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HomeMy WebLinkAbout12-07-10J 1505610101 REV-150 ~`'°~°~ ~~ euraau of IrdlMdrmlTJ~aes """~' N4iER4TANCE TAX RETURN ~ ~ a ~ ~ O G. PO810DC7s98-oGos RED DECEAEAfI' ~ ~_ etr~ err ei~OlafKtlolll sB.ow >3ods1 y Number Dais of Daalh MiiDDYY1fY Dais d BWt ttNdODYYYY 174-Q5-1984 ~ 03fi7~2009 ~ 11/17t'1906 ~ I, Daaadatti"a Last Name Su116~ DaoerMnCs Fid Name MI STONE ~~ g~-~A ! i ~ ~ 1 ~J _.__ laM~abie) Ealar survl.wr~ aporlee'!s arlbrastlsa edoar Last Nsme SuQot S~pouss s Fist Name - MI wa ~ ~ j ~ 3pouse'a Sodr SaaWlyr Naailrsr Tii1E RE1Ut04 MUST 8E t'N.El4 91 DUPtJCATE tNE .REGISTER OF WILLS FLL IN APPROMifATE o~rALS eEtow f~ 1.OrlEinal RMurn O 2 SrrppisrrerrFal Ra4an O 3. (dale of dssth l~rm 1 ii j O 4. UmNsd Estate O 4e. Future Interest Compromise (date of O 8. Federal e} Tax Return RequNad death atMr 7212.82) O 8. Daosdert Died Teateta O 7. DecadaR lulaHgafied a tivk~p Trwt 8. Total of Safe DeposN Hofoee (Attach Co*y of tNM) (AtleCb Copy of Treat) O 9. L.IYgetion Praasads ReosNsd O 1 Q. Spousal Poverty CradN (date of death O 11. Eleolbn udder Sec. 91i3(A) bsi~wesn 12-97-81 and i-1-W9) (Atgpth ) CA~BPOIii]~IT- THIS t16CilON M11dT BE Ct>NIPLL'TED, ALL CORREBPOiIDENCE AND CONRDENTIAt TAX INFfJRMA710N UE' OQECTED TO: Name Daytkna T umbac __._. Andrew M. Shaw. Esqu)re ~ (717) 243-71 5' _ ~ RL~T~ t7F ~ts t~E OIq,.Y N O Fit st 6ne d adiaas _ a ~ ; ~i '~ A ^ ~y~ ~ 200 S. * ~'i4 YGI1 St [ (~ fTl f7 7 F~ Y7 ~ Ssootrd Mle of addreaa ( v . ~ .,~ I`1 -,-, PA 17013 ~ "' ~..~ , .c Co'respoadsatss a}sail adiaac ,Q~1t uederAsssrwdpijrrp, t~oYre Tirrl i aseweilsd IkM ~ iwfk~nD sommpenyinp rd~sa~s and rilrnssws. aed tef~ ~rnselsrl0s and bMst t M Uuq Daiearpe d prehw-a#Nr leis the paaarsrl rapwearaeMa to 6aead ae a8 infaasiMop d~rlidr tale arty blorrladps. l~OR FM./i6 iiEf11RN ~- /~ ,,DATE _.'~ ADOIiES6 1'40 Stt4~e ZOB, Yak. PA 17401 ~~ ca` TltiM~l . - ~.,~ 200 S Spring C3alden Sb+eet~ Stti4e 11, C>~te, PA 170'{3 trl.ewse utu~ otir~erra~ t>~ t~.tr -~_ sips i L 1505610201 15056101 q1 J ~/.~ _ I ~ REV 1500 EX oeceder-Ys Name: BERTHA E. STONE 174-05.1984 Security Number RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 0.00 ~ 2. Stocks and Bonds (Schedule B) ....................................... 2. 0.00 3. Ckuely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. I' 0.00 4. Mortgages and Notes Receivable (Scheduie D) ........................... 4. I! 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. I 10,009.86 6. Jointty Owned Property (Schedule F) O Separate Billing Requesbd ....... 6. i 0•~ 7. Inter-~lrvos Transfers 8~ Miscellaneous Non-Probate Property I (Schedule G) O Separate Billing Requested........ 7. 