HomeMy WebLinkAbout09-08-0915056051058
REV-15 0 0 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
Po Box 2sosol 21 09 0573
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
': 174-05-0964 ' 05/14/2009 06/17/1912
Decedent's Last Name Suffix Decedent's First Name MI
Herr 'Russell ' H
(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
c:Ti~.'~ 1. Original Return c`; ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
~:;~ 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~"~;;~ 5. Federal Estate Tax Return Required
death after 12-12-82)
~°:~ 6. Decedent Died Testate ~;w;:~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
~".~.~+ 9. Litigation Proceeds Received L:M::~ 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
Michael K. Herr (717 602-2002
Firm Name (If Applicable) _ ,.__ ................ ...:. ... ...............~................~ ~ i
__ . _ __ ._ __ .. , REGISTE LLS USE LY ..
~' .'~ ~~~
ir*1 ~..;~ .~ L....
- -
"fit
- ~?;~,
First line of address _ _ _; ~ t~° ~
17 East High St.
"n
Second line of address ~ ~ "~~,~=
_ _ __ __ a .... ~,,,.
Apt. 203 .~' ~" '~'
__ _ __
fTE FILED ~
City or Post Office _ State ZIP Code ......... ......... ..........................................+.L .....:
Carlisle ' PA 17013
Correspondent's a-mail address:
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE ERSON R PONSI E F FILING R U N D
ADDRESS
17 East High St., Apt. 3, Carlisle, PA 17013
SIGN RE O P P E ER T REPRESENTATIVE DATE
~~
ADDRESS
11300 U.S. Highway On a 401, Palm Beach Gardens, FL 33408
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056051058 15056051058
•
J
REV-1500 EX
Decedent's Name: RUSS@II H Herr
RECAPITULATION
•
Decedent's Social Security Number
174-05-0964
1. Real estate (Schedule A) ............ ................................ 1.
2. Stocks and Bonds (Schedule B) ....................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages & Notes Receivable (Schedule D) ............................. 4.
5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ........ 5. 77,087.73
6. Jointly Owned Property (Schedule F) ~"°~ Separate Billing Requested ....... 6. i
7.
.
Inter-Vivos Transfers & Miscellaneous Non-Probate Property
__ _
_-j
(Schedule G) f~ Separate Billing Requested........ 7. ; i.
8. Total Gross Assets (total Lines 1-7) .................................... 8. 77,087.73
9. Funeral Expenses & Administrative Costs (Schedule H) ..................... 9. 3,674.00
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................ 10. ' 1,919.20
11. Total Deductions (total Lines 9 & 10) ................................... 11. 5,593.20
12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 71,494.53
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. 71,494.53
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
trans ers un er ec. 116
(a)(1.2) X .0_ 15.
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 10,724 18
18
10,724.18
19. TAX DUE ......................................................... 19. 10,724.18
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
15056.052059 Side 2
15056052059
15056052059
REV-1500 EX Page 3 File Num er
.. _ _ _ ~_~~~_ r._~~~_,... w.~,a..,.~.~. 21 ;~ 09 ?-:0573
VGV~rMi-i. R .7 vv...~.r.v..r . .~.~.. ---- .. ..: ~ _
DECEDENTS SOCIAL SECURITY NUMBER
'
S NAME
DECEDENT
174-05-0964
Russell H Herr
STREET ADDRESS
35 Mallard Ct.
CI.~, STATE
PA ZIP
17055
Mechanicsburg
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19) (1) 10,724.18
2. CreditslPayments
A. Spousal Poverty Credit
474.18
10
,
B. Prior Payments
C. Discount
Total Credits (A + B + C) (2)
10,474.18
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total lnterestlPenalty (D + E) (3)
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)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5} 250.00
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 250.00
Make Check Payable l*o: REGISTER OF WILLS, AGENT
__ _ . ,,
r
,,
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
^ No
a. retain the use or income of the property transferred :...................................................................................... ...
^
b. retain the right to designate who shall use the property transferred or its income : ......................................... ...
c. retain a reversionary interest; or ....................................................................................................................... ... ^
^
d. receive the promise for life of either payments, benefits or care? ................................................................... ...
If death occurred after December 12, 1982, did decedent transfer property within one year of death
2
.
without receiving adequate consideration? ...........................................................................................................
h?
