HomeMy WebLinkAbout02-26-10 (2)1505607120
REV-1500 ~ (06.05) OFFICIAL USE ONLY
PA Department of Revenue aunty Coda user File Num6ar
Bweau of Individual Taxea 1NH RI
PO eOx.ztw6o~ ~ TANCE TAX RETURN q~
Harriaburp, PA 1712&0601 RESIDENT DECEDENT 21 J ~ d
ENTER DECEDENT INFORMATION BELOW
Soaai Security Nurr-ber Date of Death Date of Birth
166 48 9958 08 10 200 10 19 1957
Decedent's Last Name
PARSON
II Suffix Decedenn's Firat Name
SHARON
(If Appiicable- Enbr 8urvivinp Spouse's Int'ormation Below
Spouse's Last Name Suffix Spouse's First Name
Spouse's Social Severity Number THIB RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
MI
R
MI
t. Original Ratum ~ 2. SupplamaMtl Ratum ~ 3. RemaMder Return (date of death
prforto 12-13-62)
4. Limited Estate ~ oZ?~ffi
4a. ~~
~ ~ ~ 5. Federal Eaate Tax Return Require0
)
t
d
[].cadent Died TsataN
8. (AMach Copy d wp) ~ Decsdwt
7' (Aearh C
o
py
d
T a
)
~ T~ 8. Tofel Number of Safe
DePdait Boxp
9. Litigation Proceeds Reoawd ~ a
p
o
wn
v
/
10. ~ t2at~i i a 1i-s5~ ~ ~ 11. EbGion b tax order See, g113(A)
(Attach Seh. O]
CORRESPONDENT -THIS CTION 11UST BE COMPLETEp. ALL C ESPONDENCE AND CONFIDENTIAL TAX aiFOtiMATION BE DIRECTED T0:
Name Daytlms Tsiephone Number
JERRY A. WEIGLE ESQ UIRE 717 532 7388
Firm Nams (H AppligbN)
WEIGLE & ASSOCIATES, P.C.
First line of address
126 EAST RING STREET
Second line or address
City or Post OfNce Stets ZIP Coda
SHIPPENSBURG PA 17257
Cotrsspondent's e-mail address:
rt b ~P ~puJury, i dadars Uwt I haw e~nrtYnad thb rNUm~ accompanykrp adtedules end sta~mants, and to Me bee or my IcnowNdga and tte5ef,
complete. Dsdaratlon o(prgraror other than the rspraentatiw b baaad on ant irNOrrnstbn or wlNCh prsparer has any Knowledge.
s ,.
, Shane J. Watson -as -
DRESS
3 Eas Garfield Street, Shi bu A 17257
NATURE R~jE ~~
'` ~ ' //Ii Jerry'A. Weigle Esquire 7 ~ 2~^~/~~
126 East King Street,
B~yYILL3 ~ ONLY s
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~I'E FILED ._
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.
17257
~/ 9ide 1
1505607120 1505607120
J 1505607220
REV-1500 EX
°s~"'•~» Sharon K. Parson Decedent's Social Securky Number
RECAPITULATION 1 6 6 4 8 9 9 5 8
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 & Misoellansous Personal Property (Schedule E) ............ .... 5.
14,524.47
g. JoMtly Owned Property (Schedule F) ^ Separate Billing Requested
..........
7. Inter-Ynos Transfers 8 Mkcellaneous NorfProbate property,
(Schedule G)
^ Separate BilNng Request
d ... g,
e
........... .. 7. 7, 3 0 5. 5 5
8. Total Goss Assets (total Lines 1-7)
............................._. ........_.... . 8. 21 , 8 3 0 . 0 2
9. Funeral Expenses & Administrative Costa (Schedule H) ..................................
...
. 9. 8 , 2 5 0 . 0 0
10. Debts of Decedent, Mortgage LlabilRles, 8 Liens (Schedule 1) .....................
........
... 10. 4 , 4 0 6 . 9 4
11. Total Deductions (total Lines 9 3 10)
............................._.............
....................
. 11.
12.6 5 6 . 9 4
12. Nat Valw of Estate (Line 8 minus Line 11) .
.
.
..................... .
13. Charitable and Governmental ....- ........................
d s~~c 9113 Trusts for which
an election to tax has not b
~
.. 12.
9 , 17 3 . 0 8
eer
a
(Schedule J) .............................. ....... 13.
