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Home My WebLink About06-30-09 (3)J 1505607121 REV-1500 EX (06-05) PA Department of Revenue Bureau of IndNidual Tazes INHERITANCE TAX RETURN PO BOX 280601 Hartishum. PA 17128-DBOt RESIDENT 1]FCFnFNT OFFICIAL USE ONLY County Code Year File Number 2 1 0 9 0 4 5 3' ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 6 6 1 8 9 1 6 5 1 0 2 3 2 0 0 8 1 2 0 9 1 9 2 9 Decedent's Last Name Suffix Decedent's First Name MI R i e g e l L o u i s C (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 Q 1. Original Retum ~ 2. Supplemental Return ~ 3. Remainder Retum (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Requir d death after 12-12-82) 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Box s (Attach Copy of Will) (Attach Copy of Trust) 9. litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1.95) (Attach Sch. O) CORRESPONDENT - THIS SECTN)N MUST 8E COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TI Name Daytime Telephone Number T h e r e s a L S h a d e W i x 7 1 7 6 5 2 8,~y 5 `o Firm Name (If Applicable) ___ _ ___~ ^ REGISTER~IMLLS USE~JLY ,^ --- ; ~~~~~~~777777 c W i x W e n g e r & W e i d n e r ~ - ~ ~~ First line of address '~, -'~ n r ' -gym w -, _' cn~ ~ = . 4 7 0 5 D u k e S t r e e t ','~ ~-~ n v Second line of address I ~ ~ ~ m S ~ Ca 4_ O City or Post Office State ZIP Code DATE FILED - ', H a r r i s b u r g P A 1 7 1 0 9 Correspondent's a-mail address: tISw2000(ci~aOl.COm Under penalfies of perjury, I dedare that I have examined this return, induding aaomparrying schedules and statements, and to the best of my knowledge and belief , it is We, correct and complete. Dedaretbn of preparer other Than the personal representative to based on all intormagon of which preparer has any knowledge, SIG TORE OF PERSO RESP NSIBLE FOR FILING R TURN DATE DRESS SIGpf{~T E OF PREP OTH HA REPR NTATIVE ATE Cs 4 ADDRESS y ~1 CS U`~~CP S 1 ~ P 7 ' ` 2. ~ CIS Nf J T PLEASE USE INAL FORM ONLY Side 1 1505607121 1505607121 _ __ - - _ I Vv~ WIX, WENGER &WEIDNER RICHARD H. WIX A PROFESSIONAL CORPORATION STEVEN C. WILDS ATTORNEYS AT LAW THOMAS L. WENGER THERESA L.SHADE WIX• DEAN A. WEIDNER DAVID R. GETZ 4705 DUKE STREET ROBERT C. SPITZER STEPHEN J. DZURANIN HARRISBURG, PENNSYLVANIA 17109-0341 Ot Counsel JEFFREY G CLARK PETER G. HOWLAND (717)652-8455 ' RI¢0 Manpe~MaMptlaM9a Ba FAX (717) 652-6290 www.wwwpalaw.com June 29, 2009 Ms. Glenda Farner Strasbaugh Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013-3387 Re: Estate of Louis C No. 2009-0453 e S +r F~n _ ~ _~ ~,~ ~ Riegel G' 0 ~o C ,~. .. 2 r o c:' Dear Ms. Farner Strasbaugh: -x; . t . .. We enclose herein for filing the original and one copy of the Pennsylvania Inheritance Tax Return for the above-referenced estate, together with the Inventory, a check in the amount of $122.10 for the tax due, and a check in the amount of $15.00 for the filing fee of the Return. Also enclosed to have time stamped and returned to me is a copy of Rev. 1500 and the Inventory. Please also forward to me a receipt for the tax due and the filing fee. I have included aself-addressed stamped envelope for your convenience in returning the time-stamped copies of Rev. 1500, Inventory and the receipts. If you should have any questions regarding this matter, please give me a call at 652-8455. Thank you for your assistance. TLSW/gc Enclosures cc: Bethann Edwards, Executrix Very truly yours, ~~ ~° l~~ Theresa L. Shade Wix Downtown Harrisburg Location: P.O. Box 845, 508 North Second Street, Harrisburg, PA 1710&0845 (717) 234-4182; Fax (717) 234-4224 1505607221 REV-1500 EX Decedent's Social Secudty Number Decedent's Name: L O U 15 C• R i e g e l 1 6 6 1 8 9 1 6 5 RECAPITULATION 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 8 Notes Receivable (Schedule D) ...................... .. 4. 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ..... .. 5. 5 3 1 1 , 0 2 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers 8 Miscellaneous N n-Probate Property (Schedule G) ~ Separate Billing Requested ..... .. 7. 2 2 7 8 , 2 8 8. Total Gross Assets (total Lines t-7) ......................... .. 8. 7 5 8 9 , 3 0 9. Funeral Ex enses & Administrative Costs (Schedule H) P .............. 9. .. 4 D 7 7 , 2 5 10. Debts of Decedent, Mortgage Liabilities, 8 Liens (Schedule I) .......... .. 10. 7 9 8 , 7 5 11. Total Deductions (total Lines 9 & 10) ......................... .. 11. 4 8 7 6 , 0 0 12. Net Value of Estate (Line 8 minus Line 11) ....................... .. 12. 2 7 1 3 , 3 0 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 Llne 13) ................ .. 14. 2 7 1 3 , 3 0 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9,16 16. Amount of Line 14 taxable at lineal rate x .045 2 7 1 3. 3 0 t6. 1 2 2. 1 0 17. Amount of Line 14 taxable at sibling rate X .,2 O. D 0 , 7, 0. 0 0 18. Amount of Line 14 taxable at collateral rate x .,6 D. 0 0 ,8. 0. 0 D 19. Tax Due .............................................. .. 19. 1 2 2. 1 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ^ ~L G Slde 2 1505607221 1505607221 _ _ REV-1500 EX Page 3 File Number _ r_ Decedent's Complete Address: z1 os 0453 DECEDENT'S NAME i Louis C. Riegel _ _ _ _ -- - _ STREET ADDRESS 1324 Lisburn Road ___ _ - - - - CITY - _ STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: ~. Tax Due (Page 2 Line 19) (1) 122 10 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount TotalCredits(A+g+C) (2) 0.00 3. InteresUPenalty if applicable D. Interest E. Penalty Total InteresUPenalty (D + E) (3) 0.00 4. If Line 2 is greater than Line 1 +Line 3, enter the difference. This is the OVERPAYMENT . Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00 5. If Line 1 +Line 3 is greater than lane 2, enter the difference. This is the TAX DUE. (5) 122.10 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 +5A. This is the BALANCE DUE. (5B) 122.10 Make Check Payable to: REGIS TER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE Bl 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferced : ................................................................ ...... ^ 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 rare? ................................................. ...... ^ 2. If death occurced after December 12,1982, did decedent transfer properly within one year of death without receiving adequate consideration? ................................................................................. ...... ^ 3. Did decedent own an'in tmst for' or payable upon death bank account or securtty at his or her death? ... ...... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ............................................................................................ ...... ® ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE 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 lax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (O) 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 benefdary. For dates of death on or after July 1,2000: The tax rate imposed on the net value of transfers from a deceased childtwenty-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 beneficiades 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, ui Section 9102, as an individual who has at least one parent in cemmon with the decedent, whether by Wood or adoption. REV-1508 EX + (fi-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. Wachovia Bank, P.O. Box 40028, Roanoke, VA 24022 2,602.43 Checking Account - 8914 (See Schedule E, Exhibit 1) Wachovia Bank, P.O. Box 40028, Roanoke, VA 24022 Savings Account - 1304 2. (See Schedule E, Exhibit 1) 126.91 The Woods at Cedar Run/GCCC 3. Refund from Assisted Living 2,581.68 (See Schedule E, Exhibit 2) TOTAL (Also enter on line 5 Recapitulation) E 5.311.02 SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY (If more space is needed, insert additbnal sheets of the same size) 7177328946 E.P. Elementary Fax wacxovrA 01:30.13 p.m. 06-06-2009 Reference ID: 2726362 Wachovia Bank N.A. Balance Confirmation Services P 0 Box 4(1028 Roanoke, VA 24022-7313 hfay 22, 2009 BETHANN M EDWARDS 13 PENNSBORO DRIVE ENOLA, PA 17025 SUBJECT: Verification / Confirmation of Account and Balance Information provided for: Customer: LOUIS C RIEGEL (SSNft XXX-XX-9165) Date of Death: October 23, 2008 De~osif Account Informatio 3 !4 Account Account Date of Death Average Date Maturity Interest Accrued YTD Date Type Number Balance Balance" Dpened Date Rate Interest interest Paid Closed CHECKAIG XXXXXXXXX89I4 32,602.41 1/15/2002 .OS 5002 $1.53 LEGAL TITLE: LOUIS C RIEGEL BEiHANN EDWARDS POA SAVLNGS XXXXXXXXX1304 SI26.91 8/25/2005 .IS 50.00 50.20 LEGAL TITLE: LOUIS C RIEGEL BEDIANN EDWARDS POA Revolvine Credit Information Account Account Date of Death Crain Date Date Times Legal Title TYPe Number Balance Limit Opened Closed Late REVOLVING XXXXXXXXXXXX2092 CREDR MBNA -Revolving credit accounts are no longer smiccd by Wachovia Bank. Please contact MANA a[ 800-477-9131. VISA XXXXXXXXXXXX3474 SO.OU IJI2@007 fACIS C RA3GEL XlIX1000814 Rev 01 Schedule E, Exhibit 1 71 7 7 32894 6 E.P. Elementary Fax WACHOViA 01:30:27 p.m. 06-06-2009 4!4 Reference 1D: 2726362 • Date of death batance does not include accrued interest. ' If date of th occurrs o a weekend or a holiday, date of death balance does not include any transactions that were made n at 'm "od. ena White Servicenter Associate Phone: (540)563.7323 mr; dw q00 000874 Rev 01 THE WOODS AT CEDAR RUN/GCCC Bethann Edwards Operating Cash 026-00236 10/31/2008 18923 2,581.68 2,581.68 Schedule E, Exhibit 2 REV-1510 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE G INTER•VIVOS TRANSFERS 8 MISC. NON•PROBATE PROPERTY ESTATE OF FILE NUMBER Louis C. Riegel 21 09 0453 This schedule must be completed and filed'rf the answer to any of questbns 1 through 4 on the reverse side of the REV-1500 COVER SHEET LS yes. ITEM NUMBER DESCRIPTION OF PROPERTY ixcwoe rxs xnx[ovrxe rw,xsvsxss. rxeix xeunoxsxivro oeceoexr nxo *xe wre av rxa~srsx. anncxncovrov rxe Deco vox xsu esrare. DATE OF DEATH VALUE OF ASSET °~OF DECD'S INTEREST EXCLUSION pvncxicaa~el TAXABLE VALUE 1. Prudential Benefits Center, P.O. Box 7871, Ocala, FL 34478 2,278.28 100. 2,278.28 Annuity (See Schedule G, Exhibit 1) TOTAL (Also enter on line 7 Recapitulation) $ 2 278 28 (If more space is needed, insert additlonal sheets of the same size) Prudential Fiudanfia/BenaBG Canfw PO. Box 7871 Financial Om/a, FL 90178-7871 ~~~~~iu~~~u~~~n~~~~u~~~n ~~~i ~i~~~i ~i ~~u~~~~~i ~i~~~~~~n~~~u ~~~u~ ww.ni iw.axe ~wio.wosr ewncxucow.ewosan» 00008] 006281PU1 BETHANN EDWARDS 13 PENNSBORO DRIVE ENOLA PA 17025 ~n~~~u~~~~n m~~~~~~~~ MESSAGES FOR ANY QUESTIONS, CALL 1-800-PRU-EASY (7-800-776-3279) AND SAY THE KEYWORDS "RETIREMENT PLAN" TO SPEAK TO A CUSTOMER SERVICE REPRESENTATIVE Name ~ Amount Rollsd Over ~ Capital Qalns ei.>.iti, m.... rs......... FINANCIAL BREAKDOWN Pa ment Amounts Deduetlon Dstalls Deduction Amounts GROSS PAYMENT $2,278.28 FEDERAL TAX $455.66 TOTAL DEDUCTIONS $455.66 NET PAYMENT gt 8PP.6P Pa ment Details Pa ment Amounts PART 1 FIXED BENEFIT $1,126.47 PART 2 FIXED BENEFIT $7 72g.g2 INTEREST $25.45 Schedule G, Exhibit 1 REV-1511 EX+(10-0a) SCHEDULE H COMMONWEALTH Or PENNSYLVANIA FUNERAL EXPENSES 8 INHERITANCE TAx RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Louis C. Riegel 21 09 0453 Debts of decedent moat he reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Sullivan Funeral Home, 51 N. Enola Dr., Enola, PA 17025 3,450.00 (See Schedule H, Exhibit 1) B. 1. 