Loading...
HomeMy WebLinkAbout10-15-10' ~ 1505610101 PA Department of Revenue l3uresu of Indtviduat fazes ~ ~~ USE ONLY'. Counh Code Year File Number P~ BOX st3o6o~ INHERITANCE TAX RETURN ZI j~ b U S~ Hsrrtsburo. PA r<~i28-o6oi RESIDENT DECEDENT 7 ENTER DECEDENT MIIr01WATION BELOW Social SecuAly Number Date d Death trildDDYYYY Date d Birth MMODYYYY 159-24-7941 03/ 12/2010 03/24/1917 Decedent's Last Name SuBbc Decedent's First Name ' MI ORRIS ANNA M (K APPI~) Ear ~~nY ttitroup's Infonrration Below ~, Spouse's Lsst Name Sutrix Spouse's First Name MI Spouse's Sodel Seaxihr Number ~ THI8 RETURN MUST BE FILED IN DUPLICATE WITH REGISTER OF WILLS FlLL IN APPROPRIATE OVALS BELOW ~ 1. C Return O 2. Supplemental Return O 3. Remainder ~ (dale d dseth prior to 12-1 ) O 4. Limited Fatale O 4a. Futuro Interest Compromise (dated O 5. Federal Edatb Ta ~C Return Required O B. Dsoedsrrt Died Tesmis O death after 12-12-82) 7. Deosdsnt Mairnained a Living Trust ._ 8. Total Numbsrld ~ Deposit Boxes (Attach Copy d 11Nd1) (Attach Copy d Trust) I O 9. Lrtipation Prooseda Received O 10. Spousal Poverty Crodit (dale d death O 11. Election m ta urk >ar Sec. 9113(A) ~ between 12-31-91 and 1-1-95) (Attach Sch. ) OOI~ONDEfR - TENS SECi10N 1MUt3T L COLLETED. ALL tPONDENCE AND CONrIDEN1tA1.TAX ItEORMIiTION sIIIOIAr Name Daytkne telephone KATHLEEN K. SHAULIS, ES REGISTER OF First Eyre d address ~ t 1633 WALNUT BOTTOM ROAD rn `. ~' Second Ifrre d address`,,' ~c r-~t Clty or Poet C)Iflce State ZIP Code I "~ CARLISLE PA 17015 a Comsapondant's a-matt add~as: Under penattiss d perJrry,1 dectaro dgrt 1 hew axsrNned this reham, fr n h sus, carerx and canpsM. Dederapon d propenr odwtr then the Sa TURF OF 8LE Fdt F RETURN av~aees era alalerrrs~, era >D tln k based on en kdortrratbn d whkh T0: tISE GNLY N 0 '~ m ~~' -t - _ _ n - to ~ ~ ~ ~ ~~.;~ ~~ r ap ` w-ri w ` ~"' ,F- .,..~~ / ~- 2241 WAGss'ONER'3 GAP ROAD CARLISLE, PA 17013 • f ~~ D 16331~VALNUT BOTTOM ROAD CARLISLE, PA 17015 rows usE olasl~ Stds 1 L 1505610101 1505610181' J Q .~n J 1505610105 REV 1500 EX o.o.d,r~r, w.,,s: ANNA M. ORRIS DecedsnYs Socid Security Number 169-24-7941 -- --- RECAf~rruuTwN 1. Red Estate (Sctredub A) ............................................. 1. __ 2. Stocks and Bonds(Sd~edub B) ....................................... 2. 3. Ck~edy Held Corporatlon, Pattrslrship or Sole-Proprielorshp (Sctredub C) ..... 3. 4. Mortpapes and Nobs Receivable (Schedule D) ........................... 4. 5. Cash, Bank Depoeita and MlsosNeneoua Personal Property (Schedule E)....... 5. 8. Jointly Owned Property (Schsdub F) O Separate BiMinp Requested ....... B. 626.55 T. Inver-Vfvos Tenders iE MboeNeneous Non-Probate Property _ ~ _ (Schedule O) O Separate BlNkrg Requested........ 7. ', 135,000.00 ._ 8. Toth Oroas Mseb (fold Lines 1 through 7) ............................. 8. 136,626.66 ', 9. Funeral Expenses and Adminiatratlve Costs (Schedule H) ................... 9. 8,633.00 10. Debts of Decedent, Mortpaye , and liens (schedub q .............. 10. ' 21,295.02 ,. 11. Total Deductions (total Lines 9 and 10) ................................. 1 L I ~,siZ3.0>: '' __ 12. Nee Vdw of Eabfe (Lies 8 mkws Line 11) .............................. 12. 105,698.47 13. Charitable and Oo+wmmarMd BequesislSec 9113 Tn~sts for which an elec8on to tax ha rat been made (Schedule J) ........................ 13. __ 14. Net Yalw 3ub)ece to Tax (Line 12 mklus Line 13) ........................ 14. 'i 706,6ii.47 TAX CALCULATION • »EE INtlTRUC770NS FOR APPLICABLE RATES 15. Amount of Line 141axabie at the apouad tax rate, or ~, 1-arpiers under Sec. 9118 (ax1.2) X .0. 15. 18. Amount of Una 14 taxable at Ynerd rate X .0 ,~ 18. ._. __. 1 T. Amount of Una 14 taxable at ablkig rata x .12 105,698.47. 17. ', 4,756.43 i 18. Amount of Una 14 taxable -~~.. ~.~_... ..____ ,,. _..._ ., a. _~_- ~__~ _ ~.__. . , .._~ ,__. _ .... __.~ _. ,; at ooNabrd rab X .15 18. 19. TAX DUE ......................................................... 19. '~ 4,756.43 20. FILL IN THE OVAL M YOU ARE REQUES71Nt3 A REFUND OF AN OVERPAYMENT Side 2 L, 1505610105 O I 1505610105.... J REV iTS7-b EX ~ (8-081 pennsylvanid sawouu b MRT ~ DEPARTMENT Of REVENUE ~~~,~ ~~ lMIER[TNrCE TAX RETUiN NOf~6VT DECEDNIT ESTATE OF FILE NtJM~ER ANNA M. ORRIS 21-10.0457 --_ -- Part 1 must lndude jointh--owned roal ssta>!e and targWle Per~o~ Pr'aPerty looted M Pe~xgylwu~ls• ~~y~ }~ eMl ~n-N'M sfd! to MClud! all taller loiNlN- bald orooarty rllnnswr lee~dd t]NLY trlrn tIr eneeerMen~.e. w..~.wd' ,d+~~- ~ii~.~.. w .~..`r..~ a~ was ons Year of iM dsosdsnt's dsM of eMulh, R must he rspsrtsd - ---- G. StIRVIVM~10 JOgVT TENANT(S) NAME ADDRESS R~LIITIONSI~ TO DECEDENT A• -2231 WAGGONER'S GAP ROAD CARLISLE, PA 17013 FRED B. ORRIS, III N B. C. . _. ~ t>Tae LErTEr; PoR JOMtT oArtr MADE r~ESCRTrTtoNOF PROPEanr DATE of r~TN % oitlE of nE,~FI yN•~ pF NUIfaER TENANT J011IT MMCh deed for peel eeteee. VALUE OF ASSET DECEDENT'S INTEREST ~ . A. otlOtN9S0 ORRSTOWN BANK CARLISLE, PA 17013 CHECKING ACCOUNT 1,253.19 I 50 626.5; N0.143000742 ', !, II ~I ~~ ~~ ~I l i II ~, i ', ill I I i I i III MR* 1 5626.55 P rtlonate Method From 50.00 ~ (Also enter on Line 6, ) ~ 1R mvre space ~ neecsa, use aOaRIOnaT sneers of paper of the same size) R -b EX + (8.06) Pennsylvania DEPARTMENT OF REVENUE D~FfBiiTAMCE TAX RETURN I~IOIfB~Bf~OECEOENT fCM~~i'1L% R MR? .'~ use Sd~sdul. F, Pert 2, oNLr for ~OIN?LY•OiMINto l~ROMRTY Prue mall,~d of irx oomputedion. ESTATE OP PILE NtIMAEp ANNA MORRIS 21-10.0457 ~~ Part 2 roust Inoluds Jointlrio~wnsd Iwl sstats sod tntarlpibts personal propsrlfl whsrwrk rrar NUI~ER Poa,I~oNVr TENArlT f~1TE WADE JOSff rndud~ nrns a ~nendd~irnlMAlon ~ irtNc number a aRrar nunber. AMech deed fa reei eebde. DATE of DEATH VALUE OF ASSET ',~ x old DAo~T-I OEf~ENi'S N'fEfiE3T t. A. I I ', 'I I ~~ 'i I i ', i I I~R! ~ (Errlsr on Line 2, I'a~t 1.) ~ "~'W (If more specs is needed, use eddldonel sheets ad paper a6 the same size) REV-1510 EX+ (08-09) P~~varyia SCHEDULE G DEPARTMENT of REVENUE INTER-VIVOS TRANSFERS AND '""ER'TA"cE TAx RE7URN RESIDENT DECEOEHr MISC. NON-PROBATE PROPERTY ESTATE OR RILE N ANNA M. ORRIS 2 -1 S7 This sdkdule must be canpkted and fNed if the ar-swer to arty of questlons i through 4 on page threx of the REV-1 00 is yes. ITEM DESCRIPTION OF PROPERTY arauoE of NwrE or txE tRw~uE, rnErA AeAnorrsrnv To oECSOert ANO DATE OF DEATH % OF DECDS I EX 'ION TAXABLE NUMBBt nE uArE aF . ATTiWi A OOM OF 7ME oem -oR IAN. BtAtt VALUE OF ASSET INTEREST VAU)E i • 161 EASY ROAD, CARLISLE PA 17013. , HOUSE IN VVFIICfi DECEDENT HELD LIFE ESTATE 135,000.00. ~ '~ ', ~ I ' I i i I I 'I i ~~ I 'I i i i 135,000.0( TOTAL (Also enter on Line 7, Recapitulation) # 135,000AO lr more space is neeaea, use aCCltlonal sheets of paper of the same size. REV-1511 EX+ (10-09) Pennsylvania SCHEDULE H DEAARTMENT of REVENUE FUNERAL EXPENSES AND INNBUTANCE TAX RETURN ADMINISTRATIVE COSTS RES1oExr oECeoENr ESTATE OP PILE N • ANNA M. ORRIS 21-10.O~t5~' DaaNNt'a dabH mwt be rapo+iN on SdN>dvle i. [TE14 NUMBER DESCRIPTION ~ AMOUr(T' A. FUNERAL EXPENSES: i' HOFFMAN ROTH FUNERAL HOME, CARLISLE, PA 17013 I 6,854.78 CEMETARY FEE 600.00 FUNERAL FLOWERS 66.78 e. ADMINISTRATIVE COSTS: 1. Personal Repn!sentative Commissions: Name(s) of Personal Representative(s) FRED B. ORRIS, III Street Address 2241 WAGGONER'S GAP ROAD ~I (~y CARLISLE State PA Z[P 17013 Year(s) Commission Paid: '~, 2. Attorney Fees: 550.00 3. Family Exemption: (If decedent's address is not the same as daimaM's, attach explanation.) aetmant Street Address --; I ~Y State PA ZIP ~ Relationship d Claimant bo Decedent 4. 5. 6. 7. 8 Probate Fees: 199.50 Atoamtant Fees: Taz Return Preparcr Fees: BARRETT REAL ESTATE APPRAISAL I I 200.00 CUMBERLAND COUNTY RECORDER OF DEEDS 62.00 TQTAL (Also ever on Line 9, Recapitulations ~ 8,633.06 , If more space is needed, use addftional streets of paper of the same size. REVN737-7 Df ~ (808) pennsytvania s~11~o11y ~ DEPARTMENT OF REVENUE ~ ~ ~~,~/ DrFrt~TANCE TAX RETUINI M~w~ ~~~~~ NONR61D9Qr OEC,EDBtT E8TATE OF ANNA M. ORRiS lJss Schedub t, Part 2, ONLY for pIC~fOrtiWHb n1lttlOd Of taX COr1lpUtati0rl. FILE NUN9ER 2i-10.0457 Part 1 must frtdude mortgage Ilabilities, liens atxl taxes against the Psnnsylvanb realty that due and owed sa of ttte date of deoedartt's dsatt-. Part 2 ONLY wihan the rnal!-od # b •+ ITEM NUMBER DES~IPTION AMOUNT 1. ~, ~ i 0.01 n'Bil NUMBER ~~~~ AMOUNT t • COUNTY AND S.D. REAL ESTATE AND PERSONNEL TAXES 2008, 2009, 2010 ', 4,256.13 2 SEARS GOLD CARD 1,162.52 3 DISCOVER CARD 9,898.12 4 COMCAST 152.43 5 CENTURYLINK 92.08 8 PECK'S SEPTIC SYSTEM 185.00 7 BANK OF AMERICA 809.23 TOTAL FROM SUPPLEMENTAL PAGE 4,759.51 '~ TtnAi Mltr I! x 21,295.02 101f~i Also enter on Lute 10, Recapitu Z 21,295.02 (If moro agave is needed, rase additlortal sheets of paper of the same size) ~ SHEDULEI ' DEBTS OF DECEDENT, MORTGAGE LIABILITIES AND L~El'kS CONTINUATON PAGE Eatate of Anna M. Orris FILE N0.21-10-0457 Moffitt Heart and Vascular Group X54.38 ' Camp Hill Emergency Physicians 33.81 Holy Spirit Hospital 1075.08 Spirit Physician Services 176.00 Orthopedic Institute of PA 74.98 ' Quantum Imaging and Therapeutic 40.07 ' Carlisle Regional Med Center ~~ 45 Cumberland Good Will Fire Rescue 344.42 ~'~, Wcst Shore EMS 623.02 Quest Diagnostic Inc 160.93 Forest Park Nursing Home __ 2157.37 ' Totsl Medical Ezpienses __ S47S9.5~ i I r~~r~~ ~ Ex+l~ t~veeaE pennsylvat~ia ~ouu ~ DEPARTMENT OF REVENUE ~+NI~N/M a ~N,~ Ir4tERITAIiCE TAX REi1MiN ~~~~AR~ NDNR~SDENr DEGECEI'IT ES'TAT'E OF ~~ tr1t1A~ ANNA M. ORRIS 21-10-0457 When flat rate method fs elected, Nst the bsneflciaries of the Pennsylvania propel When proportionate method is elected, list ail beneficiaries. ~ RELATXNiSHIP 1O ~' NUMBER NAMEAND ADDRESS OF PERSDN(S RECENING PROPERTY Oo DENT AMOUN E~SHARE I. TAXABLE D~TRi8UT10N3 ~Ckide outright apotael datrEuloru and trattalen tatder Sec. 2116 (ax1.2)I L FRED B, ORRIS III, 2241 WAGGONER'S GAP RD CARLISLE, PA 170 SON 100.00 ENTER DDLtAR AMDUffTB FOR OIBTRiBUTI0N8 SMOYYPt A80VE ON REw1737 COVER SHEET OR 7EIE PROPORTIONATE METHOD OF REV-tTd! COVER 8F~E7 A9APPROPR111TE. II. NOI~FTAXABLE ~: A SPOUSAL DISTWBIlT10NS UNDER SECTION 2113 FOR YNiICH AN ELECTION TO TAXIS NOT BEING MME L I B. CHARRABLE AND GDVERNMENTAL DISTRIBUTIONS t. _ (E:nter mts! Wort-texabls dfgrbutlorts on Une 13 of REV 1737 ootnr sh~'t. ~ ~'"".~ pf more space is needed, use additiortal sheets of •~.•`...-) ~~_~•.~..•_.-. paper d the same size) SCHEDULE G ' ~ 3. W. eamatt Rsal Esbb ~ Appraisal 8srvicss y APPRAISAL OF LOCATED AT: 161 Easy Road CariHls, PA 17013 CLIENT: Fred Orrb 181 Easy Road Carlhils, PA 17013 AS OF: March 12, 2010 BY: Cassandra J. Crockett PA GrtHisd Rssidsntial Rsai Estab Appraiser ~ ~_.__-- .___.___ _.._..___.___.__ I 3. W. Barrett Raat Esbb 3 Appnisal S~rvicp Residentlai Appraisal Report FIbNO, to-0094 The purpose of this appraisal report b to provkle dte tpbnt wNh a credibb Client NameMtbnded User Fred OMs o~0n o1 ~ ~~ vaku.ol the subject propery, given the Mftertded use of the appraisal. of prbr set a aansbr hisgry of the subject property lend t:omparabb sets, ~ eppacebb) CMerNgs, options end crutbact as of the enecave Gb of the appraisal P-eeerMLanAtltwM Netphborhopd BoUndBrlla Netphbothood DBSCrIpdOtl Market Ctxtdikons prtckrdktp arPPort fa the above earcMrsiorts) ...w u_. ~___ . __ ___..... _._.......,o,w vas ~ XYgg ~-----_- Isthe highest and best use of the subject property as improved (a as proposed Per Wens end ~~ spet~Aatlons) Ule Oaenl use9 No II No, describe. Site Comment /Wdkionel Features Comment an the Improvement ~~ ADDENDUM Pr Addross: 181 Eas Road Fib Wo.; 10-0094 City: Carlisb Case No.: State: PA Zip: 17013 Nalphtloffiopd Boundat+iss subject Is boundrad on t11s noRh by Psnp Courtly Ilra/mounbirn: east by Rt.74; soutli by IPa.Tumpb; and west by McClurss f3a Road. Addendum Pape 7 of 1 FEATURE 181 Easy Road Residential Appraisal Report_ COMPARABLE SALE N0.1 COMPARABLE S 1636 Longs Gap Rwd 6 Groan Meadow ----..... •^• . i oESCRIPTR Sale a Financing NoM, F11A concessions ..,.,, __. None, Conv AboveOrede ----•- - su nor TaIY eah TaY a0 ashy Room Count 4 2 1 ray 8 3 1 4 2 Gross Area 38.00 947 . t. 1 199 . fL -8 470 easemem&Finished Full eamtl Full Bsmt/ 8>I Roans t~ r ~ u..a_r_~_. _ .. _ Full Bsmt! 1 Adjustetl Sale Price Net Adj, -8.4% Net Adj. 10.616 -~- _ __ File No. 10-0094 LE N0, 2 COMPARABLE SALE N0.3 give 1820 Newvills Road CIsp.Csts/FHA ~ -8,680 5 2 1 1 8 1 138 ', Full BsmtP Net Adj. -4.