0.00 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. ~ 10.009.86 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. ~ 1, 823.92 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. '~, 142,844.66 11. Total Deductbns (total Lines 9 and 10) ................................. 11. ~~ 144,668.58 12. Nat Value of Estate (Line 8 minus Line 11) .............................. 12. ~! 0.00 13. Charitable and Govemmerrtal Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 0.00 14. Nst Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 0.00 TAX CALCULATION -SEE IN8TRUCTION8 FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (ax1.2) X .OQ 16. Amount of Line 14 taxable -"~~~ ~-~ at lineal rate X .0 17. Amount of Line 14 taxable at sibling rate X .12 1 B. Amount of Line 14 taxable at collateral rate X .15 1505610105 15. 1s. 17. 18. 19. TAX DUE .........................................................19. 20. FILL IN THE OVAL IF YOU ARE REpUE8TING A REFUND OF AN OVERPAYMENT L 1505610105 Side 2 15056]~0~05 I '~ 0.00 0.00 0.00 0.00 0.00 O REV 1500 EX Page 3 Decedent's Complete Address: FIM Number DECEDENTS NAME BERTHA A. STONE STREETADDRESS 801 North Hanover Street CITY Carlisle STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditsJPaymerds A. Prior Payments B. Discount 3. Irrterest 0.00 4. ff line 2 is greater than Line 1 + Line 3, en~r the difference. This is the OVERPAYMENT. Ftil in oval on txape 2, Lhla 20 to roquest a rNund. 0.00 (3) 0.00 (4) ~~ 0.00 5. ff Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE 1. Did decedent make a transfer and: a. retain the use or income of the property transferred :..................................................................................... b. retain the right to designa~ who shall use the properly transferred or its income : ....................................... c. retain a reversionary interest; or .....................................................................:............................................... d. receive the promise for life of either payments, benefits or care? ................................................................. 2. H death occurred after Dec. 12, 1982, did decedent transfer properly within one year of death without receiving adequaM cor>sideration? ......................................................................................................... 3. Did decedent own an "in mist for" or payable-upon-death bank account or security at his or her death?......... 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ................................................................................................................... IF THE ANSYYER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND 0.00 gPRIATE BLOCKS Kes No ^X g o x^ 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 ~r fdr 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 lof the surviving spouse is 0 percent (72 P.S. §9116 (a) (1.1) ('u)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory req irr~ments for disclosure of asset and filing a tax return are still applicable even if the surviving spouse is the only benefiaary. 