2 3. 4. 5. 6. 7. 8. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representatlve (s) Sneet Address City Stafe Yeal(s) Commission Paid: Anomey Fees Theresa L. Shade Wix, Esq. Family Ezempdon: (If decedent's address is not the same as daimanrs, anach ezplanation) Claimant Street Address Chy State _ Relationship of Claimant to Decedent Zip 500.00 Zip Probate Fees Cumberland County Register of Wills AaountanYs Fees Tax Retum Preparefs Fees Cumberland County Register of Wills, Carlisle, PA Inheritance Tax Return Filing Fee Photocopies, Wix, Wenger & Weidner 83.00 15.00 29.25 (If more space TOTAL (Also enter on line 9, Recapitulation) I $ i sheeb of the same size) A. CHARGE FOR SERVICES SELECTED - .- YT Prohassional Servlcea: ~° ~ n 7 F• Beak Samosa al Funeral Director 8 Stag .,. , r r?' ~, Olher'preperetbn d bqN' 2. FaGllt/as, E ui ~' q pment 8 Stafl: - :~; use al FecYNiesa Bart brviewinp/Vanetbn... ~.. ~, uaearr-aduueaasaaarrawrelGremony.:. '. .'.Use of Fecaifiesa Stall ka Memorial Service...; dOn .' Uce d Equipmem 8 Slell lsr Greaaeba Servxx,... - ~ ueeMEquipmemastep kK cnumh Service.... rc " .j' ... ... 3 ° coo .,; x r ~ S. Transportetlon• ., ~ '' Trenabr d Remva b PororM Hortr .. i ' ~ S i:Heeme * ~'' ". .. .... a.'~ s umquame a ..n ~~~Setlen. ' , ~ Service/Unury vemde ~ .." ~ / ~, D AOther Servtcea / Facllftles / EqullymanL ¢~' ` ~;: s +^ ' x " ~ ~ ~b .x ~a~ . tf ~ „ 4 TOTAL OF SERVICE3 SELECTED .r~r ~+ ' $ ~~~ Schedule H, STATEMENT OP -. FUNERAL GOODS AND SERVICES SELECTED ~" Cherpea ere omy for None acme Ihet you aeNProtl a Mel ere.: requOetl.Mwe ere required by aw orbyecemelery orcnmabry- a we.ny ttarrN, we wa,explah ale resaone M wmblp below. I/YOU SBlxled a hnlerel Met may requae~ranbaalag, such es e mwrel wNh vlewalp, you meY hew b pay M emba/marp. You da rml Mve b paY for embalmMp You tl/tl rbl epProw M you a~eldecrod~errenpemena~auch ea a dgecf crarnetbn or Mmetl/ea smbalmhp, we wa axplam whY below. CASH ADVANCES '` CartMao Copies of De)N CerLficea O CI J O S /l~L_(J each -S Clemv -~ Mwk:len _~~_ PeM Newaoaoar Notice Cemearv 1 DNef TOTAL CASH ADVANCES $ -J 17 ~/ Wa Wgle you kx wr earvbea b obabap: (epadly teen aovence tlwm). SUMMARY ToW Funerel Hpm. cnaryee ..........:........ E N U Local SWee Tax (il epplkable) ................ E sea su.a Taz cn applkame) .. .... $ Taal CaahAWerrae ..... .... q GRANDTOTAL S Lees Cretlia arM Peymana a Taal Creda ... .....................E # ,,BALANCE DUE E E UO BYling Td ~f• DISCLOSURES Reesgn ar embaenbp amryaw,~cenretary wcrwnetdyregW~yrynrq wye requhtl Me . pumhaeeWany Mrw Batatl, Ne aworrequNwnent4 aap/ruratl below. ACKNOWLEDGEMENT ANDAGREEMENT I hara4j admawletlpe Net 1 heal Ne lapel opM b ananpe the ttnel services b the deceeeerl, and I autnoriza wo Wnerel nadanmenl a pedprm cervices, Wman gootla, antl incur outeltla charyea apadfiep - on tlta SroromenL' I acknowlatlpe tlral I have received Me General :Price Lletend the Casket Priea.~el end the Outer Burial Conaaer Prks list `_- -Terms d Paymem: ` .. :Poll peypgnt k,tlue no later Nan. II arty payment a nm peltl when oue, an wantldperod LATE CHARGE '.dT`-%PermmN(ANNUALPERCFMAGEMTE_%) ~: on tlreunpeW balance wYl be tlw.l,apreab pay Ne Beance Due ~~laatl ah NaSatemem; pWa erry Lea Charya. in Ne avant I aeautt in -, €~peymanl bthlaaunenCeaabtlahmen('f spree b'peyreaeonable *anorneY'e;lase%antl-eourllcwte'In:atltlillon9p enYLea charge ..°~.appliceGa I. untlereahd end apree'bat 1 em euuming pareonel 'lledllry:br.Me oheryee sal brlh in WeSlaamenl aM Met Na' m In +;atltlitlon:b the Ilebllityampoead by lew;upon. )he'eatate of the-~ Ftlecematl By my GpnaWra'bebw, I heroby Area b ell d Ure above eno ~reeelggyy~a~~~4acapy of MaSabmenl.^~~ t; ' sin`"ir4~5 ~<~`~ `./~ce7,j'Uy~ .rnh i/i ~ S^u YNd. k u Np.i ear a'N Pa!e -. e.wrrN~e. ` ,a. ACCEPTANCEU'/Tlee~urwN retablWmem eVeee b pryvbe all wrvbea. mwdiv)tlaa gpQ~eyl aG lc _. ^E oerl'fua' SI Exhibit 1 i REV-1512 EX + (12-03) SCHEDULE I COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, IN RESID NTEDECEDENTRN MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Louis C. Riegel 21 09 0453 Report debts Incurred by the decedent pdorto death which remained unpaid as of the date of death, including unrelmbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Milton S. Hershey Medical Center, Hershey, PA 17 20 Medical Bill (See Schedule I, Exhibit 1) 11.47 Crumay Parnes Associates, Inc., 104 Ertord Road, Camp Hill, PA 17011 Medical Bill 2. (See Schedule I, Exhibit 2) Holy Spirit Hospital, 503 N. 21st Street, Camp Hill, PA 17011 3. Medical Bill 25.00 (See Schedule I, Exhibit 3) 4. Tristan Associates, 4520 Union Deposit Rd., Harrisburg, PA 17111 66.23 Medical Bill (See Schedule I, Exhibit 4) Holy Spirit Hospital, 503 N. 21st Street, Camp Hill, PA 17011 Medical Bill 5. (See Schedule I, Exhibit 5) 20.09 Alert Pharmacy Serv., Inc., 219 N. Baltimore, St., Mt. Holly Springs, PA 17065 6. Medications Bill 286 12 (See Schedule I, Exhibit 6) 7. Verizon 16.32 Decedent's Telephone Bill (See Schedule I, Exhibit 7) Dianon Systems Medical Bill 8. (See Schedule I, Exhibit 8) 15.64 Orthopedic Institute of PA, 3399 Trindle Road, Camp Hill, PA 17011 9. Medical Bill 18.64 (See Schedule I, Exhibit 9) 10. Susquehanna Valley Pain Management 23 46 Medical Bill . (See Schedule 1, Exhibit 10) PA Gastroenterology