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HomeMy WebLinkAbout04-09-09J 15056051058 REV-1500 Ex (Oli-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Cade Year File Nurr~er INHERITANCE TAX RETURN -- Posox 2sosol 21 08 0796 Hanisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 07/12/2008 01 /20/1938 Decedents Last Name Suffix Decedent's First Name MI Bender Janet W (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 O~ 1. Original Retum 2. Supplemental Retum 3. Remainder Retum (date of death 4. Limited Estate L 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received 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) prior to 12-13-82) 5. Federal Estate Tax Retum Required 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 8E DIRECTED T0 : Name Daytime Telephone Number Stacy B Wolf, Esquire (717) 241 44~Ej _..... Firm Name (If Applicable). ©...:....... ~,.. _.... _. _.. REGISTER O~V~LS USE (7RQY ~ , 5.+~' -. > WOIf & Wolf ~ -~ n ~ L : -, fa r First line of address ~ - "~ ~D ~' ':~ __ ~ t, ~ ~; ,-_~ -, 10 West High Street ~ ,~' ~=- -'o Second line of address ___ _ _J,~ N , ; ~--r~ __ F .. m City or Post Office _.._ __ .. . State ZIP Code ~ ............. DATE FILED . _, ___ 'Carlisle _ _ _ .. __. ! PA '..17013-2922 i _ __ Correspondent's a-mail address: StaCybWOlf@embargmall.COm Under penalties of perjury, I declare that I have examined this return, inGuding accompanying schedules and statements, and to the best of my knowledge and belief, a is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIG~N,IATURE OF PERSON~~E NSIBLE FOR FILING RETURN ~ DATE ~f- ~ Q ADDRESS 911 Burnthouse Road, Carlisle, Pennsylvania 17015 SIGNA--~~~~i"-{~` Py~~'~-- ~ TtiE~ESENTATIVE DATE" / / ~/ O / 10 West Hlth Street, Carlisle vania 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 REV-1500 EX Decedent's Name: Janet 15056052059 W Bender RECAPRULATION _~~._ 1. Real estate (Schedule A) . ............................................ 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. 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. I 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ~' ~~~ (Schedule G) t`"3 Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1-7) .................................... 8. 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) ................................... 11. 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 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. Decedent's Social Security Number _._ 1, 748.65 1,748.65 1,161.43 4,131.85 5,293.28 0.00 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 _...... . 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. ~. ~. _~ ~ ____ _ ~ ..~~__ _ __a......... Amount of Line 14 taxable : ___ at collateral rate X .15 18 19. TAX DUE ..................................................... .... 19.' 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 i 21 08 , 0796 _. .... ~_ DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER Janet W Bender 161-32-3545 STREET ADDRESS 1 West Penn Street, Apt. 517 CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Interest/Penalty if applicable D. Interest E. Penalty (3) (4) (5) (5A) (~) (1) Total Credits (A + B + C) (2) Total Interest/Penalty (D + E ) 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. 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. Make Check Payable to: REGISTER OF WILLS, AGENT 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, benefits or care? ....................................................... 2. If death occurred after Decemt~er 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)J. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1} (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0} percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a}(1}]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. 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) COMMONVNEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Janet W. Bender 21-08-0796 InGude the proceeds of litigation and the date the proceeds were received by the estate. All property Jointty-owned with right of survivorship must be disclosed on Schedule F to more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Janet W. Bender 21-08-0796 Debts of decedent must be reported on Schedule L ITEM NUMBER DESGRtPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 87.43 Name of Personal Representative(s) William & Erma Heiser Social Security Number(s)lEIN Number of Personal Representative(s) street Address 911 Burnthouse Road G;ty Carlisie _ state PA zip 17015 Year(s) Commission Paid: 2009 2. Attorney Fees 1,000.00 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 74.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) I $ 1,161.43 (If more space is needed, insert additional sheets of the same size) REV-1512 EX+ (12-08) Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERRANCE TAx RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Janet W. Bender 21-08-0796 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, includin g unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH _ 1' Carlisle Regional Medical Center 1,024.00 2. Carlisle Regional Medical Center 33.35 3. Kinetic Imaging, Inc. 11.21 4. Carlisle Cardiology Associates 256.41 5. Physician's Alliance Ltd. 358.46 6. Carlisle Physician Management 1,089.97 7. Alexander Springs Emer. Phys. 53.38 8. Blue Mountain Anesthesia Assoc. 