HomeMy WebLinkAbout04-29-11 (2)-.~ REV-1500 E"(01-10) 1505610143
OFFICU-L USE ONLY
PA Department of Revenue penrtay sole county code veer File Nunn»r
Bureau of Individual Taxes DEiMTMEM Of 11lVENVE
Po Box.2aosol INHERITANCE TAX RETURN 21 10 0 0 8 21
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
Social Security Number
201 16 3067
Decedent's Last Name
REED
Date of Birth
12 15 1924
Suifix Decedent's First Name MI
D A1PN A
Date of Death
07 29 2010
(If Applicable) Enter Surviving Spouse's IMorrnatlon Below
Spouse's Last Name
Suffer Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRWTE OVALS BELOW
® 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death
prior to 12-13-82)
^ 4. Limited Estate ^ qa, Future Intereet Compromise
(date of death aRer 72.72.92) ^ 5. Federal Estate Tax Return Required
® g. Decetlent Died Taetele
(Attach copy of WIN) ^ ~ Decedent Maintained a Living 7iuat
(Attach Copy of TIUa1) ~ 8. Total Number Of Safe De
posit Boxes
^ 9. Litlgation Proceeds Received ^ 10. bp0°twn»ni2at ~ er~id ~ ~~or deem ^ 11. Election to tax under Sec. 9113(A)
(Attach Srh. O)
CORREBPONDENT - THIB 8ECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTAL TAX INFORMATION HHOULL~E DIRECT TO:
N
ame Daytime Tsl~ltone NumbBE -~ ^ t
DEBRA R BALLET 717 73~1300~ .~'O
rr -v n ~ ~ ~, ~;
REGISTER~~j$ US~NLY ~` ,•~
`-~
First line of address
O 'T7 :z. n
~ J
24 NORTH 32ND
STREET ~ jD W f r T~1
~~ r
~
-
Second line of address ~
City or Poat Office
CAMP HILL
State ZIP Code
PA 17011
DATE FILED
Ccrrespondent'se-mailaddreaa: walletdeb~aol.com
Under penalties of perJury, I dedlare t I examined this return, inGuding aecompanyi_ng schedules and statements, and to the best of my knowledge and belief,
it is trios, and corn preparer other than the personal representasve Ia based on all information Of which preparer has any knowledge.
SIG T PER~nSfON R SI F F ING RETURN DATE
~V Eric R. Rued ~' Z~ - ~~
710 Louisa Lane, Mechanicsburg, PA 17050
SIGNATURE OF PREPARER OTHER TNAN REPRESENTATIVE DATE
lwQ~,, .I[, W,I,t,t,a,t- Debra K Wallet t{~~ ~ ~ i
ADDRESS
24 North 32nd Street, Camp Hill, PA 17011
Side 1
1505610143 1505610143 J
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REV-1500 EX
1505610243
Decedenrs Nine: REED , DAWN A
RECAPITULATION
1. Real Estate (Schedule A) ................................................................................. ......... 1.
2. Stocks and Bonds (Schedule B) ....................................................................... ........ 2.
3. Closet' Held Corporation, Partnership or Solo-Proprietorship (Schedule C).. ........ 3.
4. Mortgages & Notes Receivable (Schedule D) ................................................. ......... 4.
5. Cash, Bank Deposits 8 Miscellaneous Personal Property (Schedule E) ........ ........ 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... ........ 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ^ Separate Billing Requested ..... ........ 7,
B. Total Gross Assets (total Lines 1-7) ............................................................... ........ g,
9. Funeral Expenses & Administrative Costs (Schedule H) ................................. ........ 9.
10. Debts of Decadent, Mortgage Liabilities, & Liens (Schedule I) ....................... ......... 10.
11. Total Deductions (total Lines 9 & 10) ............................................................. ......... 11.
12. Net Valw of EsWs (Line 8 minus Line 11) .................................................... ......... 12.
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ......................................... ........ 13.
14. Net Valw Subject to Tax (Line 12 minus Line 13) ........................................ ......... 14.
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATE8
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .00 15.
16. Amount of Line 14 taxable
at lineal rate X .045 16.
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.
