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HomeMy WebLinkAbout07-31-09IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Estate of Norma Jean Martin, Deceased -cam Orphans Court Division ~~ ~,~ f ,;.,, No. 09- U~1 ~ ~ `:~ cn ~:~~~~ ~:M7 ~ ' t~ ~..~ ~ ~~ PETITION FOR SETTLEMENT OF SMALL ESTATE r•~ G r C4 c~ AND NOW COMES, Dorothy Haeberle, by and through her counsel, Law Offices of Peter J. Russo, P. C. and it avers the following in support of her petition for settlement of small estate: 1. The petitioner Dorothy Haeberle, who is the daughter of Norma Jean Martin., the decedent. 2. The petitianer has an interest in the estate of Norma Jean Martin. 3. The above named decedent died intestate and no letters of administration have been issued. 4. The names, addresses, and relationships of all persons having interest in the estate of the decedent as heirs or next of kin are as follows: ..~ j .~..~; ~~ ,^ ~::~ 'f:~: _---s Name Address Relationshi Norman Morgan 59 Fawn Ave Son New Oxford, PA 17350 Dorothy Haeberle 59 Fawn Ave Daughter New Oxford, PA 17350 Shawnna Varner P.O. Box 167 Daughter Cashtown, PA 17310 Beverly Brewer 34 Davis Ave Daughter Gettysburg, PA 17325 Harry Morgan 4006 Warm Springs Road Son Chambersburg, PA 17201 William Martin 368 E. King Street Son Chambers, burg, PA 17021 Dennis Morgan Camp Hill Prison Son P.O. Box 200, Inmate # GV3297 Camp Hill, PA 17001-8837 5. The decedent was not survived by any persons entitled to claim the family exemption under 20 Pa. C.S.A. Section 3121. 6. The total value of the decedent's personal estate is less than $25,000 and consists of the following assets that have the following values: Asset Value Checkin $127.52 Savin s $151.39 Comcast $36.78 Total $315.69 7. The following is a list of all known, unpaid credit tours and the amount of their claims, which claims are proposed to be paid from the assets of the decedent. Name Amount Spring Grove Family Care Center $78.24 South Penn Eye Center $32.77 Met-Ed $20.05 Choice Family Pharmacy $73.81 Hanover Cardiolo y $33.38 S rin Grove Area Ambulance Club $61.98 Department of Public Welfare $8,151.26 Total $8,451.49 8. A proposed Pennsylvania Inheritance Tax Return shall be filed in the amount of tax due upon the decedent estate will be paid as set forth therein. A true and correct copy of the inheritance tax return is attached hereto as Exhibit A. 9. It is proposed that the following distribution of the decedent estate be made to the following creditors, heirs, or next of kin: Name Distribution S rin Grove Family Care Center $78.24 South Penn Eye Center $32.77 Met-Ed $20.05 Choice Family Pharmacy $73.81 Hanover Cardiology $33.38 Sprin Grove Area Ambulance Club $61.98 Total 300.23 WHEREFORE, your petitioner respectfully requests your honorable court to decree the distribution of the decedent's personal estate to the persons entitled thereto as set forth in paragraph 9 above. Date: ~~30~ 0`~ Peter J. Russo, sE quire Attorney I.D. No. 72897 Elizabeth J. Saylor, Esquire Attorney I.D. No. 20013 Attorneys for Petitioner 5006 E. Trindle Road, Suite 100 Mechanicsburg, PA 17050 Telephone: (717) 591-1755 Facsimile: (717) 591-1756 VERIFICATION I, Dorothy Haeberle, verify that the statements made in the forgoing document are true and correct to the best of my knowledge and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C. S. § 4904 relating to unsworn falsification to authorities. Dated: ~ °~' ~ ~ ~~ Dorothy Haeber ' 15056051058 REV-1500 Ex (06-05) OFFICIAL USE ONLY PA ~partmeM of Revenue County Code Year Fde Number l3ureeu of Individual Taxes INHERITANCE TAX RETURN Po eox 280601 Harrisburg, PA 1712&0601 ~ RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 192-30-0502 11/18/2008 09!16!1938 Decedent's Last Name Suffix Decedent's First Name MI Martin Norma J (If Applicable) Enter Sutvivinp Spouse's Intormatlon Below Spouse's Last Name Suffix Spouse's First Nart~ MI spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW I, 1. Original Retum 2. Supptementat Return 3. Remainder Retum (date of death prbr to 12-13-82) 4. limited Estate 4a. Future Interest Compromise (date o1 5. Federal Estate Tax Retum Required death alter 12-12-82) 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 6. Tda1 Number of Sate Deposit Boxes (Attach Copy of will) {Attach Copy of Trust) 9. Litigation Proceeds Received 10. Spousal Povery Credit (date of death 11. Election to tax under Sec. 9113{A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - TH18 SECTION MUST BE COMPLETED. ALL CORRESPONDENCE ANO CONFIDENTIAL TAX INFORMATION 8HOULD BE DIRECTED T0: Name