The URL can be used to link to this page

Home My WebLink About12-30-0815056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 21 08 0491 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 04/15/2008 ''10/13/1910 Decedent's Last Name Suffix Decedent's First Name MI STENINGER ',HARRISON ' M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL INAPPROPRIATE OVALS BELOW ,, 1. Original Retum THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Retum ~~;~~ 3. Remainder Return (date of death prior to 12-13-82) _ 4. Limited Estate ., ,.~, 4a. Future Interest Compromise (date of w,. _,, 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate ,; 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death ~~„ 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 ,LINDA J. OLSEN, ESQUIRE ' (717) 232-1851 Firm Name (If Applicable) ._ _ _ ., _. __... - - - - REGISTER OF WILLS USE ONLY KILLIAN & GEPHART, LLP _ _ _ ~~ First line of address _~ `" ' 218 PINE STREET ~~ -% ~-.3 Second line of address O ~ P . 0, BOX 886 ~ , ~ ~ ~ ~- City or Post Office State ZIP Code DATE FI ED -x.. -- -, _ _ ,, ~ _ , 'i .. HARRISBURG ' PA 17108-0886 ~ --: __ _ _ w Correspondent's a-mail address: 1 j OISen@kllllangephart . com 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. SI TURE OF PERSON R IB OR FILING RETURN DATE ADpaRfrry Steninger, Ex utor, 1357 Pennscott Drive, Landisville, PA 17538-1816 SIGN U OF PREPARE~OTHE RE'I~RESENTATIVE DATE _ S Lin a J. Ols , Esq., Killian & Gephart, LLP 218 Pine Street, PO Box 886, Harrisburg, i PLEASE USE ORIGINAL FORM ONLY 17108-0886 Side 1 15056051058 15056051058 REV-1500 EX Decedent's Names HARRISON ~_~ Wn~...,. RECAPITULATION 1. Real estate (Schedule A) .......................... ................... L ' 0.00 2. Stocks and Bonds (Schedule B) .................... ................... 2.' 0.00 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. 6. Jointly Owned Property (Schedule F) <°„°;`„~ Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ';,,"`°a Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1-7) .................................... 8. 9. Funeral Expenses 8~ Administrative Costs (Schedule H) ..................... 9. ': 10. Debts of Decedent, Mortgage Liabilities, 8~ Liens (Schedule I) ................ 10. 11. Total Deductions (total Lines 9 & 10) ................................... 11. 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. -78,281.41 13. Charitable and Governmental 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. 0.00 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a}(1.2) X .0_ 15. ' 0.00 . "e ... ..~~.. _ ,~.~_. 16. Amount of Line 14 taxable .~ . i at lineal rate X ,0 _ ' 16. 0.00 .. _. ti...,..~.,.~ 17. Amount of line 14 taxable ...... .._ .. ` at sibling rate X .12 17. 0.00 ', 18. Amount of Line 14 taxable at collateral rate X .15 ___ 18, _ _ _ . 0.00 19. TAX DUE ................................... ...................... 19. 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 1505 REV-1500 EX Page 3 Decedent's Complete Address: Flle Number 1~ 21... 