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Home My WebLink About03-04-10 (2)~ REV-1500 E><cos-o5) PA Department of Revenue Bureau of Individual Taxes PO BOX 280801 Hanisburg, PA 17128-0601 15056051058 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY Countv Code Year File Number 21 09 ENTER DECEDENT INFORMATION BELOW - Social Security Number D_ ate of Death ~~~_.___~....~~~w..._.._~.__~_...__.___~_...._~~_~ ___,______w_~__~_~_..~..~,~__~~__~____.__------ 200-56-4097 ~ 05/13/2008 Decedent's Last Name Suffix Ballard (If Appiicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's Social Security Number Date of Birth,n^^ ^^_~___ _.~____~~~~w~~..~ .06/25/1976 Decedent's First Name MI James _.....__...~ _..~._ ~ __._~ Spouse's First Name MI ~' ~~_~~~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRWTE OVALS BELOW ;>~ 1. Original Retum O 2. Supplemental Retum C7 3. Remainder Retum (date of death prior to 12-13-82) (','~ 4. Limited Estate t~ 4a. Future Interest Compromise (date of C7 5. Federel Estate Tax Retum Required death after 12-12-82) C 8. Decedent Died Testate L~ 7. Decedent Maintained a Living Trust ,_____, 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) L_3 9. Litigation Proceeds Received Q 10. Spousal Poverty Credit (date of death C3 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 Name Daytime Telephoi `Michael Cherewka, Esq. ` (717 Firm Name (If Applicable) s~,,,~r~~ Correspondent's e-mail address: mcherewka@cherewkalaw.com BE DIRE[ er o _"""""'~ ~ ~ s USE fNLY T0: r~---., ~y r._~ ----4,~5 _i 7 ~~ ...? l'~=~ ' .. ~7 r ~~ A.~ w~` ',- r=rl '~ 7 Under Pena ' of perjury, I declare that I have examined this return, including accompanying schedules and siatemeMs, and to the best of my knowledge and belief, it is true. nd complete_l?edaratlon of preparer other than the personal representative is based on all infonnatioh of which preparer has any knowledge. SIGNAT SqN ~ SIB pOR FILING RETURN DATE ~,A Di /,~- - 02/23/10 ADDRESS 624 North Front Street, Wormleysburg, PA 17043 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 J 15056052059 REV-1500 EX Deoedenrs Name. James F Ballard Decedent's Social Security Number 200-56-4097 RECAPITULATION 1. Real estate (Schedule A) ............................................. 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Corporation, Partnership or Soie-Proprietorship (Schedule C) ..... 3. 4. Mortgages & Notes Receivable (Schedule D) ............................. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ........ 5. 1,447.45 6. Jointly Owned Property (Schedule F) Q Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property i (Schedule G) C~ Separate Billing Requested......... 7. 8. Total Gross Assets (total Lines 1-7) .................................... 8. 1,447.45.' __ __ 9. Funeral Expenses 8 Administrative Costs (Schedule H) .............. ....... 9. 1,447.45 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ......... ....... 10. 1,637.12 11. Total Deductions (total Lines 9 & 10) ............................ ....... 11. 3,084.57 12. Net Value of Estate (Line 8 minus Line 11) ....................... ....... 12. 0.00 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................. ....... 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ................. ....... 14. 0.00 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (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 18. 