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 for 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 decedents lineal beneficiaries', is X4.5 percent, except as noted in 72 P.S. §9116(1.2) [T2 P.S. §9116(a)(1)]. 0.00 (1) '~, 0.00 Total Credits (A + B) (2) ~~ • The tax rate imposed on the net value of transfers to or for the use of the decedents siblinnggss is 12 percent p2 P.S. §9h16(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption REV-1508 EX+ (698) cu scNEOU~E ~ COMMONWEALTH OF PENNSYLVANIA ~`~. BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT (If more spaioe is needed, insert a~itionel sheets of the sauna size) ,~~. ~- Sovereign. Bank a~ ,~~ .~~ . --~ ~ 1-877-50V-BANK (1-877-76&2265) www.sovereignbank.com GOAD NEWS CONSULTING INC AF B81~11C@S it~msr-t Pibrtod 04117/09 TO 05/17/09 SOVEREIGN INTEREST CHECKING A~count # 47178891 I i II Interest ~ ~~~ Earned this.Preriod $ 0.97 Paid Last Year 31.91 : . .,• . ., a , `The interest earned-and the interest paid may differ depending on when ihierest is erediled to your account. , ~i SerY~Ce iF9@S ~I ~ Date # Transactions F~e Total .1 Total ~ ~ ~~~ ~ I "~~:: ~ ~ "~ ~~ 5$.QO F Acca-unt Arrtiv~ty ~° ~~On Adtlitfons Subtnctla~ns, Balance 0497 ~~~i ~~e i 510,014.69 c~5-fe I ©I Sa.17 59o oos:a6 1 End gRi~lstince , ', $10:009.86. ~_ I I ex !, ~ ~, ~_ ~ ( _ - ~ ~ ~~ i page 3 oJ3 ~ 47178879/ ___ _ __ - STATEMENT OF ACCOUNTS REV-511 EX+ (10-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE N MBER BERTHA E. STONE 21-~9~0904 Decedent's debb must ba reported on Sdtedule L ITEM NUMBER DESCRIPTION ~ AMOUNT A. FuN~RA~ EXPEf1~ES~ ~,_. _ _. 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 500.00 Name(s) of Personal Representative(s) Good News COriSUltln Inc. street address 140 Roosevelt Ave.. Suite 206 City York state PA ZIP 17401 Year(s) Commission Paid: 2010 2. Attorney Fees: '~~ ~ - ~~ 1, 000.00 3. Family Exemption: (If decedent's address is not the same as daimant's, attach explanation.) Claimant Street Address City State ZIP ~,_ Relationship of Claimant to Decedent 4. Probate Fees: 72.00 5. Accountant fees: 6. Tax Return Preparer Fees: __ _ ._ _, 7• Advertising 251.92 .... ... __ _. ', J TOTAL (Also enter on Line 9, Recapitul tian) # 1,823.92 If more space is needed, use additional sheets of paper of the same size. REV-isiz Ex+ biz-os~ Pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT 1NHERITANCETAxRETURN aESiDENr DECEOEHr MORTGAGE LIABILITIES ~ LIENS ESTATE OF FILE NI~NBER BERTHA E. STONE 21 9-!0904 Repo rt debt inarrad by the deadant prior to death that romained unpaid at the date of death, indudbp unrol bg raed medial expanaa. ITEM ' VALUE AT DATE NUMBER DESCRIPTION Of DEATH 1• ';Department of Public Welfare 74,487.05 2. Church of God Home, Inc. ~' li i i I i II I i 68,357.61 TOTAL {Also enter on Line 10, Recapitulatio ) I# 142,844.66 iF rn ro in we.Aw.1 wi ~.IJit_iw .I wL. .L •L~ ~.., •. ...vb .