HomeMy WebLinkAbout03-0918 PETITION FOR PROBATE and
Estate of~~/~ ~. ~ No.
also known ~ts To:
Deceased.
Social
Security No.
GRANT OF LETTERS
Register of Wills for the
County of
Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Y°ur petiti°ner(s), wh° is/are 18 years of age or/~l/)~.~ t.~; .~I~ ~
in the last will of the above decedent, dated
and codicil(s) dated
in the
named
,19__
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
. D,..ec, gendent was domiciled at death in ~--~~~ ~ Count~, Penns~,lvania with
~ st famtly or prtrxc~pal resi4ence at ~'-J~O,,'~?t~ ~~. ~, ~'~--~
~'~ (list street, number and ~uncipality) - /
Dec~rl~ent, then _~_~_ years of age, died ~ /,,~ 12~. Or0 ~,,
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
after execution of the will offered for probate; not the victim of a
incompetent: "'~_ ~/~:~ was killing and was never adjudicated
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property $ O -
(If not domiciled in Pa.) Personal property in Pennsylvania $
(If not domiciled in Pa.) Personal property in County $
Value of real estate in Pennsylvania $
situated as follows:
WHEREFORE, petitioner(s) respectfully re~es_t(s~ the probate of the last will and c6dicil(s)
presented herewith and the grant of letters
theron. (testamentary; administration ~..t.a.; administration d.b.n.c.t.a.)
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA 3
COUNTY OF _jr ss
Thc petitioner(s) above-named swear(s) or affirm(s) that the statements in thc foregoing petition arc
truc and correct to thc best c~f thc knowledge and belief of petitioner(s) and that as personal rcprescn-
tative(s) of the above decedent petitioner(s) will w_e~ admini~t.~)/~state according to law.
Sworn to or aff. irnged and subscribed ,~ ~~-~ ~/~
bef~e me this ~ day of / ~ ~ / ~ ~'
~~~~L Regts~r [ ~
-
No. c~/-~.-~- ~/~
Estate Of ~_~,~ r'~, ~, n~ c'~
DECREE OF PROBATE AND GRANT
, Deceased
OF LETTERS
AND NOW /x~°vO'~°~w ~'~J
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated 0~ r,~ ~q, ~3/c~ o
described therein be admitted to probate and filed of record as the last will of
~d Letters ~ ~ ~x ~
~e hereby granted to ~t~ ~ ~ ~ [ ~ ~ ~o'a~
~'c~.ax~, in consideration of the petition on
FEES
Probate, Letters, Etc ..........
Short_Certificates( )...' .......
_ .------------------~
~e- un'~nc~a/ion ................
TOTAL . ~
File~d~.... ~. ~ ............
ATTORNEY (Sup. Ct. I.D. No.)
ADDRESS
PHONE
105.8(}f RiB/ 9/86
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent tgling.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
~ Local Registrar
No. '~ Date
COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF OEATH
~. Cynthia R. Otto · 3 1 -- -- '
· GE( ....... , ~a,~oa ~ u~.,~ , O~E~ ..... ~,C, ~ ?~e_ I' 72 01 7153 '-~t~r 14. 2003
,,. H~ I,,~ ~ H~ E~,~,~i ~o.,~) I (,
' 1700 ~ket S~t ' .~s,~ z ,. .. Wi~
,. ~p H~ll. PA 17011
~'~') ,~.c~.~ ~rland ~ ,...~ ~ ~ Hill
NF~T'S~p~ ~ 11. H~rlett Sh~n
· ~. ~ ~. ~S 501 ~r~
~ms~ ,O~O~TO. I~ ............ ~Re~ ~t ~hanlcs~o. PA 17055
LAST WILL AND TESTAMENT OF CYNTHIA R. OTTO
I, CYNTHIA R. OTTO, of the Borough of Mechanicsburg, County of
2umberland, and State of Pennsylvania, being in good bodily health
md of sound and disposing mind and memory, and not acting under
uress, menace, fraud, or undue influence of any person whomsoever,
~erely calling to mind the frailty of human life, and being desirous
Df disposing of my worldly goods while I have the strength and
Dapacity so to do, I do make, publish and declare this my LAST WILL
AND TESTAMENT. I hereby revoke, cancel and annul all my former Will~
~nd Testaments, including codicils thereto, by me at any time made,
~nd declare this alone to be my LAST WILL AND TESTAMENT.
AS TO SUCH ESTATE AS IT HAS PLEASED GOD TO ENTRUST ME WITH IN
THIS LIFETIME, I DISPOSE OF THE SAME AS FOLLOWS, VIZ:
ITEM 1. I direct that my Executors hereinafter named pay and
discharge all of my just debts, funeral and testamentary expenses.
ITEM 2. I order and direct that I be buried in a lot which I
own situate in Rolling Green Cemetery, Camp Hill, Pennsylvania.
ITEM 3. Ail the rest, residue and remainder of my entire
estate, wheresoever situate and whatsoever it may consist of, I give
devise and bequeath, absolutely and in fee, to my dearly beloved
Husband, CREEDIN H. OTTO, SR. In the event that my dearly beloved
Husband dies with me in a simultaneous disaster or fails to survive
my death by thirty (30) days, then I give, devise and bequeath my
entire estate wheresoever situate and whatsoever it may consist of t,
CREEDIN H. OTTO, JR. and LINDA K. OTTO, share and share alike, per
stirpes.
CYNTHIA R. OTTO
1
ITEM 4. I hereby nominate and appoint CREEDIN H. OTTO, SR.
as Executor of this my Last Will. Should the Executor named fail to
qualify or cease to act as Executor, then I nominate and appoint
LINDA K. OTTO as Executrix in his stead.
ITEM 5. I direct that my personal representatives, as well as
their successors, shall not be required to give bond for the faithful
performance of their duties in any jurisdiction.
ITEM 6. I direct that all estate, succession, legacy,
inheritance or other transfer taxes, however designated that shall
become payable by reason of my death in respect of all property
comprising my gross estate for tax purposes, whether or not such
property passesunder this Last Will, shall be paid by my Executor out
of my residuary estate.