Daytime Telephone Number Peter J. Russo (717) 591-1755 Finn Name (If Applicable) REGISTER OF WILLS USE ONLY Law Office of Peter J. First line of address 500fi E. Ttindte Road Secwid line of address Suite 100 City or Post Office State ZiP Code DATE FILED Mechanicsburg PA 17050 corespondent's e-mail address: PrussQpjrlaw.com Under penalties of perjury, I dealers that i have examined Ihis return. including acxonipanying schedules and statements, and to the best of my knowledge and belie!, it ~ true, oomect and complete. E)edaration of preparer other Than the personal representative is based on all infonr-atieon of which prepsrer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEABE U8E ORIGINAL FORM ONLY Side 1 15056051058 15056051058 J 15056052059 REV 1500 EX Decedent's Social Security Number Norma J Martin 192-30-0502 Decedents ~: RECAPITULATION 1. Real estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Corporation. Partnership or Sde-Proprietorship (Schedule C) ..... 3. 4. Mortgages 8 Notes Receivable (Schedule D) ............................. 4. 5. Cash. Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ........ 5. 164.30 6. Jointly Owned Property (Schedule F) Separate Billing Requested ....... 6. 151.39 7. Inter-Vivos Transfers 8 Miscellaneous Non•Probate Property {Schedule G) Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1-7) .................................... S. 395.69 9. Funeral Expenses 8 Administrative Costs (Schedule H) ..................... 9. 1,265.00 10. Debts of Decedent. Mortgage Liabilities, 8 Liens (Schedule I) ................ 10. 8,451.49 11. Total Deductions {total Lines 9 8 10) ................................... 11. 9,716.49 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. -9,400.80 13. Charitable and taov~emmental Bequests/Sec 9113 Trusts for which an electlon to tax has not been made (Schedule J) ........................ 13. 14. Nst Value Subject to Tax {Line 12 minus Line 13} ........................ 14. -9,400.80 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0 45 -9,400.80 15. 0.00 16. Amount of Une 14 taxable at lineal rate X .0 _ 16. 17. Amount of Une 14 taxable at sibling rate X .12 17. 18. Amount of Une 14 taxable at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. 0.00 Z0. FILL IN THE OVAL IF YOU ARE RECUESTiNG A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV 1500 Ex Page 3 Flle Number Decedent's Complete Address: DECEDENTS NAME OECEOENTS SOCIAL SECURITY NUMBER Norma J Martin 192-30-0502 STREET ADDRESS - -- --- ~ - -- 25 E. Third Avenue Apt E-4 cmr Spring Gorve STATE PA ZIP 17362 Tax Payments and Credits: 1. Tax Due (Page 2 Une 19) 2. Cre~itslPayments A. Spousal Poverty Credit _ l?. Prior Payments C. Discount 3. tnteresUPenalty it applicable D. Interest E. Penalty (1) Total Credits (A + 8 + C) (2) Total tnteresUPenalty { D + E } 4. K Line 2 is greater than Une 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fllf in oval on Page 2, Une 20 to roquest a refund. S. Kline 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 BAIANCE DUE. (3) (4) (s} (~) (5B) Make Check Payable to: REGISTER Of WILLS, AGENT o.oo 0.00 0.00 0.00 PLEASE AHSINER THE FOLLOWING QUESTIONS BY PLACING AH "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: f Yes ^ No erred :......................................................................................... a. retain the use or inoorrle of the property trans 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 oaxrrred after December 12,1982, did decedent aansfer 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 ocher non-probate property which contains a beneficiary designaiion? ........................................................................................................................ ^ IF THE ANSWER TO ANY OF THE A60VE 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 [T2 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or fa the use of the surviving spouse is zero (tl) percent 172 P.S. §9116 (a) (1.1) (ri)]. The statute des not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disdosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. Far dates of death on or after .iuty 1,2000: The tax rate imposed on the net value of transfers from a deceased duld twenty-one years of age or younger at death io or for the use of a natural parent, an adoptive parent, or a stepparent of the duld 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 onefialf (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 172 P.S. §9116(a)(1.3)]. Asibling isdefined, under Section 9102, as an individual who has at least one