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HomeMy WebLinkAbout10-10-08 15056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Coun Code Year File Number Bureau of Individual Taxes ty PO BOX 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 21 08 0531 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 174-20-9298 03/13/2008 09/24/1925 __ Decedent's Last Name Suffix Decedent's First Name MI !Markley ;Martha g _ _. (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI __ __ __. Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~; 1. Original Return 4. Limited Estate ~~ = 6. Decedent Died Testate (Attach Copy of Will) . _ 9. Litigation Proceeds Received „ .. 2. Supplemental Return ._,_. 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) . ~.., 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 0__ 8. Total Number of Safe Deposit Boxes _.;.... 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number r~ David A. Baric, Esq _ - _ _-„ ~ --5 (717) 249-68~3c~ `-' _; Firm Name (If Applicable) . ..._.. _ _... ~~ ~--"------ ~ ~ -~= --- --~~ - __ _. _ _ - REGISTER O~ Ilt?t1~.3~ USE ONt.Y t O'Brien, Baric & Schere - © ~ -. . First line of address . .. -- _ _.. ;_ -t 19 W. South Street _ _ _; __ - _ _ _ _ _ _. _, u~ Second line of address c:.' ~-' ,._ O City or Post Office _ DATE FILED _ _ State ZIP Code _. _..._... _ _ __ Carlisle ! PA 17013 Correspondent's a-mail address: dbarlC@ObS18W.COfT1 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. SIGf~T RE OF PERSON RESPONSIBLE FO (LING RETURN DATE 100 Brandywine PA 17037 ADDRESS ~ ( / 19 West South Street, Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY 15056051058 Side 1 15056051058 J 15056052059 1. Real estate (Schedule A) . ....................................... ....... _ ..................._.... ..... 1. _ _ __ 2. Stocks and Bonds (Schedule B) .................................. ..... 2.~~i 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages & Notes Receivable (Schedule D) ........................ ..... 4.! 5. Cash, Bank Deposits ~ Miscellaneous Personal Property (Schedule E) ... ..... 5. ', 28,647.81 6. Jointly Owned Property (Schedule F) C~:J Separate Billing Requested .. ..... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property m, ... , . _.... ,._ :, _ (Schedule G) ~:~."~ Separate Billing Requested... ..... 7. 8. Total Gross Assets (total Lines 1-7) ............................... ..... 8. 28,647.81 9. Funeral Expenses & Administrative Costs (Schedule H) ................ ..... 9. 3,204.92 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) ........... ..... 10. ' 31,557.84 11. Total Deductions (total Lines 9 & 10) .............................. ..... 11. ', 34,762.76 12. Net Value of Estate (Line 8 minus Line 11) ......................... ..... 12. ', ~-6,114.95). 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) .................... .... 13. 14. __ _. Net Value Subject to Tax (Line 12 minus Line 13) .................... . .... 14. ' ~ 6,114.95) . _~ _ .._..._.__._.._..._....__._,___....~..._.,..___._____...._..__~_._..~ __.w..._,__._ _. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES ._._._ __..~.:..: .._ ..._... ,,H .._ _...., .. 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 _ _ . 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 l4 taxable at collateral rate X .15 L 1 g, 19. TAX DUE ..................................................... ....19.! REV-1500 EX Decedent's Social Security Number Decedent's Name: Martha B Markley ' 174-20-9298 RECAPITULATION -~-.-_-_ •,--..-:-. -.--___.. _,...._.._._....__.._. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: File Number __ 21 08 ' ! 0531 DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER Martha B Markley 174-20-9298 STREET ADDRESS 442 Walnut Bottom Road CITY STATE zlp Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT 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 :......................................................................................... . ^ ^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? ............. . ^ ^x 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ................................. ...................................................................................... ^ . ^x 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 exemot 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)]. 