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HomeMy WebLinkAbout11-24-10J 1505610101 REV-150 Ex col-io, PA Department of Revenue pennsylvenie OFFICIAL USE ONLY Bureau of Individual Taxes ~'"""`~"~"~'F County Cade Year Fife Number PO BOX 280601 INHERITANCE TAX RETURN r ~ ~- , Harrisburg, PA 17128-0601 RESIDENT DECEDENT L- ( ~ ' t ~~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 168-26-4378 ' 09/29/2009 10/14/1914 Decedent's Last Name Suffix Decedent's First Name MI Koontz ! Clara M (If App{icablej Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI N/A Spouse's Social Security Number --- - - - - THIS RETURN MUST BE FILED 1N DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 4. Limited Estate Q 2. Supplemental Return O 4a. Future Interest Compromise (date of death after 12-12-82} O 7. Decedent Maintained a Living Trust (Attach Copy of Trust} O 1C. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95} Q 3. Remainder Return (date of death prior to 12-13-82} p 5. Federal Estate Tax Return Required ~ 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received ~ 8. Total Number ofi Safe Deposit Boxes O 11. Election to tax under Sec. 9113(A) (Attach Sch. O} CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number t,,, ~ __ _ _ _... _ __ __ _.. __ _ __._ __._._. _. _. .__._..... _.. _ ...j....,;.. _ _ _ ......~ _.... Michael Cherewka, Esq. ' (717) 232-47011.: ;~ ~:a~, ~~~ REGISTER OFFVIf)t~ E ON6ol~~ ~ -=j First line of address _. ` ;; : ~~ ;, _ ~a ~: _ ~, ~~ 624 North Front Street -~ ~. _ ..~ .~ ~ ; Second line of address _. __ ._ , ~ ~ - ~K~ __ j City or Post Office State ZIP Code ~ DATE FILED Wormleysburg ' PA 17043 Correspondent's e-mail address: Under penalties of perjury, 1 declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct d complete. Declaration of pr arer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF)"PER$ RESP~IB F1LiNG R~RN h ~ DATE Post Office Box 456, Lake Harmony, PA 18624 SIGNATU 6PREPARERE~fh1ERTH,q~REPRESENTATIVE ADDRESS 624 North Front Street, Wormleysburg, PA 17043 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 15056107,01 J 1505610105 REV-1500 EX Decedent's Social Security Number ... .................. __ Decedent's -vame: Clara M. Koontz :168-26-4378 RECAPITULATION 1. Real Estate (Schedule A) ............................................ . 2. Stacks and Bands (Schedule B) ...................................... . 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... , . 4. Mortgages and Notes Receivable (Schedule D) .......................... . 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)...... . 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... , . 7. Inter-Vvos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested....... . 1. ' 0.00 2. 0.00 3. 0.00 4. 0.00 ': 5. 7,932.03 ~. ' 0.00 7. ' 0.00 8. Total Gross Assets {total Lines 1 through 7) ............................. 8. 7,932.03 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. 12,401.67 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 1,534.10 11. Total Deductions {total Lines 9 and 10) ................................. 11. ; 13,935.77 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. -6,003.74 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 0 00 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. -6,003.74 TAX CALCULATION -SEE {NSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 _ _ _ __ _ _ _ _ 0 00 0 00 ' . (a)(1.2) X .o! 15. 16. .............. . ... ...: ~. ..:...... ~ ........ Amount of Line 14 taxable at lineal rate X .0 45 -6,003.74 _. ~.... ..~.. ~_...... . 1~, ' ~..~..~ _.......~ ,.,....:.~_ ... ~....r_ .~..r 0 00 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. '; 0.00 20. FILL IN THE OVAL 1F YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 1505610105 REV-1500 EX Page 3 Ile~+o~lnnf~c C_mm~lEafp ~~1[~IrP_CS _ Ftle Number DECEDENT'S NAME Clara M. Koontz STREET ADDRESS 16 South Enola Drive, Apt. #216 CITY i STATEPA Enola Zip17025 Tax Payments and Credits: 1. Tax Rue (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1} Total Credits (A + B j (2} (3} (4) (5) 0.00 0.00 0.00 0.00 0.00 Make check payable to: REGISTER OF WILLS, AGENT. .. _ . . ,~ ~~ , PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :........................................................................................ .. ^ b. retain the right to designate who shall use the property transferred or its income : .......................................... .. ^ c. retain a reversionary interest; or ........................................................................................................................ .. ^ 0 d. receive the promise for life of either payments, benefits or care? .................................................................... .. ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death wikhout receiving adequate consideration? X 3. Did decedent awn an "in trust for" or payable-upon-death bank account or security at his or her death? ............ .. ^ 4. Did decedent own an individual retirement accounk, annuity or other non-probake property, which contains a beneficiary designation? X IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. ,; . For dates of death on or after July 1,1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent (72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a} (1.1} (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a}(1.2}]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2} [72 P.S. §9116(a}(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a}(1.3}]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. ftEV-:IS~J2 f=X+ x:11-v8} Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER CLARA M. KOONTZ 21-09-0092 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. If more space is needed, insert additional sheets of the same size. REV-1503 EX+ {6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS 4NHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER CLARA M. KOONTZ 21-09-0092 Ail property jointly-owned with right of survivorship must be discbsed on Schedule F. (If more space is needed, insert additional sheets of the same size REV-1507 EX+ (6-98) SCHEDtr1LE D COMMONWEALTH OF PENNSYLVANIA MC}RTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF FILE NUMBER CLARA M. KOONTZ 21-09-0092 All property jointly-0wned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same s¢e) REV-1508 EX+ (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER CLARA M. KOONTZ 21-09-0092 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUEAT DATE NUMBER DESCRIPTION OF DEATH 1. M&T Bank, Checking Account X913072164 7,483.43 2. Refund - Enola Commons - TV Cable 50.00 3. Refund - Enola Commons -Security Deposit 398.60 TOTAL (Also enter on line 5, Recapitulation) $ 7,932.03 (If more space is needed, insert additional sheets of the same size) STATEMENT PERIaD PAGE AUG.21-SEP.18,2009 1 OF 6 17167 CLARA M KOONTZ 16 S ENOLA DR APT 216 ENOLA PA 17025 INTEREST PAID YEAR TO DATE .3.10 nrrnii~iT ciie.uwo.. WEST CHOCOLATE BEGINNING BALANCE DEPOSITS & OTHER ADDITIONS CHECKS PAID OTHER SUBTRACTIONS CURRENT INTEREST PD ENDING BALANCE N0. AMOUNT N0. AMOUNT N0. AMOUNT 7,764.57 1 1,115.00 16 1,396.45 0 0.00 0.31 7,483.43 Af`f`f111A1T Af TT\/TTV POSTING DATE TRANSACTION DESCRIPTION DEPOSITS,INTEREST 8 OTHER ADDITIONS CHECKS & OTHER SUBTRACTIONS DAILY BALANCE OS-21-09 BEGINNING BALANCE 57,764.57 08-21-09 CHECK NUMBER 3108 13.03 7,751.54 08-24-09 CHECK NUMBER 3109 20.00 7,731.54 08-31-09 CHECK NUMBER 3112 250.00 08-31-09 CHECK NUMBER 3110 54.47 7,427.07 09-02-09 CHECK NUMBER 3111 29.78 7,397.29 09-03-09 US TREASURY 303 SOC SEC 1,115.00 09-03-09 CHECK NUMBER 3114 22.69 8,,489.60 09-08-09 CHECK NUMBER 3121 60.00 09-08-09 CHECK NUMBER 3116 220.50 09-08-09 CHECK NUMBER 3115 108.46 8,100.64 09-10-09 CHECK NUMBER 3120 104.68 7,995.96 09-11-CS CHECK NL'SEr~ 3ii7 76.10 7,919.86 09-14-09 CHECK NUMBER 3119 157.98 09-14-09 CHECK NUMBER 3113 129.04 09-14-09 CHECK NUMBER 3118 70.97 7,561.87 09-16-09 CHECK NUMBER 3125 29.85 7,532.02 09-17-09 CHECK NUMBER 3122 48.90 7,483.12 09-18-09 INTEREST PAYMENT 0 31 . 7,483.43 ENDING BALANCE 57,483.43 .:: :CHECKS -PAID SUMMARY 3108 08-21-09 13.03 3109 08-24-09 20.00 3110 08-31-09 54 47 3111 09-02-09 29.78 3112 08-31-09 250.00 3113 09-14-09 . 129 04 3114 09-03-09 22.69 3115 09-08-09 108.46 3116 09-08-09 . 220 50 3117 09-11-09 76.10 3118 09-14-09 70.97 3119 09-14-09 . 157 98 3120 09-10-09 104.68 3121 09-08-09 60.00 3122 09-17-09 . 48 90 3125* 09-16-09 29.85 . rnOL~A SL-R~IQR h~OUS{NG, LP 3 6 4 6 ~ rthur Bossler ENC~~,^, connn~olvs Security Deposit 11/18/09 2114 Tenants Security D~el:-osit 398.60 Total: 398.60 .; . :. .';;1.4. ti,t t~i~:Ca~".+.~';T~ia,~..~=~~1~~.~-t?~..i:ft~~ f.~;,IrE'~~~~ . -y ¢' .~ sT~~~.a~~'~ta~r~x.ti.~*I;S ~~~.i{'~.a~~~~ ~l ` t a _ - _ ENOLA SENIOR HOUSING, LP ENOLA COMMONS NUM9ER 114 N. HANOVER ST., STE 104 'M~ CARLISLE, PA 17013-2445 so-295/313 Security Deposit *"* Three Hundred Ninety Eight Dollars And Sixty Cents **'~ DATE AMOUNT 11 /18/09 $ 398.60 PAY TO THE VOID AFTER 90 DAYS ORDER Arthur Bossler of clo Estate of Clara Koontz ,f i r~ ~. __.._ .... P.O. Box 456 - ~~ Lake Harmony, PA 18624 ---~ _ r~,~~ . ;.'s1~ , _,:;~j d :...~~r,~~a:~t, -~.,L:t~,.-~~.F~tit~'.~"~,.t.s.s~m~~S~~; •~7~ t ~+?'`"~~ :_~~!-;~~~Tl 9"r! ;.«. 1..~:~~'? k fee.., L.A.9.. t._, 1£ z . ti ~ ~~ • ++'000000 3 6 4 6++' +:0 3 ~ 30 2 9 5 5 ~: 98 3 5 1 ?8 ?0 9++' ENOLM SENIOR HQUSING, LP Arthur Bossler E~~N()IJ1 coMN~oNS Cable Y 6390.1 Other Expense; ~- E:ntity 50.00 Total: 50.00 Arthur Bossler Go Estate of Clara Koontz P.O. Box 456 Lake Harmony, PA 18624 3fi47 ~.:.,. ..._._. .. .. .,-. .~4 b,~ c i r • f Y . ~ * • ' `~ r~'a ~'` c i { f a t "} {'rl x~vt s . ,r Y "._ s"t v ~ ... .. -. .5~'.T~1,1~,1~.:"~._L~:~a'r,~~.tt~~~"~y~:~.~z.~rT~~ft.~ ~ f._ t`6~_~'~;V~~l-~ :~,lk~s.~xX3A~a:,~~i.e!.~".,~f]~i~i:~t .,, . ~~ 3647 ~~ ENOLA SENIOR HOUSING, LP ENOLA COMMONS 114 N. HANOVER ST., STE 104 CARLISLE, PA 17013-2445 *** Fifty Doiiars *** PAY TO THE ORDER OF i ~~ 4 I '~ 11/18/09 ©,~„,jr~ ~~~ NUMBER 60-295/313 Cable DATE AMClUNT "~`' 11/18/09 $ 50.00 ( VOID AFTER 90 DAYS ___ . _ , , l ~. ,~ . .. ~" y1 }}y-~ ~y q .'7y( 7.~,7~ ~j~g~ ~ ~Ty.~T ~~ ('> p g ,may ~{ ) , , : S3tL~ i.±::. is1~~. y~~~'4.~f.4llrt.:1,A.3'1.s~~).L'..',isA?,`'~1.yJC'_ASSA~~~.Y4L'4+'e.S-r~~~l`_~Y ~4.~.i..`?.ff.~{_~"~i77.i~~~-Y~f~'~.r4.t.~i.~i~.4'..I_'S~~.~n ~~s~tft~~.o-.6~.~i~.~}t~'..!:`.:.i -:_ ~. ~ _ 11'000000 3 6 4 ?u' ~:0 3 i 30 X 9 5 5~: 98 3 5 ~ ?B ?0 911' enns lvania SCHEDULE H p Y DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER CLARA M. KOONTZ 21-09-0092 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~' Neill Funeral Home, Inc. 9,672.67 2. B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Persona! Representatives} Street Address City __^_~ _ State ZIP _ Year(s) Commission Paid: 2. 