$16 k - p ~ - i Exl~mal = e~ •~. - k~-, ........... _ _ ~ Summary of Income A - -- • .. -..N gym„ ~u~ Pproach (inc6xkng support br marks rent and GRM) This appraisal is made U •aE iA• subject to completlort Par lens and subject to ~ P specrricadons an the basis of a hYpodte6cal cortditlon tltN the khpro have been completed, epairs a +>peredons have been completed I subjea b the beowing: A roisal is for lisrn one ontransHrana ~~1 n ~ ~ r Bawd on sa scope awarlt, assumptlons, INnttlny candNlons and+4-Wrwr's ardBcatlan, m our thatktlnsubjectofthisraportbi 138,000 ass 03H2J2010 Y( l~~a~~~~ ~~"s°fthsrwpropssty , whkh h Urs "reeay~e lass athb ppray~, ~M n,ae,cb u.q Ap eoa.r., mzu~m ww..awe.mm nr iamaq~groGWS '~~.. Aa w~igonaisocra. v+sezax s.r,cc„~ 3.W. Barrett Real Estate 3 A IoPUr~l cererr W.pseAwnc Ppralsal Services ~°" i ~ r F-~-~~~ 1a1 Easy Road Sak or Financing Above Grade Room Counl GrossLiuinoArea36 Basement & Finished Adju5le0 Sete Price BsmU Residential Appraisal Report COMPARABLE SALE N0.4 COMPARABL 191 Easy Road -' CIsp.Csts/FHA ~ _a,ppp Bsmt! + X• S 2a19a X* f NetAtl;. -1a.9~ Ne~Ad;. o.o% File No. 10-0094 Net Adj. % I i File No. 10-0094 -~~r• ~~ ..~rrc, nssumpuona and Limiting Conditions Scope of work b deflnad in fhe Unkam Standards of ProlewkxrN Apprahal Practlce as " the type and ercuntdreaWrch and anaysw M an Mm~kadnb tMexburtUOwhk:hthe b~~whatlMappralwrdWanddldnotdodurfngtl»courwdtMalulpjtm~artklnckrdas.butbnot barMw at opinions a conekrslom ~~ b ~ Nil Inapsepd. the type and s>reant of dW nswchW, the t~pa and exMrKOf analywa appksd The scope of tlrb apprabal and ensuing dbcuwlon b thb refaortan specille b dN nwds of do easnt, odpsr inbnrbd uw of the spat Thb rapatww prepared for the sale and excWskra uw dtlN cMerKand otlrsr IdenY~ Mrtsrrdsd users and b dpe irrMndsd uw and ks uw by any opMr partlw b prahWllM. TM ttpprdsar b net rw uwn for tlrs Wsrrdnad pomibls for wwutlbriztid rp~e ofthe settordl drascertlfleatforr~ apwrt ANsxtraad fePatbsub]scttithetokowkrpconditloneandbsuch,otl~rspeaHkaaWyonswan by apprabier in the r kwy wwmptlona and khe rMport and m wsgnmentrwWet. hYt~edcalcondklansarostafadbp iphthaveafbctsdtha 1. The appraiser assumes no responsibility br mepers of a lapel mdure a0eelurp the Property appraised or We mereb, nor does the appro~ar rerxkr ~, oprnbn as b the tltle, which is assurtred b be good and marketable. The property is appreked es tfargh under responsible ownershp. 2. Any sketch in this report may show approximate dimensbns and is krcluded only b assist dre reader in I 3. The a raiser k not ~ property. Tlteap~iaer fras made no suntiy of the property. ~ re~rired m pine leaprrrorry or appear ro court berauae of havkrp made the apprebprl adtlt reference b the praper#y b uesuon, uMess arrerrpemerns have been previou made drereb. 4. Neiber ail, nor any pan of the content of tlrls report, copy or otlrer media prereol (inckrdirrp corrcbsions as b the or the tkm wish which the appreber is connected), shop be used br Droperty value, tlre' t~ attlre appraiser, prokssbnd desipnaoons, anyone b dre pubkc thr h wive t>M PurPoaes by artyone but tlw client errd other krkrrded users as entlfkd in dris spat, na shaN it he conveyed by cep rtfSkq, pubpc relebns, news, sales, a other medic,, wftlbut the wripen consent of pre appraiser. 5. The appraiser xdq rra disclose the carpenls of tlris appraisal report unless rer)uped by epppcable kw a a4 sperhlied in tlce Unporm S 6. Inbrmatbn, eswrrates, and opinbns lurrrislred b the der~M,a~Ids of Professbnal Appraisal PreckCe. However, rro re appraiser, and wnteined in pre report, mere obtained from sources considered ~eueob and bekeved b be aue and correct. sponsibipty br accaaty of such penis furnisfred b the apprelser rs assurtred by the appraiser. 7. The appraiser assumes tlral tlrere are rro hidden or urrepperent condilbns of the property, su)xsop, or sarxdaes, rkrkdr equip render k morb or lei vakreble. The appraser assumes shoub nnot De considered ass. a for engineering or 6esap, whkh miOM be requked b discover such papas, This appraisal is oaten er~ruonmeraal assessrnera of the property and 8. The appraiser sPeci~izes in the valuatbn of real property and le not a hens inSPecbr, building corwtrobr, sbucaxal errpkreer, a ' e d t coaluct the iraensive type of firtb observadons of the Hind inkrabd b stick and tlbco~tir property debcls. The rt' urdess °Q ~. The appraiser bProo an opinbn of the deprred vakre of pre property, given pre Inbnded use of the asspnmerp. Stakrrrenis repardcoandlgn a~ ~ ~OYe h b pub of appraiser claims no special expertise repsrdirrp bsrres krckrdirrp, but not Nmlbd b: bundetlon setUnnen4 basement molaure problems, Mood de n sure ol>servapons ony. The radon pas, lead based pekrt, mold or etwkonmerbl Imrres. Unless othenWSe lrrdicaeQ rnedrenical sYsbw were not atdlvaped a reaped. boYbY (a oprer) insects, Pest infestabn, This appraisal report should not be used b disclose dre condpbn of the property as il rekbs b the preserrrxMbserru of delecb. The cp~nt rs ~mdled orb encoruaged b empty Quelited experts ro inspect end address areas of concern. Ii rrepative conditlons are discovered, the opinbn of vakre may pre affected. «~ Ise nassd, the appraber assumes tla components dntwnstlorb tlw wbJeet property lm''~~""~~~~ ~~ ~~""'' r~w.rrrwrgs) ~Irre firrrdanpantaNy aarapd and in ~Y vwxrq 01 the property by the appraiser WBS tbked b readily observabb 8feas, Unless otlrenvise rabd, BplCa antl Crewl space ereati W!!e n9I8CCeS9ed. The BPPfaISe! did r101 mOVe furnierre, floor covennps or other gems drat may restriq dre vleadnp of the property. ~ ~dY ~~ ~YI~edCal conditions relabel b complepon of new oorrsbucdon, regales or eperatbn are Dosed on the aMtrmpbh dra~ Such conrPleUOn, akeradon a repairs sIq 10. Unless the inkrrded use of pris appraisal sPecplcapy irtrdudes rues of property insurance carerape, tlris appraisal Sib ~ ~ b a' h WrPoses. Retxodrx;bn or Replacenrem cost figures used in the cost approach are fa vekreDOn purposes oNy, given the baerrded use of the aMgnmera. The Debi~on o~ value used in this assignment is unpkey ro be consistent wph the defxriporr of Insaabb Value br property insurance coverapeltrse. ]l. The Ap f3erreral Purpow Appraisd~ (( ~ b not lepberpded /or uw in trargacdona tlW nquke a Fannie'"T 100YFroddie Mac 70 form, abo known as fM UMlorm Residential ~~~ Addlebnd CommerNa Rslaasd To Scope Of Work, Awumptlons and I.imkkrp Condklons ~~ vrar File No. 10-0084 Appraiser's Certification The appraiser(s) eerftlNs tl1at, b the fsest of dre apPralser's 1. The statements of ad conained in this rayon are Due and correct. ~~~ and belNf: 2. The reported analyses, opinions, and conclusions are GmPoed ony by the repored aswmptlons and lirnitirp conddorts and are da appraser's personal, impartial, and unbiased prokssbnal analyses, opinions, and corrdusions. 3. Unless otherwise sreted, the appraiser has no present er prospectlve inkrest in the propery Ifat is the wbject of Itus report erW has no IPersonsl merest wph respect a dte mvohred. Parties 4. The appraiser has no bias with respect a dte property that 6 the wbieCt d this repot a a Cte parties involved wNh This asspnmea. 5. The appraiser's ergagemem in this assignment was not contirfgent upon devebping a reporfkrp predearrtwrred rewks. 6. The appraiser's compensation for compktirq tltb amgnmem k tat contingent upon the deve the diem, the amount of the value opinion, the aneinment of a ioprrrem a reportlrtg of a Wedearmirted a direction in value dW eves the cease of atipuaad rearfL a the occwrertce of a slrfxsequsM evem directly r to 7. The appraser's anayses, opinions, and conclusions were ihknded use of tlrrs apprekaL developed, and thk report has been Prepared, n conbrmay wtih dta Urr~brm tatrderds of Prolessioraf Appreisal Practice, 8. Unless otlterwise rakd, tine appreker has made a personal inspedan of the properly that is the wbject of Ihis report 9 Unless nokd below, no one provided signilfcartl real progeny aPPreisal +lssisance a the appraiser sgning ale certification. sgnMit;artt r~al property appraisal assisarxe Provided by: Additional Certiecations; De1lrNllan of VaNa: ©aaarNet Value ~alhsr Vslus: Sotece of Detinitiort: USPAP w~rldmtbnsprobable prke !n trmle of money which a property should briny in competltlw a affeeted requiske to a hlr saM, tM buyer and Helier, each acynp pr~ntly~ n art mortal under all by undw stlmulue. knowledpa~bl ahd assuming tlIe Price is not ADDRESS lJF THE PROPERTY APPRAISED: 181 Eas Rwd Carlisle PA 17013 EFFECTIVE DATE OF THE APPftAlsgl; March 12 2010 d. O. d. APPRAISED VALUE OF THE SUBJECT PROPERTY = 138.000 APPRAISER sigraarre: Name: Cassandra J. Crocktrtt srak Certiarxtion a RL001388L -'---- aLicense a or Otlter (describe): state a: sae: PA Expiration Dale of Certiacation a License: 08/30/2011 Dale of spnaarre and Report 06/07/2010 Date of progeny Viewiftg; 03/12/2010 d. o. d. Degree of progeny viewing: XO Interor and Exkrior ~ Exterior Ony ^ Did rat persoratiy view SUPERNIS-ORy~Appp~p ~' Name: 8bYM W, g Bad. R state CenrACatlon a ~~ "'- a License a RB028Y21A safe: PA --_ Egkalbn Oele of Cerlitcatiat a License: ',06! 012011 Dale otSgnewre: 06/0712010 Dee of progeny Viewatg: 03/12/10 d. .d' Degree d progeny vkwitlp; ---°-----_- XOInterior and Exkrfor ~ Exkria pny ~ Did not Personatiy view RaacrE uyp qq ~ anr.nn~wn.xewe.mn my yr„u~a~ of I50 GYnM911M 3. W. Barrett Real Estate 3 A s''"a"I c~.r ~ ppraisal Services SKETCH/AREA TABLE ADDENDUNr Cans No SUBJECT PROPERTY PNOTA AAr]FNM 1\A Client: Fnd Orris File No.: 10-OOi4 Property AddrAss:181 Easr Road Case No CiN: Carlisb State PA 2io~ 17015 FRO VIEW OF SIi1B~ECT PROPERTY Appraised Date: Aprtl 9, 2010 Agpr ed Value: $ ~,i II SCR IET SCENE I-._ ~-T __ __ _. _._ _ -_ COMPARABLEPROPERTY PHOTO ADDENDUM COMPARABLE SALE #1 .r %~ , ~~ ,~ ,, y w r...,,,, -"7 7 1 ~ Lonps (3ap Road Clark 17013 Sale te:910! S rice: $136,000 C~OI~PARABLE SALE #2 bla Meadow Drive GItrU ~ 17013 te: 11!0!1 S le rice: $130,000 C~OI~PARABLE SALE #3 I 120 I ilia Road Ia,17013 S :8lOY le iCe: $ 142.000 i I COMPARABLE PROPERTY PHOTO ADDENDUM GOIy'IPARABLE SALE #4 V Road ~~o~s a: uoe e: S ~as,ooo 'i CkON~PARABLE SALE #5 S~elle ate: S rice: $ i COMPARABLE SALE #6 S~le Mete: Sale Brice: S LOCATION MAP Clete ~ sit ~ ~ ~f ~ Comparable Sale 1 ~ Sr 1535 longs Gap Road & Carlisle, PA 17013-8658 -•~,,~ (1.31 miles NNE) $ Y~'~ ~ ~''` A p @ ~i I _ 'po, ' R' `~ Subject 161 Easy Road ~, Carlisle, PA 17013A594 Cteek Qd= a i t~ 74. I Comparable Sale 4 ~ 191 Easy Road Comparabb Sab 2 ~ Carlisle, PA 17013-9594 4 5 Green Meadow Drive p (0.05 miles SW) ~~ Carlisle, PA 17013-1213 ' Ci~D~WId ~ ~ (2.14 miles ESE) + cf' ~`~ ~i ~ ~ 'R. E ~4 -'~ Q~ ~., ~^ .l i _ ~ 1,.----.. _ raa., ,, p-~ ~.• Comparable Sala 3 _ 8f~M~ ~ 1620 Newville Road - ~ ~' ~ ~ ~ ~ Carlisle, PA 17015-7400 ~~~' `~ ~ ~ e .w ~ ~ Y - ^ (2.85 miles SSW) 1+~balnii»ta 1Ae . ~r 'Dt ~ ~~ CemefaY ..r -_ . &' ',, _ ~ 11. ~ _ $__. Z' Newel[e ~ ~ oCrade _ _ SE. ' -. ~ .O° . . „ ~ i ~.., ~ ~~ Bamslabk Rd vabyc ~ , I ~' ~ ' *~ oerdsna 1t1 ~ 1 ~. ~ ,:9r. $ ~~ N. A~ ~,",~a `~~-. ~ ~. ,fir w . ~ 1 ~ _...''~~ Mme.'"_ I_'__. - ~ ~no~o rNwsroy loooe -~ ~ +~pl~i~~ /~~/L1 /`1 ~/~ ~~~~~andu i~1i~1l~I~i~11~~~11YR ilia ~N~ ~~~~I~INN~~ ' ~~ """""""'* QUALIFICATIONS """""""~' TM following checked items are SPECIFIC SPECIAL CONDITIONS that ware Identlfleld this appreburr during the Inspeetlon of tla subject properly, tM comparable ele, and theH neighborhooM nd k~catlom. UMes otlunwhe noted, tM conditlons that apply to the subject properly or tM comparebN sale NOT AFFECT THE MARKET VALUE OR THE FUTURE MARKETABILITY OF THE SUBJECT PROPERTY BEING A SED. Thts Is not a home Inspeetlon service. This is an appretsal to etlmab market valve. 