ITEM 7. I grant to my personal representatives herein named, in
addition to, but not in limitation of those powers vested by law, to
be exercised without prior application to or approval of any court,
the power and authority to retain indefinitely any property, to
invest and reinvest any assets or the proceeds derived from the sale
of assets, although said investments may not be of the character
prescribed by law, to sell, convey, assign, transfer and encumber any
property, to pay, settle or compromise all claims, to make
distribution or divisions in cash or in kind, and in general to
exercise all powers in the management of any property hereunder which
any individual could exercise in the management of similar property
owned in his own right, and to execute and deliver any and all
instruments and to do all acts which may be deemed necessary and
proper.
CYN~IA R. OTTO
.... END
2
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
ss
I, CYNTHIA R. OTTO ,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 that I signed it as my free and
voluntary act for the purpose therein expressed.
Sworn or affirmed to and acknowledged before me,
by
of
CYNTHIA R. OTTO
June
, the TESTATRIX, this 29th day
I" NOTARIAL SEAL
COLE£N H. GLESSNER, Notary Publ$c
Cumberland County
fqy Com~isstcm Expires Oan. 3,
Mechanicsburg, PA
My Commission Expires:
The preceding instrument consisting of this and two (2)
other typewritten pages, identified by the signature of the
TESTATRIX, was on the date thereof signed, published and
declared by CYNTHIA R. OTTO, the TESTATRIX therein named
as and for her LAST WILL AND TESTAMENT.
//AMES M. ' BACH
BARBARA ~. GLESSNER
Residing at 352 S. Sporting Hill Road
~echanicsburg, PA 17055
Residing at 352 S. Sporting Hill Road
Mechanicsburg, PA 17055
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA )
) ss
COUNTY OF CUMBERLAND )
We JAMES M. BACH and BARBARA A. GLESSNER, the
witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, do depose and
say that we were present and saw TESTATRIX sign and execute the
instrument as her LAST WILL; that she signed willingly and that she
executed it as her free and voluntary act for the purpose therein
expressed; that each of us in the hearing and sight of the
TESTATRIX signed the WILL as witnesses; and that to the best of our
knowledge the TESTATRIX was at the time 18 or more years of age, of
sound mind and under no constraint or undue influence.
Sworn or affirmed to and subscribed to before me by
JAMES M. BACH and BARBARA A. GLESSNER, witnesses, this
29th day of June
I NOTARIAL SEAL I
COLEEN #. GLESSNER, Notary Public
Cumberland County
I~y Cofl~issiofl Expires 3an. 3, 1994{
, 19 9Q
ARY PUB .......
Mechanicsburg, PA
My Commission Expires:
LAST
WILL
AND
TESTAMENT
for
Cynthia R. Otto
JAMES M. BACH
ATTORNEY AND COUNSELOR AT LAW
:~2 SOUTH SPORTING HILL ROAD
MECHANICSBURG, PENNA. 17055
T~.i. EPHONE (717) 737-2033
-~ COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21 _ 03 0918
COUNTY CODE YEAR NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
~- Otto, Cynthia Raudabaugh 172-01-7153
Z
~ DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR THIS RETUEN MUST BE FILED IN DUPLICATE WITH THE
ILl 10/15/2003 04/13/1915 REGISTER OF WILLS
I,LI (~F APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
~ N/A
Z
Z
0
0
r~l. Odginal Return
r--] 4. Limited Estate
r-~6. Decedent Died Testate (Attach copy of Will)
~--] 9. Litigation Proceeds Received
NAME
Linda K. Otto-Sanders
FIRM NAME (IrAppli~ble)
N/A
TELEPHONE NUMBER
(717) 697-5487
~-]2, Supplemental Re~um [] 3. Remainder Return (date of death prior Io 12-13-82)
[] 4a, Future Interest Compromise (dele of death af~e 12-12-82) [] 5, Federal Estate Tax Retum Required
~]7. Decedent Maintained a Living Trust (^~ o~py of'rust) 8. Total Number of Safe Deposit Boxes
[] 10. Spousal Poverty Credit (data ofde~ betwee, 12-31-§1 and 1-1-95) [] 11. Election to tax under Sec. 9113(A) (A~ch Sch O)
COMPLETE MAILING ADDRESS
501 N. Market Street
Mechanicsburg, PA 17055-3348
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Padnership or Sole-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
r'-~ Separate Billing Requested
7, Inter~Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)(10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
0.00
0.00
0.00
0.00
6,379.12
0.00
0.00
(8)
291.25
(11)
(12)
(13)
(14)
6,379.12
6,087.87
6,087.87
6,087.87
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18, Amount of Line 14 taxable at collateral rate
19. Tax Due
...................................................................... x .0 __. (15)
x .0 .... (16)
x .12 (17)
x .15 (18)
(19)
0.00
O.00
0.00
0.OO
0,00
Decedent's Complete Address:
STREE%ADDRESS ,
ManorCare HRC
1700 Msrket Street
cITYCamp Hill
I STATEpA
ZIP 17011
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B Prior Payments
C, Discount
(1)
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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.
Check box on Page 1 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.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5)
(5A)
(5a)
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
IF THE ANSWER
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? ...................................................................... [] []
If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. [] []
Did decedent own an "in trust fo(' or payable upon death bank account or security at his or her death? .............. [] []
Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ []
TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT
AS PARTOFTHE 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, con'ect and complete.
Dedaraiton o.f preparer othej, t[3an the personal representative is based on all informalton of which preparer has any knowledge,
ADleR
SIGNATUR[-OF 15REPARER OTHE~,~'f'HAN REPRESENTATIVE i DATE
ADDRESS
501 N. Market Street, Mechanicsburg, PA 17055-3348
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 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 0% [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 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)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1511 EX+ (12-99~
COMMONWEALTH OF PENNSYLVANtA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNEP. AL EXPENSES &
ADMINISTP. ATIVE COSTS
ESTATE OF FiLE NUMBER
Otto, Cynthia Raudabaugh 21-03-0918
Debts of decedent must be reported on Schedule [.
ITEM
NUMBER OESCRIPTION AMOUNT
5.
6.
7.
FUNERALEXPENSES:
Malpezzi Funeral Home - Charges for Services
$4,391.45 - Balance from Burial Trust $4,809.04
Funeral Luncheon
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
N ,, Linda K. Otto-Sanders
ame of Personal Representative,s)
Social Secudty Number(s)/EIN Number of Personal Representative(s)~
S~eetAddress 501 N. Market Street~
City Mechanicsburg State
Year(s) Commission Paid: N / A
Attorney Fees
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant N / A
Street Address
City State __ Zip
Relationship of Claimant to Decedent
~F~ntinel - Legal Advertising Ltrs.
