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Home My WebLink About09-08-08 (3)J REV-1500 EX (06-05) PA Department of Revenue Bureau of Individual Taxes PO BOX 280601 Harrisburg, PA 17128-0601 15056051058 OFFICUIL USE ONLY Countv Code Year File Number INHERITANCE TAX RETURN RESIDENT DECEDENT (If Applicable) Enter Surviving Spouse's information Below Spouse's Last Name :None Spouse's Social Security Number 08 Date of Birth 06/30/1917 Suffix Decedent's First Name MI A ~ Helena Suffix Spouse's First Name MI _.._..._......._. .................... i________..__._Y_____________..___.__________ „____ _.._........__....._.._.___ .............................._........ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE __~ _._.._-__..____._________._._.y...-___ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~} 1. Original Return 2. Supplemental Return 3. Remainder Retum (date of death prior to 12-13-82) C'~ 4. Limited Estate 4a. Future Interest Compromise (date of t~ 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate C 7. Decedent Maintained a Living Trust __0 __. 8. Total Number of Safe Deposft Boxes (Attach Copy of III) (Attach Copy of Trust) t' 9. Litigation Proceeds Received G' 10. Spousal Poverty Credit (date of death t~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number _. Michael Cherewka I ~ (717) 232-4701 _.. Firm Name (IfApphcable) .. _ .......... tV r.._-._.__...._-_---.._.~. -....._._.__...~ ,_, _.. ..... ......... ...... .... ................. _ .... ~ REGISTE LLS USE~9ILY f Law Offices of cn ° ~ ' ~ ' t., •. ~ L7 hl U f z .: ~ _: ""~ First line of address ~ ~ ~1'I ~'' ~ . ° _.::~r ' ' `- ~ 624 North Front Street ~~ ~ - - Second hne of address C7 ~ _ ` -~ ., ; ~ .......__. ____. __. _. __ ~ _.._.._. _ _ ._ ___M__.___._.~. _. ~ __ ~.._______.. _ _.__.. ~ _ _..__ N _ _...... _ City or Post Office _..... .. ............... .. State ZIP Code i . E FILED Q =~;x i Wormleysburg IPA :17043 • ' i Correspondent's a-mail address: Under penalties of pery'ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, tt is true, corcect and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. OF PERSON RESPOIy81gLE FOR rL~ a~,~ a, L-rLhnD~x-v~~ ~l`L l Z o THAN RE67RESE TATIVE U " ` Side 1 15056051058 15056051058 J 15056052059 REV-1500 EX Decedent's Name: Helena Alexander Decedent's Social Security Number 189-18-7484 RECAPITULATION 1. Real estate (Schedule A) ............................................. 1. 0.00 2. Stocks and Bonds {Schedule B) 2. 58,250.27 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00 4. Mort a es l;< Notes Receivable Schedule D 9 9 ( ) ............................. 4. 0.00 ; 5. Cash, Bank Deposits 13< Miscellaneous Personal Property (Schedule E) ........ 5. 71,602.25 6. Jointly Owned Property (Schedule F) C".:7 Separate Billing Requested ....... 6. 0.00 7. Inter-~vos Transfers & Miscellaneous Non-Probate Property ___,. 0 00 (Schedule G} C~ Separate Billing Requested........ 7. . 8. Total Gross Assets (total Lines 1-7) .................................... 8. 129,852.52 9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9. 9,299.12 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................ 10. 8,678.67 11. Total Deductions (total Lines 9 & 10) ................................... 11. 17,977.79 12. Net.Value of Estate (Line 8 minus Line 11) .............................. 12. 111,874.73 13. Charitable and Govemmentat Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 111,874.73 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 - ~``~~~'~`-`~W~ (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable ~._ at sibling rate X .12 17. 18. Amount of Line 14 taxable ~ µ.____~ 111 874 73 16 781.21 , . at collateral rate X .15 18 , 19. TAX DUE ......................................................... 19.~ 16,781.21 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 .'3 15056052059 REV-1500 EX Page 3 1'lnrnrlcnt'c f_mm~lp+p ~fI[II'P_SS' i_Ig.~lgm.,~gy.._.._______.