08 0491 DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER Harrison M Steninger STREET ADDRESS Green Ridge Village 210 Big Springs Road CITY STATE ZIP Newville PA 17241 Tax Payments and Credits: 1. Tax Dins (Page 2 Line 19) 2. CreditslPayments 0.00 A. Spousal Poverty Credit B. Prior Payments 226.80 C. DiscAUnt 0.00 3. InterestlPenalty if applicable D. Interest E. Penalty 0.00 0.00 (1) Total Credits (A + B + C) (2) Total InterestlPenalty (D + E) (3) 4. tf 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. (56) Make Check Payable to: REGISTER OF WILLS, AGENT o.oo 226.80 0.00 226.80 0.00 0.00 0.00 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................... ...... ^ 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, benefds 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? .................................................................................................................. ...... ^ ^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) (i)]. The statute des not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disdosure of assets and filing a tax return are still applicable even if the surviving spouse is the only benefdary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child iwenty-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 benefidaries 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 isdefined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adopfion. REV-1512 E:X+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER HARF;ISON M. STENINGER 21-08-0491 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. (If more space is needed, insert additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 1 7 7 05-8486 November 3, 2008 LARRY STENINGER ADMIN INSTATE OF HARRISON STENINGER 1357 PENNSCOTT DR LANDISVILLE PA 17538 Re: HARRISON STENINGER CIS #: 660185350 SSN: 205-09-3663 Date of Death: 04/15/2008 Dear Mr. Steninger: Please be advised that the Department of Public Welfare is attempting to recover the monetary value of any and all eligible assets in the subject estate. Although the amount in the estate may be considerably less than that which is owed to the Department, our claim is against the estate, no one else. Your responsibilities, as the primary next of kin/administrator/executor, is to advise the Department of any assets in the estate and to insure that the remaining money, after all funeral and administrative costs are deducted, is sent to the Department. The Department of Public Welfare maintains a claim in the amount of $78,281.41 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 $32,489.95, 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 $45,791.46, is to be entered as a priority Class 6 claim against the estate. Please acknowledge receipt of this letter and advise 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, Karen P. Georgoulis Claims Investigation Agent 717-214-1283 717-772-6553 FAX Enclosure ?~ r. I , , .~ ,_,4, ~~: ~~ 1 i COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 November 3, 2008 STATEMENT OF CLAIM SUMMARY NAME Estate of STENINGER, HARRISON ID 660 185 350 MEDICAL CLASS,3 CLASS 6 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 32,452.14 45,518.70 77,970.84 DRUG 37.81 272.76 310.57 REIMBURSEMENT TO DPW 32,489.95 45,791.46 78,281.41 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE i EIN - 23-6003113 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 3, 2008 STATEMENT OF CLAIM NAME STENINGER, HARRISON I D 660 185 350 SWAIM HEALTH CENTER 210 BIG :SPRING RD EWVILLE PA 17241 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN 11/01/Ofi - 11/30/06 04/23/07 55071080036150001 DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT DIAGNOSIS 2 : 0 PROC