HomeMy WebLinkAbout05-20-11 (3)REV~7 ~~~ Exro1-1o) 1505610143
PA Department of Revenue pennsy~lvania OFFICIAL USE ONLY
Bureau of Individual Taxes OEP~NTMENT OF aEYENUE County COd@ Year File Numher
Po Box.zaosot INHERITANCE TAX RETURN 21 11 018 7
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
Social Security Number
199 07 x162
Decedent's Last Name
LOGAN
W
Date of Death
10 31 2010
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name
Spouse's Social Security Number
Date of Birth
06 19 1923
Suffix Decedent's First Name MI
JR. MAURICE R
Suffix Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
® 1. Original Return ^ 2. Supplemental Return ^ 3_ Remainder Return (date of death
prior to 12-13-82)
^ 4. Limtted Estate ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required
(date of death attar 12-12.82)
^ g Decedent Died Testate
(Attach Copy of Will) ^ ~ DecetleM Maintained a Living Trust ~ a. Total Number of Safe De
(Attach Copy of Trust) pOSit Boxes
^ 9. Litigation Proceeds Received ^ 1 p. spousal aoverty Credit (date of death 11, Election to fax under Sec. 9113 A
between 12-37- 1 and 7-1-85) ^ ( )
(Attach Sch. 0)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name
Daytime Telephone Number
GERALD J BRINSER 717 838 6348
First line of address
6 E MAIN STREET
Second Ilne of address
PO BOX 323
City or Post Office
PALMYRA
Correspondent'se-malt address: jerry~bwzlaw.com
Under penalties of perjury, I dedare that I have examined this return, inGudin
it is true, correct and complete. Declaration of preparer other than the person
State ZIP Code
PA 17078
REGISTER WILLS USEBNLY
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schedules and statements, and to the best of my kno
is based on atl infonnadon of which preparer has any
~ l Berwyn P. Logan 5'-" l ~,
ADDRESS
443 W. High Street, Apt. 208, Elizabethtown, PA 17022
L 1505610143
1505610143 J
6 E. Mafn Street, Palmyra, PA 17078
Side 1
..J 1505610243
REV-1500 EX Decedent's Social Security Number
necedent~sName: LOGAPI, MAURICE R. JR. 199 07 2162
RECAPITULATION
1. Real Estate (Schedule A) .......................................................................................... 1.
2. Stocks and Bonds (Schedule B) ............................................................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3.
4. Mortgages & Notes Receivable (Schedule D) .......................................................... 4.
1 0 3 , 8 2 8 . 2 1
5. Cash, Bank Deposits & 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.
8. Total Gross Assets (total Lines 1-7) ....................................................................... 8. 1 0 3, 8 2 8. 2 1
10,931.94
9. Funeral Expenses & Admmistrative Costs (Schedule H) ........................................ . 9.
4 , 0 7 5 . 0 4
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................... . 10.
1 5 , 0 0 6 . 9 8
11. Total Deductions (total Lines 9 & 10) ..................................................................... . 11.
12. Net Value of Estate (Line 8 minus Line 11) ........................................................... .. 12. 8 8 , 8 2 1 . 2 3
13. Charitable and Governmental BequestslSec 9113 Trusts for which
an election to tax has not been made (Schedule J) ................................................ . 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) ................................................ . 14. 8 8 , 8 2 1 . 2 3
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
15.
(a)(1.2) X .00
16. Amount of Line 14 taxable 16
at lineal rate X .045
17. Amount of Line 14 taxable
2 14.15
5 9 17 7 , 1 0 5 . 7 0
,
at sibling rate X 12
18. Amount of Line 14 taxable
6 0 7. 0 8
2 9 1 g 4, 4 4 1. 0 6
,
at collateral rate x .15
19. 1 1, 5 4 6. 7 6
19. Taz Due ................................................................................................................... ..