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-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCI~IEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Martha B. Markley 21-08-0531 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) EV-1511 EX+ (12-99) SCHEDULE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Martha B. Markley 21-08-0531 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES:. t. .Eby Granite Works _ __ _ 110.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 1,000.00 Name of Personal Representative(s) ShaUne Markley Social Security Number(s)/EIN Number of Personal Representative(s) , street Address 100 Brandywine Lane City;lckesburg State'PA Zip .17037 Year(s) Commission Paid: '..2008 2. Attorney Fees 1,500.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City 'State' .Zip Relationship of Claimant to Decedent 4. Probate Fees 297.46 5. Accountant's Fees 6. Tax Return Preparer's Fees ~. Cumberland Law Journal (legal advertising) 75.00 s. The Sentinel (legal advertising) 222.46 TOTAL (Also enter on line 9, Recapitulation) $ 3,204.92 (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Martha B. Markley 21-08-0531 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 ~ Thornwald Home 3,021.94 2. Three Springs Family Practice 132.44 3. Commonwealth of Pennsylvania (DPW) 28,382.80 4. Ophthalmology and Surgical Institute Of Central PA 3.50 5. Philhaven 17.16 TOTAL (Aiso enter on line 10, Recapitulation) $ 31,557.84 (If more space is needed, insert additional sheets of the same size) WILL OF MARTHA B. MARKLEY i, Martha B. Markley, of Carlisle, Cumberland County, Pennsylvania, declare this to be my last Will and hereby revoke all prior Wills and Codicils. This Will is of little financial significance. It is a gift of love. Each person named in this Will was a child who enriched my life by their love they shared with me and now I wish to tell them this one time of my love for them which has been there since the first moment I saw them and will be there always. But little children grow up and are sometimes corrupted by adults. Jesus said "Suffer the little children to come unto me -and forbid them not, for of such is the Kingdom of Heaven. 1. I direct that all my just debts, funeral expenses, gravemarker and administrative expenses shall be paid from my residuary estate as soon as practicable after my death. 2. I direct that all inheritance, estate, transfer, succession and death taxes of any kind whatsoever which may be payable by reason of my death shall be paid out of my residuary estate. 3. I direct that my entire estate be distributed as follows: A. I leave 70% of my estate to my grandson Shaune K. Markley. Should Shaune K. Markley predecease me, his share shall go to his heirs. Should Shaune predecease me leaving no heirs, his entire share shall then go to the Christian Children's Fund at P.O. Box 26507, Richmond, Virginia 23261-6507;., B. I leave 10% of my estate to be divided equally to my step children Roger L. Markley, Marlin C. Markley, William F. Markley, Jr. and Charlotte Markley; LAW OFFICES OF STEPHEN J. NOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 yaw ~Q C. I leave 10% of my estate to be divided equally to my nieces Denise Girard, Leslie Bailey, Lisabeth Downs and Louella Anne McKee; D. I leave 5% of my estate to be divided equally to Lisa Markley, Janeile Carbaugh and Andrea Carbaugh; E. I leave the remaining 5% of my estate to the Christian Children's Fund of Richmond, Virginia. 4. I appoint Shaune K. Markley and Denise Girard, jointly, as Executors of this my last Will. If either Shaune or Denise shall predecease me or cease to act in such capacity, I appoint the surviving Executor to so serve alone. 