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Home My WebLink About07-31-09 (2) 15056051058 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes ~ INHERITANCE TAX RETURN PO BOX 280601 ~ f /~ ~ /~ Harrisburg, PA 17128-0601 RESIDENT DECEDENT 1 L/! V 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 Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI r °I ~. • Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return 4. Limited Estate 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Return 3. Remainder Return (date of death prior to 12-13-82) 4a. Future Interest Compromise (date of 5. Federal Estate Tax Return Required death after 12-12-82) 7. Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Peter J. Russo (717) 591-1755 r,,, j Firm Name (If Applicable) REGISTER ~..LS USE LY ~,a ~!~-~ r'S "~ Law Office of Peter J. --v ~ ~~ ~ , ~ { First line of address ~~ try .3 , ~ ~ iM ~'~ ~ ~ .; ~ f ~~~ 5006 E. Trindle Road .. i ,. .. "-~ Second line of address ~ ~ ~ ~.._. ~ s , , Suite 100 ~ -v G~ , ~ ~ ~ } City or Post Office State ........ZIP Code DATI~`ILEC} W Mechanicsburg ' PA 17050 Correspondent's a-mail address: pruSS@pjrlaW.COm Under penalties of perjury, 1 declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. Side 1 15056051058 15056051058 <.f'L (o F r ~, .9.5~.+~ ~.~ Y'`~1 c c.~~..~ ~ ~ ~~ ~ 1P~ l ? U J L~ PLEASE USE ORIGINAL FORM ONLY / ~ 1 15056052059 REV-1500 EX Decedent's Social Security Number Norma J Martin 192-30-0502 Decedent's Name: 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. ' 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) .................................... 8. 315.69 9. Funeral Expenses 8 Administrative Costs (Schedule H) ..................... 9. '!' 1,265.00 10. Debts of Decedent, Mortgage Liabilities, & 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 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. -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 Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 ' 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. '' 19. TAX DUE ......................................................... 19.' 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 R~.V-150$ EX~+ (6-98} ~f :~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPCtSITS, & MISC. PERSONAL PRCIPERTY ESTATE OF FILE NUMBER Norma J. Martin I Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. RE.V-1509 EX+ (6-98) l COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNED111LE F JOINTLY OWNED PROPERTY ESTATE OF FILE NUMBER Norma J. Martin JOINTLY-OWNED PROPERTY: fTt::M NUWIBER LETTER i~OR JOINT TENANT DATE MADE:. JOINT DESCRIPTION OF PROPERTY INGI.UDE: NAME: Of~ FINANC;IAI.. INS'ifiUTION ANE) BANK ACCOUNT Nl1MBE:R OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE: Of' t)t~AiH VALUE OF ASSET °:~ OF DEi:CD'S iPJTEREST DATE OF DEATH VAt.UE~ {?F' DECEDENT'S INTEREST ~ ~ A. Savings Account 571.87 25 151.39 TOTAL (Also enter on line 6, Recapitulation) I $ 151.39 (If more space is needed, insert additional sheets of the same size) if an aASpt was made ioint within one veer of the decedent's date of death, it must be reported on Schedule G. RFV-1511 EX+ (12-99) ' SCNEDt~LE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Norma J. Martin Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1 ~ Grove-Bowersox Funeral Home, Inc. 1, 230.00 B. ADMINISTRATIVE COSTS: 1. 