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Home My WebLink About09-14-10 (2)PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE +BOREAU OF INDIVIDUAL TAXES F "f":r r AND .FILE N0. 21"[0-O~'TT PO BDx 280601 ' .'r;'1,,~ ~~AXPAYER RESPONSE ACN 10146368 FUIRRISBURG PA 17128-0601 , (~~~{ ;1 "~~ ~ ~ DATE 08-23-2010 J ~~ i~ _ yi~.~•_~ REV-iSf3 EX AFP (ER-Ra) 2010 SEP 14 PM 2~ 0 3 CI.~RK OF QRPHAN'S CAURT Cl~{BERLANL~ C0 . PA. HELEN F JONES 12 GREENSPRING DR MECHANICSBURG PA 17050-7908 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 Departwent with the inforaation below, which has been used ~n calculative the potential tax due. Records indicate that at the death of the above-naaed decedent, you were a ioint owner/banef',igiary of this account. If you feel the inforaation is incorrect, please obtain written correction frog th• financial institution, attach a copy to this fora and return it to the above address. This account fs taxable in accordance with the Inheritance Tax laws of the',Ceaaonwealth of Pennsylvania. .Please tali C717) 787-8327 with questions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRI~~TIONS Account No. 000005140255024 Date 05-01-1978 To ensuro vroper credit ~tq the account, two Established copies of this notice ays1~ accoaparry p°ywent to the Register ,off Wills. Make cheek Account Balance 7 , b61 .26 payable to "Register of iW~lls, Agent". Percent Taxable X 16.667 NOTE: If tax payaents ere aade within three Amount Subject to Tax ~ 1 F 276.90 aonths of the decedent's date of death, Tax Rate X . 045 deduct a 5 percent discdurMt on the tax due. Any Inheritance Tax duew~ll becoae delinquent Potential Tax Due ~ 57.46 nine aonths after the d~}ta of death. PART TA PAYER RESPONSE 0 A. ~ The above infonation and tax dw is corroct. Raait payaent to the Register of Wills with two copies of this notice to obtain a discount or avoid interest, or check box "A" and return this notice to the R$gister of CHECK Wills and an official assessaent will be issued by the PA Departaent of Rbvehus. C 0 NE ~ BLOCK B. ~ The above asset has bean or will be revorted and tax paid with the Pennsylvania Inheritance Tax return 0 NL Y to be filed by the estate representative. C. ~ The above inforaa ion is incorrect and/or debts and deductions were paid. Coaplete PART 2~ and/or PART 3~ below. PART If indicating a different tax rate, please state relationship to decedent: TAX RETURN - COMPUTATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Established 1 S - \- \°~R a 2. Account Balance 2 ~ R G~-~-1L 3. Percent Taxable 3 X l4 -C.C.~"- 4. Amount Subject to Tax 4 ~ ~>-r'1C. q0 5. Debts and Deductions 5 - 1~+~+~'~~~ S'd"' 6. Amount Taxable 6 7. Tax Rate 7 X 8. Tax Due 8 PART DEBTS AND DEDUCTIONS CLAIMED ^3 DATE PAID PAYEE DESCRIPTION AMOUNT PAID ~.o\o b~ T ~ ~ V l3 u ~R~O QB'1 ~O O i bra o ~A t -E+. ~~ v~ ~TOTAL~ce~nter On Line 5 Of TaX GOmpULaL10n) i ~j~gd, Under penalties otf p rjury,_I dec~ar-a tfiat~th~ facts I have reported above are true, cor'~ect and complete to the best~o\f my knowledge and belief. HOME ( ~\''~) f1C,c~-~e..v O_ _~ ~ \\\~..