~tan~W~berland Law Journal - Legal Ad.
Register of Wills, Cumberland
Tax Retum Preparer's Fees
Testamenta y
Co - Probate &Shor
Certificate
101.08
N/A
78.17
75.00
37.00
TOTAL (Also enter on line 9, Recapitulation $ 2 fl I. 2 5
(If more space is needed, insert additional sheets of the same size)
REV-150~ EX* (6-98)
.COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS,. & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Otto, Cynthia Raudabaugh 21-03-0918
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.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1
12/1/03 Check ~007147 From Malpezzi Funeral
Home
*(Balance from Irrevocable Burial
Trust ~123-0008142, in the amount
of $9,100.49 - Malpezzi Funeral Home
Charges were $4,391.45 for services)
$4,809.04 is the difference which
was returned to the EsLate.
12/5/03
11/17/03
Manor Care Residents Trust Account
Transfer from Checking Acct.
~2519-66763 to Estate Account
TOTAL (Also enter on line 5, Recapitulation) $
$ 4,809.04*
155.40
1,414.68
6,379.12
(If more space is needed, insert additional sheets of the same size)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUI~EAU OF FJNANCIAL OPERATIONS
OIVISION OF TNIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO IK)X 8488
HARRISBURG, PA 17105-8486
January 23, 2004
I,INDA K OTTO-SANDERS EXEC/ADMIN
~.ISTATE OF CYNTHIA R OTTO
501 N MARKET ST
MRCHANICSBUR(] PA 17055
Re: CYNTHIA OTTO
CIS #: 340146135
SSN: 172-01-7153
Date of Death: 10/14/2003
Dear Ms. Otto-Sanders:
I am in receipt of your correspondence dated January 21, 2004 regard~.ng
the above-referenced estate.
The Department has reviewed the information presented and agrees with
the accounting of the estate. Please notify ua of any change in
circumstances as they may change this agreement. Please make the check
payable to Commonwealth of Pennsylvania.
Thank you for your cooperation in this matter.
questions, please contact me,
If you have any
Sincerely,
Janet L, Brown
Claims Investigation Agent
717-772-6612
717-705-8150 FAX
ENV272 (1/96) 1422411 2110-1102
FIRST-CLASS MAIL' P, ERMIT NO. 9314 HARRISBURG PA
POSTAGE WILL BE PAID BY ADDRESSEE
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OFPUBLIC WELFARE
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG PA 17105-9095
NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED,STATES
i,,,lll,,,I,,,lili,,,,l,l,l,l,,ll,,,i,h,,hh,,il,I
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCe, AL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 171058486
January 13, 2004
LINDA K OTTO-SANDERS EXEC/ADMIN
ESTATE OF CYNTHIA R OTTO
501 N MARKET ST
MECHANI CSBL~RG PA 17055
Re: CYNTHIA OTTO
CIe #: 340146135
SSN: 172-01-7153
Date of Death: 10/14/2003
Dear Ms. Otto-Sanders:
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 conslderably 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
$138,209.95 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 $21,785.92, was incurred
during the last six months of the decedent's life; therefore, it is a Class
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 $116,424.03,
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.
Enclosure
Sincerely,
Janet L. Brown
Claims Investigation Agent
717-772-6612
717-705-8150 FAX
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FJNANCIAL OPERATIONS
TPL SECTION - CASUALTY UNIT
PO BOX 8486
HARRISBURG PA 1710~.,~486
January 13, 2004
STATEMENT OF CLAIM SUMMARY
Estate of OTFO, CYNTHIA
I N PATI E NT .00 .00 .00
OUTPATIENT .00 51.50 51.50
LONG TERM CARE 20,859.67 1'15,642,39 '136,502.06
DRUG 926.25 730.'14 1,656.39
· 21,785.92 116,424.03 138,209.95
January 13, 2004
STATEMENT OF CLAIM
I
HERITAGE MEDICAL GROUP
WATKIN FRESHMAN & NIPPLE
845 SIR THOMAS CT SUITE-3
HARRISBURG PA 19109
02101103 - 02/01103 05105103 3'10065038402 000000000000 78.00 tl.50
DIAGNOSIS 1: 4280 CONGESTIVE HEART FAILURE
DIAGNOSIS 2: 4139 ANGINA PECTORIS NEC/NOS
PROCEDURE: 993'12 SUBSQ NSG FAC CARE/DAY, EVA4. & MGMT RESPOND INADQ-MINOR COMP 25 MIN BEDSIDE
'PROVIDER SUB'TOTAL] HERITAGE MEDICAL GROUP 78.00 11.50
,' 01 1708683
January 13, 2004
STATEMENT OF CLAIM
I.~. ::'i!' I 340 146 135
WEST SHORE ADV LIFE SUP SVC
I
503 N 2tST STREET
CAMP HILL PA 17011 I
04117102 - 04/17102
DIAGNOSIS 1: 78559
DIAGNOSIS 2: 78900
PROCEDURE: W0017
08/12/02 219786145601
SHOCK WIo TRAUMA NEC
ABD PAIN, UNSPECIFIED SITE
ADVANCED LIFE SUPPORT (ALS) SERVICE
IpROv,DER,sUB I
WEST SHORE ADV LIFE SUP SVC
18 1173277
000000000000 343.78 40.00
WITHOUT TRANSPORT (PRE44OSPITAL)
· I 343.78 I 40.00
.January 13, 2004
STATEMENT OF CLAIM
I .XM 'I o o. C T.,A
ID",i:~. :i 'l 340146135
NEIGHBORCARE-¥ORK
7010. SNOWDRIFT ROAD #1
ALLENTOWN PA 18106
~ ~.D.~ L.. ,.....~.. :: .,L.~ .~, ,~
0g/02/02 - 0g/02/02 10/07102 225489707101 000000000000 t33.47
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
XPP OV 'D1
12.70
09118102 - 09118102 10114/02 226174237001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 35.80 17.21
09118102 - 09118/02 t01t4/02 226174236701
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 46.16 10,21
09118/02 ~ 09/18102 10114/02 226174236901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
OIAGNOSIS 2:
PROCEDURE:
000000000000 37,26 9.95
09/18/02 - 09/18/02 10114/02 226174216501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 8.02 5.57
09118/02 - 09118/02 101t4/02 226174221301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 24.85 9.60
09/30102 - 09130102 10/28102 227789814601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 133.47 t2.70
10116,'02 - 10116102 1tltt/02 228974132901
DIAGNOSIS I; PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 35.80 t7,21
January 13, 2004
STATEMENT OF CLAIM
NEIGHBORCARE-YORK
7010 SNOWDRIFT ROAD #t
ALLENTOWN PA 18106
10/16/02 - t0/16/02 t1111102 228974065701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 24.85 9.60
10/16/02 - 10/16/02 11111102 228974108901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 46.16 10.2t
t0/t6/02 - t0/16/02 111t1102 228974160601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 8.02 5.57
10/16/02 - 10/t6/02 11111102 228974150301
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 37.26 9.95
10/26/02 - 10/28/02 11125/02 230174481301
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 133.47 12.70
11108102 - 11106/02 12/09102 231788849901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 112.49 10.47
111t3102 - t1113102 12109102 231774570201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 37.26 9.95
11113102 . 11113102 12/06/02 231774437301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 24.85 10.42