5. The Executors of this Will shall have the power to distribute my estate in kind or in cash, or partly in either. 6. I direct that no Executors acting under this Will shat{ be required to enter bond in any jurisdiction. IN WITNE ER , I have hereunto set my hand this ~~ day of , 2005. ~) ~ Martha B. Markley LAW OFFICES OF ~PHEN J. HOGG i. HANOVER STREET SUITE 101 '.ARLISLE, PA 17013 v The preceding instrument consisting of this and two other pages was on the day and date hereof signed, published and declared by Martha B. Markley, as and for her last Will in the presence of us, who at her request, in her presence and in the presence of each other have subscribed our names as witnesses hereto. pl.s~j .- WITNESS LAW OFFICES OF STEPHEN J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 ACKNOWLEDGMENT State of Pennsylvania County of Cumberland ss I, Martha 6. Markley, the testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my last Will; that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Markle 2005. STEPHE CARLISLE MY COMMIES State ~~~ ~ - ~ Martha B. Markley Sworn to or affirmed a acknowledged r me by rtha B. y, the testatrix, this day of NOl''ARIAL sEAL N J. NOGG, NOTARY PUBLIC Nota Public/Attorn BORO. CUMBERLAND CO., PA rY ION EXPIRES SEPTEMBtR 3, 2006 AFFIDAVIT of Pennsylvania ss County of Cumberland We, '~ and ~(.ai5 ~ ~2~ ,the witnesses whose ames are signed to the attached or for going instrument, being duly qualified according to law, do depose and say that we were present and saw the testatrix sign and execute the instrument as her last Will; that the testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the testatrix signed the Will as a witness; and that to the best of our knowledge the testatrix was at that time 18 or more years of age, of sound mind and under no constraint or due influence. 2 worn to orl~%r~e and scribed to be/ forme me by witnesses, this ay of %G ~2~A05. LAW OFFICES OF TEPHEN J. HOGG 19 S. HANOVER STREET Publ SUITE 101 NOTARULL SEAL CARLISLE, PA 17013 STEPHEN J. NOGG, NOTARY PUBLIC CARLISLE eORO. CUMBERLAND CO., PA MY COMMISSION EXPIRES SEPTEMBER 3, 2005 Q M&TBank 499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12 Law Offices of O'Brien Baric & Scherer 19 West South Street Carlisle, Pennsylvania 17013 Re: Estate of Martha B Marklev Social Security: 174-20-9298 Date of Death: March 13, 2008 Phone (888) 502-4349 Fax (302) 934-2951 September 25, 2008 Dear Sir or Madam: Per your inquiry dated September 24, 2008, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: Type of Account Account Number Ownership (Names o~ Opening Date Balance on Date of Death Accrued Interest Total Checking Account 1079158 Martha B Markley 08/31/90 Closed 07/10/08 $28, 647.81 0.00 $28, 647.81 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 andlor reimbursement of funds, etc., please contact our Stonehedge Office # 717-240-4524. Sincerely, ~~~ ~'~ Nancy Clagett Records Management 00 Account: Markley, Martha B. (211385) Program: Consult-Older Adult Admit Date: 02/02/2006 Discharge Date: Statement Date: September 5, 2008 Please Pay This Amount: $17.16 Due Date: September 20, 2008 Amount Enclosed: $ MARTHA MARKLEY 100 BRANDYWINE LANE ICKESBURG, PA 17037 3399-45 Gard t~ Exp I}ate: Sig~dture: Prir-ta d N emei ~O Please check this box if vour address or insurance has chaneed and then complete the form on the back of this paee• Payment Arrangement Exists? No : i'~ ~~ `'S~YfaIF~ eeJks~Pailtabl`e `Tu '~'-~ - A TYEiYT' ~'" --------------------------------------------------------------------------------------------- <Detach Here and Return Top Portion with Your Payment. Bottom Portioa is for Your Records.