Consultants, 899 Poplar Church Rd., Camp Hill, PA 17011 Medical Bill 11. (See Schedule I, Exhibit 11) 26.69 (If more space is nee TOTAL (Also enter on line 10, Recapitulation) I $ sheet of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent Louis C. Riegel Decedent's Name Schedule I -Debts of Decedent, Mortgage Liabilities, & Llens 21 09 0453 File Number ITEM NUMBER DESCRIPTION AMOUNT Holy Spirit Hospital, 503 N. 21st Street, Camp Hill, PA 17011 12. Medical Bill 25.00 (See Schedule I, Exhibit 12) 13. Milton S. Hershey Medical Center, Hershey, PA 17033 34.28 Medical Bill (See Schedule I, Exhibit 13) Milton S. Hershey Medical Center, Hershey, PA 17033 Medical Bill 14. (See Schedule I, Exhibit 14) 130.87 Holy Spirit Hospital, 503 N. 21st Street, Camp Hill, PA 17011 15. Medical Bill 30.54 (See Schedule 1, Exhibit 15) 16. Holy Spirit Hospital, 503 N. 21st Street, Camp Hill, PA 17011 25.00 Medical Bill (See Schedule I, Exhibit 16) PA Gastroenterology Consultants, 899 Poplar Church Rd., Camp Hill, PA 17011 Medical Bill 17. (See Schedule I, Exhibit 17) 26.20 SUBTOTALSCHEDULEI 271 89 GRAND TOTALSCHEDULEI E 798.75 NEE 824 LISBURN RD APT 236 CAMP HILL PA 77011-7110 ACCOUNT # 871284 STATEMENT DATE: 11/1 _ LAST STATE DATE: D4/1 ~"Y \\ ,~' Schedule I, Exhibit l FED TAX II .20 xas -t~Y IF ANY QDESTN)NS, PLEASE COtITACT: NL4HU[_ PATIFI~T Flusur~e~ ecn\nn~n~ AGES EXPLAINED BELOW Insurance Charges pending to.Prv: 395.80 Ins Pay/Adj against Ins pending 320.63 -75.17 0.00 09/11/08 1 5 Office Visit Est Level 3 99213 709.8 60.00 10/07/08 Medicare Payment 45.86 10/07/08 Acce t Assign Adj. -2.67 10/20/08 AETNA US HEA Payment 0.00 11.47* ~~ ~\ `-~ ~\ \~ ~ ~~~ DATE LAST PAID AMOUNT • i • . ~ • • ~ • ~ . , 00/00/00 0.00 11.47 0.00 0.00 0.00 0.00 0.00 0.00 11.47 CRUMAY PARNES ASSOCIATES, INC :IHECK 104 ERFORD ROAD ~nvaeLETO: CAMP HILL, PA 17011 11.47* Ph:(717)-763-7685 PAT// 1-LOUIS C RIEGEL PRV/~ 5-DANNUNZIO, DONALD R., M. Acct~~: 56270 Date: 10/30/08 Page 1 of 1 Schedule I, Exhibit 2 Transaction Date Description Amount PREVIOUS BALANCE 00 09/24/08 VENIPUNCTURE 09/24/08 09/24/08 METABOLIC PANEL,C 17.00 145.00 09/24/08 URIN, (NO MICRO.) CBC,AUTO DIFF 32.00 09/24/08 URINE CULTURE 99.00 09/24/08 09/24/08 ABD/OBSTR SERIES W 1V CHEST 85.00 544.00 10/17/08 LEVEL III FC MEDI PYNT-HOSP OP H10 MEDICARE OP A -192.44 10/17/08 10/27/08 MEDI C/A HOSP-OP N10 MEDICARE OP A AETNA PYNT -1,201.59 Q38 AETNA -21.97 YOUR INSURANCE HAS BEEN BILLED.THIS IS YOUR CURRENT BALANCE. YOUR PAYMENT IS DUE UPON RECEIPT. THANK YOU. M10 MEDICARE OP A .00 Q38 AETNA .00 PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID. ww Schedule I, Exhibit 3 rau6ut. LVUW nLWCt_ - - - - - Account: TRA24834 Services Rendered At: Tristan Associates West Shore Office Date raw Code Description Charge Ad'ust~ments 10/1/2008 72131 CT LSPINE 859.00 11/12/2006 PMT MEDICARE HGS ADMINISTRATORS 183.91 CR Adjustment MEDICARE HGS ADMINISTRATORS 429.11 Message: MEDICARE HGS ADMINISTRATORS Payment Reduced/Mulltiple _ Services Gudel 12/3/2008 PMT AETNA US HEALTHCARE 5.55 Message: AETNA US HEALTHCARE COINSURANCE WAS APPLIED _ 10/1/2008 78377 3D INDEPENDENT WORKSTATION 309.00 11/12/2008 PMT MEDICARE HGS ADMINISTRATORS 103 22 CR Adjustment MEDICARE HGS ADMINISTRATORS . 179 gg Message: MEDICARE HGS ADMINISTRATORS CONTRACT FEE / _ ACCEPTED ASSIGNMENT 12/3/2008 Message: AETNA US HEALTHCARE COINSURANCE WAS APPLIED _ BALANCE DUE 566.23 PAY BY January 0 Please call with your insurance coverage or For billing questions call: 717-652-6105 remit the balance due today to: Fax: 717-652-2165 4520 Union Deposit Rd Office Hours: Mon -Fri 7:OOam to 7:OOpm Harrisburg, PA 17111-2910 Hl~un~~~INII~~ STATEMENT I~ SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION ~~g, _,,, Schedule I, Exhibit 4 HOLY Holy Spirit Hospital 503 N 21ST STREET P A L CAMP HILL PA 17011 - ~ - ----- ,v ---• Transaction Date Description PREYIOUS BALANCE 09/29/08 VENIPUNCTURE 09/29/08 METABOLIC PANEL,C 09/29/08 CBC,AUTO DIFF 09/29/08 LEVEL II FC 10/22/08 10/22/08 NEDI PYNT-HOSP OP M10 MEDICARE OP A 11/03/08 MEDI C/A HOSP-OP M10 MEDICARE OP A AETNA PY H7 Q38 AETNA Amount .00 17.00 145.00 99.00 204.00 -88.35 -356.56 .00 ~~,~3I~g YOUR INSURANCE HAS BEEN BILLED.THIS IS YOUR CURRENT BALANCE. YOUR PAYMENT IS DUE UPON RECEIPT. THANK YOU. M10 MEDICARE OP A .00 Q38 AETNA .00 PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID. Yta Schedule I, Exhibit 5 HOLLY ~~ffkt* ACTIVITY FOR RIEGEL, LOUIS -_ -RIEGLO - -57 I10/06/08 7405517 28 DIGOXIN 125 MCG O1 5.00 10/DB/08 7286921 . 28 VITAMIN D 400 O1 * 3.37 10/08/08 ..7365143 . 84 `: CARB.ID/LEVO *ER* 01 20.00 10/08/06 7365147 84 MIRAPEX 0.5 'MG TA O1. 45.00 10/08/08 4365146 : 28 THERA.TABLET 01 .* 3.12 10/08/08 :7419261 28 AMLODIPINE 5MG O1 5.00 10/08/08 .7434465 56 POTASSIUM 10 MEQ O1 5.00 10/08/08. 7397983 26 . ASPIRIN B1MG EC O1 * 3.01 :10/11/08 ~ 7365145 28 FLOMAX. 0.4 MG CAP ( O1 25.00 .. LEGEND NON-LEGEND' FOR MONTH FOR MONTH Prevloua Balanee Charyea this month Finanea Char a TOTAL CHARGES Told veym•ne a crwia 169.08 + 114.50 + 2.54 - 286.12 - .00 FOR ALL PHARMACY RELATED INQUIRES PLEASE CALL Alert Pharmacy Services, Inc at 1-800-266-9954 7065 .00 5.000 '.. .00 3.37 .00 20.000 '~ .00 45.OOcl .00 3.12 .00 S.OOc i .00 S.OOc .00 3.01 I .00 25.000 ~~ PAST DUE ~~\~~ .oo LTOTAL TAXI AMOUN DUE - 286. Schedule I, Exhibit 6 ~~ LOUIS C RIEGEL Billing Date: 11/12/08 Page 1 of 6 Telephone Number : 717 737-7776 Account Number: 717 737-7776 459 47Y Account Summary Previous Charges $ 17 07 No Payment Received 00 Past Due Charges (please pay now) $17,07 New Charges Verizon(page3) _$ 75 Total Now Charges Due _ $ .78 Total Due ~I~~\\ \ $ 1 3 Please pay upon receipt ~,,,,_ /~ J f'~ ~ \ - FINAL BILL - C v- \ 1 This Final Bill may have already been referred to an outside cpllection agency. 