" ... ^
^
...........
or payable upon death bank account or security at his or her deat
3. Did decedent own an "in trust for ...
Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
4
.
contains a beneficiary designation? ..................................................................................................................... ... ^ 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (3) percent (72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
fi{ing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling isdefined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV 1508 EX+ (6-98) •
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Russell H. Herr 21-09-0573
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION VALUE AT DATE
OF DEATH
1 M&T Bank, High St., Carlisle, PA - Classic Checking Account #523315646 11,447.90
2 M&T Bank, High St., Carlisle, PA -Checking account # 1344560 5,518.90
3 M&T Bank, High St., Carlisle, PA -Money Market account #015004214055087 57,296.64
4 Refund from Heartland Healthcare Services, for medical care for pre-deceased wife 56.17
5 Refund from HRC Manor Care for Decedent's Personal Fund 78.11
6 Fraternal Order of Eagles death benefit to the estate 500.00
7 Refund from HRC Manor Care for Decedent's room and board 2,190.01
8
TOTAL (Also enter on line 5, Recapitulation) ~ I 77,087.73
(If more space is needed, insert additional sheets of the same size)
EV-1511 EX+ (12-99) ~ •
SCHEDULE N
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Russell H. Herr 21-09-0573
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' Hoffman-Roth Funeral Home & Crematory, Inc., 219 North Hanover St., Carlisle, PA 894.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s) Michael K. Herr
Social Security Number(s)IEIN Number of Personal Representative(s)
Street Address 17 East High St., Apt. 203
city Carlisle .state PA zip 17013
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 .Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Retum Preparer's Fees
~. Miscellaneous Administration Fees
TOTAL (Also enter on line 9, Recapitulation) I $
(If more space is needed, insert additional sheets of the same site)
280.00
2,000.00
500.00
3,674.00
REV-a.s~z ex+ biz-os)
~ ~" Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I •
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
ESTATE OF FILE NUMBER
Russell H. Herr 21-09-0573
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
• 1• Carlisle Regional Medical Center -Debt 1,068.00
2 Kinetic Imaging -Debt 207.74
3 Blue Mountain Anesthesia Assoc -Debt 27.56
4 Alexander Springs Emergency Physicians -Debt 33.81
5 West Shore EMS -Carlisle -Debt 79.27
6 Darryl K. Guistwite, D.O. Inc. -Debt 154.75
7 Kinetic Imaging -Debt 22.80
8 Darryl K. Guistwite, D.O, Inc. 15.79
9 Allan J. Mira, MD 270.18
10 Kinetic Imaging 13.82
11 Carlisle Urology 25.38
TOTAL (Also enter on Line 10, Recapitulation) I $ 1,919.20
If more space is needed, insert additional sheets of the same size.
K~v-I.s~.3 t»x+ (~.a.-cad
r :, Pennsylvania SCHEDULE ~
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Russell H. Herr 21-09-0573
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec. 9116 (a) (1.2).]
1. Michael K. Herr,17 E. Hight St., Apt. 203, Carlisle, PA 17013 Nephew 50%
2. Karen Hough, 7 Alnwick Rd., Palm Beach Gardens, FL 33418 Niece 50%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUG H 18 OF REV-1500 COVER SHEET, A S APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
1. .
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed, insert additional sheets of the same size.
~ •
ESTATE OF RUSSELL H. HERB
DATE OF DEATH: 05/14/2009
SOCIAL SECURITY #: 174-OS-0964
PA INHERITANCE TAX RETURN
EXHIBIT INDEX
1. Copy of Will dated October 14, 1996.
2. Exhibit for Schedule E
3. Exhibit for Schedule I
LAST WILL AND TESTAMENT
OF
RIISSELL H. HERR
I, Russell H. Herr of Carlisle, Cumberland County,
Pennsylvania, declare this instrument to be my Last Will and
Testament, in manner and for following:
1. I hereby expressly revoke all Wills and Codicils
heretofore made by me. }
2. I hereby direct my personal representative to pay all my
just debts, funeral and administrative expenses out of my estate,
as soon as practicable after my death.
3. Should my wife, Anna M. Herr, survive me for a
period of sixty days following my death, I devise and bequeath
my entire estate, real and personal wherever situate to Anna M.