parent in oammon with the decedent. whether by Mood or adoption. REV•t508 EX+ (6-98) r COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDI~LE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FlLE NUMBER Alnrm~ _1 Marfirl Include the proceeds of litigation and the date the proceeds were receArea oy the estate. ell eNne.rty teintly-owned wllh rlaht of survlvorshlp must be disclosed on Schedule F. (If more space is needed. insert additional sheets of the same size) REV•1509 EX+ (6.98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCMEDIIILE F JOINTLY OWNED PROPERTY ESTATE OF FlLE NUMBER Norma J. Martin If an aaaet waa made joint within one year o11he deadent'e date of death, it must be roported on 8chadule G. SURVIVINN(33 JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Norman Morgan 59 Fawn Ave Son New Oxford, PA 17350 B. C. .IAINTLY.OWNED Pt~OPERTY: ITEM tdlldpER LETTER F=OR JOINT TENANT DATE MADE JOINT DESCRIPTION Of PROPERTY INCLVUE NAME OF FINAkCIAL INSTITUTION AND RANI( ACCOUNT NUN{BER OR SMAILAR IDENTIFYING NUbtBER. ATTACH OEEO FOR JOINTLY•HELD REAL ESTATE. OAr E OF DEATN VALUE OF ASSET ~, OF DECO 5 AJTEREST GATE OF DEATN VALUE OF OECEOENtS INTEREST t• ~ Savings Aooount 571.87 25 151.39 TOTAL Also enter on tine 6. Recapitulation] I S 151.39 (li more space is Headed, insert addtiortal streets of the same sine) REV•1511 EX. (12.99) SCNEp1~LE H COMMONWEALTH OF PENN6YLYANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATNE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Norma J. Martin Debts of decedent must be reported on Sctledule 1. ~~ DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: ~ ~ Grove-Bowersox Funeral Home, Inc. 1, 230.00 B. ADMINISTRATIVE COSTS: ~, Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s}IEIN Number of Personal Representative{s} Street Address City State Year(s) Commission Paid: 2. Attamey Feas 3. Family Exemption: (H decedent's address is not the same as daimant's, attach explanation} Claimant Street Address City State Relationship of Claimant ~ Decedent 4. Probate Fees g. AcoountaM's Fees 6. Tax Retum Prepares s Fees 7. Zip Zip 35.00 TOTAL (Also enter on line 9, Recapitulation) ~ S 1,2fi5.00 4~ ~ space k asedss<, iastA addiliaaal sheet,` oil tihR sam~a sl=,e) Grove-Bowersox Funeral Home, inc. 64 S. Broad St, Waynesboro, PA 17288 (717)762 2811 DAB November Z0, Za08 SERVICE NO. M~ DECEASED NAME Notma Jean AAarflrt DATE OF DEATH November 18, ~ PLACE OF DEATH Residence Spring Grove, PA Chsrpes am only br rx are we are required b!I law a ~ a or a pay use any' we Mn e pay rar yam, d~rsbt apprvre cif ~m~ipen e a a ~ae~ina fon~tm~~iata b~7r1aG K weld ior- bm~bailmi~np, wa Milt Yeo~ w~hy- bebw. _ _ . ~'- ~ STA'~EMENT t3F FUNERAL GOODS~AND SERYICES~ SELECTED ~ ~ :. . 1. Professional Services - - - - - FORWARDING OF REMAINS TO: PROFESSIONAL SERVICES $ $ BASIC SERVICES OF STAFF $ 500.00 RECENING OF REMAINS FROM: EMBALMING $ $ OTHER CARE OF THE BODY S $ HAIR DRESSER $ CREMATION OF BODY $ $ 500.00 $ 2. Faaiities ~ Equipment $ FACILITIES FOR SERVICE $ D. CASH ADVANCES: $ FACILITIES FOR VIEWING $ CEMETERY OPENING /CLOSING S SERVICE AT OFF PREMISE $ CEMETERY LOT S MEMORIAL SERVICE $ WEEKEND CHARGES $ GRAVESIDE SERVICE $ LAMINATED OBITUARIES $ 3. Automotive Equipment $ CLERGY HONORARIA $ s MUSICIAN HONORARIA $ TRANSFER TO FUNERAL HOME $ 195.00 ~-~ST $' HEARSE $ OBITUARY NOTICE $ OTHER VEHICLES $ OBITUARY NOTICE S $ DEATH CERTIFICATE $ ADDITIONAL MILEAGE -SPRING $ 175.00 CORONER FEE $ 60.00 ADDITIONAL MILEAGE -HERSHEY $ 300.00 MARKER ENGRAVING $ $ We charge you far our services in obtaining:(specity cresh advance items). $ ~~'~ B. CHARGES FOR MERCHANDISE: CASKET $ $ 80.00 Cash SUMMARY OF CHARGES: OUTER CONTAINER $ A. Ctii4RC3ES FOR SERVICES $ 1170.00 Outer Container B. CHARGES FOR MERCHANDISE $ ALTERNATE CONTAINER $ C. SPECIAL CHARGES $ REGISTER BOOK $ D. CASH ADVANCES $ gp.pp MEMORIAL FOLDERS $ E. SALES TAX, IF APPLICABLE $ THANK YOU CARDS $ TOTAL FUNERAL. HOME CHARGES $ 1230.00 BURIAL CLOTHING $ LESS CREDIT AND PREPAYMENTS: CREMATION URN $ TO BE PAID BY PRE-NEED S UNNERSAL VAULT $ CREDIT BY CREDIT CARO $ CRUCIFIX $ LESS VA BENEFIT $ TEMPORARY MARKER $ LESS AMOUNT PAIO $ $ TOTAL CREDIT $ $ BALANCE DUE$ 1230.00 of any Iaw, a crematory re4uireneenb have required the purchase of The only w~n~r on the casket and / a outer trurlal corrtoirter sold in . any err the ion s Nsted ataov~e the hw or t Is e~lained below. oaraKa~n wMh t(ria aavEoa to the areas n warranty. itany. prantad - Cemetery requires a cave proof outer container by the ~ ThY turreral home aakras rro werrardy, or lmp6ed~ ~P~ to