19. TAX DUE ...................................................... ...19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 0.00 0.00 0.00 0.00 0.00 15056052059 Side 2 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 09 0135 DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER James F Ballard 200-56-4097 STREET ADDRESS 53 John's Drive CITE' Enola STATE PA ZIP 17025 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 0.00 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 A. Enter the interest on the tax due. (5A) 0.00 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 0.00 Make Check Payable to: REGISTER OF WILLS, AGENT R ....~ L. ..ch.. ..., ~ .. -.nX.:Y .~c~'~ _ ..{ .:~{.. M. ~. {a u... t.-.. .... .. _i ~... .. ..... .~J..i ...x .K.. ~.if ... ~.c. ..arm ~. 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 :.......................................................................................... ~ X~ b. retain the right to designate who shall use the property transferred or its income : ............................................ ~ ~c c. retain a reversionary interest; or .......................................................................................................................... ~ X~ d. receive the promise for life of either payments, benefits or care? ...................................................................... 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ~ .X~ 3. Did decedent own an "in trust fora or payable upon death bank account or security at his or her death? .............. ~ X7 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. ..., ra~....5 _..~ , r? ,., s -. _ .. , ~. _. .,. x: ,.. a... ..f. ._ . ...~. ..ter ~ :~ 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 filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child. twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX+ (6-ga) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER James F. Ballard 21-09-0135 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 VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1.' 2007 PA Property Tax I Rent Rebate 650.00 2. 2007 IRS Income Tax Refund 197.00 3.' .Camp Hope Refund 151.00 4. CPARC FICA Refund 140.92 5.' CPARC Replacement Payroll Checks 176.53 6. 'CASH 132.00 ~. a i! „ -~ ~ ~~ n x I 00000 002 018 013109 82040056 093546 CDC FUND DEPT PREP DATE VOUCHER WARRANT ID 8•..'~ tl..KJ ~ ~~ ~.~_r ~r~~,~ Ft~LTON BAN)~C: 'LX~NCAST~R, PA s ~' y '''k' VERIFICATION AVAILABLE - "-POSITIVE PAY ~~~ TO THE ORDER OF JAMES F BALLARD DLN 077000665331 REV REBATE 53 JOHNS DR :PROTEGTEb r ~Y r`- ENOLA PA 17025-2694 N of r °o I~~~III~~~lll~~~~~l~l~l~i~~~l~l~ll~~l~l~~y; I~I~I~~~II~~11~~1 ' 3;13'' J I i ~ ~ T ~ `CHECK NUMBEEj' ` \ - ~ ~ ~~ `~ - .02~/ 17/2009, ~' DATE ~~ _. 1 ~ !, .VOID AFTER 180 DAYS 1 ,/..., ...,......,,........,...._....,...,.. __. ...............,. ;~~s~: / / ~ EASURER OF PENNSYLVANIA: ', :,J <i. 11'5865 133011' x:03 130 14.2 2~: 1 2 i9 5384711' - - _ - - - - - - ~ ~['c ,. _ COMMONWEALTH'OF PENNSYLVANIA . ~EV-is2s Ex a-os ` `- - DEPARTMENT OF`REVENUE -~~ ~ ' ~.. a `We are ;pleased to send you this check for your 2007 Property Tax/Rent Rebate: Revenue from slats~aming~allowed us to give more rebates ,to older and disabled Pennsylvanians and increase the maximum rebate.; = '~. =. ~-,- ~r ., .._ - Some homeowners may receive~a Jarger.rebate.than requested. Based~orl, where you live, income and/orproperty taxes; you may ~~have pualified,for a supplemental property`tax rebate added toyouur fegular ~ebafe.~,In addition, historic state-funded local tax relief ~~~will begin this "summer further cutting property taxes for millions af.homeowners across the commonwealth - -The Property Tax/Rent Rebate program is one of the many benefits that the Pennsylvania Lottery provides to older Pennsylvanians. I am very proud Eo say that~we have the only state lottery tHat~desig`nates all its proceeds to'programs that benefit older residents. You may be familiar with some of the~other programs that the Lottery provides, including PACE and PACENET,'our low-cost prescription ~"~dru. programs; free and reduced ,transportation services- ion terrri care services; senior centers; :and the:Area:Agencies~on Aging. , p~ 9- . _. _.