~n/W ~J ~~GGYGY, 111iG1 l DVYIlIV1101 i11GGW VI YIG 7YIIIC JILL. _. ____... _.. __ ~_.. _.. _._ -_.. _.. .. ... __.... --___._... ___~.-.- Ly__-_-_. COMMONWEALTH OF PENNSYLVANIA DEPARTMEN70F PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DNISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105$486 December 18, 2009 ANDREW H SHAW ESQUIRE LAW OFFICE OF ANDREW H SHAW PC 200 S SPRING GARDEN ST SUITE 11 CARLISLE PA 17013 Re: BERTHA STONE CIS #: 030439336 SSN: 174-05-1984 Date of Death: 03/07/2009 Dear Attorney Shaw: Please be advised that the Department of Public Welfare mai twins a claim in the amount of $74,487.05 against the above-mentioned es ate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to rei urse the _ Department according to Act 49, 62 P.S. 1412, effective August 1 , 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the epartment's itemized statement of claim. A portion of this medical expense, namely $33,633.48, was i curred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fi uciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $ 0 853.57, is to be entered as a priority Class 5.1 claim against the estate. Please acknowledge receipt of this letter and advise whethe the Commonwealth's claim is admitted and when payment may be expects If the estate accounting is complete, please provide a copy. If the es ata coataias real estate, please provide copies of the deed, the latest tax a slessmeat, wad a current appraisal, if available. Sincerely, ~~ o~-~. Karen P. Georgoulis Claims Investigation Agen 717-214-1283 717-772-6553 FAX Enclosure RESIDENT STATEMENT FROM CHURCH OF GOD HOME, INC B01 N HANOVER STREET CARUSLE, PA 17013 717-249.5322 Statement Date Due Date ACCOUNT NUMBER 06/30/2009 Upon Receipt 802320 $68.357.61 AMOUNT PAID $ Please make check payable to CHURCH OF GOD BERTHA E STONE c/o EDITH ECKART 527D SOUTH NfEST STREET CARLSSU:, PA 17013 Comments $0.00 ~ ${91 Remit Ta: ' CHURCH OF GOD HOME, IN~ 801 N HANOVER STREET '' CARLISLE, PA 17013 ''~ INC Balance Forward $160,279.77 $160,279.77 06/05107 -06/05/07 set (1) $11.25 $(11.25) $160,268.52 06/05,107 -06/05/07 Wash 8~ Set 1 $11.25 $11.25 ! $160,279.77 06/12/07 - 06/12/07 set (1) $11.25 $(11.25) ', $180,268.52 06112/07 - 06/12107 Wash 5 Set 1 $11.25 $11.25 $160,279.77 06/19/07 - 06/19/07 set {1) $11.25 $(11.25) ', $180,268.52 08/19/07 -06119/07 Wash & Set 1 $11.25 $11.25 $180,279.77 06/26/07 -06/26/07 set (1) $11.25 ${11.25) $160,268.52 06/26/07 - 06/28/07 Wash $ Sat 1 $11.25 $11.25 ', $160,279.77 07/03/07 - 07/03/07 set (1) 511.25 $(11.25} ', $160,268.52 07/03/07 - 07/03/07 Wash & Set 1 $11.25 $11.25 ' $160,279.77 07/10/07 - O7/10/07 set (1) $11.25 $(11.25) ', $180,268.52 07/10/07 - 07/10/07 Wash & Set 1 $11.25 $11.25 5160,279.77 07/17/07 - 07/17/07 set (1 } $1 i.25 $(11.25) ' $180,268.52 07/17/07 - 07/17/07 Wash 8 Set 1 $11.25 $11.25 $160,279.77 07/24/07 - 07/24/07 set (i} $11.25 $(11.25) ~, $160,268.52 07/24/07 - 07/24/07 Wash 8 Set 1 $11.25 $11.25 ', $160,279.77 08/14/07 -08/14107 set (1) $11.25 $(11.25) $180,288.52 08/14/07 -08/14/07 Wash 8 Set 1 $11.25 $11.25 ' $160,279.77 08/21/07 - 08/21/07 set (1) $11.25 $(11.25) ', $160,268.52 08/21!07 - 08/21/07 Wash & Sat 1 511.25 $11.25 ' $160,279.77 08/28/07 - 08/26/07 set (i) $11.25 $(11.25) ' $160,268.52 08/28/07 -08/28,/07 Wash & Set 1 $11.25 $17.25 $160,279.77 09/04/07 -09/04/07 set (1} $11.25 $(11.25) $180,268.52 09/04/07 -09/04107 Wash & Set 1 $11.25 $11.25 $i 60,279.77 0911 1/07 -09/1 1107 set (1) $11.25 $(11.25) $160,268.52 09/11/07 -09/11/07 Wash & Set 1 511.25 $11.25 $16D,279.77 FACILITY NAME RESIDENT NAME ACCO~Nt NUMBER ___ CHURCH OF GOD HOME, INC BERTHA E STONE 802320 Please detach and return this portion with your remittancie to the addn3ss above. RESIDENT STATEMENT FROM CHURCH OF GOD HOME, INC 801 N HANOVER STREET CARLISLE, PA 17013 717-245-5322 Statement Date Due Date 06/30/2009 Upon Receipt AMOUNT PAID ~ BERTHA E STONE c/o EDITH ECKART 527D SOUTH YVEST STREET CARLISLE, PA 17013 Please make check payable to CHURCH OF GOO ACCOUNT NUMBER 802320 .61 ' IOM , INIC i Remit To: CHURCH OF GOD HOME, IN~ 801 N HANOVER STREET CARLISLE, PA 17413 ~~ Please detach and reium this portion with your remitta tm the address above. I._.. ::::::Dabs:.::,~:•;:?:.:; .:''.<:.:.,°:;.;:.~;`;~::Descriptio~ '°; ;`:.:.'.~.;. pays! . ~ ::~:.'~.. .`:;Rsbs~°~ : ~: ha~ges/...,':~~•.Pa~ :;'C eehts:.:a : iBalance . : : . U ; , • ; ) .:~:. :: 09/1 8107 -09/1 8/47 set (1) $11.25 ${11.25} $160,268.52 09/18107 - D9/18/07 Wash ~ Set 1 S1 i.25 $11.25 ~, $160,279.77 09/217 - D9/21/07 set (1) $11.25 $(11.25} ~I $160,285.52 09/21/07 -09121107 Wash $ Set 1 $11.25 $11.25 ', $160,279.77 09/25/07 -09/25/07 set (1) $11.25 $(11.25) ~! $160,268.52 09/25/07 -09/25/07 Wash & Set 1 $11.25 $11.25 ', $160,279.77 1 0102/07 -1 0/02107 set (1) $11.25 $(11.25) $i 60,268.52 10/02/07 -1 0/42JD7 Wash 8 Set 1 $11.25 $11.25 I~ $160,279.77 10/09/07 -10/097 set {i) $11.25 $(11.25) $160,268.52 10/09/07 -10/09/07 Wash & Set 1 $11.25 $11.25 ~, $160,279.77 1 411 6/07 -1 0116/07 set (1) $1 i.25 $(11.25) ', $160,268.52 10/16/07 -10116107 Wesh & Set 1 $11.25 $11.25 I $160,279.77 10/30/07 -10130/07 set (1) $11.25 $(11.25) !, $160,268.52 10/30/07 -10130/07 Wash & Set 1 $11.25 $11.25 ' $160,279.77 11/08/07 -11108/07 set (1} $11.25 $(11.25) ', $160,268.52 11/06/07 -11106/07 Wash & Set 1 $i 