Herr.
4. In the event my wife, Anna M. Herr, shall predecease me
or die on or before the sixtieth day following my death, I give,.
r
devise, and bequeath all the rest, residue, and remainder of
my estate, real, personal, and mixed, of whatever nature and
wheresoever situate, which I may own or have the right to dispose
of at the time of my death, to the following nieces and nephew
who are living at the time of my decease; Karen Elizabeth Hough,
Elise Carolyn Bojanowski, and Michael Kenneth Herr.
-1-
- ~ _ ;,_
t ~ i
5• I do hereby nominate, co
nstitute, and a ~'' ~''
Apoint my wife, k-;
Anna M• Herr, as Executrix of
this my Last Will and
Testament; and as a~substitut
e Executor I nominate and appoint m
nephew, Michael Kenneth Herr, Y
I further direct that they shall not
required to post any bond to secure the be
faithful performance of
their duties in the Commonwealth of
Pennsylvania or in any other
jurisdiction.
IN WITNESS WHEREOF, I have signed a
Last Will and Testamen nd published this my
t consisting of 3 pages in the presenc
the Subscribin e of
g Witnesses, this 14th day of Qctober
it to be in . 1996_, declaring
y true will and testamentary wishes.
ussell H• Herr
We, the subscribing witnesses certif
signed this Will in our Y that the Test
declarin presence after reading the same andr
g it to be his Last Will and Testament,
i certify that the Testator was of sound.a We, further
memory and un nd disposing mind and.
~n c ns ra'
:. _ . ° or undue influence. ; -
- M
x
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ACKNOWLEDGMENT TO LAS`. ~L
'! ~ AND TESTAMENT OF
~"~' RUSSELL H. HERB
:~•:
a'
,::
COMMONWEALTH OF PENNSYLVANIA )
)SS•
COUNTY OF CUMBERLAND )
I, Russell H. Herr, Testator, whose name is1996riehav~nghbeen
within Last Will dated this 14th~day of October,
duly qualified according to law, do hereby acknowledge that I
signed it willingly as my free and voluntary act for the purpose
therein expressed.
n ~
v
ussell H. err
Sworn to and acknowledged before me by .Russell H. Herr
this 14th day of October, 1996. ~ ~^~,
"~. ..
Notary Pub 1 i NOTARIAL SEAL ~ .
MICHELLE D. RIBBON. NOTARY PUBLIC
AFFIDAVIT O F WITNESSES CARLISLE BOROUGH; -Ct~MB@~CAND CO., PA
. MY COMMISSION EXPIRE.S,MAR~H,14; 1995
..
COMMONWEALTH OF PENNSYLVANIA )SS:
COUNTY OF CUMBERLAND ) ~~ '
!~i'!1~714 77 ~E~/~S , the
We, Edward W. Harker, Esquire and:!`
• names are signed to the ~ast Will of Russell H.
witnesses whose ualifie.d.:according.
Herr, dated October.'i4, 1~996~,~ being duly q
esent and saw, the Testator;
to ..law; do. depose :and •,say~~ that we were - pr . ~ that ~h~. a -
tYi.e in~trum~.nt asa his Last- T~1i11, ~ .j.T# ~~ t~.r1,. ~ : s ~,. , ~ ~~, {:.~. ~ ...
gn and ,.execute _ t~ r:.~ ~ ~ ~ ~ .~.~ .~ ~ .•* _ 3 ~~ ~-3~~ .~ :~: -
.-i.. Sl _. _. ,. ... .. -~~ .=ic'1. -~~.1~.iw.~~~l'~:~'iG~i~.+.A;Y:P~^114~ _ ~a
>f; ct q? t r~ - - ~t:. ,~.,,' ~ _ • ~.•„q; r ti v~ : ~` +~cg~,N'.F~""E•~sc~:3.'S:~ :~~ ~ ' ti 7- `3~~r ~ - ti F - r~ ~ :.a.. qty
^.ez.~. "~' ..'w.''In'... a~ ,•Z:,. ~ : h. }~.. .'tiryta ~ T`~4:~.. 's., ~iq+. ., ~T . ~~ ~ :•i r r i t+,~;,.'-'^rt:.:'M~' ~.z,... -i 'C?'- ~~ `y - ~ ~!i ~~ : ~t r ..a.. ,r.