__-___._ DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER Helena Alexander 189-18-7484 STREET ADDRESS 128 Bosler Avenue CITY STATE PA ZIP 17043 Lemoyne Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 16,781.21 2. Credits/Payments 0.00 A. Spousal Poverty Credit B. Prior Payments 0.00 C. Discount 0.00 Total Credits (A + B + C) (2) 16,781.21 3. Interest/Penalty if applicable 0.00 D. Interest E. Penalty 0.00 Total InterestlPenalty (D + E) (3) 0.00 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) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 16,781.21 A. Enter the interest on the tax due. (5A) 0.00 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 16,781.21 Make Check Payable to: REGISTER OF WILLS, AGENT i ~ r PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APP ROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :............................................................................. .......... ... ^ b. retain the right to designate who shall use the property transferred or its income : ............................... .......... ... ^ c. retain a reversionary interest; or ............................................................................................................. .......... ... ^ d. receive the promise for life of either payments, benefits or care? ......................................................... .......... ... ^ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ................................................................................................. .......... ... ^ 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? ........................................................................................................... .......... ... ^ 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 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12} percent [72 P.S. §9116(a)(1.3)j. 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. ^ REV-1502 EX+ (6-98) SCHEDULE A COMMONWEALTH OF PENNSYLVANIA REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT _ __ TOTAL (Also enter on line 1, Recapitulation) 3 0.00 (If more space is needed, insert additional sheets of the same size) REV-1503 EX+ (6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER 21-08-0278 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH t. iU. S. Savings Bonds, See List Attached 20,618.27 2. ;PPL Corporation, 400 Shares, CUSIP #69351T-10-6, Close on 02/27/08 $47.04/share 18,816.00 3.. ,PPL Active Shareholders Account #3099026414, 400 Shares Close on 02127/08 $47.04/share 18,816.00 __ __ _ __ _ __ TOTAL (Also enter on line 2, Recapitulation) 5 58,250.27 ': (If more space is needed, insert additional sheets of the same size) Estate of Helene A. Alexander Schedule B File No. 21-08-0278 Series Denomination Serial Number Issue Date Date of Death Value 1 EE 75 K19663717EE Jul-82 $184.38 2 EE 75 K19663716EE Jul-82 $184.38 3 EE 75 K19212187EE Jun-82 $184.38 4 EE 75 K19212186EE Jun-82 $184.38 5 EE 75 K19209193EE Ma -82 $184.38 6 EE 75 K19209192EE Ma -82 $184.38 7 EE 75 K19205020EE A r-82 $184.38 8 EE 75 K19205019EE A r-82 $184.38 9 EE 75 K19205018EE A r-82 $184.38 10 EE 75 K19200489EE Mar-82 $184.38 11 EE 75 K19200488EE Mar-82 $184.38 12 EE 75 K19197915EE Feb-82 $188.07 13 EE 75 K19197914EE Feb-82 $188.07 14 EE 75 K19193831EE Jan-82 $188.07 15 EE 75 K19193830EE Jan-82 $188.07 17 EE 75 K19188801EE Dec-81 $188.07 18 EE 50 K19188800EE Dec-81 $125.38 19 EE 75 K19188191EE Nov-81 $188.07 20 EE 75 K19188190EE Nov-81 $188.07 21 EE 75 K18685783EE Oct-81 $188.07 22 EE 75 K18685782EE Oct-81 $188.07 23 EE 75 K18685781EE Oct-81 $188.07 24 EE 75 K18684453EE Se -81 $188.07 25 EE 75 K18684452EE Se -81 $188.07 26 EE 75 K18679269EE Au -81 $191.82 27 EE 75 K18679268EE Au -81 $191.82 28 EE 75 K18675737EE Jul-81 $191.82 29 EE 75 K18675736EE Jul-81 $191.82 30 EE 75 K18672413EE Jun-81 $191.82 31 EE 75 K18672412EE Jun-81 $191.82 32 EE 75 K18668249EE Ma -81 $191.82 33 EE 75 K18668248EE May-81 $191.82 34 EE 75 K18664980EE A r-81 $200.37 35 EE 75 K18664979EE A r-81 $200.37 36 EE 75 K18664978EE A r-81 $200.37 37 EE 75 K18301985EE Mar-81 $200.37 38 EE 75 K18301984EE Mar-81 $200.37 39 EE 75 K18295471EE Feb-81 $204.36 40 EE 75 K18295472EE Feb-81 $204.36 41 EE 75 K18292188EE Jan-81 $204.36 Estate of Helene A. Alexander Schedule B File No. 21-OS-0278 42 EE 75 K18292187EE Jan-81 $204.36 44 E 50 L2204595410E Mar-80 $200.40 45 E 50 L2204595409E Mar-80 $200.40 46 E 50 L2204590017E Feb-80 $204.40 47 E 50 L2204590018E Feb-80 $204.40 48 E 50 L2201556374E Jan-80 $204.40 49 E 50 L2201556375E Jan-80 $204.40 50 EE 75 K17946282EE Dec-80 $204.36 51 EE 75 K17946283EE Dec-80 $204.36 52 EE 75 K17944250EE Nov-80 $204.36 53 EE 75 K17944249EE Nov-80 $204.36 54 EE 75 K17938830EE Oct-80 $222.96 55 EE 75 K17938829EE Oct-80 $222.96 56 EE 75 K17938828EE Oct-80 $222.96 57 EE 75 K17734168EE Se -80 $222.96 58 EE 75 K17734167EE Se -80 $222.96 59 EE 75 K17359313EE Au -80 $227.43 60 