14. Net Valw Su~ect to Tax (Line 12 minus Line 13) ...................... _
14
9 • 1 7 3
0 8
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES .
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9118
(a)(1.2) x .o0 0 . 0 0
16. Amount of Line 14 taxable 1s.
0 . 0 0
at lineal rate x .045 5, 5 0 8. 5 3
17. Amount of Line 14 taxable 1 g.
2 4 7 8 8
at sibling rate X .12 0 . 0 0
18. Amount of Line 14 taxable 17,
0 . 0 0
at collateral rate X .15 3, 6 6 4. 5 5 1 g,
549.68
19. Tax Due ................
............................................. .
... ..............................................
19.
7 9 7. 5 6
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT,
1505607220
Side 2
1505607220
1 '
REV-1500 EX Page 3
Decedent's Complete Address:
Sharon K. Parson
329 East Garfield Street
Shippensbu
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. CredkslPayments
A. Spousal Poverty Crodd
B. Prior Payments
C. Discount
3. InterosUPenalty if applicebb
D. Interest
E. Penalty
0.00
Fils Number 21..
Total Credits (A + g + C)
TotallnteresUPenalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the dilferonce. This is thaDVERPAYMENT.
Cheek box on Pape 2 Line 20 fA request a refund
5. If Line 1 + Line 3 is greater than Lina 2, enter the difference. This is theTAX DUE
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5q, Thy is theBAt.ANCE DUE
Make Check Payab/e to: REGISTER OF WILLS, AGENT
(3)
(4)
(5) 797.56
(5A)
(5B> 797.56
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and:
a. rotaln the use or income of the Yes No
........................................... x
b. retain the right to deaignate who shartuse the ~~ .............................. .
c. retain a reversions Property transferred or its.income :................................ x
ry interest; or ............................._...... .
d. rece'we the promise for life of either a .................................................. .
_ ................ x
................................. . x
2. If death occurred a}Eer December 12, 1982, did ndeoedent tronsferarro ...................... .
receiving adequate consideration? .................... P Perk' within one year of death without
...........................................
3. Did decedent own an 'in trust for' or payable upon death bank account or security at his or her death?......... ~ U
4. Did decedent own an Individual Retirement Axount, annuity, or other non- rebate ro x
contains a beneficiary designation? ............................_............. P p party which
............................................ x o
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 alter January 1, 1998, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero
(Oj percent p2 P.S. §9116 (a) (1.1) (ii)]. The statutedoas not exemn-a transfer to a surviving spouse from tax, and the statutory requirements
for disclosure of assets and filing a tax return an: still applicable even if the surviving spouse is the only benef~iary.
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 chile is zero (0) percent p2 P.S. §9716 (a) (1.2)].
The tax rate imposed on the net value of transfers to ar for the use of the decedent's lineal .beneficiaries is four and one-haH (4.5) percent,
except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)].
sibling s definedounder Sectiont9102, asf an individualwho t a at lea thoneeparenttin common with the(decedernt whether by blk~od(or adoption.
PA ~ 17257
(1> 797.56
(2> 0.00
aev-tbos oc+ Ia-n)
cowo~avea~rn of ne~eanv~ru
neearr~ Twx aatuaw
aeaoewr eecmdrr
SCFIEDULE E
CASH, BANK ~~pOSiTS, 8 MISC.
PERSONAL PROPERTY
EsTaTi= of
Sharon K.
LE NUMBER
21--
a,eaa. ~ p<oo..a. or aq.um rW ar aaa a» procy.ds.ve r.eeiwa ey n».suu.
M wop«ir k+ndr-owm.a wnn eN r~ of eulvlvonhip nwa w dhebe~d an eeMdee F.
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
1 Highmark -premium refund 160.58
2 Highmark -benefit check 859 58
3 H(ghmark -benefit check 725.40
4 Nationwide Insurance -auto premium refund 43.00
5 Orrstown Bank Checking Account 602396 3,490.91
6 2002 Honda Accord - proceeds of sale 10/07/2009 7,500.00
7 Household Contents -1/2 of total appraised value of 53,490.00 1.745.00
TOTAL (Also enter on Line 5, Recapitulation) I 14.524.47
(H rtgro apace is needed, addltlonal pspea of the same size)
Copyright (c) 2002 form software only The Lackner Group, Ine. Form PA-1500 Schedule E (Rev. 6-98)
Rw-isto EX+ (s-se]
CW,6IWNYEALTH or PENNeVLVANIA
eVHERRANCE TAX RETURN
RE&pENT OECEOEWT
ESTATE OF
Parson, Sharon K.