.r } 1. .%s~~+t,='.~s~~'3L.:r!~+it.wr~h~?eA~..r-..s~n.i'~i.rt.~ n ,rr "S~"±.. .t~ z., +~,r`. -*y;'".~#s, ~ .'.y.n: ~r~.5;. ~ .i..~ ~ .:.z'.
~K ~t t ~. .... ~. .': ., ., ,., ..
• 'bed before me by Edward W H-arker, ~Esquir
• i -
Sworn .to and ~-~subscri ..
witnesses• `this .-14th day of =0ctober~ 1996.
- andV~~n~aQ0.n~e)6' -
N~otary~Pu is NOTARIAl.,5FA1. ~ -~
MICHELLE D. RISBpN;~:NO'~ARY PUBLIC
CARLISLE BOROUGH,-~1,I~BEfl~AND CO.. PA,.
MY COMMISSHIF! DcPIRES• MARCH 14,,1995
- ~ ~. ~ •
~::.
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.~r,s ~T'.d"
-~~ l~l&T Banlc
STATEMENT PERIOD PAGE
ACCOUNT NO. ACCOUNT TYPE
MAY.02-JUN.03,2009 1 OF 2
523315646 ~ CLASSIC CHECKING
00 0 04345M NM I17
2927
RUSSELL H HERR
ANNA MAE HERR
35 MALLARD CT
MECHANICSBURG PA 17055
STONEHEDGE
ACCOUNT SUMMARY ~ ~ CURRENT ENDING
DEPOSITS &. ~ OTHER
BEGINNING CHECKS PAID SUBTRACTIONS INTEREST PD BALANCE
BALANCE OTHER ADDITIONS AMOUNT
N0. AMOUNT N0. AMOUNT N0.
2,386.64 1 -40.91 1 20.00 0.00 13,543.63
11,217.90 3
ACCOUNT ACTIVITY
DEPOSITS,INTEREST CHECKS 8 OTHER DAILY
BALANCE
-...~.~.. •nnTTTH-IC c11RTRACTIONS
DATE ~ R,r~~..... ~.... --- -- - -
511,217.90
05-02-09 BEGINNING BALANCE 20.00 11,197.90
05-OS-09 Adj Services Case # 001-01-9071000452 250.00 11,447.90
05-07-09 US TREASURY 303 SSA ERP 40.91 11,406.99
05-18-09 CHECK NUMBER 2246 670.64 12,077.63
06-01-09 EMBARQ MTR TRUST PENSION 1,466.00 13,543.63
06-03-09 US TREASURY 303 SOC SEC
513,543.63
ENDING BALANCE
.. .
.... ....
, ............. .....:.:::::::::` .:CHECKS >'PAID : SUMMARY ~ ..:::.:.:
2246 05-18-09 40.91
.r ~^x+ ~}b.5
.. ~ _ ~~'~' ~~~'T''~t r-a...
LOOBA (6/07)
-,r. .'
-~~ M&1' i~anlc
STATEMENT PERIOD PAGE
MAY.02-JUN.03,2009 1 OF 2
00 0 04319M NM 017
15907
ANNA MAE HERR
RUSSELL H HERR
35 MALLARD CT
MECHANICSBURG PA ].7055
SELECTED ACCOUNT SUMMARY
ACCOUNT ACCOUNT INTEREST EARNED MATURITY ENDING
TYPE NUMBER YEAR-TO-DATE DATE BALANCE
CLASSIC CHECKING 000000001344560 0.00
M8T MARKET ADVANTAGE 015004214055087 42.89
TOTAL DEPOSITS
5,518.90
57,307.01
62,825.91
ACCOUNT ANNA MAE HERR
CLASSIC CHECKING TITLE RUSSELL H HERR
ACCOUNT N0. 1344560 HIGH STREET-CARLISLE
Af`('`fl11NiT CItMMd1aV
BEGINNING :
'BALANCE DEPO$~TS:~
~OTHER::ADDITIONS _
CHECKS 'PAID OTHER
SUBTRACTIONS CURRENT
INTEREST PD ENDING.:::
BALANCE
NO. AMOUNT N0. AMOUNT N0. AMOUNT
5,518.90 0 0.00 0 0.00 0 0.00 0.00 5,518.90
~f_rf111NT drTTVTTV
POSTING
-DATE
TRANSACTION~DESCRIP7ION DEPOSITS,INTEREST
& OTHER: ADDITIONS CHECKS ~ OTHER
SUBTRACTIONS ~ QAILY : ~:
$ALANCE
05-02-09 BEGINNING BALANCE 55,518.90
ENDING BALANCE $5,518.90
L008A (6%07) };-i `- ' '? . .