January t3, 2004
STATEMENT OF CLAIM
NEIGHBORCARE-YORK
7010 SNOWDRIFT ROAD #1
ALLENTOWN PA 18106
t1113102 - 11113102 12/09102 231774489101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 8.02 5.57
11113/02 - 11113/02 12/09102 231774563301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 46.16 10.21
11113/02 - 11113102 12/09102 231774570301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 35.80 17,85
111t8/02 - 111tlV02 12/16102 232274969901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 25.63 22.96
ttl25/02 - t1/25/02 t2/23/02 232975328501
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 t33.47 12.70
12111102 - 12/11102 01106103 234670535201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 8.02 5.57
12/11102 - 12111102 01106/03 234670552801
DIAGNOSIS 1: PRESC PRESCRIPT]ON DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 37.26 9.95
12/11/02 - 12/11102 0tl06103 234670399901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 35.80 t7,85
L;~MML)NW I:=AL I H ~P-.: I-'I=NNLSYLVAN A: :
· ,.' DEPA ME O~' PL~BL[C LF. ARE~:::' -'.' ~'
January t3, 2004
STATEMENT OF CLAIM
NEIGH BORCARE-YORK
7010 SNOWDRIFT ROAD #1
ALLENTOWN PA 18106
12/11102 - t211tl02 01/06103 234670560901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ':
OO0OOOOO000O 24.85 9.63
1211tl02 - 12/11102 01/06103 234670106901
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE;
000000000000 46.16 10.21
12/20102 - t2120102 01/20103 236091044101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 133.47 12.70
t2J2t/02 - 12/21102 0t/20/03 236091044201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 8.99 8.70
12/30102 - t2J30102 01/27103 236475691401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 106.77 15.37
01105103 - 0t/05/03 02/03103 301096435701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 35.80 t8.66
01105/03 - 0tl05103 02/03103 301098435401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
0tl05103 - 0tl05/03 02/03/03 301098435601
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 46.16 18.21
000000000000 37,26 t7.95
I- ' " . .,,COMI~ONWEALTH OF PENNSYLVANIA-.
· ,: . ,,~ .... ::, ,?',. ' '"i~.' [JEP'ARTi~I'ENT::~F ~SUi~'LI'~WI~I'¢AR~''~.!~ ,:.,': ? ?,,,, ~'"
January13,2004
STATEMENT OF CLAIM
340146135
NEIGHBORCARE-YORK
7010 SNOWDRIFT ROAD #1
ALLENTOWN PA 18106
01105103 - 01/05103 02/03/03 301098435501 000000005000 25.14
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
t7.63
0t105103 - 0tl05103 02/03103 301098435801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 8.02 5.57
01124/03 - 01124/03 02/17/03 302473498201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
005000000000 106.77 23.37
02/02/03 · 02/02/03 03103103 303671977801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000005000000 47.69 18.26
02/02/03 - 02/02/03 03/03103 303672050701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
500000000000 38.40 17.99
02/02/03 - 02/02/03 03~03~03 303672015901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 8.02 5.57
02/02103 - 02/02/03 03103103 303672005501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE i
000000000000 25.80 17.06
02/02/03 - 02/02103 03103/03 303671901501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 35.80 18.66
January 13, 2004
STATEMENT OF CLAIM
NEIGHBORCARE-YORK r
7010 SNOWDRIFT ROAD #1
ALLENTOWN PA 18106
~' '% "~:"~ /*/"::I '' ':"' f~' ~'':' '~*:"~ '!"~¥'"" '**I '? "-" "'""~ ~ ~*' *~' ""
% ~E O~ SE~V~C~~
I
PAYMENt,. DATE -¥=- ?o~IGINA~CRN ~:- ~-.' A-I~J~J~TE~ CRr~ "~;:,'
02/21103 . 02121103 03/17/03 305470726601 000000000000
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
,'~SU~L'~H~RGEs AMOUN~ApPROVED
t06,77 23,37
03~02~03 - 03102/03 0313t103 306473802201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
35.80 24.97
03/02/03 - 03102103 03131103 306473772601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
03102/03 - 03102/03 03131103 30047374970'1
DIAGNOSIS 1; PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
000000000000
8.02 5.57
25.80 t7.63
03/02/03 - 03/02/03 0313'1103 306473758301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
47.69 t8.26
03/02/03 - 03102103 03/31103 306473772501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
38.40 17.99
031'17103 . 03/t7103 04/2t/03 308787397601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
03/t8/03 . 03/18/03 04114/03 307970353701
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
000000000000
8,71 1,67
9.82 6.03
Janua~ 13, 2004
STATEMENT OF CLAIM
NEIGHBORCARE-YORK
7010 SNOWDRIFT ROAD #1
ALLENTOWN PA 18106
03121103 - 03/21103 04/21103 308370268901
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
03130103 . 03130103 04/21103 308970613401
DIAGNOSIS t: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 1t0.08 23.58
000000000000 25.80 t7.63
03~30~03 - 03~30~03 04/21103 308970597001
DIAGNOSIS 1: PRESC PRESCRIPTION DRuGs
DIAGNOSIS 2:
PROCEDURE:
000000000000 47.69 t8.26
03130103 - 03/35/03 04/21103 308970534901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 35.80 24.97
03130103 - 03/30103 0412tl03 308970613501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 38.40 17.99
04/12/03 - 04/12103 05105/03 310370499801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 8.1t 5.61
04/18/03 - 04118/03 05/19103 311170392701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 110.08 23.58
04119103 - 04/t9103 05/19103 311170466601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 7.82 6.04
.......:~!.:.: COMMONWEALTH OFP.,EN.NSYLVAN1A
January 13, 2004
STATEMENT OF CLAIM
NEIGHBORCARE-YORK
70t 0 SNOWDRIFT ROAD #t
ALLENTOWN PA 18106
04/23103 - 04123103 05/19103 311374128201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 25.63 22.96
04/27/03 - 04127103 05/26/03 312090215601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 38.40 t7,99
04/27103 - 04~27~03 05/26/03 312090215501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 25.80 17.63
04/27103 - 04127103 05/26103 31209021540t
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 47.69 18.26
04127103 - 04/27/03 05~26~03 312090215701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 35,80 24.97
05/10103 - 05/10103 06/02/03 313170751101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 8.71 5.67
05116103 - 05/16/03 06116103 313972333201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 5.37 4.97
05/t6/03 - 05116103 06116/03 313972306201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 41.65 13.33
": ";. i! DI~AR~'ME'NT'OF ~UBL C ~ELF~E,L!;, : : -" ~'" ' ,, :.