SCHEDULE 6
INTER-VIV(~5 TRANSFERS ~
MISC. NON-PROBATE PROPERTY
ILE NUMBER
21-
This uMduls must hs compNtay antl flNW d tlis enswA. b Rr y, d QwR~ ~ ~Oh ~ ~ y~ ,~~ side d tM REV•150U COVER SHEET is yp,
ITEM
NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSNN TO DECEDENT AND DATE OF DEATH % OF DECas ExcwswN TAXABLE
THE DATE OF TTUWSFER. ATTACH A COPY OF 7HE DEEP FOR REAL ESTATE. VALUE OF ASSET INTEREST 1F APPLICABLE) VALUE
1 Orratown Bank Health Savings Account 7,304.80 100,000 7,304.80
103008367 -beneficiary Shane J. Watson,
companion
PARTIAL FUNERAL COST OF;3,641.00 WAS
PAID BY SHANE J. WATSON FROM THESE
FUNDS
Accrued income on Item 1 through date of death
0.75 i 100.000
0.75
TOTAL (Also errter on Line 7, Recapitulation) 7 305 55
(H more specs is needed, edditlonal padpes of the same slxe)
Copyright (c) 2002 form software only The Lackner Group, Inc. Fonn PA-1500 Schedule G (Rev. 6-98)
REV-1151 EX• (10-06)
'
caaeoNwEACTH of PENNSnvaNu
INHERRANCE TAX RETURN
RESIDENTDECEDEHr
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Parson, Sharon K. 21
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
Fogelsanger-Bricker Funeral Home
5,395.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commtssrons
Name(s) of Paraonal Representative(s)
Shane J. Watson
street Address 329 East Garfield Street
city Shippensburg state PA Zip 17257
Year(s) Commission paid 2009
2. Attorney's Fees Weigle b Associates, P.C.
3. Family Exemption: (H decedent's addroas a not the same as dalmant's, attach explanation)
Claimant
Street Addross
C~' State Zip
Relationship of Claimant to Decedent
4. ~ Probate Faes
5. ~ Axountant's Fees
6. ~ Tax Return Proparor's Fees
1,092.00
1,528.00
7. Other Administrative Costs 235.00
See continuation schedule(s) attached
TOTAL (AI#o enter on Ilne 9, RecapltulaHon) 8 250.00
Copyright (e) 2009 form sottwaro only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. tl)-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Parson, Sharon K. 21--
ITEM
NUMBER DESCRIPTION AMOUNT
Other Administrative Coats
1 Linda K. Klein -notary fee 20.00
2 Register of calls, Cumberland County - fililhg PA Inheritance Tax Return 15.00
3 Register of Willa, Cumberland County - filimg Family Settlement Agreement. 100.00
4 Terry Shatter Auctioneer -appraisal of personal property 100.00
H-B7 3u~ofal 235.00
Copyright (c) 2002 form software only The Lackner Group, Inc. ~ Form PA-1500 Schedule H (Rev. 8-98)
Rw-1612 E2+ (12-0a)
co-woNUkfAiT,l of sarsav~wraA
INIERRANCE TAX ItETUNl
REaXXNT b[~!M
ESTATE OF
Parton, Sharon K.
ILE NUMBER
21-
R~poR awa ~ne,wnd ny al. a.a.d.m prior ro awn mr ~w ward r nla can or a..nl, rleWetrp w+nhn6waad nrdieal aXpa mx.
ITEM
NUMBER
DES~^RIPTION VALUE AT DATE
OF DEATH
1 Chambersburg Hospital 2,60S.8S
2 Discover Cards 40.00
3 Shippensburg Arsa EMS 806.00
4 West Shore EMS 855.09
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, 8 LIENS
TOTA~ (Also enter on Line 10, Recapitulation) I 4406.94
,
(H more apace is needed, addMional a o(the name ai2e)
Copyright (c) 2009 form soflwaro only The Lackner Group, Inc. ' Form PA-1500 Schedule 1 (Rev. 12-08)
REV-ta~a Ex.lt~-oel
SCHEDULE J
CorAMONWEALTN OF PENNSYLVANIA BENEFICIARIES
iNhIERRANCE TA7( R~qN
RESIDENT D
ECEDENT
ESTATE OF FILE NUMBER
Parson, Sharon K. 21--
NUMBER NAMEAND ADDRESS OF
PERSON(S) RECEMNG PROPERTY RELATIONSHIP TO
DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE
Do Not Lht Tnn • (Vyords) (3SS)
TAXABLE DISTRIBUTIONS [indude outright spousal
distrbutbns and tranafeAs
under Sec, ¢t t8(ax1.2)]
1 Barbara A. Hammond Mother 100°~ of 5
508
53
6852 Olde Scotland Road probate estate ,
.