1. TM subject Is located in a rani area and k less than 26% built-up _2. CommerciaUlndwtrial urea are located within the subjects neighborhood. use ere typical of similar neighborhoods. x_S. Vacant and undeveloped land uses are located within the subjects nelghborl~oo~l. These uses are typfcal for tl+e area. _4. The predominant valor In tfie Mighborhood is kas than that of tM market r~lwot tM subject property. This is rive to the wry wide range of valve of propertles in tM area and superior gwlHy tl~~ subject property. _8. TM subject property Is located in • F.E.M.A. Identified Flood Zone. Flood ira'urance coverage is required and suggetsd. _x_8. Dampness b noted In fM basement of tla subject. 8tnding or running wat~r w~ not present on basement floor. This condklon Is considered typical in dwellings ~ this style. ; i x_7. The subject property Is serviced by privet well andlor septlc systme which ~ clbmmon for the are. x_8. The subject Is older than five(8j years. All mechanical systems Including tbe~heddng, ellactrful and plumbing systems apper upon a vkwai exterior inspectlon to be in working order. No wawa re ImplNd in thb statement. _8. Repair items were noted In the comments sectlon of the report. Thep com't on repair items are for decAptlw purposes only and are not required repalre. TM Items Ihtted are eosin loll nature _10. TM basement floor b a dirt floor. Thb condWon fs common and typical for ~ ire. and doss tat pose a health or pfery hasard. _11. TM wbject property doss contain tunetlonal obsokrscena u noted fn the I This:condltion is considered typical and common for tM are and tht styN dwelling. I I _12. The land valve exceeds 30% of total wive rive to tM high demand for vacant ~;lan~l In this neighborhood. This conditlon is considered common and typical for the nelphborhood. _13. The land valve exceeds 30% of total wive. Thb is rive t the large size of ttn` sit. This condition ht comidered to be typical and common. , _14. Individwl adjustment were required that exceed 16%. Thep adjwlments similar eomparablq on that individual reting. All eomparebNs wed are 1M bet e x 18. Total adjustment exceed Z6%. Tht b rive to the lack of comparable eNs t subjects market area. All compareble used are the bet awilabN. x 16. One or more comparebN glee are older than eix(8) months. Affhough there subjects area, none have sold ree.ntly; therefore, ele in excess of six(8) months wad are tM bet available. x 17. One or more compareble used were In dxces of one (1 j mile from the eubjr eomptreble propertle in the immedlab area, none haw sold recently. TMrefore, K saNs outside of the immediat area. All comparable used are locatd In similar nel marketlng area. All comptreble wed are the bet availabh. _18. TM electrical system wa not connected during inspectlon. _18. The water prvice was not connectd during Inspectlon. _20. The hearing system was shut down during inspeetlon. _21. Rooflng_Plumbing,_Electrical_Hetlng_certlflcatlon(a~ lalare su _22. Inground swimming poor out buildings are included .not inclup guidelines. _23. According to lenders guidelines a maximum of acn» were conelderod fo~ acreage was given no valor. M rive to lack of more more similar in tM ~anpr•rable propertles in tM to be used. All comparebles "oparty. Altlwugh there are necer•sary to we comparable Kboods and within fhe same to lenders valwtlon. Remaining _1.. _~T _ ____ __ ' _. ', _.._ - -- - ----- .. P-201-AT--1Marr~nt;r oad, Sho.-t Fam. Act of 1~--arnn~a for Pnoto-Recoroins Henry ifaU, InC., ndisea, Pa. v ~ ~•„ t:7 ~, I ... :. ', ~ ~,, ';7 -~' ri ~~. ~ Iz l W ~ ri7 f~ 1 I . ~ .r ...~ •~ v'3 ..t «i y n MADE THE cal ri UC_. ~', of otlr Lord one thousand nine hundred. dad of September ' ~I i~~t the year and eighty-three (1983)., !~ BETWEEN ANNA M. ORRIS, wid.Ow Cumberland County, penes 1 ' of North Middleton Tdw$~ship, y vania, i Grnntur , a9:d ANNA M. ORRIS ,and FRED B. ORRIS, ITI and NANCY M~ IORRIS, his wife, of North Middleton Township, Cumberland County,!~P nnsylvania, ~~ tii~ITNESSETA, that in considelr~tion of One ($1.Op) dollar I Grantee s: plus gt~,er good and valuable considerations, i~a hand vrcid, the receipt whereof is hereby acknowledged, the said g~c~ntor dv~ s ~o~le~>ls~ arad convey to the said grantee s, their heirs and assigns, the ~. terest of the said Anna M. Orris being a 1i.fe estate or as long as s e hereby ~ra.nt remain there, with remainder interest at her death or ~h nesheenotlon er desires to remain there, whichever occurs first bein i the said g Fred B. Orris, III and Nancy M. Orris, his wife, 5' ALL that certain tract of land situate in North Mid l to County of Cumberland ~nri c+.~~:., „r „ _ -- ~ ~ n Town~h; n _ ~-T, --~~j"'~~.~~ dz a point in the center of a public road leading from the Waggoners Gap Road to the Westminster Road, at corner of land formerly of .Harvey A. Dick, now of Ronald Dick; thence Northwardly along lands of said Dick, a distance of three hundred thirty (330} feet to a point (iron pin); thence Westwardly along other lands formerl of the said W. Parker Brown, one of the prior Grantor~,~ now of Charles Fraker, a distance of two hundred sixty-four (264) feet to a point (iron pin); thence Southwardly along other lands form~r~ly of said W. Parker Brown, now Faye Zeigler, a distance of three hpn'Idred thirty (330) :Ceet tc, d point in the center of said Public Ro d''; thence East- wardly along the center of said Public Road a distane~ sixty-four (264j feet, to a point, the place of begin~i~f andhbndred improved with a brick ranch type dwelling house with ~g~ sing outbuildings. ttw~ car garage and BEING the same premises. which his wife, by deed dated November the Recorder of Deeds in and for Deed Book "B", Vol. 13, page 441, Jr. and Anna M. Orris, his wife. June 6, 1983 whereby the title to vested in the said Anna M. Orris, the Grantor herein. The fence provision as set forth in the above mentic~n'd deed has been made void and of no effect by Instrument dated July 11~ 956 and recordec in said Recorder's Office in Misc. Book 121, Page 368. W. Parker Brown and i~i~zie L. Brown, 3, 1945 and recorded,i the Office of Cumberland County, Pelnr~sylvania, in granted and conveyed~!,t$o Fred B. Orris, And, the said Fred Bj.iOrris, Jr. died the above described ~ act of land the surviving tenant,b~~i the entireties II AND the said gra,etor 11c reby roz:euant g ancl. agree $ that she will warrant generally tke t,raopertg kereby co~t:eycad. IN WITNESS WHEREOF, said gr•cr~ the day card gear first abovr rc•ritterr. nea, !Neaten ate ~etibereD itt tl~e ~rsgentc of ._..._.. /._.... 4..~~~'..._~ ......... .......................i. for ha $ hererrntn sr~t her ka~rrl anal rrE•al ~l. (Anna M. Orris) ' - `°~°' ....._.....-•--• ......................•--•---....__..._._. _.._ .._......---. asaL ................................................................1---.' ........._.. ~aL i .~-_~. ......................._.._...._....-•--•--....._.....__ ... ~..........._... SAL ._.. ~~ Steetr of PENNSYLVANIA Corrntp of CUMBERLAND O» this, the ~`~ n~ day of a Notary Public, the unclersignc~d nfJiccr•, pc~rsunally a/~heared ss. September , 1!1 83 ,before »rc,, ANNA M. ORRIS, wiclot~t, 1~->ratc%n to me (or satisfactorily yroven) to be the person ~vhose name is subscribed to the •roitlain instrument, and acknozvledged that she executed same fnr the ~,r~rpuses thc~,•rir~ contained. I ~ ` `. ~ ' ~'~' ,~ .. IN WITNESS WHEREOF, 1 hereunto set my hand and o~aciad seal. i~ II • ~ ~; ~~ • - ~,S-?~v ICAYLTsNI Ii. XrA ,LOTI[ NO'CA4tY Y~tJBY.T(: ._... . CAYti.7SLE. CUaiB88LA1VD COUNTY. 1'A T~tIN of D;Qrcer'. M'Y' COMMISt~XdN EX~ltY~B!! M~.RCS S. 191118 s~ do hereby ce-•ti~, that, the y~reefse residence a»d cpmplete I ~o~t o,~ce add ress of thc~ tuithirt ~tramed ,grantee is ; G i ~ ''~'`'°~"~, ~"~"'~--'=°•~ ~ k ~7 ~' ~, ~', i .~ ,.- ;; `=- i s t Attorney for __~~,~~:::L?:~-f.•_=1---a....--•-------------------- ,,.' . r . ~..x .~ r, . ~ .y 1~~t1. sx.i _._. __.. A c.r cn H .~ Cq O QW ~ ~ a b W U .r., b 3 ro z H H O a ~ O a OH S H ~ ~ ~ 3 ~ ~ N ~O ~ Q ~~/ i~if U a H 7 H a W x COMMONWEALTH OF PENNSYLVANIA I II County of ..!~-~.~ y; ~_ ~") i~ t:C~':~?.? ... ............................. ~. ,~ RECORDED on this .____... day of ..._...._...~._ " G;?'.`.1 " A. D. 19...f`.: in the Recorder's ogee of the said County, ~ eed Bonk _~ Vol ............. ~~_._ Paye ....J~~~::~ ---..... ' r t --~ Liven antler my hand and the seal of the said once, the d~zte~ above tv~-~etten. -- I ~ li d . SCHEDULE H r r ~` 219 North Hanover Street Carlisle, Pennsylvania 17013 717.243.4511 '_ , ~~ ` "' "'_._ ,~~ toll free 1.866.451.4511 o. ~!'1.~~'~ [ ~./~' .. - ~ 9~..~ ~'~ ~,~' ."" ~ ~~' ~.~+'~./~'~~' ~' fax 717.243.3723 www.hoffmarroth,com '' i~ FUNERAL HOME bi CREMATORY, INC: info~shoffmanroth.com A~ril~, 27, 2010 Fred B. Orris III ~ 2241 Waggoners Gap Road ' ~~ Carlisle, PA 17013 j Statement of Funeral Expenses. for: Anna Mary Orris ', Date of Death: March 12, 2010 Accou t d: 15892-69 PACKAGE: 'T'r' Traditional Funeral Service 'i TRADITIONAL FUNERAL SERVICE PACKAGE $ 4,350.00 ~I ', Sub Total: 'I ~ 4,350.00 MERCHANDISE: Casket: Kinsey $ 990.00 ~ Outer Container. Cave Proof Box $ 975.00 ~ Sub Total: . I .1,965.00 TOTAL FUNERAL HOME CHARGES: ~ I 6,315.00 CASH ADVANCES: ~~ 10 Certified Death Certificates at $ 6.00 each $ 60:00 Newspaper Notice -Sentinel $ 129,78 ' ', Clergy ~ $ 50.00 ~, Hairdresser $ 40.00 ~', Sub Total: ~ 279.78 Total Funeral Expense: 6,594.78 Payments made: I! Total Balance Due: ~!~ ~~~'~~~4.Z$ c-I 1 ~y~ ~ V 1~ ~~~ ~< a~* ~~a ~~u 2 p, u QtAQ ~N~ ~ ~ wS(`~ A Ar~ V 1 O ~. V ~ J ~ O '0 ~tl 1 o° r ~ r~ d0 1I~11~ :~1\q • :. i_ c~ 0 0 •N M. .-~ I ('L,1 . ~ ~~ o n.+ ~. s d O Q ~' O .r.. ~- d OU M DO Q' r- HOY's GRBBNHOUSB 585 Cranes Gap Rd .. Carlisle, PA 17013 (717) 249-3698 ACCOUNT NO: 163 Fred B. Orris III ' ~I 2241 Waggoners .Gap Road ', Carlisle, PA 17015 I ', ACCOUNT NO: 163 3 IDlte Mar31/10 Date Units Description P~ice Amount Mar. 16 1 #tinger Spray I'6 .00 <N/A> 60.00 1 Roae ~ ~.00 3.00 <N/A> <N/A> <N/A> PAID ' !, <N/A> ~~~ ./ o DATE <N/A> ,., <N/A> ', <N/A> Please Pay by the 20th '~ ' ~ <N/A> <N/A> Return. Yellow copy -with 4?ayr~ent TOT SAL AX $63.00 3.78 TOT- DUB $66.78 .....r _ .. __... _._ _ THE ~i,W Z!t C ItrCLa Vt _KATHLEEN ~. $HAUL3, ES^~. P.~. ~~~ : z~`„z,~ '?~ lei ill F~ ~~ '~ ~O ~ 3 PI~IONE t71 'T) ~;43r6655 FAX Cl'1 T3 18 ' EMAIL: JRS037CARLl3LE~SPRINTMAIL.COM Invoice submitted to: Fred B. Orris, IIl I, 2241 Waggoner's Gap Road I, Carlisle, PA 17013 ! ~I Re: Estate of Anna M. Orris Account to Date HrsJRate Amount 4/9/10 Preparation of Probate Petition; i Filing N/A $100.00 ~1 ''~ 5/5/10 Preparation of Deed and Agreement of Sale N/A $100.00 5/11/10 Recording Fees for Deed 62.00 '~ 'i 5118/10 Certification of Benefiaai Interest Notice to Beneficiary NIA 50.00 ~ ~! 8/13110 Check # 1011 (BathaviC) ($312 00) ~' 9/14/10 Preparation of Inheritance Tax ReturN I ~i Finalization of Estate 300.00 ~,'', Balance 9/14/1.0 .$300.00 ~I i cc: Susan Bathavic ' ~~ 161 Easy Road '; ~I, Carlisle, PA 17013 (717) 241-2586 I~ RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 ORRIS ANNA M Receipt Da$e,: Receipt Tirhe,: Receipt No• Estate File No.: 2010-00457 Paid By Remarks: FRED B ORRIS III DM ----------------------- - Receipt Distrib ution ----- Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 90.00 CUMBERLAND WILL 15.00 CUMBERLAND CODICIL 15.00 CUMBERLAND CODICIL 15.00 CUMBERLAND JCS FEE 23.50 BUREAU OF SHORT CERTIFICATE 16.00 CUMBERLAND AUTOMATION FEE 5.00 CUMBERLAND Check# 1620 $179.50 Total Received......... $179.50 4/30/2010 15:20:34 1060945 GENERAL FUN GENERAL FUN GENERAL FUN GENERAL FUN & CNTR M.D GENERAL FUN GENERAL FUN S. W. Barrett Raal Esbb 3 Appnissl Ssrvicss __ CUAiEiERtIIND COUNTY RECORDER OF DEEDS RECEIPT C~wlsase Last Ch~ings: KATIIL~1 iliAtA.R9 Po sox i?Z9 CARLISLE, PA 4701s Rc-cEIPT Br: courn'ER ~ DEED t~+1or - ORRIS, FRED 8 ul C,fa~Nss - &ITMAVIG, Sl1SAN MARIE CanaidarMion - 31.00 Tax saris - so.00 Relum Vla -MAIL PARCEL WENTIFICATION NUMBER 29-4;i-0425~097- Fee Dela3: SABLE HOLISNrfi FEE COUNTY RFl:ORDNiO FEE a1D+R01lFMENi' FEE -COUNTY M1i~ROVEMENTFEE-RECORDER .ICS / ATJ / CJEA FEE PARCELS FEE STATE WRIT F~ NORTH M~70LETON MUNICIPAL REALTY TAX FEE SCtIOOI DISTRICT REALTY TAX TOTAL CiiAR66S PAYMENTS CASH TOTAL PAYMENT`8 ItYOUNT DUE PAYM~IT ON NV'OICE BALANCE Due Ie~uNO DuE cASrI REwrlo 51 ! .50 541.50 52.00 S:I.OD 123.50 s4o.oo StI.50 30.00 10.00 SS'2.00 570.00 570.00 362.00 (582.00) io.o0 ~.