> Please mail'your payment and this prryment stub using [he supplied pre-addressed envelope (Ijyou are plying for multiple accounts with one payment, please include aU prryment stubs.) Summary Statement of Services (Detail on Reverse Side) Account: Markley, Martha B, (211385) ~ Due Date• September 20, 2008 Program: Consult-Older Adult Statement Date: September 5, 2008 Admit Date: 02/02/2006 Previous Statement Balance: $17.16 Discharge Date: Payments Received Since Last Statement: $0.00 Total New Charges: $0.00 _ Amount You Now Owe: $17.16 SECOND NOTICE Our records indicate that your account balance has not been-paid nor have payment arrangements been made. Your outstanding balance is due in full at this time. Payment in full or satisfactory payment arrangements must be made within fifteen (15) days to avoid further collection activity. Please remit the balancts.in full within fifteen (15) days using the enclosed reply envelope. Our office accepts checks and credit cards. If you are unable to.pay your balance in full or need assistance in understanding your statement, please contact our office at (717) 270-2413 or toll free at 1-800-932-0359, ext 2413 Monday -Friday 8:30AM - 4:OOPM. Someone will be glad to assist you. -- - Thank you_for choosing-Philhaven-for your-healthcare-services.----- - - - . -, - _ _ . _. _ _ _ _ _ 60-119 ,: rf1.i PO Box 550 Mt Gretna, PA 17064 ;Phone (888) 302-4710 Ext. 2413 or (717) 270-2413 Y r ~~~~ ~`,,,~ Business Office Hours: 8:30am - 4:OOpm M & F and 8:OOam - 8:OOpm T,W,Th ~,:, c ^~ ,:i . ::P!s~,~ trnz COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-6486 May 15, 2008 O'BRIEN BARK & SCHERER DAVID A BARK ESQUIRE 19 W SOUTH ST CARLISLE PA 17013 Re: MARTHA MARKLEY CIS #: 910181289 SSN: 174-20-9298 Date of Death: 03/13/2008 Dear Mr Baric: Please be advised that the Department of Public Welfare maintains a claim in the amount of $28,382.80 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $.00, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $28,382.80, is to be entered as a priority Class 6 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, f ~ ~ ~ ~ r Kelly I. Wells TPL Program Investigator 717-214-1870 717-772-6553 FAX Enclosure 19 tXi COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 May 15, 2008 STATEMENT OF CLAIM SUMMARY NAME. Estate of MARKLEY, MARTHA -ID 910 181 289 MEDICAL. CLASS 3 CLASS 6 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE .00 28,375.15 28,375.15 DRUG .00 7.65 7.65 REIMBURSEMENT TO DPW .00 28,382.80 28,382.80 COMMONWEALTH QF PEN@tSYLVANIA DEPARTFdENT OF PUBLIC 1i"JELFARE EIN- 23-6003113 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE May 15, 2008 STATEMENT OF CLAIM .NAME. MARKLEY,MARTHA ED 910 181 289 THORNWALD HOME 442 WALNUT BOTTOM RD ARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ,ADJUSTED CRN, USUAL CHARGES 'AMOUNTAPPROVED 03/02/06 - 03!31/06 07/03/06 20061594027770001 20061594027770001 4,905.30 3,938.50 DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX DIAGNOSIS 2 : 0 PROC CODE : 000000 04!01!06 - 04/30/06 07/03/06 20061594027780001 20061594027780001 4,905.30 4,019.80 DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX DIAGNOSIS 2 : 0 PROC CODE : 000000 05101106 - 05!31/06 07/03/06 20061594027760001 20061594027760001 5,068.81 4,183.31 DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX DIAGNOSIS 2 : 0 PROC CODE : 000000 06101!06 - 06/30/06 12111/06 20063184026180001 20063184026180001 4,905.30 4,019.80 DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX DIAGNOSIS 2 : 0 PROC CODE : 000000 07!01106 - 07/31/06 04/16/07 55071034576340001 55071034576340001 5,068.81 4,352.88 DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX DIAGNOSIS 2 : 0 PROC CODE : 000000 08/01/06 - 08/31/06 04116/07 55071034576690001 55071034576690001 5,068.81 4,352.88 DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX DIAGNOSIS 2 : 0 PROC CODE : 000000 09/01/06 - 09/26/06 04/16/07 55071034577010001 55071034577010001 4,251.26 3,507.98 DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX DIAGNOSIS 2 : 0 PROC CODE : 000000 PROVIDER SUB TOTAL THORNWALD HOME 34,173.59 28,375.15 03 100755529 0006 COMMONWEALTH OF PENNSYLVANIA: ? DEPARTMENT OF PUBLIC 1lVELFARE May 15, 2008 STATEMENT OF CLAIM NAME MARKLEY, MARTHA ID 910 181 289 PHARMERICA INC #22000 491A BLUE EAGLE AVE IARRISBURG PA 17112 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 03!10!06 - 03!10!06 07/17!06 25061745221160001 25061745221160001 7.65 7.65 DIAGNOSIS 1 : 0 NDC CODE : 00472017956 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS PROVIDER SUB TOTAL PHARMERICA INC #22000 7 65 24 100751181 0013 . 