Z0. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Decedent's Social Security Number
201 16 3067
75,601.44
0.00
75,601.44
17,510.95
77,250.03
94,760.98
-19,159.54
-19,159.54
0.00
Side 2
1505610243 1505610243
REV•1500 EX Page 3 File Number 21 - 10 - 00821
Decedent's Complete Address:
Reed, Dawn A
STREET ADDRESS
1000 Claremont Road
--
CITY
STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) 0.00
2. Credks/Payments --
A. Prior Payments
B. Discount
Total Credits (A + B) (2) 0.00
3. Interest
(3) 0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (q)
Check box on Page 2 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the drfference. This is the TAX DUE. (5) ~ . ~ 0
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 :.................................... ^ n
c. retain a reversionary interest; or .................................................................................................................. ^ ^x
d. receive the promise for i'rfe of either payments, benefits or care? .............................................................. L ~ ^x
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ....................................................................................................................... ~ ^
3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death?......... ^ 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a benefciary designation? ...................................................................................................................... ^ U
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 January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
p2 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 H 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 21ye ars 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, wfiether (y bloo~ or adoption
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
co~+raRwExmoFawnanvnRia PERSONAL PROPERTY
MlMERRANCE TA%RERIRN
RESIDENT DECEDENT
ESTATE OF Reed, Dawn A
FILE NUMBER
21 - 10 - 00821
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must [» disclosed on schedule F.
ITEM DESCRIPTION VALUE AT DATE OF
NUMBER DEATH
1 M 8 T Bank checking acct. #433578 66,873.02
2 I Highmark refund ~ 11.94
3 I Wachovia Bank Burial Reserve Fund ~ 7,776.25
4 Claremont Nursing Home & Rehab Center Savings Account 940.23
TOTAL (Also enter on line S, Recapitulation) 75,601.44
COMMONNVEALTH OF PENNSYLVANIA SCHEDULE G
INHERITANCE TAX RETURN INTER-VIVOS TRANSFERS ~
RESIDENT DECEDENT M13C. NON-PROBATE PROPERTY
ESTATE OF Reed, Dawn A FILE NUMBER
21 - 10 - 00821
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is ves
ITEM Induce a» nm
NUMBER I e„aa,ede~em~
1 Cash gift to son,
TOTAL (Also enter on line 7, Recapitulation) I 0.00
canMDNwEwTNOFVENNSVwaNw
INHERfTIWCE TA7(RETURN
RESIDENT DECEDENT
ESTATE OF Reed, Dawn A
9G'fDI~E H
FI~BiAL DQ 8r
ADIII~ISTRATNE WSTS
FILE NUMBER
21 - 10 - 00821
Debts of decedent must be reported on Schedule I.
ITEM I __
NUMBER ~ FUNER_AL EXPENSES: DESCRIPTION
A. 1 'I Ewing Brothers Funeral Home, Ina
2 Gingrich Memorials
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Repreaentatlve(s)
Eric R. Reed
2.
3.
4.
Street Address 710 Louisa Lane
city Mechanicsburg State PA zip 17050
Year(s) Commission paid 2010
Attorney's Fees Debra K. Wallet, Esq.
Famiy Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
Probate Fees
5. I Accountant's Fees
6. j Tax Retum Preparer's Fees
7. ~~ Other Administrative Costs
1 I Postage, photocopies, etc.
AMOUNT
8,891.45
1,294.00
3, 500.00
3,500.00
305.50
20.00
TOTAL (Also enter on Ilne 8, Recapitulation) 17,510.95
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
DDMNONWEALTN OF PENNBYL°""'" LIABILITIES, & LIENS
INHERRANCE TA% RETURN
RESIDEM DECEDENT
FILE NUMBER
ESTATE OF Reed, Dawn A 21 - 10 - 00821
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
-_
1 Pharmerica 129.70
2 I Claremont Nursing & Rehab Center ~ 65.00
3 I Public Welfare claim (see attached) ~ 77,055.33
TOTAL (Also enter on Line 10, RecapltulaUon) I 77,250.03
REV-7673 EX+(77-°C) ~ ~ -
SCHEDULE J
COMMNHER ANCETAXRETURNANIA BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF
Reed, Dawn A FILE NUMBER
21 - 10 - 00821
NUMBER ~
NAME AND ADDRESS OF PERSON(S) RELATIONSHIP TO
DECEDENT SHARE OF ESTATE
(Words) AMOUNT OF ESTATE
($$$)
RECEIVING PROPERTY ooNauarnna.(s)
I+ TAXABLE DISTRIBUTIONS [include outright spousal
distributions and transfers
i under Sec. 5116 (a) (1.2)]
I
1 Eric R. Reed Son 100% of residuary
710 Louisa Lane Estate
Mechanicsburg, PA 17050
I
~~
~,
i
',
I
i
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover
heet, es appropriate.
III NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
I B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
~~.~x i11 ~trc~ ~~~~~tmrnx
OF
DAWN A. REED
Y
I, DAWN A. REED, of Monroe Township, Cumbefiland County, Pennsylvania,
make, publish and declare this as and for my Last Will and Testament, hereby re-
voking all other Wills and Codicils heretofore made by me.
FIRST: I direct the payment of all my just debts and Funeral expenses,
including my grave marker and all expenses of my last illness, shall be paid
from my residuary estate as soon as practical after my decease as a part of the
expenses of the administration of my estate.
SECOND: I devise and bequeath all the rest, residue and remainder of
my estate of whatever nature and wherever situate, together with any insurance
policies thereon, unto my husband, GUY R. REED, provided he survives me by sixty
(60) days.
THIRD: Should my husband, Ouy R, Reed, predecease me or die on or be-
fore the sixty-first (61st) day following my death, I devise and bequeath all
the rest, residue and remainder of my estate of whatever nature and wherever
situate, together with any insurance policies thereon, unto my son, ERIC E.
REED.
FOURTB: In addition to all powers granted to them by law and by other
provisions of this Will, I give the fiduciaries acting hereunder the following
powers, applicable to all property, exercisable without court approval and
effective until actual distribution of all property.
(A) To sell at public or private sale, or to lease, ,for any period
of time, any real or personal property and to give options gor sales, exchanges
or leases, for such prices and upon such terms orconditions as are deemed
proper.
(B) To partition, subdivide, or improve real estate and to entefi into
agreements concerning the partition, subdivision, improvement, zoning or
management of real estate and to impose or extinguish restrictions on real
estate.
(C) To compromise any claim or controversy and to abandon any
property which is of little or no value.
(D) To invest in all forms o£ property, including stocks, common
trust funds and mortgage investment funds, without restriction to investments
authorized for Pennsylvania fiduciaries, as are deemed proper, without regard
to any principle of diversi€ication, risk or productivity.
(E) To exercise any option, right or privilege granted in insurance
policies or in other investments.
(F) To exercise any election or privilege given by the 'yederal and
other tax laws, including, but not necessarily being limited to, personal ins
come, gift and estate or inheritance tax laws.
( G) To make distribution to my herein named beneficiaries in cash oR
in kind or partly in each.
FIFTH: I direct that all inheritance, estate, transfer, succession
and death taxes, of any kind whatsoever, which may be payable by reason of my
death, whether or not with respect to property passing under this Willa shall be
paid out of the principal of my residuary estate.
SIBTH: All interests hereunder, whether principal qr incgmes while
undistributed and in the possession of the. fiduciaries acting hereunder, even
though vested or distributable, shall not be subject to attachments execution
or sequestration for any debt, contract, obligation or liability o~ any bene~
ficiary, and furthermore, shall not be subject to pledge, assignment, convey-
ance or anticipation.
SEVENTH: I nominate and appoint my husbands GA'X' R. REED, Executor of
this, my Last Will and Testament. In the event o€ the death, resignatign or
inability to serve for any reason whatsoever of the said any 'R. Reed, I
nominate and appoint ERIC E. REED, Executor of this, my Last Will and Testament.
I hereby relieve my Executor from the necessity of posting security in
connection with his duties as such in any jurisdiction in which he may be
~-
called upon to act insofar ae I am able by law to do so.
IN WITNESS WHEREOF, I havefiexeuvto set my hand and seal to this,
my Last Will and Testament, this day of 1986.
o(~~ n~.u1y,~ lT.; '~i'.~CcL~!- (SEAL)
Dawn A.' Reed ~ ''
Signed, sealed, published and declared by the above named Testatrix
as and for her Last Will and Testament in our presence, who, at her request,
in her presence and in the presence of each other, have hereunto subscribed
our names as attesting witnesses.