EE 75 K17359312EE Au -80 $227.43 61 EE 75 K6325564EE Jul-80 $227.43 62 EE 75 K6325563EE Jul-80 $227.43 63 EE 75 K6323954EE Jun-80 $227.43 64 EE 75 K6323953EE Jun-80 $227.43 65 EE 75 K6318263EE Ma -80 $227.43 66 EE 75 K6318262EE Ma -80 $227.43 67 EE 75 K6318261EE May-80 $227.43 68 EE 75 K6315381EE A r-80 $225.18 69 EE 75 K6315380EE A r-80 $225.18 71 E 25 Q6329140265E Jan-79 $104.08 72 E 25 Q6329140264E Jan-79 $104.08 73 E 25 Q6330717081E Feb-79 $104.08 74 E 25 Q6330717082E Feb-79 $104.08 75 E 25 Q6330735799E Mar-79 $102.04 76 E 50 L2167518101E Mar-79 $204.08 77 E 50 L2168076227E A r-79 $204.08 78 E 50 L2168076228E A r-79 $204.08 79 E 50 L2174862375E May-79 $206.06 80 E 50 L2174862376E Ma -79 $206.06 81 E 50 L2174862377E Ma -79 $206.06 82 E 50 L2176176289E Jun-79 $206.54 83 E 50 L2176176288E Jun-79 $206.54 84 E 50 L2181990208E Jul-79 $206.54 85 E 50 L2181990207E Jul-79 $206.54 Estate of Helene A. Alexander Schedule B File No. 21-08-0278 86 E 50 L2182004704E Au -79 $206.54 87 E 50 L2182004703E Au -79 $206.54 88 E 50 L2187138887E Se -79 $202.48 89 E 50 L2187138886E Se -79 $202.48 90 E 50 L2187146074E Oct-79 $202.48 91 E 50 L2187146073E Oct-79 $202.48 92 E 50 L2199363974E Nov-79 $204.40 93 E 50 L2199363975E Nov-79 $204.40 94 E 50 L2199363976E Nov-79 $204.40 95 E 50 L2201544153E Dec-79 $204.40 96 E 50 L2201544154E Dec-79 $204.40 98 E 25 Q6249673511E Mar-78 $106.27 99 E 25 Q6249673512E Mar-78 $106.27 100 E 25 Q6256986820E A r-78 $106.27 101 E 25 Q6256986819E A r-78 $106.27 102 E 25 Q6265294704E Ma -78 $104.58 103 E 25 Q6265294705E Ma -78 $104.58 104 E 25 Q6280952675E Jun-78 $104.85 105 E 25 Q6280952674E Jun-78 $104.85 106 E 25 Q6280952676E Jun-78 $104.85 107 E 25 Q6282176874E Jul-78 $104.87 108 E 25 Q6282176875E Jul-78 $104.87 109 E 25 Q6288963160E Au -78 $104.87 110 E 25 Q6288963161E Au -78 $104.87 111 E 25 Q6288981320E Se -78 $102.81 112 E 25 Q6288981321E Se -78 $102.81 113 E 25 Q6305824707E Oct-78 $102.81 114 E 25 Q6305824708E Oct-78 $102.81 115 E 25 Q6307014986E Nov-78 $103.79 116 E 25 Q6307014987E Nov-78 $103.79 117 E 25 Q6307014988E Nov-78 $103.79 118 E 25 Q6320534013E Dec-78 $104.07 119 E 25 Q6320534012E Dec-78 104.07 $20,531.08 ~ - ~ III M1ti ;'~ ~ ~ ~~,~ ., ,u ~` ~~~ x' ~ t~ ~ ~ ~ xy ~ ~ i~ b~ ti ~~` ,. ,~tt~i ~; 4ii~Q~ ~n _' 4 ',. ,. ~ ~ ~ ~2" =r~ ~T,4 ~ f' '~1---~ ~_"' ~3's3Kj~,,,~~ ~-s,. __ ~ i ~ ~' ,it ~~ r~~ . 4 ~ }~t``~~,~ ~ ~ `cr..~v -~ F ~Y.":P~;l~~.. G~~i ~.?•q~ A;~sl~R " o,,.t~`ir.P ~F:.~~~' ~:~i~..1~._ae~~f+f~~~~/J3 y '~ ~i."_•.I.._~-~t ~`Y'~~\~ ,~51u~5ti IIIIIIII f~ ~'~. ~Y+' ~.'j`~Y/.' ~~~~~ a z a v y a D D Z a ~ n a V n a z v m f/1 O m 1 Z O n x T X m n m O n 9 (! 0 c c~ -p z ~ o rZ (f~ o mD ~ ~ r < ~ Z m m O N A ZO D ~ 0 '~ Z r O O O 1 m o O = O O ~ z m ~ v D Z i m m Z9 n z D F ~ 'i °O~a Zz °m p A r c = Z r ~ Z N y ~ O Z ~ ~ -f CJI ~ 77 ~ Z ~ ~ ~ V Z <T.p m m w Z 2 D j ~ D m r G m a Z ~ D m (1 ~ n m ~ W ~ O C O m 9 a W ~ N ~ r Z ~ m Z m L~ ~ H+ A fH O T "I ~1 0 O C7 (J y THE COMPANY WILL FURNISH WITHOUT CHARGE TO EACH SHARE OWNER WHO SO REQUESTS A STATEMENT OF THE DESIGNATIONS, TERMS, RELATIVE RIGHTS, PRIVILEGES, LIMITATIONS, PREFERENCES AND VOTING POWERS AND THE PROHIBITIONS, RESTRICTIONS AND QUALIFICATIONS- OF THE VOTING AND OTHER RIGHTS AND POWERS OF -THE SHARES OF EACH CLASS OF STOCK WHICH THE COMPANY IS AUTHORIZED TO ISSUE AND OF THE VARIATIONS IN THE RELATIVE RIGHTS AND PREFERENCES BETWEEN THE SHARES OF EACH SERIES OF EACH CLASS OF STOCK WHICH THE COMPANY IS AUTHORIZED TO ISSUE IN SERIES INSOFAR AS THE SAME HAVE BEEN FIXED AND DETERMINED, AND OF THE AUTHORITY OF THE BOARD OF DIRECTORS TO FIX AND DETERMINE THE RELATIVE RIGHTS AND PREFERENCES OF SUBSEQUENT SERIES. The following abbreviations, when used in the inscription on the face of this certificate, shall be construed as though they were written out in full according to applicable laws or regulations: TEN COM - as tenants in common UNIF GIFT MIN ACT- Custodian TEN ENT - as tenants by the entireties (Gust) (Minor) JT TEN - as joint tenants with right of under Uniform Gifts to Minors survivorship and not as tenants Act in common (State) Additional abbreviations may also be used though not in the above list. c/I9~ Z ~~' f <in !T . dPiliL, II.GG~/ni C!/IZQi ~.?~GT~~L/ f.