78.96 9. Comcast 28 78 10. Embarq 43.43 11. AAC/Fingerhut 940.68 12. PPL 213.22 TOTAL (Also enter on Line 10, Recapitulation) ($ 4,131.85 If more space is needed, insert additional sheets of the same size. ' REV-1513 EX+ (11-OS) ~ Pennsylvania SCHEDULE ] DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Janet W. Bender 21-08-0796 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 2116 (a) (1.2).] ~ ~ ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 2113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. Carlisle Church of Christ, 971 Walnut Bottom Road, Carlisle, PA 17015 100% TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ If more space is needed, insert additional sheets of the same size. LAST WILL I, JANET W. BENDER, of the Borough of Carlisle, Cumberland County, Pennsylvania, declare this to be my Last Will and revoke any wills previously made by me. I. I direct that all my just debts, funeral expenses, all inheritance, estate and transfer taxes imposed upon my estate passing under my will or otherwise, shall be paid out of the principal of my residuary estate. II. I devise and bequeath my estate of whatever nature or wherever situated to the Carlisle Church of Christ, 971 Walnut Bottom Road, Carlisle, PA, 17013. III. I appoint William Heiser and Erma Heiser to be executors of this my Last Will. IV. I direct that my executors need not file bond in this or any other jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last will this 26th day of April, 2005. • SEAL) The preceding instrument consisting of one (1) page(s) was on the date thereof signed, published and declared by JANET W. BENDER, the testator herein, 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. ~: STATE OF PENNSYLVANIA COUNTY OF CUMBERLAND SS We, JANET W. BENDER, Frances H. Del Duca and Wanda K. Hunter, the testator and witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testator signed and executed the instrument as her Last Will and that she had signed willingly, and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testator, signed the will as witness and that to the best of her. knowledge the testator was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. ~ .~ ~estator Witness fitness f SUBSCRIBED, sworn to and acknowledged before me by JANET W. BENDER, the testator, and subscribed and sworn to before me by Frances H. Del Duca and Wanda K. Hunter this 26th day of April, 2005. " A ~ Notary Publ' ~Itfi of Penn aNa Nor~lla~ s~~~ SH^Iw-H~In.~E~I,'_P. Gt.~'~~,r;:~l, il~fary pt~l'ic ~/p~IN1p , ~~i1kVY11~ C~aaop~stbn moires l~jl t~, . 04/09/2009 wEO 13:07 FAX 7172490655 F&H TRU6T ~002l002 . ,. w~uw.fnth~~sto~l~ne.cam ~- .. ~ ~ - - - - TRUST Apri] E, 2009 1tE: Janet W Bender 1 w Penn St. Apt 517 Carlisle Pa 170]3 To whom It May Concern: This letter states that as of date of death 07/17J08; 7anct Bender had a balance of X600.00 in her account #34-57389_ Any further questiolls please feel free la contact me. Yours truly, Annetti J. ittgle Customer Service F & M Trust Company 14 North Hanover St Carlisle Pa 17013 717-249-1331 717-2646116 888-264-6116 P.O. Box 6010 Chambersburg, PA 17201-6010 - ' FINA.NCCAL'SO.LU'TIONS...~'FROM P.,EOPLE YOU KNOW 140 Sprint Drive Blountville, TN 37617 61539576 0 5029 WOLF & WOLF ATTORNEYS AT LAW 10 WEST HIGH STREET CARLISLE, PA 17013 NATHAN C. WOLF NCO FINANCIAL SYSTEMS, INC. MAR 04 2009 PHONE: 800-877-4127 OFFICE HOURS: MON - TUE - 8:OOAM-11:OOPM EST WED - THUR - 8:OOAM-8:OOPM EST FRI - 8AM-S:OOPM, SAT: 8AM-NOON EST Re: JANET W BENDER Creditor: CARLISLE REGIONAL MEDICAL CENTER Account #: 7811233 Balance: $1024.00 Our Account #: 61539576 Dear WOLF & WOLF ATTORNEYS AT LAW: We have been given authorization from JANET W BENDER to contact you. We are providing information for the above-referenced account. Should you have any questions, please contact us at the phone number or address listed above. Sincerely, NCO Financial Systems, Inc. This is an attempt to collect a debt. Any information obtained will be used for that purpose. This is a communication from a debt collector. Calls to or from this company may be monitored or recorded for quality assurance. NCO Financial Systems, Inc. 140 Sprint Drive Blountville, TN 37617 5029 NCO Financial Systems, Inc. February 10, 2009 Stacy B. Wolf, Esq. Wolf & Wolf 10 W. High Street r Calisle, PA 17013 RECEIVED FER ~ 3 ZQQg 507 Prudential Road Horsham, PA 19044 1-866-305-9426 Office Hours: 8:00 a.m. - 9:00 p.m. Monday through Thursday, 8:00 a.m. - 5:00 p.m. Friday, 8:00 a.m. - 12:00 noon Saturday Re: Your Client: Janet VV. !3e.nder Our Reference No(s). Creditor s 60269392 (kgport) Carlisle Regional Medical Center Account No.: 7807643 60034253 (kgport) Carlisle Regional Medical Center Account No.: 9398452 Dear Stacy B. Wolf, Esq.: Total Balance(s) $33.35 Closed We are in receipt of your inquiry regarding the above-referenced accounts. In response to your