~ lieoo1 Inst * ~ Nlst Data 90+0 a~a oanlno 9aa:~ To1ai Pates: 3 j ~: oaal eY: Icw TOYYNSHIP alt: May 11.3010 !.-3!:>I3 AM I Paps 1 ', i __ i SCHEDULEI _. T Cumberland County Pennsylvania TAX COLLECTOR COPY -RETURN WITH PAYMENT FOR PROPER CREDIT ORRIS, ANNA M 8 fRED B III 181 EASY ROAD 8 NANCY M ORRIS Acres 2.000 Dead: 00301-01193 161 EASY RD LAND LESS THAN 1 ACRE CARLISLE, PA 17013-9594 RosideMial Building Payable To: ROBIN K SOLLENBERGER 5 HILL DRIVE CARLISLE, PA 17013 Phone: (717) 249-0747 I~~~~~~~ Payable To: ROBIN K SOLLENBERGER 5 HILL DRIVE CARLISLE, PA 17013 Phone: (717) 249-0747 MAP NO: 29-05.042b-097 Dear: 181 EASY ROAD Acres 2.000 Dead: 00301-01193 LAND LESS THAN 1 ACRE Residential Building 31.00 FEE FOR ADDITIONAL RECEIPTS Tax Payer: ORRIS, ANNA M 8 FRED B III 8 NANCY M ORRIS 181 EASY RD CARLISLE, PA 17013-9594 Bill lVo: 3016 Bill Date: 3/1/10 Control No: 29000312 MAP NO: 29-05-0425-097 Assessed Value: Land: 34,520 Improvement: 85,820 Tota1:100, Discount Face Penalty COUNTY R!E 2.39900 $235.91 240.72 $284.79 COUNTY LIB .18000 $17.70 $18.08 $19.87 MUNIC. R/E TAX AMOUNT DUE If Date Of Payment Is On .88900 $87.42 3341.03 3N/10 thru 4/30/10 $89.20 SNNO t ru /30/10 $98.12 $362.78 7/1/10 or Later Office Hours: MAR,APR,JUL,AUG TOES 10-48 THUR td-8 I Bill No: 3018 MAY,JUN,SEP,OCT THURS 10-8 ' ' Bill Dats: 3/1N0 APPT ONLY JAN,FEB,NOV,DEC; CALL FO~i ', Control No: 29000312 HRS LAST WK OF DISC PHONE (717) 249-0747 Assessed Value: Land: 34,520 Improvement: 85,820 Tota1:100, i DlecouM ~ Face _ Penalty COUNTY R/E 2.39900 $235.91 .72 $284.79 COUNTY LIB .18000 $17.70 $18.08 $19.87 MUNIC. R/E .88900 $87.42 $89.20 $98.12 TAX AMOUNT DUE If Date Of Payment Is On 3341.03 3N/10 thru 4130110 5/1/10 t!hruj8J30/10 $382.78 711110 or Later TAXPAYER'S COPY -KEEP THIS PORTION FOR YOUR RECORDS ROBIN K SOLLENBERGER 5 HILL DRIVE CARLISLE, PA 17013 RETURN SERVICE REQUESTED 87110 - 4890 ORRIS, ANNA M & FRED B III ~ 8 NANCY M ORRIS ~• ~ 161 EASY RD ' CARLISLE, PA 17U13-9594 ~ ti~ Sri, ~'~ (I~NI~~~~~~~~~~ p 2, s711aR-~s9o Cumberland County Pennsylvania TAX COLLECTOR COPY -RETURN WITH PAYMENT FOR PROPER CREDIT ANNA M. ORRIS 161 EASY RD CARLISLE, PA 17013-9594 Payable To: ROBIN K SOLLENBERGER 5 HILL DRIVE CARLISLE, PA 17013 Phone: (717) 249-0747 Payable To: ROBIN K SOLLENBERGER 5 HILL DRIVE CARLISLE, PA 17013 Phone: (717) 248.0747 51.00 FEE FOR ADDITIONAL RECEIPTS Tex Psyer: ANNA M. ORRIS 181 EASY RD _ CARLISLE, PA 17013-9594 ill No: 4705 Control No: 29-002503 OCC COUNTY OF CUMBERLAND DlscouM Face ~ Penalty COUNTY PC 54.90 55.00 x5.50 TWP OF NORTH MIDDLETON MUN PC 54.90 55.00 55.50 MUN OCC 50.00 50.00 50.00 TAX AMOUNT DUE If Date Of Payment Is On 59.80 311/10 thru 4/30110 5/1/10 t ru 1 511.00 7/1/10 or Later Off~e Hours: MAR,APR,JUL,AUG TOES 10-4 & THUR 10}8 ', BIII No: 4705 MAY,JUN,SEP,OCT THURS 10-8 BIII Date: 3/1H0 APPT ONLY JAN,FEB,NOV,DEC; CALL FOI~~,' I'~, Control No: 29-002503 HRS LAST WK OF DISC PHONE (717) 249.0747 ', OCC I COUNTY OF CUMBERLAND Discount I Face Penalty COUNTY PC 54.90 !I 55.00 55.50 TWP OF NORTH MIDDLETON MUN PC 54.90 ' 155.00 $5.50 MUN OCC 50.00 50,00 50.00 TAX AMOUNT DUE If Date Of Payment Is On 59.80 3/1/10 thru 4!30/10 511/10 t I ru x/30/10 511.00 7/1/10 or Later TAXPAYER'S COPY -KEEP THIS PORTION FOR YOUR RECORDS ROBIN K SOLLENBERGER 5 HILL DRIVE CARLISLE, PA 17013 ', RETURN SERVICE REQUESTED i 87110-42825 ANNA M• ORRIS ~ 161 EASY RD ~~ CARLISLE, PA 17013-9594 IIN~IIN~IMIYN~~I~I~N~W~ '' ' s7~~aP-42e2s PO BOX 988 HARRISBURG, PA 17108-0988 2010/03/29 #IBW NMZSX #80112174000911! ANNA M ORRIS 161 EASY RD CARLISLE, PA 17013 ~~y~ ~~~;~- ~~~~~ 800 900 13 2 Hours: Mon-Thug m-10pm, Fri Sam-Spm, Sat n~-12pm (Eastern Starx~a Time) NOTICE OF COLt~E~TION [ A C tA.-L WCMMI~InIriY, ', 1f~1~ CLIENT: Cumber I n County TOTAL BALANCE U $36.00 Our clienn has referred your delinquent account(s) refererxed below for collectbn. Our client is about collecting all monies owed them and I am sure your intentbns are to honor your debt. Send payment using t e heed envebpe or you may go online to account.penncredit.com malae payment or contact our oftk;e to pay over the p ne. Contact our offk.e ff you are unable to pay the amount due. Unless you notffy this office within 30 days after receiving this notice that you dispute the validity ~ debt or any portbn thereof, this offbe wifl assume this debt is valid. If you notify this office in writing within 30 days f wing this notice that you dispute the vaNdRy of this debt or any portbn thereof, this office will obtain verifbatbn oft or obtain a copy of a judgment and mall you a copy of such judgmerk or verifk~tbn. It you request this office in writ within 30 days after receiving this notbe this office will provide you w~h the name and address of the original creditor, ff Brent from the current creditor. ~ This is an attempt to collect a debt by a debt collector and any informatbn obtained will be tared for purpose. The important rights fncluded above apply to each axount indivfdualy and you have the right to dispute or all of the accounts incitxkd in this notice. In the event you choose to exercise your important rights included please indicate which accourrt(s) you are disputing. 2008 TOWNSHIP PER CAPITA TAX NORTH MIDDLETON TOWNSHIP 2008/00/00 737475 2 8 536.00 PAlD ~ ~ ~ b CK~ DATE ~ AMOUNT 3L oo ~~~t- ~~~~c~ ~ ~ . d~~~ ~~ PO BOX 988 HARRISBURG, PA 17108-0988 800 910*1372 . Hours: Mon-Fri 8am~1 pm, Sat Sam-2pm ~~~ (Eastern St~~rd Time) `~~~oas.s #BWNMZSX ~ •~ s #601121740009# ', ', •'~,~~' ANNA M ORRIS ~Ay,~t~OM 161 EASY RD ' ' CARLISLE, PA 17013 CLIENT: Cumber I n County TOTAL BALANCE t~U $36.00 :36.00 GATE AMOI Y. _.._.-_. - ._ .... _.. . _.. _... _ _ __ __ _ __ __ ~~ Q94~17a~ w ~ ~~Sovereign Bank ~~o~cr~, c~c~x ~: ~r~a~ci~y ~~.+~~' ~csd ~~` Aunt Q~rer ~~~~~~~~w:~~~~~~~'~. ~. PAY TO THE ORDER OF ~'~~ ~.~' ~~~ ~ ~~-~~~ ~~ Drawer Soverei In nk NON ~ GOTIABLE CU MER COPY .~ pRAWEE: SpVEREiON BANK ISSUED BY: SOVEREIGN BANK ~6overeignBanl~ Me~aa Q4f 29/20.14 9t~c**'E'~~.82b.15 Account Holder: FRED ORRIS Account Nuiiii~aer: 167101Q559 _ 6 ranch Nuiiiiilber : 017 _. _ GARY BCHELBERGER CHAJRMAN~ RICHARD ROVEGNO VKE CHAIRMAN BARBARA B. CROSS SECRETARY DENNIS MARION CHIEF OPERATIONS OFFICER EDWARD SCHORPP SOLICITOR TAX CLAIM BUREAU OF CUMBERLAND COUNTY STEPHEN D. T1LEY One Courthouse Square, Room 106, Carlisle, PA 17013-3389 ASSISTANT SOLICITOR Printed: ,4/28/10 C (717)240-6366 ' Receig~t~ No.: 74764 8:22:42 Recei~t~~IDate: 4/28/2010 Control Number: 29-000312 **** RECEIPT **** Page:' ', 1 Property Desc~i~tion: ORRIS ANNA M & FRED B & NAN~Y M ORRIS 161 EASY ROAD CARLISLE PA 17013 Map No: 29-05-0425-097 III LAND LESS T 1 ACRE Residential B i ding Situs Informa i n: 161 EASY RO NORTH MIDDLET~NITOWNSHIP Tax Year Description Face Penalty & Interest ',Costs Total 2008 CTY-NORTH MIDDLETON 229.28 48.73 278 01 2008 CLB-NORTH MIDDLETON 18.06 3.91 ' ' . 21 97 2008 MUN-NORTH MIDDLETON 89.20 18.97 ' , 108 17 2008 2008 SCH-CARLISLE AREA BUREAU COSTS 1250.03 265.70 l .66 ' . 1515.73 . 13.00 8.00 Received For Year C~f'~ 2008 $1946.54 2009 CTY-NORTH MIDDLETON 240.71 29.50 I' ' 270 21 2009 CLB-NORTH MIDDLETON 18.06 2.23 ' . 20 29 2009 MUN-NORTH MIDDLETON 89.20 10.93 ' . 100 13 2009 2009 SCH-CARLISLE AREA BUREAU COSTS 1306.39 160.04 1 .00 ~ . 1466.43 ' .55 7.55 Received For Year (~fI12009 $1879.61 Tendered > CHECK Received By > JC Paid By > ORRIS, ANNA M & FRED B III Remarks > 0940756 * Continued GARY EICHELBERGER CH/iIRM~tN RICHARD ROVEGNO VICE CHAIRMAN BARBARA B.CROSS SECRETARY Printed: 4/28/10 8:22:42 DENNIS MARION CHIEF OPERATIONS OFFICER EDWARD SCHORPP SOLICITOR TAX CLAIM BUREAU OF CUMBERLAND COUNTY sTEPHEN D. TILEY One Courthouse Square, Room 106, Carlisle, PA 1 701 3-3 389 ASSISTANT SOLICITOR (717) 240-6366 TAX CLAIM RECEIPT ORRIS, ANNA M & FRED B III Receipt ~To.: 74764 Receipt bate: 4/28/2010 Page. ', 2 Tax Year Description Penalty & Face Interest s Total Balance Duei~As Of 4/28/2010 Claim Balance: .00 Receipt Number: 74764 Total Re~e~ved: $3826.15 I I ___ _ _, ra~r-~mw,.,.,....,,,,,,r._..___._. . ~. Coon .Rapids, MN 55433-586 (888) 806-9074 Phone - (763) 235-4055 Fag j x ~~. ~ ?' ~' ~ - Hours: Monday -Friday 8:OOAM to S:OOPM CST ~, Creditor: Citibank South Dakota NA Assignee of SEARS GOLD MASTERCARD Account No.: 5121070166832937 ! Reference No.: 223279 Balance: $1,550.02 `--'" '! April 7, 2010 Dear estate of ANNA ORRIS, We would like to offer cur deepest condolences during this time of loss for you and your ff amily. Thank you in advance for promptly attending to this important matter in the life of ANNA ORRIS. ~ The Citibank South Dakota NA Assignee of BARS GOT,i) ~ cTFRraun account i~ t ~ amount of $1,550.02 for ANNA ORRIS has been placed wit outer office for collection. In an effort t assist you during this d ifficult time, our client would like to extend an offer to settle the debt of ANNA ORRIS n full for $1,162.52. Upon receipt of sufficient funds, our records will be updated to reflect that the above ac~o nt has been satisfied. We are not obligated to renew this offer. The estate is liable for this debt. Payments frum survivors or the next of kin will be accepted only on a voluntary basis. Please send payment of $1,162.52 and/or the estate information using the coupon on the', r erse side no later than 05/05/2010. For your convenience, we offer you the option to pay by phone using ~ ~hecking/savings account by contacting one of our representatives at: (888) 806-9074. Very truly yours, Christina Mallen AscensionPoint Recovery Services, LLC Unless you notify this office within 30 days after receiving this notice that you dispute the Ialidity of this debt or any portion thereof, this office will assume this debt is valid. If you notify this office in v~ri 'ng within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof,'',, t 's office will obtain verification of the debt or obtain a copy of judgment and mail you a copy of such judgme'~t or verification. If you request of this office in writing within 30 days after receiving this notice this office will rovide you with the name and address of the original creditor, if different from the current creditor. This communication is from a debt collector. Tlris is an attempt to collect a debt and a~j- irrmation obtained will be used for that purpose. * * * PLEASE SEE REVERSE SIDE FOR Il1~IPORTANT INFORMAITI ABOUT YOUR RIGHTS AND THE PROBATE COUPON. * * *bN 1 N T g ICT 1 O N A L !i Thr. Association of Credit and Collection I'mfessionals PLEASE DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT I ~Wcmbe~ II I I ~! it ~I . par~-Z Estate Information Services, LLC 2323 Lake Club Drive Suite 300 Columbus, OH 43232 ® • ~ ~" „ ~:? ~ `,,,; ~T ~t~- t':iY:j ~(:' CI (4.11'El Dili X37 '+~ , ., .... Hours: Mon-Thu Toll Free: (800) 604-5435 Phone: (614) 322-2758 Fax: (614) 322-2761 wd 8 To the Family of ANNA M ORRIS 161 Easy Rd, Cazlisle, PA 1 "013-9594 ~n~~~~m~~~unn~~n~~~~~~n~~~~~~~~n~~n~~~~m~~~~~~n~~ -Fri Sam-Spm EST .probate-care.com 05/03/2010 RE Creditor Name: DISCOVER FINANCIAL SERVICES, LLC ~, Account Type: DISCOVER CARD Debtor: ANNA M ORRIS ~, Amount of Debt: $9,898.12 Reference #: 2688805 Deaz Family: I, We understand this may be a difficult time for the family. Estate Information Serviced ha been hired by our client to assist