__. 9 -All of these services are part., of our commitment to ensuring a healthier, happier life for you and Pennsylvania's older residents . If you have questions about this check or your rebate clam, call toll-free 1-888-222-9190_. - ~ ~""- ~ - ~.~Edwacd G. Rendell, ` ~~~~~ ,Governor :~ LorrotY Note: You will automatically receive an application in the mail -; PENN VANIA ^--°-~~ y y because you received a rebate this year.': ~.,~ _ rRO_~rRrr r-a icuEr earl neXt ear ~r. W ~~~ ~~ - .:~ `•..~~~ ^~~ ~, ~'rl ':~~iri y~~jxa~ _' j ~~/.~^~t,+~~ ~~~~ ~ ~ I~".. as Z!r QQ~~~ ~''1~ ~~ ~ O ."'= ~. ~ o ,.~ U - 00 u1 = Q to Q Lrl p = mza O Y ~ oo _ ~ - D .~ NO'=tAOQ D ` E . ~o - N - '-O _ u1 QMZ D .~ ",O - -~ v5 ts.i D .^ ^ , ; . :, ra ~ $ r i An p ~ ~[q~~ ~y ~s ~l~ qy Vb K '~~~/~'d 7 "' 3' ~ ~d``~~~ iF „~} ~ , ~~ ,t Zvi 1 ~ s ~.~g ' J { ~ 'fi t ~ J O~ s~ .. ~ I ~ , C.1 t'. ~ *~ ~ "~.<` i x~ ' :~ '~~3 ~; ~ ~ ra~° ~ R < ~- ~~ • .. } ,~z ~ ~~ ~ O` , Y ; 1 9 E '~ a i^~ z .. 1~ f R.1 ~ .- ~~'~- ~ ~ ~ `~ ~ ' ~ o*.l f y -_ ~.. r ' r ~ .y ,ic ~' ~ - >ti~ ~ _ ~' S"'~'1 ~~ m ti, .~. ~ ~ 1 ~ f ' O i ~-~ -it _ ~ _~ e~ ~ w ~ ~ ~m .- - > ~ 4-- ~ Q _. f;~` ~3" LLI ~ W' N F ~:` N ' = r2; ~ dj~~ _ ~}Oh ~:-. ~_~ F"# ~ cc ' OLBB;£4:6-0£J~t i~t ~ ";Jhl ltRtt41S00Z®. i i r ru W W i ^ W r W O r r m ~_~ w -,~ ti r m I I ~ ~ ~ C C ~ W i I I I I i I I ~. rt - , ~~, i ,n:- - ~ tN O ~{ ~ '= ~ti~r 4 I; .~ - ,z,. o,'- ' c n- ~. ~ z?? ~. _ , ~ I -o:. --i , "a Z !~ W (~/~l1~ 'Z.. D o I i Z.:. :'r-1 i i i i I I i j i~ I 1 1. -'~, i I i N j ~ n N e- 10 ~ ~ O O U-I 4=i _ ~ o o ~~;` H I O N F ' H~ I 1.f1 to +? , H T+ O O Q ~ ~ I ~~ ' LL LL N J V I ~ ~ Q I FW.. 01 m f D O rd O ~ N ~ I ~ ~O ' ~o 0o Y rn Z ~ M M W ~ Y n ~ V r- I N N V N = N ~k V .~ U N .[; U S-I O 4-a x U N ti W V N H V ~ O ~ ~ O U W r„~ S QI ~ UI tai ~ Z O ~ 4 ~. w -~I o h H a ;~' ' z °C ~ , o c 0 W - W p } ? ~.: Q J~: ~ W - - ° a ~ ° ' m F- :. fA N ~ O': w w W ~ ~ '.~'.. W J W J ~ Z V 1 Ul C~ N [~ fY1 ~~ CD 1 a r'f'f a rf1 O ~~ ~_ L.0 r.~ N f7J .:~ REV-1511 EX+ (10-09) Pennsylvania DEPARTMENT OF REVENUE INHERTfANCE TAX RETURN SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER James F. Ballard 21-09-0135 Decedent's debts must be reported an Schedule I. _ __ .___ B, ADMINISTRATIVE COSTS: i. Personal Representative Commissions: 1,170.00 Name(s) of Personal Representative(s) Michael Cherewka, Esq. street Address 624 North Front Street C;ty Wormteysburg state PA zIP 17043 Year(s) Commission Paid: 2010 2. 3. Attorney Fees: 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 59.00 4. Probate Fees 5. Accountant Fees: 6. Tax Return Preparer Fees: 7• Legal Notices -Sentinel 135.84 B.' Legai Notices -Cumberland Law Journal 75.00 s. Miscellaneous Administrative Costs _ 7.61 TOTAL (Also enter on Line 9, Recapitulation) $ .1,447.45 If more space is needed, use additional sheets of paper of the same size. RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Receipt Date: 2/06/2009 Cumberland County - Register Of Wills Receipt Time: 15:11:35 One Courthouse Square Receipt No.: 1055651 Carlisle, PA 17J13 BALLARD JAMES F Estate File No.: 2009-00135 Paid By Remarks: MICHAEL CHEREWKA JN Receipt Distribution Fee/Tax Description Payment Amount Payee Name PETITION LTRS ADM 20.00 CUMBERLAND COUNTY GENERAL FUN AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 24.00 CUMBERLAND COUNTY GENERAL FUN JCP FEE 10.00 BUREAU OF RECEIPTS & CNTR M.D ---- Check# 4030 ------------ $59.00 Total Received......... $59.00 RETAIN THIS PORTION FOR YOUR RECORDS THE SENTINEL - LEGAL MICHAEL CHEREWKA P.O. BOX 130, CARLISLE, PA 17013 AD NUMBER CLASS SALESPERSON BILLING DATE LINES ' 364980 10 PUBLIC NOTICES heckb 03/11/09 2.0 * 2 AD DESCRIPTION START DATE STOP DATE NOTICE NOTICE IS HEREBY GIVEN THAT 02/25/09 03/11/09 PUBLICATION INSERTIONS RATE NET AMOUNT GROSS AMOUNT 3 THE SENTINEL.