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Home My WebLink About08-27-10 (2) 1505610140 REV-1500 ~` (°'-'°' PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po sox 2sosol INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2 1 1 0 0 7 2 8 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 4 3 2 8 4 9 1 9 0 8 1 8 2 0 0 9 1 0 1 0 1 9 1 2 Decedent's Last Name Suffix Decedent's First Name MI S P O T T S D O R O T H Y F (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW Q 1. Original Return 4. Limited Estate 6. Decedent Died Testate (Attach Copy of Witl) 9. Litigation Proceeds Received THIS RETURN MUST SE FILED IN DUPLICATE WITH THE REGISTER OF WILLS •2. Supplemental Return 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) State ZIP Code CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL Name R O G E R B I R W I N First line of address 6 0 W E S T Second line of address City or Post Office C A R L I S L E Correspondents a-mail address: 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) REGISTER OF WILLS USE ONLY ~., ('1 c ~ ~_ ^ ~ ~.~ ~I~C~ ,--- cr; _"`.~ ...,~ , _' ~ ! ' ~ _~_r il ~ ~i ~fl FILED c.1 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 a lete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE F PER RESP/ON IBL . R FILI RETURN DATE ~~hrf/l~ _. f~~t~i~~t~ ADDRESS X~ ~ 2923 W• CORDON STREET SIGNATURE OF,P~ RED HER~N~ OWN CARLISL PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610140 AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Daytime Telephone Number 7 1 7 2 4 9 2 3 5 3 P O M F R E T S T R E E T PA 18104 TE Z 7(i.~ PA 17013 1505610140 J ~, L~,~~. 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: DOROTHY F• SPOTTS 1 4 3 2 8 4 9 1 9 RECAPITULATION 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 and Notes Receivable (Schedule D) .......................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers & Miscellaneous N -Probate Property (Schedule G) ~ Separate Billing Requested ....... 7. 3 1 4 4 9. 7 1 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 3 1 4 4 9 . 7 1 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9• 1 1 3 1 2 . 2 5 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10. 11. Total Deductions (total Lines 9 and 10) ............................... 11 12. Net Value of Estate (Line 8 minus Line 11) ............................ 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... 13. 1 6 5 4. 4 5 1 2 9 6 6. 7 0 1 8 4 8 3. 0 1 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... 14. 1 8 4 S 3 . 0 1 TAX CALCULATION -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.o _ 0. 0 D 15. 0. 0 0 16. Amount of Line 14 taxable at lineal rate X .045 1 8 4 8 3. 0 1 1s. 8 3 1. 7 4 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17. 0. 0 0 18. Amount of Line 14 taxable 0 0 0 0 0 D at collateral rate X .15 . 18. . 19. TAX DUE ......................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1505610240 Side 2 8 3 1. 7 4 1505610240 J Ktv-i 5w tx Nage s Decedent's Complete Address: DECEDENT'S NAME DOROTHY F. SPOTTS STREET ADDRESS 10 ABBEY COURT CITY CARLISLE STATE PA 21P 17013 Fue Numner 21 10 0728 Tax Payments and Credits: Tax Due (Page 2, Line 19) Credits/Payments A. Prior Payments B. Discount (1) 831.74 Interest if Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. FNI in oval on Page 2, Line 20 to request a refund. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. Total Credits (A + B) (2) 0.00 (3) 9.24 (4) 0.00 (5) 840.98 Make check payable to: REGISTER OF WILLS, AGENT 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? ....................................................... ^ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ^ 0 3. Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death? ......... ^ [~ 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. For dates of death on or after July 1,1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan.1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 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 21 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 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 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 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, unde 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) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER DOROTHY F. SPOTTS 21 10 0728 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. WACHOVIA BANK -CHECKING ACCOUNT 2,431.53 2. (TEAM CAPITAL BANK -CHECKING ACCOUNT 3. (TEAM CAPITAL BANK -SAVINGS ACCOUNT 3, 897.04 25,121.14 TOTAL (Also enter on line 5, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) 71 REV-1511 EX+ (10-09) Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN RESIDENT DECEDENT ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER DOROTHY F. SPOTTS 21 10 0728 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. HOFFMAN-ROTH FUNERAL HOME 1,891.55 2. WILDWOOD CEMETERY COMPANY -CREMATION 425.00 3. MINISTER 100.00 4. GIANT -FLOWERS FOR FUNERAL 44.49 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) RICHARD H. SPOTTS 1,600.00 Street Address 2923 W. GORDON STREET City ALLENTOWN State PA zIP 18104 Year(s) Commission Paid: 2, AttomeyFees: IRWIN & McKNIGHT, P.C. 2,500.00 3. Family Exemption: (If decedents address is not the same as claimants, attach explanation.) 3, 500.00 Claimant DAVID A. SPOTTS Street Address 10 ABBEY CT. City CARLISLE State PA ZIP 17013 Relationship of Claimant to Decedent SON 4. Probate Fees: REGISTER OF WILLS 136.50 5 Accountant Fees: MARK WEISHOLTZ -TAX PREPARATION 350.00 6. Tax Retum Preparer Fees: PATRICIA A. ROSENDALE, CPA 350.00 7. REGISTER OF WILLS -FILING FEE 30.00 8. CUMBERLAND LAW JOURNAL -ESTATE NOTICE 75.00 9. THE SENTINEL -ESTATE NOTICE 187.54 10. POSTAGE 6.97 11. AAA -TRAVEL EXPENSE 115.20 TOTAL (Also enter on Line 9, Recapitulation) ~ $ If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-OS) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER DOROTHY F. SPOTTS 21 10 0728 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. INTERNAL REVENUE SERVICE - 2008 INCOME TAXES 316.00 2. SOLOMON AND SOLOMON P.C. (VERIZON) 56.45 3. GESSLER CLINIC, PA -MEDICAL 5.00 4. CARLISLE HMA PYSICIAN MANAGEMENT -MEDICAL 5.00 5. CARLISLE REGIONAL MEDICAL CENTER -MEDICAL 1,272.00 TOTAL (Also enter on Line 10, Recapitulation) ~ $ 1 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE) BENEFICIARIES ESTATE OF: FILE NUMBER: DOROTHY F. SPOTTS 21 10 0728 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 [Indude outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. RICHARD H. SPOTTS Lineal 6,161.00 2923 W. GORDON STREET 1/3 REMAINDER ALLENTOWN PA 18104 2. DAVID A. SPOTTS Lineal 6,161.00 10 ABBEY CT 1/3 