1.25 $11.25 $160,279.77 11/13/D7 -1 1113/47 set (1) $11.25 $(11.25) ' $160,268.52 ii/i3/07 -11113107 Wash & Set 1 $11.25 $11.25 ! $160,279.77 11/20/47 -11/20/07 set (1) $1.1.25 $(11.25) I~ $160,268.52 1 1/20147 -1 1/20/07 Wash 8~ Set 1 $11.25 $11.25 ~ $160,279.77 11/27/07 -11/277 set (1) $11.25 $(11.25) ' $160,266.52 11/27/07 -11/277 Wash & Set 1 $11.25 $11.25 ~ $164,279.77 12/01/07 -12/06147 Patient LJatHlity $920.64 ', $161,200.41 12/01/07 -12131107 Room & Board (31) $(210.00) $(6,510.00) '~, $154,690.41 12/04/07 -12/04/D7 set (1) $11.25 $(11.25) $154,679.16 12/0407 - 12/04/07 Wash & Set 1 $1 f.25 $11.25 $154,690.41 12/11/47 -12/11107 set (1) $11.25 $(11.25) $154,679.16 12/11/47 -12/11/07 Wash & Set 1 $11.25 $11.25 $154,690.41 12/18/D7 -12/18107 set (1) $11.25 $(11.25) $154,679.16 1 2/1 8/07 -1 2/1 8107 Wash & Set 1 $11.25 $11.25 ', $154,690.41 FACILITY NAME RESIDENT NAME ACC Nt NUMBER CHURCH OF GOD HOME, INC BERTHA E STONE 802320 RESIDENT STATEMENT FROM CHURCH OF GOD HOME, INC 801 N HANOVER STREET CARLISLE, PA 17013 717-249-5322 Statement Date Due Date 06/308009 Upon Receipt AWIOUNT PAID $ BERTHA E STONE Go EDITH ECKART 527D SOUTH WEST STREET CARLISLE, PA 17013 ~~:: pate::.~;:;':.: I ..~::::.: ~::...:::`Description:.:~;;;`:.;,.;.....~.~.: ~. ~. . 12/21/07 -12/21/07 Pullups -Large 12/24/07 -12/24/07 set 12/24/07 -12/24/07 Wash & Set 12/31 /07 - i 2131!07 set 1 2/31107 -1 2/31107 Laundry i 2/31107 -1 2/31(07 Wash & Set 011/08 - 01/06/08 Patient Liability 01/01/08 - 01/31/08 Room 8 Board 01/31/06 - 01/31/08 Laundry 02/01/08 - 02/06/08 Patlent Liability 02/01/08 - 02/29/08 Room 8~ Board 02/28/08 - 02/26/08 Pullups -Large 02/29/08 - 02/29/08 Laundry 03/01/08 -03/06/08 Patient Liability 03/01/08 -03/31/08 Room ~ Board 03/16/08 - 03/16/08 Pullups -Large 03/31/08 - 03/31/08 Laundry 04/01/06 -04/06108 Patient Liabt'liiy 04/01/08 -04/30/08 Room & Board 04/02/08 -04/02/08 Pullups -Large 04/29/08 - 04/29/08 Puliups -Large 04/30/08 - 04/30/08 Laundry 05/01/08 - 05/06/08 Patient Liability 05/01/08 - 05/31/08 Room & Board 05/31/08 - 05/31/08 Laundry 06/01/08 -06/05/08 Patient Liability 06/01/08 - 06/30/08 Room 8~ Board 06/02/06 - 06/03/08 Pullups -Large 06/28/08 -06/28108 Pullups -Large 06/30/08 -06130108 Laundry Please make check payable to CHURCH OF GOD i. ACCOUNT NUMBER 802320 .61 IoM, INc Rerntt To: CHURCH OF GOD HOME, IN~ 801 N HANOVER STREET CARLISLE, PA 17013 Please detach and return this portion with your ,......... .~:{Cry (1) $14.82 (1) $11.25 1 $11.25 {1) $11.25 (i) $25.00 1 $11.25 (3i) $(227.00) (1) $27.50 (29) $(227.00) (1) $14.82 (1) $27.50 (31) ${227.00) {i) $14.82 {1) $27.50 (30) $(227.00) (1) $14.82 {i) $14.82 {i) $27.50 (31) $(227.00) (1) $27.50 (30) (2) (1) (1) $(227.00) $14.82 $14.82 $27.50 $(14.82) $(11.25) $11.25 ${11.25) ${25.00) $11.25 $933.86 $(7,037.00) $(27.50) $893.86 $(8,583.00) $(14.82) $(27.50) $933.86 $(7,037.00) ${14.82) S(27.50} $933.86 $(6,810.00) $(14.82) $(14.82) $(27.50) $933.86 $(7,037.00} $(27.50) $833.86 $(6,810.00) $(29.64) $(14.82) $(27.50) to the address above. wits ...