fie casket sndiar oubrtuahl aorrleLnr. ~ - - . BUAng Toffy Brewer Reason for Embatrning PubBc 9 or holding body longer than 24 hours 3a ~~ s~ I hereby spree Ihart I have examined the abOVe staled i0eras and forard glerrr to be correct and aooordinp to the anarrgernerrts requesEed and I hereby adatoMrledpe rooeipt of a Dopy of this rtrerrrorar-dum and apreernent. I hereby represent that I hsvs sttlAdertt funds artd assets legally available for payment of cash price and hereby agree acrd oovenaM jointly and sevwa to make paynrrrMs or t o.00 wtMrirt 30 deya A late charge of ~ 9t- per month smountirtg to ~~X. per year is applied ~ the unpaid balance trepinninp days hnm the date of this apneerrrerrt AM addttbnal servioee or merd~dbe ordere0 or requested atbet the dale of the aQreearerrt wbi be considered part of this agreement artd ttre coat thereof wilt be're0ecled on the ltrrd 1 adcnoyNedpe that I have received lire general prone list and have been opened for review the casket price list end the outer burial oontairter price pet AOCEPTIINCE: x x y err' rareral Grove-~o~e~sox FvNERAi,$oME, nvc. So S. Broad Street Waynesboro, PA i~2b8 Telephone:717-76z-28u JAM~P~+~~/owner OX JAMES W. l:'R1TLiNGER JEANETTE M. MOORS Funeral Dltectoa M~e~-~®®verso~ HOME Divl:ioa of Grove-Bowaaaoc Fnneial Homo. Ine. WsyAaboro. PA ~ S. WashinSton Street Greencastle, PA 17~ Telephone: n7-597-251s JEREMYA. BOWERSOX NATHAN NARDI M~s~ June 4, 2009 Mrs. Beverly Brewer 34 Davis Avenue Gettysburg, PA 17325 Dear Bev. We thank you for your payment of $180.00 as payment in full for the services of your mother, Mrs. Norma Jean Martin. We highly value the trust you have placed in us and work very hard to exceed your expectations and maintain your confidence in us. It has always been the goal of our staff to provide meaningful services and ease your burden at a difficult time. If we can be of any further assistance, now or in the future, please do not hesitate to call or stop in. Sinc ely, J es~~B owersox President www.bowersoxfuneraThomes.com STATEMENT Grove-Bowersog >rUx~ewL xo~, n~rc. so s. Broad street Waynesboro, PA i7zb8 Telephone: 717-76~2Bii 3ames A Bowetao~c, Superviaor Bev Brewer 34 Davis Ave. Gettysburg, PA 17325 Date: June 1, 2009 Services for: Norma Jean Martin M~i]ler-Bowersog r~.rNlaa~-i.xo>~ su s. w~~C°n street Green A irrss Telephone: n~-597-25ii Jeremy A Boweraox, Supervisor ~rt~ts: Net so eqs tran seMoe. tx tm dyra on ~ unpaid t~at~noa 31 drys ate eaeNoa and each moM- n~.tex t~.~ nats,rx. 11 /20/2008 Services Rendered $1,230.00 Humanity G'rfts payment $50.00 $1,180.00 12/24/2008 Payment Received $100.00 $1,080.00 112112009 Payment Received $100.00 $980.00 2119!2009 Payment Received $100.00 $880.00 3/18/2009 Payment Received $100.00 $780.00 4/27/2009 Payment Received $300.00 $480.00 5/16/2009 Payment Received $300.00 $180.00 As per our agreement no interest will be charged as long as monthly payments of $100 continue. www. bowersoxfuneralhomes.com ~ enns lvania SCHEDULE I ~PARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT pEC~ENT __ ESTATE OF FILE NUMBER Norma J. Martin R~m~t ~hts Ineurl~ tw the decedent orio~ to death that romained unpaid at the Ante Of death, inclining unreimbursed medical expeaees. If more space is needed, insect additional sheets of the same size. SPRING GROPE FAMILY CARE CENTER 22 ROTH CHURCH ROAD SPRING GROPE, PA 17362 Forwarding Service Requested 23b60 NORMA J MARTIN 25 E THIRD AVE APT E4 SPRING GROVE PA 17362-1241 12/31/08 MC PISA Card~~ Sign SPRING GROVE FAMILY CARE CENTER 22 ROTH CHURCH ROAD SPRING GROVE, PA 17362 ~RFTURNT,OP".PORTION •'RETAlN LOWEA j . .'.2*. .t-.~: MESSAGES EXPLAINED 8 *** PLEASE PAYtUFON RECEIIPT,ddIFttBI11LLtING QUESTCCION1S CtALL 87p~~7-856-i22t79!l!EXT 2024 *** *** P~~~~~~~~~~*~~~~*~~*~ :~I ~h~k~1F~~k~F~Fiti1b~F~k*~~~kikit~*ilt~t~:Ut~c~Ir9lr~Ir~~,Ar~Ilr~~knAc~fr~r~k~k~llr~k~~F**~*~***~r*~**~ *~r**** Insurance Charges pending to.Prv: 148.00 Ins Pay/Adj against Ins pending 83.31 0.00 b4.69 03/08/07 1 2 F HOME VISIT EST PATIENT 2 99348 692.0 91.00 91.00 05/31/07 2 Unapplied Check-Personal Payment 12.76 -12.76* F-Your ins did not pay us so it has become your responsibility to pay us. DATE LAST PAID AMOUNT ~ • • 05/31/07 12.76 78.24 0.00 0.00 0.00 0.00 64.69 0.00 142.93 SPRING GROVE FAMILY CARE CENTER ~~ ., • MAKE cHecK 22 BOTH CHURCH ROAD PAYABLE TO: SPRING GROVE, PA 173b2 78.24* Ph: (877)-SSb-2279 PATS 1-NOAMA J I4ARTIN PRY 2-FAULRNER, NANCY MD Acct: b19 Date: 12/31/08 Page 1 of 1 rn tD ~ ,- O M OM - ~ "t' <y C rl ~ ~ p O ~ ~ _ _ "'i . ~`~ U Z ~'~ ~,~ .._I ~ ~~ _ ~ I J 1 _`c C13 „L` W 1 ~? `n U ~ ~N ~ OD W OC ~ cn~0~ °'~ ~CO~ a c ~~~,~~ V N~~ !o ,,. . ~ (LS ~ ~ ~~ ~~~ W O c ~pX T Q W rn2~e tI L H '"~ y j M MM M C r ~ W ! N ~, ~~ W p ~ L(7 r Q N=r~LL. = D !j ~ Z ~ ~ ~ ^ J ~ ~ _ ~ U r J y: U • ~ = ~ ~- ~ C' (J r ~ ~_ i a ~' ~ ° ~ ~ ~ O ~C ~ O w ~ O O ~ U -- Q F.Q. u; ~~a ul ~ 'I ~'~ `fY :. il; W -- ... ~,v lL• .c.. W ~ N ~ ~~ • 1 "~ Ll: _~ ~:.. a~•- .