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. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Zip _ Zip 35.00 TOTAL (Also enter on line 9, Recapitulation) I $ 1,265.00 (If more space is needed, insert additional sheets of the same size) Grove-Bowecsox Funeral Home, Inc. 50 S. Broad St, Waynesboro, PA 17268 (717)762-2811 DATA November 20, 2008 SERVICE NO. MARNOR DECEASED NAME Norma Jean Martin DATE OF DEATH November 18, 2008 PLACE OF DEATH Residence Spring Grove, PA Charges are only for ose ems at you ar are regw we are required by law or y a cemetery or a crematory to use any dems, we wn exp ain e reasons in venting below.. ff you selected a funeral that may require embalming such as a funeral with viewing, you may have to pay for embalming; You do not have to pay for embalming you did not approve if you selected anangements such as a direct cremation or immediafie burial. ff we charged for embalming, we wall explain why below. STATEMEN'-~ 4F FUI~I~RAL G+~O-DS ANCf SERVICES SELECTED 1. Professional Services PROFESSIONAL SERVICES BASIC SERVICES OF STAFF EMBALMING OTHER CARE OF THE BODY HAIR DRESSER 2. Facilities 8~ Equipment FACILITIES FOR SERVICE FACILITIES FOR VIEWING SERVICE AT OFF PREMISE MEMORIAL SERVICE GRAVESIDE SERVICE 3. Automotive Equipment TRANSFER TO FUNERAL HOME HEARSE OTHER VEHICLES ADDITIONAL MILEAGE -SPRING ADDITIONAL MILEAGE -HERSHEY $ $ 500.00 $ $ 500.00 $ $ $ $ $ 195.00 $ 175.00 $ 300.00 $ B. CHARGES FOR MERCHANDISE: $- RECEIVING OF REMAINS FROM: FORWARDING OF REMAINS TO: CREMATION OF BODY D. CASH ADVANCES: CEMETERY OPENING /CLOSING CEMETERY LOT WEEKEND CHARGES LAMINATED OBITUARIES CLERGY HONORARIA MUSICIAN HONORARIA FLORIST OBITUARY NOTICE OBITUARY NOTICE DEATH CERTIFICATE CORONER FEE MARKER ENGRAVING $ $ $ $ $ $ 60.00 We charge you for our services in obtaining:(specify cash advance items). 670.00 CASKET $ $ 60 00 Casket . OUTER CONTAINER $ SUMMARY OF CHARGES: Outer Container A. CHARGES FOR SERVICES $ 1170.00 ALTERNATE CONTAINER $ B. CHARGES FOR MERCHANDISE $ REGISTER BOOK $ C. SPECIAL CHARGES $ MEMORIAL FOLDERS $ D. CASH ADVANCES $ 60.00 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 $ UNNERSAL VAULT $ CREDIT BY CREDIT CARD $ CRUCIFIX $ LESS V.A. BENEFIT $ TEMPORARY MARKER $ LESS AMOUNT PAID $ $ TOTAL CREDIT $ $ BALANCE DUE$ 1230.00 ff any law, cemetery or crematory regwrements have required the purchase of The only wartanty on the. casket and ! or outer burial container sold in any of the items listed above the law or requirement is explained below. c°nnecti°n w-~h this service is .the express wrttren warranty, if any, 'granted Cemetery requires a cave proof outer container by the manufacturer. _ This funeral'. home no.Mrarrarrty; express or implied, with respea to. the casket and/or