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Home My WebLink About09-14-106UREA11 OF INDIVIDUAL TAXES ~ PO BOX 284b01 HARRISBURG PA 17128-0601 PENNSYLVANIA INHERITANCE INFORMATION NOTICE AND ~`~ I~~ ~FTAXPAYER RESPONSE rrn r - ~:~;~~, riE * REVISED NOTICE TAX FILE N0. 21-IO~Oq~~ ACN 10146367 * DATE 09-06-2010 2010 SEP 14 PN 2~ 04 N CLERK OF ORPHAN'S COURT Cl~v1BERLAND CO , FA RITA J S~HULTZ 580 PINE HILL RD LANDISBURG PA 17040 EST. OF LOIS H JONES SSN 196-16-1278 DATE OF DEATH 03-05-2010 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS ® CHECKING TRUST CERTIF. PNC BANK NA provided the Dapartaant with the infonation below, which has bean us d in calculating the potential tax duo. Records indicate tfiat at the death of the above-naaed decedent, you ware a ioint owner/bangrfieiary of this account. If you feel the inforaation is incorrect, please obtain written correction frog the fineneial institution, att#ch a copy to this fora and return it to the above address. This account fs taxable in accordance with the Inheritance Tax laws of th6 Coaaonwealth of Pennsylvania. Please call C717) ?87-8327 with awstions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTt~UCTIONS Account No. 000005140255024 Date 05-01-1978 To ensure proper credit.. to the account, two Established covies of this notice must aeeowpany Account Balance Percent Taxable A~aount Subject to Tax Tax Rate Potential Tax Due $ 7,661.26 X 16.667 $ 1,276.90 X .045 $ 57.46 payunt to the Register of Wills. Make check payable to "Register of Y~ills, Agent". NOTE: If tax payfints Pre aade within three wonths of the decedent'h data of death, deduct a 5 perwnt disepunt on the tax dw. Arty Inheritanea Tax dw'will becou delinquent nine aonths after the dMtp of death. C. ~ The above info a ion is incorrec and/or debts and deductions were paid. Coaplete PART ~ and/or PART ~ below. PART If indicating a different tax rate, plaasa state relationship to decedent: TAX RETURN - COMPUTATION OF TAX ON TRUST ACCOUNTS JO NT/ I LINE 1. Date Established 1 ~ ` Q I "l"~ y 2. Account Balance 2 ~ •2 3. Percent Taxable 3_ X ~ t~~P 4. Amount Subject to Tax 5. Debts and Deductions 6. Amount Taxable 7. Tax Rata 8. Tax Dua 5 - 1 lC ~~J ~ 1 I T 6 ~ ~` 7 X -- 8 $ ~- PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID L 1D c. ~O c c. r 1 S ~ vgll ~ 3 . o - ~ ~sn ~ ~ , a ~ r- ~ TOTAL CEMer on L1ne S or lax GOalpUtaLiOn7 s.. ,~ tt20. ~ Z_ Under enalties o perjury, 1 decla a t at the facts I have reported above are ct and t rue, cor re to #,pa Il t ofimy knowledge com ' and belief. HOME C'7~r] ) ( ~ - 4 1'OS ~'_]'oZ~I ~ e ~ /~/Jo(~ ~ - ~J-Ll> WORK C 71 ~ ) 7_'~i~-(7 Q ~ q 17 I G w. ~ 1 ine above 3nroraacion ana iaa oue a correct. ~, LJ Raait payaant to the R®gistar of Wills with two copies of this notiea to obthih CHECK a discount or avoid interest, or chock box "A" end return this notice to the Register of C ONE ~ Wills and an official assessaent will be issued by the PA Dapartaant of Revehuw. BLOCK B. ~ The above asset has bean or will be reported and tax paid with the Pennsylvania Inheritance Tax return 0 N L Y to ba filed by the estate representative. °~"'~'"'a°'~"""r'°"'°'~'~""'"~""'°~P"'""E'er ~ STATEMENT •I~~FlCATIONCODE:LA9TTHREEDIGIT30NBACKOFMC,ANDVISA DATE DESCRIPTION OF SERVICE AMOUNT INS. BAL PAT. BAL LINE ITEM BAL 01/11/10 ENCOUNTER 371175 FOR LOTS WITH TAYLOR MD, DEBRA D 01/11/10 98213 -Level Three Est Patient $73.00 $63.41 01/18/10 Medicare Adjustment (PR1 (Deductible Amount)) -$9.59 01/18/10 Medicare Payment (PR1 (Deductible Amount)) $0.00 02/09/10 AARP Payment (8 (Per 2nd Ins Pt Pays Medicare $0.00 Deductible)) 01/11/10 17000 -Destroy benign/premalig lesion, 1st $71.00 $70A2 01/18/10 Medicare Adjustment (PR1 (Deductible Amount)) -$0.98 01/18/10 Medicare Payment (PR1 (Deductible Amount)j $0.00 02!09/10 AARP Payment (8 (Per 2nd Ins Pt Pays Medicare $0.00 Deductible)) ENCOUNTER TOTAL ;133.43 $0.00 ;133.43 ;133.43 Balance is your responsibility. Please notify us of insuranco changes promptly. Thank