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505610243 1505610243 J
REV-1500 EX Page 3
Decedent's Complete Address:
Fite Number 21 - 11 - 0187
Logan, Maurice R. Jr.
STREET ADDRESS
Manorcare Health Services
1700 Market Street
CITY
Camp Hill STATE
PA ZIP
17011
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
3. Interest
(1) 11,546.76
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box 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.
Total Credits (A + B)
(2) 0.00
(3) 0.00
(4)
(5> 11,546.76
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 :.................................................................................. x
b. retain the right to designate who shall use the property transferred or its income :....................................
c. retain a reversionary interest; or .................................................................................................................. x
d. receive the promise for life of either payments, benefits or care? .............................................................. ^
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ....................................................................................................................... ^ ^x
3. Did decedent own an "in trust 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
wntains a beneficiary designation? ...................................................................................................................... ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving
spouse 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
[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 Juty 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)1. A
sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, wfiether by blood or adoption.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
°0"AAOTM~"E"Ngri~""" PERSONAL PROPERTY
NINERRANDE Thl(RETURN
REBWENT DECEDENT
FILE NUMBER
ESTATE OF Logan, Maurice R. Jr. 21 -11 - 0187
Include the pproceeds of litigation and the date the proceeds were received by the estate. All property Jointly-owned with the Hght of
survivorship must be disclosed on schedule F.
ITEM I I VALUE AT DATE OF
NUMBER DESCRIPTION DEATH
1 ~ The Columbia Bank -Checking Account #0155003986
2 I Railroad Retirement
103,620.22
207.99
TOTAL (Also enter on Line 5, Recapitulation) ~ 103,828.21
SCEEISU.E H
Fl~6iALD~B~ES~
co~eAONwEUTN aF reNNSr~vANa
INNERITANCE TAX RETURN MIIIf-ICTt?A~ ~~
RE&DENi DECEDENT vw~v
FILE NUMBER
ESTATE OF Logan, Maurice R. Jr. 21 -11 - 0187
Debts of decedent must be reported on Schedule 1.
ITEM DESCRIPTION AMOUNT
NUMBER FUNERAL EXPENSES:
A.
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Berwyn P. Logan
Street Address 443 W. High Street, Apt. 208
city Elizabethtown state PA zip 17022
Year(s) Commission paid 2011
2. Attorney's Fees Brinser, Wagner & Zimmerman --Gerald J. Brinser
3. Family 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
a. Probate Fees Register of Wills (Ctrs. Pd. $90.00)
Register of Wills -Renunciation
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1 Register of Wills - Additonal Cost of Letters
5,200.00
5,200.00
130.50
10.00
170.00
TOTAL (Also enter on Ilne 9, Recapltulatlon) 10,931.94
C ScNedt~e H
COMMONWEALTH OF PENNSYLVANIA Fu>e~al
INHERITANCE TAX RETURN ~ \/\JD~ (`~'x~
ESTATE OF Logan, Maurice R. Jr.
21 -11 - 0187
Register of Wills - Addtional Short Certificates
The Sentinel -Legal Advertising
4 ~ Cumberland Law Journal -Legal Advertising
12.00
134.44
75.00
Page 2 of Schedule H
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
coNrgNwEN.TNDFaENNSYLVANw LIABILITIES ~ LIENS
INNERITANCE TN( RETURN 7
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Logan, Maurice R. Jr. 21 -11 - 0187
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses
ITEM
NUMBER DESCRIPTION AMOUNT
1 Vascular Associates 19.39
2 Philhaven Hospital 42.86
3 West Shore Pathology 260.00
4 Holy Spirit Physicians Services, Inc. 109.55
5 ADS Baltimore 400.00
6 MobileEX USA 604.50
7 PA Dept. of Revenue - PA 40 Income Tax 94.00
8 Physicians Group 40.00
9 James Harty 54.33
10 Heartland 183.27
11 MCHS 1,000.00
12 Golden Living 200.00
13 Trust Ambulance 1,058.75
14 Wheelchair Rental 8.39
TOTAL (Also enter on Line 10, Recapitulation) ~ 4,075.04
REV-1513 EX+ (11-08)
SCHEDULE J
COMM MERITANCE TAX RETURN AN'A BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF I FILE NUMBER
Logan, Maurice R. Jr.