outer twriad. oor~ir>eG Billing ToBeverly Brewer Reason for Embalming Public viewing or holding body longer than 24 hours 3d Davis ,4ve Gs~lfrshu ~~ PA 17~9~ 1 hereby agree that I have examined the above stated ifarrrs and found them to be oomect and according to the arrangements requested and I hereby acknowledge receipt of a copy of this memorandum and agreement I hereby represent that I have sufficient funds and assets legally available for payment of cash price and hereby agree and covenant jointly and severally to make payments of $ 0.00 within 30 days. A late charge of ~ °~ per month amounting to ~~/o r beginning 30 days from the date of this regiment pe year is applied to the unpaid balance agreement and the cost thereof will be rid on the ~~dsta~erlit~l a~cknorwl~edge-that haver~eoev~ the generaepncee~iastth nd have been eoffered fo review the cask t pn~ce list and the outer burial oorrtainer price list x ACCEPTANCE: ~gn x Cotisigned a By licensed Funeral Director or Funeral Service License Grove-Bo~erso~ . ' FUNERAL HOME, INC. 5o S. Broad Street Waynesboro, PA 17268 Telephone: 717-762-2811 JAMES A. BOWERSOX Supervisor/Owner JAMES W. FRTTZINGER JEANETTE M. MOORS P~rneral Directors Miller-Bowerso~ HOME Division of Grove-Bowersox Funeral Home, Inc. Waynesboro, PA 521 S. Washington Street Greencastle, PA 17225 Telephone: 717-597-2511 JEREMY A. BOWERSOX Supervisor NATHAN NARDI Manager 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~ s A Bowersox President www.bowersoxf uneralhomes. com STATEMENT Grove-Bowersog i;o~, nvc. 5o S. Broad Street Waynesboro, PA 17268 Telephone: 71~-~b2-2811 James A Bowersox, Supervisor Bev Brewer 34 Davis Ave. Gettysburg, PA 17325 Date: June 1, 2009 Services for: Norma Jean Martin Miller-Bowersog xo~ 52~ s. washington Street Greencastle, PA 17225 Telephone: ~i~-g97-2511 Jeremy A. Sowersox, Supervisor PERMS: Net 30 days from Service. ~ % isle on any unpaial balance 31 days enter service and ~ month lhsrealler. EffaClMe Mrnral Rate 12X. 11 /20/2008 Services Rendered $1,230.00 Humanity Gifts payment $50.00 $1,180.00 12/24/2008 Payment Received $100.00 $1,080.00 1 /21 /2009 Payment Received $100.00 $980.00 2/19/2009 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. pvwersoxrunerainomes. com enns lvania SCHEDULE I • a y DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT EST!-TE OF FILE NUMBER Norma J. Martin Reuort debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. ,SPRING•GROVE FAMILY CARE CENTER 22 ROTH CHURCH ROAD SPRING GROVE, PA 17362 Forwarding Service Requested 23660 NORMA J MARTIN 25 E THIRD AVE APT E4 SPRING GROVE PA 17362-1241 12/31/08 ~ 619 78.24'' _MC _V I SA Card~~ Sign SPRING GROVE FAMILY CARE CENTER 22 ROTH CHURCH ROAD SPRING GROVE, PA 17362 Security Code Exp _/_ MESSAGES EXPLAINED ~ BELOW ~~~ PLEASE PAY UPON RECEIPT, IF BILLING QUESTIONS CALL 877-856-2279 EXT 2024 '~** '~*'~ Pa Account Balance Immediatel to Avoid Collection A enc ! ! ! ! ! ! '~'~"ti ~r~~r~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~r~~~~~~~~~~~~~~~~~~~:~~~~~~~ti~~~~~~~ Insurance Charges pending to-Prv: 148.00 Ins Pay/Adj against Ins pending 83.31 0.00 64.69 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 • - 1 • - . ~ • - • ~ • - ~ • • • . 