Address
Address
~ ~~~ ____
~3-
AUG 2 5 2010
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF PROGRAM INTEGRITY
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-0488
August 23, 2010
DEBRA K WALLET ESQUIRE
24 N 32ND STREET
CAMPHILL PA 17011-2917
Dear Attorney Wallet:
Re: Dawn Reed
CIS #: 050218370
SSN: ###-##-3067
Date of Death: 07/29/2010
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $77,055.33 against the above-mentioned estate. This
claim is for restitution of medical assistance granted on behalf of the
decedent for which the Probate Estate is now responsible to reimburse the
Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as
amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's
itemized statement of claim.
A portion of this medical expense, namely $.00, was incurred 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 Fiduciaries Code, 20
Pa. C.S.A. 3392(3). The balance of the claim, namely $77,055.33, is to be
entered as a priority Class 5.1 claim against the estate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and when payment may be .expected. If the
estate accounting is complete, please provide a copy. If the estate contains
real estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available.
Sincerely,
~,
Dianna L. Stoneroad
TPL Program Investigator
717-265-7688
717-772-6553 FAX
Enclosure
COMMONWEALTH OF PENNSYLVANUI
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION -CASUALTY UNR
PO BOX 8488
HARRISBURG PA 17105-8488
August 23, 2010
STATEMENT OF CLAIM SUMMARY
~~
ti ~~E~~ Estate of REED, DAWN
t~+ a-~, .
,ID r ~~:1 060 218 370
~[Jl - ~
~. ° a+. ~..
'i
.~ . ~ .ea ~°
~ ~f19 ~ 4.
w ',~
,
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE .00 76,956.00 76,956.00
DRUG .00 99.33 99.33
~" ~,, ,~,
°~'~ ~E" ~ D
.00
77,055.33
77,055.33
August 23, 2010
STATEMENT OF CLAIM
E
~-'
~ REED, DAWN
ID,„~ ,~~ 050 218 370
,'~,,~aa'.~;
CUMBERLAND CO COMMRS
1000 CLAREMONT RD
PA 17013
03/14/08 - 03/31!08 07/28/08 20081854039490001 20081854039490001 3,599.28 3,599.28
DIAGNOSIS 1 : 29411 DEMENTIA IN CONDITIONS CL
DIAGNOSIS 2 : 311 DEPRESSIVE DISORDER NEC
PROC CODE : 000000
04/01/08 - OM30/08 06/30/08 20081574030010001 20081574030010001 5,998.80 5,763.98
DIAGNOSIS 1 : 29417 DEMENTIA IN CONDITIONS CL
DIAGNOSIS 2 : 30000 ANXIETY STATE NOS
PROC CODE : 000000
05/01/08 - 05/31/08 06/30/08 20081574030020001 20081574030020001 6,198.76 6,963.94
DIAGNOSIS 1 : 29411 DEMENTIA IN CONDITIONS CL
DIAGNOSIS 2 : 30000 ANXIETY STATE NOS
PROC CODE : 000000
06/01/08 - 06/30/OS 08/25/08 61082144022370001 61082144022370001 5,998.80 5,512.98
DIAGNOSIS 1 : 29411 DEMENTIA IN CONDITIONS CL
DIAGNOSIS 2 : 311 DEPRESSIVE DISORDER NEC
PROC CODE : 000000
07/01/08 - 07/31/08 03/02109 55090574337690001 55090574337690001 6,198.76 5,774.94
DIAGNOSIS 1 : 29411 DEMENTIA IN CONDITIONS CL