request for validation, enclosed please find the materials we received from the creditors that correspond to the above- referenced account 60269392. Please forward payment on the above accounts to NCO Financial Systems, Inc., P.O. Box 15273, Wilmington, DE 19850. Please be advised that the above-referenced account 60034253 is closed in our office. Further inquiry regarding the underlying debt may be directed to Carlisle Regional Medical Center. According to our files, we have not reported the above-referenced account to a credit bureau. Please be advised that NCO Financial Systems, Inc. cannot effect a change to how a.n_y other company or entity may have listed the account on your credit profile. We appreciate the opportunity to respond to your inquiry and to provide you with the enclosed documentation. Very truly yours, Regina Tracey Incoming Data Management This is an attempt to collect a debt. Any information obtained will be used for that purpose. This is a communication from a debt collector. Calls to or from NCO Financial Systems, Inc. may be monitored or recorded for quality assurance. DEC 22, 2008 KINETIC IMAGING, INC. 4520 UNION DEPOSIT ROAD HARRISBURG,PA 17111 FEDERAL ID#: 204912847 PHONE#: (717)652-6105 DOCTOR: LADD, MD CHRISTOPHER REF. DOCTOR: GRIFFITHS DO, RICHARD L 7807643 BENDER,JANET W PATIENT: BENDER, JANET W 911 BURNTHOUSE RD CARLISLE, PA 17015 ## TRN-DATE CPT/CD DESCRIPTION ICD9/CD AMOUNT 1 06/05/08 74240 RF UGI WO KUB 537.0 140.00 2 07/02/08 XACT MEDICARE PAYMEN -26.13 3 07/02/08 XP.CT MEDICARE ADJ - 107.34 4 07/02/08 FR 06-05-08 TO 06-0 .00 5 07/02/08 CO-INS. 6.53 .00 --- - - - -- --- END --------- OF LIST ---------------------------------------------------- -- - - - - 6.53 DEC 22, 2008 KINETIC IMAGING, INC. 4520 UNION DEPOSIT ROAD HARRISBURG,PA 17111 FEDERAL ID#: 204912847 PHONE#: (717)652-6105 DOCTOR: LADD, MD CHRISTOPHER REF. DOCTOR: GRIFFITHS D0, RICHARD L 7811233 BENDER,JANET W PATIENT: BENDER,JANET W 911 BURNTHOUSE RD CARLISLE, PA 17015 ## TRN-DATE CPT/CD DESCRIPTION ICD9/CD AMOUNT 1 06/21/08 71010 XR CHEST 1 VIEW 518.3 40.00 2 07/23/08 XACT MEDICARE PAYMEN -6.83 3 07/23/08 XACT MEDICARE ADJ -31.46 4 07/23/08 FR 06-21-08 TO 06-2 00 5 --- 07/23/08 --------- CO-INS 1.71 ------------------ . .00 END OF LIST -------------------------------- ---------------- 1.71 r DEC 22, 2008 KINETIC IMAGING, INC. 4520 UNION DEPOSIT ROAD HARRISBURG,PA 17111 FEDERAL ID#: 204912847 PHONE#: (717)652-6105 DOCTOR: WRIGHT MD,SCOTT C REF. DOCTOR: CRIM MD, LAURA 9398452 BENDER,JANET W PATIENT: BENDER, JANET W 911 BURNTHOUSE RD CARLISLE, PA 17015 ## TRN-DATE CPT/CD DESCRIPTION ICD9/CD AMOUNT 1 04/07/08 74150 CT ABD 789.00 250.00 2 04/07/08 72192 CT PELVIS 789.00 250.00 3 05/13/08 XACT MEDICARE PAYMEN -85.82 4 05/13/08 XACT MEDICARE ADJ -392.72 5 05/13/08 FR 04-07-08 TO 04-0 .00 6 05/13/08 CO-INS 21.46 .00 7 11/17/08 BAD DEBT NATIONAL RE -------------- -21.46 ---------------- --- END --------- OF LIST ---------- -------------------------- .00 DEC 22, 2008 KINETIC IMAGING, INC. 4520 UNION DEPOSIT ROAD HARRISBURG,PA 17111 FEDERAL ID#: 204912847 PHONE#: (717)652-6105 DOCTOR: WRIGHT MD,SCOTT C REF. DOCTOR: GATRELL MD, LLOYD B 9405969 BENDER,JANET W PATIENT: BENDER, JANET W 1 W PENN ST APT 517 CARLISLE, PA 17013 ## TRN-DATE CPT/CD DESCRIPTION ICD9/CD AMOUNT 1 06/30/08 74022 XR ABD COMP ACUTE W 789.00 75.00 2 09/17/08 XACT MEDICARE PAYMEN -11.88 3 09/17/08 XACT MEDICARE ADJ -60.15 4 09/17/08 FR 06-30-08 TO 06-3 .00 5 09/17/08 CO-INS 2.97 .00 END OF LIST 2.97 STATEMENT CARLISLE CARDIOLOGY ASSOCIATES DAVID KANN, MD 850 WALNUT BOTTOM RD, SUITE 102 COLETTE LASEK, MD CARLISLE, PA 17013 BILLING INQUIRIES: 717-258-8862 VISA AND MASTERCARD ACCEPTED ~ ~ Janet W Bender 435754 12/19/08 1 MC 911 Burnthouse Road Carlisle, PA 17015 ~ ~ ~ ~ ', L J PERFECT .~ PLEASE DETACH HERE AND RETURN TOP S TUB WITH YOU R PAYMENT i CARE ~j )PYRIGHT 20W.ST7COMPUTERSERVICES ,INQ ~P1 • • ~ •. 16/02/08 99213 OFFICE VISIT - EXPANDED, E CL 1.00 71.00 11.47 06/24/2008 HGSA ADMINISTRATORS 45.86 13.67 6/09/08 78465 MYOVIEW NUCLEA STRESS ' CL 1.00. 675.44 97.33 .06/26/2008 HGSA ADMINISTRATORS 389.30 188.81 6/09/08 78478 WALL MOTION ANALYSIS OF : CL 1.00 150.84 13.26 06/26/2008 HGSA ADMINISTRATORS 53.04 84.54 6/09/08 78480 EJECTION FRACTION ANALYS CL 1.00 160.00 11.47 06/26/2008 HGSA ADMINISTRATORS 45.89 102.64 6/09/08 93015 STRESS TEST COMPLETE CL 1.00 280.00 19.53 06/26/2008 HGSA ADMINISTRATORS 78.14 182.33 6/09/08 A9502 TETROFOSMIN IMAGING AG CL 2.00 185.64 37.13 06/26/2008 HGSA ADMINISTRATORS 148.51 0.00 6/09/08 J1245 DIPYRIDAMOLE INJECTION CL 1.00 22.00 0.15 06/26/2008 HGSA ADMINISTRATORS 0.58 21.27 6/09/08 J0280 AMINOPFIYLIN INJECTION - 2 CL .1.00 2.50 0.07 06/26/2008 HGSA ADMINISTRATORS 0.30 2.13 6/11/08 93307 ECHOCARDIOGRAM CL 1.00 600.00 35.67 07/12/2008 HGSA ADMINISTRATORS 142.67 421.66 6/11/08 93320 ECHOCARDIOGRAM - DOPP CL `1.00 200.00 15.77 07/12/2008 HGSA ADMINISTRATORS 63.06 121.17 6/11/08 93325 COLOR DOPPLER ECHOCARD CL 1.00 300.00 14.56 07/12/2008 HGSA ADMINISTRATORS 58.25 227.19 MESSAGE: SEE REVERSE SIDE IF AN INSURANCE MESSAGE APPEARS PLEASE PAY ~ 256.41 Please pay within 30 days...thank you Janet W Bender 435754 256.41 Carlisle Cardiology, Assoc, P.C. • 850 Walnut Bottom Road, Suite 102 • Carlisle, PA 17013 4 ~_ ASSET MANAGEMENT~i.c DEC 23 2008 Janet W Bender 9l 1 Burnthouse Rd Carlisle PA 17011-7762 1891 Snnln Barharn Drii~e, #?0-t Lancaster, I?