3. Attorney Fees: Family Exemption: {If decedent`s address is not the same as claimant's, attach explanation.) Claimant 2,500.00 0.00 Street Address City ___ State __ ZIP Relationship of Claimant to Decedent 4. Probate Fees: 5. Accountant Fees: 0.00 6. Tax Return Preparer Fees: 0.00 ~~ Legal Notices -Cumberland Law Journal 75.00 $. Legal Notices -The Sentinel 154.00 TOTAL (A1so enter on Line 9, Recapitulation} I $ 12,401.67 If more space is needed, use additional sheets of paper of the same size. i I Funeral Home, Inc. 350'1 Derry Street Harrisburg, PA 171111817 (717) 564-2633 Supervisor :Stephen J. Wifsbach The fallowing is a detailed bill far the professional services andlor merchandise arranged for Clara May Koontz Date of Service :October 05, 2009 Mr. Arthur Bossier Statement Date October 14, 2009 PO Box 456 Contract Number 741200200525 Lake Harmony, PA 18624 Arranger Name Stephen J Wifsbach Initial Selection Final Selection Difference Funeral Director and Staff Services Basic Professional Service Fee Total Funeral Director and Staff Services Care and Preparation of Remains Embalming Dressing and Casketing of Deceased Total Care and Preparation of Remains Use of Facilities and Related Services Chapel Funeral Ceremony Total Use of Faci~ides anti Related Services Transportatoor- Transferring Remains to Funeral Home Service Vehicle Total Transportation Other Goods and Services Memorial Booklet Prayer Cards Flowers Cemetery Equipment Rental Fee Total Other Goods and Services $2,680.00 $2,680.00 -- $2,680.04 $2,680.00 -- $795.00 $795.00 --- $395.00 $395.00 --- $1,190.Q0 $1,190.00 -- $495.00 $495.00 --- $495.00 $495.00 --- $495.00 $495.00 --- $395.00 $395.00 -- $$90.00 $8sa.o0 - $25.00 $25.00 --- $60.00 $60.00 -- $210.00 $210.00 -- $159.00 $159.00 ~- $454.00 $454.00 Initial Selection Fic~a! Selection Difference lVlecchandlse Churchill Blue 20 Ga Steel Cskt -Full Couch $1,095.00 $1,095.00 --- Guardian Asphalt Coated Concrete Vault $1,195.00 $1,195.00 --- Total Merchandise $2,290.00 $2,290.00 - Cash Advance Cemetery $1,385.00 $1,385.00 -- Clergy ; Religious Facility $125.00 $125.00 --- Certified Copies $30.00 $30.00 --- Newspaper Notice -- $133.67 $133„67 Total Cash Advance $1,540.00 $1,673.67 $133.67 Total Services, Merchandise and Cash Advance $9,539.00 $9,672.67 $133.67 Total Charges (Total Services +J- Allowances + Taxes) $9,539.00 $9,672.67 $133.67 Less Cash Received $0.00 Unpaid Balance Due $9,672.67 Page 2 of 2 ft.E•.1/-:t4:t~ L".X•~• X17.•••",•8i ~ enns lvan~a SCHEDULE I P Y DEPARTMENT OE REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER CLARK M. KOONTZ 21-09-0923 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 • Pinnacle Health Emergency Services 33.81 2. Pinnacle health Hospitals 1,068.00 3. AT&T 10.28 4. HealthSouth 89.99:' 5. Heritage Hospitalist Group 101.14 6. Susquehanna Valley Pain Management, P.C. 40.29 7. Internists of Central PA 48.11 8.' Cardiology Diagnostic, LLC 3.54 9. Medical Express Ambulance Service, Inc 49.24 10.' Physicians of Rehabilitation, Industrial & Spine Medicine, P.C. 57.00 11. Verizon Telephone 32.70 TOTAL {Also enter on Line 10, Recapitulation} $ ' 1,534.10 If more space is needed, insert additional sheets of the same size. PINNACLE HEALTH EMERG 6$80 W.SNOWVILLE RD SUITE 210 BRECKSVILLE OH 44141 To Pay Your Bill pnline Please visit: ~ ,:'=;-~ .~ ~ www.meddatabillpay.com/PHE . ,, CLARA KOONTZ 16 5 ENOLA DR APT 216 ENOLA PA 17025-2732 {rrrtttrrrt{trrrrr{rtrtrtrrr{rt{rrrtrrttrrrtr{rt{rrr{trrtrtrrt If paying by credit. card, please check box and fill out Information below. ..- 'CARD NUMBER AMOUNT ~r SIGNATURE EXP DATE Pay This Amount 33.81 Account Code PHE ,Account Number 168264378 Statement Date ~ 10/22/09 Payment Due Date 11/08/09 SHOW AMOUNT PAID HERE $ _ ~;t. PINNACLE HEALTH EMERG PO BQK 8500-55168 PHILADELPHIA PA 19178--5168 trrrttlrlrrrrrlttrrrltrrtrrtrlrrrrltrtlrrtrrlrrtrrtt PLEASE CHECK BOX IF ABOVE ADDRESS IS INCORRECT OR INSURANCE PLEASE DETACH AND RETURN TOP PORTION WITH PAYMENT. tNFORhAAT10N NAS CHANGED, AND INDICATE CHANGE(S) ON REVERSE SIDE Account #: PHE 188284378 Please Pay: $33.81 Payment Due: 11/081t}9 R ~ 09/15/09 IZANKIN D EMER DEPT HIGH SEVERITY&T 451.00 33.$1 MEDICARE PAYMENT -;135 . ~3 MEDICARE AD3USTMENT --281.96 *~~ IMPORTANT NOTICE ~*~ PAYMENT IN FULL I5 REQUIRED. IF YOU ARE UNABLE TO PAY IN FULL, PLEASE CONTACT US IMMEDIATELY TO MAKE FORMAL PAYMENT ARRANGEMENTS. Patient Name: CLARA !M KOONTZ Physician Services Provided By: ~ " "~~ '~ To Pay Your Bili Online gifting Inquiries: PINNAGLE HEALTH EAAERG ~ ~~ry` .r~'-~ Phase Visit: "77- ~ ~' -l3 i 9 PO BOX 85UU-55168 ~ ~' ~~ www.meddatabillpay.com/P o ~' PHILADELPHIA PA 19178-51G8 ~. _ ~' ~ E-M.A}L: puss#ions~shcsenrice.com ;t. ~/ rM~~. ~T?. ~j MON. -FRI. R-Uo?m #0 6:QO~rm EST „ ;; ,~ I~ o~ PINNAGLEN~AL~"H HOSPITALS CI,.ARA M KOONTZ 16 S ENOLA DR APT 216 ENOtA PA 17025-2732 Patient Name: Koontz, ,Clara Statement Date: 10/30/09 Service Date(s): 09!15/09-09/20f09 Account Number: 100074446 Primary Diagnosis Code: 434.11 Financial Aid is Available For Those Who Apply And Qualify. Customer Service Can Assist You ~-~-~`- With This Process. ~..__.._ For Account Information, """' Please Call (717) 230-3717 or 1-80Q-603-6Q64 for Uut of Area Catty. If payment has been sent, please disregard. Total Charges: #15, 222.90 Payments/Adjustments: ~14,154.9Q- Account Balance: ~1, 068.00 Patient Balance: S1, 068.00 Please Pay This Atnt; $1,Ofi8.00 Ins. 1: MEDICARE A .p0 For questions, call our Billing Help line at: fns. 2: 717-230-3717 for local calls or lns. 3: 1-800-603-6064 for Out of Area. Ins. 4: Customer Service Hours: Mon-Wed-Fri 7:00 AM to 4:00 PM Tues-Thurs 7:Ot3 AM to 6:00 PM Please Note: Your physician wiH bill separafeiy fir professional services. Make Checks Payable To: PinnaCleHeai#h Hospitals ~'~ tltiN ~~~~ ~n NR~ ~ ~~ ~ ~ ~~ ~~ ~'~.nr~acle~~er~ltt~ ~~os~tta.s r-"j Check box if your address or insursnte information J_,,,J hss changed. Please mab chsngss an track t]DDt]1094 001 0.53 CLARA M KOONTZ 16 S ENOLA DR APT 216 ENOLA PA 17025-2732 OOOOD3t000?4446DDDD01Db8D000DpDDOD1 Account Number. 