5 Pay your bill online at verizon.com/payfinalbill ~y~ \~ Questions about your bill? Call 1800 880-2215 See page 2 for all other Verizon contact information. Change of billing address? Go to verizon.com/billingaddress or see page 2. Moving? Mo vlnp7 1.866•VZ•MOVES One call gets you up 6 running! Count on the Vedzon netwodr to make at least one part of your move easier Across the street or across the natbn all you need is one call to Verizon to set up your Internet, phone & digital TV in your new home in no time. Service availability varies. r~' Verizon Foundation Visit ThinMinity. org for thousands of FREE educational resovroes for teachers, students, parents and the a/ter-school community. ~ Detach 8 return payment slip with your check, payable to Verizon. Schedule I, Exhibit 7 DIANON Systems ~' A LabCorp Company TAX ID# : 06-1128081 Laboratory Bill I1111111111111111IIIII1III 1111111111111111IIIIIIIIIIIIIIIIIIIIIIIIIIII DUE UPON RECEIPT www.la bco rp. com/bi I I ing LOUIS C RIEGEL 824 LISBURN RD APT 236 CAMP HILL, PA 17011-7110 IlJndullull 1i1~~"I~I~Illlllludll'llll~llll~l~lllldrl~lll Patient Name: Invoice Date: Test requested by: L-47640-DIGESTIVE DISEASE INST 699 POPLAR CHURCH ROAD CAMP HILL, PA 17011 Insurance that has been filed is listed below: AETNA PPO PLANS-ALL MARKETS ID#: W08811619601 PULICY GHUUP#: 10196413201 Payments made via an online banking service must include this invoice # ounnvolce >s: (Facture): 30460839 Amount Due: $15.64 LOUIS C RIEGEL 02/25/09 BILL REPRESENTS THE CO-INSURANCE, 1CTIBLE OR CO-PAY AMOUNT DUE AFTER FICATION FROM YOUR INSURANCE COMPANY. .SE REMIT PROMPT PAYMENT. IF YOU HAVE 1NDARY INSURANCE PLEASE CALL 1-n00.845- THANK YOU. Date of Service Description Charges Adjustments Medicare/ Insurance Patient You Pa y edicaid Paid Paid Paid 09/26/08 GI TECHNICAL COMPONENT 91.45 g1,g6 ADJUSTMENT(S) (13.24) (13.2q PAYMENT(S) (62.57) (62.571 Web payment and insurance /fling options are available at: www.labcorp.comlbilling or 800.845.6767 91 as (13.za) (s2.57> $15.64 II you received an Explanation of Benefits from your insurance company, and the patient responsibility is less than the amount of this bill, please pay the lesser amount. Call our Customer Service Department at 800-845.6167 with any questions. Only your doctor can answer questions concerning diagnosis and results. TEST PERFORMED BY: DIANON CYTO HISTO i FOREST PARKWAY SHELTON, CT 06484 We accept the . ttttttttttt~ Insurance and credit card payment information is located on the back of following credit cards: ~-~« ® Vf~t this invoice. For proper credit, return the below portion with payment. Schedule I, Exhibit 8 ~, CHARGES APPEARING ON THIS STATEMENT ARE NOT "fi ' I ~ , . 0 100908 ODLTZ, COATIB CPTi 99213 DIt 733.13, OPPICB ODTPT VIeIT H8T 0 111908 MEDICARE PAYMENT ° 111908 MEDICARE ADJ08TMENT n1pi 120908 11.47 AETMA CO INe TLA ~ 100908 OOLTZ, CORTIB CPTi 72100 DAe 733.13, a m LOM608ACRAL ePINE, 2 VIEN 111908 MEDICARE PAYMENT 111908 MEDICARE ADJOBTMBNT 120908 7.17 AETMA CO IN8 TLA m N _UDED ON ANY HOSPITAL ~~ LOOIB RIE08 88274848{ LOOIe RIEOE 882748484 .OR STATEMENT ~ ~ ~: •, 78.00 -45.86 -20.67 81.00 -38.66 -45.17 4 OB PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE: 251 CORRBL4T 30-60 DAYS 60-90 DAYB > 90 DAYS TOTAL PATIENT BAIANLE PAY THIS AMOUNT 18.64 18.64 18.64 SEND INQUIRIES TO: 08L DBA ORTH INBTITOT6 OF PA (717) 761-5530 3399 TRINOLE ROAD CAMP HILL PA 17011 IA8 it 231975547 Schedule I, Exhibit 9 PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE DATE DESCRIPTION CHARGE PAYMENTS PAID BY INS DUE PT DUE Balance Forward 0.00 10/03/08 OFFICE CONSULTATION, DETAILED 225.00 11/11/OB Medicare Payment 93.84 MEDICARE 11/11/08 Medicare adjustment 107.70 MEDICARE 12/08/08 Insurance Denied 0.00 AETNA PPO PER AETNA, BALANCE I3 PATIENT RESPONSIBILITY. THANK YOU Insurance Pending ................: ~ 0.00 Patient Amount Due This Statement: ~ 23.46 0.00 23.46 LAST LAST `"-~~ PAYMENT PAYMENT CHECK ---------- -------- PATIENT BALANCE AGING --------------- DATE AMOUNT NUMBER CURRENT 30 60 90 120+ 0.00 23.46 0.00 0.00 0.00 0.00 IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT THE BILLING OFFICE AT (717)652-8670. sse~~_____z_~~m::____::a:.m~_~~____%:./_e___~saesaa~a.~sas.as_~____za Patient Name: LOUIS RIEGEL DATE: 12 08 08 Account Number: 23298 Schedule I, Exhibit 10 PLRABA NOTa: If a "1" appears in this column, we have f;led with your primary carrier. If a "2" appears, 1: xlotDiAnx Maa1cAR8 s we have also filed with your secondary carrier. Our records show your insurance as follow: I: AsTNA ANo PRO- ICD9 RAF.N DHSCRIPTION O8 S8RVICE ANODNT PAYM6NTa/ INPIIRANCB YOUR DASB VIDRA CRAAOAp ADJ. pRNDINO BALANCE Insurance Balance 1030.00 1030.00 0.00 09/25/08 MRR 789.00 99204 OFFICE VISIT, NEW 370.00 26.69 2 11/04/08 AETNA HMO PAYMENT 0.00 10/16/08 HGS ADMIN ADJ 236.53 10/16/08 HGS ADMIN PAYMENT 106.78 Visi our ne and improved web site pagi consu It nts. tom for answ rs to m ny of your frequently asked questi ns If y u disag ee with this billing statement cal your insu ante ca rier and ask about your out of pot et benefits ~ ~ AccovNT AALANCR (REFER TO 'DUE FROM PATIENT' FOR S 1066.69 ANODNf TO PAY. ) CDRRRNT BALANCE OVHR 30 DAYS OVER 60 DAYS OVRR 90 DAYS OVBR 130 DAYS DDE PRON BHT 50.00 526.69 50.00 50.00 50.00 ~ 526.69 PROVIDRAB MORAN R RENGEN DO ACCODNT NW®RR 103634 NANA LOUIS C RIEGEL )OA BILLING INQIIIRI@3-C L 17171763-0430 8TAT81DSNT