ - - Enter Payment Amount Encbxo: Mail this payment coupon along with a check or money order payable to: BANK OFAMERICA ~~ ~~ -_ ~_ ~~ m ~ o_ A ..... .~~~~ ~~ ~~ ~~ ~: 5 240 2 2 2 50t: 09400 248 3 L80 3911' Earn cash back rtua ly ANIERrCAN Blue Cash® eve here oa'use tho '~ r EJ(PriESS Ca d. from American Express .~ Prep~rcC For Account Number Closing Date DARLENE D GALLOWAY XXXX-XXXXXS-91005 02/29/08 Page t of 6 is New Actively $ inc. Adtustments and Ch it i Minimum Payment Due Date Amount Dues E $ _ Previous Balance $ Payment Actively $ any arges F narrz New Balance $ ~3/2i)/~I3 4 2,354.52 -50.00 +22.84 =2,327.36 ~ ~ Please refer to page 2 for important information 0 regarding your account 4 Credit Line Total Credit Available Credit Cash Advance Available Cash Summary Line $ Line $ Limit $ Limit $ on 02/29/08 7,760.00 5,372.64 400.00 400.00 "ro manage yot+.r Card A.count online or to pay your bill, please visit us at www.americanexpress.com. For additional contact information, please see the reverse side of this page. Blue Cash® Online Calculator Adds Up Your Cash Back ,,1M1e~,~, Whether you spend $10, $100 or $100,000, you can earn up to 5% cash back with Blue Cash®. o~sess And now, you can also use the new Blue Cash® Online Calculator to see just how much cash ® back you're earning. With the Online Calculator, you'll find it's easy to estimate your annual cash back return anytime. Try it out today--simply visit americanexpress.com/cashreward. And while you're there, you can also learn how to maximize the cash back. --- ----- --- ACt1Vlt`y 'Indcatespcuengdate Amarxs .. ~m_~._ _.~._,~_ ___. _..__._._~_, ___ ___ _. _ __ __. ___ _ ___ ---_ ___ _.. ~.._ _____ - -- - - - -- -~ _____ O~Jf4/08' PAYMENT' RECEIVED ACH - rl^fAN4f YOU __ __ -~ ~Q New Activity for DARLENE D GALLOWAY ~ ~ ~ ~°`"w s card xxxx-x~oocs-stool -- ^0.J29/08 Periodic FINANCE CHARGE ~•~ _ Total of New Activity 22.84 Please tok! on the peAoration below, detach and return with your payment Payment Coupon N 0 0 0 °< W Q a 0 Account Number 3772-117535-91005 Continued on Page 3 Payment Due Date: Please enter your account 03/20/08 number on all checks and correspondence. New Balance Make check payable to ~ 2,327,36 American Express. Minimum Amount Due See Finance Charge $47.00 section on reverse stile for a description of when additional Finance Charges are not assessed $ on Purchases. l ' l Check here if your address Amount enclosed or phone number has changed. Please note chanoes on reverse side. II'I1'i"I'~~'Ili'lllllulr~~"II'~~~~Inlu~lll'1'llluil~l~l~l~ ~_~ DARLENE D GALLOWAY 239 MIDDLE RD -- NEWVILLE PA 17241-9311 ~~ Mail Payment to: ~nn~l'ri~l'I"111'nlllll"Irlrll'llll~lll~,l~~~llllll"Ills n AMERICAN EXPRESS ~-J P.0. BOX 2855 NEW YORK NY 10116-2855 0000377211753591005 000232736000004700 25 ri HARRISBURG PHARMACY 2645 NORTH THIRD STREET HARRISBURG, PA 17110 //~„~ , PHONE: 717-232-0400 STATEMENT OF ACCOUNT ~-~ , -~~rr~ 05/01/loos A FINANCE CHARGE OF 1.50 % PER MONTH (AN ANNUAL PERCENTAGE RATE OF 18.0%) OR A MINIMUM SERVICE CHARGE OF $ 1.00 WILL BE CHARGED ON ALL AMOUNTS 30 DAYS OR MORE PAST DUE PMT DUE:": D5/"IZfD8 ""'• DARLENE GALLOWAY 30 DAYS. 1.00 HCPA 60 DAYS. 4.50 ! 239 MIDDLE ROAD NEWVILLE PA 17241 AMT DUE .. 6 . ~Q__~'~ PLEASE DETACH HERE AND RETURN TOP PORTION WITH YOUR PAYMENT GALLD GRP-HO PAGE 1 AMOUNT PAtD ~~ ~ ~ • '' • • * * TITS AMOUN I, PAS DUE j ~ i i I I PAST DUE I t j ~' I ~ i - __ _ - - -- -- 2 . 0 0. _ - - ~--- --- . 0 0 .. . YTD FIN ~~ty~Jq CHARGE ~; ~ , ,~ .:~ ~sYxx~.~ i~u6ei 5 50 . 00 ~ 1.00_.__ _~ ~"_ _ 6.50 , . 00 • 6.50