0 74446 Pteasa Pay this Amount: anent sme: Koontz ,Clara ue y: Due Now a^ a~~~ and umber: CW2 Na:" Exp. date: Signature: Rmount paid: "` T!-e E1/V2 Nun+ber is tta Isar 3 diy'RS an the trattt of your credit card, by Yarn si0rratnre ~~~~~~~~~~~~~~~~~{~r~~~~~~~ PINNACLE HEALTH HOSPITALS P.Q. BOX 2353 HARRISBURG, PA 17105-2353 ,. Your A'~`&'T` statement August 30 -October 29, 2009 ~"t~ .~ r #BW NCJFM eQ422Q4Qts705Q1~7e 8 CLARA M KOONTZ 16 S ENOIA DR APT 216 ENOLA PA 17026-2732 Previous balance ...........................................................................70.97 Payn-er~t rece~ed Sep 11 -Thank You ...........................................-7f3.S7 Other charges and credits ...........................................p 2 ...............9.18 Taxes and surcharges ................................................p 2 ...............1.07 Tatal amount due $10.28 Date due (dovember 12, 2009 This statement includes charges from the last two months. ..._ Never Mail Another Check to Pay Your ATBT Bitt. For tl~e ultimate convenience, enroll in AT&T Automatic Bill Payment (ABP) and have your future payments automatically deducted from your checking account. To enroll, check the box and sign on the fine on the back of the remittance coupon, and return with your payment. Or sign up for online billing to review and pay your bill each month by logging onto your ATBT Online Billing account at www.att.com/remitdoc ~=' Extra! Extra! Need to pay your bill quickly? By using ATBT's free automated system, you can make your bill paying easier! Just dial 1.840.288.2747 arrd tray your bill today! Great Rates and No Card to Carry - just a click awayt ATBT Virtual Prepaid Phone Cards make it easy to call worldwide. You can buy prepaid phone minutes instantly and conveniently online -with no card to carry. Available from $7 up to $40. Call from a landline phone, or use with a mobile phone plan that has free nights and weekends and save on calls from the US to international countries. All just a click away! Buy yours today at www.att.com/prepaid. Cuatomer ID: 717 732-3157 0406705 , Page 1 of 2 Customer Service: 1 800 222-Q300 Text Phone (TTY): 1 800 855-2880 Internet Address: www.att.com ~.. Extra! Extra! ~`'' Need to pay your bill quickly? Dial 1.800.288.2747 and use ATBT's automated system to make your life easier! a o Benefit news Sign up for ATBT Online Billing and you won`t get another paper bill! To sign up just visit www.att.com/online Continues on back ~1 Healthsouth Of Mechanicsburg 178 Lancaster Blvd Mechanicsburg, Pa 17088 ..... ~_ s ..... .~.. ..... ....r "'~ ..~. ..... ..~ ...~. 1 U/21 /2009 '~~'~",,,~"'-'- 000376 HS1TA294 r.....` G~ARA M KOONT~ 16 S ENOLA DR '~ ENOLA PA 17025 ~~~ `~i Patient: Clara 141 Koontz Account: 00073 813 8 Admit Date: 08/26/2009 Account Balance: $89.99 Dear Clara M Koontz, "thhis is to advise you that the amount of $8y.99 on your account is now due and payable. Please send pa}~ment in fitll. If ~~ou r~ish to use a credit card. complete the bottom portion ~~f th~~ l~r~;." and mail it directl}~ to this office. We accept Viso, Mastercard..american E~prea and D>~~c~~ cr if you have any questions regarding -our account or you «ish to sit up a paim~nt plan. ~~l;a~~ ~,:r ia~~i hesitate to call (717) 691-3700 for assistance. We appreciate your prompt payments. Thank ~~ou for choosing HealthSouth. Patient Accounts (717) 691-3700 DetacA Coupon Here Det.tch Coupon Here '~ PLEASE INCLUDE THIS COUPON N7]"H POUR CIIECK OR CRIUIT CARll Pal"~IE1T. 7kL~.\K 1 Ot . Patient: Clara M Koontz Admit Date: 0$/26/2009 Hospital ID -Account: 030031 - 000738138 Account Balance: $89.99 To pay by credit card, please provide the following information: ^ American Express ~_Z Visa L1 Master Card ^ Discover NAME ON CREDIT CARD :~ v a CREDIT CARD Nl3MBER EXPIRATION DATE u''tynature ~, PI.L~,ASE INCI.LllE THIS COUPON WITH YOUR CHECK OR CREDIT BARD PAYMENT. THANK YOU. Irrrlllrirrr~rllirrrilr~ltlr~lrrllt~~rllttllrri HEALTHSOUTH OF MECHANICSBURG PO BOX 5500-$636 PHILADELPHIA PA 19178-8636 082609 030033~OOD738~3+6 3 Oi]08999 2 ~... ~`~ Heritage Medical Group, LLP HERITAGE HOSRITALIST GROUP 3 Walnut Street Lemoyne, PA 17043 FORWARDING SERVICE REQUESTED ~ " ~ Please check if address or insurance information ~ _ ~ is incorrect and complete form on back. ~~~~~~~~~~~{~~~~~{~~~'~~Ill~~~~l~~l~l~l~~ll~~~l~lr~ll~~~~11~ 00 ;si ""'""'MIXED AADC 442 THE ESTATE OF CLARA M KOONTZ ENQLA CQMMONlS PO BOX 456 LAKE HARMONY PA 18624-0456 HERITAGE ME[)ICAL GRL3UP LLP PO Box 70850 Philadelphia, PA 19176-5850 DD43b699DDDD226g?2DOODD~D~1~# ~ PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT Account ~E_ 226972 Please Pav- X101 _~ ~ Dire DatEs- 7 7 ~~~~~~ tnsurance Patient Date Description Charges Balanc® Balance THE ESTATE OF CLARA M KOONTZ ID# 226972/JAMIE L HETTICK MD 09/15/2009 INITIAL HOSPITAL CARE, COMPREHENSIVE 244.00 244.00 0.00 10!02!2009 SYSTEM CONTRACTUAL ADJUSTMENT FROM MEDICARE -66.24 0.00 10/02/2009 PAYMENT FROM MEDICARE -142.21 0.00 i0/OZ/2009 PATIENT RESPONSIBILITY - THE BALANCE IS YOUR CO-INSURANCE WHICH IS NOT -35.55 35.55 --> COVERED BY YOUR INSURANCE. BALANCE TICKET #IH117491 .00 35.55 THE ESTATE OF CLARA M KOONTZ ID# 226972/JAMIE L HETTICK MD 09/16/2009 SUBSEQUENT HOSPITAL CARE, EXPANZ?ED PROBLEM FOCUSED 90.tt0 90.00 0.00 10/07/2009 SYSTEM CONTRACTUAL ADJUSTMENT FROM MEDICARE -24.30 0.00 10/07/2009 PAYMENT FROM MEDICARE -52.56 0.00 10/07/2009 PATIENT RESPONSIBILITY - THE BALANCE IS YOUR CO-INSURANCE WHICH IS NOT -13.14 13.14 --> COVERED aY YOUR INSURANCE. BALANCE TICKET #IH117617 .00 13.14 THE ESTATE OF CLARA M KOONTZ ID# 226972/ELENA R DAILEY MD 09/17/2009 SUBStQUENT HOSPITAL