~I 17G0! '1 elephol~e: 717-519-1770 Toll Free: 888-5>?-?I ,~,t AccountFor: PHYSIAN'S ALLIANCE LTD Client Account. #; 647177 Balance Due: $318.46 Your account(s) with PHYSIAN'S ALLIANCE LTD has been placed for collection. List of accounts: Name Client Reference Visit Date Balance Due BENDER JANET W 647177 CARLISLE HOSPITALISTS ()6/24/08 6.92 BENDER JANET W 647177 CARLISLE HOSPITALISTS 06/25/08 6.92 BENDER JANET W 647177 CARLISLE HOSPITALISTS 06/26/08 6.92 BENDER JANET W 647177 CARLISLE HOSPITALISTS 07/01/08 6.92 BENDER JANET W 647177 CARLISLE HOSPITALISTS 07/03/08 6.92 BENDER JANET W 647177 CARLISLE HOSPITALISTS 07/12/08 6.92 BENDER JANET W 647177 CARLISLE HOSPITALISTS 07/08/08 6.92 BENDER JANET W 647177 CARLISLE HOSPITALISTS 06/20/08 12.36 BENDER JANET W 647177 CARLISLE HOSPITRLISTS ()6/21/08 12.36 BENDER JANET W 647177 CARLISLE HOSPITALISTS (16/22/08 12.36 BENDER JANET W 647177 CARLISLE HOSPITALISTS 06/23/08 12.36 BENDER JANET W 647177 CARLISLE HOSPITALISTS 07/02/08 12.36 Please contact this office at 717-519-1770 or 888-592-2144 to make suitable arrangements to pay this outstanding balance. This is an attempt to collect a debt and any information obtained will be used for that purpose. Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will assume this debt is valid. If you notify this office to writing within 30 days after receiving this notice, this office will obtain verification of the debt and mail you a copy of such verification. If you request from this office in writing within 30 days after receiving this notice, we will provide you with the name and address of the original creditor, if different from the current creditor. This communication is from a debt collector. You should act to avoid the possibli~ of this account becoming a part of your credit history. Any account not paid in fill before 01!27!04 r.~uy vv rC1:,J:'teu Ori yoar C;Cdit vilrGau iv lvr JV ve.i yCarS i'Giii tii% uatc Gf SCrV1GC. 31 ?-AP E ti 124 I -T YA3776? FR Please refer to our acetn.~~i~E~~a,~,5,d~y~q,~1}j~~~,~~~I,,,t}H~~,~~ent ~~y IIII II III it III II III II III ~ III II III II III II III II III II III I IIII If yon ~isb to pay by credit card, lease ente-. tiie requested inrarn,ation in spaces provided PO Box 7044 ~ ®^ ~ a ^ ~ ^ Lancaster PA 17604-7044 ^ RETURN SERVICE REQUESTED Date: DEC 23 2008 Amount: $358.46 Account: 647177 PALGEN 67912=F5 1241 LAN Janet W Bender 91 I Burntliouse Rd Carlisle PA 1701 i-7762 ~~~III~~~III~~~~~~ILI~I~I~~~IL~~I~II~~~~IJ~~~II~~~II~J~II curd#:__ ____ Expiration Date----- Amount Authm•ized: $---- Signatw•e: 3 Digit Security Code (back of card) _ Wining Address• Send Payment To: APEX Asset Management, L! C PO Box 7044 Lancaster PA 17604-7044 I~~~III~~~LII~~II~~~~I~~II~~~III~~~~I~~I~I~~LI~~I~I~~ILI~~I ~~ ASSET MANAGEMENT«c 1891 Santa Barfirna Drive, #?0-! Lrn7ca.cler, ~=1 17<0/ 'T'elephone: 7/ 7-S / 9-1770 701/ Free: 888- ~ 9?-21-t-1 DEC 23 2008 Account-For: PHYSIAN'S ALLIANCE LTD ClientAccount #: Janet W Bender 67177 911 Burnthouse Rd Balance Due: Carlisle PA 17015- 7762 $318.46 Your account(s) with PHYSIAN'S ALLIANCE LTD has been placed for collection. List of accounts: Name Client Reference Visit Date Balance Due BENDER JANET W 647177 PHYSIAN' S ALLIANCE LTD 07/03/08 6.92 BENDER JANET W 647177 PHYSIAN' S ALLIANCE LTD 07/12/08 6.92 BENDER JANET W 647177 PHYSIAN' S ALLIANCE LTD 07/08/08 6.92 BENDER JANET W 647177 PHYSIAN' S ALLIANCE LTD 06/20/08 12.36 BENDER JANET W 647177 PHYSIAN' S ALLIANCE LTD 06/21/08 12.36 BENDER JANET W 647177 PHYSIAN' S ALLIANCE LTD 06/22/08 12.36 BENDER JANET W 647177 PHYSIAN' S ALLIANCE LTD 06/23/08 12.36 BENDER JANET W 647177 PHYSIAN' S ALLIANCE LTD 07/02/08 12.36 BENDER JANET W 647177 PHYSIAN' S ALLIANCE LTD 07/07/08 12.36 BENDER JANET W 647177 PHYSIAN' S ALLIANCE LTD 07/09/08 17.73 BENDER JANET W 647177 PHYSIAN' S ALLIANCE LTD 07/11/08 17.73 BENDER JANET W 647177 PHYSIAN' S ALLIANCE LTD 06/30/08 21.17 Please contact this office at 717-119-1770 or 888-192-2144 to make suitable arrangements to pay this outstanding balance. This is an attempt to collect a debt and an inforn~ation obtained will be used for that purpose. Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will assume this debt is valid. If you notify this office in writing within 30 days after receiving this notice, this office will obtain verification of the debt and mail you a copy of such verification. If youu request from this office in writing within 30 days after receiving this notice, we will provide you with the name and address of the original creditor, if different from the current creditor. This communication is from a debt collector. You should act to avoid the possiblity of this account becoming a part of youur credit history. An_y account not paid in full before O t n7/r~o may be reported on your credit bureau file fcr seven years from the date of service. 313-APEYI?41-TYA3776300 Please refer to our acs.~~r~~~iaAd,?~,i,~.