~ WORK C ) ~\~~~0 TAXPAYER SIGNATURE TELEPHONE NUMBER ~ DATE PLEASE DETACH AND RETURN ToP PORTION WITH YOUR PAYMENT STATEMENT ~ ~DENnFlCATIIXJ CODE: LAST THREE DICdT3 oN BACK aF MD, AND V13A DATE DESCRIPTION OF SERVICE AMOUNT INS. BAL PAT. BAL LINE ITEM BAL 01!11/10 ENCOUNTER 371175 FOR LOIS WITH TAYLOR MD, DEBRA D 01/11/10 99213 -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 benigNpremalig lesion, 1st $71.00 $70.02 01/18/10 Medicare Adjustment (PR1 (Deductible Amount)) -$0.98 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)) ENCOUNTER TOTAL 5133.43 $0.00 5133.43 $133.43 Balance is your responsibility. Please notify us of insurance changes prompty. Thank you. ~~ ~~~~ ~\Z\~a ~ w l33 _ k~ CURRENT 30-60 DAYS 60-90 DAYS 80-120 DAYS OVER 120 DAYS TOT/1L ACCOUNT BALANCE DUE FROM PATIENT $133.43 $0.00 $0.00 $0.00 $0.00 $133.43 ~'~~-~ MASLAND ASSOCIATES INC 220 R'ILSON STREET SUITE 109 CARLLSLE, PA 17013 @PNCBANK 040 WINDSOR PARK (115} 5288 SIMPSOM FERRY ROAD MECHANICSBURG PA 17055 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 devosit or payrent is accevted sub3ect to verification end to the rules and re9uletions of this bank. Deposits rar not be auaiiable for irradiate withdrawal. Receipt should be held unt11 verified with your staterent. Malpe.zzi Funeral Home 8 Mazket Plaza Way Jemmy J. March 22, 2010 Helen F. Jones 12 Greenspring Drive Mechanicsburg, PA 17050 The Funeral Service for Lois H. Jones (717)697-4696 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 s#atement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTME 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 ~?~,435.00 SELECTED MERCHANDISE: Memorial folders ' $40.00 THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED $2b475.00 AT THE TIME FUNERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. CASH ADVANCES: Certified Death Certificates '$48.00 Newspaper Notices -Patriot '$'151.87 Clergy/Mass Offering $'.150.00 Flowers $;106.00 TOTAL CASH ADVANCES AND SPECIAL CHARGES CONTRACT PRICE HISTORY: 03/22/2010 Homesteaders 03/22/2010 Overpayment Refund TOTAL AMOUNT DUE $455.87 $2,30.87 $3,140.00 $109.13 $0.00 Patient: L JONES Doctor: PHILIP D CAREY O1/04/10 99213 OFFICE/OUTPATIENT VISIT, EST, EX 75.00 75.00 DX: 011.00 O1/15/10 MEDICARE # 159861 Filed 01/15/10 AARP HEALTH CARE OPTION5 # 159862 Fileid 02/01/10 PMT MEDICARE c# 159861 33.47- 41.53 02/01/10 W/O MEDICARE c# 159861 11.59- 29.94 02/01/10 Deductible 21.57 02/11/10 PMT AAR 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`~ , .o '?~ ...~. ~- CURRENT 0.00 30-60 DAYS 21.57 60-90 DAYS > 0.00 90-DAYS TOTAL 0.00 21.57 INS PE I T O.qO 21.57 INSURANCE: 41.84 PLACE OFSERY..CODES PHILIP D. CAREY MD , 3 6 0 ALEXANDER SPRNG RD 11 Office cart Number 12 7 67 CARLISLE PA 17 015 t2 21 Patient's Home Inpatient Hospital j ll To 22 Outpatient Hospital ace of Service PHILIP D . CAREY, 23 Emergency Room-Hospital 24 Ambulatory Surgical Center one 717 243 7444 Referring Physician TAYLOR 31 32 Skilled Nursing Facility Nursing Facility i 81 Independent Laboratory 99 Other Unlisted Facility f /Z1 IYervrx l2l(.mr(9(Aldt) MISYS HEALTHCAFE SYSTEMS {900187!-5678 (694060) 0bflBB62 CUSTOMER: LOIS H, JONES DATE: 03/07/10 FACILITY: CLAREMONT NSG & REHAB CENTER ACCOUNT: 5713 -14-04164 PAGE: 1 of 1 1 "Tf ' F~harMe ca 1123 PEARL STREET BROCKTON, MA 02301 PREVIOU5 PAYMENTS NEW BALANCE $204.47 $204147 CREDITS: DUE: CHARGES: BALANCE: RECEIVED• DATE RX NUMBER DESCRIPTION QTY BILLED DUE FROIv1 INSURANCE CHARGES/ AMT INSURANCE ADJUST CREDITS ` I e I I 0 1 02/19/10 272158.00 IPRATR ALBUTEROL 0.5-3 MG 180.000 136.0 22.26 72.39 41.35 DENIED B CIISTOMER' INSURANCE FOR PRODIICT/SE VICE NO 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' INSIIRa~NCE FOR SIIBMIT BIL TO OTH R PROCESS R 03/03/10 273002.00 XENADERM OINTMENT 60.000 69.52 69.52 Amount Due: `~ 204.47 BILLING QUESTIONS: MEDICATION QUESTIONS: ~ PAYI~NT ADDRESS: 08:00 AM - 05:00 PM 08:30 AM - 05:00 PM P.O.13gX 644458 PHONE: 866-251-5966 PHONE: 717-249-2370 PTr'T31~URGH, PA 15264-4458 ~~~~~~~~~~eA~~®~~