//l7~LL~ PLEASE INSERT SOCIAL SECURITY OR OTHER IDENTIFYING NUMBER OF ASSIGNEE PLEASE PRINT OR TYPEWRITE NAME AND ADDRESS INCLUDING POSTAL ZIP CODE OF ASSIGNEE. c~uu~ ~ ~fza-ri~~ X: .X _ NOTICE: UPONITHET FACES~OF THIE CERTIFICATE IN SEVERYRPARTICULAR, WITHOUT~ALTERATO OR ENLARGEMENT OR ANY CHANGE WHATEVER. Signature(s) Guaranteed i3y THE SIGNATURE(S) SHOULD BE GUARANTEED BY AN ELIGIBLE GUARANTOR INSTITUTION (BANKS, STOCKBROKERS, SAVINGS AND LOAN ASSOCIATIONS AND CREDR UNIONS WITH MEMBERSHIP IN AN APPROVED SIGNATURE GUARANTEE MEDALLION PROGRAM), PURSUANT TO S.E.C. RULE 17AC-15. REV-1507 EX+ (6-98) SCHEDULE D COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER Helena A. Alexander 21-08-0278 (If more space is needed, insert additional sheets of the same size) REV-1508 EX+ (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Helena A. Alexander 21-08-0278 Include the proceeds of litigation and the date the proceeds were received by the estate. Ali property jointly-owned with right of survivorship must be disclosed on Schedule F. TOTAL (Also enter on line 5, Recapitulation) 5 I' / ~ ,fiU"L."15 ', (If more space is needed, insert additional sheets of the same size) '~~ Soverei n BankSM -~, ~ g Court Ordered Processing \ Decedents - MAl-MB3-02-10 - P. O. Box 841005 -Boston, MA 02284 April 25, 2008 Michael Cherewka Law Office 624 North Front Street Wormleysburg, PA 17043 RE: Estate of Helena A Alexander Date of Death: 02/27/2008 Dear Michael Cherewka: Per your request, enclosed please find the account information as of the date of death for the above-named decedent. For your information, accrued interest is not included in the date of death balance. Please feel free~to contact me if I can be of any further assistance. Very truly yours, Donna Pen a Lead Specialist 617-533-1789 Sovereign Bank ESTATE OF Helena A Alexander SOCIAL SECURITY #: 189-18-7484 DATE OF DEATH: February 27, 2008 Account #: 1051065755 Type Checking Open date: 8/27/2002 In the name of: Helena A Alexander or James G Alexander Date of Death Balance: $1,460.80 Int.(YTD) from 1/1/2008 to 2/13/2008 $1.03 Accrued interest to date of death: $0.25 Otherlnfo: Closed 4/21/08 Account #: 1051068886 Type: Checking Open date: 3/9/1995 In the name of: James G Alexander or Helena A Alexander Date of Death Balance: $42,462.29 Int.(YTD) from 1/1/2008 to 2/8/2008 $26.94 Accrued interest to date of death: $7.86 Other info: Closed 4/21/08 Page 1 of 1 O ~_; fD a v' G N O w m 1 O N O O 7 .-. 3 C ~ .... m O S p p ~ a. 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N "S to ~ a N O O a 0 C ~F C Q ~D ,~,^ /W/~.~ VI J O V W N ..- W N O .Q a ~ o ~ ~ Q ~ ~ Q ~ N 0 1° ~ ~ S w N 3 n 0 p ~ 3 ~ w 0 A W 0 A N 3 D _~ Z N m z I~ m o ~ Z m N Z ~ ~ o '00001883 Forest Park Health Center ~~' 700 Walnut Bottom Road Carlisle,PA 17013 Questions Concerning This Invoice? Biller Name Sharon @ Ext. 833 Phone 1-888-880-7090 Fax 1-814-265-1377 Email Sharon@publiccredit.com Janet Arnold 128 Bosler Avenue LEMOYNE PA 17043 Please Detach and Return with your payment PAGE 1 Resident# 22595 Resident ALEXANDER HELENA A Discharge Date 02/27/2008 Statement Date 06/30/2008 Payments Posted Through 06/30/2008 ZANY QUESTION REGARDING BILL CALL 1-888-880-7090 ,RON EXT 833 ACCEPT VISA/MASTERCARD PAYMENT ENCLOSED DATE DESCRIPTION UNITS REFERENCE AMOUNT BALANCE PREVIOUS BALANCE -190.32 -190.32 09/17/2007 LAB SERVICES - -25.68 -216.00 ~ ENDING BALANCE ~ ~ -21ti nn YOUR PAYMENT OF 00 IS DUE UPON RECEIPT Y~ccav,.r ~ aa,5 9 ~, ~~ D~~ ~~~ ~o~ ~.a7a~, o~ 'orest Park Health Cent 1-888-880-7090 ALEXANDER HELENA A 22595 REV-1509 EX+ (6-98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Helena A. Alexander 21-08-0278 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 ADDRESS RELATIONSHIP TO DECEDENT A• None _. - B. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY °/n OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITU710N 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. None TOTAL {Also enter on line 6, Recapitulation) $ 0.00 (If more space is needed, insert additional sheets of the same size) REV-1510 EX+ {6-98} COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Helena A. Alexander 21-08-0278 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 DESCRIPTION OF PROPERTY DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENTAND NUMBE THE DATEOFTRANSFER.ATTACHACOPYOFTHEDEEDFORREALESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE 1. 'None 0.00 TOTAL (Also enter on line 7 Recapitulation) b 0.00 __ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Helena A. Alexander 21-08-0278 Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: __ 1. Hetrick Funeral Home, Inc. 670.52 _. 