January 13, 2004
STATEMENT OF CLAIM
NEIGHBORCARE-YORK
70t 0 SNOWDRIFT ROAD #1
ALLENTOWN PA 18106
05/16/03 - 051t6/03 06/t6/03 313972257201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 272.28 33.57
051t6/03 - 05116103 06/t6/03 313971754401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 t10.08 23.58
05/21103 o 05121103 06/16/03 314174661501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 35.80 24.97
05/21/03 - 05/21103 06/16/03 314174632101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 38.40 t7.99
05/2tl03 - 05121103 06/16/03 314174597401
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 40.44 t6.82
05/21103 - 05121103 06/16/03 314174588401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 25.80 17.63
05/21103 - 05/21/03 06/t6/03 314174588201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 8.29 8.10
06/21/03 - 05/21103 06/16/03 314174588101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 5.37 .97
COMMONWEALTH OF PENNSYLVANIA
· DE~R¥~EN~ O~-P~'~LIC WE'EFARE ?' '~:.i ']! ...
January 13, 2004
STATEMENT OF CLAIM
o o,
~..D ? *=il 340 146 135
NEIGHBORCARE-YORK
70t0 SNOWDRIFT ROAD #t
ALLENTOWN PA 18106
05121103 - 05121103 06/16/03 314174569601
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
05/21103 - 05/21103 06116103 314174652801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
t10.08 19.58
06115/03 - 06115/03 07/t4/03 316991677101
DrAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 25.80 t7.63
06/t5/03 - 06/15/03 071t4/03 316770848101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 5.37 4.97
06/15/03 · 061t5/03 07114/03 316991677001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 40.44 t5.00
06/15/03 - 06/t5/03 07114/03 316770900601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE;
000000000000 8.71 5.67
061t5103 - 06/15103 07114103 316770855501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 35.80 24.97
06115103 - 06/15/03 07114/03 316770776301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 110,08 23.58
000000000000 8,71 1.67
COMMONWEALTH OF PENNSYLVANIA
.';ii':'; ~; D~PARTMENT oF PUBLIC WELFARE
t
January13,2004
STATEMENT OF CLAIM
,340 t46 135
NEIGHBORCARE-YORK
7010 SNOWDRIFT ROAD #1
ALLENTOWN PA 18106
...' [
06/15/03 - 06/15/03 07114/03 316770661401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
07/13103 - 07113103 06/11103 319570524301
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
07113103 - 071t3103 08/t1103 319674604501
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
07113103 - 07113103 08111103 319674536801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
07113/03 - 01113103 08/t1103 319570042501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
07113103 - 07113103 08/ttl03 319570042301
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
07113103 - 071t3103 08/11103 319570603701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
07113103 - 07113103 08/11103 319570623301
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000050 38.40 t7.99
050000000000 5.37 4.97
000000005000 25.80 23,1t
000000005000 40.44 40.44
000050000000 110.08 23.58
000000000000 38.40 17.99
000000000050 35.80 24,97
000005000000 8.71 5.67
, ... COMMONWEALTH OF PENNSYLVAI~IA
,. ~' "DEi~RT'i~N~0F:~,U:~LC.':~E~FAi~E 2~i!' : .... "~.
: I
January 13, 2004
STATEMENT OF CLAIM
NEIGHBORCARE-YORK
7010 SNOWDRIFT ROAD
ALLENTOWN PA 18106
08/10103 - 08/t0103 09108/03 322588169501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
08/10103 - 08110103 09108/03 322674021801
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
08110103 - 08/10103 09108103 322588169601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
08/10103 - 08110103 09108/03 322588169401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
08/t0103 - 08110103 09108/03 322588169301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
08/10/03 - 08/10103 09108103 322370576401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
08/10103 - 08/10103 09108/03 322673986301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
09104103 - 09104/03 t 0106/03 325170278401
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 8.71 5.67
000000000000 40.44 15.00
000000000000 110.08 23.58
000000000000 35.80 24.66
000000000000 40.50 19.27
000000000000 5.37 4.97
000000000000 25.80 t7.81
000000000000 12.51 7.37
January 13, 2004
STATEMENT OF CLAIM
NEIGHBORCARE-YORK
7010 SNOWDRIFT ROAD #1
ALLENTOWN PA 18106
.... .~ ~ ,' .:, .,,~ ,:
I.AMOUNT'AP , >VEDI
09108/03 - 09108/03 t01t3103 325975041601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 40.44 15.00
09108103 - 09108/03 10113103 326174316701
DIAGNOSIS 1: pRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 26.51 23,71
09108/03 - 09108/03 10106/03 325274471101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 35.80 24,66
09108103 - 09~08~03 10106103 325274451101
DIAGNOSIS I; PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
09108/03 - 09106/03 10106103 325274409301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 40.50 19.27
000000000000 t10.08 23.58
09108103 - 09108/03 10106103 32527447t201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 8.71 5.67
09111103 - 0911tl03 16/06/03 325474177901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 12.51 3.37
09~20~03 - 09/20103 10113/03 326370734701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 6.74 5.95
January 13, 2004
STATEMENT OF CLAIM
NEIGHBORCARE-YORK
7010 SNOWDRIFT ROAD #1
ALLENTOWN PA 18106
· '"
10/02/03 - 10/02/03 11/03103 327970441201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
10/02/03,- 10102103 11103103 327970441301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000900000 83,02 20,03
10/02/03 - 10/02/03 11/02/03 327970435301
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 .'