the Estate in bringing to a resolution the outstanding balance owed by the detted~ttt on the above account. Therefore, we need to receive from you pertinent estate information so that we can fil$ ar} estate claim for our client. Please call this office at the number above with this information. If the family merely wants to pay the balance on the account now, return the below pa~~ with payment of the amount referenced above, $9,898.12, and no estate claim will be filed. The>j•e liability associated with a payment. However, if an estate has been filed, at that time the estate i$'' Again we extend our deepest sympathies to the family during this difficult time. You h~° that we will do our best to make the resolution of the payment process as quick and as easy as pp~ Unless, within thirty (30) days after receipt of this notice you dispute the validity of the ~ thereof, we will assume the debt is valid. If you notify us in writing within said 30 days that the, c thereof is disputed, we will obtain verification of the debt and will mail such verification to you.:. your written request within said 30 days, we will provide the name and address of the original c>Fe from the current creditor. ' This is an attempt to collect a debt from the Estate and any information obtained will be purpose. This communication is from a debt collector. Cut along this Please Make Check Payable To: DISCOVER FINANCIAL SERVICES, LLC Mail Payment To: Estate Information Services, LLC. 2323 Lake Club Drive, Suite 300 Columbus, OH 43232 Debtor Name: ANNA ORRIS Reference #: 2688805 Amount Due: $9,898.12 See Reverse Side for Special State Disclosures nt coupon along r<o personal our commitment it, or any portion ~f or any portion addition, upon qr if different for that ~JCJ- Z ~ ~ ~~~ I P.O. Box 837 Newtown, CT x'70 Change Service Requested February 8, 2010 PERSONAL & CONFIDENTIAL #BWNLPGJ #0654 2700 0992 5460# Im111u~116nnd1u11~I~ImIJdJu~lnhllun~lhlull ~ Orris, Anna 23926425 0 161 Easy Rd Carlisle, PA 17013-9594 P.O. Bo~C 837 Newtown, CST 06470 (800)~Sa-6343 Fax (203) 4I~6-9630 EAS Account Number: 23 Creditor #: 374816- 1 Creditor: Comcast Hanisbi Notice D e ruarv . . Service Balance Dued'$ 152.43 Equipment Balance (i~ not returned): $ 0.00 Total Balance Due: $152.43 * * * FINAL NOTICE * * * Our records indicate that you owe $152.43 which is long past due. Pay this account immediately. This is absolutely final. * * IMPORTANT To be sure of proper credit and to stop further procedure make your payment in full. This is an attempt to collect a debt. Any information obtained from you or anyone else w~ll be used for that purpose. This communication has been sent by a debt collector. - -Detach and Return with Payment-------------- ---------------------------____ Enter the requested information in the spaces provided below: Change of Address: For: Anna Orris Street Address: City, State, Zip: Telephone: Eastern Account System of Connecticut, Inc. P.O. Box 837 Newtown, CT 06470-0837 IIh~~~Ih~d~JI~~~IIh~~Ih~d~~6~J66~~6~161~~~Lh61 So~v~ Z Pa~-1- 2 #~ EASTERN ACCOUNT SYSTEM OF CONNEC~'ICUT, INC. New York License # 1244261 Creditor #: 374816- 1 Creditor. Comcast Harrisburg Notice Date: February 8, 2bj1( EAS Account Number: 23926 Service Balance Due:: Equipment Balance (ii Total Balance Due: $ Amount Enclosed: $ Please charge to my []visa Card Number Expiration Date Name of Cardholder _ Signature Enclosing t ~s nonce wit account. X25 $ 152.43 not returned): $ 0.00 152.43 []American Express []Discover your • • _._: ~111(]t1G@d CE~CflV~r~I~,.,.--~ Statement Date: Februa 23, 2010 corpflra~llfln ry Creditor: ENTURYLINK Original Creditor: m a~6 rq Account Number: 7172432192672 ' Amount of Debt:;92.08 Reference Number. 28231588 Dear Anna M Orris, j This letter is to inform you that the above referenced account has not been paid and has been placed with dur }Il.dmpan for collection procedures. r y Please remit the Amount of Debt listed above or contact our office to discuss the account. I'I Telephone: (800) 326-1755 Toll Free; Fax: (904) 645-3009 III! i ® Send correspondence to: Enhanced Recovery Corporation, 8014 Bayberry Rd, Jacksonville, FL ~i2256-7412 8 Pay online by check or credit card at www.oa~rc.com. All transactions secured through Veri$ig II © Office Hours (Eastern Time): Mon -Thu, 8:00 am - 9:00 pm; Fri: 8:00 am - 5:00 pm; Sat: 8:00' a -12:00 pm Sincerely, '~ dad A. Daniels, Recovery Specialist i, ~i P.S. We are very interested in helping you resolve this debt in a manner that suits your financial situation. Iii This is an attempt to collect a debt. Any information obtained will be used for tltlat urpose. BBB., ' NOTICE -SEE REVERSE SIDE FOR IMPORTANT NOTICES AND CONSUMER Itl HTS "°""""'" Please do not send correspondence to this address. I~~~~~~ PO Box 1967 Southgate, MI 48195-0967 February 23, 2010 EM61P1CL1/1/ 202174598039 000486910021 'lllllllll~~~~~l~~lll~l~l~~~llllll~ll~l~l~lll~ll~l~lllll~'~'I"I Anna M Orris 161 Easy Rd Carlisle, PA 17013-9594 IF PAYING BY CRED C D, FILL OUT BELOW. O ^ i -, ^~. CARD NUA6ER CC SIGNATURE EXP. DATE REFERENCE NUMBER 28231588 PAX TN $ Al10UNT 208 AM U t $ Make Payment Tb: Enhanced Recovery Corporation 8014 Bayberry Rd. II Jacksonville, FL 32257412 I~~IL~~IJ~~I~I~I~I~~~I~ I~~~IJ~~I~~JL~I~IL~1~1 SGhc .1`_ Z ~.~"' IlPeck,s Septic 3ervice~~ ~~68 Pine School Road ~~ ~~Gardners Pa. 17324 ~~ ~~ (717) -486-5548 ~~ n n CUSTOMER BILLING MRS ANNA ORRIS 161 EASY ROAD CARLISLE PA 17013 PAID - CK~ G~ ~-~ DATE ~-G~ AMOUNfi ~ ~ = 1 .... ~~ ~~ ' ~~ ~' ~~ ~ i (I ~~ BILLING INFORMATION ~~ I' r ~~ ~~ ~~ ~~ ~ it ~~Previous Date Pumped: !II 5/25/2004I~ ~~Date Pumped: I 3/9/2009~~ ~~Billing Date: ''~~ 3/12/2009~~ ~~Pumping Charge: $165.OOII II Labor Charcre : $ 0 . 0 0 ~~ ~IMaterial Charge: ', ', ~ ~ $O.OOII it ~ ~I Service Charge : $ 0 . 0 0 II I~Total Due: 10$ Added After 30 Daysl~ ~ j $165.OOI~ ~~ ~ ~ ~~ i~IORR DONE I II*************** (PUMPED SEPTIC TANK, LOCATED AT) ***'*I I ********* ~~ il II*************** (161 EASY ROAD,CARLISLE)*********** ~~ I~NORTH MIDDLETON TOWNSHIP INSPECTION. ~~ (~ THANK YOU . ', I ~~ I ~~ ~' ~~***************** *****i*I THANK YOU, PLEASE CALL AGAIN ~~ *;******** ~~ ~~Next Scheduled Pumping: 3/8/2012~~ ~~(Please call 1 month ahead if you would like to sch~ Ile) ~~ r---~ ~) ~I PECKS SEPTIC SERVICE, SERVING THE COMMUNITY S~ ~~ CIE 1968 ~~ ~~ ~ ~ THANK YOU FOR LETTING US SERVE YOU.,; ~~ ~ ~ ~~ I Pa ~oX eoso Hauppauge, NY 11788-0154 FORWAR© SERVICE REQUESTED __ _ _ _ _ PAID ~ ~ 3 ~ ~~.~,_ CK# Ib DATE ~ ER So1u ~r~ouwT D 3 Po BoX Mon-Thu 7A~ G-14312831-G115 330989146 'lu'l'11~'lllll"11'rlt~hlllll'~~H11hl~t~l~~lyii~:u~lll~ l~l Date: 05/05!2010 Anna M Orris Creditor: t3ank Of 161 Easy Rd Client Account #: Carlisle PA 17013-9594 ERS Account.#: Total i i ,~!,Inc.'800 SW 39th St. i -Renton, WA 98057 ~: ISM, Fri & Sat 7AM-11AM i MST '' $ 809.23 $.809.23 Dear Anna M Orris: Your past due account with l~ fJ€Ame~ica in ttre amraurtt of $ 8Q9.23 remains unpaid and we would tike to offer our assistance. Our client and sun ers a~ that financial hardship Can occur to anyone at anytime. In an effort to help you resolve this debt, we are pleased io inform you. that you may be eligible for one of the': following optional solutions: 1. A settlement on your accounf. 2. A temporary monthly payment plan.. I I We appreciate your immediate .attention to this matter and strop advise that ~ 9-y you take advantage of one of'the above opportunities. To take advantage of this opportunity, pieiase coq >~8$-SQ5-0035. Please contact our office within the next 15 days to take advantage of this offer. This is an attempt to collect a debt and any. information obtained ~viH be used for that .purpose. This comiinunication is from a debt collector. Sir-cerely, Ben Hamilton, 88&505-0035 Debt Collector ~~,ol,,,~lc. z --------------------------------------------------------------------------- MESSAGES EXPLAINED ~ BELOW *** Your Account Balance is Overdue! Please make Payment Immediately!!! *** *** ANY ~UESTIC)NS~ REGARDING YOUR BILL PLEA~E CALL (717) 731-8315 *** ********* *****s:* ************************* ************* ********* ******* ********~~* 06/10/09 1 10 TRANSTELEPHONIC PACER CHK 93293 426.0 40.00 07/13/09 Medicare Payment 13.33 07/13/09 . Accept Assign Add. -23.34 09/17/09 Cash Payment 3.~3 0.00 09/17/09 1 17 L PROGRAM EVAL PACER, DUAL 93280 426.0 135.00 10/05/09 Medicare Payment 50.,74 10/05/09 , Accept Assign Add. ', -71.58 12.68* 09/23/09 1 58 L HOSPITAL CONSULT INITIAL 99254 780.2 225.00 ' 10/15/09 - Medicare Payment 110.58 10/15/09 . _ Accept Assign Add. I -86.65 27.67* 09/23/09 1 108 L ECHO (2D) COMPLETE, HOSPI 93306 780.2 160.00 10/14/09 Medicare Payment - 56.0 10/14/09 . Accept Assign Add. -89.87 14.03* PAI C~ 1 ~ ~ Z ~, CK# .., DAl'E .~' ~„ ~ O ' AM~UNT,~? .~ L-The 'PLEASE PAY' :includes unpaid co-pay or co-ins. Please make payment. DATE LAST PAID AMOUNT 09/17/09 3.33 0.00 0.00 54.38 0.00 0.00 O.Op 0.00 54.38 , MAKE MOFFITT HEART & VASCULAR GROUP CHECK 1000 NORTH FRONT STREET PArABLETO: WORMLEYSBI7RG, PA 17043 PAT~~ 1-ANNA ORRIS PRV~~ 10-LINE, DENNIS E, MD, FACC PRV~~ 17-RADTKE, NANCY, MD, FACC PRV~~ 58-ERNST, CRAIG, PA PRV~~108-ISKANDAR, EMAD, D.O. • r.. ~ R I 1 S4.38* Ph:(717)-731-0101 Acct~~: 179479 Date: 12/24/09 ~ Page 1 of 1 G16TCE01 R1001001UD10117001'TCE' CAMP 1-~ILL EMERGENCY PHYSICIA PO BOX 13693 PHILADELPHIA, PA 1 91 01-3693 0 N m ~ihlur~i~llilll~r~~l~l~ll~hlli~~ilii~ll"~uihidl~ll~lli~t 082516-0000035522085-06 #BVVNJF'DB #OOOODOHYP2991507# ANNA M ORRIS 161 EA~~Y RD CARLISLE PA 17013-9594 _ _ _T ,_ - - STATEMENT OF ACCOUNT (4) Statement Date: April 144, 2010 ACCOUNT NUMBER: HYP35522085 Patient Name: ANNA M ORRIS Tax ID #: 20-4667340 Account Balance: $33.81 Amount Pending Insurance: $0.00 Amount Due From Patient (Current): $0.00 Amount Due From Patient (Past Due): $33.81. (Pay This Amount: ;33.81 YOUR ACCOUNT IS NOW SERIOUSLY PAST DUE, AND iA 0 LINQUENCY REVIEW iS BEING GON UCTED. Please refer to coupon belo for payment instructio s. Accou Date nr u # era~i Description Charge Paid By First Ins. Paid By Other Ins. Paid By Patient Amount Ad' sled D e Frem In$urance PATIENT BALANCE 09x22109 1 99285 EMERGENCY EVAL & MGMT 3962.00 ~, (LVL 5} 2 DR. PAUUHOLY SPIRIT HOSPITAL DX'7t30 11/13/09 . BLUE SHIELD CLAIM DENIED • ~-0'~ 121:x1109 12/30/09 COVERAGE TERh11NATED MEGICARI= CONTRACTUAL ALLOV1fAIVCE MEDICAR'= PAYMENT i $-135.23 S'92 90' ,533.531 il~i`~ri~ j ~ .Z c~# DATE ~ .'G AMOUNT 3 I i ~ TOTAtS: 3962.00 50.00 5-135.23 50.00 ~-792 96 $O t30 333.81 Important Mesaages: This statement 5 for the drreK treatment and/or supervision of care you recently received from an Emergency Hhysiaan at Holy Spirit Hospital. The f@es fdrr this private physician are billed separatey From any hospital charges or other professional fees for which you may also be responsible. Therefore, should you receive a bill fromthe hosptal or other physicians for charges in connectbn with this visd, it will not include the items listed on this statement. "Payment Plans" Accepted Questions about this statement? ! Llame de Lunes a Viernes? Call 1-800-355-2470 Monday through Friday 9:30AM - 4:OOPM. Your automated system access code Is 0801-35522085, or you can send dmi~lit to billing_questionsuva emcare.com. .Al..l. ~~~~ Pam 2. -~© Y P AL The Spirit of Caring Holy Spirit Hospital 503 N 21ST STREET CAMP HILL PA 17011 717-763-2138 For Acoo~mt Ia/brmatiain, Please Call 7i7-763-2138 N 0 ~. .o r ~~ if#lf ACt , ~~ «'~~ T ~ -- - Traasactiaa Date .'xx - Descriptioe ~ !~ ! R ~. Anwunt PREVIOUS BALANCE 19,014.70 10/01/09 10/21/09 MED C/A HOSP-IP MEDI PYMT-HOSP IP M90 M90 MEDICARE MEDICARE I/P ~ I/P ~I -13,042.03 10/21/09 MEDI C/A HOSP-IP M90 MEDICARE I/P -4,922.83 -12 879 87 10/21/09 12/18/09 MED C/A HOSP-IP M90 MEDICARE I/P I , . 