REMAINDER CARLISLE, PA 17013 3. WILLIAM E. SPOTTS Lineal 6,161.01 2200 OLD CHURCH ROAD 1/3 REMAINDER TOMS RIVER, NJ 08753 II. 1 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. , $ If more space is needed, use additional sheets of paper of the same slze. Refixmue ID: 3121791 WSCb047a BSn)< Balat>ce Cozifiattation services P O Boa 40028 Roanoke, VA 24022 August 9, 2010 IRWII~T & tiilCKlvIGHT PC ** SUBIECT: Verification / Confirmation of Account and Balance Infotmatwn provided for: CaettTmer: DOROTHY F SPOTT3 (S9N# 11XX XI~~919) Date ~ Deatb: Augnst 18, 3009 Denoeat Acegant Informatloe pccoa~t Amomn laese of Death Axrage T~alanm t>otz Maturity TnEered Aaaued Y7't) T~ Type Numbs Balaaae Opined Date Rate Lterat Lfeceat Paid Clo>cd ,~;~TN~} 7ZXX7[)f7f7~711I14A( $2,431.53 71241t9R5 $Q_fIR $I.qO 7i2f1/2pT0 T F.tiAT. TITT F:: IiOROTHY F 9PQT'1'9 /POAADELE LPODWAN CY.o61Nti IiAL.ANCL~: $Z432.7Z ACOniTNT A.91'Cf[ F.<19TNCR tlh-02d39 Page 1 of 2 ~HO~i-It~1 No SateDepasitBox fold facoKmler. » Due otdeath haLece does not iocluda accrued iaere~t RefirmacID:31Z1791 • tf data of loath aoourss as awaokand ar s tmliday, deto at doath6elanao dons mtiooludo erry traaseotiom that wore mado during the limo period ~f~"i~T `~~i~~~fRiV lliana McGuire 3erviceatet Associate Phone:(i44)563-7323 dnt; tto- Byace~iog thisinfrlttmtioo,lhe rac~iontthaaofraprma>Ct andtsatrantg m WelhFafre BssIc,DLA ("LVaDsFago'~,tl>atlhe raapinmis mthuiacdbythe atstoc>er mreaniot latvfitllythia iaformaGoa llu rseipianc a~ees duttitcsill mtdiadase this iaffsmadonm asy thirdparq, uoleas eompalkd m do so hY legal process, and that it will lawlidlyuse thu ieformatioo. The reeipuat aelmowkdges flat Walls Rarga dam nrirclrmsmtandurtrmt LhaLthn m fenmalinn n mmpldnasdaa.•ursle.'11ss nsiPiad {'uAFnr acknmv4slgst< ihaL tlm inR~nndion mey nr0.diaelnsa the enliro rolatimship hel~em cmum~r eta Welt Faroo. The infomstioni: atd~ect to chafe without mtioe to the recipient The reapiad agfaes m indemnify. defend, ad hddweaa Fatgo 6armlma from and drieleeum and use ofthe iufamatiott by the mapieot ar from the 6seach 6y the aeopimt. of auyagrormseeS reptasmTatiaq arurarraety mstaioed berme ~t a4y alait¢ ttaalting (iemthe Wadaavia Rank andR'aelova Rank of l~laware aro diviuions of Welk Fart Aenk, N.A Pale 2 of 2 TeamCapitalBank Re: Estate of Dorothy F. Spotts Date of Death: August 18, 2009 ~E~~E IJUL 2 9 2010 i~llQl & McIW16NT LAW OfF{Cf~ Tuesday, July 27, 2010 Dear Attorney Roger B. Irwin, ~. ~:, At the time of Ms. Dorothy F. Spotts' death August 18~' 2009, she had a single checking account 12203907 and a single savings account 20037297. Mr. Richard H Spotts had Power of Attorney on both accounts. The accounts were opened on June 11, 2009. There was no account ownership change within the month of June, July nor August 2009. There was no account closed during the period June 2009 and August 2009. From June 2009 to August 18, 2009, the checking account accrued $1.93 and the savings account accrued $121.14.On August 18, 2009 the checking account balance was $3,897.04 and the savings account balance was $ 25,121.14', The checking account was closed on July 20, 2010 and the savings account was closed July 21, 2010. If you have any further questions, please feel free to contact me at (484) 241-4296. Sincerely, v Andree Hastoy"Bluske Personal Banker Officer Team Capital Bank 1901 W Hamilton Street, Suite 6 Allentown, PA 18104 Phone 484-241-4296 Fax 610-432-6730 E Mail abluskeC~teamcapitalbank.com ,: ..