PROCEDURE:
000000000000 25.30 t7,83
10/02/03 - 10/02/03 1tl03/03 327970398201
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 8,02 5.57
10102/03 - 10/02/03 11103103 327970368101
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 71.49 19.59
10107103 - 10/07/03 11103103 328170769001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 19.71 7.57
10111103 - 101t1103 111t0/03 328670435601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 t43.55 22.34
PRovIDER SUB TOTAL NEIGHBORCARE-YORK
· :, t9 1702886
I 5,050.89 I 1,656.39
000000000000 115.96 tl.29
January 13, 2004
STATEMENT OF CLAIM
340 t46 t35
MANORCARE HLTH SVCS CAMP HILL
ATTN MICHAEL MCCAFFERTY
2555 KINGSTON RD STE 200
YORK PA 17402
11101199 - 1tl30199
DIAGNOSIS 1
DIAGNOSIS 2
PROCEDURE
04103100 009098359601
000000000000 1,899.80 1,899.80
1~01~9 - 1~31~9
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
04103100 009098359701
000000000000 t,994.67 t,994.67
01~1100 - 0tl3t~0
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
04/03100 009098359401
000000000000 2,055.20 2,055.20
02101~0 - 02~29~00
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
04/03100 009098359501
000000000000 1,861.20 t,861.20
03~1100 - 0~31100
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
04/10100 009887794901
000000000000 2,055.20 2,055.20
04/0tl00 . 0~30~0
DIAGNOSIS1:
DIAGNOSIS2;
PROCEDURE:
05/15100 013290653901
000000000000 2,366.40 2,366.40
05~1100 - 0~31~0
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
06126100 017586796101
000000000000 2,270.34 2,270.34
06/01/00 - 06/30t00
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
07/t0100 018989901201
000000000000 2,166.40 2,166.40
January 13, 2004
STATEMENT OF CLAIM
MANORCARE HLTH SVCS CAMP HILL
ATrN MICHAEL MCCAFFERTY
2555 KINGSTON RD STE 200
07101100 - 0713t100
DIAGNOSIS 1
DIAGNOSIS 2
PROCEDURE
08107/00 021785965701 000000000000 2,485.57 2,485.57
08/01100 - 08/31100
DIAGNOSIS 1
DIAGNOSIS 2
PROCEDURE
09118/00 02589898580'1 000000000000 2,373.57 2,373.57
09101100 - 09130100
DIAGNOSIS I
DIAGNOSIS 2
PROCEDURE
t0109100 028086752201 000000000000 2,266.30 2,266.30
10101100 . 10131100
DIAGNOSIS 1
DIAGNOSIS 2
PROCEDURE
11/13100 031288913201 000000000000 2,479.59 2,479.59
t110'1100 - 11130100
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
t2J'11100 034589428401 000000000000 2,368.90 2,368.90
12/01100 - t2/31100
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
07102/01 118085389901 100588796901 2,504.79 2,504.79
0110110t - 01/3tl0t
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE;
021t210¶ '103992662201 000000000000 2,822.85 2,822.85
02/01101 - 0212810.1
DIAGNOSIS 1
DIAGNOSIS 2
PROCEDURE
03119101 107586222701 000000000000 2,434.80 2,434.80
January 13, 2004
STATEMENT OF CLAIM
I
MANORCARE HLTH SVCS CAMP HILL I
ATTN MICHAEL MCCAFFERTY I
2555 KINGSTON RD STE 200 I
YORK PA 17402 I
i
03/01101 - 03131101 04/t6/01 110387081301 000000000000 2,797.65 2,797.65
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
04/01101 - 04/30101
DIAGNOSIS 1
DIAGNOSIS 2
PROCEDURE
06/14/0t 113186624701 000000000000 2,659.60 2,659.60
05101101 - 05/31101
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
11105/01 130693853501 11598843520t 2,787.86 2,787.86
06/01101 - 06/36/01
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
11105101 130693853601 119089743601 2,667.48 2,667.48
07/01101 - 07131101
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
t1109102 231311009701 121685594601 3,3t3.47 3,313.47
06/01101 - 08/31101
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
t1109102 231311009801 125489257801 3,t38.47 3,138.47
0910tl0t - 09130101
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
11109102 231311009901 128588230501 3,006.78 3,006.78
10101101 - 10131101
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
11109102 231311010001 131089063801 3,075.23 3,075.23
COMMONWEALTH OF PENNSYLVANIA
January 13, 2004
STATEMENT OF CLAIM
I
340 145135
i
MANORCARE HLTH SVCS CAMP HILL
t
ATTN MICHAEL MCCAFFERTY
2555 KINGSTON RD STE 200
YORK PA 17402
DATE` OF SERVICE ;" PA N~ I~A~
,:::..
1110tl01 . 11130101
DIAGNOSIS 1
DIAGNOSIS 2
PROCEDURE
11109102 231311010101
12/01101 - t213110t
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
0t107102 200486126401
0tl01102 - 01131102
DIAGNOSIS 1
DIAGNOSIS 2
PROCEDURE
11109102 231311010201
02101102 - 02~28~02
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
03111102 206786868601
03/0t102 - 03131102
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
04/06/02 209591162701
04/01102 - 04130102
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
05/13102 212990572501
06/0t/02 - 05131102
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
06/10~02 2t 5890293901
06~01102 - 06/30102
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
07115102 21898926080 t
134189314801 2,945.58
2,945.58
000000000000 2,739.83 2,739.83
000000000000 3,136.91 3,136.91
000000000000 2,324.15 2,324.15
000000000000 3,283.85 3,283.85
000000000000 3,146.75 3,146.75
203987235301 3,136.91 3,136.9t
000000000000 3,075.23 3,075.23
,. COMMONWEALTH Q.F PENNSYLVANIA
" ...:'": ,i' . "..;." ..,:-'~,..:"~)Ep~,~M~NT ~F.]~UBLI~ WEI~FARE:'
January 13, 2004
STATEMENT OF CLAIM
i'l~ .'.;' :~ 340 146 135
MANORCARE HLTH SVCS CAMP HILL
ATTN MICHAEL MCCAFFERTY
2555 KINGSTON RD STE 200
YORK PA t7402
· "^, ,..