DIAGNOSIS 2 : 311 DEPRESSIVE DISORDER NEC
PROC CODE : 000000
08101/08 - 08/31/08 03/07J09 55090574339790001 55090574339790001 6,198.76 5,836.34
DIAGNOSIS 1 : 29411 DEMENTIA IN CONDITIONS CL
DIAGNOSIS 2 : 311 DEPRESSIVE DISORDER NEC
PROC CODE : 000000
09/01108 - 09/30/08 03102/09 55090574342190001 55090574342190001 5,998.80 5,319.58
DIAGNOSIS 1 : 29411 DEMENTIA IN CONDITIONS CL
DIAGNOSIS 2 : 311 DEPRESSIVE DISORDER NEC
PROC CODE : 000000
10/01108 - 10/31108 03/23/09 55080774430630001 55090774430630001 1,866.31 943.78
DIAGNOSIS 1 : 29411 DEMENTIA IN CONDITIONS CL
DIAGNOSIS 2 : 311 DEPRESSIVE DISORDER NEC
PROC CODE : 000000
August 23, 2010
STATEMENT OF CLAIM
N
AME;,
~ REED, DAWN
ID~~'
t 050 2t8 370
CUMBERLAND CO COMMRS
1000 CLAREMONT RD
PA 17013
12/01/08 12131/08 03/23/09 55090774434910001 56090774434910001 6,798.84
DIAGNOSIS 1:29411 DEMENTIA IN CONDITIONS CL
DIAGNOSIS 2 : 4590 HEMORRHAGE NOS
PROC CODE : 000000
01/01/09 - 01/31/09 04/13/09 66090984349740001 55090984349740001 6,198.78
DIAGNOSIS 1 : 29411 DEMENTIA IN CONDITIONS CL
DIAGNOSIS.2 : 4590 HEMORRHAGE NOS
PROC CODE : 000000
02/01/09 - 02/28!09 04/13/09 55090984351840001 55090984351840001 5,598.88
DIAGNOSIS 1 : 29411 DEMENTIA IN CONDITIONS CL
DIAGNOSIS 2 : 4590 HEMORRHAGE NOS
PROC CODE : 000000
03/01/09 - 03/31/09 OM27/09 20091004028510001 20091004028510001 8,198.78
DIAGNOSIS 1:29411 DEMENTIA IN CONDITIONS CL
DIAGNOSIS 2 : 4590 HEMORRHAGE NOS
PROC CODE : 000000
04/01/09 - 04/30/09 05/25/09 20091274051270001 20091274051270001 6,058.80
DIAGNOSIS 1 : 29411 DEMENTIA IN CONDITIONS CL
DIAGNOSIS 2 : 4590 HEMORRHAGE NOS
PROC CODE : 000000
05/01/09 - 05/31/09 06/22109 20091554048840001 20091554048840001 6,260.76
DIAGNOSIS 1 : 29411 DEMENTIA IN CONDITIONS CL
DIAGNOSIS 2 : V7251 VENOUS THROMBOSIS AND EMB
PROC CODE : 000000
06/01/09 - 08130109 07/20/09 20091824059790001 20091824089790001 8,058.80
DIAGNOSIS 1 : 29411 DEMENTIA IN CONDITIONS CL
DIAGNOSIS 2 : V1251 VENOUS THROMBOSIS AND EMB
PROC CODE : 000000
5,432.42
5,796.44
4,864.66
5,470.54
5,594.48
5,796.44
5,268.58
August 23, 2010
STATEMENT OF CLAIM
¢„
NAM= REED, DAWN
Id ` 050 218 370
,..~.
CUMBERLAND CO COMMRS
1000 CLAREMONT RD
PA
07/01/09 - 07/04/09
DIAGNOSIS 1 : 29411
DIAGNOSIS 2 : 30000
PROC CODE : 000000
17013
09/07/09 27092304020580001
DEMENTIA IN CONDITIONS CL
ANXIETY STATE NOS
27092304020580001 807.84 17.62
~~'~ ~ ~" ~ ~~
,a~. ~ . [~ ,S~ _ CUMBERLAND CO COMMRS
84,839.71
76,956.D0
:~
~ 03 100007309 0009
r .,~.' , m : ' h v:
August 23, 2010
STATEMENT OF CLAIM
NAME.,.'° REED, DAWN
I,p-~;~;;,' 050 218 370
PHARMERICA
1000 CLAREMONT RD
PA 17013
03/17/08 - 03/17/08 O6/16/08 25081445242860001 25081445242860001
DIAGNOSIS 1 : 0
NDC CODE : 17478004001 LORAZEPAM 2 MG/ML VIAL - SEDATIVE NON-BARBITURATE
03M 7/OS - 03/17/08 O6N 6/08 25081445255980001 25081445256980001
DIAGNOSIS 1 : 0