2. Hetrick Funeral Home, Inc., grave opening 850.00 s.; JC Penny, funeral clothes 59.99 __ a. 'Hammaker'sFlowerShop 282.97 _. 5. !Hetrick Funeral Home, Inc., Marker 300.00 - B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 0.00 Name of Persona- Representative(s) ': ` Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City i State '.Zip Year(s) Commission Paid: i 2. Attorney Fees 6,490.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City i State !~ Zip Relationship of Claimant to Decedent 4. Probate Fees 330.00 - 5. Accountant's Fees 0.00 6. Tax Return Preparer's Fees 90.00 ~. ,Legal Notices 225.64 TOTAL (Also enter on line 9, Recapitulation) $:, 9,299.12 (If more space is needed, insert additional sheets of the same size) f_~ :. c~~~,~ IEvery dad iUfatiers :..' -r;."°~;~ -,:: JCPENNEY 2712 .,~.:~„ !;:: =mar _;~~~__ js{.:~-~~-:__.:°,~-..~1=_.- CAPITAL CITY MALL ~~:~::;~_.~=~;:-_-=_-.>~_-.___:_~_:<_'=:=.f=.-,-~ 3501 CAPITAL MALL DR - ~-~ ~ ~ ~ ' - CAMP HILL PA 17011 717-730-6064 _-_-----------•--------___..._-..._.._.._.._.------------...- i -- - y_;.. q -..~~ M j 223/3430/010408 PLZ 2PC 3/4 JKT SKRT ~°=~_ ~Eu ~ _E~~ ~~ -_~ ~- - UPC No. 884827621378 E_=~:- ~_ _,_y- ~ ~~=mar , r -_._ __~~;1 QTY 1 90.00 - ~ - -~ Sale Disc -20.01 --..~,:~- ~::}_. =__ - T~ = ': ;;,; r+~; Cert Disc -10.00 i ~ :..`~=~~ `7.iW 4~+- ~ ~~ Total Discounts -30.01 ~ ~ •r : _ ;_;,;~„•-s I Discounted Price 59.99 ! -` i Net Sales/Return Value 59.99E _-- -°' _- t :r:~,: ii i+ jai"(L '_(`';=!l! .'~~ali.~: Total Certificate 10.00 = •-- -~-- ~ ~' Subtotal 59.99 ='-C`== - ;~;.'+ '- - -... ~~; r;.r--:_. ,'' ~. Loca 1 Tax 0.00006 17011 0. GO i ' •' `~-' ' `='' ~~ ~' Total 59.99 I - i 7CYtX~C~~Y(~IC 7C YC;C k~C 1t YC YC YC IC'KY(~YCr7t Yt YC~YfXYC Y(~:t fC~~JC~:tk ~ -_• a:1+.'•_+e: YC7CYl7C YC~IC X'Yt~CY(~7C:CYC YC)tYCYfYt 7K YCK7C Yl ~C~~YC IC~Y(YCYf YI Y[Yt Yt :l'YC %C ~ ._ .~' Tell us about your visit, at ~ _ ~ - www . JCPSurv~y _ corn _...-___.~_ ____.________._-_._.-w_:==___ ~ and recei ve a ~-.~~~:-~~, .e ~pa~:_B ~:~ r_3 ~ "~ _' 15°6 o-f~f coupon t I - _ ~__ _~~.t. ~~ ~ r - See websito for detai 1s and exclusions. i - ~ f - °=- ,~- --~~=' - Access code valid for 30 days. -_-_---_-•--_-------~._-._~.__..__,~_____. Access Code:2712 410 0887 022908 1155 5 ' :CY(Yf;r 1CX~C1Ck7i 7C 7C 7C YfYC*)C ~C IC ~CKk~1C k]CY(Y(X~YC 7Q~7c Yt 7[)C 1C*7k 7C HETRICK FUNERAL HOME, INC. R E C E I P T 3125 Walnut Street s~ Harrisburg, Pennsylvania 17109 DATE~,~- ~~ - ~c~0~ ~. (7 i 7) 545-3774 o RECEIVED FR o ~ For _~ Z Tl2ank you Invoice Hetrick Funeral Home, Inc. 3125 Walnut Street Harrisburg PA 17109 Bill To Janet Arnold 128 Bosler Ave. Lemoyne, PA 17043 Quantity Description Engraving of Marker _ It's been a pleasure working with you! Date Invoice # 7/22/2008 1537 Terms I Due Date I Client Net 30 8/21/2008 Helena Alexander Rate Amount 300.00 300.04 Total $300.00 Payments/Credits $-300.00 Balance Due $o.oo Hetrick Funeral Home, Inc. 3125 Walnut Street Harrisburg PA 17109 Bill To Janet Arnold 128 Bosler Ave. Lemoyne, PA 17043 Equipment Rental, Clergy offering 10 Death Certificates Obituary in Patriot News Quantity It's been a pleasure working with you! Description Terms Net 30 OB '~a~ C CJ` ~ , ~ Invoice Date Invoice # 3/3/2008 1373 Due Date 4/2/2008 Rate 295.00 150.00 6.00 165.52 Total Client Helena Alexander Amount 295.00 150.00 60.00 165.52 $670.52 Payments/Credits $0.00 Balance Due $6~o.s2 RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse S uare Carlisle, PA 1713 ALEXANDER HELENA ANNA Estate File No.: 2008-00278 Paid By Remarks: JANET L ARNOLD CJ ------------------- Fee/Tax Description PETITION LTRS TEST WILL SHORT CERTIFICATE JCP FEE AUTOMATION FEE Check# 2148 Total Received......... Receipt Date: 3/13/2008 Receipt Time: 09:31:28 Receipt No.: 1051911 Receipt Distribution ----- -------- ------- ---- Payment Amount Payee Name ' 260.00 CUMBERLAND COUNTY GENERAL FUN 15.00 CUMBERLAND COUNTY GENERAL FUN 40.00 CUMBERLAND COUNTY GENERAL FUN 10.00 BUREAU OF RECEIPTS & CNTR M.D 5.00 CUMBERLAND COUNTY GENERAL FUN ---------------- $330.00 $330.00 REV-1512 EX+ (72-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Helena A. Alexander 21-08-0278 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH t. Guardian Long Term Care Pharmacy 307.91 2. Pinker & Associates 37.84 3. Associated Cardiologists 7.63 4. .,Bryant General Surgery 22.31 5. Moffitt Heart & Vascular Group 6.84 6. Carlisle HMA Physician Management 30.00 7. Darryl K. Guistwite, D.O., Inc. 100.54 8. .Carlisle