'iii°.~~~.:'... .
-„~~ lvinc.~t .~antc
STATEMENT PERIOD PAGE
MAY.02-JUN.03,2009 2 OF 2
ANNA MAE HERR
RUSSELL H HERR
ACCOUNT RUSSELL H HERR
M&T MARKET ADVANTAGE TITLE
ACCOUNT N0. 15004214055087 STONEHEDGE
INTEREST EARNED FOR STATEMENT PERIOD 10.36
ef`f`fIIINT CIIMMeRY
BEGINNING
BALANCE DEPOSITS.B
OTHER ADDITIONS WITHDRAMfALS BOTHER
SUBTRACTIONS CURRENT
INTEREST PAID ENDING
BALANCE
NO. AMOUNT N0. AMOUNT
57,296.64 0 0.00 0 0.00 10.37 57,307.01
erf f1i1NT ef'TTVTTY
POSTING
DATE :..
TRANSACTION DESCRIPTION pEPOSIT&,xNTEREST
& OCHER ADDITIONS W/DRAWALS.B OTHER
SUBTRACTIONS ~. DAILY ..:.~
BALANCE
05-02-09 BEGINNING BALANCE 557,296.64
06-03-09 INTEREST PAYMENT 10.37 57,307.01
ENDING BALANCE 557,307.01
AfiINUAL PERCENTAGE YIELD EARNED = 0.20
** END OF STATEMENT ~*
~,y~ ~,~ 1 : ~ ~
~' rr
LOOSA (6/07)
. ,~// ~ARUS(~~
Boy 4100
~c~a~,
MEDICAL CENTER Carlisle,PA, 17015-3661
1
June 02, 2009
2541-100
MIKE HEAR
35 MALLARD COURT
MECH.ANICSBURG PA 17055
STATEMENT
006557057
PATIENT: RUSSELL H HEAR
PATIENT #: 9430848
BALANCE: $1,068.00
ADM. DATE: 04/09/09
DEAR MIKE HEAR
Thank you for choosing Carlisle Regional Medical Center for your
healthcare needs. We value your use of our facilities.
Your insurance company was billed and has paid according to the
benefits of your policy. However, there is a patient balance due
which is indicated above. Your payment is important to the efficiency of
the hospital and our attempts to hold down costs. Please mail your check
or money order today. For your convenience, we accept Visa, MasterCard,
Discover and American Express (see below).
If you have additional insurance information which you have not previously
provided, please notify us immediately. Furthermore, if you are not able
to pay this account in full at once, please contact us for payment
arrangements.
If you have questions regarding the balance of this account, please do not
hesitate to call us at the number shown below. Thank you for your prompt
attention to this matter.
PAY ONLINE 7 DAYS A WEEK 24HRS/DAY AT www.carlislermc.com
PLEASE RET jRN LOWER PORTION WITH YOUR PAYMENT
CARLISLE REGIONAL MEDICAL CENTER
PATIENT REPRESENTATIVE
800 381-9160
8:30 A.M. TO 5:00 P.M.
PIA 03
** CREDIT AUTHORIZATION **
VISA(_) MC (_) DISC ( )AMX (_)
EXP DATE ( ) VIN# ( )
CARD # ( )
PMT AMT ( )
SIGN ( )
CARLISLE REGIONAL MEDICAL CENTER
P.O. BOX 4100
CARLISLE PA 17015-3661
03 .