~-. •~. 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Zz W as a, W Q U } W~~ W ~^ d Ja H ~> poz V) N = x ~v W ~- U~ Y< r Sn LL! m z U Q Q H } O C z w Q Q W O ~1. ~ •~, •z w i'i ~ ~ ~ `y ~ SPRING GROVE PA 173fi2 Billing Period: Nov 01 to Dec 01, 2008 for 31 days Bill Based On: Actual Meter Reading Final Bill Stanr~arrl RQ~irionti~l .,~: court um-, .,, - - oun ue Your previous bill was 238.44 Total paymentsladiustments _110.38 Batance at billing on December 03, 2008 126.06 126.06 Current Basic Charges Met•Ed -Consumption x,29 Met-Ed -Payment Plan Balance -19fi.30 Total Current Charges ~~b`~ -106.01 o ue an - ease a s amoun ?.!,'.~Y1ir. ~ t _ 4'.1: ~I:'~t '1 .'_. J - y~. •~' ! •ro1',1 t rit .~.. ~}~ 11. , ~ 1. ~ :.513'. +l l .v.- '~1 ~,. ~ sera n orma on ~:~ r ~:~ -~.: . • Bill issued by: Customer Service 1-800-545-7741 Met-Ed Automated O e R rU ` • ~ ~-'~77 PO Box 1fi001 a ~ Collectio ~ 1~-• ~ ns Reading PA 19612.6001 1-800-962-4848 visit us on-line at www.firstenergycorp.com ~~~ •! l.k• ~. `.i '1 1 ~ t ~ J:~% 1 _ s ~~ ..!y~ r v t t . x' 1t~. 'w, _ • ,T. ,~ i ~' ~_.~ ~~ ~~- = ~ , Price;to;Com are'tMe sa e.' ~ - Your current PRICE TO COMPARE for generation and transmission from Met-Ed is listed beiow..For you to, save, a supplier's price must be lower Standard Residential - 0002241698 6.6 cents per kWh Customer reserves the right to shop for an electric supplier. ,- ' _ ee o erg. es or a ona_ - i orma on~ an a one;.n.4rr~ ers . , ~~~ ----•~ a FistFi~ergry. carrpen` ~i~~~~~~~~~i~~~~~,e~~~~»i~~~~~~~~~~~~~~~~e~~~~~~~~~~~~~~~~~~~ *****e****a**AUTO**3-DIGIT 173 00020367 O1 AT 0.346 P2 NORMA JEAN MARTIN DOROTHY HAEBERLE MET-ED 59 FAWN AVE PO BOX 3687 NEW OXFORD PA AKRON OH 44309-3687 17350-9778 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~•~~~~ Return this part with a check or money order Payable to Met-Ed Account Number: 100059015055 Amount Paid Please Pay s2o.os Due By January 02, 2009 i i i 7 i i 0210005901505500000000000000000000000000000000020055 . ~ When contacting an Electric Generation Supplier, please provide the customer numbs below. Call Met-Ed at 1-800-545.7741 wlth questions on these charges. ~; Total Distribution Charges Transition Generation Transmission Basic Charges Customer Number: 08035873210002241698 -Standard Residential - ME-RSD Distntw6on Customer Charge 824 KWH x 0.026165 State Tax Surcharge Total State Tax Surcharge Charges Total Charges Payments: 1lrosros 824 KWH x 0.007760 824 KWH x 0.046580 824 KWH x 0.019040 8.11 21.56 0.06 0.10 i 29.67 6.39 38.38 15.69 1 t. ~.. 0.16 09 - _ .~• • t. Amount -110.38 Total Payments .~.~$ ; Total Payments and Adjustments -~110.~ l . A 'r` ^w^ ~ Standard Residential ~• f' • Meter Number W87350119 I Present KWW Reading (Actual) 4,091 Previous KWH Reading (Actual) 3,267 Kilowatt Hours Used 824 Usage Comparison ~~ ~• I ~soo X400 X200 1~ •~ rfi II ~ _ 4• + ; '7W ~ A A A A A A A A A 0 D J F M A M J J A S O N D ~~ A-Actual E-Estimate C-Customer N-No Usage I Average Daisy Use (KWH) Average Daisy Temperature Days in Billing Period Last 12 Months Use (KWH) Average Monthly Use (KWH Dec O7 33 42 31 Dec OS 27 43 31 11,085 924 ' CHOICE FAMILY PHARMACY A FINANCE CHARGE OF 1.50 ~ PER MONTH 8 SOUTH SIXTH STREET (AN A13NU'AL PERCBNTAGE RATS OF 18.0) OR A MCSHERRYSTOWN, PA 17344 MINIMUM SERVICE CHARGE OF $ 1.00 WILL BE CHARGED ON ALL AMOUNTS 2$ DAYS OR MORE PAST DUE STATEMENT OF ACCOUNT PAYMENT DUS~~:BY: 03/02/09 WARNING! TIiIS ACCOUNT IS NQW 90 DAYS PAST DUE!!• .. ~. STATEMENT DATE: 02/03/2009 .:. '~ . ~ .:, PHONE: 717-630-200 PMT DUE. .03/02/09 MARTIN, NORMA JEAN MARTNJ 0 DAYS . ;.1:.,Q6 :.: 59 FAWN AVENUE GRP-CF 0 DAYS . 2 8 .: 2 3 :~ NEW OXFORD PA 17 3 5 0 PAGE 1 0 DAYS. ~ >: ' 42.36 ?2.72 AMOUNT PAID DUE..'> _ _ _ _ _ _ _ _ _ _ _ _ _ P_ LBASE DETACH H_ER8 A_Np FtET_ URN TOP PORTION WIT~i YOUR PAYMENT CHOICE FAMILY PHARMACY - - 9 S~LiTFi RTXTU Crr+o~~r - - - ~' -~itn~ir~+flnvn~nn:~:: - ;~,~- ~ .: ~ :.- - - - - - - - - - - - - i i L C 11Y -.-_.~.~. CHARGE ,, .. p~ou~ .~-t.~TCS rr~urc~ cr~ ~L cuss;`, AMOIINT ??UB 'PlIIB;Ir .. :,. ... ...:_.. .:.. PAY~SSHTB &.