DATE NARB CAECA PAYABLR TO 12/30/2008 PENNSYLVANIA GASTROENTEROLOGY CONSULTANTS PENNSYLVANIA GASTROENTEROLOGY CONSU pAYNRNT DIIR eY 899 POPLAR CHURCH ROAD 01/19/2009 CAMP HILL, PA 17011-2206 io~wa~i~a~n~^~~a~n~ma Schedule I, Exhibit 11 Holy Spirit Hospital sytrir of caring For Account InOrcmatim~ Pkase Call 800~997$S73 StatBlllCRt `of ACi Transaction Date Description PREVIOUS BALANCE 09/22/08 LEVEL II FC 09/22/08 THERAPEUTIC INJECTION 09/23/08 CHEST 2V 09/23/08 THORACIC SPINE 10/16/08 NEDI PYMT-HOSP OP M10 MEDICARE OP A 10/16/08 HEDI C/A HOSP-OP H10 MEDICARE OP A 10/27/08 AETNA PYNT Q38 AETNA 1~'~~~o~~ ~~1~ YOUR INSURANCE HAS BEEN BILLED.THIS IS YOUR CURRENT BALANCE. YOUR PAYMENT IS DUE UPON RECEIPT. THANK YOU. M10 MEDICARE OP A .00 Q38 AETNA .00 PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID. Amount .00 204.00 83.00 326.00 297.00 -146.50 -721.72 -16.78 Schedule I, Exhibit 12 STATEMENT OF PHYSICIAN SERVICES PENNSTATE LOUIS C RIEGEL The Miltun S. Hershe Medical Center 73 PENNSBORO DR ® The Collef*e of hTedicme ENOLA PA 170257537 ACCOUNT # 971284 ~~ iF aev puesnoes, aLtase: cowrncr: MSHMC PATIENT FINANCIAL SERVICES " FED TAX ID # 251857035 . DATE PROCEDURE DIAG CODE COk~E ~ ~ 4N i ~ ^DE'SCRFPTION . ~ - -~~ INS CHARGE hAYMENT! GUARANTOR »> PATIENT: LOUIS C RIEGEL. , 971284 ADJUSTMENT BAL/-NCE 9203743 PERFORMED BY: VERNNE N 6REINER DO PENN STATE FAMILY HEALTH PLACE OF SYC: SATELLITE CLIIIIC * 12/19/0" 94213 421.31 OUrppTIENf y1SI1' EST 93.00 rt 01/17/08 MEDICARE PAYMENI3: 45 34_ rt 01/17/08 MEDICARE CONTRACTUAL AD.AE . 36 32- ~ 04/2L08 AETNA PAYMENT 0 00 >' 11/25/08 CO-IlBIIRANCE BALAN . 0 00 rt 12/OLOA THdNC YOU Fdt PAYMENT . 11.34- 0.00 9291391 PERFORMED BY: VERNNE M 6REIIIER DO PEN4 STATE FAMILY HEALTH PLACE DF SVC: SATELLITE CLINIC 12/26/07 49214 48~ OUTPATIENT VISIT EST 143.00 OL17/08 MEDICARE PAYNENT~ 68,x_ OL17/OS MEDICARE CONTRACTUAL AD.bE 57 02- 04/2LD8 AETNA PAYMENT . 0 00 1L10/DS CO-INSURANCE BALAN . 0 00 E 12/OL08 THANC YOU FOR PAYMENT . 5.86- 1134 9659245 PERFORMED BY: VERNNE N 6REINER DO PENN STATE FAMILY HEALTH PLACE OF SVC: SATELLITE CLINIC 04/07/08 49213 4tib.0 OUTPATIENT VISIT EST 128.00 04/24/08 MEDICARE PAYMENTS 45 86_ 04/24/08 MEDICARE CONTRACTUAL ADJ1[ . 7D.67- 05/12/08 AETNA PAYMENT O DO 05/12/08 AETNA PAYMENT . 0 00 11/2L08 CO-INSURANCE BALANCE . 0.00 11.47 9892575 PERFORMED BY: VEANlff M 6REINIER DD PEMI STATE FAMILY HEALTH PLACE OF SVC: SATELLITE CLINIC Db/18/08 99213 414,)0 OUTPATIENT VISIT EST 128.E D7/07/De MEDICARE PAYMENTIE 45 86- 07/07/08 MEDICARE CONTRACTUAL AD.AF . 70 67- OB/D4/08 AETNA PAYMENT . 0 00 ,,.~,.~ -- --- - -- . INDICdTES NEN FINANCIA+. ACl"IVITY SINCE LAST BILL. OTHER CHARGES BILLED 70 YOl1R INSURANCE COMPANY, 17.26 If YOU HAVE ANY QUESTIOIiS ABOUT TIRi AI~!!T YOUR INSURANCE COMPANY PAID, CONTACT TIRBI DIRECTLY. FOR ANY OTHER 411ESTIDNS REGARDING YOUR BALANCE, PLEASE CONTACT OUR OFFICE. IF PAYNENT HAS BEEN MADE, THANC Y41 AND DISREGARD TIIS BILL. Schedule I, Exhibit 13 CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK ,~~, _ __ STATEMENT OP PHYSICIAN SERVICES iPIRIT PHYSICIAN SEF21/ICES 'AS GRANDVIEW AVE STE :'.10 :AMP HILL PA 1701'11 LOUIS RIEGEL 824 LISBURN ROAD APT 236 CAMP HILL PA 17011-7110 ACCOUNT # 1353994 ~ iv nNV Quesnows, a:~ase r_oeTncT: SPIRR PHYSICIAN SERVICES 717-97&4490 BATE PROCEDURE DIAG ~ f ' ' ~ QTY r~DkRGRip7WfA ~ti CODE CODE ~ : »> PATIENT: LOUIS RIEGEL 1353994 PERFORMED BY: SNARNALATNA NEEMA ND MD PLACE OF SVC: 21 PERFdBIED AT: FIS 10/'15/08 99223 781.2 INITIAL NDSP CARE LEVEL I 1L13/08 MCARE ERA PMI 11/13/08 MCARE ERA CgdfRlADJ 12/03/DS 433.61 CO INS - Cpp PERFORFR:D AT: HS 10/16/08 942:52 78L.2 StbSEQUENF NDSP, LEVEL II 11/13/08 MCARE ERA PM 1L13/OS MCARE ERA COlRR/ADJ 12/03/08 912.36 W IILS - C~ PERFORMED AT: ILS 10/17/08 942-i2 78L.'t SIJDSEQIfiM NDSP, LEVEL II 1L13/08 MCARE ERA PMF 1L13/OB MCARE ERA CDNFR/ADJ 12/03/08 912.36 CD IIS - COP PERFORMED AT: HS 10/18/08 99232 78i 2 SIbSEgFJENF NDSP, LEVEL II 1L13/08 MCARE ERA PIR 1L13/OS MCARE ERA CONFR/ADJ 12/03/DS 912.36 CO IHS - COP PERFORMED dT: NS 1D/:L9/08 992x2 id'a 2 SIBSEQUENF IDSP, LEVEL II 11/13/08 MCARE ERA PMf 11/13/08 MCARE ERA CONFR/AD,I 12/03/08 S12.36 CO INS - COp PERFD AT; NS 10/2D/OS 9423.2 i'81.2 SIBS~IJENf HDSP, LEVEL II 11/13/08 MCARE ERA PMi 1L13/OS MCARE ERA CONFR/AD.1 12/03/DS 912.36 CO I18 - COP PERRIAlED BY: VIDA FARIII FRI MD PERRIAMED AT: NS 10/'tL08 ~'r9238 78].2 FIOSpITAL DISCNAR6E c30 MI 1L13/OS MCARE ERA PMi 11/13/08 MCARE ERA CONTR/ADJ 12/03/08 912.54 CO MS - COP PERFORMED BY: VIDA FARID: MD FR1 PLACE OF SVC: 21 PERF01805D AT: MS 10/^c2/DS '9222 Q95.41 INITIAL NOSP CARE LEVEL I 1L17/08 MCARE ERA PMf 1L17/D8 MCARE ERA CDRR/ADJ I!®ICATES NEN FINANC:I:p.L ACTFVITY SINCE LAST BILL. 134.42- 29.97- 0.00 33.61 73.00 44.46- 11.18- O.DO 12.36 73,D0 49.46- 11.18- O.DO 12.36 T3.00 49.46- 11.18- 0.00 12.36 73.00 49.46- 11.18- D.DO 12.36 T3.00 49.4b- 11.]B- O.DO 12.36 lOD.DO 5D.34- 37.07- 0.00 12.59 ]54.00 91.46- 39.67- Schedule I, Exhibit 14 BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK Patient: LOUIS C. RIEGEL Chart Number: RIEL0000 Services ProHOed at: I1ULY SF1RR HOSPITAL- MGBS Amount Paid by Paid By Dates Procedure Procedure Charge Insurance Guarantor Adjustments Remainder 10/18/08 99254 HOSP CONSULT LEVEL 4 270.00 -122.15 -117.31 30.54 •' PATIENT RESPONSIBILITY ?AYPA~NI" UU~ ~Y: /p Z4~o9 ~ ~~,~ ,~~ ~~~ "PAYMENT IS EXPECTED UPON RECEJPf OF 1st STATEMENT BY THE STAMPED "PAYMENT DUE Q4TE' Past Due 30 Day Past Due 60 Days Past Due 90 Days Balance Due o.oo o.oo o.o0 30.54 IF PAYMENT HAS BEEN MADE RECENTLY, PLEASE DISREGARD THIS STATEMENT, THANK