05/31/07 12.76 78.24 0.00 0.00 0.00 0.00 64.69 MAKE SPRING GROVE FAMILY CARE CENTER CHECK 22 ROTH CHURCH ROAD PAVAe~ETO: SPRING GROVE, PA 17362 PAT~~ 1-NORMA J MARTIN PRV~~ 2-FAULKNER, NANCY MD 0.00 I 142.93 ., ~ 78.24* Ph: (877)-856-2279 Acct~~: 619 Date: 12/31/08 Page 1 of 1 :~.. ,if +~ Kf: ,r. ~l'. V J CO ~ r ~ ~O ~ O T O Z~ Y 1,,. 1 (Y~ :: U ~,. •`~ Ira U L y > ~ ~.~ _• C VJ G m~' f i ^Zw 1 1`.1 w Q m ~, W ~ J 1 J J ~ Z Q Q ~ LLl Z ~ ~ O J C3 w ~ w ~~ O Q n ~ z o c ~ U T. 1- z ~- z r ~ cN ~ ~ O W ~ c.~~ ~ U ~ W ~ c~n~0~ °° ' Q OC ~ L ~ ~ cy- ~~~ cn ~r :~ ° ~, c~ co U `~n-•~aoo L ~ ~ r ~ ~~'~~ W o~~ox W a~2S t~ Z LL~ N n ' i ~ 1~ ~ r ` ^ M ~ V, h , w r ~ I ~ N ~ CO ~ W ~~~ _ ~~_ 1- ~+ O "' ~ x ~ .~ ~ . 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W ,OO -Z O F- .O . ~ . ~ m W W J H Z W W Q H Z U_ a L Z f-- Q w ~ ','' CJ U i Z ~ .-=; Q ~ i ~ ~ I ~ ~ '_ z z ~ Z Z ltl t1J F- ~ d , ..: _ =. =; L~ r~ :r ~ ~ ~ o - - . ~ - ~i - '_.,~ o ~. . .~ • .~ ~ T -.. ~ • ~ • ... ._._ .1 .... 'f ~ •_1 ~.} O V • ~ . . •~1 t > zw ... W ~ r . ',s_ ~ d ^-, ., ~ ::: ~Z .-.~ ~ w _ +- ~~.. - ~ . ,.. C7 ...~ ~ . r f `~ • • o ~ ° .-; - ;~ °_ . w ' w ~ ~ ~ ° ~ a a O U _ a T .J U r? 1 j 1J ~' J = ~ N ~~ ~v ~Z ~~ ~m ~~ ZZ W W H as U ~Z~~ ti w ~T a~~ ~~w ~ WO ~ o= U w~ =w U~ w m Y} Q ~a w m Z z O U Q 0 a z w Q d w ~' o r ` w w a _ ~ I , Billing Period: Nov 01 to Dec 01, 2008 for 31 days ' - Bill Based On: Actual Meter Reading Final Bill SPRING GROVE PA 17362 Standard Residential -. , ~ ~ ee 4 ~ ~ e~ or ~tt~ r ~a ion an +~ ~ ..~~ s ~~~~ A FrstFsergy Company Return this part with a check or money order Payable to Met-Ed Account Number: 100059015055 I~~~III~~~I~~II~~I~I~II~~~I~I~~I~~~II~~~II~~I~~I~I~I~I~~I~I~~I *************AUTO**3-DIGIT 173 00020367 O1 AT 0.346 P2 NORMA JEAN MARTIN Amount Paid Please Pay $20.05 Due By January 02, 2009 DOROTHY HAEBERLE MET-ED 59 FAWN AVE PO BOX 3687 NEW OXFORD PA AKRON OH 44309-3687 17350-9778 I~I~~I~I~~I~~II~II~~~I~I~~~~II~~II~~I~~I~I~~~II~~I~I~~~I~~~III 02b0005901505500000000000000000000000000000000020055 When contacting an Electric Generation Supplier, please provide the customer numbers below Call Met-Ed at 1-800-545-7741 with questions on these charges. Basic Charges Customer Number: 08035873210002241698 -Standard Residential - ME-RSD Distribution Customer Charge 8.11 824 KWH x 0.026165 21.56 Total Distribution Charges 29.67 29.67 Transition 824 KWH x 0.007760 6.39 Generation 824 KWH x 0.046580 38.38 Transmission 824 KWH x 0.019040 15.69 State Tax Surcharge 0.06 0.10 Total State Tax Surcharge Charges 0.16 Total Charges $ 90.29 u: - r Date Reference Amount Payments: 11/06/08 -110.38 Dec 07 Dec 08 Average Daily Use (KWH) 33 27 Average Daily Temperature 42 43 Days in Billing Period 31 31 Last 12 Months Use (KWH) 11,085 Average Monthly Use (KWH) 924 CHOICE FAMILY PI~[ARMACY A FINANCE CHARGE OF 1.50 % PER MONTH 8 •SOUTH SIXTH STREET (AN AIv'NUAL 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 PAST DUE >~ ;~?:~~''<;~;; BSS':: 0 3 f ~ ~ (~:g;:<: >:>:;': <::;~ <:>:: STATEMENT OF ACCOUNT .:: f .:. .:.