- LEGAL 3 LGL 106.20 TOTAL AD CHARGE 106.20 PROOF OF PUBLICATION ~O1PRF ~ 7..00 ORDE estate ballard PAY THIS AMOUNT I 113.20 I 135.84* MESSAGE: Thank you for advertising with The Sentinel. Deadlines for in-column legal advertisements: Monday is Thursday at 5 p.m; Tuesday is Friday at 5 p.m.'; Wednesday is Monday at 5 p.m; Thursday is Tuesday at 5 p.m; Friday is Wednesday at 5 p.m Saturday is' Wednesday at 12 Noon; Sunday is Wednesday at 5 p.m. If you have any .questions regarding your Legal bill please call Classified Manager at 717-240-7176 Fax•your legals to 717-243-3754 attention Classified Manager you can also EMAIL your legal to Classified ads: classifiedC~cumberlink.com Please send a cover letter including your name and address as an attachment DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT THE SENTINEL -LEGAL estate ballard P C1 RfIY 130 CART ISI F PA '17013 AD NUMBER CLASSO START DATE STOP DATE 364980 PUBLIC NOTICES 02/25/09 03/11/09 AD DESCRIPTION BILLING DATE TELEPHONE NUMBER NOTICE NOTICE IS HEREBY GIVEN THAT 03/11/09 717-232-4701 MICHAEL CHEREWKA 624 NORTH FRONT STREET WORMLEYSBURG, PA' 17043 I~~~III~~~III~~~~I~~I~~II~~I~I~I GROSS AMOUNT OF 135.84 DUE AFTER 04/10/09 TOTAL AMOUNT DUE 113.20 ENTER AMOUNT ENCLOSED .. ,. ,. ,. ,. ,. ,. „ ,. ,.., ~ . ~ „ ,. ,. ,. ,. „,. „„,. „,. ,. „,. „„., ~., r.. „ . ,. „„„,.., , ., ., ,. CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717) 249166 Fa~c (71 ~ 249-2663 March 13, 2009 Cumberland Law Joumal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas. as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Michael Cherewka, Esquire RE: James F..Ballard Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on the following dates: February 27, March 6 and March 13, 2009 Advertising Cost ~ $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received . $ 0 .00 Total Amount Due $ 75.00 Payment received by REV-is>_2 ex+ t>_z-os~ ~ Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER James F. Ballard 21-09-0135 Report debts incurced 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. MAKE CHECKS PAYABLE TO: East Pennsboro Ambulance Service Inc Billing Office TIN: 23-2464545. P.O. Box .726 New Cumberland,. PA 17070 - Patient Name: Patient SSN: Date of Service: From: To: Primary Payor: Secondary Payor: BALLARD, JAMES F. XXX-XX-0000 5/13/2008 07:27 RESIDENCE Holy Spirit Hospital Bill Patient ® MASTERCARD ~ DISCOVER Y~S~ ~SA CARD NUMBER EXP. DATE SIGNATURE AMOUNT INVOICE DATE 6/1/2008 RUN NUMBER 08-29868 PAY THIS AMOUNT, $701.00 Local Telephone: 1-717-214-6018 Para Espanol /lame 1-866-724-4114 Toll Free : 1-877-214-6018 FAX: 1-717-214-6020 errral: info@ambulancebillingoffice.com JAMES F. BALLARD 53 JOHNS DRIVE ENOLA, PA 17025 III~IIIIIIIIIIIIIIIIII III Ill~lllalllllllllllllllllllllllllllllllll~q PLEASE MAKE ANY CORRECTIONS TO ADDRESS ABOVE. DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT. Procedure `Total ' Disbounts / .. Date Description ..Code Qty bnit Pnee Charge Adjystrnents 'Payments -- 5/13/08 Basic Life Support/Emergency _ A0429 1 600.00 600.00 5/13/08 Mileage A0425 4 9.00 36.00 5/13/08 Oxygen A0422 1 40.00 40.00 5/13/08 BLS Routine Disposable Supplie A0382 1 25.00 25.00 Total 701.00 0.00 0.00 ** Please -read -this