21 -11 - 0187
NUMBER
NAME AND ADDRESS OF PERSON(S)
RECEIVING PROPERTY RELATIONSHIP TO
DECEDENT
oo Nauss Trusaw(s) SHARE OF ESTATE
(Words) AMOUNT OF ESTATE
($a$)
I~ TAXABLE DISTRIBUTIONS[includeoutright usal
di
t
ibutions and~nsfers
s
r
under Sec. X116 (a} (1.2)J
1 Berwyn P. Logan Brother 1/3 Residue 29,607.01
443 W. High Street, Apt. 208
Elizabethtown, PA 17022-3141
2 Dorothy M. Cole Sister 1/3 Residue 29,607.01
117 Bunker Hill Road
New Cumberland, PA 17070-2534
3 Thomas G. Liddick Nephew 1/3 Residue 29,607.01
(Son of Predeceased Sister,
Elizabeth Liddick)
49 Longwood Drive
Mechanicsburg, PA 17050-7973
Enter dollar amounts for distributions shown above on lines 15 t hrough 18 on Rev 1500 cover she et, as appropriate.
II NON-TAXABLE DISTRIBUTIONS:
. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI O.OO
THE COLUMBIA BANK
LISTENING IS JUST THE BEGINNING.s'"
Apri14, 2011
Brinser, Wagner & Zimmerman
6 East Main Street-Second Floor
(East Main & South Railroad Streets)
P.O. Box 323
Palmyra, Pennsylvania 17078
Dear Mr. Brinser:
RE: Maurice R. Logan, Jr., deceased October 31, 2010
In response to your recent inquiry concerning the accounts maintained in the name of
the decedent, please be advised that the following accounts were open at the date of death:
Checking # 0155003986, open 10/25/2005, date of death balance $103,620.22,
in his name only with Berwyn Logan as Power of Attorney.
If you should have any further questions, please do not hesitate to contact me at (717) 291-
2437.
Very truly yours,
Karen D. Hillegas 0
Credit Inquiry Processor
~~ ~ ~ t business ~~'~~s`i
;rfc~nation is fumishn! as a matt:.r ° rya ~+;ia! use cniY•
Yhi; .: sn,; is ~.,r , co. ~ ~5, ~vnt
nstr~e to our inquiry: ~ n rc~s nat r..;-ram {
Ill ryst ~: 11$ ,fi:. {g`;;11t r, y.~
1 _ Y' ~C'.~`.
(., l .i :
F
1 10 I'.i a r,. iyC~.iY.~i:.\.t e. !ili t I~F'1~.' IrJ C:`J~JIJrnP~
r. ~j Lq: ~ i~.7 'p~~lJ J: .. J ~•nt ~ Mon
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'~~,r¢{ 4 ii -. ~I p.b - i It~.i~ Wltt rv
P.O. Box 1493, Columbia, MD 21044-0493
888.TCB.BANK I thecolumbiabank.com
RL-24 (11-88)
RAILROAD RETIREMENT NOTICE
U.S. Railroad Retirement Board
844 N. Rush Street Chicago, Illinois 60611-2092 Date: Hay 2, 2011
BERWYN LOGAN
443 W HIGH ST
APT 208
ELIZABETHTOWN PA 17022
You are due a payment of $9.65.
INFORMATION ABOUT THIS AWARD
IN REPLY, REFER T0:
M A LOGAN
BERWYN LOGAN
This benefit is due you as a payer of the deceased employee's burial
expenses.
A lump-sum death benefit is payable to either the funeral home, if there are
unpaid burial expenses on the deceased employee's account, or to the person or
organization who paid the burial expenses.