7.65 Ophthalmology & Surgical Institute of Central PA ~rY~LY1~ MARKLEY 100 BRANDYWINE LANE ICKESBURG, PA 17037 - 17037 Regarding Patient: MARKLEY, MARTHA B. / 0000673 Ophthalmology & Surgical Institute of Centra 5 Tyler Court Ste A CARLISLE, PA 17015 Date Transaction [Payer] Provider Amount 07/03/07 OPACIFIED CAPSULE SECONDARY TO CATARACT EXTRACTION WITH IMPLANT [FF]STOKEN, DREW J 900.00 07/10/07 MEDICARE ADJ -596.50 07/31/07 MEDICARE PAYMENT -242.80 05/13/08 INSURANCE PAYMENT -57.20 *** END OF STATEMENT *** THIS BILLING IS 80R YOUR FACILITY CHARGES NOT YOUR PHYSICIAN CHARGES. IF YOU HAVB QUESTIONS REGARDING YOUR STATEMENT, PLEASB CALL TH8 FACILITY DIRECTLY. YOUR PHYSICIAN'S OFFICB CANNOT HELP YOU WITH YOUR QUESTIONS FOR FACILITY CHARGES. THANK YOU. DUE DATE: 10/02/2008 TOTAL BALANCE: 3.50 DUE FROM PATIENT: 3.50 EBY GRANITE V1/~JRKS P.O. Box 187 Newville, PA 17241-0487 Phone: 717-776-5118 Cemetery Deceased Dat,.~= °f~ Other name on marker Location in cem. Type of Letters Person ordering ~ ~=' ) Address ~~~ l~Ci.L`JC1Qc,~~C~ e ,/13 ~ ~}..~ T£~~Sl~ir Phone ~~~~~~ ` ~ ~ Price 1 ~~ : l~l~ / ~~ ~ Bill _ Paid I agree that the above information is correct. Signed Per - ~ ~--~ When Sent ~~` (.tom ~ ~~ ~~' r~~ ~ ,~ ~ ~~-- ~~ ~~~~ Billed ~~~G ~~ INSCRIPTION FORM Date ~ ~ ~~ ''"'L'` Pay ) : : • ~ ~ : 7 ACy-~ fount Balance Immediately to Avoid Collection Agency ! ! ! ! ! '"'L''G • 1 4 ~ > ~ ' t :~ ' ~ ' ' ~ ' I ~ ~ ~ ' ~ ~ ~ C7 7 7 .) C C 7 7C C > ;7: 7. C ; 7 ~ C) C> C) 7~~C iCY.lC~::t iCX) C7 C> ;~Ll C:C 7C SC 7:7:...C )C 7C 7.).7.)C):.)C)C)C7C):X: f:C7 C JC•. T C 7.7. C•' :C)C7 :7C~C7 C ). 7. ): ) C) C •. 7; 7. 7C ~C ).7. 7 : i C 10/30/07 1 1 L SUB NURSING EVALJMANAG 2 99307 714.'0 36.00 11/2.0/07 Accept AssignAdj. -5..38. 11/20/07 Medicare Payment 24.50 05/2.9/08 PRIMESOURCE Payment 4..30 1.82'' 12/07/07 1 1 L SUB NURSING EVAL/MAN9G 2 99307 466.'0 36.00 01/07/0.8 Accept Assign Adj. -5.38 01/07/08 . Medicare Payment 24.50 05/29/08 PRIMESOURCE Payment 4.30 1.82'' 12/11/07 1 1 L 'SUB NURSING EVAL/MANAG 2 99307 290.3 36.00 01/07/08 Accept Assign Adj. -5.38 01/07/08 Medicare Payment 24.50 OS/29/Q8 . PRIMESOURCE Payment 4.30` 1.82' 01/14/08 1 1 E SUB NURSING EVAL/MANAG 2 99307 290.21 36.00° 08/01/07 Check-Personal Payment 1:31 01/29/08 Medic DEDUCT Payment 0.00 05/29/.08 PRIME DEDUCT Payment 0.00 34.69) 02/04/08 1 1 E SUB NURSING CARE EVAL/MAN 99308 465.9 60.00 02/11/08 02/11 Accept Assi gn Adj. ' -3.7'1' /08 Medic DEDUCT Payment 0..00 06/22/0$ PRIME DEDUCT Payment - 0.00 5G..29''~ 03/05/08 1 1 E .SUB NURSING EVAL/MANAG 2 .99307 714.0 36.00 03/20/08 . Medic DEDUCT Payment 0.00' 36.00 L-The 'PLEASE E-Thi bill PAY' li d includes unpaid co-pay or co-ins. Please i i Y make payment. s app e aga nst your deduct ble. . ou are respon sible to pay us. 7ATE LASTPAID AMOUNT • - ~ • - . ~ • - • i s - ~ - . . , , 08/01/07 1.31'' 0.00 0.00 92.29 38.33 1.82 0.00' 0.00 132.44 c,K€ THREE SPRINGS FAMILY PRACTICE s, ~ ' NecK 303 NORTH BALTIMORE AVE ® ~ ~ ~ wds~Ero: MT. HOLLY SPRINGS, PA 17065 132.44" Phc(717)-486-8550. PAT~~ 1-MARTHA B MARKLEY PRV~~ 1-DANIELS, MICHAEL 0, M.D. Acct~~ 1261 Date: 09./09/08 Page 1 of 1 Statement United Church of Christ Homes Thornwald Home 442 Walnut Bottom Road C,'arlisle, PA 17013 Statement Date: 09/01/2008 5haune Markley 100 Brandywine .Lane Ickesburq, PA 17037 Dtte Date: 04/25/2008 Re: Martha B Markley Account Nr: 966 Date Description Days Rate Charges Payments Balance (want -----------------------....--T----------------------------------------------------- BALADICE FORWARD 03/0.9/0 PAYMENT 03/01/08 Room & Board - Semi 31 226.00 03/12/08 Medical Equipment R 1.00 2'1.88 03/12/08 Inconti nence Suppli 1.00 14.25 03/12/08 Medical Supplies 1.00 123.05 03/31/08 Room & Board - Semi 12 226.00 9,273.46 9,273.46 2, 116.'0 '7, 7.56.76 -7,006.00 150.76 21.88 172.64 14.25 186.89 123.05 309.94 2,712.00 3,OZ1.94 ~G 7 31 ~ ~lo~ (00/[00 ~ ;;V3 LO ll 8002/ll/60