07101102 - 0713t102
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
09130102 227085355101 222187859801 3,773.03 3,773.03
08/0tl02 - 08131102
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
09130102 227085355201 224990004601 3,773.03 3,773.03
09101102 - 09130102
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
t0107102 227786658701 000000000000 3,620.15 3,620.15
t0101102 - t0131102
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
ttlt1102 231287074101 000000000000 3,679.t0 3,679.t0
11101102 - 1tl30102
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
t2109102 234185809901 000000000000 3,529.25 3,529.25
12/01102 . 12131102
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
01/13103 301098077701 000000000000 3,679.10 3,679.10
0tl01103 - 01131103
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
02/10103 303887301601 000000000000 3,460.36 3,460,36
02/01103 - 02/28/03
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
03110103 306589919701 000000000000 3,026.68 3,026.68
COMMONWEALTH OF PENNSYLVANIA
· . ~)E'PARTMENT OF PUBL C WELFARE
,¥,, :,; .;? ',, ,, ~ , -, . ,, :..,:,. .~. :, ,,,~
January 13, 2004
STATEMENT OF CLAIM
34O 146 135
·
I
MANORCARE HLTH SVCS CAMP HILL
ATTN MICHAEL MCCAFFERTY
2555 KINGSTON RD STE 200
YORK PA 17402
..... . . · ~' ,...::' :"; ...:. /., '? ,?.' 'L' ,.;:'., -.'" '.?=;? ,*'~-; r*'~" "~ ':'~' ":' :~ '.:.' ':' ''-' "' " '"" ' "" " , "
03101/03 - 03/31/03 04/07/03 309489858101 00000000050o 3,460.38 3,460.36
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
04/01103 - 04130103
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
05112/03 312889575901 000000000000 3,492.90 3,492.90
05101103 - 05131103
DIAGNOSIS 1
DIAGNOSIS 2
PROCEDURE
06/09103 315788629801 000000000000 3,237.06 3,237.06
06/01103 - 06130103
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
07114/03 319287807801 000500000000 3,383.90 3,383.90
07/01103 - 07131/03
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE;
08/1 t103 322089612701 000000000000 3,530.73 3,630.73
06/01103 - 08/31103
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
09108103 324790166001 000000500000 3,530,73 3,530.73
09101103 - 09136/03
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
10/13~03 328296180801 000000000000 2,894.45 2,894.45
COMMONWEALTH OF, PENNSYLVANIA
' '. '~,. :~:' ..: D'~P,~RT~ENI'OF P~BL'I'C WrY'[FARE . ::.. '
January t3, 2004
STATEMENT OF CLAIM
MANORCARE HLTH SVCS CAMP HILL
i A'I'rN MICHAEL MCCAFFERTY
2555 KINGSTON RD STE 200
YORK PA 17402
10101103 - 10113103
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
11/10103 331098817501 000000000000 789.90 789.90
SU.'T0?*L "1
MANORCARE HLTH SVCS CAMP HILl.
36 0747669
136,502.06 136,502.06
JRD/June 30, 1992/17858
In Re: Estate of CYNTHIA R OTTO
Late of CAMP HILL BOROUGH
Estate No.: 21-03-918
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
PENNSYLVANIA
NO. 21-03-918
NOTICE OF FAILURE TO FILE CERTIFICATION AND REQUEST TO CONDUCT A
HEARING PURSUANT TO RULE 5.6(e), SUPREME COURT
ORPHANS' COURT RULE
Personal Representative: LINDA K OTTO
Counsel for Personal Representative:
Date of Grant of Original Letters: 11-05-2003
Date of Delinquency Notice: 02-15-2004
The undersigned, Glenda Farner-Strasbaugh, Register of Wills, in accordance with Rule
5.6, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court Division, Court of
Common Pleas of Cumberland County, that neither the above named personal representative nor
the above named counsel for the personal representative have filed with the Register of Wills or
Clerk of the Orphans' Court his, her or its certification required by Rule 5.6(e), Supreme Court
Orphans' Court Rule and that the requisite notice, pursuant to Rule 5.6(e), Supreme Court
Orphans' Court Rules, was given by the Register of Wills on FEBRUARY 15, 2004, and that
the ten (10) day notice to file the certification has expired. Accordingly, in accordance with Rule
5.6(e) the Court is hereby notified of such delinquency and the undersigned requests that a Court
conduct a hearing to determine whether sanctions should be imposed upon the delinquent
personal representative or counsel for the delinquent personal representative.
Date: 03-15-2004
Distribution:
Personal Representative
Counsel for Personal Representative
Estate File
A hearing is scheduled for .~c/at/r off4c' c/ at 7."_~ ~. ~ Courtroom No. 3. If the
Certification of Notice is fil~'d prior to the hearing date, the hearing will automatically be
cane elled. ,J/~ l/~~
Geor~e~Io£ , .3.' ~
BUREAU OF TNDZVZDUAL TAXES
TNHER/TANCE TAX Dz¥/SZON
DEPT. 180601
HARRTSBURG, PA 17118-0601
LXNDA K OTTO SANDERS
501 N HARKET ST
HECHANXCSBURG PA 17055
CONHONNEALTH OF PENNSYLVANZA DEPARTHENT OF REVENUE
NOTZCE OF ZNHERZTANCE TAX
APPRATSEMENT, ALLONANCE OR DZSALLONANCE
OF DEDUCTZONS AND ASSESSMENT OF TAX
])ATE O$-Zg-ZOOq
ESTATE OF OTTO
,, ,DAT~. OF DEATH 10-1q-2005
· ~ ~ ~ t=!~L~ NUHBER Zt 05-091S
COUNTY CUHBERLAND
ACH 101
t~:/~ '~' ~ [ Amount Remitted
REV-l;4? EX &FP (01-03)
CYNTHIA R
HAKE CHECK PAYABLE AND REN/T PAYNENT TO:
REGISTER OF HILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG TH~S LZNE ~.~ RETAIN LONER PORTZON FOR YOUR RECORDS ~
REV-15q7 EX AFP (01-03) NOT~CE OF INHERZTANCE TAX APPRAZSEHENT, ALLOWANCE OR DZSALLONANCE OF DEDUCTZONS AND ASSESSNENT OF TAX
ESTATE OF OTTO CYNTHIA R FZLE NO. 11 05-0918 ACN 101 DATE 05-29-200~
TAX RETURN NAS: ( ) ACCEPTED AS FZLED (X) CHANGED SEE ATTACHED NOTICE
RESERVATZON CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAZSED VALUE OF RETURN BASED ON: ORZGZNAL RETURN
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
$. Closely Held Stock/Partnership /ntarest (Schedule C) ($)
~. Mortgages/Notes Receivable (Schedule D) (~)
S. Cash/Bank Dapos~ts/M~sc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Total Assets
APPROVED DEDUCTIONS AND EXEHPTZONS:
9. Funeral Expanses/Adm. Costs/MAsc. Expenses (Schedule H) (9)
10. Debts/Mortgage L1abilitles/L1ans (Schedule Z) (10)
11. Total Deductions
12. Net Value of Tax Return
O0
O0
O0
O0
6~$79 12
00
00
(8)
NOTE: To ~nsure proper
credit to your account,
submit the upper portion
of th~s form w~th your
tax payment.