>::.>: ; ::::.:.......: :> ~;::WA:I1~G:~ >'I'~IS ~.A;C:COU~dT : TS; >NOW:::::~.4.:.DAYS;: ~ P.AST:::::DU'E'l::;~::>':: ~ :::; :::::::: S TATEM N D :::.::::::;::::: E T ATE . 02 2 ~ ::>;::::::.>:<:> :<:>?>:::: , ..... - .::::>:.:>; ::::::.:.::::...;.:<::::;:;> :::: ~:::>:::> /03/ 009 PHONE: 717-630-20 0 PMT DUE. .03/02/09 MARTNJ GRP-CF PAGE 1 AMOUNT PAID PLEASE DETACH HERE AND. RETURN TOP PORTION WITH YOUR PAYMENT CHOICE FAMILY PHARMACY 8 SOUTH SIXTH STREET MCSHERRYSTOWN, PA 17344 ~.AT~~~>:~' ~ T~:'F~'~:R ~"4'T"~" : ~ ' ...:..:1:1• F:Et:(?T?~:F~!'#':T'':~h7`:; ::::::: <>:>.::;;;,;:., ,~ r ,: '.r3s 3~A'f1TTh'F'i'~:~ ` ;:::: "`:::: •:.:::: <:> " ::: 'c.~:Y::~~:•: m~t:xr• ~ -rm,c±i-* mnrna t *** PREVI US ** T IS PAST DUE ** 71.65 (-- ~ 2.13 (-_ • YTD FIN PREV'T(JU,~:. >$lkhAi~G;~~ .. ,:.::::.::• .... 71.65 + CHARGE is<:~:` ~: ` :. ~!'f NAT!TC~:•.:.:.. '; `Pt#~5.: ~I >,:. :•:.: - :• ~... ,.::. ~.:::::.:. ,: .00 + 1.07 ..T(>'iAL..<, FEAR < T4~!~,'14~::• : ; •. <::. ,: C ..... ~~~ ..: PA7~1"fEN~'S &. ;CKS~z3'S :; : = 72.72 - .00 = .00 amvc~rr nun ~z.~a A FINANCE CHARGE GF 1.50 o PER MONTH (AN ANNUAL PERCENTAGE RATE OF 18.0%) OR A MINIMUM SERVICE CHARGE OF $ 1.00 WILL BE CHARGED ON ALL AMOUNTS 28 DAYS OR MORE Pr~ST DUE ..:: .:: :<:;.; ....:.. . <.: ~ ::: <.. :: .; :_:: >: • :':::`: '::': `~..:`: • ~ AMOUNT .:: ; : « S~E~ :~'A~: ITI'f'~"~'A~; ...; ~3A:. ;::::... <;: <..I~~~~ ,..:;.:~'Ty'':: :. .. L~E~.~CR~~.?~z0~3'... ::...cap : ~.:::: ;...:: ; ..::.... ..::... ; ::.::... *** PREVI US BALANCE 70.59 ** T IS AMOUN PAS DUE ** E s I I .00 ~c~~A~. CHOICE FAMILY PHARMACY 8 SOUTH SIXTH STREET MCSHERRYSTOWN, PA 17344 ~ ~ 1.06 YTD FIN CHARGE :.. .. .. P >; ::;:.<:;~•.•~~:••>: ~: , >:.;:. .>,:"'i`HIb:~>~'ifll~i.;::: ::;: .. . •:.::<~::.:.: ;.:: ~.;.: .. :: •.::.:::• ..:.:• . ; :~ ~<:•:::: : A7~i~fE#~~5~ &:;CI~~T~FS 70.59 + .00 + 1.06 = 71.65 - .00 ~oczrt?r nun '. 71.65 CHOICE FAMILY PHARMACY A FINANCE CHARGE OF 1.50 ~ PER MONTH 8 SOUTH SIXTH STREET (AN ANNUAL PERCENTAGE RATE OF 18.0 0) OR A MCSHERRYSTOWN, PA 17344 MINIMUM SERVICE CHARGE OF $ 1.00 WILL BE CHARGED ON ALL AMOUNTS 28 DAYS OR MORE PAST DUE ::~::::::.~>::>:::::>::::.:.~:::~::: ~y. ~y ~y TATEMENT F A C T S 0 C OUN ::WAR~1'ING...:::~.5.::.ACC~3I::..TB.:.:SOW::::~:~::T3AY~>:>PABT:<:~3UE.~ :.. ::::::.....:::::::..:::.:::::.:.... . TA S TEMENT DATE: 03 03 2 009 ~ / MARTNJ GRP-CF PAGE 1 AMOUNT PAID PHONE: 717-630-200 PMT DUE..03/30/09 PLEASE DETACH HERE AND RETURN TOP PORTION WITH YOUR PAYMENT CHOICE FAM ILY PH ARMACY 8 SOUTH SIXTH STREET MCSHE RRYSTOWN, P A 17344 ....... ................. .... ............................................................... ......... .... ........ ............................. .............................. ............................. ............................... *** PREVI US BALANC 72,72 ** T IS AMO PAS DUE ** -- .00 r 1 3 .2 2 ~ ~ . :::.. YTD FIN : . ` ' ... CHARGE .. :: ": ~ 72 72 ~ ~. ~~~~~~~~ E . + . 00 + 1. 