~ ,,;., 1901 Hamilton Street, Allentown, FA 18104E Member FDIC ~~ r' t f ~' ~4 j .z '~i.~ David Spotts 10 Abbey Court Carlisle, PA 17015 FUNERAL HOME ~ CREMATORY, INC. 219 r 717 24 toll free 1 866.451 451 .fax 717243 3723 www.hoffmanroth.com infoC~?hoffmanroth.com . August 26, 2009 Statement of Funeral Expenses for: Dorothy F. Spotts Date of Death: August 18, 2009 Account Id: 15707-191 PACKAGE: Immediate Cremation OPTION 5 -Cremation $ 1;690.00 ..Sub Total: $ 1,690.00 TOTAL FUNERAL HOME CHARGES: $ 1,690.00 CASH ADVANCES: 5 Certified Death Certificates at $ 6.00 each $ 30.00 Newspaper Notice -Williamsport Sun Gazette $ 116.55 Additional Death Certs 5 ~ $ . 30.00 Coroner's Fee $ 25.00 Sub Total: $ 201.55 Total Funeral Expense: $ 1 5 Total Payments Made: 1,891.5 Payments made: David Spotts Credit Card Aug 26, 2009 1,745.00 David Spotts Credit Card Aug 26, 2009 146.55 Total Balance Due: $ 0.00 Please return this portion with your Remittance $ Amount Enclosed Dorothy F. Spotts Service ID #: 15707-191 SERVING OUR COMMUNITY SINCE ~ 9O7 ~~ ~~ `~ N D D • o m O 0 O O v n O 3 v D O .•t• b b r~ ~~~ a II~~~- v ~o ~N rr- 5 w ~y O~~ ... y D~ AAA East Penn mvv~CE HEAD9UARTERS/GROUP OPERATIONS PO. BOX 1910, 1020 Hamilton St., Allentown, PA 18105-1910 Phone: (610) 778-3300 Fax: (610) 778-3358 Travel CALL CENTER:1-800-472-9367 ALLENTOWN STORE 2072 Downyflake Lane, Allentown, PA 18103 Phone: (610) 434.5141 Fax: (610) 778-3390 BETHLEHEM STORE 1520 Sfetko Blvd., Bethlehem, PA 18017 Phone: (610) 867-7502 Fax: (610) 867.4602 IANSDALE STORE 1250 N. Broad St., Lansdale, PA 19446 Phone: (215) 855.8600 Fax: (215) 855-9140 r ~ POTTSTOWN STORE , - 95 S, Hanover St., Pottstown, PA 19464 Phone: (610) 323.6300 Fax: (610) 323.6684 ~ Agents for: Cruises • Tours • Hotel bt Local Getaways • Car Rentals • Airlines • Rail Travel ~ -- UL 2~i Ec:1t_a~' '~C17c~N 14's? DA I TH F~: T WF'RG POL T CY ACCE1=- T ED . „ . „ . ,AAA SEFiF:k=i...YCAFiE ... „ .. SUF`F'L_ T EF't COVERAGE MY AGEC~IT HAS FtEC01`'l( IEi~DE^u THAT T CHAFiOE h1Y TRAVEL ARFiAitiGEt'IEN T SYTi~ MY CF iED I T CflRi~ . AS : ~t COf~iSUMEF~ - I MAY HAVE ADD I T T OVAL PROTECT T Ohl I N -I"HE L.VEPdT~ OF SUF'F'L I ER DEFAULT" L~4` CHARG T NC3 THE F'AYNIEt~iT TO A C;FtE D I T CARD 1"F-iF~1N 3: F° T F'AY FOR -f RAVEL ARFiANGEMEf~ITS D4` CA,.'`iH OFi CHECh:: . IF YOU PAID BY CREDIT CARD YOUR SIGNATURE WILL ACT AS AUTHORIwATIC3N Ti-iE AL-~OVE :L T T NERARY WAS EXAMINED AND FOUND CORI;ECT . ...... T HAVE READ AND UNDERS"fAND THE IMPORTANT IhIFOi,MATION T NCLUDED Old THE FRONT AND ACt:: OF Ti•-I I S T NVC] I CE . SIGNA"PURE X..... .......,.., HAV _ A NICE TR I F' . T T Ct~::E'T' NUMitER /S o SF'0"i°"f'S /E~RADLEY CA~;D V T V I r. r`•~ T R -:-RfltdSPOR T AT I ON ELECTt1ON I C ?J$9 IJCC7~-~ 1 FOR ~ ~t~ , Ec:1 ~sG• . 1 ~ TAX 26 . i_11 TTL TRANSACT TON FEr" SUEt TOTAL CRED T T CARD F'AYi~iL--=N'T AMOUI'~iT DUE: 5~1. F? . 