Shlppensburg,PA 17257
2 Shane J. Watson
328 East Gal'fleW Street Friend Health Savings 3,664.55
Shippensburg, PA 17257 Account Isss
cost of funeral
Total
Enter dollar amounts for distributions shown shove on lines 15 through 18 on Rev 1500 cover sheet, as apps
~~ NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAK
CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
9,173.08
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIB TIONS ON LINE 13 OF REV-1500 COVER SHEET O,QQ
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 SchedukJ (Rev. 11-08)
f~
Y
,.
~-
~' A Tr~ati&'osn of Frcelleu~
Date September 30 2009
To Weigle 8c Associates, P.C.
126 E King St.
Shippcasburg, YA -17267
Fax (7]7)532-5189
Attention: Jetty A Weigl®, Esquire
From: Shirley Wescott
Onstown Bank
PO Box 250
Shippensburg, Pa 17257
Re: Estate of Sharon K ]'arson
Date of death :August 10, 2009
O ~ BaNx
1 VVII UVL
77 East King Street
Shippenstwrg, PA 17257
1T ISHEREBYCERTIF/ED THAT THEABOYENAM~D DECEDENT, ONTHEABOV,tr D,47'~ HAD THE
FOLLOA?NCACCOU1V75 WTIHORRSTOWN$ANEG
CHECKINGACCOL~'/'
Account # Title of Account
602396 Sharon K Parson
Date opened
2/23/83 X3490.91
Accrued Interest DOD Ida ,
.00 $3490.91
S!1 NNGSACCOC~'r'
Account # Tit)q ofAccount
103008367 Sharon K Parson
CERTIFICATE OF AF,AOSIT
Account # Title of A~~~Tt
N/A
Date opened '
.11/07/08 57304.80
Date O~enad Wrinci
Best re~g
-/U~~
Shirley escott
Receptionist
Accrued interest DOD Bel
.75 57305.55
Accrued Interest D~ I3al
^
V~
PED~RAL EREDIT UNION eo-~ea~ns i a 01 0000472157
Mu1r Iyrrr+IGYl rir liYivww
P.O. BOX 778 ~~" .:
CHAMBERSBURG, PA 77201.0778 IO/O7/O9 ~7~500,00
f717) 269-4444 ~~
PAY -
** Seven Thousand Five Hundred and 00/100 DOLLARS **
. ~ CASHIER'S. CHECK
..
V08) R 180 DAYS
ESTATE OF SHARON K PARSON ~y
To z~ `r
oxngx
OF
_ ..
.. .. .. .. ........ ..
_.
--'4?2i57-~' ~:231379979~: 7700f9100005--'
~~~ 9
U ~ ~,~
.~
~~
~.
__
Terry L. Shorter, LLC
~ u~ctu~,n,ee~r/,4 pp ra~i.~a.L Sprv%ce.
365 Musser Road, Sluppensburg, PA 17257
717-2164-3885
Appraisal for. Sharon Parson Estate
Date: 8-25-09
APPRAISAL VALUE
KTTCHEI~i ITEMS:
Pots, pans, etc.