CODE : 000000 12/01/OE~ - 12/31/06 04/23/07 55071080036140001 DIAGNOSIS 1 : 7812 ABNO RMALITY OF GAIT DIAGNOSIS 2 : 0 PROC CODE : 000000 01/01/07 - 01/31/07 06/11/07 69071374021810001 DIAGNOSIS 1 : 436 CVA DIAGNOSIS 2 : 0 PROC CODE : 000000 02/01/07 - 02/28/07 06/11/07 69071374021860001 DIAGNOSIS 1 : 436 CVA DIAGNO:>IS 2 : 0 PROC CODE : 000000 03/01/07 - 03/31/07 06/11/07 69071374021950001 DIAGNO:~IS 1 : 436 CVA DIAGNOSIS 2 : 0 PROC CODE : 000000 04/01/07 - 04/30/07 06/04/07 20071284032800001 DIAGNOSIS 1 : 436 CVA DIAGNOSIS 2 : 0 PROC CODE : 000000 05/01/07 - 05/31/07 07/09/07 27071644023600001 DIAGNOSIS 1 : 436 CVA DIAGNOSIS 2 : 0 PROC CODE : 000000 06/01/07 - 06/30/07 08/06/07 20071924028200001 DIAGNOSIS 1 : 436 CVA ADJUSTED CRN f USUAL CHARGES I AMOUNT APPROVED 55071080036150001 2,457.28 1,765.21 55071080036140001 2,106.24 1,557.45 69071374021810001 5,572.87 4,750.28 69071374021860001 5,033.56 4,210.97 69071374021950001 5,572.87 4,743.17 20071284032800001 5,175.00 4,576.50 27071644023600001 5,347.50 4,402.20 20071924028200001 5,175.00 4,229.70 DIAGNOSIS 2 : 0 PROC CODE : 000000 COMMONWEALTH OF PENNSYLVANIA _ DEPARTMENT OF PUBLIC WELFARE November 3, 2008 STATEMENT OF CLAIM NAME STENINGER, HARRISON ID 660 185 350 SWAIM HEALTH CENTER 210 BIG :iPRING RD EWVILLE PA 17241 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN 07/01/07 - 07/31/07 09/15/08 69082334020490001 69082334020490001 DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT DIAGNOSIS 2 : 0 PROC CODE : 000000 08/01/07 - 08/31/07 10/22/07 55072904286380001 55072904286380001 DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT DIAGNO;>IS 2 : 0 PROC CODE : 000000 09/01/07 - 09/30/07 11/05/07 55072904286890001 55072904286890001 DIAGNO~~IS 1 : 7812 ABNORMALITY OF GAIT DIAGNOSIS 2 : 0 PROC CGDE : 000000 10/01/07 - 10/31/07 09/15/08 69082334020540001 69082334020540001 DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT DIAGNOSIS 2 : 0 PROC CODE : 000000 11/01/07 - 11/30/07 12/31/07 20073414045750001 20073414045750001 DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT DIAGNOSIS 2 : 0 PROC CODE : 000000 12/01!07 - 12/31/07 02/11/08 20080144022510001 20080144022510001 DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT DIAGNOSIS 2 : 0 PROC CODE : 000000 01/01/08 - 01/31/08 03/03/08 20080394052440001 20080394052440001 DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT DIAGNOSIS 2 : 0 PROC CODE : 000000 02/01/08 - 02/29/08 04/07/08 27080724020620001 27080724020620001 DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT USUAL CHARGES f AMOUNTAPPROVED 5,347.50 5,496.21 5,347.50 5,348.01 5,175.00 4,439.00 5,788.01 5,194.51 5,601.30 4,661.00 5,788.01 4,847.71 6,103.28 5,572.18 5,709.52 4,769.22 DIAGNOSIS 2 : 0 PROC CODE : 000000 . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 3, 2008 STATEMENT OF CLAIM NAME STENINGER, HARRISON ID .660 185 350 SWAIM HEALTH CENTER 210 BIG ;SPRING RD EWVILLE PA 17241 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN 03/01/0!3 - 03/31/08 05/05/08 27081014020040001 27081014020040001 DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT DIAGNOSIS 2 : 0 PROC CODE : 000000 04/01/08 - 04/15/08 06/09/08 27081344020820001 27081344020820001 DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT DIAGNOSIS 2 : 0 PROC CODE : 000000 PROVIDER SUB TOTAL I SWAIM HEALTH CENTER 03 100749488 0012 USUAL CHARGES I AMOUNTAPPROVED 6,103.28 5,162.98 2,756.32 2,244.54 90,160.04 ~ 77,970.84 COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF PUBLIC WELFARE November 3, 2008 STATEMENT OF CLAIM NAME STENINGER, HARRISON I D 660 185 350 CONTINUING CARE RX 28 S 2ND ST tw1'VKT PA 17074 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN .ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVEO 01/05/Oi~ - 01/05/07 04/16/07 25070785698970001 25070785698970001 21 69 DIAGNOSIS 1 : 0 . 6.51 NDC CODE : 63304076301 AMOXICILLIN 875 MG TABLET - PENICILLINS 01/15/07' - 01/15/07 02/26/07 25070295559900001 25070295559900001 38 68 DIAGNOSIS 1 : 0 . 7,65 NDC CODE : 00378003001 CLORAZEPATE 3.75 MG TABLE T - ATARACTICS-TRANQUILIZERS 01/15/07 - 01/15/07 02/26/07 25070295683150001 25070295683150001 DIAGNOSIS 1 : 0 5.04 4.33 NDC CODE : 00904323392 CALCIUM WITH VIT D TABLET - ELECTROLYTES & MISCELLANEOUS NUTRIENTS 01/15/07 - 01/15/07 04/16/07 25070785693210001 25070785693210001 96 18 DIAGNOSIS 1 : 0 . 3.14 NDC CODE : 00173071204 AVODART 0.5 MG SOFTGEL - MISCELLANEOUS 01/15/07 - 01/15/07 04/16/07 25070785695250001 25070785695250001 78 59 DIAGNOSIS 1 : 0 . 25.17 NDC CODE : 00597005801 FLOMAX 0.4 MG CAPSULE SA - MISCELLANEOUS 01/15/07 - 01/15/07 04/16/07 25070785695740001 25070785695740001 300 71 DIAGNOSIS 1 : 0 . 5.06 NDC CODE : 00186504031 NEXIUM 40 MG CAPSULE - AN TI-ULCER PREPS/GASTROINTESTINAL PREPS 01/15/07 - 01/15/07 04/16/07 25070785696560001 25070785696560001 203 44 DIAGNOSIS 1 : 0 . 10.39 NDC CODIE : 00025152551 CELEBREX 200 MG CAPSULE - ANTIARTHRITICS 01!15/07 - 01/15/07 04/16/07 25070785698150001 25070785698150001 134 30 DIAGNOSIS 1 : 0 . 22.26 NDC CODEE : 63653117105 PLAVIX 75 MG TABLET - ANTIC OAGULANTS C - COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF PUBLIC WELFARE November 3, 2008 STATEMENT OF CLAIM NAME STENINGER, HARRISON I D 660 185 350 CONTINUING CARE RX 28 S 2ND ST EWPORT PA 17074 DATE OF SERVICE PA YMENT DATE ORIGINAL CRN ADJUSTED CRN. USUAL CHARGES AMOUNT APPROVED 02/14/Oi' - 02/14/07 04/16/07 25070785697200001 25070785697200001 203 44 DIAGNOSIS 1 : 0 . 10.39 NDC CODE : 00025152551 CELEBREX 200 MG CAPSULE - ANTIARTHRITICS 02/14/07' - 02/14/07 04/16/07 25070785698510001 25070785698510001 134 30 DIAGNOSIS 1 : 0 . 22.26 NDC CODE : 63653117105 PLAVIX 75 MG TABLET - ANTICOAGULANTS 02/14/07 - 02/14/07 05/07/07 25071035636600001 25071035636600001 38 68 DIAGNOSIS 1 : 0 . 7.65 NDC CODE : 00378003001 CLORAZEPATE 3.75 MG TABLET - ATARACTICS-TRANQUILIZERS 03/02/07 - 03/02/07 04/23/07 25070855424230001 25070855424230001 20 85 DIAGNOSIS 1 : 0 . 5 76 NDC CODE : 50383074120 ALBUTEROL 5 MG/ML SOLUTION - BRONCHIAL DILATORS 03/12/07 - 03/12/07 04/09/07 25070715730860001 25070715730860001 15 76 DIAGNOSIS 1 : 0 . 5.01 NDC COC)E : 57664049918 MIRTAZAPINE 15 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 03/16/07 - 03/16/07 04/16/07 25070785376220001 25070785376220001 203 44 DIAGNOSIS 1 : 0 . 19.01 NDC CODE : 00025152551 CELEBREX 200 MG CAPSULE - ANTIARTHRITICS 03/16/07 - 03/16/07 04/16/07 25070785376320001 25070785376320001 134 30 DIAGNOSIS 1 : 0 . 22,28 NDC CODE : 63653117105 PLAVIX 75 MG TABLET - ANTICOAGULANTS 03/16/07 - 03/16/07 04/16/07 25070785376390001 25070785376390001 78 59 DIAGNOSIS 1 : 0 . 