13,042.03 12/18/09 MEDI PART B PYMT-IP MEDI PART B C/A-IP M90 M90 MEDICARE MEDICARE I/P i I/P i -28.36 I I ~' -108.56 Due: .00 otal Patient Cttidits : i ~I ~' I I Aooouat 73A8 M90 MEDICARE I/P .00 II PLEASE DISREGARD THIS STATEMENT IF YOU HAVE PAID. 35522085 HOLY SPIRIT HOSPITAL S03 N 21ST STREET CAMP HILL PA 17011 ADDRESS SERVICE REQUESTED ADM DT: 082309 $5 DSH DT: 092809 ~~ ~tO~ s6: 21020 ORRIS ,ANNA M 7, ~-243~5'19a a ^ bee: MR:818696 584.9 hCa.~rkha0ongetl P/~se~rr~ek ohen~8esura~ i~nkormation Make Check Payable To: HOLY SPIRIT HOSPITAL • Tba CV{r1 Number is the Fett 3 disks on tAa beds of your credit nM, bq Yo sisnuuro 00019018 001 0.53 35522085 ANNA M ORRIS 161 EASY RD CARLISLE PA 17013-9594 I~~dlil.l~~~~~lll~.l~~~l~ll HOLY SPIRIT HOSPTTAtI_ P.O. BOX 822183 PHILADELPHIA,PA 191$2 0000355220850000000010750bOD100735000D00D11304 01/22/10 83 ~./ ~- t ~~~ Z. STATEMENT OF PHYSICIAN SERVICES SPIRIT PHYSICAN SERVICEES 205 GRANDVIEW AVE STE 2"10 CAMP HILL PA 17011 ANNA ORRIS 161 EASY RD CARLISLE PA 170139594 ACCOUNT # 1783669 ~~~~: ~ ~~ ~u~~' ~~~a i dh'~f' _ h~Yl'~ ~ ~ 2~ 2 STATEMENT DATE: 04/17/1 ~ LAST STATEMENT DATE: 03/13/10 ~-€~° IF ANY QUESTIONS, PLEASE I~NTACr: SPIRIT PHYSICIAN SERVES 717-972fa1490 jFED TAX ID #251766971 DATE PRD~DtIRE 4~G' CORE CODE ~ DESCRIF+I'K~N 1NB CFE PAYIif~'! " CUA,R~IM'roR . :: At~lU~8 tiYflaNT E3AL,A1~1+CE 11/1Ql09 !CARE ERA. CONTR/ADJ 7.3D- 1]llOJ09 MGAItE ERA XFER 13.14 PERFORMED AT: HS 10/2L04 94238 276.1 IQSPITAL DLSCHAR6E c~ IQ 100L01~ 1L10l09 MCARE ERA PMT ~ b2.10- 11/10/04 ICARE ERA CONTR/ADJ 34.87- 11/1Q/04 _ -- --_- ----- -- MCARE ERA XFER ~ 13.03 ME NAVE NDT RECEIVED YOUR PAYMENT. T'IEREFORE, ME HAVE ND CNDICE. NE NILL BE 'RBBQJ~G THIS BALANCE OVER TO OUR COLLECTIaI AGENCY AND NAVE BEGUN PIIDf~EDIN6S TD DISCMAI~E YOU AND Y'QAI FAMILY FROM DUR FAMILY IEALTH SYSTEM. w e e 0 :IeesIT1ESE SERVICES HERE PRDVIOED BY SPIRIT PMfSICIAN lase! Ieee44ERVICES AND ARE SEPARATE FN011 ANY HOSPITAL FEES IeeeE ~eeelpl.EASE CALL 717-472afi490 NIT'N ANY QUESTIa6 !seal Ieee~COB:EI~~ TTF.SE CHAIlsES. 9ee61 $I2 SPIRIT PHYSICIAN SERVICES 206 GRANDVIEW AVE (HP) S'iE Z10 CAMP HILL PA 17011 I,,,lil~„III,,,,,.II,,,IN,.,,111,,,111,,,1„I„II„II,„I„I,I ~~~ SPIRIT PHYSICIAN SERVICES ra 205 6RANDVIEW AVE STE 210 CAMP HILL PA 17011 OEf~CE USE ONLY STATEMENT DATE: GUARANTOR EE NS161LITY: OM17/10 S 1 ~B. 0000.1514 ANNA ORRIS 161 EASY RD CARLISLE PA 170113-9594 F'OR CREDR CARD PAYMENT, PLEASE RLL IN INR9RMAT1011 BELOII CHECK ORE I I I I ~ I ~ I' ~ ~ I I' I I M/C CARD NUMBER EXP DATE VISA HC: 1230 I CARDHOLDER NAME (PRINT) CREDIT CARD SIGNATURE CHECK BOX AND ENTER ANY ADDRESS OR IN6URANCE CORRECTKIH$ 1 MINIMUM PAYMENT: 176.E 02 SERVICES ~ :, aw~:...~,.~t.. 6 :. ~~".':~r~+~i~,.8'„`,~~ ;,:._ - v'I::i~.,4~~"h:...r,~.axk~';~*tm.°.".t„a.+':Y,fk~tiELr7 STATEMENT OF PHYSICIAN SERVICES . ~ ~ "~ ~ ~' ~"4~a~ .tzi ~ l~ I i 4 k ~ ~~tq ~A v °r. ~l .~E'n,...~~~.~d..su>M*.t ivF^I~.~n~`~~M~+v-'~~GeAS~1f,.b~.fk~~.!~u~a~.~~4 SPIRIT PHYSICIAN SERVICEES ANNA ORRIS 205 GRANDVIEW AYE STE x'10 161 EASY RD CAMP HILL PA 77011 CARLISLE PA 17013-9594 ACCOUNT # 1783869 E~- IF ANY QUESTIONS, PLEASE I~ONTACT: SPIRIT PHYSICIAN SERVICES 71T--972-4490 DATE 'PROCEDURE DltlG QN DESCRIPTION CQDE GQ DE >» PATIENT: ANNA DRRIS 1783864 _. Vr ~AtY~ ~rro'i'~Yr'cis+.n!,cx:.Mamax.iv„~i~.,.a.uvn......r-a~..a,~n ~aexa 1~2 STATE~AENT naTE: 04/17/10 LAST STATEIMENT ou-rE: 03/13/10 FED TAX ID #251766071 INS CHARGE PAYMENTS GUARAIY1iDR kDJLtST~iIENT $ALAI~ICE PERFORMED BY: AHUTI DESAI MD PLACE OF SVC: 21 PERFORMED AT: HS D9/23/04 94223 780.2 INITIAL IDSP CARE LEVEL T 194.00 1QJ14/09 MCARE ERA PMf 10/19/D9 MCARE ERA CONTR/ADJ 10/19/04 MCARE ERA XFER PERFORMED BY: CHRIS KAIR.ENBORN MD MD PERFORMED AT: HS 09/24/09 94232 780.2 StA3SBQUENf HOSP, LEVEL II 73.00 10/19/09 MCARE ERA PMT 10114/09 MCARE ERA CONTRlADJ 1Q/14/09 MCARE ERA XFER PERFORMED BY: RASHID AI~Llu! MD MD PERFORMED AT: NS D9/2S/09 99232 780.2 SISSEI~IJENT IQ"P, LEVEL II 73.00 10/19/09 MCARE ERA PKf 10/19/09 MCARE ERA,CONTR/ADJ 10/19/04 MCARE ERA XFER PERFORMED AT: HS 09/27/04 94232 401.9 StJ8SEQIAENT IRSPs LEVEL II 73.00 10/19/09 MCARE ERA PMT 10/14/09 MCARE ERA CQNi'R/AOJ 10/14/09 MCARE ERA XFER PERFDRED AT: ILS 09/ffi/09 94238 401.9 H06PITAL DISCHARGE c30 MI 1D0.00 ~ 10119/09 MCARE ERA PMT 0 1Q/19/04 MCARE ERA Cl~ITRlADJ m 10/14/04 MCAItE ERA XFER PERFORMED BY: SHANJAHAN MDLLA MD MD PLACE OF SVC: 21 PERFORMED AT: HS 10/17/09 99223 274.1 INITIAL HDSP CARE LEVEL I 196.00 11/10/09 MCARE ERA PMT 11/10/09 MCARE ERA Call'R/ADJ 1L10/04 MCARE ERA XFER PERFORMED AT: MIS 10/],8/09 44232 276.1 ANT HOSP, LEVEL II ~.Op 11/10/04 MCARE ERA PMT 1L1Q109 MCARE ERA CON1'R/ADJ 11/10/09 MCARE ERA XFER PERFORMED AT: HS 1N19/09 94232 276.1 SIIB.SEQUENf HDSPs LEVEL II 73.00 1L10/09 MCARE ERA PNT 1L1Q/09 MCARE ERA C0N1'R/AOJ 1L10/09 MCARE ERA XFER PERFOIil~D BY: SMAANALATNA NEEgA !D !0 PERFORED Ar: HS 1N20/04 44232 276.1 SlBSEQUENf MDSPs LEVEL II ~.OO 1L10104 . ~ MCARE ERA PMT ~ CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK 142.21- 20.24- 35.5,5 52.56- 7.30- 13.14 5P.56- 7.30- 13.14 52.56- 7.30- 13.14 52.10- 34.87- 13.03 1412.21- 20.24- 35.55 52.56- 7.30- 13.14 52.56- 7.30- 13.14 52.56- - ,~~ f~~„ - C)iZT't-K)i'°'F:i;)if: tlv~"C`iTCJ'i'l='; STATEMENT ADDRESSEE: ~m~~~nr~~~nun~~n~~~~n~~~ Orris, Anna M 161 Easy Road Carlisle, PA 17013 IF PAYING BY CREDR CARD, FILL GUT BELOW CHECK CARD USING FOR PAYMENT DISCOVER' MASTERCARD I..~J VISA CARD NUMBER AMOUNT SIGNATURE EXP. DATE STATEMENT DATE 04/26/10 PAY THIS' $74.'98'' UNT ACCOUNT NBR 213672 SH PAI .AMOUNT HERE $ REMIT T0: Orthopedic Institute Of PA 3399 Trindle Road Camp Hill, PA 17011 I ^ Please check box if above address is incorrect ar insurance information has changed, and PLEASE DETACH AND RETURN TOP PbR#ION WITH YOUR PAYMENT indicate chanoe!s) nn reverse side. (717)761-5530 ~ DATE DESCRIPTION OF SERVICE AMOUNT f~A S NCE BALANCE BALANCE 1fl/71R1Q CWCn1IUTCO ~~s~ne~sn ran emu... . _____._ _. .__... ~.. .~....-~ ...... •.v~r mV. X71 GYGA '~~cG'1: 1T.....pA .~.,~liL., ?l~~.F ...ieSlClQ.Qit3A~-i ~LT~9. - ~r)'W~IIFJI#rMrl~.hi l+ ~0~1,4 '" '.-. 12/07!09 Medi Pa (PR2 Coinsurance Amount)) ~ °' ~ ~ `mil ~~. h ~ ; xe Y -$272.54 __ ENCOUNTER TOTAL $68.14 $0.00 $68 14 $68.14 UL ._, a.r '~ .t St~9 ~ '~ S. r s ~f~.+„rh'a a, .. Ri nt. ~~,n' - 1.... r"~:.~ 11/19/09 ENCOUNTER 1750030 FOR ANNA WITH DAHL DO RAYMOND E ~ ~ ,~, . , ~: ~#f ` 1.1/19/09 73510 -X-RAY EXAM OF HIP ~ $72.00 $6.84 .~~ 1F~ ~ 3 rh` ~~.' .. ., .. ... ~.. ,, M9... _ ' nv .. ~" I ,~ ~ , I02/05!10 Medi Pa PR2 (Coinsurance Amount _$27 ~'`' ` " '~' - r ~~_ e _ .m ~ l~~Q~~~___ Cpl . ~. - .,~~g ~~~'~:~r ~ ~' ~ - _ ~IF~1~ ti ~ t r 4 r s t ~- .. a r c~ ~ t~ s. d ~t ~+~ ~~~t(~~'7r<.~3Y11A°~r.~-~. t- ~~~~'~fS~ '".~.in~.~,~ ~i. ..~ .. - --- - ~~ ... .. .. ,~ _ .':.. ~,~ t35 !.~ ~"M~:. ~.4~G~+.~cZk!['i.d~6/..~ ,FA3~,.' - if -~ ~ .'~:~`~ f 7.'~~a'`"~. StfTrt. ';"..'~~2~~~~'y~i k ,~r~ %`~~4~1 'T d ~' ~: S ... ~. ;_~.. _,. _, _k ~.. w . ~~ :. ~ ,.~l~F~t:h~~.. F,~.L ',.j t~~.nti:.zu'v ~.7t:'"~.e~r~~, .. AC~.'s.~.,.rd`~.. T~M~'s~Sl'... ~~ .. .-~!. _ . L i. .- ... _ _. .. .. _. .~._ ,_ a ;.\, ~..,{ ~.. .. ~kr.r..n-` .~,t~~}iEYL.ISE'G2r~tr +~'ik., ~~~,y~.~~At:1~ ~a+Yra1 ~;:S,`~7~~'_'~.."~!~~i"~~^~'+~rs'it~;iS~~y(~~iv, ",n ,';4~y.:~1d,~~k?,~-ltf{l. 2 ,,. ...~.. !~',-_. "''``.. ~,~ _. 4'..n ..°~i ...a. ~., ir.+~la~~~+J~'iY;'n/., I*~~'if<io~~`nkfll-~[_}?iis'~kC:~A: '~~+~.b,.`.r~3k:~~~.~:~ L'.1~1a"~)~:.. f'[~~~'_*~ _*n -. ~... ,v'. sic.: .w~4~:'S~ ~z~,. `~*~r ~'_~ r ~~.;oy'r`~,~~~rrv~: xrh,;'yx,''_~S:'.{1,.~.:i~i;.~"'~'C~'^cy.~..~.'~::'. ~_:# ~s?~~''~ '.~S/ ry: i`.ll ~~~ 4.rti~~ ,J 4 ref u' Tom.:-r ~4. ,: _ ~ _ _ ACCOUNT NBR CURRENT 30 DAYS 60 DAYS 90 DAYS 120 DAY`S T~TAL ACCOUNT SALANCE 213672 I $0.00 I $0.00. I $6.84 I $0.00 I $68.14 I ', $74.98 MESSAGE: If You Have Questions Call 717-761-5530, Option 3 PLEASEi, P Y THIS AIiiNO MT ~»u~ $74.98 ** PAYMENT DUE UPON RECEIPT * THANK YOU ** STATEMENT PAGE: 1 __ _ _ _ i __ ~ _ Patient: ANNA M ORRIS ...;~ ~~:.~~- - Account: 188881 Services Rendered At: HOLY' SPIRIT HOSPITAL Date Code Description _ __ Charge__' Adjustment 9/22/2009 70450 CT SCAN BRAIN WJO CONTRAST 198.00 10/29/2009 PMT MEDICARE PART B 34.31 10/29/2009 CR Adjustment MEDICARE PART B 155.11 9/22/2009 72125 CT CERV SPINE WO CONTRAST 238.00 10/29!2009 PMT MEDICARE PART B 46.5 10/29/2009 CR Adjustment MEDICARE PART B 179.8 9/22/2009 71020 CHEST 2 VIEWS PA & LATERAL I 45.00 10/29/2009 PMT MEDICARE PART B L 8.7`- 10/29/2009 CR Adjustment MEDICARE PART B ~ 34.0 9/22/2009 73030 SHOULDER MIN 2 VWS I~ 38.00 10129!2009 PMT MEDICARE PART B ' I 7.3: 10/29/2009 CR Adjustment MEDICARE PART B I 26.7: 10/17/2009 71010 ~ CHEST SINGLE VIEW FRONTAL I, 36.00 11/30/2009 PMT MEDICARE PART B 7.1i 11/30/2009 CR Adjustment MEDICARE PART B ~ ~~°, ~ 27.1' 10/17/2009 73510 HIP COMPLETE MIN 2 VIEWS I 43.00 11/30/2009 PMT MEDICARE PART B ~~~~ -"-'-- ~` ~ ' 8.5~ 11/30/2009 "?~ - ~ CR Adjustment MEDICARE PART B i~;~,,T~ ~ ~• 32.3 10N7/2009 70450 CT SCAN BRAIN W/O CONTRAST ~, ~' I 1NT ~N:?l 198.00 11/30!2009 . PMT MEDICARE PART B Ii 34.3 11/30/2009 CR Adjustment MEDICARE PART B I 155.1 10!17/2009 73550 FEMUR AP 8 LATERAL I 35.00 11/30/2009 PMT MEDICARE PART B 6.8' 11/30!2009 CR Adjustment MEDICARE PART B ', 26.4 10/20/2009 73000 CLAVICLE L 32.00 11/30/2009 PMT MEDICARE PART 8 6.5 11/30/2009 CR Adjustment MEDICARE PART B 23.8 Current 31 - 80 61 - 90 91 -120 0.00 0.00 40.07 0.00 Over 120 ~ I BAL 0.00 PAY DUE YOUR ACCOUNT BALANCE REMAINS UNPAID. PLEASE For billing quesdior~s call: (717)932-5955 REMIT BALANCE IN FULL, THANK YOU. ~~ or: (877)932-5955 Fax: (717}932-4856 Office Hours: 8:100 AM - 4:30 PM Tax ID: 2$192806 STATEMENT SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION ~~TO-'1742 r~ease ssetacn ane~ reiu_rn oor~c~m .~oni~n wrm vour ~avmenr m the dnc sea enveloue GUARANTOR NAME AND ADDRESS sP~,rMww ort oMOOV~ ru.ouraaow ANNA M ORRIS ~ ~ ~ ~ ~] 161 EASY RD wlo o~.ol~. CARLISLE PA 17013-9594 IMIiE I -g13T MK;LUDE 3 DIGIT SEGIHITY G1DF. fND1A Final Notice Date: 2/18/2010 Patient Name: ANNA M ORRIS Account #: 168881 Balance Due: 540.07 I Remit To: Quantum Ima ~ in and Therapeutic Associates P O Box 62 l6 Baltimore, 2 264-2165 I~~I~I~~~II~~I~I~II~~~I ~I~~I~I~~~II~II~~~I~I~~II~~~I~I~II~~~I (~~~~~~~~~~~~ 19Q72 - 36 __ I - _ _ _ _. _ _ _~_ ~ ' 007852 858HMA 000048E RC~~A` RLI~S'LE 1 ~L.V~~I WlL 45 Sprint Drive MEDICAL CENTER Carlisle, PA 17013 ADDRESS SERVICE REQUESTED ' ~ tt ~~~~UPON RECEIPT Anna M Orris 161 Easy Rd Carlisle PA 17013 (u~ll~~urr~~~nnu~~u~~r,~i~n~~r~~~~~ur~n~~~~nnri~r~u~~ IF PAYING BY CREDIT CARD, FILL OUT BELOW AND SEE REVERSE SIDE CHECK CARD USING FOR PAYMENT ^ CI ~ ^ ^ MASTERCARD DISCOVER ~ ,.~~ VISA AMERICAN EXPRESS ACCOUNT NO. STATEMENT CIATE BALANCE DUE ~ ~ ~ II 7969659 01/11/2010 $7.45 MAKE CHECKS PAYABLE TO: CARLISLE REGIONAL MEDICAL CENTER P.O. BOX 281442 ATLANTA GA 30384-1442 ~u~~r~~nnr~~i~n~u~u~n~~~r~n~r~u~u~~~r~n~u~r~r~~~i~ 00000796965900000000745ANNA M ORRIS 5 ^ Please check if above address is incorrect and indicate change on reverse side. TO INSURE PROPER CREOIT, DETACH AND RETURN THIS PORTION IN THE ENCLOSED ENVELOPE. PATIENT NAME PATIENT ACC LINT N0. DATE OF SERVICE TYPE OF SERVICE Anna M Orris 7969659 12/17/2009 OUTPATIENT DATE DESCRIPTION PAYMENT/ADJUSTMENTS OTHER TREATMENT 01/05/10 MEDICARE DISCOUNT 125.84- 01/05/10 MEDICARE PAYMENT 29 82- PAYMENTS AND CHARGES RECEIVED AFTER THE STATEMENT DATE WILL BE REFLECTED ON THE NEXT STATEMENT. ; $7.45 MESSAGES The amount shown on this statement is outstanding at FOR BILLING QUESTIONS, PLEASE CALL: this time. Your prompt payment will be greatly (717) 960-1680 ~ appreciated. ~: ~0 ~ 3.~ -T Bills can be paid online at our hospital Internet web site p~ fi www.carlislermc.com PON RECEIPT ~~ o s / 01 / 1 o iiaLTi x~-~aai~~rr ~-SSOCxaTiS ' aao s coxa : a 5 • accoIIxs *:~~~ axsca~-Aai ~-ccovi~ra Ascaxv~-iLa AicoAa PAT xAi: s OAAZS • 33~A x ADILIT s 13 / 10 / 0 t !*=AL CLiSS t 7C = OiAA xa1~i s OAA= S • 33iSA K DI SCiA7tQi s 13 / 10 / 0 S C •'1'7tAC'1' lAiQ s S S'1'Aii'1' s 161 i~-SY AD Ll-S'1' PAY s 13 / 9 3 / O 9 1fA=L Ai'1'IIAA s ADaA-3s PAOQ~: 'I PAT 'PYPis sl C='1'Y s CA7tLI SLi PA 17 O l3 COisA7-CT s . 0 0 PAT S!Z s ! PsOxi s _ (717) 3 S 3 - 519 8 COII1P1'7tY s IIS CIIAA iAL s . O.