~,~1}j~~;~,~~I,,,I~j~,nt ~~ IIIII II III II III II III IIIII II III II III IIIII IIIII II III II III iIIII PO Bow 7044 Lancaster PA 17604-7044 RETURN SERVICE REQUESTED if you wish to pay by credit card, please enter the requested h>Irormation in spaces provided ~~ ^ ~ ^ ~ ^ a Card#•__ ____ Expiration Date----- Amowit Authorized: $---- Date: DEC 23 2008 Amount: $358.46 Account: 647177 PALGEN 6791245 1241 LAN Janet W Bender 911 Burnthouse Rd Carlisle PA 17015-7762 ~~~III~~~III~~~~~~II~I~I~I~~~II~~~I~II~~~~I~h~~II~~~II~~I~II Signature• _ 3 Digif Security C.'ode (back of card) Billing Address• Send Payment To: APEX Asset Management, LLC PO Box 7044 Lancaster PA 17604-7044 I~~~IIL~~IJI~~II~~~~I~~II~~~III~~~~I~~I~I~~I~I~~I~I~~II~I~~I ~ ASSET MANAGEMENT~Lc 1891 Santa Barbara Drive, X204 Lancaster, PA 17601 717-519-1770 or 888-592-2144 Dear JANET W BENDER, Acct For. CPMG CRNA CRMC RE: 646143 Date: ' November 26, 2008 Balance Due: ' 51,050.00 We thank you for choosing CPMG CRNA CRMC for your health care needs. You should have received a bill for services provided by CPMG CRNA CRMC. The balance in full of 51,050.00 is now due for payment in full. We realize this could be an oversight and not a deliberate attempt to disregard your obligation. You may take care of this obligation today by returning a check, money order, or charge card information with__this_I~tter.Please___ _ mail your payment in the enclosed envelope. VISA and Mastercard are also accepted over the phone by calling 717-519-0753 or toll free at 877-205-3879. If you need to make other payment arrangements, please call 717-519.0753 or toll free at 877-205-3879. If full payment is not received in thirty days your account may be considered for collection activity. In the event full payment has been made or payment arrangement has been established, please accept our thanks and disregard this notice. This is an attempt to collect a debt. Any information obtained will be used for that purpose. lJnless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will assume this debt is valid. If you notify this office in writing within 30 days after receiving this notice this office will obtain verification of the debt and mail you a copy of such verification. If you request from this office in writing within 30 days after receiving this notice, we will provide you with the name and address of the original creditor if different from the current creditor. This communication is from a debt collector. APEX ASSET MANAGEMENT LLC Please tear off and return lower portion with payment. PO Box 7044 Lancaster PNNA 17604.7044 ~I~1~,~~ 00155 If ou wish to a b credit wrd ease enter the information in the s aces rovided. ^ ^ j visa Card # Security ode Exgration Dafe Billing Address Signature Amount Authorized r.riil~ilii~~i~i~~iliil~il~~iliiriirr~riillllilrli~tiiliri~rllri CARL78 6517298 105 LAN HSP JANET W BENDER 16345-25 9116URNTHOUSERO 1 CARLISLE PA 17015.7762 CPMG CRNA CRMC PO BOX 468 EAST PETERSBURG PA 17520.0468 Account: 646143 Pay this amount: 51,050.00 date: November 26, 2008 ASSET MANAGEMENTLLc 1891 Santa Barbara Drive,l/204 Lancaster, PA 17601 717.519.1770 or 888.592.2144 Dear JANET W BENDER, We thank you for choosing CPMG CRNA CRMC for your health care needs. You should have received a bill for services provided by CPMG CRNA CRMC. The balance in full of S39.97 is now due for payment in full. We realize this could be an oversight and not a deliberate attempt to disregard your obligation. You may take care of this obligation today by returning a check, money order, or charge card information with this letter.. Please mail your payment in the enclosed envelope. VISA and Mastercard are also accepted over the phone by calling 717-519.0753 or toll free at 877-205.3879. If you need to make other payment arrangements, please call 717-519-0753 or toll free at 877-205-3879. If full payment is not received in thirty days your account may be considered for collection activity. In the event full payment has been made or payment arrangement has been established, please accept our thanks and disregard this notice. This is an attempt to collect a debt. Any information obtained will be used for that purpose. Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will assume this debt is valid. If you notify this office in writing within 30 days after receiving this notice this office will obtain verification of the debt and mail you a copy of such verification. If you request from this office in writing within 30 days after receiving this notice, we will provide you with the name and address of the original creditor if different from the current creditor. This communication is from a debt collector. Acct For: CPMG CRNA CRMC RE: 646143 Date: November 26, 2008 Balance Due:. 539.97 APEX ASSET MANAGEMENT LLC PO Box 7044 Lancaster PA 17604-7044 ~'~~ Please tear off and return lower purtiori with Itaymeot. 00156 ~lilrr~ii,iiiillrrii,i,iliUl~rilirrl~ilrl~nlli~iil~uirrrriri,ll CARL78 6517299 105 LAN HSP JANET W BENDER 16sa5-25 1 9116URNTHOUSERD CARLISLE PA 17015-7762 - --- ~-----..._...._.........