1 j.J. ii5. (:Y , a 'i ; i .) File Number: Account No.: Client: Amount due as of 03!29/2010: Dear D F Spotts: 22882746 8632995112850913 VERI ON $5.5 SOLOMON AND SOLOMON P.C. Attorneys at Law °"~'°"~~ Five Columbia Circle Albany NY, 12203 The above named creditor has referred your account to our office fvr collection. If your records do not agree with the amount above, then contact our office. Otherwise please make your check or money order payable to the creditor and mail directly to this office. This is an attempt to collect a debt. Any information obtained will be used for that purpose. This communication is from a debt collector. Calls are randomly monitored to ensure quality service. VALIDATION NOTICE Unless you notify this office within thirty (30) days after receiving this notice that you dispute the validity of the debt, or any portion thezeof, the debt will be assumed to be valid by this office. If you notify this office in writing within the thirty (30) day period that the debt, or any portion thereof is disputed, this office will obtain verification of the debt or a copy of a judgment against you and a copy of such verification will be mailed to you by this office. Upon your written request within the thirty (30) day period, this office will provide you with the name and address of the original creditor, if different from the current creditor. Contact us to find out if you are eligible for a payment arrangement I Telephone Hours Are: Mon - Thur 8:OOam to 10:00pm Friday S:OOam to S:OOpm Toll Free: 1-877-803-1942 Fax: (518)456-0651 Send Mail To: Solomon and Solomon P.C. Columbia Circle P.O. Box 15019 Albany, NY 12212-5019 Se Habla Espanol Make payments via the Internet www.solomonpayments.oom email us n myaccount(al}olomonpc.mm or text us r 518-708-7330 "' Please return the below portion with your payment in the enclosed envelope *s -- ~ P.O. Box 2060 .Check One: ^ MasterCard ^ VISA .... ........ .. ,. ,. ,.: .. ... South to MI 48195-4060 ~ ` Card Number: ~ ' ' ' ~ ~ ` II~~ q ~~pp qq :....., :....... :....:~ ,: ;; (~ ~~~uI~~~NNglt ,: :: . `...... .................. ~ Last3digitson Expiration Date• ~ ' ` ' ` ' ` ` CCV#: '• ' ` ~ ~ ' ...s. the back of Card Signature: Account No.: 8632995112850913 Amount due as 556.45 of 03/29/2010: 03/29/2010 File Number: 22882746 VItZW12 Amount Enclosed: $ Make Payable To: VERIZON SOLO/IA 1277018970701 1608/000001608Po00000005 Ill~~dl'II~~I~IIIIr1~nlluyr~I~J~I~~Jdllrlll'~Irl~Jlllll" D F Spotts 2923 W Gordon St Allentown, PA 1 8 1 04-48 1 5 Solomon and Solomon P.C. Columbia Circle P.O. Box 15019 Albany, NY 12212-5019 It~tllttl~lt~l~ltrtllt~ltltltltllt~tt~tlll~l~tlttill IA 1 Page 1 of I 8632995112850913 MAKE CHECKS PAYABLE TO _~ _~. LER CLINIC, PA .O. BOX 3069 WINTER HAVEN, FL 33885-3069 TEMP-RETURN SERVICE REQUESTED 0101 ., CARD NUMBER AMOUNT SIGNATURE EXP. DATE a• • • 11 /03/09 224957 ~~ V (7 ~30?~ Please check hox if address or insurance information has changed, and indicate changesls) on reverse side. 12 01 DOROTHY F SPOTTS GESSLER CLINIC, PA 10 ABBEY CT P.O. BOX 3069 CARLISLE, PA 17015-4384 WINTER HAVEN, FL 33885-3069 Irr~lllr~~llix~r~~~ll~lrl~~lx~l~rll~l~~l~xl~xl~~~llll~x~xll~xl PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT. • ~ ~ 07/21/09 GASNER EST PT OV/OUTPT VISIT LE 100.0 08/04/09 UNITED HEALTHCARE PAYMENT -55.45 08/04/09 UNITED HEALTHCARECONTRAC -39.55 10/15/09 GASNER `t~6-911~ INTMENT ~ ~ ~ ~~ ACCOUNT # CURRENT 30 DAYS 60 DAYS 90 GAYS 120 DAYS 224957 25.00 .00 5.00 .00 .00 I DOROTHY F SPOTTS I (863) 298-3355 ( 11/03/09 MESSAGE APPTS NOT CANCELLED WITH 24 HR NOTICE WILL BE CHARGED. LONG DISTANCE-(IN FLA ONLY) CALL 800-822-6239 NIN4,s511B~~fl 755-GESSLERSTM-363415-499429185-P; 2302297-1-12; 30304119-1; 1 5.00 ne no ~' .f.' ~` ~A-AO~ CARbISI~E HMA PHYSICIAN 1!lANAGEHI PO ~p ~Q+629 ATT.AI~ITA, GA 303841629 RETURN SERVICE REQUESTED >36538 7476507 001 092096 DOROTHY SPOTTS 10 ABBY COURT CARLISLE, PA 17015 V IMI GIYIGIr 1 Check # - - Amt $ V1301T 073 5392D TU05 Please Include SecurR Code From Back Of Card CHECK CARD USING FOR PAYMENT MASTERCARD tI/SA VISA DISCOVER CARD NUMBER EXP. DATE CARDHOLDER NAME SECURITY CODE SIGNATURE AMOUNT REMIT TO: CARLISLE HMA PHYSICIAN MANAGEM PO BOX 281629 ATLANTA GA 30384-1629 ,* ~n~~i~~uu~~~~~u~n~u~m~~~~~nn~~~~~~uu~~~~~~nu~~i~ PLEASE RETURN THIS PORTION WITH PAYMENT Office Phone Number Statement Date Your Account Number Page No. Patient Balance SHOW AMOUNT 17 519-0753 01/04/10 715345 1 5.00 PAID HERE --------------------------------------------------------------------------------------------------------------------- CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT 5.00 vent PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE: 01/04/10 715345 PATIENT BALANCE nrrent 31-50 Days ~ 61-90 Days >90 Days Total Ins Pending PAY THIS AMOUNT O:OU 0.00 5.t?0 0.00 5.00 0.00 5..0.0 INQUIRIES % PAYMENTS T.Oc CARLISLE HMA 'PHY3IC,IAN MANAGEDQ PO BOX 281;529 All unpaid balances .will b'e ATLANTA, CAA 303841629 sent to a'collection,agency 77.7 519-0753 and. all collection/legal fees will be your responsibility.. 3 7476507 036539 036539 00001/0000'1 920966902 .. ,.. P.O. BOX 15270, DEPT 55 WILMINGTON, DE 19850 ~'i~I'~'~~~I I~I~I'I'~I'~~'~'~~~' ~'II"~I~' ~'~I I"I 50445969/8 NCO FINANCIAL SYSTEMS, INC. 2665 ELIZABETH LAKE RD. WATERFORD, MI 48328-3277 January 17, 2010 OFFICE HOURS: MON: 11:OOAM - B:OOPM EST TUES - FRI: 8:OOAM - S:OOPM EST 11959.8476 PHONE:800-785-1426 DOROTHY F SPOTTS m~ 10 ABBEY CT CARLISLE PA 17015-4384 CARLISLE REGIONAL MEDICAL CENTER / RE: DOROTHY F SPOTTS /~ RE: 9441917 t DATE OF SERVICE: 0 /09 a ~+' BALANCE: $ 1575 ~ ~ -L~~ ~~i'~ Your Account May be Credit Reported! Our records indicate that your balance of $1575.00 is due in full. It is our intention to wor esolve this collection accom-t. However, subject to your dispute and validation rights provided on the reverse side of tlus letter, if you fail to resolve this collection account, we may report the account to all national credit bureaus. To assure proper credit, please put our internal account number 50445969 on your check or money order. Calls to or from this company may be monitored or recorded for quality assurance. You may also make payment by visiting us on-line at H~ww.ncofinancial.com. Your unique registration code is f25.2396592U.50445969.10:t1. To receive future notices for the account(s) by a-mail, visit v<tivw.ncofinancial.cont for details. This is an attempt to collect a debt. Any information obtained will be used for that purpose This is a communication from a debt collector. J ~~ ~~~ ^~~` ~~ "~ v (~'; ,~ a~ ~~ ~~~ ~,. 6~ Notice: See Reverse Side For Important Information. See Reverse Side for Federal Validation Notice. PLEASE RETURN THIS PORTION WITH YOUR PAYMENT (MAKE SURE ADDRESS SHOWS THROUGH WINDOW) Creditor Reference #: 9441917, DOROTHY F SPOTTS NCO Financial Systems, Inc. 2665 ELIZABETH LAKE RD. WATERFORD, MI 48328-3277 PHONE: 800-785-1426 - - Our Account # Total Balance 50445969 $ 1575.00 Payment Amount j Credit Card Number (VISA and MasterCard only) 0 Make Payment To: NCO FINANCIAL SYSTEMS,INC. P.O. BOX 15270 WILMINGTON, DE 19850 NCO 8 P 0255504459695001]D00551700000~0001575004 8476