CARE, EXPANDED PROBLEM FOCUSED 90.00 90.00 0.00 10/07/2009 SYSTEM CONTRACTUAL ADJUSTMENT FROM MEDICARE -24.30 0.00 10/07/2009 PAYMENT FROM MEDICARE -52.56 0.00 10/07/2009 PATIENT RESPONSIBILITY - THE BALANCE IS YOUR CO-INSURANCE MtHICH IS NOT -13.1.4 13.14 --> COVERED BY YOUR INSURANCE. BALANCE TICKET #IH117722 .00 13.14 THE ESTATE OF CLARA M KOONT2 1D# 226972/ts'LENA R DAILEY MD 09/18/2009 SUBSEQUENT HOSPITAL CARE, EXPANDED PROBLEM FOCUSED 90.00 90.00 0.00 10/07/2009 SYSTEM CONTRACTUAL ADJUSTMENT FROM MEDICARE -24.30 0.00 10/07/2004 PAYMENT FROM MEDICARE -52.56 0.00 10/07/2009 PATIENT RESPONSIBILITY - THE BALANCE IS YOUR CO-INSURANCE WHICH IS NOT -13.14 13.14 --> COVERED BY YOUR INSURANCE. SALAkCE TICKET #LH117768 .00 I3. I4 IMPORTANT MESSAGE ABUT YOUR ACCOUNT Prompt payment is greatly appreciated! TOtSi ~® ~ ~ i • i 4 -Insurance Pending . 0 0 Amount Due l01 . 14 Make Checks HERITAGE MEDICAL GROUP LLP Payable To: PLEASE DO NOT SEND CASH THROUGH THE MAIL •2olo2ocoo> EG2651-32 ~ Check Card Used and Fill in t3elow ito Pay by Cred t Card visa -_ -, ~ (~ MasterCard ~ ` [~ Visa ~,_ _~--- ~ Discover ar umber - rr~o~ un~ ignature ~' xp. to tatement ate ay is mount Accoun 11/04/09 X101.14 226972 a cnectit ~ y ate UNT 11125/09 P D HERE For Billing Questions Call (717) 909-7118 X22 PAGE 1 OF 2 O1 10564 a b n v b b O n q .. STATEMENT OF ACCOUNT ~4AKE PAYMLAITS TO: SUSQUEHANNA VALLEY PAIN MGMT,P.C. 825 SIR THOMAS CT, STE B HARRISBURG, PA 17109 PATIENT INFORMATION: CLARA M KOONTZ 16 SOUTH ENOLA DR ENOLA, PA 17025 DATE: 09/29/09 ACCOUNT NUMBER: 26257 AMOUNT DUE: 40.29 AMOUNT PAID: WANT TO USE YOUR CREbI'P CARD? (we accept visa and Mastercard) Card NO: ----_-__..__ :Exp : _. -- ~---- 3 DIGIT SECi.;RITY ~O~E (ON BACK OF CARD): c; ~^a~~:re PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE _____________~~~__-_-_===~=x_~ ~~______--___=_=~___-____~_______,~~__=-___~____-_~_-___--_-_-____- DATE DESCRIPTION CHARGE PAYMENTS PAID BY ZNS DUE PT DUE Balance Forward 0.00 08/26/09 OFFICE CONSULTATION, DETAILED 225.00 09/29/09 Medicare Payment 76.71 MEDICARE 09/29/09 Medicare adjustment 129.11 MEDICARE 08/26/09 LUMBAR EPIDURAL STEROID INJECTION 500.00 09/29/09 Medicare Payment 62.18 MEDICARE 09/29/09 Medicare adjustment 422.27 MEDICARE 08/26/09 FLOUROSCOPIC GUIBANCE AND LOCALIZ 140.00 09/29/09 Medicare Payment 22.25 MEDICARE 09/29/09 Medicare adjustment 72.19 MEDICARE BALANCE IS YOUR COINSURANCE RESPONSIBILITY. THANK YOU. 0.00 19.18 0.00 15.55 0.00 5.56 Insurance Pending ................. 0.00 Patient Amount Due This Statement: 40.2,9 LAST LAST PAYMENT PAYMENT CHECK ------------------ PATIENT BALANCE AGING ---------------------- DATE AMOUNT NUMBER CURRENT 30 60 90 120+ 0.00 40.29 0.00 0.00 0.00 0.00 IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT THE BILLING OFFICE AT {'717)652-8670. aocccsaxacc==xsssxssc=xxasxassxasasszs:.xmsxs===sssxstcsescaacscxc=xsss=acsao~=amsmaacas=xa=xrsx Patient Name: CLARA M ROONTZ DATE: 09/29/09 Account Number: 2625'7 r3f%~'~, ~~4~Yli~'~R~ii~ INTERNISTS OF CENTRAL PA 108 LOWTHER STREET LEMOYNE, PA 17043 11/11/09 62868 ' ,~~' ~"i+~r r, ~ ,+t- 48.11 Forwarding Service Requested 25877 CLARA M KOONTZ 16 SOUTH ENOLA DR APT 216 ENOLA PA 17025-2732 _MC _VISA Disc Card ~,~ Sign INTERNISTS OF CENTRAL PA 10$ LOWTHER STREET LEMOYNE, PA 17043 ~ iVi~:SSAGEv LXF'LAiNEQ BELOW Security Code EXP .~/~ ~_~~~ PLEASE PAY UPON RECEIPT. IF BILLING QUESTIONS CALL 774-1366 BETWEEN 10 ~`~`~ ~ ''~'"~ AM AND 4 PM AND CHOOSE $ILLING. ' ' ` ' ' ' ' ' ~'' ` ' ' ' ' ' '.cs'c-,'t s'c;k~cs' cs'rs`c'cs r :3c;c~`cs'cs'c ~~'c-!c~'c:c~'c;;~csc:c~'c~- :: s'c;ci::'c3c~'r~ c' c~ c:c;c~ c~ c:c~ ;c~'c:c~ti~ c~'c~'cs c';:c'c;'c~ c:c:cx ~ s; :'cics c;cs;i; c; c:c~ c:c rs c:c:c: 09/21/09 1 13 L INPATIENT CONSULT C4MFREH 99254 434.91 202.00 11/09/09 Medicare Payment 130.21 11/09/09 . Accept Assign Add. -39.24 32.55't 09/23/09 1 13 L SUB NURSING EVAL/MANAG 2 99307 434.91 54.00 11/09/09 Medicare Payment 31.14 11/09/09 , Accept Assign AdJ. -11.08 7.78* 09125/09 1 13 L SUB NURSING EVAL/MANAG 2 99307 434.91 50.00 11109/09 Medicare Payment 31.14 ` 11/09/09 . Accept Assign Add . -11.08 7.78' = ~ L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make payment. DATE LAST PAID AMOUNT • ~ • - . 1 • - • ~ • ~ . . - • .. :. , 00/00/00 0.00 48.11 0.00 0.00 4.00 0.00 0.00 0.00 48.11 ~nai~E -^ INTERNISTS OF CENTRAL PA ct~ECK 108 LOWTHER STREET aAVAB~.E-ra: LEMOYNE, PA 17043 7.~ Y~ ~aY u - t ,,I' 7=-~., ash, :~n1~~~~.'.`51~r.~ ~'-a~`~i!' y ~ 48.11^ , PAT/~ 1-CLARA M KOONTZ PRV~~ 13-KAPOOR, V. MARTHA, M.D. Ph: (717) -774-1366 Accts/: 62868 Date: 11/11/09 Page 1 of 1 .mot ..Y.., r~tt ~~yy~•. r. .-rrT~.a. 1.. ( $«itemen~ :,:~~:u 3 Ghart ~smE~~;• _ ` ~A~.'d i _,.:•' t~lAr LE Rv 'E'U{r~;2t~t?c ~ FG~7w LUf3" w a' i TO pc3~ b~7 G:'G~'~ti CckCC{, com~l@tf! 2tiiy Cf~r2, i~.''l:a i ~?°,•'iJ: r. '~~~~JLEiOWI~. FA ~?~?~? Ck card type Ns~sterGarG Visa :.:p :.~a:e __ =,::.~~RESS SEF2VfGE t'~ OJ S i Eu Card# 3 c4igt: see c;~~ Cardhok~r t~~ _ ~~ ~ "''. >?REPORT CREQIT CARt7~ To t?RAC E'fCE C3i~..~`. ~ Cardholder Sign ~_ CLARA M. KOOn~TZ ? 