Regional Medical Center 512.00 9. .Carlisle HMA Physician Management 49.69 10 Darryl K. Guistwite, D.O., Inc. 23.83 11. West Shore EMS 74.08 12. Forest Park Health Center 7,057.00 13. PA Department of Revenue, (2007 PA-40) 449.00 TOTAL (Also enter on line 10, Recapitulation) $ I 8,678.67 (If more space is needed, insert additional sheets of the same size) GUARDIAN LONG-TERM CARE PHARMACY 123 BRUBAKER ROAD BROCKWAY, PA 15824 814-503-7400 PAGE 1 STATEMENT OF ACCOITNT QUESTIONS REGARDING YOUR BILF, - PLEASE_CALL 814-503-9400 CREDITCARDPYMT: - VISA. .MAS'PERCARD DISCOVER EXP DATE: CREDIT CARD NO. 3 DIGIT CARD CODE: SIGNATURE: - STATEMENT DATE 02/25/08 JANET ARNOLD PA17456 ' 128 BOSLER AVE 47.22595 ~/ LEMOYNE, PA 17D43 ~ 0 7, 7 / AMOUNT DibE : 3 0 7.91 ` AMOUNT PAID PLEASE DETACH HERE AND RETURN TOP PORTION WITH YOUR PAYMENT Uiilt 1FfHIVJHG IIVN tt.R if v~aanrr~~e+.a ** ACTIVITY FOR ALEXANDER, HELENA 22595 02/20/08 CHARGE 8250122 PREVACID 30MG CAPSULE DR (:COPAY) 0,,2/2.0/08 CHARGE 02/20/08 eF~ARGE 02/20/08 02/20/08 D2/20/'08 C~:TARGE -CHARGE ~;eHARGE 822266'5 .8218208 8212'9:8 3 ,,R~ 12~~8:T ;821298'0 u ;,. ~s~U~4~°s~~q-1_s 'LOUAZA "FORMER3~Y OMACOR" 1GM CAPSULE (RP:OMAC6R) (COPAY) 657:26-0425-27 POTASSIUM CHLORIDE lOMEQ CAPSULE SA (COE?AY) 58177-0001-09 GUISTWIT 28 RX GUISTWIT 28 RX 28.00 _~ _ - -- 2-8,00 GUISTWIT 28 ~2X 5.00 METOPROLOL SUCCINATE F/C GUISTWIT 28 RX 5.00 „~50MGTAB.SR 24H (CO'PAY) gb0.I8~~-.0282-01 'LE.'%A~'RO 20MG TABLET (CO~AY) ~ GUISTWIT 28 !RX" .. 28.00 00.45E-2020-O1 ~- ~'L18OSEMIDE 40MG TABLET GUISTWIT 28 ` RX 5.00 (COPAY) _ 00378-0216-10 _ /~ e~ `~i , 99.00 208.91 0.00 0.00 0.00 PREVIOUS BALANCE CHARGES SKIS MONTH FINANCE CHARGE = TRTAL CHARGES ' TGTACiPAYMENT$'& CREDITS 208.91 + 99.00 + 0.00 307.91 0.00 PHYSICIAN QTY TYPE TOTAL AMOUNT DUE 307.91 INH o82s05 Reorder From: MED-PASS' 800-438-8884 ~ I ,,a.,,,w„e,,,, Form # MP6941L Rev. 11/0 PINKER & ASSOCIATES PODIATRIC MEDICINE AND FOOT SURGERY MARK E. PINKER, D.P.M., F.A.C. F.A.S. MARK S. GOLEC, D.P.M. 47 BROOKWOOD AVENUE CARLISLE, PA 17013 (717) 243-2236 HELENA A ALEXANDER FOREST PARK HEALTH CENTER 7 0 0 ~v~IALNUT BOTTOM ROAD CARLISLE PA 17013 PINKER & ASSOCIATES 47 BROOKWOOD AVENUE CARLISLE, PA 17013 02/13/08 • 50182 DETACH THIS STUB AND RETURN WITH PAYMENT ~, f ~ rr~:, a ~ 1' • A[ ~ ~. K fl ~ S t~,y,: t t s . ~r y ~ r :~~, ~. 50182.0) 37.84101/03/08 37.84 ~' . `~ lh +~ ~~~. k. ~ ~ ~r r ~ dr~~ W FOR.';VOl 'CASH O] vnr ~~ a ; ,~.mayy . 'c~~a...~:.r.;... ii;. „'rw 'r ": Y J~~~v,~t!~~~4Y3 t .~'5~~: "t !. .fun."• • t -r f.. 02/13/08 50182 (1) ~ ?'µ n . i ~ I ~Y'. ~. .,, T t, ~ ~~ i ~ ~' s ~ '. ~ 4 t ' 1 t ~ , __ t~~,~ j," ~: . , ~ ~ ,`f ' j' j Eµ of 'I ~ r ~ ~r ~ 4} ` _ ~ ~ ~~ ~ ~. . M l ~ . ~(t +L ^ L. ~, !i , . '~, z _ ~ , F.: ,~ :.t~ F ~ , ~ ~ ~ 4 ~` t ~ ~ ~ ~} ~f ~..~ ' v, z h ~ ~ ~~~~ ~ ~ ~ ~~ r ! I I V ~i X S . F \ y1 '~t 1 \ ~r"11 ~ r y,.. s t~ }° ~ry ~~ ' =~ ,: .j R CONVENIENCE ~n?E ACCENT VISA, DISCOVER, TIASTERCri _] CHECK. IF "YOU =SAVE A QUESTION OR CODTCERN ABOUT' ..' T T TT (' P, - '~ TP. T C T.' (! T T T ~ -. fP U"G' : (1 F` F' T (' Ca' "~ d 2 - "~ 7 ~ ~, ~ .'. TOTAL DUE CURRENT __ 31-60 DAYS 61-90 DAYS __ 91 -120 DAYS OVER 120 DAYS 37.84 37.84; 0.00 0.00 0.00 G.OQ 3 7f 8 4 pAY THIS AMOUNT ASSOCIATED CARDIOLOGISTS 856 CENTURY DRIVE MECHANICSBURG, PA 17055 For Billing Questions Call: (717) 591-7122 For Toll Free Call: 1-800-845-1742 Patient Name: HELENA ALEXANDER ADDRESSEE: 0122-17 HELENA ALEXANDER 700 WALNUT BOTTOM RD CARLISLE PA 17013-3631 []VISA Lv ^M4STERCARD CARD NUMBER AMOUNT SIDNATURE ~ EXP. DATE 03/9 7/2008 $ 7.63 9 71326 -CHARGES AND Ct3EDITS MADE~.AFfER STATEMENT SHOW AMOUNT ~ ,7 ~ ~~ DATE~VJILL APPEAR ON NEXT-STATEMENT. PAID HERE ~ I~ MAKE CHECKS PAYABLE /'REMIT TO: ~ I~r~111,~~III~r~~IrI~J:~I~L~Ir~Lllll~~r~Ll~ri~Lllirr~i~;lf ASSOCIATED CARDIOLOGISTS 856 CENTURY DRIVE MECHANICSBURG, PA 17055 ] Please check bo x'rf above address is inc orrect or insurance a PLE ASE DETACH AND RETURN TOP POR TION WITH Information has changed, and indicate c hange(s),on reverse side. _ _ .; _ -. . -_ ____ _~_~, ;_. _ .. _ _ YOUR PAYMENT I N ENCLOSED ENV ELOPE _ `~ „ pt x H , ;,Dings Guar, ..• ~ldlt Ba~~e~ t ~ ~_ ~ ~ ~ ~ ~"' ~1 85-00 7r 3~~ 7 n3 ~ Y .. . _ _ . •~:: ~ ~. .