__ ..........................N~,,. ^ ^ ~v~ ~ Card # Security Code Expiration Date Billing Address Signature .Amount ~ CPMG CRNA CRMC PO BOX 468 EAST PETERSBURG PA 17520.0468 Account ll: 646143 Pay this amount:.. 539.97 Date: November 26, 2008 ALEXANDER SPRINGS EMER PHYS •~$OX 37720 PHILADELPHIA, PA 19101-7720 0 IV IIIIIIIIIIIIIIIIIIIIIIIII1~111 "III~I~IIIIIIIIIIIIIII II~IIIt'I ~' 031212-0000094059698-04 #B WNJFDB #OOOOOOOCLL178721# JANET W BENDER 911 BURNTHOUSE RD CARLISLE PA 17015-7762 Account Detail S l A I CMt=N I UF- AC:(;UUNT (Z) , Statement Date: November 2, 2008 ~CCOUNT NUMBER: CLL94059698 Patient Name: JANET W BENDER _ Tax ID #: 26-2419497 _ Account Balance: $21.41 Amount Pending InsLlrance: $0.00 Amount Due From Patient (Current): $0.00 Amount Due From Patient (Past Due): $21.41 ~ Pay This Amount: $21.41 ~ I YOUR ACCOUNT IS NOW SERIOUSLY PAST DUE, AND A DELINQUENCY REVIEW IS BEING CONDUCTED. Please refer to coupon below for payment instructions. Date # Description Charge Paid By First Ins. Paid By Other Ins. Paid By Patient Anwunt Ad~usted Due From Insurance PATIEIJT BALANCE 06/30/08 1 99284 EMERGENCY EVAL 8 MGMT $569.00 (LVL 4) DX:789A9 UR GATRELUCARLISLE REGIONAL MEDIC L CENTER 09/24/08 MEDICARE CONTRACTUAL ALLOWANCE $-461.84 G9r?4108 MEDICARE PAYMENT 4-85.65 10/15/08 MEDICAID CLAIM DENIED -COVERAGE $-O. W $21.41 TERMINATED ~~ ~3 TOTALS: $ss9 00 $-as ss $o 0o so.oo $-as1 9a $o 00 $21.41 Important Messages: This statement is for the direct [reatrnent and/or supervision of care you recently received from an Emergency Physician at Carlisle Reyional Medical Center The fees fur this pri/ate physician are billed separately from any hospital charges or other professional fees for which you may also be responsible Therefore, should you receive a bill from [he hospital or other physicians for charges in connection with this visd, it will not include the items listed on this statement. "Payment Plans" Accepted Questions about this statement? / Llame de Lunes a Viernes? Call 1-800-355-2470 Monday through Friday 9:30AM - 4:OOPM. Your automated system access code is 947-94059698, or you can send email to billing_questions aeemcare.com. y y Please detach and return bottom portion with your remittance. JANET W BENDER 911 BURNTHOUSE RD CARLISLE PA 17015-7762 YOU MAY PAY THIS BILL WITH YOUR CREDIT CARD PLEASE SEE REVERSE SIDE. Make Check/Money Order payable to: IIIII'll'l llll'~I'111111'IIIIIII111'11 ~1"I11111't ~I ALEXANDER SPRINGS EMER PHYS PO BOX 37720 PHILADELPHIA, PA 19.101-7720 MED HGS ADMIPJ MEDICARE PART B 71 ti096973D ^ If your address has changed, check this box and complete the reverse side of this form STATEMENT OF ACCOUNT Statement Date: November 2, 2008 ACCOUNT NUMBER:CLL94059698 Patient Name: JANET W BENDER Payment Due By: PAST DUE Amount Due: $21.41 Amount Enclosed: ~-1 031212D000094D59698000D2141DDOOOOOOOOD00 The insurance information in our file appears below. Please make any corrections and/or additions on the reverse side of this form and return d to us. Thank you. STATEMENT OF ACCOUNT (2) ;XANDER SPRINGS EMER PHYS v BOX 37720 PHILADELPHIA, PA 19101-7720 0 r N I~~tlll~~tlli~~~~~~ll~l~l~lt~tll„~I~II~t~~l~lrt~ll~~~ll~~l~ll ~' 031212-0000094066834-04 #BWNJFDB #OOOOOOOCLL146876# JANET W BENDER 911 BURNTHOUSE RD CARLISLE PA 17015-7762 ACCOUnt Deta%l Statement Date: October 17, 2008 ACCOUNT NUMBER: CLL9406fi834 Patient Name: JANET W BENDER Tax ID #: 26-2419A97 Account Balance: $31.97 Amount Pending InsLlrance: $0.00 Amount Due From Patient (Current): $0.00 AmoLlnt Due From Patient (Past Due): $31.97 Pay This Amount: $31.97 YOUR ACCOUNT IS NOW SERIOUSLY PAST DUE, AND A DELINQUENCY REVIEW IS BEING CONDUCTED. Please refer to coupon below for payment instructions. Date # Description Charge Paid By First Ins. Paid By Other Ins. Paid By Patient Amount Ad'usled Due From Insurance PATIENT BALANCE 07/07/08 1 99285 EMERGEIJCY EVAL S MGMT $847.OU (LVL S) 0X.560 9 DR. RANKIN/CARLISLE REGIONAL MEDICAL EMTER 09/08/08 MEDICARE CONTRACTUAL ALLOWANCE $-fi87.17 09/08/08 MEDICARE PAYMENT ~ $-127.86 09/29/OA MF_DICA!O CLP.IM DENIED -COVERAGE $-000 $31.97 TERMINATED TOTALS: $84700 $-127.86 50.00 $0.00 $-487.17 $9 t~ $31.97 i Important Messages: This statement 5 fur the direct lreahnent and/or supervision of care you recently received from an Emergency Physician at Carlisle Regional Medical Center. The Fees For this r private physician are billed separately from any hosptal charges or other professional fees For which you may also be responsible. Therefore, should you receive a bill from the I' hospital or other physicians For charges in connection with this visit, it will not include the items listed on this statement. "Payment Plans" Accepted Questions about this statement? / Llame de Lunes a Viernes? Calf 1-800-355-2470 Monday through Friday 9:30AM -4:OOPM. Your automated system access code is 947-940fifi834, or you can send email to billing_questions(_a~emcare.com. Please detach and return bottom portion with your remittance. J JANET W BENDER 9 911 BURNTHOUSE RD ~ CARLISLE PA 17015-7762 Y YOU MAY PAY THIS BILL WITH YOUR CREDIT CARD P PLEASE 5EE REVERSE SIDE. N Make ChecklMoney Order payable to: Inrllltlnntllllnunllln~lln+lnl>vlllnurll~ll ALEXANDER SPRINGS EMER PHYS PO BOX 37720 PHILADELPHIA, PA 