YOU Statement NumUer: 12750 **NOTICE: TOALL CO PAY PATIENTS** Date of istStatement: IF YOUR POLICY R~UIRES A CO-PAY AMOUNT 81T IS NOT PAID AT THE TIMEOF OFFICE VISIT ~ ONLY 1-COURTESY STATEN ENi WILL BE SENT. ACCOUNT WILL BE SENT TO COLLECTION WITHOUT FURTHER NOTICE Schedule I, Exhibit 15 __ _. JHOLY Holy Spirit Hospital ~ m~._. ~..... , ..a,..._ .e. ~.: 503 N 21ST STREET p q CAMP HILL PA 17011 The Spirit of Caring # 800-997-8573 For Account Information, Please C~11 800-997-8573 ~ ' Statement of ~Ac Transediaa Date Drscription .. .. . PREVIOUS BALANCE 09/30/08 DICYCLONINE lOMG 09/30/08 OXYGEN PER HOUR 09/30/08 NON EMERG LVL 3 FC 09/30/08 NON-EVA EAR/PUL OX FOR 02SATUR 10/24/08 MEDI PYMT-HOSP OP N10 MEDICARE OP A 10/24/08 NEDI C/A HOSP-OP N10 MEDICARE OP A 11/03/08 AETNA PYNT q38 AETNA -P~r~i~~ YOUR INSURANCE HAS BEEN BILLED.THIS IS YOUR CURRENT BALANCE. YOUR PAYMENT IS DUE UPON RECEIPT. THANK YOU. M1D MEDICARE OP A .00 038 AETNA .00 PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID. Amount .00 .50 54.00 519.00 55.00 -93.16 -502.43 -7.91 Schedule I, Exhibit 16 PLEASE NOTE: If a "1" appears in this column, ue have filed with your primary carrier. If a "2" appears, 1: HIGHNARR M®ICARB 8 we have also filed with your secondary carrier. Our records show your insurance a3 follow: 2: AETNA FINO PRO- ICD9 REB.N DESCRIPTION OP SERVICE AMOONT PAYMENTS/ IN90RANC8 YOUR DATE VIDHA CHAAOBD ADJ. pENDINO BALANCE 09~26~08 HJV 564.00 88305 TISSUE EXAM 8Y PATHOLOGIS 265 00 03/17/09 AETNA HMO PAYMENT . 0.00 7.05 2 03/03/09 HGS ADMIN ADJ 229.74 03/03/09 HGS ADMIN PAYMENT 28.21 0926/08 HJV 535.50 88305 TISSUE EXAM BY PATHOLOGIS 530 00 03/17/09 AETNA HMO PAYMENT . 0.00 14.10 2 03~03~09 HGS ADMIN ADJ 459.48 03/0309 HGS ADMIN PAYMENT 56.42 09/26/08 HJV 535.50 88312 SPECIAL STAINS 235 00 03~17~09 AETNA HMO PAYMENT . 0.00 5.05 2 03/03/09 HGS ADMIN ADJ 209.74 03/03/09 HGS ADMIN PAYMENT 20.21 Visi our ne and improved web site pagiconsult nts. com for answ rs to ny of your frequently asked questi ns \D \M ' \ _ ~ \ \ ~~ ~ AccovNr BALANCE (REFER TO "DUE FROM PATIENT' FOR S26.20 AMOONT TO PAY.) CORAENT BALANCII OVER 30 DAYS OVER 60 DAYS OVER 90 DAYS OVER 120 DAYS DDR PROM PATIENT 526.20 E0.00 50.00 50.00 50.00 826.20 PROVID8R9 xENRY s vENeRVA rro ACCODNT NDMBSR 103634 NAME LOUIS C RIEGEL FOR HILLINO INQDIRIE9, CALL 1717)763-0430 STATEMENT DATE MAEE CNSCR PAYABLH TO 03/26/2009 PENNSYLVANIA GASTROENTEROLOGY CONSULTANTS PENNSYLVANIA GASTROENTEROLOGY CONSU PAYMENT 899 POPLAR CHURCH ROAD DDE 8Y CAMP HILL, PA 17011-2206 04/15/2009 IIANIIk91~~I11N~11RY1MIN16~H9WtlIY~6 Schedule I, Exhibit 17 REV-1513 EX + (9-001 SCHEDULE) COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT Louis C. Rie el 21 09 0453 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME ANO ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outr' ht spousal distributions, and bansfers under Sec. 9116 (a) (1.2)] 1. Bethann Edwards Lineal 2,713.30 13 Pennsboro Drive, Enola, PA 17025 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OFPART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET S (Ir more space Is needetl, insert additional sheets of the same size) LAST WILL AND TEBTAMENT OF LODIS CLARENCE RIEGEL I, Louis Clarence Riegel, presently residing in Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind and memory, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils previously made by me. ITEM I I direct that all inheritance and estate taxes becoming due by reason of my death, whether such taxes may be payable by my estate or by any recipient of any property, shall be paid by my Executor out of the property passing under this Will, which is not specifically devised or bequeathed, as an expanse and cost of administration of my estate. My Executor shall have no duty or obligation to obtain reimbursement for any such tax paid by my Executor even though such tax was paid on proceeds of insurance or other property not passing under this Will. If the assets not specifically devised or bequeathed are not adequate for the payment of all such taxes, then the recipients of the property specifically devised and bequeathed shall each pay a pro rata portion of any such tax based upon the valuation of the property received by each such recipient as finally determined for Federal Estate Tax purposes, or if no such deterinination is made, then for applicable State Inheritance Tax purposes. ITEM II: I hereby exercise all powers of appointment which I may have at the time of my death in favor of my Executor, and all property subject to all such powers of appointment shall be included in my estate. PAGE 1 OF 5 PAGES rTEM I r: I hereby give, devise and bequeath all of my estate, whether real, personal or mixed, of whatsoever nature or kind and wherever located, unto my daughter, Bethann M. Edwards, provided that she survives me by thirty (30) days. ITEM IV: In the event that my daughter, Bethann M. Edwards, predeceases me or does not survive me by thirty (30) days, then I give, devise and bequeath all of my estate, whether real, personal or mixed, of whatsoever nature or kind and wherever located, in equal shares, unto my grandsons, Shawn M. Edwards, Brett K. Edwards and Scott B. Edwards, or their issue, per stirpes. ITEM V: Zn addition to such other powers as my Executor may be granted by law, or under previous portions of this Will, he shall have the following powers: a) To retain investments I may have at my death so long as my Executor may deem it advisable to my estate or trust to do so. b) To vary investments, when deemed desirable by my Executor, then to invest