{~ a1-A SiZ s ! i1fPLOYiAS Ai'i'IAiD 300* '1'0'1' Ci7-7tQiSs 3,155.6 AOiACY CACLs CSA COai aA'1'i S1~SII1t~Ci is 900 09/03/09 335.03 COai PL7-ffi Da'Pi *T fL' POLE=C'" fir 3s ZOO 09/03/09 395.03- ,is 300 1~CA 09/03/09 3, 155'~P YifNA00985s3300 3: 97• 10/07/09 50.00- 3s as 973 13/39/09 25.00 3s S: 150 19/33/09 35.00- LS'1' ACTAs lC7[ Oi/93~09 3s 'L 03/33/09 P7-Y ~-IID is W 08/15/09 s: S 03/09/09 PAOCiSS AsYIlN P1-Y ~-IIa 3s Z: OS/06/09 5s 'S 03/09/09 DA'l'i IISiA DA'Bi Ot/35/09 ASi'1' 00/00/00 lit3a 1~ ii 6159. 66SOi 08/93/09 ASi'1' 00/00/00 15:35 ist~r •999 •t '1'O9PLLCA isad~ 09/33/09 ASi'1' 00/00/00 15s35 i5f070s3a9 61596 5616 06/30/09 A=t 00/00/00 sO[L-1p-Cilxi 1OSS1-fii Li!'1' (717-3s3-'.~1 i (CO1~'1') (CII) lat 1~IIP, 3~P'P, 3~fi1-A, *~=lfS, S~IIa, 6~i=S, 7~A'1'i, S~CI!'PI, 9~CK'1'V, lO~Di'1', ~1 LOO, 13•AaJ, iA'1'~!M o s / 01 / 1 o ss~-s~TS x~-~~-asxs~r ~-ssoc xnTSS ano ~ coxa: e a s a ~-ccv • s ~ axsca~-~eas accoIIS~r• ~escsxvnsss ssco~eD :sT ~rs~: o~e~exs, axsta x s~xT: 11/zs/oe r*x~cxas. crass: ~ x once aa~ : osrexs, sxx~- x axscsa~eos : 11 / a s / 0 8 c ~rr~-cT r~esp: s s'1'iss'1' s 161 s7-sY is rai'l' l3tiY t 1 Z / 3 Z / O 9 ', ~xL 7ts'1'V7ti s nary-9• P7tOO1tiKt ~ P1-'1' '1'Y'ss sl Cx4'Ys C3~tLxsLS p~- 17013 CO1~'1'ft3tiC'i's .00 i paT ssZt ! lsOxs s (717) 9 4 3 -!i 19 i COV1~T~tY t IIs CD7t7t a]-L : . O ~i~t 8sZ t ! sxlr.0YS7ts ~!s'1'x~tsa 2004 '1'0'1' C~1tOSSt 879. ris1~C7[' C~CL coal aa-TS xssv~cs i s 2 0 0 i Z/ 17 / O S 16 9 .0 0- COas PL33t Dl-TS s s ppy ICY iO 9s 966 19/19/08 7.90- it Z00 I[C~t lZ/17/08 879'PI YMN80098lf43300 3s 978 09/zZ/09 SO.00- 9: ' 4: 97Z is/93/09 ZS.00 3e S: 1'.f0 iZ/?9/09 Z'.i.00- Ls'1' ~-C'1'1~: ii Os/ZO/09 3 • ' L 01/s6/09 p~Y 1-ZTa is 'QII Os/13/09 4s ',s O1/1/09 PiOCSSS 7tsYxsN p~-Y 1-ZTa Zt ii 09/09/09 !St S is/ZZ/0• anTS vss7t anTS Os/Z3/09 3tiss'1' 00/00/00 18 t'.i3 is N8 6153'.f 67997 Os/21/09 ais'1' 00/00/00 iS:'.i9 ls~r X999 at TO9PLLC7t iad~a~ ~ Os/91/09 ~ss'1' 00/00/00 li t'.i9 144451308? 61'.f33 683 8 OS/Z1/09 ~xx 00/00/00 VOP-VOICS O'1'as7t P7-7!'i'Y (1ts8 laxV) ii 1~IIP, Z~P'1', 3.0~, 4~x1is, S~IIa, 6~axs, 7~7t'1'i, S~C1~'1'x, 9~C11'1'II, lO~as'1', ~1~ V _ _ -_ __ _ • Cumberland-Goodwill FireRescue ' PO BOX 12910 PHILA, PA 19176-0910 _ Phone #: (800) 367-0512 Federal Tax ID: 23-2298422 _ `•'~ { ~;~: ANNA ORRIS P;~E'ictJ~' fVLvi~~~: 3319 PP CALF. i~t3~+~~rR: CG0805524 NONE -~ ~~-- MEDICARE B 159247941A ~'~s4 ~~' ~~~~-~-~ .~~,,~.,,.,,,.,~ SENIOR BLUE - NO CON- YWW80098543300 ~ ~~~~ ~~ ~~~~~~~ ~~~ ~ V~wv~ ' C,'.~L~.E~t: CG0805524 `~~~~°' CARLISLE f~E IONAL MEDICAL CTR ~~' HOLY SPIRI~' OSPITAL ANNA ORRIS 161 EASY RD ~`AS~iVi~} BRADYCAR I' CARLISLE PA 17013 FAR ~ , CARDIAC C M LICATIONS ~A~v3P~o--`Y CARDIAC DYS HYTHMIA ~V ~~~~y -~~ . ~ %iESCRIPTE~JN ~F G'tiARi,~ CfJAiVT9TY ~ UiV37 PftWC~ ~~f,~ ` .-~isi.~.:k~f ""`._._.__ -i- MICU EMERGENCY LEVEL 1 A0427 1 0 ~ 1274 23 I _....._..____ ._._.._._.__._.._._ { COMBINATION DEFIB/PACER PADS A0392 1.0 i 59.85 ~ 1274.23 59 85 GLOVES A0398 j 2.0 ~ ~ 3.65 ~ I . 7 30 OXYGEN A0422 j 1.0 ~ 50.00 j . 50 00 MILEAGE CHARGE A0425 '• 24.0 ! s i H I ~ 3 11.50 # !I y I . 276.00 , ~ ~ { 9 _. _.______._..._ _... .r._.______ ? __ 1 I j ~~. ~ __ 667.3$_ __ ...' _____ _ ! " ..~_~~. ._._K_______~ ~~ __. _.__ ~_ __.____W r7r~~,r i!€~Y§~fd C)F Ps-~'f94'i~;~'~" ~;icC~tCP-~ ~ ~~i~YNt~ivT, e L~.~Tt ~ I „~f~'i,,:-;~ ./ j S ~ r I ~ f S"~.i.~~v~ f"I~':i ~t"P,F3 ~t~J4V..I P'iy~ r°"'d~9o' ~ __~. ~____ .. ~ ,~~ 1 ~ i ~~ . . ~_ ;~~'R"ti:C;i a4LC?it~~ P~Fi,F`J~ ~eiViCi°c It7iV :i~~ t~~~"UeAi9+7 S C:i~3 L'4': h! r tk`+ iV! ~.s+i i _ ~_ _..__.. -__.~.__._._ __._. . ~ ~~~ ~~ t ~. ORRIS, ANNA ~=~~-~- ~v~~~~~ CG0805524 ~~~`"~~~~~~ ~~~';" r~i a ~: ~°t: 3319 ~i9~.LPi~iG ~h~'~: 01/27/2009 '~;vt;LU{~~ __.~___...___ _._.__._...._ ' __..____._._._._ _~ - _ _ - . -~.___ ~.________ __.___ ~._.__...__.___: PAY MENT FOR THESE SERVICES WERE PREVIOUSLY PAID TO YOU BY ' YOUR INSURANCE CARRIER. PLEASE REMIT PAYMENT AND THE ~ ~~~' j a~ ,y ~~ ~~ EXPLANATION OF BENEFITS TO US! ~- ~' '~"~"' ~`'~'='~~ ~i i.. f.,~~i°i:: 'mil Cumberland-Goodwill FireRescue PO BOX 12910 PHILA, PA 1~1 ~, ~~ 6{0910 Cumberland-Goodwill FireRescue • PO BOX 12910 PHILA, PA 19176-0910 :: ,;, Phone #: (800) 367-0512 Federal Tax ID: 23-2298422 r s~i° ~ r: s~:: ANNA ORRIS w:~Ty~~vT ~3~i~~~FE~. 3319 ~A~ ~" M19~3fv70Ef?: CG0805522 t`~'- ~~~~~ =~ MEDICARE B 159247941A O~T~ t~F ~^~-=-~ 12!10/2008 SENIOR BLUE - NO CON" Y1MN80098543300 T~N3~ O~ G~~.~.: I CG0805522 `~'~'~'~ 1s1 EASY RQ ~' ~~'' CARLISLE R F~ ANNA ORRIS , 161 EASY RD ~~,~SC~~Y,S~ BRADYCAR[~IA CARLISLE, PA 17013 ~~+~ '~Sai'V~FC~~€'f ~~ b/~ I' - `OESC~i4~T~i~IV i"3F Cii~~tG~ ~ QL~,~.NT~TY -,--- -r ± i7t+li~f' ~F~C MICU EMERGENCY LEVEL 1 A0427 ~ 1.0 ~ 1274.23 i '~ ATROPINE 1 MG A0394 1.0 ~ ~ 5.00 ' '~ COMBINATION DEFIB/PACER PADS ! A0392 I 1.0 59.85 EKG ELECTRODES (4pk) A0398 { 1.0 ~ 4.54 ~ ~~ OXYGEN A0422 ~ 1.0 ~ 50.00 4 PERIPHERAL IV A0394 j 1.0 i 36.75 ~~ MILEAGE CHARGE A0425 6.0 1 11.50 ~tLC~P tl ~ '.'~''/~e~''IU'CE Eli i ~;~ T ~: PLEASE PAY TI-fitS r~,3`JIOUN~' ~- PP NONE MEDICAL CTR ~tlt?~)iVl ,' 1274.23 5.00 59.85 4.54 50.00 36.75 69.00 h' r~_ .._.. 1499,37 __.__ ~~ :a9lf JF~6G i;cTA;3~ :~~ia+~~ ~'i::s~1=()'F~fvI~GTii~7i~7 ;~fSf~" ~~ T li~?~ STUCK d"t'~~'+ti Y,'~.`'lilil~iy'~ _,._ _.._ aA~v3ii'tJ€'~S'3' !7 .,~ ~ ..r - ORRIS, ANNA ~~Z ~i;tvV~st~ CGO~fl5522 :;f`riL~l~,s'f - ,,;:, ~`Y;~s 3319 i39~..~ltit.~ 3~+;ai'c: 01/27/2009 Ev~.LCS=,. i i 1499.37 PAYMENT FOR THESE SERVICES WERE PREVIOUSLY PAID TO YOU BY _____. ~:~~ ,h~ i ~ ~j;~~ ~~ ~ ____ _ _ "' INSURANCE CARRIER. PLEASE REMIT PAYMENT AND THE Ir~~~i :~ ON OF BENEFITS TO US! - `~"~ Gi,~_F 39~.d. Cumberland-Goodwill FireRescue PO BOX 12910 PHILA, PA 1917 .0910 cJ g' - - __ _ __ Cumberland-Goodwill FireRescue _ _ ,_. __ _. - PO BOX 12910 ~ ~ ' ~. ~a ,» ; PHILA, PA 1917fi-0910 ~;~°" °~' Phone #: (800) 3fi7-0512 Federal Tax ID: 23-2298422 :~;a s~Cv-i fv~rJt~: ANNA ORRIS PATiEi~T ~;r3rJt~~~: 3319 BALL fl~3htS~R: NMCI .~e~~:;s .ar,c~: MEDICARE B 159247941A t3ATE of CALF.: CG0805258 11/25!2008 SUP2 SENIOR BLUE -- NO C ON YW1N80098543300 Tlr"~E +~F ~A~.a_: CALLEa=s: CG0805258 T~C~' 161 EASY RQ ~ CARLISLE ~EC ~IONAL MEDICAL CTR ANNA ORRIS 161 EASY RD REASONS} Hip Pain ~ CARLISLE, PA 17013 FOR ' ~I TRAf\3SPOf~T i ~~>~~~ - DESCRIPTION OF CHARGE QiJAPdTITY lfrJlT PRICE ~ AiViCJ3JtiT - ~ --{I BLS EMERGENCY BASE RATE A0429 1.0 ~ 400 00 ~ ' MILEAGE CHARGE A0425 ' ~ _ __ ; 6.0 ! i ~ I f . ~ 11.50 ~ t # I d ~ i 400.00 i ~ ', 69.00 ,. !, ~. !, i ! i Tn1~a1 Rh~re,ae 469.00 _..,' DESCRfPTiGi~ Oi PAYruitiUT s Medicare Assignment Adjustment Insurance Payment -SENIOR BLUE -- NO CON i - ~iE~:EiPT~~~ ~v,YiL9E~IT 1~A1"E f ~ kN1CDl3rST - ~, 3 3 ; 02/10/2009 ~ '~ 76.43 '; 101663386 9 02/10/2009 ~ 314.06 3 II~ '~ IaLE;~:aE rA~Y 9 sil5 A~lIC1.9N~' --~- $78.51 DETACH ALOl~G PEa~FOR1UlATiO~P ANJ HETt1RN S"dl~f3 W3TH I~A`(fUilE- 7 T Alwoufv ° t~UE 78.51 i :E=a ,~.f~T ~~~t~: ORRIS, ANNA CALL ~U~,t01=R CGOi0525~8 A'~°~'~'~ ~~ ~~ E_~ti; tu.;1rYRER: 3319 t31Li..~7G JAt'E: 04/10/2009 EhCLOSEtf! _ j ' i i , This account is now PAST DUEII Payment must be received I ~-.~ "'THIN 10 DAYS. Collection process will begin. vos~ „' VISA '' ~,Sr~~,•:,'=,~ e~uc __ . ~I ~`I~sT~a CAn~ ccE~Tww~ Cumberland-Goodwill FireRescue PO BOX 12910 PHILA, PA 1176-0910 I __, ,_,_ Cumberland-Goodwill FireRescue '" PO BOX 12910 ~~ ~' PHILA, PA 19176-0910 ~~ i ~~`~~-.,'' Phone #: (800) 367-0512 Federal Tax ID: 23-2298422 ~__ __: ~~T.~"dT hslvtr_' ANNA ORRIS !'ATlE+VI' ititlMBt~: CALL ~IPJiU'sBeFi: '~`~~ ~+"s'i;asvC=" MEDICARE B 159247941A D~T~ ~~ CALL: SENIOR BLUE - NO CON' YWW80098543300 Ti'iviE C3F C:~LL: C,4L± ~R: CG0804532 ~'~~~'~ TO: ANNA ORRIS 1B1 EASY RD ~tE.ASOhI(S} CARLISLE, PA 17013 ~®~ '~'F~Ao~iSis^vEcT ~~iv 3319 IBAL CG0804532 ' IBAL 10/12/2008 161 EASY Rl?~ ' CARLISLE REGIONAL MEDICAL CTR DIZZINESS -!V~RTIGO Syncope i I I D~Si;RfPTtCi~ OE CHLIRGL ~ i~t~AN'i VTY __ I UBIT P'R4CE ~ ~ AiMt'ii1i~9T - r : MICU EMERGENCY LEVEL 1 A0427 ~ _~ 1.0 1274 23 --~} ! - 1 EKG ELECTRODES (4pk) A0398 ! . 1.0 4.54 ~I 1274.23 a 4.54 GLOVES A0398 2.0 3.65 ~ 7 30 GLUCOSE BLOOD A0394 1.0 ~ 6.74 I . 6 74 { i OXYGEN A0422 1 1.0 50.00 . 50 00 SALINE LOCK A0394 ~ 1.0 ~ 26.25 . 26.25 '~ MILEAGE CHARGE A0425 I 6.0 ~ 11.50 ~ ~ ; I 69.00 ~ I r ._____.....~.~ __.v ~__ ~ s ~~.____._.._.,1__ . ~ 3 ! ~ ~ ~! Tot~i ` 1438.06 ! ~ ~p~ _, ~ , ,_ ~~. ~ Dc;:CNIPTlOi~! t^+.i~ PAYfVlENT 9 ~~:L":EII T_._.__~_.PAYiUIEivT DATlr ~.~~~I r~Nit7~ia~T _._.._..._ 1 ;Medicare Assignment Adjustment 02/10/2009 `' 979 25 Insurance Payment -SENIOR BLUE - NO CON- _... i ~~ 101668273 ~ 02/10/2009 e ~ I it i . 367.05 I ._. ~ t ~ ._..-._ Q -- -- ~ _-~.~. .~ t i ~ ~j~ (. dits 13d6 '~0 - --~~- _ ~ ;-~C ____... -_____._____, q~ }}pp ~,„~7 r~ ,, p, ~},^~y p T'~l: ~"~h1~ ~A AYV l'iI~SS3'IJB~T `"~'~g' ~ ~,~ ICI ( I ! I I y~i ~'^ ~~1ACH AL&'iv~:+ ~~EirC.c"u~FaTt~OlV;$1VG ~3E':"i.i~a'V' STc;S Vl/iTFi PA`aiVlitli4T~Tr ._.~. _~~._..~ ~ ;a+~~ ~,' ~vA1=~: ORRIS, ANNA ~ CALL s~~r+,~~i~~t CG0804532 t~ri9~~t T iV+.i1~o~ER: 3319 83LUPd+a DATE; 03/06/2009 .~r~~ouri`~; D X34'+~~~~' ~ ENCLOSE ~ 91.76 ~.___._ __ This account is now PAST DUEII Payment must be receive d I '~ WITHIN 10 DAYS. Collection process will begin. I l__ °~~ ~'~"" `~ z~s~n "~;~' ~.CE't'°fED Cumberland-Goodwill FireRescue PO BOX 12910 PHILA, PA 191170910 __ _ _ _ __ _ _ _ I PATIENT NAME INSURANCE: -- WSEMS - Chambersburq ALS/BLS 205 GRANDVIEW AVE ~~ SUITE 211 ~~„ CAMP HILL, PA 17011 ~~~ Phone #: (800) 367-0512 Federal Tax ID: 23-2463002. NEST SHORE ANNA ORRIS PATIENT NUMBER. CALL NUMBER: MEDICARE B 159247941A DATE OF CALL: SENIOR BLUE -- NO CON- YWW80098543300 TIME OF CALL: AARP 01770916511 CALLER: 183390W FROM: TO: ANNA ORRIS 161 EASY RD REASON(S) CARLISLE, PA 17013 FOR TRANSPORT INVOICE 53243 IBAL 183390W IBAL 12/16/2008 11:37 AM HOLY SPIRIT' H SPITAL HOLY SPIRIT` H SPITAL CUMBERLANID ROSSINGS HEART BLOCK I DESCRIPTION OF CHARQE QUANTITY UNIT PRICE AMOUNT Wheelchair One Way Transport ~ A0130 1.0 59 45 ~ Transport Van Mileage A0999 i 21.0 . 3.74 ~ 59.45 78.54 ~ II i To t har es 137.99 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT ~ III ~ 111 III I !I II PLEASE PAY THIS AI~AOUNT -INVOICE DUE UPON RECEIPT ->. RETURHED CHECK FEE - $31.00 DETA~H ALONG PERFORMATION AND RETURN STUB WITH PAYMENT AMOUN1r D NAME: ORRIS, ANNA M CALL NUMBER 183390W AMOUN1r $ NUMBER: 53243 BILLING DATE: 03/09/2009 ENCLO~I $137.99 137.99 This account is now PAST DUE!! Payment must be received VISA WITHIN 10 DAYS. Collection process will begin. - N ~, I AND ~~ M STER CARD CCEPTED WSEMS - Chambersburg ALS/BLS 205 GRANDVIEW AVE CAMP HI~.L PA 17011 ]~ L ii ',J __ • WEST SHORE EMS -BLS 205 GRANDVIEW AVE SUITE 211 ~~~; CAMP HILL, PA 17011 ~~~~~ 5~~~ Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 PATIENT NAME: ANNA ORRIS INSURANCE 194817W ANNA ORRIS 161 EASY RD CARLISLE, PA 17013 PATIENT NUMBER: CALL NUMBER: DATE OF CALL: TIME OF CALL: CALLER: FROM: TO: REASON(S) FOR TRANSPORT INVOICE 53243 WCS 194817W B osi2a~2oos 08:10 PM HOLY SPIRII~ H SPITAL HOLY SPIRIT H SPITAL FOREST PAF~I~ EALTH CENTER Syncope DESCRiPT10N OF CHARGE QUANTITY UNIT PRICE ' AMOUNT Wheelchair One Way Transport A0999 1.0 59.45 I'i 59.45 Transport Van Mileage A0999 21.0 3.74 ' ~ i 78.54 ~, I ~~~ I 37.98 DESCRIPTION OF PAYMENT RECEIPT .PAYMENT DATE AMOUNT PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT --- ~ I~ $137.99 RETURNED CHECK FEE - $31.00 - DETACH ALONG. PERFORMATION AND RETURN STUB WfrH PAYMENT AMOUNT UE 137.99 NAME: ORRIS, ANNA M CALL NUMBER 194817W AMOUNT NUMBER: 53243 BILLING DATE: 11!16/2009 ENCLOSE This account is now PAST DUEII Payment must be received VISA WITHIN 10 DAYS. Collection process will begin. AND ASTER CARD ACCEPTED WEST SHORE EMS -BLS 205 GRANDVIEW AVE CAMP HILL, IP 17011 J ~__ _ ' WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE STE#211 '" ' ~ / ,. CAMP HILL PA 17011 ~ ''y~~' Phone #: , (800) 367-0512. Federal Tax ID: 23-2463002 PATIENT NAME: ANNA ORRIS PATIENT NUMBER: 53243 IBAL CALL NUMBER: 9007480 ~! NONE INSURANCE: DATE OF CALL: 09/22/2009 TIME OF CALL: 06:50 PM CALLER: 90074$0 FROM: 161 EASY R~ li ANNA ORRIS TO: HOLY SPIRIt H bSPITAL 181 EASY RD CARLISLE PA 170 REASON(S) Syncope I , 13 FOR ~ I TRANSPORT INVOICE DESCRIPTION OF CHARGE QUANTITY _ UNIT PRICE ' AMOUNT MICU EMERGENCY LEVEL 1 A0427 ALS MILEAGE A0425 OXYGEN ADMINSTRATION A0422 1.0 23.0 1.0 1404.84 13.73 65.01 ~~, 1404.84 315.79 ~ 65.01 I I i ~I I I I Tot I C ar s 1785.84 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Medicare Assignment Adjustment 11/20/2009 Medicare Part B Payment 109668607 i 1173.69 11 /20/2009 489.56 i Tota C PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -~-- ' i ' x122.39 RETURNED CHECK FEE - $31.00 DETACH ALONG PERFORMA710N AND RETURN STUB WITH"PAYMENT ORRIS, ANNA M AMOUNT, D E 122.39 'TENT NAME: CALL NUMBER 9007480 AMOUN1rj $ TENT NUMBER: 53243 BILLING DATE: 12/24/2009 ENCLO~~ i This is the amount due after your Insurance Carrier's - - payment. ~ VISA - visa AND ~ - _ _ . __ .