0 9 - 73.81 - . 00 = 73 81 . COLLECTION NOTICE HANOVER CA.RDIOZOGY ASSOCIATES 310 STOCK ST SUITE 3 HA~NOVF~'R PA 17331 4555 609aA SA14 Please Include Securit Code From Back Of Card CNECK CARD USlNO FOR PAYMENT ~~ ~MASTERCARD V~ aSA ® DISCOVER A^MERtCAN EXPRESS CARD NUM9ER EXP. DATE CARDHOLDER NAME SECURITY CODE SIGNATURE AMOUNT ADDRESS SERVICE REQiJESTED >04704 7140382 001 092096 NORMA J MARTIN 59 FAWN AVE NEW OXFORD PA 17350-9778 OFFICE PHONE DATE (717) 637-1738 02/13/09 HANOVER CARDIOLOGY ASSOCIATES 310 STOCK ST STE 3 ••: HANOVER PA 17331-2276 ACCOIINT NiJNHER PAC3E BALANCE 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 on payment methods. Please call our office at (717) 637-1738, within 5 days, to make arrangements to pay this balance in full, or to set up a monthly payment plan. If we do not hear from you, your account will be turned over to our collection agency. Thank you for your prompt attention in this matter. If you have already sent payment regarding this past due notice, please disregard this letter. Sincerely, Collection Supervisor OFFICE HOIIRS FOR COLLECTION CALLS 8:30 AM TO 4:00 PM 920966902 92096S110 04704 7140382 004705 004705 00001100001 .iii /r HANOVER CARDIOLOGY ASSOCIATES 310 STOCK ST SIIITE 3 HA'~TOVER •PA 17331 ADDRESS SERVICE REQIIESTED >03359 7077753 001 092096 NORMA J MARTIN 59 FAWN AVE NEW OXFORD PA 17350-9778 HAVEvCOVERED-THIS BILL+ ~.j ••..., PLEASE CALL US AT 717-637-1738 OUR BILLING IS SEPARATE FROM HANOVER HOSPITAL Please Include Securit Code From Back Of Card CHECK CARD USING FOR PAYMENT ®^ ^ ~, ~MASTERCARD Y~SA VISA ~ DISCOVER AMERICAN EXPRES: CARD NUMBER EXP. DATE CARDHOLDER NAME SECURITY CODE SIGNATURE AMOUNT HANOVER CARDIOLOGY ASSOCIATES 310 STOCK ST STE 3 ~•• •~ HANOVER PA 17331-2276 ~~ n~~~~n ~~~~~i~~~~~~i~~~~~~~~~i~~~~ n~~~~~~~~~~~~~~~~~~~~~~~ PLEASE RETURN THIS PORTION WITH PAYMEN" Office Phone Number Statement Date Your Account Number Page No. Patient Balance SHOW AMOUNT 0 CONTINUED PAID HERE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT BRIDENBAUGH MD/FAULKNER'MD - 061307` P03: O1 ERG INTERPRETATION 6c REPORT NORMA 35,00 070207: DENIED WELLCARE DRUG COV,Oc# 26949:3.1 0,00 01100$ PMT WELLCARE c# 2694931 -6.43 011008 W/O WELLCARE c# 2694931 -2.6'.'96 01100$ Co-ins 1.61 ****** Vieit Totals: 35.00 0.00 -33.39 1.I FREER MD/FAULRNER MD 061307 POS: O1 ERG INTERPRETATION 6c. REPORT NORMA 35.OD 070207 DENIED WELLCARE DRUG COV Oc# 269494.1 010408' PMT WELLCARE c# 26943.41 010408° W/O WELLCARE c# 2694941 010408 Co-ins 1.61 ****** Visit Tota s: 35.01) 0.00 FREER MD/FAULRNER MD 061407. POS: 01 SPELT IMAGINC3 INTERPRETATION NORMA 200.00 061407. POS: O1 WALL MOTION STUDY INTERPRETATION & REPQR 85.-00 06140? P03: 01 EJECTION FRACTION INTERPRETATION & REPOR 85.00 061407 POS: O1 STRESS TEgT ADENOSINE'CARDIOLITE 200.00 061407 POS: O1 STRESS TEST PHYSICIAN SUPERVISION 50.00 070207' DENIED WELLCARE DRIIG COV Oc# 2694951 011008 PMT WELLCARE c# 2694951 011008 W/O WELLCARE c# 2694951 011008 Co-ins 30.16 OQO -6.43 -26.96 -33.39 1.