*CALLS/INQUIRIES MAY BE MONITORED FOR QUALITY CONTROL*
100 ~ ,
~;
PATIENT: RUSSELL H HEAR
PATIENT #: 9430848
BALANCE: $1,068.00
ADM. DATE: 04/09/09
Account: KIN21169 ~
Services Render ~Carlisie Regional Medical Center
raymenis
Date Code Description Charge Ad'ustments
4/9/2009 73510 XR HIP UNILAT COMP 2 VIEWS 50.00
5/15/2009 PMT MEDICARE HGS ADMINISTRATORS 8.50
CR Adjustment MEDICARE HGS ADMINISTRATORS 39.37
Message: MEDICARE HGS ADMINISTRATORS CONTRACT FEE / -
ACGEPTED ASSIGNMENT
4J9/2009 72170 XR PELVIS 1 OR 2 VIEWS 40.00
5/15/2009 PMT MEDICARE HGS ADMINISTRATORS 6.82
CR Adjustment MEDICARE HGS ADMINISTRATORS 31.48
Message: MEDICARE HGS ADMINISTRATORS CONTRACT FEE / -
ACCEPTED ASSIGNMENT
4/9/2009 71010 XR CHEST 1 VIEW 40.00
5/15/2009 PMT MEDICARE HGS ADMINISTRATORS 7.10
CR Adjustment MEDICARE HGS ADMINISTRATORS 31.12
Message: MEDICARE HGS ADMINISTRATORS CONTRACT FEE / -
ACGEPTED ASSIGNMENT
4M1/2009 73510 XR HIP UNiLAT COMP 2 VIEWS 50.00
5/15/2009 PMT MEDICARE HGS ADMINISTRATORS 8.50
CR Adjustment MEDICARE HGS ADMINISTRATORS 39.37
Message: MEDICARE HGS ADMINISTRATORS CONTRACT FEE / -
ACCEPTED ASSIGNMENT
419/2008 73700 CT LOWER EXTP.EMITY 250.00*
4/9/2009 73530 XR HIP INTRAOPERATIVE 70.00*
4/9/2009 76377 3D INDEPENDENT WORKSTATION 200.00
~ ~ C,
~. ~ ~ ~ .
~
~~~~ e ~ c:~~lr~. ~~
BALANCE DUE X207.74
PAY BY June 2 009
Your account is now past due. Please remit For billing questions call 717-652-6105
payment to: 4520 Union Deposit Rd . Fax: 717-652-2165
Harrisburg, PA 17111-2910 to avoid refeFral Office Hours: Mon -Fri 7:OOam to 7:OOpm
to our collections department.. ~ _
Those charges shown with an "*" indicate pending insurance.
~~~~ STATEMENT
SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION ~~_44
Date Procedure
Code Patient
Name
scription Btlle
Amol.
Balance
Physician/Location
04/09/09
05/01/09 OI230 MIKE HERR
MIKE HERR ANESTHESIA UPPER 2/3 FEMUR OPEN PRO
Payment HIGHMARK MEDICARE 1,050.00
110.25 27.56
- DANIEL CHESS
361 ALEXANDER SPRING RD
05/01/09 MIKE HERR MEDICARE ADJUSTMENT 912.19 -
--
.
/~ C -
... ~ ~ ,
Please Pay
YOUR ACCOUNT IS PAST DUE. PLEASE SEND YOUR PAYMENT WITHIN
10 DAYS OR THE ACCOUNT WILL BE FORWARDED T0" COLLECTIONS.
IF YOU NAVE ALREADY SENT 1N YOUR PAYMENT, PLEASE DISREGARD.
27.56
STATEMENT
I~~~~ SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION 17480-BM4.31
V IDII.CVI VIW IVU IUUIV IOt[VU1~'I~..t~
A~ DER SPRINGS EMER PHYS
PO BOX 37720
PHILADELPHIA, PA 19101-7720
0
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0
„~lil,,,IiI,,,,i,l„i,i„I„1„Il,,,11„I„I„11„I,i,ii,,,
031212-000009430848304
#BWNJFDB
#OOOOOOOCLL571396#
RUSSELL H HERR
35 MALLARD CT
MECHANICSBURG PA 17055-4334
a .........,t naf~a
TATEMENT F CC NT (1)
Statement Date: June 14, 2009
ACCOUNT NUMBER: CLL94308483
Patient Name: RUSSELL H HERR
Tax ID #: 2G-2419497
Account Balance: $33.81
Amount Pending
Insurance: $0.00
Amount Due From
Patient (Current): $33.81
Amount Due From
Patient (Past Due): $0.00
Pay This Amount: $33.81
PLEASE REMIT PAYMENT BY
"PAYMENT DUE BY" DATE. THANK YO
Please refer to coupon below for paymE
instructions.