6 S ENOLA Er~o~.,a, PA ~ ~a2~ CARt310LOGY t:31A,G~OSTiG, LLG 725 MAPLE RD MIDDLETOWN, PA 17057 rroff ^ ^ ^ Make checks PAYABLE and SEi~D to the above ^ ^ " ** THIS BILL WAS PREPARED BY ACCUMED BILLING. ** FOR ALL BILLING QUESTIONS PLEASE GALL 1.80D~-290-2528. ~oun# Enclosed $ Check # please cut on dotteal line and return top portion with payment Balance Forward From Previous Statement 0.00 Patient: CLARA M. KOONTZ Case Descrip: ER/HGS/6-18-09 Primary tns. HtGHMARK MEDICARE 1015/2009 Amount Paid by Amount Paid By Dates Procedure Procedure Desorption Charge tnsurance Guarantor- Adjustments Remainder 06!18/09 93010 EKG INTERPRETATION & 35.00 -7,09 0.00 -26.14 1.77 Patient: CLARA M. KOONTZ Case Descrip: ER/HGS/7-16-09 Primary Ins. HIGHMARK MEDICARE i Amount Pard by Amount Paid By ,Dates Procedure Procedure Description Charge Insurance Guarantor Adjustments Remainder 07/16/09 93010 EKG tfYTERPRETATION & 35.00 -7.09 0.00 -26.14 1.77 t~ST PATIENT PAYMENT $ *'' Before you are billed, charges are submitted to ar~y inscxance carriers you prcavided This balance is now the patient's responsibility. Payment is due within 15 day: from the statement date. Amount Due We Thank ~Yvu for paying your account pror~ptlyl ._. CARDIOLOGY DIAGNOSTIC, LLC ~,~q. Please Remi'~ ~~ayrnen` ~-o: tl~edica! Express Ambulance Service !nc Billing cJffi~~e P.O. Box i 26 New Cumberland, PA 47470 t~t1ESTIONC, ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 717-214-6020 Email: info@ambulancebillingoffice.com Date of Service: 9/2012009 14:42 Please visit our website to provide insurance or make payment, and Patient Name: KOONTZ, CLARA M. for additional payment options and frequently asked questions: From: Harrisburg Hospital (Pinnacle To: GOLDEN LIVING CENTER -WEST SHORE www.ambufanCebifiingoffiCe.COm Medicare has paid their portion of these charges. The balance due is your responsibility, If you have supplemental insurance which covers this co pay amount, please complete the back of the invoice or contact our billing office. Thank you. 9/20/09 BLS Non-Emergency Transpol A0428 1 750.00 9/20/09 Mileage A0425 6 10.65 9/20/09 Adjustment -Insurance 11/19/09 Payment 11 /19/09 Payment Total 750.00 63.90 -567.67 813.90 -567.f 7 -164.01 -32.98 -19fi.99 DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT. We accept payment in full by check* credit card or electronic Flease'Make Check Vayab(e To: check deduction. Please indicate your payment choice below and fill in required information. If other arrangements are tVtedieat Express Ambulance necessary, please call us at 877-214-6018. SerVICe Inc . ~. ~;' ~.. .. Credit Card: ^ MASTERCARD ^ VISA ^ AM ERICAN EXPRESS ^~ DISCOVER Electronic Check Deduction i ~ Please send a vaided check OR provide information nelow . _~_ ._..._ Please make any corrections to address below. To the Estate of CLARA RA. KOONTZ PO BOX 45fi LAKE HARMONY, PA 18624 *Returned checks -You will be responsible for ail incurred bank fees permissible under state law. ~I~Y~I~I,~I~1~ fly F~~F~#.~F~l~..fT.•~.Tl~~l, !f"IQU~T~tI~""i!{>~ ~'~ ~~'!~'1~f=~ r~'~r'~~'~`1~~`, ~°.`'. ~~~A-~~ iVl ~f~~T -- ---- - -- -- ~? 5 _<ancasler ,~~ui~=vary A3i a I_onctundei ry Road M~chael ! . ~.u nr~ac .i ~`Y' C . ~ ;;TATE~MENT DATE PAGE 1'.C). Box ?_U2t~ E,lontn Bldg. Su to 10E~ W Iliarn ~ . i=3o 'r~ ,. r iul. ). ~-- ----_.--- .-. __...____- ItJ4c~rhanicr,burg, ('A 1-1(a'~", ~ t-lam,burg, PA i7-i09 (717) G91-37!:i~~ (:%'1 i') 561-424.?. w~rw.~trism~:ire .:;~r~~ _; ~w~.`J_... ~ . _. ..., Lisa A. Eaton, PsyD J AccouNr-~ _------ ~----~. 13illirig Degt: {717) 591-~3~t0[r fax: I.I). #25--i65150~ ~'loas„ ret~tit~ ti~i> portion of statement for yr~~ar r~~:«rd~, NUMBER ~%11~,.';~{`•:,;:; NSACTION OATE~{NV,NO_~POS~ PATiEN l~~ ~ PROCEDUi~E , ~ `__ _ _)(_SC~ IPTION OF SERVICES ~ DIAGNOSIS ~' AMOUNT ~% r # K -t '!.( .. i. .. s~.J t... .. i.°~d ': ~~ .t ~3. if~ . ~ ~~. ... ... -1..~ f+ a I;.E ., i 't a - ., ~ ~ ~ _~Ii f~! t !t i l~~ 1.,~_ ~ ~ ' s: t; ~~ i t `~`r'I I ~'ll'!_ r:~i"!.'i~'t~,~ i ' .., .. ~~~..i~.~ f T:?~ I'"~_+a :...f:;I•ri.l. ~ ~ I t - ~ 1 ~ i ~ ~'` ~t I '~ai:a `':1?I.. . ~. ... t _ .° ~ ~ ~ I ) ~ ; ': i } i .. t;!. i ~ ~ i t 1,; , i , t....i ~: tt 'if", r.. i... _.. _; ...i .. t .., ~ tt ; .~. .. , ., t :::y ° E r_ ~. t a _ ~~° L. {.f .'. ,_.r~..,~ 1. i I J, .!~ L...~::. i Y.i (.J I j' ~ i s ~ c- i ~ ._ 1 r .; .. rp~ =. ;~ i' .. l....' } r ... r- ! ~ ,° ' . '~ ify ~.,t . . _. i _ ,.. •-x';-. _. ,,i.. I . ~t ltt _ _ ~~''.. I.; : -'....'i..r .., t i 1. w;r:~tl.._;...t..li,.! t ~ _ t 1 1'~I" 1.. ... ~~, ±{; _ { } , r i { { t _1~:~.f t It ` ~ i , _. i ' ~' i i i i ~~ 1 ;. I t s, t~ I ; •t{.. i.~{-:. f:: (•.~ - s it :: I t t ~~~h:: I~-'i...E•.t~'...;~: i_;f=ti...~t t~_~`:~ :i • ; ;.._-t __._ ..~ .... Fti!-• t ! ({" ( ~•'! f; ::_i!~'t (.1t i ! { li .? 'I t, t•' .,, - ~ ' .... ..#.. 1 i t t ~ 11 ' t'ir-~. ~ 1~ t~'t i ' ~t`.I `. . s.. `If ~I( i;i"f ;; f"tl' li t`t' :J .. t_.i i ~.._• .;. s ; _ .. ~i , f ,?a. .:°~ .!. n t=?-~:; - ----- j---i'- CURRENT OVER 30 DAYS ____-- -~.- __-- - - _____ OVER 60 DAYS OVER 90 DAYS' - ____ _- I ~ ACCOUNT 7tJTAL AGE ~ AMOUNT OVER 120 DAYS ANALYSIS DLIE _ 1 PLEASE DETACH AND RETURN THIS PO _ _.______ RTION WITH YOUR REMITTANCE ACCOUNT NO_ lilt?Y{'-I~I~~., t I n .!. L .? , .#. I{.33.. tftill ~. CSI ;;' ,. i xi t~::'.! ::J ~::. a t". ± .J t:- ~,... .,,p ~. -}. ~..~. ~ i u {i.l ~: ~ ~. i 3 t7t ? f S ~:i ` K !!I 4%1 PLEASE MAKE YOUR CHECK PAYABLE TO PRISR~. ..,.~...P-._ ~~"`~~~~~ Manage Your Account Phone Number ~~,r.