in such bonds, stocks, notes, real estate mortgages, or other securities, or in such other property, real or personal, as he shall deem wise, without being restricted to so-called " legal investments " c) In order to effect a division of the principal of my estate or of any trust or for any other purpose, including any final distribution, my Executor is authorized to make said divisions or distributions of the personalty and realty partly or wholly in kind. If such division or distribution is made in kind, said assets are required to be divided or distributed PAGE 2 OF 5 PAGES at their respective values on the date or dates of their division or distribution. d) To sell either at public or private sale and upon such terms and conditions as the Executor may deem advantageous to the estate, or any trust, any or all real or personal estate or interest therein owned by the estate or trust severally or in conjunction with other persons or acquired after my death by my Executor, and to consummate said sale or sales by sufficient deeds or other instruments to the purchaser or purchasers, conveying a fee simple title, free and clear of all trusts and without obligation or liability of the purchaser or purchasers to see to the application of the purchase money or to make inquiry into the validity of said sale or sales; also, to make, execute, acknowledge and deliver any and all deeds, assignments, options or other writings which may be necessary or desirable, in carrying out any of the powers conferred upon my Executor in this paragraph or elsewhere in my Will. e) To mortgage real estate, and to make leases of real estate. f) To borrow money from any party, to pay indebtedness of mine or of my estate or of a trust, expenses of administration or inheritance, legacy, estate and other taxes. g) To pay all costs, taxes, expenses and charges in connection with the administration of my estate or trust. My Executor shall pay the expenses of my last illness and all funeral expenses. PAGE 3 OF 5 PAGES h) To vote any shares of stock which form a part of the estate or of any trust, and to otherwise exercise all the powers incident to the ownership of such stock. i) In the discretion of my Executor, to unite with other owners of similar property in carrying out any plans for the reorganization of any corporation or company whose securities form a part of the estate or of any trust. ITEM VI: Any person who shall have died at the same time as Testator, or in a common disaster with him, or under such circumstances that it is difficult or impossible to determine who died first, or who shall have died less than thirty (30) days after the death of Testator, shall be deemed to have predeceased him. ITEM VII: I hereby nominate, constitute and appoint my daughter, Bethann M. Edwards, to be the Executrix of this my Last Will and Testament. My Executrix is specifically relieved from the duty or obligation of the filing of any bond or bonds in this or any other jurisdiction. ITEM VIII: All references to the Executor and/or any such terms in the masculine form shall be deemed to include a reference to the Executrix and/or any such comparable term in the feminine form, when and if applicable, and shall have the same force and effect as if set forth originally in the feminine form. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my Last Will and Testament, consisting of this page, the preceding three (3) pages, and the following one (1) page, this s1" ,o ~~(n~ 31" day of VC.LO~,~ , 1996. ~ti,, Ceti,-~~P ~a;~.P Louis Clarence Riegel PAGE 4 OF 5 PAGES We, the undersigned, hereby certify that the foregoing Will was signed, sealed, published and declared by the above- named Testator, as and for his Last Will and Testament, in the presence of us, who, at his request and in his presence and in the presence of each other, have hereunto set our hands and seals the day and year above written, and we certify that at the time of the execution thereof, the said Testator was of sound and disposing mind and memory. ~/, ~9A-0/y{A.~r~~E. ~I~i'W (SEAL) Residing at ~~7 ~fn ~r <~~,3.~~ ~etc~Y, II/I %% I YTRnninY,4i.rn/ ~~ 171 U ~~C,Sv~2 \ 1 ~~Unr„-._~. (SEAL) Residing at S`~" YVurl ~, ~Nwn~,e J lYc~~ ~~,..ls(r~. PF} l7a13 Residing at 'E E,o1 C~c-~~ "°Y~v1~ utv~,~.~~o l~.nci,~ f~ ~ 7 I ~ ~') PAGE 5 OF 5 PAGES ACKNOWLEDGMENT OF PENNSYLVANIA COUNTY OF DAUPHIN I, Louis Clarence Riegel, the Testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that Z signed and executed the instrument as my Last Will; and that i signed it willingly and as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by Louis Clarence Riegel, the Testator, this 3~ -~' day of ~ r_=t~(,,,,J 1996. ~C7~G~~ l:~~u~V~(t.C:P !l;(t fir. ~) Louis Clarence Riegel Testator C~ ._ C Notary ublic My Commission Expires: AFFIDAVIT ~ NoMrlal Seal GYnNIa M. Maeyyhew, Notrvr, °~mec ~UWOr Paeton 7wp., Dauc~ ~:~~ ^,centy COMMONWEALTH OF PENNSYLVANIA j ~V Commlasion Explrea ?:- ~~>, tggg ) __ COUNTY OF DAUpIIji~;]I]N ( ~j p~ /) sr~,We, V ~.KAnJ.Mt~ rn7. , e~IK~t~7 (~~iu/. ! ~. ,_ ~Qr~ and \ `\~~-v~Q .C ~,.~,,, ~. , 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 tha Testator sign and execute the instrument as his Last Will; that the Testator signed willingly and executed it as his free and voluntary act for the purposes therein expressed; that each subscribing witness, in the hearing and sight of the Testator, signed the Will as a witness; and that, to the best of . our knowledge, the Testator was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. 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