~ D to N "# . ~~~~~• Description Charge Paid By
First Ins. Paid By
Other Ins. Paid By
Patient Amount
Ad'usted Due From
Insurance PATIENT
BALANCE
04/09/09 1 99285 EMERG INJURY EVAL & 5907.00
MGMT-LVL 5
DX~820.8 DR. GUARRACINOJCARLISLE REGIONAL ME ICAL CENT R
05/06/09 MEDICARE CONTRACTUAL ALr_OWANCE $-737.96
8'
533
05/06!09 MEDICARE PAYMENT $-135.23 .
~I U
~s ~~ c ~ .
~c .~~.~
TOTALS: 5907.00 $-135.23 $0.00 50.00 $-737.98 $0.00 $33,81
Important Messages; 1,,.,,_/'
This statement is for the direct treatment and/or supervision of care you recently received from an Emergency Physician at Carlisle Regional Medical Center. The fees for this
private ~hysician are billed separately from any hospital charges or other professional tees for which you may also be responsible. Therefore, should you receive a bill from the
hospita or other physicians for charges in connection with this visit, it rriil not include the items listed on this statement.
"Payment Plans" Accepted
Questions about this statement? / Llame de Lunes a Viernes?
Catt 9-800-355-2470 Monday through Friday 9:30AM - 4:OOPM.
Your automated system access code Is 0947-94308483, ar you can send email to
billing_questians@emcare.com.
Please detach and return bottom portion with your remittance. ~'"~
EST- SHORE EMS -CARLISLE ~ ~~,
~5 GRANDVIEW AVE STE#211 ~_
P HILL, PA 17011 `~.ST SH~RE
CAM Federal Tax ID: 23-2463002
Phone #: (800) 367-0512
PATIENT NAME: ANNA HERB
MEDICARE B 1740509648
INSURANCE: U0917650202
CIGNA
0900717
ANNA HERR
CIO RUSSELL HERR
35 MALLARD ST
MECHANICSBURG, PA 17055-4334
DESCRIPTION OF CHARGE
MICU EMERGENCY LEVEL 1 A0427
ALS MILEAGE A0425
DEXTROSE 25GM A0394
EKG ELECTRODES (4PK) A0396
GLUCOSE BLOOD A0394
OXYGEN ADMINSTRATION A0422
SALINE PREFILLED SYRINGE A0394
.l ~ ~7 d
~~ ~
~ /U~ ~
es ~~`~e Qcc~u~~
PATIENT NUMBER: 79328 REJ
CALL NUMBER: 0900717 NONE
DATE OF CALL: 02/1012009
TIME OF CALL:
CALLER:
NORCARE HEALTH SVCS - CARLI:
FROM: MA
CARLISLE REGIONAL MEDICAL CTR
TO:
REASON(S) ALTERED LEVEL OF CONSCIOU
FOR Hypoglycemia
TRANSPORT
INVOICE
QUANTITY
1.0
1.0
1.0
1.0
1.0
1.0
1.0
DESCRIPTION OF PAYMENT
Medicare Assignment Adjustment
Medicare Part B Payment
UNIT PRICE
1337.94
13.08
5.58
5.19
7.08
61.91
1.76
RECEIPT PAYMENT DATE
0312012009
109323516 03120/2009
AMOUNT
1337.94
13.08
5.58
5.19
7.08
61.91
1.76
1 5234 4
Total Charges
AMOUNT
1036.15
317.12
T
OUNT -INVOICE DUE UPON RECEIPT -- ~
PLEASE PAY THIS AM
RNED CHECK FEE $31.00
RETU
~+ < ~r o :
1 .c3E'8bf`~ .ova ea~-~°
1353.27
$79.27
Darryl K. ~istwite, D.4., Inc.
56 Ashton Street
Carlisle, PA 17015-6914
(717) 609-2639
RUSSEL HERR
C/O MIKE HERR
35 MALLARD COURT
MECHANICSBURG PA 17055
,c~
.-
~-
Darryl K. Guistwite, D.O., Inc.