Gas stove
Frigidaire refrigerator
DINING ROOM:
Oak table & chairs
Oak shat front desk
Sideboard
Longaberger basket
Glass basket
LIVING ROOM:
Sofa
Stuffed chairs
Recliner
Coffee table ~ end stand
Stereo 8t cabinet
Mirror
2 floor lamps
Stuffed swivel chair
Longaberger baskets
TV
Child's chair
UPSTAIRS:
Oak dresser
Vanity, dresser, mirror & suite
Oak chair
Cupboard
Longaberger baskets
Safe
Blanket chest
Chest trunk
95.00
35.00
100.00
500.00
250.00
300.00
125.00
25.00
100.00
30.00
150.00
50.00
45.00
25.00
40.00
30.00
35.00
200.00
30.00
100.00
250.00
20.00
25.00
85.00
45.00
65.00
85.00
r~
J`f A~
fd
,-
2 °~ ~~~ 300.00
Night end stand 20,00
BASEMENT:
Maytag washer ~t dryer 85.00
Freezer 75.00
Basement contents 35.00
GARAGE:
Bike 20.00
Mower 20.00
Small tiller 30.00
Wheelbarrow 20,00
Misc. tools & chairs 45.00
TOTAL: 3 4 0.00
APPRAISAL FEE: ~ 100.00
_~- ~ ..
~~~:~i ~~~~`~Emt~9~°~y,,, MESSAGE
Hobp/~ifa/ ~ ~' ~ ~~• ~ a ~ti , ~ P f ~~
an a~ii~M of I Summit HeaMi 9 ~~ ~,~,~, r ~5~ ~ ~#;~i111 ar9 ~Ur r9SpOI13fb11Ry. PI~Sa s
x~ ;~ ~ Is`noiw~' T DUE. ff have uestbns call
760 E. Washington St. Chambersburg, PA 17201 ~ .(~ s ,2 ^~a1~ *,~-~ k~g-r~~- ~--._,.~_'~._..a_....,.~.~~a~_-„
pg"~i~~ ,~„
~ ~` C,~d ~ 4r ~ t~ TV {~ C ]Ja i
t~~!„~ _tIP're.' L fPL!~-n 'G.aY ~~A....` ....
- SUMMARY OF CHARGES
Pharmacy S 14.10
Supplies S 28.00
Laboratory S 26.00
Respiratory Services S 341.00
Emergency Room S 2485.00
Pharmacy s 27.60
Physician Fees -Emergency Room E 570.00
PATIENT 3ERYICE CHARGE3 s 3491.70
' .r
An itemized copy of your biN is aveflable upon request
- INSURANCE INFORMATION
Primary Insurance:
Policy Number.
HIGHNARK B. S. PPO
ZAK101740555007
~ r~ewse NETAR7 THI$ PORTION FOR YOUR RECORDS
I
PI.ES,sE oETacN aND RETURN THIS PORTION WITH vtwR PavMENr
I. H~~
an a//1ilLte of Summit Heaitlr
760 E. Washington St. Chambersburg, PA 17201
AMOUNT PAID:
PATIENT NAMEISARSON
ACCOUNT NUMBER: H00036194082
M1
otot Illll~~~lltllnltlltll~ldlllll'~I~~II11'~~II'll~l~"~Illltltlltl
SHARON K PARSON
329 EAST GARFIELD STREET '
SHIPPENSBURG, PA 17257-2003
- ACCOUNT SUMMARY
Statement Date September 30, 2009
Dete(s) of Service OB/10/09 -08/10/09
Patient Name SHARON K PARSON
Guarantor SHARON K PARSON
Account Number H000~79~
Patient Service Charges S 3481.70
Total Transfers s 0.00
Insurance Payments s -52.58
Adjustments s -833.27
Patient Payments S 0.00
Balance Due s 2605.85
~i
~ ..
`m bP
s ~ k .~t r
.. _
~ P R~ k,i ~ e
.
- AUESTIONS
ff you have questions regarding your bill, please contact us
by calling:
(717) 267-7169 (Insurance-related questions)
(717) 267-7129 (Patient payment questions)
ff a payment plan is necessary, Please call to set up an
agreeable arrangement.
Office hours:
8:00 AM to 7:00 PM
8:00 AM to 4:30 PM
8:00 AM to Noon
Monday -Thursday
Friday
Saturday
Our business office is boated at:
760 East Washington St.
Chambersburg, PA 17201
You may pay your account online at
sEF.b9gK f.OR AI?DJTIQNAI,_IyFOR1.~gTK)N,
IF PAYING BY MASTERCARD VISA OR DISCOVER FILL OUT BELOW.