<CR$AZ , 71.65 + .00 + ~ 1.07 a 72.72 - .00 a 72.72 • CHOICE FAMILY P~l[ARMACY A FINANCE CHARGE OF 1.50 ~ PSR MONTH 8 SOUTH SIXTH STREET (AN ANNUAL PERCENTAGE RATE OF 18.0) OR A MCSHERRYSTOWN, PA 17344 MINIMUM SERVICE CHARGE OF $ 1.00 WILL BE CHARGED ON ALL AMOUNTS 28 DAYS OR MORE Pi~ST DUE STATEMENT OF ACCOUNT ``paYr~T nUE BY: o2/oz/o9 'tniARNING! THIS ACCOUNT I3 NOW 9-0 DAYS PAST DIIE!! STATEMENT DATE: 01/06/2009 .. PHONE: 717-630-200 PMT DUE..02/02/09 MARTIN, NORMA JEAN MARTNJ 0 DAYS.. '2@.23 59 FAWN AVENUE GRP-CF 0 DAYS. 42.c5 NEW OXFORD PA 17350 PAGE ~ DAYS. .11 - 'DUE .. 71.6 5 _PLEA38 DETACH HERE AND RETURN TOP PORTION WITH YOUR PAYMENT 1 AMOUNT PAID MCSHE RRYSTOWN, ----- PA 17344 ATE , NUMHE .QTY . .. .; DESCRIPTI ~ ~ 4N arr m . / M a , ~ ~ AMOUNT :. . ;;.. ALES TAX TEM TOTAL *~t PREVI ** i ! ~ ~ i US BALANC IS AMOUN PAS ~ I i ~ ~ I~ ,~ i ' i DUS ** I 70.59 ~- - ~ ~~ 1.06 ( ~ TOTAL TAX i aa~ r ia~ CHARGE Ptl31-IOtlS ~l1fi11iCB 70 59 TRIO 00 pI1W~CS ~C~(iB , TOtAL CIWA~i85 AYI~ITS i CR®I . + . + 1.06 71.65 - AMOUNT DUS .00 ~ 71.65 CHOICE FAMILY PHARMACY A FINANCE CHARGB OF 1.50 ~ PER MONTH 8 SOUTH SIXTH STREET (AN ANNUAL PERCENTAGE RATE OF 18.0 ~) OR A MCSHERRYSTOWN, PA 17344 MINIMUM SERVICE CHARGE OF $ 1.00 WILL BB CHARGED ON ALL AMOUNTS 28 DAYS OR MORE PAST DUB .:,, STATEMENT OF ACCOUNT _ pA~ Dus=.s~~ .03%30/.09 : WARNING ! THIS AC:COiJldT IS N09i 90 . DAYS PAST DUE ! ! ,< STATEMENT DATE: 03/03/2009 `, ,. ... ;. .. ,: PHONE: 717-630-200 PMT DUB. .03/30/09 MARTIN, NORMA JEAN MARTNJ 0 DAYS.. ~ 1.0 ,. 59 FAWN AVENUE GRP-CF 0 DAYS.: 1106;; NEW OXFORD PA 17350 PAGE 1 0 D,A'YS . 70 . S~:. ~ AMOUNT PAID ;DUE . ;: .?3.81>~. _ _ _ _ _ _ _ _ _ _ PLEASE DETACH HSRFs AND RBT_ t1RN TOP PORTION WITIi YO[1R PAYMENT ------------------ --- - --- CHOICB FAMILY PHARMACY 8 SOUTH ST7CTH STREET MCSH$RRYSTpWN, PA 17344 :, .. .. >; .. _ ,: ::: . . . ~~~ DATE NUMBF.. >,~'3.''Y• ,.. DFSCRIPTIO.N ., co / ~ ,AMOUNT . > : < . ;SALES TAX ITBM.TOTAL *** PREVI US BALAN 72.72 ** IS AMO PAS DUE ** ~~ 3.22 .00 _] To~rAts T YTD FIN CHARQE pRSVZOVS a~su~rs ,e, .... ~us:.~a~ ~ :~.c~s :c ~ Ar~rs~s ~ AMOUN;T DIIE 72.72 + .Ott + 1.09 73.81 - .00 ~ ~ 73~~.81 )lANOVER CARDIOLOGY .ASSOCIATES 310 STOCK ST SUITE 3 RANOVER PA 17331 `555 609211 ADDRESS SERVICE REQl1ESTED 81114 CQLLECTIQN NaTTCE P Includ ec h Cod rom 8a Cu CHECK CARO flSMK~ FOR PA,'MEHT 0 ® [~ MASTERCARD VIiA OISl~VER AMERICAN EXPRESS _ CARD NUMBER EXP. DATE CARDHOLDQt NAME SECURITY CODE sIONATURE AMOUNT >04704 7240382 001 Q92096 HANOVER CARDIOLOGY ASSOCIATES NORNA J IKARTIN 310 STOCK ST STE 3 59 FAWN AVE '= HANOVER PA 17331-2276 NEW OXFORD PA 17350-9778 ~ ~,,,~~~,,,~„tl,,,~~~~„~~„~,1„~,~1,„~~~~„~~~,,,,~~,~~~~~~ OFFICE PHONE DATE ACCOONT NVNHEA PAGE BALANCE (717) 637-1736 Oa/13/09 51953 O1 33.38 Dear Norma J Martin, It is the policy of Hanover Cardiology Associates that patients are directly responsible for full payment of all medical fees . At this time your account balance of $33.38 is past due. We realize that even with insurance coverage that all medical bills are not completely paid for and financing medical care may be a burden. Our staff would be pleased to discuss any problems you may be experiencing and to provide confidential counsel oa payment methods. Please call our office at (71?) 637-1738, within 5 days, to make arrangements to pay this balance is full, or to set up a monthly payaaent plan. If we do not hear from you, your account will be turned over to our collection agency. Thank you for your prompt attention fa this matter. If you have already seat payment regarding this past due notice, please disregard this letter. Sincerely, Collection Supervisor OFFICE HOURS FOR COLLECTION CALLS 8:30 AM TO 4:00 PM sto~~ aTa T~4o~az oa~os oa7as aooo~roooo~ szoees, ~o r ~ r ~ •. .. .r~. ••~. ~ . vv •r.~r ~.•r-.~\.~•vr •.-.. •~vvrr 1/ANOYER CRRDIDLQGY ASSQCIA3'ES HAVE COVERED THI9 BILL 310 STf3G~ ST SDITE 3 PLEASE CALL 03 AT 717-637-1738 1DlNOVER PA 17331 OOR BILLING I9 SEPARATE FRO>!Q OSSS HANOVER HOSPITAL 5372A Please Indtisde Securit Code Frvm Back Of Card FA2 6 CHECK CARP USING FOR PA 1'A/E1VT ADDRESS SERVICE' REQOF.STED MASTERCARD wSA DSA ®aSCOVti:a AMERICAN EXPRES: CARD NUMBER EXP. DATE CARONOI.DER NAME SECURITY CGOE REMIT TO: >03359 7077753 OOZ 092096 HANOVER GARDIOLOGY ASSOCIATES NORNA J MARTIN 310 STOCK ST STE 3 59 FAWN AVE ~' ': HANOVER PA 17331-2276 NEW OXFORD PA 1 7 3 50-9 7 7 8 ~ IIII" ~~II'~~~~s~l~~ssss~~s~~~~I~~~'IIII'1 "fad "II~I~II,I~~~~~ PLEASE RETURN THIS PORTION WITH PAYMEN' ONice Phorse Number Statement Date Your Account Number Page No. Patient Balance SHOW AMOUNT - PAID HERE CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL 8{LL OA STATEMENT HRIDENHAOOH MD/FAOLKNER MD 061307 POBs 01 EKE INTERPRETATION 6c REPORT NORMA 35.00- 070207 DENIED WELLCARE DROQ COV OC# 2694931 ~ 0.00 011008 PMT WELLCARE c# 2694931 -6.43 011008 W/o WELLCARE c# 2694931 -26.96 011008 Co-ins 1.61 "":'~ - - - Visit Totals: - - - - - - - - - - - - - - - - - - - - - - - - - 35.00 0.00 -33.39 1.1 - FREER MD/FAQLRNER MD - - - - - - - r - - - - - - - - - - - - 061307 P09s O1 EKO INTERPRETATION ~ REPORT NOR1s+lA 35.00 070x07 DENIED WELLCAR'~ DROQ COV Oc# 2694941 0.00 010408 PMT WELLCARE c# 2694941 -6.43 010408 W/O WELLCARE c# 2694941 -x6.96 010408 Co-inss 1.61 "*~"' - - - Visit Totals: - - - - - - - - - - - - - - - .. w - - - - - - - - 35.00 0.00 -33.39 1.