56 Ashton Street
Carlisle, PA 17015-6914
05/28/09 05/28/09
i
.- ~ .-
185. 0 (1) 185.0
y
~, , r. .,
~. ~ ~ -
.. ~ .::,
.G ge¢
r
RUSSEL HERR ( 185.0)
04/09/09 NURSING HOME EST. PATIENT 105.00
05/05/09 Ins Pmt-MEDICARE 63.14
05/05/09 Adjustment 26.07
04/12/09 NURSING HOME NEW PATIENT L 170.00
05/05/09 Ins Pmt-MEDICARE 113.12
05/05/09 Adjustment 28.60
04/13/09 NURSING HOME EST. PATIENT 105.00
05/05/09 Ins Pmt-MEDICARE 63.14
05/05/09 Adjustment 26.07
04/1.4/09 NURSING HOME EST. PATIENT 75.00
05/07/09 Ins Pmt-MEDICARE 47.53
05/07/09 Adjustment 15.59
04/15/09 NURSING HOME EST. PATIENT 105.00
05/07/09 Ins Pmt-MEDICARE' 63.14
05/G7/G9 Adjustment 26.07
04/16/09 NURSING HOME EST. PATIENT 75.00
05/12/09 Ins Pmt-MEDICARE 47.53
05/12/09 Adjustment 15.59
04/20/09 NURSING HOME EST. PATIENT 105.00
05/12/09 Ins Pmt-MEDICARE 63.14
05/12/09 Adjustment 26.07
04/21/09 NURSING HOME EST. PATIENT 75.00
05/12/09 Ins Pmt-MEDICARE 47.53
05/12/09 Adjustment 15.59
04/29/09 NURSING HOME EST. PATIENT 75.00
In Pmt-MEDICARE 47.53
Total Due
i0 Days 61 - 90 Days 91 -120 Days Over 120 Days ~ -
Piease -
pay this
amount!
Detach this stub and return with payment.
Hccvuni: n~tyL'17by Services Rendered At: Carlisle Re Tonal Medical Center
Date Code Description _ _ _ _ _ _ _ _ _ _ _ _ Charge * Adjustments
4/9/2009 73700 GT LOWER EXTR TY ~ 250.00
5/28/2009 Message: MEDICARE HGS ADMINISTRATORS PMT lS DENIED WHEN -
PERFORMED BY THIS TYP
4/912009 73530 XR HiP iNTRAOPERATIVE 70.00 *
5/28/2009 Message: MEDICARE HGS ADMINISTRATORS PMT IS DENIED WHEN -
PERFORMED BY THlS TYP
5/12/2009 74150 CT ABD 250.00
6/29/2009 PMT MEDICARE HGS ADMINISTRATORS ~ 47.64
CR Adjustment MEDICARE HGS ADMINISTRATORS '190.45
Message: MEDICARE HGS ADMINISTRATORS CONTRACT FEE / -
ACCEPTED ASSIGNMENT
5/12/2009 72192 CT PELVIS 250.00
6/29/2009 PMT MEDICARE HGS ADMINISTRATORS 43.95
CR Adjustment MEDICARE HGS ADMINISTRATORS 195.06
Message: MEDICARE HGS ADMINISTRATORS CONTRACT FEE / -
ACCEPTED ASSIGNMENT.
,~, r
~~ 1.~ E. 1 ~ .~,~'s~ 2 !. ~
~~ ~ ~j~s ,~ u r ! ~/~/ ~ ~- to
~~ ~ _
~~1~ ~ ~ ~~
.~,o~ y
_ ~ G1 ~ ~ BALANCE DUE $22.90
PAY BY J u I y 30, 2009
lease call with. your insurance coverage or For billing questions call' 717-652-F105
:mil the balance due today to: , .: Fax: 717-652-2165
520 Union Deposit,Rd _ <. ' '~x' Office Hours: Mon -Fri 7:OOam to 7:OOpm
arrisburg, PA 17111-2910
hose charges shown with an "*" indicate pending insurance. ~ ~ .
STATEMENT
IIii !! I I II II (Iff (f ++!!II ++ SEE REVERSE SIDE fOR IMPORTANT BILLING INFORMATION ~ssos-zs `
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