~ .. . ~ r; SM fjr Y .. ,.7 ~ M '~'* f ~ ~ ~ "v~ _ '""~ 9t ~ r~ ,cam ~ ~ 1 t- t. ~ ~, r '~'k I '~ _ _ ~c x -., ,x Z '~ ~ t Y t ~ ~~ ~ ~. f ? r ~ if' t ~~ { fir. ~' + ~ ~ `T. ~- ".r ~ ~ ~ Y". ~ (/ ~, i ~ ' ~ ~ i ce V ~ m 2~ [ ~ . \., - I' .. MEDIGAP BLUE DENIED MEDICARE DEDUCTIBLE NON CD~/ERED Total Current 31-60;Days 61-90 days 9i-120 Day§ Over 120 Insurance: Balance Patient Balance ~ 7-63 $ 00 $ .00 $ .00 $ .00 :Account Balance I ~ 7.63 L_,BrtreaAlthouse~M;Ds FACC-(1941-1998) - Bawd L. Scher- .AGC Andrea U Wali, M.D.,,FACC n ~d~ ~ W~:D FACC - ~o ~ „L Coflors lvlic 'ae ~ D Bosak, M.D., FACC ~5~~g~KD O FACC '~°tSadkrtlan; r~ra ~rkl, M.D. Sfu~ E~'8 ; ~ D= FACC FSGAt .,,. Robert Q Aroh ~;C - . , Ra~~l .Dave, M.D. I~ennef~i.J-Nta`y~~r M'.D FACC; _ ~D'awdE~Nla~a ~ ~~ Sang~,m,M.D. _-Robetf AYSkotmc~Cl [Y:fT, FACE . - EdwardG. Bre- a ,., pCC - _._ - _ _ ~; ;y~ SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION ~~~~~~~ ~~~~ ~~~~~ ~~~~~ ~~~~~ ~~~~I ~~~~~ ~~~~~ ~~~~~~~~~~~ ~~~~ ~~~~ STATEMENT .Amount Due: I $7.63 ASSOCIATED CARDIOLOGISTS 656 CENTURY DRIVE MECHANICSBURG, PA 17055 All billing questions can be made between the hours of 8:30 AM and 4:00 PM. 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O..O U O ~',: Q r sA;filO '- ~~- W rn rn rn M W rn rn at cn '`A4 ~ ~ . ~: a WritE.,F~r'. ~,; ~ o W w n n ~ W p ° a W cn ro ~a t~ t o c r h y .1 i' O(R + ~ ' , w u ? o 0 0 o h 0 0 0 0 ~ ~ W ~m r - -~ - - ,"H ~, ro N ~ ` ~ a m ~ o m H ~ O ~A ~ o " N ~ ~ ~ v a+ W r~ ~ CV N ~ N N N . U ~-~- ri ~ ~ .:. ~ t~ m m~ o. N . C m E d ~' N' L C O m C C O m Q' ~. 3 c a~ ~~ m ro I y N L_ C O Ol C .~ m d a m 0 c M C N E T a a c y m m `N t U W 0 Z _ Darryl K. Guistwite, D.O., Inc. 56 Ashton Street Carlisle, PA 17015-6914 (717) 609-2639 HELENA A. ALEXANDER C/O JANET ARNOLD 128 BOSLER AVENUE LEMOYNE PA 17043 Darryl K. Guistwite, D.O., Inc. 56 Ashton Street Carlisle, PA 17015-6914 . - 03/13/08 03/13/08 . .- ~ •- 5295.0(1) 5295.0 Detach this stub and return with payment HELENA A. ALEXANDER ( 529 .0) 5295.0) 10/04/07 NURSING HOME EST. PATIENT 75.00 12/04/07 Ins Pmt-MEDICARE 40.58 12/04/07 Adjustment 24.27 12/05/07 Rebill-UNITED HEALTHCARE 0.00 02/13/08 Rebill-UNITED HEALTHCARE 0.00 03/13/08 Ins Pmt-UNITED HEALTHCAR 10.15 03/13/08 Payment - Thank You 10.15 03/13/08 Ins Pmt-UNITED HEALTHCAR 5.07 5.08 10/04/07 10/23/07 NURSING HOME EST. PATIENT 75.00 12/04/07 Ins Pmt-MEDICARE 40.58 12/04/07 Adjustment 24.27 02/13/08 Rebill-UNITED HEALTHCARE 0.00 03/13/08 Ins Pmt-UNITED HEALTHCAR 5.08 5.07 10/23/07 11/08/07 NURSING HOME EST. PATIENT 75.00 12/04/07 Ins Pmt-MEDICARE 40.58 12/04/07 Adjustment 24.27 0 2 /"1 ~ /~8, - :. -- tZeb ~ ~: l I7~~ I ED ~E17I~'1~~I CAE ;.~_ "~F."6 0 03/13/08 Ins Pmt-UNITED HEALTHCAR 5.08 5.07 11/08/07 11/29/07 NURSING HOME EST. PATIENT 75.00 01/03/08 Ins Pmt-MEDICARE 40.58 01/03/08 Adjustment 24.27 01/17/08 Rebill-UNITED HEALTHCARE 5.08 5.07 11/29/07 02/28/08 Ins Pmt-UNITED HEALTHCAR 12/13/07 NURSING HOME EST. PATIENT 75.00 01/10/08 Ins Pmt-MEDICARE 40.58 01/10/08 Adjustment 24.27 01/17/08 Rebill-UNITED HEALTHCARE 0.00 02/28/08 Ins Pmt-UNITED HEALTHCAR 5.08 5.07 12/13/07 01 08 08 NURSING HOME EST. PATIENT 100.00 ~ °~ Total Due Currenf 31 - 60 Days 61 - 90 Days 91-920 Days Over 120 Days .. ~ P/ease pay this amount '~ _, Darryl K. Guistwite, D.O., Inc. 56 Ashton Street Carlisle, PA 17015-6914 (717) 609-2639 HELENA A. ALEXANDER C/O JANET ARNOLD 128 BOSLER AVENUE LEMOYNE PA 17043 Darry( K. Guistwite, D.O., Inc. 56 Ashton Street Carlisle, PA 17015-6914 -_ ~~r ., 03/13/08 03/13/08 .• .- 5295.0(1) 5295.0 Detach this stub and return with payment. 01/31/08 Ins Pmt-MEDICARE 0.00 $75.18 was applied to your de uctible 01/31/08 Adjustment 24.82 02/28/08 Ins Pmt-UNITED HEALTHCAR 0.00 $75.18 was applied to your de uctible TOTAL F R HELENA A ALEXANDER ~~ 75.18101/08/08 100.54 -_ r .. _ - _._._~~--_ __ _ _ .- -.c-r . _ _ _ . _..~ _ _ _ _ -- Total Due Current 31 - 60 Days 61 - 90 Days 91 -120 Days Over 120 Days 100.54 100.54 0.00 0.00 0.00 ~ 0.00 100.5 Please pay this amount! Darryl K. Guistwite, D.O., Inc. 56 Ashton Street ~,,~~ Carlisle, PA 17015-6914 ~~"- (717) 609-26~,~, ~~ a Statement Date 05/09/08 HELENA A. ALEXANDER ~. ~. C/O JANET ARNOLD 128 BOSLER AVENUE 5295.0(1) LEMOYNE PA 17043 HELENA A. ALEXANDER ( 529 .0) 02/07/08 NURSING HOME EST. PATIENT 100.00 03/06/08 Ins Pmt-MEDICARE 42.56 $21.98 was applied to your de uctible 03/06/08 Adjustment 24.82 04/22/08 Ins Pmt-UNITED HEALTHCAR 16.31 02/27/08 NURSING HOME EST. PATIENT 100.00 03/06/08 Adjustment ~ 100.00 03/27/08 .Ins Pmt-MEDICARE 60.14 03/27/08 Adjustment 24.82 04/22/08 Ins Pmt-UNITED HEALTHCAR 7.52 ~.,, TOTAL F R HELENA A ALEXANDER ~~ a3~~~ .5' a~l~ P~ ~~~ ~~ Tofa/ Due Current 31 - 60 Days 61- 90 