+ • F'REER >MD/ FAIILKNER MD - - - - - - - - - - - - - - - - - - - - OS1407 POSs O1 9PECT IMAQINC; INTERPRETATION NORbIA 200.00 0.51407 PO3s O1 WALL MOTION 9TODY INTERPRETATION ~ REPOA 85.00 061407 POSs 01 EJECTION FRACTION INTERPRETATION ~ REPOR 85.00 061407 P08s 01 STRESS TEST ADENOSINE CAADIOLITE 200.00 061407 P09s O1 STRESS TEST PHYSICIAN 30PERVIBION 50.00 070x07 DENIED WELLC:~RE ID:~IIC3 ~^OV Oc# 2694951 0.00 011008 PMT WELLCARE c# 2694951 -120.63 O1i008 W/O WELLCARE c# 2694951 -469.21 011008 Co-ins 30.16 ~~a-~~~~e~~~ Date: 12/26/06 PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE: 51953 PATIENT BALANCE PAY THIS AbtOUNT CONTINOED atnu Ilr[ItJIMlt5 / PAYIUIENTS TD: HANOVEA CARDIOLOGY ABBOCIATEB (7i7) 637-1738 310 BTOCR 8T 80"['1"E 3 pLg.AgE CONTACT .OS DORINO _THE AANOVER PA 17331-aa26 AOORB OlQ' 8 s 00 A!~ TO 4 s 30 P~ IRS # s ~ ~ x 31745 6 4 3 ~ ~~ ANY QDEBTIONB OR CONCEA[Q8 WE LOOK , FORIPARD TO : BERVINO ' Y00 D31S9 7am~ ooa»a taarr~a Ot]Ot]1to0DD2 9209H890Z NOTE: Charges and Payments Rat appearing on this statement will wear on nttoct month's statement. 92096St t HANOVE~t CA.RDIDI-OGY ASSOCIATES 310 STOCK ST SDITE 3 FIANOVER PA 17331 ADDRESS SERVICE REQUESTED HAVE COVERED THI9 HILL PLEA3F. CALL US AT 717-637-1738 OOR BILLING IS SEPARATE FROM 4555 unt-tnvr_o vna~rmnr_ 5373A FR16 Please Jude Securit Cod ~ eac C ~ MASTERCARO CHECK CARD USMfO FOR PAYMENT v ®v a tY~SA VISA DISCOVER AMERICAN EXPRES; CARD NUMBER _ EXP. DATE CAROIiOt.DER NAME SECURITY CQOE SIGNATURE AMOUNT REMIT TO: HANOVER CARDIOLOGY ASSOCIATES NORMA J HARTIN 310 STOCK ST 3TE 3 rr •~ HANOVER PA 17331-2276 I~ulltu~ll~ll~rillii~~Il~rlrli~I~IIr~rI~II~~II~~I~rll~~l~l~l PLEASE RETURN THIS PORTION WITH PAYMEN' Office Phone Number Statement Date Your Account Number Page No. Patient Balance SHOW AMOUNT 7 7 637-1738 12 36 08 51953 02 33.38 PAID HERE ----------- CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL 61LL OR STATEMENT """' Vieit Totts].>B: 620.00 0.00 -589.84 30.: PAYMENT IS DIIE RITHIN 10 DAYS IIPON RECEIPT OF THIS BTATENENT THANK YOQ Statement Date: 12/26/08 PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE: 51953 CURRENT 3 0 - 6 0 DAYS 6 0 - 9 0 DAYS > 9 0 DAYS TOTAL IN8 PENDINt3 PAY TlNiIS AMO 33.38 33'.38 0.00 33.: SEND tN0UIRIES /PAYMENTS TO: HApOVER CARD=OLOt37C AB80CIATEB (717) 637-1738 31b STOCK ST SOITE 3 PLEASE CONTACT UB.DUAINt3 THE HANOVER )PA 17331-22x6 80DRS OF . S t 00 _ A>!~ TO 4 tt 3 0 PM IRS ~s 231745643- 1PITH ANY; QUESTIONS: OR CONCLrANB - WE LOOK FOR9PAAD TO: BRRVINO YOU 03388 7077783 OOtj719006719 00002/iODOpT - ~ ~ _ rvvTe charges and payments not appearing on this statement will appear on nett rllonth's statement. 9ao96S11 ..-~- ..-...... w,... r..- •r• - Spring Grove Area Ambulance Club Billing Office P.O. Box 726 New Cumberland, PA 17070 QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 EspaRot: 866-724-4114 Fax: 717-214-6020 Ernait: intoclltsmbulanceblllingofflce.com Date of Service: 9/232008 17:48 Please visit our website to provide insurance or make payment, and Patient Name: MARTIN. NORMA JEAN for additional payment options and frequently asked questions: From: RESIDENCE To: HANOVER GENERAL HOSPRAL ~+~+~++r~+•ambulancebiliingoffice.com icYefiled a claiiit~with your i~rsYpa-nce~coinpwry~received apartial parymen~ The renialning bidla~tce ~s your respoasfbillty:~~~~~. ~ ''.; Pleiase. remit payment. ?dank you. • - - - - . 9123108 BLS Emergency A0429 1 495.00 9/23108 Mileage A0~25 10 9.00 90.00 9/23108 Adjustment -insurance -217.00 2103109 Adjustment -Insurance 7.38 2103109 Payment _ _ -313.40 Total ~ ~~ -' ~+ w ~~ 585.00 -209.62 -313.40 DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT. •w..w-r~wwwwwrw~.-~-w www rw--w~wwww~www~~wrA~r,f- ww.~-,wwww ~w -w~~~wwwwwwww ww wwwwww r ~• ,...W~e Payment In full by d~ec!%* cr+edlt'i~ or~etectrcntc ~.P/ease°Mekie~Check~Payable To: . dtedc dedutttan. Please Indicate. your payment chdoe, below ~. . and fill in required Infortnatlon. If other arrangements are Sprang GrOVB Area AmbUlence •. necessary, please Gait us at 877.214-6018. Club ~/ ~o CISC01/ER Credit Card: O MASTERCARD O VISA O AMERICAN EXPRESS O DISCOVER --- i ~_-,-- T- ~ ~ ---r- - ; -- ------- -- ~ ~ i Card Numt~ ... 