NDC CODE : 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS
03/21/08 - 03/21/08 06H8/08 25081445242870001 25081445242870001
DIAGNOSIS 1 : 0
NDC CODE : 00188001131 BACITRACIN ZN 500 UNIT/GM OINT - OTHER ANTIBIOTICS
04!28/08 - 04/28/08 06/16/08 25081445242820001 25081445242820001
DIAGNOSIS 1 : 0
NDC CODE : 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS
06125108 - 06/25/08 07/21/OS 25081775625500001 26081775526500001
DIAGNOSIS 1 : 0
NDC CODE : 17478004001 LORAZEPAM 2 MG/ML VIAL - SEDATIVE NON-BARBITURATE
07N 9108 - 07N 9/08 OSN 8108 25082015302240001 25082015302240001
DIAGNOSIS 1 : 0
NDC CODE : 11701004514 BAZA ANTIFUNGAL 2% CREAM - FUNGICIDES
07/30!08 - 07/30/08 08!25108 25082125421160001 25082125421160001
DIAGNOSIS 1 : 0
NDC CODE : 11701004514 BAZA ANTIFUNGAL 2% CREAM - FUNGICIDES
OSI25108 - 08/25/08 09/22108 25082385424710001 25082385424710001
DIAGNOSIS 1 : 0
NDC CODE : 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS
10.89
21.73
7.82
21.15
10.89
15.83
15.63
21.73
9.74
5.95
7.00
5.89
9.74
13.57
13.57
5.54
August 23, 2010
STATEMENT OF CLAIM
.~ i`€s
NAME^~ REED, DAWN
iD ~`"~~' 050 218 370
PHARMERICA
1000 CLAREMONT RD
PA 17013
10/03/08 - 10/03!08 10!27/08 25082775707600001 25082775707600001 15.83 13.85
DIAGNOSIS 1 : 0
NDC CODE : 11701004514 BAZA ANTIFUNGAL 2% CREAM - FUNGICIDES
02/09!09 - 02/09/09 03/09!09 25090405669200001 25090405569200001 8.47 5.30
DIAGNOSIS 1 : 0
NDC CODE : 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS
05/20/09. - 05/20/09 06/16/09 25091406768780001 25091405758780001 5.43 4.74
DIAGNOSIS 1 : 0
NDC CODE : 00168006231 ZINC OXIDE 20% OINTMENT - EMOLLIENTS PROTECTIVES
05/22109 - 05/22109 06/15/09 25091425370350001 2509142537D350001 5.43 .74
DIAGNOSIS 1 : 0
NDC CODE : 00168006231 ZINC OXIDE 20% OINTMENT - EMOLLIENTS PROTECTIVES
05/26/09 - 05/26/09 06/22!09 25091465525160001 25091465525160001 5.43 .74
DIAGNOSIS 1 : 0
NDC CODE : 00168006231 ZINC OXIDE 20% OINTMENT - EMOLLIENTS PROTECTIVES
06/01/09 - 06/01/09 06/29109 25091526638120001 25091525538120001 5.43 .74
DIAGNOSIS 1 : 0
NDC CODE : 00168006231 ZINC OXIDE 20% OINTMENT - EMOLLIENTS PROTECTIVES
06104!09 - 06/04/09 06/29/09 25091555365080001 25091555365080001 5.43 .74
DIAGNOSIS 1 : 0
NDC CODE : 00168006231 ZINC OXIDE 20% OINTMENT - EMOLLIENTS PROTECTIVES
06/06/09 - 06/06/09 07J06I09 26091676246480001 25091575246480001 5.43 .74
DIAGNOSIS 1 : 0
NDC CODE : 00168006231 ZINC OXIDE 20% OINTMENT - EMOLLIENTS PROTECTIVES
August 23, 2010
STATEMENT OF CLAIM
1000 CLAREMONT RD
PA 17013
06/09/09 - 06109109 07/06/09
DIAGNOSIS 1 : 0
NDC CODE : 00168006231
e~ ,+~e
NAME' REED, DAWN
ID "°" 050 218 370
25091605588880001 25091805588880001
5.43
74
ZINC OXIDE 20°h OINTMENT - EMOLLIENTS PROTECTIVES
'p ~~`'~~ `~~`~"~~
~R.Si~&~1±t~1T
~'~
~ PHARMERICA
24 100751181 D032
186.18
99.33
~
~
" 4„~t;i d s n ~'~ ~.a.