® ~ ERCARD
®
- O
VISA R
CARD NUMBER SECURITY CODE
AMOUNT TO BE CHARGED TO CREDIT CARD EXPIRATION DATE
SI MATURE
653026A
Itllt~tllitllllt~tt~llttit~lt~t~~I'1111~I~t~Illlttll~~~~1111~~111
CHAMBERSBURG HOSPITAL
760 E. WASHINGTON ST.
CHAMBERSBURG, PA 17201
Make check payable to Chambersburg Hospital
34931 •TQ.1014540000483 ~^,~,^'.~.,.....~~
Shippensburg Area EMS C/O ProMed Svc Inc
f3----~ W MAIN STREET
SHIREMANSTOWN, PA 17011
1-866-678-6855
Patient @ill
SHARON PARSON
329 E GARFIEIp ST
Shippensburg, PA 17257
Page: 1
Printed: 10/05/09 07:24
ID: Cvern-5633
DOB: 10/19/1957
Pattsrtt: PARSON, SHARON ID: 5633 DOB: 10/1yV1957
Claim Number: 7390135(DII'aagg~nosis 1) 427.5
Ins: 1) BCH/Non ZAK101740555d01/039gg
01 08/10.06/10/09 003 A0429SH 1 A 650.00 1 650.00
Procedure: BL3 EMERGENCY SERVICE 0•~ 0'00 650.00 650.00
Date first billed: 06/14/09 Over 30
02 08/10.08/10/09 003 A0425SH t A 156.00 13 156.00
Procedure: MILEAGE 0•~ 0.00 156.00 156.00
Date first blued: 08/14/09 Over 30
Pattern Totals: 806.00 806.00 0.00 0.00 0.00 806.00 806.00
~6 ~;.~~ .~„.,~ .;~_ ; Total Amount Due Guarantor: gDg.Op
4~t
F _ ~~?~g~~
~~ 1~' h s e.,q ::
C_ ~
~U
[°~~ ,,~`
~t
vvvvvw DETACH HERE vvvvvvv
PLEASE MAKE CHECKS PAYABLE TO SHIPPENSBURG AREA EMS
Prov Codes: 003=Shippensbury Area EMS
• - - - To hewn Proper endit clip and msN the Iwttom eectlon for each
Guar. PARSON, SHARON N: Cvem- Clms: 73901350 pays and include with payment - _ _ _ .. _ . _
Page 1 Total Due (aB pages); 806.00
WSEMS -Chambersburg ALS
205 GRANDVIEW AVE
~~ SUITE 211
CAMP HILL, PA 17011
Phone #: (800) 367-0512 Federal Tax ID: 23-2463002
PATIENT NAME: SHARON PARSON PATIENT NUMBER:
CALL NUMBER:
INSURANCE: HIGHMARK ZAK101740555001 DATE OF CALL:
TIME OF CALL:
CALLER:
009004815 FROM:
TO:
SHARON PARSON
329 EAST GARFIELD ST REASON(S)
SHIPPENSBURG, PA 17257 FOR
TRANSPORT
INVOICE
~,
~~-
WEST SHORE
84077
009004615
08/10/2009
PP
PP1
Police/Fire/911
BRITTON RD/FOGELSONGER RD
CHAMBERSBURG HOSPITAL.
CARDIAC ARREST
DESCRIPTION OF CHARGE OUANTrTY UNR PRICE AMOUNT
ALS EMERGENCY LEVEL 1 ~ A0999 1
0
EKG ELECTRODES (1)
gpg96 .
1
0 879.65
879.85
ENDOTROL ET TUBE
A0422 .
1
0 1.30 1.30
ET TUBE HOLDER
A0422 .
1
p 33.08 33.08
ETC02 (ADULT) FILTERLINE SET
A0422 , 8,68
8'~
STYLET
A0422 1.0 25.80 25.80
1.0 6.60
io5 6.60
~~l3
~
~~ i/~:
~
,/
/~ "
955.OSa
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -.-
'RETURNED CHECK FEE - $31.00
5955.09
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE 955.09
PATIENT NAME: PARSON, SHARON K CALL NUMBER 009004615 AMOUNTS G~
PATIENT NUMBER: 84077 BILLING DATE: 09/03/2009 ENCLOSED ` '~ S ~ ~ ,
rAYMENT FOR THESE SERVICES WERE PREVIOUSLY PAID TO YOU BY
YOUR INSURANCE CARRIER. PLEASE REMIT PAYMENT AND THE VISA
EXPLANATION OF BENEFITS TO USI AND
MASTER CARD
ACCEPTED
WSEMS -Chambersburg ALS 205 GRANDVIEW AYE CAMP HILL, PA 17011