7 -.-~ a -. .._ ~ .. I Please make any corrections to address below. ~1aRC Un Cartl c"a,~rat~Cn dectronk Check Deduction ~~ Please send a voided check OR provide tnlorntation below: :~ NORMA JEAN MARTIN 25 EAST THIRD AVE. APT E-4 Bank RbUt~ng t+umber Checking Account kumner SPRING GROVE, PA 17362 Signature 'Rewmed checks -You will be responsible far all inwrred bank fees permksible under slate law. •.......~. ..-....~../r.......- •v• ~ ~ 1 Spring Grove Area Ambulance Club Billing Office P.O. Box 726 New Cumberland, PA 17070 QUESTIONS A80UT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 7i7-214-6020 Email: info~iambulanceblllittgoftice.cam Date of Service: 9/23/2008 17:48 Please visit our website to provide insurance or make payment, and Patient Name: MARTIN, NORMA JEAN J. for additional payment options and frequently asked questions: From: RESIDENCE www.ambulancebiliin office.colm To: HANOVER GENERAL HOSPITAL 9 •~• We have not.received your payment. Your itts>ia~ance made a partial payment, acrd you are:respo>zsible for tlie~remalniRg .. balance. Please,remit payment. Thankyor~ - - e ~ • 9!23108 BLS Emergency A0429 1 495.00 9/23/08 Mileage A0425 10 9.00 90.00 9123!08 Adjustment -Insurance -217.00 2103109 Adjustment -Insurance 7.38 2x'03109 Payment -313.40 Total ~ 585.00 -209.62 •313.40 DETACH ANO RETURN BOTTOM PORTION WITH YOUR PAYMENT. •a1.lt/l~wrwr wr-~.----w..rw..www....--.~wr w..wwwww~w•w•ww wwwwwwww..w-wrww w-w wwwww w.. .-•ww-wr Wte accept payment in full by chsdc,* credit card or electronic Please Make Check Payable To: check deduction. Please Indicate your payment choice below and flit in required information. if other arrangements are Spring Grove Area Ambulance n~~rY, Please call us at 877-214-6018. Club ,; y~o ascgvar .~ ,_ Credit Card: C MASTERCARO ~ VISA G AMERICAN EXPRESS ~ DISCOVER ----,----_ f .. ~_- ~ _ __ - ---- - --- -- 1-- _. _ . .. __... - I- --- 1~. ~ ~ ~ f !. Card Number -- - - --- Please make any corrections to address below. Name on Card @Ypiratwn Electronk Check Deduction akese surd a voided check tXt provlQe information terow: ~--_-- -- NORMA JEAN J. MARTIN 59 FAWN AVE Bank iiouUrtg Number ~~~ Checking ticcouni 'JUmber NEW OXFORD, PA 17350 S+gnature `Returned checks -You will tae responsible for all tnwrred bank fees permissible under state law. COAIMONWEALTM OF PEI~WSYwAN1A oE~-AaTSer~nr of P~nuc wE~ARE sou of Fvwscw, cpEa-n~-s OMSOON OF fl10RD PARTY LIABItf~Y ESTATE REOOVI~JtY PROGRAM P'O 80X 8108 IIARRlSBlJRQ PA 1710S8H8 May 21, 2009 LAW OFFICES OF PETER J RUSSO PC PBTBR J R[1530 BSQ 5006 BAST TRINDLF ROAD 8UIT8 100 NISCNAMICSBURG PA 17050 Re: NORMA MARTIN CIS #: 830102470 ESN: 192-30-0502 Date of Death: 11/le/2ooe Dear Attorney Russo: Please be advised that the Department of Public Welfare maintains a claim in the amount of $6.151.26 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Bstate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20.95, effective June 30, 1995. 8nclosed is the Department's itemized statement of claim. A portion of this medical expense, namely .00, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3}. The balance of the claim, namely $8,151.26, is to be entered as a priority Class 5.1 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth s claim is admitted and when payment may be expected. Zf the estate accounting is complete, please provide a copy. If the estate eoat:iae real estate, please provide copies of the deed, the latest tax assessment, sad a auarreat appraisal, if available. Sincerely, ~.~Q~. Judy 8. Deaven Claims 2nvestigation Agent 717.214-1284 717 -.3~@ -o48i~ FAX cos-~tsa Bncloeure .. ~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: :Orphans Court Division Estate of Norma Jean Martin, Deceased : No. 09- CERTIFICATE OF SERVICE I hereby certify that on July 31, 2009 I have served a true and correct copy of the foregoing document upon the following persons, in the manner indicated: FIR5T CLASS MAIL Norman Morgan Harry Morgan 59 Fawn Ave 4006 Warm Springs Road New Oxford, PA 17350 Chambersburg, PA 17201 Dorothy Haeberle William Martin 59 Fawn Ave 368 E. King Street New Oxford, PA 17350 Chambersburg, PA 1702 Shawnna Varner Dennis Morgan P.O. Box 167 Camp Hill Prison Cashtown, PA 17310 P.O. Box 200, Inmate # GV3297 Camp Hill, PA 17001-8837 Beverly Brewer 34 Davis Ave Gettysburg, PA 17325 THE LAW OFFICES OF PETER J. RUSSO, P.C. BY: ~. Ashle .Sipe, Para egal