~~ra~~ur~t Numr,e~~ l~ Rlsr~~~ C ~tf ,. My Account at verizon.com/biliview 7 ? i" ar32-31 ~;' 430 30Y° ~ 0/ M 3t'2~10!a -- _Venton_News Get More, Save More Call 1-888-610-7288 to make sure you're getting the best Verizon services at the best value -from phone and Internet, to TV and money- saving bundles. Together we'll evaluate your current services, and find ways to save you even more. Moving? Let Verizon Help Cali 1.866.UZ.MOVES to bring the power of the Ne~hroork to your new home. We can connect your TV, Intemet & phone quickly -maybe before you're finished unpacking. Plus, we have Bundles to frt your needs and your budget. Service availability vanes. Verizon i=oundation Visit Thinkfinity.org for thousands of FREE educational resources for teachers, students, parents and the after-school community. Quick Bi~~ Summary for CLARA M KOONTZ Previous Balance Payments Received Sep 17 Balance Forward NeMr Charges Voice Services (See pg 3) Taxes, Fees & Other Verizon Charges Other Providers (See pg 4;1 Total New Charges Total Amourrt -Please Pay iwiow 948.90 -$48.90 5.00 - $10.95 __ $.55 $21.20 $32.70 $32.70 CONSUMER ALERTt Cheat yew bill 1f1ds ntee~ fer a new sertrtce prsvider. Revised Rnaf Bill Non-Basic Charges Pay Your IdN ealiae st 1la~iiop.ooartpayllnalbRl To avoid referral to sn oubide collection agency, the full annount is due upon receipt. Direct Payment Enrollment 'Online Billing b Payment Questions about your bill? vetlzon.com/bilipay _ verizon.comlbliivlew ! verizon.com or 1-800-VERIZON (1•~-800--83~-496G) Please return this remit slip with payment ,~~~ ~ Total Charges Due Pieasa~ Pay Now ,~.~ Account Number 717 732-3157 430 80Y Total Amount Due: 532.70 ], 013 0 9 Yesi I want to be a Literacy Champion. Make Check Payable to Verizon [~ Sign me up fora $1 monthly donation to (._._J Verizon Reads 0007234101 AT 0.357 VPC2861 i 0240 Xx CIARA M KOOIYTZ 16 S ENOLA DR APT 216 ENOLA PA 17025-2732 ~1~1~~~~1~'~'~{~1~~111~111~1~~~111,~~1~'Il~l~~~lrlllll~~~~l~~i~ll $ D^ ^0 YERQON PO SOX 280G0 i.EFitGi°f V~EY PA t>l002 x000 ~~r~l~~~~l~~l~~~~l~i~~~l~~~~~1~~~~~~1~~~~~1~~~~~~ill 11??~,70732315743030280210299999100000000000000000~2?0600000 !I ~p Y LAST WILL AND TESTAMENT KNOW ALL MEN BY THESE PRESENTS, that I, CLARA M. KODNT'Z currently residing in Enola, Cumberland County, Commonwealth of Pennsylvania, being in good. health. and. of sound and disposing memory do hereby make, declare and publish this as my Last Will and Testament, hereby revoking all former Wills and Codicils heretofore made by me. FIRST: I direct that all of my debts not barred by the statute of limitations, expenses of my last illness, funeral expenses, costs of administration and claims allowed in th-e administration of my estate shall be paid by my Executor hereinafter named, from my estate as soon after my decease as shall be found convenient. SECOND: I give, devise and bequeath all of my pictures to my son, ARTHUR R. BOSSLER to either keep or distribute to various members of our family in his sole discretion. THIRD: I give, devise and bequeath all of my clothing and j ewelry to my sister, VERNA CARTER.. If my sister, VERNA CARTER predeceases me, or for any reason does not take possession of these items, then I give, devise and bequeath all of my clothing and jewelry to nay friend, LINDA EVER. FO-[1-RTH: I give, devise and bequeath my table that has my pictures on it to my grandson, BRYAN E. BOSSLER. FIFTH: I give, devise and bequeath my Magnavox radio and tape player, and alI of my tapes, to my grandson, GREGORY A. BOSSIER. SIXTH: I give, devise and bequeath the winter scene picture hangir.~g on the wall in my apartment and my tabletop VD system/clock radio to SHERRY LESSENS-. ~- ~,: SEVENTH: I give, devise and bequeath my microwave oven, floor lamp, table lamp, Sanyo television set, two (2} telephones and my Bible to my son, GLENN E. BOSSLER. EIGHTH: I bequeath my remaining household and personal effects and other tangible personalty of Like nature {not including cash or securities), together with any existing insurance thereon, to my sons, ARTHUR R. BOSSLER and GLENN E. BOSSLER, in equal shares. NINTH: I request that the monies in my checking account be used to purchase a plaque for my grave, and any balance remaining be distributed one-half (1/2) to my son, ARTHUR R. BOSSLER and one-half (1/2) to my son, GLENN E. BOSSLER. TENTH: I have already given my Epiphone Guitar to my son, GLENN E. BOSSLER. If he still owns it at the time of his death, I request that he bequeath it to my Grandson, BRYAN E. BOSSLER. ELEVENTH: My Cemetery Lot Deed #7912 at Blue Ridge Memorial Gardens, I request that I be buried in the space next to my son, HAROLD BOSSLER. The remaining two (2) spaces are for my son, GLENN E. BOSSLER and his wife, AUDREY BOSSLER. TWELFTH: I give, devise and bequeath the rest, residue and remainder of my estate, whether real, personal or mixed, and of any nature whatsoever and wherever situate, to my suns, ARTHUR R. BOSSLER and GLENN E. BOSSLER, in equal shares. In the. event that ARTHUR R. BOSSLER or GLENN E. BOSSLER should predecease me, I give, devise and bequeath the rest, residue and remainder of my estate, whether real, personal or mixed and of any nature whatsoever and wherever situate, to the survivor of them. THIRTEENTH: I hereby nominate, constitute and appoint my son, ARTHUR R. BOSSLER, as Executor of this, my Last Will and Testament. In the event that ARTHUR R. BOSSLER shall predecease me, or be unwilling or unable to act as my Executor, as aforesaid, then I nominate, constitute and appoint my son, GLENN E. BOSSLER without necessity for posting security regardless of state of residence, as Executor of this, my Last Will and Testament. All references to the Executor herein shall be applicable to said substitute Executor. FOURTEENTH: My Executor shall have, in addition to the powers and: authority conferred upon him by law, the following additional powers and authority: 1. To sell at public or private sale, exchange, transfer, partition, give options upon, lease, mortgage, pledge or otherwise dispose of any property, real or personal, at any time constituting a portion of my estate, and upon such terms and conditions as the Executor shall deem wise. 2. To invest any money at any time in such bonds, stocks, notes, real estate, mortgages, life insurance, annuities or other securities, or such property, real or personal, as the Executor shall deem wise, without being limited by any statutes or rule of law regarding investments by the Executor.. 