6,$79.12
291.15
1:58,209.95
(11)
(12)
1~8.;01.20
1:52,122.08-
1:5.
NOTE:
Charltable/governeental Bequests; Non-elected 911:5 Trusts (Schedule J)
Nat Value of Estate Sub~act to Tax (lq)
15 and/or 16, 17,
Zf an assessment Nas issued previousZy,
refZect fSgures that ~nc~ude the totaZ of ALL returns assessed to date.
(15) .00 x O0 =
(16) .00 x Oq5=
(17) .00 x 12 =
(28) .00 x 15 =
(19)=
AMOUNT PAZD
ASSESSHEHT OF TAX: 15. Amount of Line lfi at Spousal rate
16. Amount of Line lq taxable at Lineal/Class A rate
17. Amount of LAne lq at Sibling rata
18. Amount of Line lq taxable et Collateral/Class B rata
19. Principal Tax Due
TAX CREDITS:
PAYMENT RECEIPT DZ$COUNT (+)
DATE HUMBER ZNTEREST/PEN PAZD (-)
~F PAZD AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATZON OF ADDZTZONAL ZNTEREST.
.00
1:51,172.08-
18 and 19 ~ill
.00
.00
.00
.00
.00
TOTAL TAX CREDXT I
BALANCE OF TAX DUEI
ZNTEREST AND PEN.I
TOTAL DUE I
.00
.00
.00
.00
( XF TOTAL DUE XS LESS THAN $1, NO PAYMENT XS REgUXRED.
XF TOTAL DUE XS REFLECTED AS A "CREDXT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE S/DE OF THXS FORM FOR /NSTRUCTXONS.)
~EV-1470 EX (6-88)
INHERITANCE TAX
EXPLANATION
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE OF CHANGES
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG~ PA 17128-0601
FiLE NUMBER
DECEDENT'S NAME Cynthia Otto 2103-0918
ACN
REVIEWED BY ANITA MCCULLY 101
ITEM EXPLANATION OF CHANGES
SCHEDULE NO.
The Department of Public Welfare claim was not correctly reported on schedule I or carried
forward to the recapitulation page.
ROW Page
Name of Decedent:
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Cynthia R. Otto
Date of Death: October 14, 2003
21-03-918
21-03-918
Will No. Admin. No.
To the Register:
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on N o v e m b e r 18, 2 0 0 3:
Name Address
Creedin HeiseH Otto, Jr. 220 Silver Springs Road, Mechanicsburg, PA 17055
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except lq / A
Date:
March 29, 2004
Og
Address
501 N. Market Street
Mechanicsburg, PA 71055
%lephonepl~ 697-5487
Capacity: P~~ersonal Representative
Counsel for personal representative
Postage
Certified Fee
Return Reciept Fee
(Endorsement Required)
Restricted Delivery Fee
(Endorsement Required)
Total Postage & Fees
Postmark
Here
1. Article~ to:
D. is delivery address dilf~a~t from item 17
ff YES, enter deilvepj addrea~ beirut:
OTTO LINDA K
501 N MARKET STREET
MECHANICSBURG PA 17055
tr-I Insured Malt I'1 C.O.D.
7003 1010 0001 1203 8212
Cumberland County - Register Of Wills
One Courthouse Square
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 9/15/2005
OTTO LINDA K AKA
501 N MARKET STREET
MECHANICSBURG, PA 17055
RE: Estate of OTTO CYNTHIA R
File Number: 2003-00918
Dear Sir/Madam:
It has come to my attention that you have not filed the Status
Report by Personal Representative (Rule 6.12) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO.
103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing is due by: 10/14/2005
Your prompt attention to this matter will be appreciated.
Thank You.
Sincerely,
~~~
J
GLENDA FARNER STRASB~UGH
REGISTER OF WILLS
cc: File
Counsel
Judge
\~
(~-
Register of Wi Us of Cumberland County
STATUS REPORT "(J1\1DER RULE 6.12
Name of Decedent:
Cynthia R. Otto
Date of Death:
October 14, 2003
2003-00918
Estate No.:
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following
with respect to completion ofthe administration of the above-captioned estate:
1. State wh$ilier administration of the estate is complete:
Yes M' No 0
2. If the answer is No, state when the personal representative reasonably believes that
the administration will be complete:
3. If the answer to No.1 is Yes, state the following:
a. Did t~ersonal representative file a final account with the Court?
Yes h1 No 0
b. The sep~rate ~rJ' Court No. (if any) for the personal representative's
account IS: ~
c. Did the person~ r;;:presentative state an account informally to the parties in
interest? Yes ~ No 0
Date:
c. Copies of receipts, releases, joinders and approval of fonnal or informal
accounts may be filed with the Clerk of the Orphans' Court and may be
attached to this report.
9/23/05
K. Otto-Sanders
J
In
Name
501 N. Market Street
Mechanicsburg, PA 17055
Address
L......
'.n
... ._~
(717) 697-5487
Telephone No.
Capacity: ~rsonal Representative
o Counsel for personal representative
.
c
{~ -,~;
c-<
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