Days 91 -120 -Days Over 120 Days 23.83 23.83 0.00 0.00 0.00 0.00 ~~ •~y WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE STE#211 CAMP HILL, PA 17011 Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 PATIENT NAME:. HELENA ALEXANDER INSURANCE: UNITED HEALTH CARE - [ 871729991 MEDICARE B 2070758666 ODYSSEY HEALTHCARE 189187484 0800784 HELENA ALEXANDER 700 WALNUT BOTTOM RD CARLISLE, PA 17013 PATIENT NUMBER CALL NUMBER: DATE OF CALL: TIME OF CALL: CALLER: FROM: TO: REASON(S) FOR TRANSPORT INVOICE 1818 0800784 02/23/2008 ~~ 0 ~_ ~~~ EIviERGENCY MEDICAL SERVICES SUP INS1 FOREST PARK HEALTH CENTER CARLISLE REGIONAL MEDICAL CTR DYSPNEA ~;~~ ~~ DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT ALS EMERGENCY LEVEL 1 A0427 1.0 1274.23 1274.23 ALS MILEAGE A0425 1.0 11.89 11.89 SYRINGE (1000) A0394 1.0 1.00 1.00 CPAP PROCEDURE PACK A0422 1.0 94.23 94.23 EKG ELECTRODES (4PK) A0396 1.0 4.94 4.94 LASIX 1OOMG A0394 1.0 2.21 2.21 NEEDLES (ALL) A0999 1.0 1.11 1.11 Oxygen Administration A0422 1.0 58.96 58.96 Total Charges 1448.57 f I v DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Medicare Assignment Adjustment ~ I 04/04/2008 1078 17 Medicare Part B Payment ~ t ~ ~ 108770981 04/04/2008 . 296.32 \ Total Credits 1374.49 PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -~ 74.08 RETURNED CHECK FEE - $31.00 i WILL AND TESTAMENT OF HELENA A. ALEXANDER I, HELENA A. ALEXANDER, of Camp Hill, Cumberland County, Pennsylvania, being of sound mind, memory and understanding, -~ do make and publish this my last will and testament, hereby ~ _ revoking and making void all former wills by me at any t-t~~ 7 :~~ 'y, heretofore made. _-~? ~ ~ ' =--' r, ;. -' ~~~ ~' r = ~ -- --, And first, I direct that my funeral be conducted; Y`r~'~' -" ~ .- -- manner corresponding with my estate and situation in life=and r'-~ .,~; that all my just debts and funeral expenses be fully paid and satisfied as soon as conveniently may be after my decease. As to such estate as it hath pleased God to intrust me with, I dispose Of the same as follows: I direct that all my succession, inheritance, and estate taxes that may be imposed shall be paid by my Executors as costs of administration. I give, devise and bequeath all of my property, real, personal and mixed, of whatsoever kind and wheresoever situated, to my beloved husband, James G. Alexander. If my beloved husband, James G. Alexander, shall predecease me or fail to survive me by thirty (30) days, then I give, devise and bequeath all my property, real, personal and mixed, of whatsoever kind or wheresoever situated, to my friends, William Arnold and Janet Arnold in equal shares to share and share alike. And I hereby nominate, constitute and appoint my husband, James G. Alexander, as Executor of this my last will and testament. If he fails to survive me, I then appoint William Arnold and Janet Arnold as Co-Executors of this my last will and testament. In Witness Whereof, I, Helena A. Alexander, the Testatrix, have to this, my will, written on three sheets of paper, set my hand and seal, this ~ day of ~~ ~~ 1~~ A.D. One Thousand. Nine Hundred and Ninety-Seven (1997). ~s Signed, sealed, published and declared by the above named HELENA A. ALEXANDER as and for her last will and testament, in the presence of us, who have hereunto subscribed our names at her request as witnesses thereto, in the presence of the said Testatrix and each other. (WITNESS) ( WITNESS ) ..~k.. ,.~ , t~ '7 ~' COMMONWEALTH OF PENNSYLVANIA SS: COUNTY OF DAUPHIN /~ /~ ~ ~ ~ ~ j~ ~ and ,~ ~~~~~~~~ ~ ~~:,~~ ~-~,, 5. , the tes~a~rix and the witnesses respectively, w~ose names are signed to-the attached foregoing instrument, being first duly sworn, do hereby declare_to the undersigned authority that the testatrix signed and executed the instrument as her last will and that she has signed willingly (or willingly directed another to sign for her), and that she executed it as her free and voluntary act for the purposes therein expressed and that each of the witnesses, in the presence and hearing of the testatrix, signed the will as witness and that to the best of their knowledge the testatrix was at the time eighteen years of age or older, of sound mind and under no constraint or undue influence. r r. ~L. ` . Sworn. and subscribed to before me this ~.~ day of ~.~1 - ~~_~' , 1 997 No~~ary Pub~~c NOTARIAL SEAL S~JSAN E. PEFFLEY, Notary Public Lower Paxton Twp., Dauphin County DAv Commission Expires Sent. 27. 1997