~. ~ Balance :. . ~; ::: ~.. $154,675.59 $154,664.34 ', $154.675.59 $154,664.34 $154,639.34 $154,850.59 $155,584.45 $148,547.45 $148,519.95 $149,453.81 $142,870.81 $142,855.99 $142,828.48 $143,762.35 $136,725.35 $136,710.53 $136,683.03 ', $137,816.89 ', $130,806.89 $130,792.07 $130,777.25 $130,749.75 $131,683.61 ', $124,646.61 ', $124,619.11 $125,452.97 $118,642.97 $118,813.33 $118,598.51 $118,571.01 FACILITY NAME RESIDENT NAME ACCO NT NUMBER CHURCH OF GOD HOME, INC BERTHA E STONE 802320 RESIDENT STATEMENT FROM CHURCH OF GOD HOME, iNC 801 N HANOVER STREET CARLISLE, PA 17013 717-249-5322 Statement Date Duo Date 08/30/2009 Upon Receipt AAAOUNT PAID $ BERTHA E STONE Go EDITH ECKART 527D SOUTH WEST STREET CARLISLE, PA 17013 Please make check payable to CHURCH OF GOO _ _ r _~~_ ACCOUNT NUMBER 802320 .61 10M ,1NC Remit To: ~' CHURCH OF GOD HOME, IN~ 801 N HANOVER STREET CARLISLE, PA 17013 ~, - Please detach and return this portion with your remiltan to the addn3ss above. _:: ,..:Oats. ;~ ~::::~: ; L ~':~.:.: ': ~~°Deacriptbn;;: ,~~: ::~;:.,:..::~.`. ~`~~';: ~:~yeJ :~:Rabe;`:~;~.' . .e ~ :: CFiargs~l,~.: ;. ' Balance -- .____-..~_.~ -- _._ .. J~.---__.._----.__......- - U ~ tts~~:~ R - . :~ C _ ~.~~ ... . 07/01/08 - 07/05/08 Patient Liability $833.88 $119,404.87 07/01/08 - 07/31/08 Room & Board (31) $(227.00) ${7,037.00) !, $112,367.87 07/07/08 - 07/07/08 Pullups -Large (1) $14.82 $(14.82) I ~ $112,353.05 07/22/08 - 07/22/08 Adult Wipes (1) $3.25 $(3.25) ~~, I $112,349.80 07/30108 - 07/30/08 Pullups -Large (1) $14.82 ${14.82) CI $112,334.98 07/31/08 - 07/31/08 Laundry (1) $27.50 ${27.50) I $112,307.48 08,101108 - 08J05/08 Patient Uabtiity $833.86 I, $i 13,141.34 08/01/08 - 08/31/08 Room & Board (31) $(227.00) $(7,037.00) I~, $108,104.34 08/05/08 - 08/05/08 Wash Cream (1) $8.75 $(8.75) ~~ $106,097.59 08/18/08 - 08/168 Pullups -Large (1) $14.82 $(14.82) ~', ~ $106,082.77 08/29/08 -08/29/08 Pullups -Large (1) $14.82 $(14.82) ~,i $106,087.95 08/31/08 -08/31108 Laundry (1) $27.50 $(27.50) ~, $108,040.45 09/01/08 -09/05/08 Patient Liability $833.86 'i $106,874.31 09/01/08 -09/30/08 Room & Board (30) $(227.00) ${8,810.00) ', $100,064.31 09/13/08 -09/13108 Pullups -Large {i) $14.82 $(14.82) I $100,049.49 09!30/08 - 09/30/08 Laundry (1) $27.50 $(27.50) ' $100,021.99 09!30/08 -09/30108 Pullups -Large (1) $14.82 $(14.82) ' $100,007.17 10/01/08 - 10/05/08 Patient Liability $833.86 ~'~ $100,841.03 10/01/08 -10/31/08 Room & Board (31) $(227.00) $(7,037.00) II $93,804.03 10/16/08 -10/16108 Pullups -Large (1) $14.82 $(14.82) ~, $93,789.21 10/31/08 -10/31/08 Laundry (1} $27.50 $(27.50} ~~ $93,761.71 11/01/08 - 11/05/08 Patient Liability $833.86 ' $94,595.57 11/01/08 -11/30/08 Room & Board (30) $(227.00) ${8,810.00) ~~, $87,785.57 11/09/08 - i 1/09/08 Pullups -Large {1) $14.82 $(14.82) ~~ $87,770.75 11/27/08 -11/27/08 Pullups -Large (1) $14.82 $(14.82) ~ $87,755.93 11/30/08 -11/30/08 Laundry (1) $27.50 $(27.50) $87,728.43 1 2101/08 -1 2/05/08 Patient Liability $833.88 $88,562.29 12/01/08 -12/31/08 Room & Board (31) $(227.00) $(7,037.00) ~i $81,525.29 12/13/08 -12/13/08 Pullups -Large (i) $15.78 $(15.78) ' I $81,509.53 12/22/08 -12/22/08 Pharmacy (1} $x.49 ${89.49) ', $81,440.04 FACILITY NAME RESIDENT NAME ACCO NT NUMBER CHURCH OF GOD HOME, INC BERTHA E STONE 802320 RESIDENT STATEMENT FROM CHURCH OF GOD HOME, !NC 801 N HANOVER STREET CARLISLE, PA 17013 717-249-5322 Statement Date Due Date ACCOUNT NUMBER 08/30/2009 Upon Receipt 802320 .61 AMOUNT PAID $ BERTHA E STONE c/o EDITH ECKART 52TD SOUTH WEST STREET CARLISLE, PA 17013 Please make check payable to CHURCH OF (iOD Remit To: '~ CHURCH OF GOD HOME, IN~ 801 N HANOVER STREET CARLISLE, PA 17013 INC Please detach and return this portbn with your remittances tp the address above. :, ~. - ~.;:Dab`~:::::~.~:.;:~:::° :::.::::::::.:~:.:Oescrl o `' :~~: :Da :. '::'C n :'. :.'.;~::Rat~~€.:;~ ha ~: ~~:P rots .~. ~.°Balance.::.~ ........... .. PO ..l-rW : ..~., . .ay. . . ... ................ ........... .. .........:.:... . .... .... ........:....:: ...:. .. . ~( .).. ~~~~~~~ ` 12/28/08 -12126108 PuUups -Large (1) $15.78 8(15.78) i $81,424.28 12/31/08 - 12/31/D8 Laundry (1) $27.50 $(27.50) $81,396.78 01/01/09 - 01/06/09 Patient Liability $894.88 I~ $82,291.64 01/01/09 - 01131109 Room ~ Board (31) $(236.00) $(7,3113.00) ~ $74,975.64 01/23/09 - 01/23/09 Pharmacy (1) $190.12 $(190.12) $74,785.52 Di/23/09 - 01/23109 Pharmacy OTC (1) $5.04 $(5.04) ~' $74,780.48 01/31/09 - 01/31109 Laundry (1) $33.00 $(33.00) $74,747.48 D2/01/09 - 02/06/09 Patient Liability $894.86 $75,64234 02/01/09 - 02/28/08 Room & Board (28) $(238.00) $(6,808.00) ', $69,034.34 02/07/09.02/07/09 Pullups -Large (1) $15.38 $(15.38) $69,018.98 02/1 4109 -0211 4/09 Oxygen Concentrator (t 5) $3.00 $(45.00) $68,973.96 02/19/09 - 02/19/09 Pullups -Large (1) $15.38 $(15.38} $68,958.58 02/25/08 - 02/25109 Oxygen Cyciinders (1) $12.00 $(1200} ~, $88,948.58 02/27/09 -02/27/09 Puilups -Large (1) $15.38 $(15.38} 'I $68,931.20 02/28/09 - 02/28/09 Laundry (1) $33.00 $(33.00) ' $68,898.20 03/01/09 -03106109 Room & Board (6) $(236.00) $(1,416.00) ~, $67,482.20 03/01/09 -03106/09 Patient Llebiltty $894.86 ~ $68,377.06 03/02/09 - 03/02/09 Oxygen Cyclinders (1) $12.00 $(1200) !, $68,365.06 03/07/09 - 03/07/09 Laundry (i) $7.45 $(7.45) $68,357.81 TOTAL BALANCE DUE: ~, $6e,3S7,61 FACILITY NAME RESIDENT NAME ACCO Nt NUMBER CHURCH OF GOD HOME, INC BERTHA E STONE 802320