3. To retain, without incurring any liability, as investments, any property owned by me at the time of my death, as long as my Executor may deem it wise, and even though such property is not the kind of property an Executor would purchase as an investment; and even though to retain such property might violate sound diversification principles. 4. To cause any security or other property which may constitute a portion of my.estate to be issued, held or registered in the Executor's own name, or in the name of a nominee, or in such form, that title will pass by delivery. 5. To consent to the reorganization, consolidation, .readjustment of the financial structure, or sale of the assets of any corporation or other organization, the securities of which constitute .a portion of my estate, and to take any action with reference. to such securities .which, in the opinion. of the Executor is necessary to obtain the benefit of any such reorganization; consolidation, readjustment or sale; to exercise any conversion privilege or subscription right given to my Executor as owner of any securities constituting a portion of my estate resulting from any reorganization, consolidation, readjustment, sale, conversion or subscription. 6. To pay all costs, taxes, charges and expenses in connection with the administration of my estate, including such compensations to. Executor which shall be in accordance with established fees throughout the period of administration of my estate. 7. To determine what is "income" and what is "principal" hereunder, and my Executor's decision thereon shall be final; and to purchase securities at a premium. or discount, and to apply or charge said premium or discount against income or principal as the Executor may determine. 8. The Executor may make payments to or on behalf of any person who i.s the beneficiary hereunder but in no event, however, shall payments be made to any creditor or other such person because of anticipation of payment by the beneficiary, and any such claim made by way of anticipation by the .beneficiary shall be of no validity or legal effect. 9. To borrow money from any person, f rm or corporation, including any corporation acting as an Executor hereunder, for the purpose of protecting and preserving or improving my estate hereunder; to execute promissory notes or other obligations for amounts so borrowed. 10. To employ legal counsel, accountants, brokers, investment advisors, custodians, managers and other agents and employees and to pay reasonable compensation out of my estate or any funds held hereunder to which said compensation is attributable. -~~~~~ a 11. To carry on any business owned or controlled by me at my death for whatever period of time my Executor shall think proper, and my_ Executor sha1l~ have the power to do any and all things my Executor deems necessary or appropriate, including the power to close out, liquidate or sell the business at such time and upon such terms as my Executor shall deem best. 12. To do all other acts in my Executor's judgment necessary or desirable for the proper and advantageous management, investment and distribution of my estate. FIFTEENTH: I direct that all transfer and inheritance taxes, state or federal, assessed because of my death, whether the funds, property or insurance proceeds to which such taxes are attributable pass under this Will or not, shall be paid out of my residuary estate; that my Executor pay, or provide for payment of all such taxes at such time, or times, and in such manner _ as my Executor deems best, 1N WITNESS WHEREOF, I, CLARA M. KOONTZ, the Testator to this, my Last Wi11 and Testament, typewritten on six sheets of paper which I have identified at the bottom of each page by my signature, hereunto set my hand and seal the ~,~`" day of ~~, ~ 2005. CLARA M. gOONTZ The preceding instrument consisting of this and five other typewritten pages, each identified by the signature of the Testator, CLARA M. KDONTZ, this day and date thereof signed, published and declared by CLARA. M. KOONTZ, the Testator therein named, as and for her Last Will, in the presence of us who, at her request, in her presence, and in the presence of each other have subscribed our names as witnesses. ~~r,~~ccr~3L ~irw. YI'l. C'at~d~ COMMONWEALTH OF PENNSYLVANIA COUNTS OF CUMBERLAND SS I, CI~ARA M. KOONTZ, Testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. ~ . ~~GZJLl,Z, ~'Y,i. CLARA M. KOONTZ Sworn or aff rmed to and acknowledged before me by ~C'LARA M. KOONTZ, Testator, the day of , 2005. (SEAL) 1~ ' - Notary Public COMMONWEAI:Thi Of= PENNSYLVANIA Notarial Seat M""ichae{ Cherewka, Notary Pubi'~c Wamleysburg Baro, Cumberland County My Commission Expires Apr. 27, 2009 Member, Pennsylvania Association of Notaries COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND We ~S ~ ~-z ~, ~ tea. cr~ and ~ ~• ~~~Q fQ t ,the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Testator sign and execute the instrument as her Last Will; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testator signed the Will as witnesses; 'and that to the best of our knowledge the Testator was at that time eighteen or more years of age, of sound mind and- under no constraint or undue influence. ~r/~~/v l UI Ill m• ~~~Ztt~-Uw - Sworn or affirmed to and subscribed to before me by 1.~5)~e l.~rcc.~ and Ts~ Cad; witnesses, this ESQ- day of `, 2005. s ' (SEA_L) ~ ~ _ Notary Public COMMONWE~q~T~ pE pENNSYLVANtA Notarial Seal ~ Mi~ael CF-a-~wka, Notary Public Wo+~'nl~y$burg Boro, Cumberland t`.n~ ~nfi, .. ..