19101-7720 The insurance infonnalan is our file appears below. Please make any corrections and/or additans on the reverse side of this form and return it to us. Thank you. MED FIGS ADMIN MEDICARE PART B 7160969730 ^ If yoL1r address has changed, check this box and complete the reverse side of this form STA~ME_NT_OF ACCOUNT Statement Date: October 17, 2008 _ACCOUNT NUMBER:CLL94066834 Patient Name: JANET W BENDER Payment Due By: PAST DUE Amount Due: $31.97 Amount Enclosed: `~~ 0. D3121200D0094D6683400003197000000000D001 FrL• BLUE MOUNTAIN ANESTHESIA ASSOCIA PO BOX 947 CHAMBER.SBUR.G, PA 17201 05178lT24 P1 BENDER, JANET TO: 1 W PENN ST APT 517 CARLISLE, PA 17013-2356 STATEMENT STATE DATE 10/04/08 GUARANTOR N M BENDER, JANET ~ BMA 8678-G AMOUNT 78.96 AMOUNT REMITTED MAKE CHECK PAYABLE TO: BLUE MOUNTAIN ANESTHESIA ASSOCIA PO BOX 947 CHAMBERSBURG, PA 17201-0947 I~~~III~~~I~~l~ill~~r~~~llll~~~l~l~~~l~~ll~~~l~l~~ll~~~ll~~l~l I~~~III~~~IIL~~~~JL~II~~~IJ~~t1~~I~I~~IL~J~~L~LI~II~J We also accept ^ ® ^ Ptease detach top portion and return with CARD NO. EXP. DATE SECURITY CODE" your remittance in the enclosed envelope. 'Security code can be AMT. AUTHORIZED SIGNATURE found on the back of the card Retain this portion of statement for your tax records. **Services For BENDER, JANET** 06/19/08 22 00790 Start 07:38 End 10:24 1,425.00 35.64 HOWARD ALSTER 07/16/08 Denial HIGHMARK MEDICARE 261 ALEXANDER SPRING RD 08/04/08 Payment HIGHMARK MEDICARE 142.56 08/04/08 MEDICARE ADJUSTMENT 1,246.80 07/10/08 21 00790 Start 19:36 End 23:21 1,650.00 43.32 DANIEL CHESS 08/04/08 Payment HIGHMARK MEDICARE 173.27 361 ALEXANDER SPRING RD 08/04/08 I i MEDICARE ADJUSTMENT 1,433.41 ~~ -PACE of SERVICE ?FOR 8#LLING .QUESTIONS CALL i IRS NUMBER = ~ : ;;. P#iDYID~R$,BIELENG`ADDRESS ._...: 11. OFFICE ,z. HOME INPATHOSP 21 CUSTOMER CARE BLUE MOUNTAIN ANESTHESIA ASSO . 22. OUTPAT HOSP aD0-827-.34rJS 251690800 78.96 PO BOX 947 23. EMERG ROOM I EXT 1407 CHAMBERSBURG, PA 17201 31. SNF . 32. NURSING FAC. s ~AM-4~~1 33. CUST CARE FC MESSAGE ~ YOUR ACCOUNT IS PAST DUE. PLEASE SEND YOUR PAYMENT WITHIN 10 DAYS OR THE ACCOUNT WILL BE FORWARDED TO COLLECTIONS. IF YOU HAVE ALREADY SENT IN YOUR PAYMENT, PLEASE DISREGARD. P.O. Box 837 Newtown, CT 06470 Change Service Requested November 3, 2008 PERSONAL & CONFIDENTIAL #BWNLPGJ - #0654 2700 0177 8172# 1~~~111~~~116~~~~~161JJ~~~Ih~~h11~~~~61~~~Ii~~~11~~IJl _ ~ Bender, Janet 23442099 ti 911 Burnthouse Rd Carlisle, PA 17015-7762 +e P.O. Box 837 Newtown, CT 06470 (800) 750-6343 Fax (203) 426-9630 ACCOUNT IDENTIFICATION EAS Account Number:. 23442099 Creditor #: 364651- 3 Creditor: Comcast Harrisburg Service Notice Date: November 3, 2008 Service Balance Due: $ 28.78 Equipment Balance (if not returned): $ 0.00 Total Balance Due: $ 28.78 * * * FIRST NOTICE * * ~ i'our account has been placed with this office for collection. To avoid further collection activity, pay it in full. If you can not pay it in full or have a problem, contact our office. * * IMPORTANT * * Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will assume this debt is valid. If you notify this office in writing within 30 days from receiving this notice, this office will: obtain verification of the debt or obtain a copy of a judgment and mail you a copy of such judgment or verification. If you request this office in writing within 30 days after receiving this notice, this office will provide you with the name and address of the original creditor, if different from the current creditor. To be sure of proper credit and to stop further procedure make your payment in full. This is an attempt to collect a debt. Any information obtained from you or anyone else will be used for that purpose. This communication has been sent by a debt collector. Office hours are gam to Spm EST, Monday -Friday. ----------------------------------------------------Detach and Return with Payment-------------- ---------------------------------------- Enter the requested information in the spaces provided below: Change of Address: For: Janet Bender Street Address: Creditor #: 364651- 3 Creditor: Comcast Harrisburg Service Notice Date: November 3, 2008 EAS Account Number: 23442099 Service Balance Due: $ 28.78 Equipment Balance (if not returned): $ 0.00 Total Balance Due: $ 28.78 City, State, Zip: Telephone: Eastern Account System of Connecticut, Inc. P.O. Box 837 Newtown, CT 06470-0837 III~~~JI~~~I~~II~~~III~~~II~~J~~I~~~II~I~~~L~161~~~1~1~1~1 EASTERN ACCOUNT SYSTEM OF CONNECTICUT, INC. New York License #1244261 Amount Enclosed: $ Please Charge to my []Visa []MasterCard []American Express []Discover Card Number Expiration Date Name of Cardholder Signature Enclosing t is nonce wit your payment wt expe tte cre tt to your account. =IRSTCBL 003212P 1 215 000537 308 065427 S-CRE EMBARQ Payment Dptians & Contact Infa Current Charges At-A-Glance Retail Store in Your Area a CARLISLE EMBARQ Services 20Z Westminster Drive in _r_..-----._-::..:_._.-_:-,:.:,_,._,:_„-.-:_.-:::_::::-::::_: The Carlisle Crossings Center FTetaTCur~~Ct~ir=,. <_ --- Pay Online EMBARQ.com/myaccount Pay by Phone 1-877-813-7604 Customer Service 1-800-829-8009 Repair Service 1-800-788-3600 Internet Address EM BARQ.com/residential Total ...