25.17 NDC CODE : 00597005801 FLOMAX 0.4 MG CAPSULE SA - MISCELLANEOUS ' ' ~ COMMONWEALTH OF,PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 3, 2008 STATEMENT OF CLAIM NAME STENINGER, HARRISON I D 660 185 350 CONTINUING CARE RX 28 S 2ND ST EWPOR7 PA 17074 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 03/16/07 - 03/16/07 04/16/07 25070785686470001 25070785686470001 DIAGNOSIS 1 : 0 38.68 7.65 NDC CODE : 00378003001 CLORAZEPATE 3.75 MG TABLET - ATARACTICS-TRANQUILIZERS 03/20/07 - 03/20/07 04/23/07 25070855485540001 25070855485540001 DIAGNOSIS 1 : 0 7.82 7.00 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 04/10/07 - 04/10/07 05/21/07 25071165318760001 25071165318760001 DIAGNOSIS 1 : 0 38.68 7.65 NDC CODE : 00378003001 CLORAZEPATE 3.75 MG TABLET - ATARACTICS-TRANQUILIZERS 04/25/07 - 04/25/07 05/21/07 25071165340030001 25071165340030001 DIAGNOSIS 1 : 0 7.82 7.00 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 05/14/07 - 05/14/07 06/25/07 25071495687970001 25071495687970001 38 68 DIAGNOSIS 1 : 0 . 7.65 NDC CODE : 00378003001 CLORAZEPATE 3.75 MG TABLET - ATARACTICS-TRANQUILIZERS 06/29/07 - 06/29/07 08/06/07 25071905371470001 25071905371470001 DIAGNOSIS 1 : 0 38.68 7.65 NDC CODE= : 00378003001 CLORAZEPATE 3.75 MG TABLET - ATARACTICS-TRANQUILIZERS 08/17/07 - 08/17/07 09/17/07 25072345241380001 25072345241380001 38 68 DIAGNOSIS 1 : 0 . 7.65 NDC CODE:: 00378003001 CLORAZEPATE 3.75 MG TABLET - ATARACTICS-TRANQUILIZERS 09/07/07 •• 09/07/07 1 0/22/07 25072685399270001 25072685399270001 4 18 DIAGNOSISi 1 : 0 . 4.07 NDC CODE : 45802006070 BACITRACIN 500 UNITS/GM OINTMN - OTHER ANTIBIOTICS COMMONWEALTH OF PENNSYLVANIA l DEPARTMENT OF PUBLIC WELFARE November 3, 2008 STATEMENT OF CLAIM NAME STENINGER, HARRISON ID 660 185 350 CONTINUING CARE RX 28 S 2NC1 ST EWPOR.T PA 17074 DATE OF SERVICE PAYMENT DATE ORIGIN L A CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 09/07/07 - 09/07/07 11/19/07 25072965248810001 25072965248810001 7 82 DIAGNOSIS 1 : 0 , 7.00 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 09/15/Oi' - 09/15/07 10/22/07 25072685400430001 25072685400430001 38 68 DIAGNOSIS 1 : 0 . 6.92 NDC CODE : 00378003001 CLORAZEPATE 3.75 MG TABLET - ATARACTICS-TRANQUILIZERS 10/02/07' - 10/02/07 11/19/07 25072965248850001 25072965248850001 7 82 DIAGNOSIS 1 : 0 . 7.00 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 10/08/07 - 10/08/07 11/19/07 25072965248940001 25072965248940001 7 82 DIAGNOSIS 1 : 0 , 7.00 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 10/19/07 - 10/19/07 11/19/07 25072965299110001 25072965299110001 38 68 DIAGNOSIS 1 : 0 . 6.92 NDC CODE : 00378003001 CLORAZEPATE 3.75 MG TABLET - ATARACTICS-TRANQUILIZERS 11/07/07 - 11/07/07 12/24/07 25073315386620001 25073315386620001 38 68 DIAGNO~~IS 1 : 0 . 2.92 NDC COCIE : 00378003001 CLORAZEPATE 3.75 MG TABLET - ATARACTICS-TRANQUILIZERS 11/11/07 - 11/11/07 12/24/07 25073315384240001 25073315384240001 38 68 DIAGNOSIS 1 : 0 . 2.92 NDC CODE : 00378003001 CLORAZEPATE 3.75 MG TABLET - ATARACTICS-TRANQUILIZERS 12/03/07 - 12/03/07 01/07/08 25073455296930001 25073455296930001 7 82 DIAGNOSIS 1 : 0 . 7.00 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 3, 2008 STATEMENT OF CLAIM NAME STENINGER, HARRISON I D 660 185 350 CONTINUING CARE RX 28 S 2ND ST NtW I'UK I PA 17074 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 02/13/Ofl - 02/13/08 03/24/08 25080585647040001 25080585647040001 4.63 4.05 DIAGNOSIS 1 : 0 NDC CODE : 51079041720 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS PROVIDER SUB TOTAL CONTINUING CARE RX 2,111.84 310.57 24 100731447 0011