you. l33 _~~ CURRENT 30-60 DAYS 60-90 DAYS 80-120 DAYS OVER 120 DAYS TOTgL ACCOUNT BALAMC& pUE FROM PATIENT $133.43 $0.00 $0.00 $0.00 $0.00 $133.43 X133•'43 MASLAND AS50CIATES INC 220 WILSON STREET 5U1TE 109 CARL ~,F, PA Ib013 ~PNCBANK 040 WIND50R PARK (115) 5288 SIMPSON FERRY ROAD MECHANICSBURG PA 11055 Cashbox 03 AM * Deposit Check 13:25 MAR 24 2010 Account Number XXXXXX5024 Tran Amount $209.13 W/S ID WWSOOAA9 Sequence Number 00061 Batch 401 This devasit ar percent is eccevted subiect to uerificetion end to tha rules end re4uietions of this bank. Deposits car not be euailebte far tccediete withdrewat. Receipt should be held until verified with Your steteeent. 8 Market Plaza Way Mechanicsbur¢. PA 17055 Malpezzi Funeral Hone March 22, 2010 Helen F. Jones 12 Greenspring Drive Mechanicsburg, PA 17050 Michael J. Malpezzi, Owner, FD (717)697-4696 Kyle C. Knipe, The Funeral Service for Lois H. Jones We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this $tiitement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONAL SERVICES: Memorial Service $540.00 Services of Funeral Director/Staff '.$1,895.00 FUNERAL HOME SERVICE CHARGES '$2,435.00 SELECTED MERCHANDISE: Memorial folders $40.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED $2,475.00 AT THE TIME FUNERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGGES. CASH ADVANCES: Certified Death Certificates '$48.00 Newspaper Notices -Patriot $151.87 ClergylMass Offering $.150.00 Flowers $106.00 TOTAL CASH ADVANCES AND SPECIAL CHARGES $455.87 CONTRACT PRICE $2,930.87 HISTORY: 03122!2010 Homesteaders $3,140.00 03122/2010 Overpayment Refund $209.13 TOTAL AMOUNT DUE $0.00 01/04/10 01/15/10 01/15/10 02/01/10 02/O1/10 02/01/10 02/11/10 Patient: L JONES Doctor: PHILIP D CAREY 99213 OFFICE/OUTPATIENT VISIT, EST, EX 75.00 75.00 DX: 011.00 MEDICARE # 159861 Filed AARP HEALTH CARE OPTIONS # 159862 Filed PMT MEDICARE c# 159861 33.47- 41.53 W/O MEDICARE c# 159861 11.59- 29.94 Deductible 21.57 PMT~AARP HEALTH CARE OPTIONc# 159862 8.37- 21.57 PLEASE USE THE ENCLOSED PRE-ADDRESSED ENVELOPE FOR YOUR PAYMENT. CALL OUR OFFICE IF YOU HAVE ANY QUESTIONS. ~.~ ~C> ~+`~ ~ ~9 .x. _ I .CURRENT 30-60 DAYS 60-90 DAYS > 90 DAYS TOTAL INS PEND'NG T ~ i 0.00 21.57 0.00 0.00 21.5? O.OC- 21.57 A INSURANCE• 41.84 PLACE OFSERY.CODES PHILIP D CAREY MD . , 3 6 0 ALEXANDER S PRNG RD 11 Office i )art Number 12767 CARLISLE PA 1?015 21 npa6ent Hospital I To 22 Outpatient Hospital PHILIP D CAREY y e e g =ce of Service . , 24 Surgical C r Ambu tator t i 31 Skilled Nursing Facility me 717 243 7444 Referring Physician TAYLOR '32 Nursing Facility 81 Independent Laboratory 99 Other Unlisted Facility i MISYS HEALTHCARE SYSTEMS (800) 877-5673 (1 gbf38863 CUSTOMER: LOIS H, JONES DATE:` ~ 03/07/10 FACILITY: CLAREMONT NSG & REHAB CENTER P h a r M e r i c a 1123 PEARL STREET ACCOUNT: 5713-14-04164 BROCKTON, MA 02301 PAGE: 1 of 1 PREVIOUS PAYMENTS NEW BALANCE CREDITS: $2(k1.47 $204.47 BALANCE: RECEIVED: CHARGES: DUE: DATE RX NUMBER DESCRIPTION QTY BII,LED DUE FROM INSURANCE CHARGES/ AMT INSURANCE '' ADJUST CREDITS i ` Balance Forward: I I 1 1 721 8.00 02/19/10 2 5 IPRATR-ALBUTEROL 0.5-3 MG 180.000 136.00 22.26 ?2,39 41.35 DENIED B CUSTOMER' INSORANCE FOR PRODIICTjSE VICE N COVERED 02/19/10 272146.00 OYSTER SHELL 500MG + D TA 36.000 4.96 4.96 02/19/10 272147.00 CETIRIZINE HCL 10 MG TABL 18.000 44.46 44.46 02/19/10 272152.00 MUCINEX ER 600 MG TABLET 36.000 18.24 18.24 02/19/10 272155.00 VIACTIV TABLET CHEW 60.000 10.15 10.15 02/19/10 272156.00 VITAMIN D 1,000 UNITS SOF 18.000 5.10 5.10 02/19/10 272160.00 BACITRACIN ZINC OINTMENT 28.350 6.39 6.39 02/26/10 272435.00 OYSTER SHELL 500MG + D TA 11.000 4.30 4.30 DENIED B CUSTOMER' INSURANCE FOR SUBMIT BIL TO R PROCESS R 03/03/10 273002.00 XENADERM OINTMENT 60.000 69.52 69.52 Amount Due: `~ 204.47 BILLING QUESTIONS: MEDICATION QUESTIONS: PAY~T ADDRESS: 08:00 AM - OS:00 PM 08:30 AM - 05:00 PM P.O. B b44458 PHONE: 866-251-5966 PHONE: 717-249-2370. PTITS L9RGH, PA 15264-4458 ICI®d^*~II~M~.i®Y1~