~ o.oa -120.63 -469..21 Statement PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE: Date: 12/26/08 51953 PATIENT BALANCE PAY THIS AMOUNT CONTINUED SEND iNQUIRIES7 PAYMENTSTO:. HANOVER CARDIOLOGY' A38aDCIATE3 (717) 637-1738 310 STOCK: 3T'SULTE 3 PLEASE CONTACT US DURING .THE HANOVER PA 17 3 3.1- 222 6 HOURS OF , 8 : O O AM TO 4 : 3 0 PM IRS #:. , 2..31745643 WITH ANY ' QUESTIONS. OR CO~iCERN3 WE LOOK, FOR~PARD TO` SERVING YOU` -_43369 7077753 0{16718.006718.00001/00002 920966902 NOTE: Charges and payments not appearing on this statement will appear on next month's statement. 92o96St ~ 4555 5372A FRa6 REMIT TO: HANOVER CARDIOLOGY ASSOCIATES 310 STOCK ST SUITE 3 HANOVER •PA 17331 ADDRESS SERVICE REQDESTED NORMA J MARTIN HAVE COVERED TH23 BILL PLEASE CALL US AT 717-637-1738 OUR BILLING IS SEPARATE FROM HANOVER HOSPITAL Please Include Securit Code From Back Of Card CHECK CARD USING FOR PAYMENT ~W ~ ^MASTERCARD V~Sa VISA ®DISCOVER O ERICAN EXPRESt CARD NUMBER EXP. DATE CARDHOLDER NAME SECURITY CODE SIGNATURE AMOUNT HANOVER CARDIOLOGY ASSOCIATES 310 STOCK ST STE 3 ~• •~ HANOVER PA 17331-2276 I~~~III~~~I~~II~~~II~~~~II~~i~l~~l~ll~~~l~ll~~ll~~~~~ll~~l~l~l PLEASE RETURN THIS PORTION WITH PAYMEN' Office Phone Number Statement Date Your Account Number Page No. Patient Balance SHOW AMOUNT 717 637-1738 12 26 08 51953 02 33.38 PAID HERE ----------------- -------- -- CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT PAYMENT IS DUE WITHIN 10 DAYS. UPON RECEIPT: OF THIS 3TATE1I~ENT THANK YOU Statement PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE: Date: 12/26/08 51953 CIIRRENT 3 0 - 6D DAYS 6 0 - 9 0 DAYS > 9 0 DAYS TOTAL INS PENDING. PAY TH s AMOUrwT 33.38 33'.38 0.00 33.; SEND fNQU1RlES /PAYMENTS TO: HANOVER CARDIOLOGY ASSOCIATES (717) 6 3'7 -17 3H 31b STOCK ST SUITE 3` PLEASE CONTACT US..DURING THE HANOVER PA 1733.1-2,22.6 HOURS OF.$'i00 AM: TO 4s30 PM IR8 #s 2.3 1745613 WITH ANY.QUE9TION3 OR;.CONCERN$ WE LOOK FORWl~RD TO SERVINGS YOII . 03359 7D77753 006719006719 00002/OOQOZ NOTE: Charges and payments not appearing on this statement will appear on next month's statement. s2ossS1 i 4555 5372A FR26 REMIT TO: Springy, Grove Area Ambulance Club Billing bffibe P.O. Box 726 New Cumberland, PA 17070 QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 717-214-6020 Email: info@ambulancebillingoffice.com Date of Service: 9/23/2008 17:48 Patient Name: MARTIN, NORMA JEAN From: RESIDENCE To: HANOVER GENERAL HOSPITAL We fled a clairn~with your;insurance ~eompcmy'an~i~ece Please remitPEryment. Tlumkyou. Please visit our website to provide insurance or make payment, and for additional payment options and frequently asked questions: www.ambulancebillingoffice.com ~. a partial pa}~ment. The remaining balance is your responsibility. 9/23/08 BLS Emergency A0429 1 495.00 9/23/08 Mileage A0425 10 9.00 90.00 9/23/08 Adjustment -Insurance -217.00 2/03/09 Adjustment -Insurance 7.38 2/03/09 Payment -313.40 Total 585.00 -209.62 -313.40 DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT. t~.,.~ ,, ...,~.