-_ ~' i.. F3 ~'L~ ra__~~ -~ -- __f--_ :~_:- _--- Previous Balance Payments & Adjustments Past Due, Please Pay Now Total Current Charges Total Amount Due 43.43 I .00 I 43.43 ` .00 I 3.43 Current Charges Due By: 6 10/26/08 Please Recycle Account Number 717-243-3734720 543.43 Please return this portion with payment Customer Service Internet Address 1-800-829-8009 EMBARQcom/residenfial Please Qay past due amount of EMBARQ x43.43 immediately Total Amount Due: AV 01 036840 429538144 A**SDGT ~ui~~~m~~~nuu~~~~~~~~u~~~m~i~~uu~~~m~~m~~u~~~~ JANET W BENDER 911 BURNTHOUSE RD CARLISLE PA 17015-7762 Monthly Statement October 1, 2008 Page 1 of 3 Account Number 717-243-3734-720 N Amount Enclosed: Write your 13-digit account number on check Make checks payable to: Embarq PO Box 96064 Charlotte NC 28296-0064 ~n~~~~u~ni~~~~~~m~~n~~m~~nn~~~n~u~n~~~~ 12 71724337347208 00000000000000 000043430 0833517 J.C. CHRISTENSEN AND ASSOCIATES, INC. P.O. ROX 519, SAUK RAPIDS, MN 56379 FILE #: 8131041 OR{G{NAL CREDITOR(S) REGARDING CURRENT CREDITOR(S) AMOUNT OWED AAC/FINGERHUT 6/02 13625745339 ASSET ACCEPTANCE $940.68 CORPORAT{ON TOTAL DUE: $940.68 11/01/08 _ _ _ __. _ _ _. _. _ Dear Executor: We understand the person listed below has passed away. On behalf of our client, ASSET ACCEPTANCE CORPORATION we would like to extend our condolences for your loss. We realize that this is a trying time however there is an outstanding amount due of $940.68 to our client. In an effort to resolve this matter as quickly as possible our client has authorized us to offer you a generous settlement offer of 70°10 of the total amount due. A one time payment of $658.48 will clear the matter up. The opportunities listed above do not alter or amend your validation rights described below. To take advantage of this opportunity or to discuss otheroptions please contact us at 866-768-5813. Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will assume this debt is valid. If you notify this office in writing within 30 days from receiving this notice that you dispute the validity of this debt or any portion thereof, this office will obtain verification of the debt or obtain a copy of a judgment and mail you a copy of such judgment or verification. If you request this office in writing within 30 days after receiving this notice this office will provide you with the name and address of the original creditor, if different from the current creditor. This communication is from a debt collector. This is an attempt to collect a debt and any information obtained will be used for that purpose. JCC receives incoming calls Central Time Monday-Tuesday Sam-9pm, Wednesday-Friday 8arrF5pm, Saturclay Sam-noon. PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT PO Box 1952 SoI'ullt'hgate, uMII 4N8195I-0I9N52 (II~II VIII IIII VIII INII VIII II II III III IIII IIII IIII IIII III 11 /01108 224023995331 6947!0005781/0024 1. ~ I ~~~ I. III Ill ~~I~II n.. II h~ I. I ~ III I d I Ill IIII I II III II I hl Ills The Executor of: Janet Bender 0 911 Burnthouse Rd ° Carlisle, PA 17015-7762 ~~ P1 D7 I authorize the following amount to be charged to my credit card shown. ~ ~ ~ ~ Cardholder naturre: t~: ~~11 :~~11 Exp. fD~ate: Account #: ~ I.... ~ ~ ~ ~ ~ ....I :.....I ~ ~ [....' `.~'•~'^ Amount $: Signature: File Number: 8131041 Client Account: 13625745339 Balance Due: $940.68 PLEASE SEND ALL CORRESPONDENCE TO: J.C. CHRISTENSEN AND ASSOCIATES, INC. P.O. BOX 519 SAUK RAPIDS, MN 56379 I~1~1~~11~~~~11~1~~~11~1~~11~~~~1,I~~~~III~I~~~I~I~I PO 130.\ 165(125 COLLIMI3US, 0[I 43216-5(125 ADDRESS SI~RVICI: RI;(1UESTL:D #BWNDVFW 111 #210827309982# JANET W BENDER C/O WILLIAM HEISER 91 l BURNTHOUSE ROAD CARLISLE, PA 17015-7762 4155 - 1238 Client Name: Pp&t Electric Utilities Client Aceount#: 772~t076043 Your past due account has been placed with This office for payment. I.K October U 1, 2008 Amount Due: $213.22 Account Balance: $213.22 Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will assume this debt invalid. If you notify this office in writing within 30 days from receiving this notice that you dispute the validity of this debt or any portion of it, this office will obtain verification of the debt or obtain a copy of a ,judgment and mail you a copy of such judgment or verification. If you request of this office in writing within 3(1 days after receiving this notice this office will provide you with the name and address of the original creditor, if different from the current creditor. This communication from a debt collector is an attempt to collect a debt and any information obtained will be used for that purpose. ACCOUNT REPRESENTATIVE (=112) SU3-1230 IANET W BENDER `/O WILLIAM HEISER )1 I BURNTHOUSE ROAD CARLISLE, PA 17015-7762 'p8tl Electric Utilities account # : 2~I-082730998 3alance: $213.22 248273099800021322 SEE REVERSE SIDE FOR IMPORTANT INFORMATION RETURN THIS PORTION WITH YOUR PAYMENT o1 IF PAYING BY VISA OR IIAASTERCARD, FlLL OUT BELOW ^VISA ~ ^ 4AA5TERCARO QAflD MMBEA ElfP. wTE AYIXINT BIONATIiE HONE(Wlh area coda) CBCS 2~1 P.O. Box 16-1059 Columbus, OH X3216--1059 I~I~~I~rll~~~l~l~~~llrll~~~l~~lll~~~~l~l~l~lr~l 4155-1238