~ IIM STER CARD WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE STE#211 CAMP IHI L, PA 17011 WSEMS -Chambersburq ALS/BLS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011 ~~' Phone #: (800) 367-0512 f=ederal Tax ID: 23-2463002 ~~~ ~~0 PATIENT NAME: ANNA ORRIS PATIENT NUMBER: 53243 ' GWCS CALL NUMBER: 195867W NONE INSURANCE: DATE OF CALL: 10/21/2009 TIME OF CALL: 09:37 AM CALLER: HOLY SPIRII~ H SPITAL 195867W FROM: HOLY SPIRII~ H SPITAL TO: FOREST PAf~K EALTH CENTER ANNA ORRIS ~ i 161 EASY RD REASON(S) ALTERED M~N~'AL STATUS CARLISLE, PA 17013 FOR TRANSPORT ', ~', I INVOICE DESCRIPTION OF CHARGE QUANTITY UNIT PRICE ', AMOUNT Stretcher One Way Transport A0999 1.0 96 06 ' ' Transport Van Mileage A0999 17.0 . 3.74 ! 96.06 ~ ' 63.58 OXYGEN ADMINSTRATION A0422 1.0 65.01 65.01 I i I T I ' 224.65 I DESCRIPTION OF PAYMENT I RECEIPT ~ .PAYMENT DATE I ~ ~' AMOUNT I PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ~-~- !I $224.65 RETURNED CHECK FEE - $31.00 DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT AMOUNT!, Q<~E 224.65 NAME: ORRIS, ANNA M CALL NUMBER 195867W AMOUNTI$ NUMBER: 53243 BILLING DATE: 11/09/2009 ENCLOS~p ~i THIS SERVICE IS NOT COVERED BY MEDICARE OR MEDICAL , ~! VISA ASSISTANCE. AND A~IA TAR CARD A~CEPTED WSEMS -Chambersburq ALSIBLS 205 GRANDVIEW AVE CAMP HILL, PA 17011 ,~ i r ~ __ Quest o ~ Diagnostics G%918V 28125 27154 1-1 172410010073797 SR>5579122 1 ANNA ORRIS 161 EASY RD CARLISLE, PA 17013-9594 Phone Fa* III III " II I ' III ' ~ ~ II " I II 1-900-766-2604 t~spo-sot-6608 u r n r n u u u I r u r r r 1 u t u r u u r r u Weekdays 8AM - 6PM Se Habla Espajrlol pM-6PM Tiempo del Este ~ Please have your invoice available fon ref rence. l.rlboratory Testa YYete Fiegttealed By: Moat I~trcelft tt-anra~ce Clelim ffted To: Referring Physician: G64482HARRIS,JEFFREY Insurance Name: HIGHMARK BLUEISIiIELD Physician Address: 100 S HIGH ST Insurance ID: YWW8009854330b NEWVILLE, PA 17241 Group Number. 00910002 Lab l3es+:llts 8rict >pasFm Qulk~ttol~slWUal Be Aruwerett 9ff Your t'ttYskliut Patient Name: .ANNA ORRIS Invoice Date:. July 22, 2009 Responsible Party: ANNA ORRIS Amount Due: $160.93 Date of Service: May 20, 2009 Payment Due Date: 08/12/2009 ', ', PAYMENT FOR THIS INVOICE WAS DENIED BY HIGHMARK BLUE SHIELD. THEY INDICATED THAT THE PATIENT DID NOT IIHA~IE COVERAGE ON THE DATE SERVICES WERE PROVIDED. THE BALANCE SHOWN IS YOUR FINANCIAL RESPONSIBILITY. PLEASE PROVIDE PROMPT FPA NT AND/OR REMIT VALID INSURANCE INFORMATION FOR THIS PATIENT. THANK YOU FOR USING OUEST DIAGNOSTICS. CPT Insurance Insuranc~r i Medicare) Patient Patient Date Code• Test Description _ _ __ - -- -- Cha~ Discount Paia '' Medicaid Paid Paid Owes 05/20AD9 84443 - __ -- TSH _- ___--- 8111.40 ------ -~ __ - _ _ . ~-----_ _ _ ~ _ --- _ .._ --- - --_ _ U5/20/Q9 80053 ~ COMPREHEN METABOLIC PANEL 549.53 ~ ICI I Tax ID: 38-2084239 K:D-9 Codes: 244.9 401.9 itso.s3 t0.0o it}.1)0 So.oo io.oo 1160.93 Page 1 Laboratory Invoice For services not included in your physician's bill. Invoice Number Lab Cade 5855579122 KQP Customer Service LOG ON NOW at vlrww. uest is ostics.comlbill io conveniently pay your invoice or give us yotNr'f .edback on our patient survey. w•..o.~Qee..~~r...,,~.,~ ~~...~~~,.~.,..~.,....~r,.,~~r, r Quest i ~ Diagnostics •The CPT codes provided are bas~'d on AMA guidelines and without regard to specific payor requlremeMs _ _.. oPe rpvl - - .. _ - _ - - - _ - • Please fold and tear payment coupon along perforation and remit with payment in the envel p ided • A55 N 616 Payment Coupon Lab Code. KOP LOG ON NOW. Pay your bill online securely anytime - day or night at www.questdiagnostics.comlbitl or call 1-800-71~i-2604 Quest Diagnostics also accepts credit cards and on-line check payments visa ~ . Please make your check payable to Quest Diagnostics. Be sure to include invoice number on your check. ^ Check here if address has changed. ~.i~ Please provide your new address information on the back. t ouact Oie pnwlles reserves Ine riptM to assign tMs receiwble to any of ils affipetes. Amount Due X160.93 Due Date: 08/12/2009 Invoicei N~mber: 5855579122 Patient Name: ANNA ORRIS I-~i Amount Enclosed: IF you received an explanation of benefits shgvyin ypur responsibility is less than the amount shown on this bill, please pay the le5ser~n~ount. To fully resolve your invoice, please provide a copy of your explanation of been fnf. MAIL PAYMENTS ONLY TO: ', QUEST DIAGNOSTICS' I1~CORPOItATED PO BOX 74077> CINCINNATI OH ~527~4-(~77~ ~t~u~t~I~tu~t~~ul~t~n~~~nl~ut~~~t~~~~t~t~nt~l~l~l~ut~~ _ ~, ~'~,~, (11KOP48~158555791221100160934U?22217019101358900~0~~0 P~'~,~ - - __ Forest Park Health Center 700 WalnutjBottom Road Carlisle,P~ 17013 Questions Concerning Tk~is Invoice?. Biller Name Dawn J. Ert. 865 Phone 1-888-880-J090 Fax 1-819-265-1377 Email. djordan@gu~rdianeldercare.net __, ;FRED ORRIS .CARLISLE PA 17013 case Detach and Return with your payment Resident` 22913 Resident ORRIS ANNA h1 Discharge Date Statement Date 02/28/2010 Payments Posted Through 02/28/2010 DATE D$SCRIPTION :UNITS REFERENCE AMO T BALANCE 1 PREVIOUS BALANCE i ' 11,0 9.53 11,039.53 1/31/2010 ROOM & BOARD -1 -239 .00 10, 805.53 1/31/2010 Patient Pay!,Adjustment 2111.98; '' 11,017.01 2/10/2010! PRIVATE PAYMENT ! ICHECIC X2693 -2,2a0.1! 00 ~ 8 817 01 2/28/2010 ROOM & BOARd i ~ 28 i ~ -6,5512.00 , . 2,265.01 2/28/2010 ; TELEPHONE ~ 1 2I 8.~96 ~ 2 293 97 2/28/2010 ~ Patient Pay ,'Adjustment , i -1, 65I9.i7 I i , . 639.30 3/01/2010`: PATIENT PAY MARCH ~ ~ ~ 1, 51'18. ~7 ~ ' 2,157.37 ~I' 4~ ~ ~ ~ n d I .i ce ~~ ..,~ Y j YOUR PAYDIENT OF 2,157.37 IS DUE UPON RECEIPT .. __., 2,157. r ~_~~ ~~ _ ~~ ............ ORRIS ANNA M ~(,~' I i ~~ SCHEDULE J RE(iiSTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA `~ r„ _-` ~ r1 ~ . _ Y ~.: -- - _ - -;, ~-;. _ r ~_ -r ~ _ ~.~.--~~ No . 20 f ©- 00457 &s to to Of : ANI1G ORRIS CERTIFICATE ~F GRANT QF LETTERS PA No. 2~- 1p- 0457 ORat ~+~e. toad Late Of : ~MB RMLIADNO G~'OOt N ~SHIf Deceased Social Securi ty No: (59-24-7941 WHEREAS, on the 30th day of April 202D instruments datlec~: May 27i/t (977 December 6th 1333 re admitted January 26th 1398 to probate as the Last will and codicil of ANNA M ORRIS ~~., per, rra~, uro '~ Tate of NORTH M/DDLETON TOWNSHIP, CUMBERLAND County, who died on the 12th day of l-tarch 2020 and, ~~ WHEREAS, a true copy of the will &codiciZ as probated!i 'annexed hereto THEREFORB, I, GLENDA EARNER STRQSBJQUGH Register ',o Wills in and for CUl-iBE'RLAND County, in the C~onwealth of FennsyZvanfa~, hereby eerti fy tha t I have this day granted Letters TESTAMENTARY l to FRED B. ORRIS Ill '~, who has duly qualified as EXECUTORtRiXI ~ and has agreed to administer the estate according to Iaw, 'a I of whic/i fully appears of record in my office at CUMBERLAND COUNTY C URT HOUSE, CARLISLE, PENNSYLVANIA. IN TESTIMONY WHBREQF, I have hereunto set my hand and'a~'fixed the seat of my office on the 3thh de}~ of April 2010. ~~ w ~ *NOTE* * ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, $+A~S'1`) ~' I I I Catttnoaaealth rational Bank as substitute executor. IN iTI7'!~BSS 1PHEREEIF, I have he]Ceunta set >tty hand and seal this the day of ~~„~ 977. y .. _ LSEAL) Signed, sealed, published aad declared. by the testatrix shave naee8, as and for jer last will sad tastatten~, written an 2 sheets of paper, i.n our presence, in ~, her presence. aad in the presence of each other ~I hav hereunto subscribed our natter as attesting witnesses: ,^.``, e .; ., ~ COMN10PfWEALTH OF PEDiNSYLVAidIA COtS*7TY OF Cuaber2and ` ~ ~ and f~Je , ` whose asses are signed to the attached or foregoing instr~ being duly qualified aeaordiaq to lar, do deposes and saY were present and saW testatrix sign and execute the iristr her last will, aryd that she signed Willingly and twat she it as her free and voluntary act for the purposes therein that each of us in the hearing and sight of the testatrix the will as witnesses; and that tro the best of our xnoWle testatrix was at that time 18 ar ere years of age, of so rind under no caAStraint ar undue infl~~erece. Sworn to and subscribed bafox® ms this "l~ day of '~n~~ r 11 . ?dotary ~-mb. Ca r.cne. ~ {breods~f~!i 6q+p J1d/ lb 1~ ~ '- ~r. ~ _ _ ~- WE as cot~s~onn~sALrg ©s psxasnvni;u- f SS:, ^_oUNTX OF Caaberlaad I,~ a M. O ris ,chose Hams is signed to ttte atlcached or foregoing instacunent, having been duly qualified according to law. do hereby acknowladgw that 3 signed and executed the iactruaaat as gY last will; that I sigr-ed it willingly; an~dithat I signed it as my free cad vaiuntary act for the pu;cpose: tl~srein expressed. ~'t,'Lw ~.,, Anna H. O s Sworn to and subscribeQ before me this ~ , day of ^~'V~ ,1977 f W~1PP P. tt7L IWSEY ~ 1M'di. C~tr, Ctl. PGr'a. ~1he ~enxinel Unlne : l;ommutury : Amiouncements : Ubituanes ArcMws tf+ Page 1 of 'l Goods Autos .lobs Nomss 12 indsz Homes Newas Sportss Opinlona Arts d, Entertelnmenta LHestylss CommunHys Featuresr Marketplaces ', S sae Mnouncanairta GMndar Forum Gspsry Pops ~ Orlais aDlhwNS ero poafad by 12:00 noon an the acne day Msy ere ptbpahsd In The Santlnsl. AfWs: YNra~NendPoebl'pAinAamaywry. ~ Back t0 today's obituaries ®PriM 0 Emtait to a fiend Send flowers 3eor'ch obtuaries Last Name: Anna Mary Orris Ama Mhry Orris, 92; of Forest Park h1aalMt Cantor. CaAble, died Friday, Manic 12, 2010, in the osnler. eom tlbrt;h 24.1917. in Garble, aha ww the dsttghber of fits lab J. Clyde and Ama MsN Sheellbr and the widow of Fred B. Oafs Jr. Amt was a of Garble High Sdhobl. She was a member of Wapponers United MsBtodist Midrbbn Seniors Citizens Group and the Ladies AtudWary at North Middlebn Fins FtaN. M ~~ iwonieoes, Mary ltlBiZabeftt Wbrt and ~ huabartd Larry Arena LouNe Group and tier' lstebarW PaW, Cartbb; acrd a rtepltsw, Clyde Lebo. Cade. She was prsosdsd b death by a sister, Margaret E. Lebo. Furtsral ssnbes will bs held at 11 a.m. Nkrirtssday March 17, 2010, in the IAhggorters lJrtiled MlaBrodMt Ctsach,1065 Lorrps Clap Road, CarNMe, with the Rev. TlrrtdFty A. Funk be a vtawirp d~S p re. ~uaWsy (nHolhr~-Ro1Fr Funeral Home y. Thera wIN Ffarroerer St, CarNSle, and from 10 a.m. Wednesday urtltl the tfms of aervio~ 2tistrch. Memorisi corrMbudorts may be made to the VYagpaters lhtibd llAStltodist Church.1055 Longs Gap Raad, Carlisle. To sign the guest book, visit www.hofrmanroth.com. Archive March 2010 8 M T W T F IS 28 29 30 31 Apr112010 S M T W T F S 1 2 3 4 5 6 7 8 9 h0 11 12 13 14 15 16 h7 18 19 20 21 22 23 X24 25 26 27 28 29 30 Send your sympathies from a local florist ® ~, ~ Peeler's Flovwers b Company 3720 Trirtdls Road Camp tiRl, PA 17011 1-800$76-/S08 Tire wads be haul to 1kW. Let ua help you say them witlt a taslsfid arrajrge~rrrsnt. pealers.cwm George's Flower Shop 101 -199 G 86set Carob, PA 170131-800-~0-4294 Let Geoiga's FI w~ delirbr a bvely floret expnesafon of sympathy and reverence for ypu. ~eorgesflowershop.~m Gllaat BOOk http://www.cumberIinlc.com/arCicles/2010/03/13/community/announcements/obit~ie~/do... 4/30/2010 _ _ _ _ _i_ I for Hart informataoe AOrc~~t.or~