-------------~---- -- - - ~:- - - ---- ------ -- - acc±e~t.payment in full by chei~~` cn=dit Card c~" ~{et~r~anit ..Please Make Check Payable T¢; cttectfi de+duetion, Please indicate.your payment d~aicef below ,and' fill in required information. If other arrangenerits are Spring Grt?Ve t41'P,cx Ambulance necessary, please call us at 877-2~4-6018. Club' Credit Card: ^ MASTERCARD ^ VISA ^ AMERICAN EXPRESS ^ DISCOVER -i -,r---1,~ ,---i~ ~r-,r- ~--~ `-~r- ~ ~I I' ~i I! ~~ ~I ~; '~ ~ ~'; ~' ' ' i Card Number Name on Card Electronic Check Deduction ~- -- -- ----- •~ Please send a voided check OR provide information below: ::..w =-_=--...__.... __ Expiration Bank Routing Number Checking Account Number 5lgnature Please make any corrections to address below. NORMA JEAN MARTIN 25 EAST THIRD AVE. APT E-4 SPRING GROVE, PA 17362 *Returned checks -You will be responsible for all incurred bank fees permissible under state law. Spring, Grove Area Ambulance Club Billing Office P.O. Box 726 New Cumberland, PA 17070 QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 717-214-6020 Email: info@ambulancebillingoffice.com 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.ambulancebillingoffice.com To: HANOVER GENERAL HOSPITAL We have no1° received your pcryinent. Yaur insurance made a partial payment, and you are: responsible for the remaining ba~ari~ce. Please remit payment. 7`hank you. 9/23/08 BLS Emergency A0429 1 495.00 9/23/08 Mileage A0425 10 9.00 90.00 9/23/08 Adjustment -Insurance -217.00 2/03/09 Adjustment -Insurance 7.38 2/03/09 Payment -313.40 Total 585.00 -209.62 -313.40 DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT. N!e adcept payment in full by check* credit card or efectrQnic = Pfeas~ l+~ak~ Cfieck Payable Ta. check dec#uction; Please indicate your payment ctsoice below and fill in required information. If other arrangements are Spr"rng GrOVe Area Ambulance .necessary, please cell us at 877-214-6018. Club ~ DISCOVER' Eiwn.~ visa ~~ r Credit Card: ^ MASTERCARD ^ VISA ^ AMERICAN EXPRESS ^ DISCOVER Card Number Please make any corrections to address below. Name on Card Electronic Check Deduction --- I Please send a voided check OR provide information below: ~,` Expiration Bank Routing Number Checking Account Number Signature NORMA JEAN J. MARTIN 59 FAWN AVE NEW OXFORD, PA 17350 *Returned checks -You will be responsible for all incurred bank fees permissible under state law. .~ s ` • a , COA+IMONWEALTN OF PENNSrivANIA DEPARTNtEM OF PUBLIC WELFARE BUREAU OF FIIiANCIAL OPERATIONS OMSION OF THIRD PARTY LIABItJ1Y ESTATE RECOVERY PROGRAM PO BOX 8~d8 FNRRISBURG, PA 1710Sd488 May 21, 2009 LAW OFFICES OF PETER J RUSSO PC PETER J RUSSO BSQ 5006 EAST TRINDLE ROAD SUITE 100 MECHANICSBURG PA 17050 Re: NORMA MARTIN CIS #: 830102470 SSN: 192-30-0502 Date of Death: 11/18/2008 Dear Attorney Russo: Please be advised that the Department of Public Welfare maintains a claim in the amount of $8,151.26 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely .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. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, Judy E. Deaven Claims Investigation Agent 717-214-1284 717 -~ -~ FAX '705-~t5~ Enclosure