bill, is your responsibility. **. We have no insurance information on file for you. Please provide your insurance .information on .the back of this bill or remit payment. ' Thank you. East PennsboroAmbulance Service Inc, s77z~4-so18 PAY THIS AMOUNT IIII• $701.00 BALLARD, JAMES F. 08-29868 II~II Igllllllll III II III II • WEST SHORE EMS -ALS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011 Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 ~~~ (~ EMERGENCY IvIEDICAL SERVICES PATIENT NAME: JAMES BALLARD PATIENT NUMBER: 72342 NSOF CALL NUMBER: 3105770A C INSURANCE: MEDICARE B 200564097A DATE OF CALL: 05/13/2008 `~ DEPARTMENT OF PUBLIC 9301196995 TIME OF CALL: 07:21 AM CALLER: 3105770A FROM: 53 JOHNS DR TO: HOLY SPIRIT HOSPITAL JAMES BALLARD 53 JOHNS DR REASON(S) CARDIAC ARREST P O BOX 575 FOR ENOLA, PA 17025-0575 TRANSPORT INVOICE DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT PARAMEDIC INTERCEPT A0999 1.0 797.87 797,87 ATROPINE 1MG A0394 1.0 5.13 5.13 COMBINATION DEFIB/PACER PADS A0392 1.0 59.85. 59.85 EKG ELECTRODES (4PK) A0396 1.0 4.94 4.94 ENDOTRACH TUBE A0422 1.0 3.30 3.30 EPI 1 MG 1:10000 PFS A0394 1.0 5.13 5.13 ET TUBE HOLDER A0422 1.0 8.25 8.25 PERIPHERAL IV A0394 1.0 36.75 36.75 STYLET A0422 1.0 6.29 6.29 SYRINGE (1000) A0394 1.0 1.00 1.00 Total Charges 928.51 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Total Credits 0.00 PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -->• o~T~ ~o~~cn r+ucr~t CcC _ @Qi nn x928.51 DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT AMOUNT DUE 928.51 PATIENT NAME: BALLARD, JAMES CALL NUMBER 3105770A AMOUNT $ PATIENT NUMBER: 72342 BILLING DATE: 09/22/2008 ENCLOSED This account is now PAST DUE!! Payment must be received ~ Vlsa WITHIN 10 DAYS. Collection process will begin. ~ AND MASTER CARD ACCEPTED WEST SHORE EMS -ALS 205 GRANDVIEW AVE CAMP HILL, PA 17011 ~_ =_ -_ ~~~~Heritage Medical Group, LLP HERITAGE CARDIOLOGY ASSOC. 425 North 21st Street Camp Hill, PA 17011 ~ - ~ Please check if address or insurance information ~ _ ~ is incorrect and complete form on back. ~~~III~~~III~~~~~I~I~I~I~~~I~I~II~~I~I.~~I~~I~I~I~~~II~~II~~ a`o'ess's`"""""'""'3-DIGIT 170 JAMES F BALLARD 53 JOHNS DR ENOLA PA '17025-2694 HERITAGE MEDICAL GROUP, LLP PO Box 70850 Philadelphia, PA 19176-5850 00262671000D3498550000000761 5 PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT e~.~.~tllt,t ~- 349855 Please Pav_ 7.07 Due Date:10/27/08 Insurance Patient Date _Descrip6on Charges Balance Balance . JAMES F BALLARD ID# 349855/VENKATESH K NADAR MD 05/13/2008 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE D 69.00 69.00 0.00 05/13/2008 DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPING (L 31.00 31.00 0.00 05/13/2008 DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS 15.00 15.00 0.00 09/12/2008 SYSTEM CONTRACTUAL ADJUSTMENT FROM MEDICARE -76.94 0.00 09/12/2008 PAYMENT FROM MEDICARE -30.45 0.00 09/25/2008 PAYMENT FROM MEDICAL ASSISTANCE 0.00 0.00 10/01/2008 PATIENT RESPONSIBILITY - MEDICAL ASSISTANCE DENIED THIS CLAIM STATING -7.61 7.61 --> THE RECIPIENT WAS NOT ELIGIBLE ON THE DATE OF SERVICE. PLEASE --> REMIT PAYMENT. THANK YOU! BALANCE TICKET #002686 .00 7.61 YQUR ACCOUNT IMPORTANT:MESSAGI ABOUT . l B t l T Prompt payment is greatly appreciated! ance o a a 7.61 -Insurance Pending .00 'Amount Due 7.61 Make Checks HERITAGE MEDICAL GROUP, LLP Payable To: ~ Check Card Used and Fill in Below to Pay by Credit Card viSA ^ MasterCard r ~-• ^ V I sa ^ Discover ar um er moun Signature xp. Date Statement ate ay !s mount ccount 10/06/08 ST.61 349855 ayment ue ate SHOW AMOUNT 10/27/08 PAID HERE For Billing Questions Call (717) 972-2829 x 20 PLEASE DO NOT SEND CASH THROUGH THE MAIL