If more than one person or organization paid the burial expenses, the amount
of the lump-sum death benefit payable to each is proportional to the amount of
the burial expenses paid by each.
The total burial expenses were $9,651.00, of which you paid $1,695.77. As the
maximum amount payable in this case is $1,183.70, your share of the lump-sum
death benefit is in proportion to burial expenses you paid. The amount payable
represents your share of the lump-sum death benefit. This benefit is based on
the employee's combined railroad earnings and social security earnings, if
any. Therefore, no survivor benefits are payable by the Social Security
Administration based on the same earnings.
Although this lump-sum payment does not fully reimburse you for the burial
expenses, it is the maximum benefit payable by law.
This payment supplements our previous award and represents the balance due.
INFORMATION ABOUT YOUR PAYMENT
The payment will be delivered to you at the address shown on this letter.
If you have not already received this payment, you should receive it within
the following two weeks.
... nt /.. nn\
BERWYN LOGAN
443 W HIGH ST
APT 208
ELIZABETHTOWN PA 17022
You are due a paym~t~
snow
INFORMATION ABOUT THIS AWARD
IN REPLY, REFER T0:
M R LOGAN
BERWYN LOGAN
This benefit is due you as a payer of the deceased employee's burial
expenses.
A lump-sum death benefit is payable to either the funeral home, if there are
unpaid burial expenses on the deceased employee's account, or to the person or
organization who paid the burial expenses.
If more than one person or organization paid the burial expenses, the amount
of the lump-sum death benefit payable to each is proportional to the amount of
the burial expenses paid by each.
The total burial expenses were $9,651.00, of which you paid $1,695.77. As the
maximum amount payable in this case is $1,128.80, your share of the lump-sum
death benefit is in proportion to burial expenses you paid. The amount payable
represents your share of the lump-sum death benefit. This benefit is based on
the employee's combined railroad earnings and social security earnings, if
any. Therefore, no survivor benefits are payable by the Social Security
Administration based on the same earnings.
Although this lump-sum payment does not fully reimburse you for the burial
expenses, it is the maximum benefit payable by law.
INFORMATION ABOUT YOUR PAYMENT
The payment will be delivered to you at the address shown on this letter.
If you have not already received this payment, you should receive it within
the following two weeks.
If you do not receive this payment, please refer to this number when writing
U.S. Railroad Retirement Board
844 N. Rush Street Clucago, Illinois 60611-2092 Date: April 20, 2011
The Sentinel
www.cumb~rlink.com
~Pi
~~E :J1rPEr~56UP.G PERK+C(k:N'Y
ZIMMERMAN BRINSER, WAGNER 8
8 E. MAIN STREET, 2ND FL.
P.O. BOX 323
PALMYRA, PA 17078
717~38~348
AD NUMBER PAGE NO.
395620 1 of 1
BILL DATE SALESPERSON
04/14!11 wolfs
START DATE STOP DATE
03/31!11 04!14!11
Publication Insertions Rate Net Amount Gross Amount
3 THE SENTINEL -LEGAL 3 LGL $127.44
TOTAL AD CHARGE $127.44
3 PROOF OF PUBLICATION 01 PRF $7.00
II ~~
Purehaw Order ESt.M.R. Logan PAY THIS AMOUN $134.44 $161.33"
'AFTER 05/09/11
THE SENTINEL
Thank you for advertising with The Sentinel! Deadline for c/o LEE NEWSPAPERS
in-column legal ads is 4:00 p.m. two business days prior to PO BOX 840
date of insertion. For questions, call (717) 240-7130. WATERLOO IA 50704-0540
PROOF OF PUBLICATION
State of Pennsylvania, County of Cumberland
Jackie Cox, Retail Sales Manager, of The Sentinel, of the County and State aforesaid,
being duly sworn, deposes and says that THE SENTINEL, a newspaper of general
circulation in the Borough of Cazlisle, County and State aforesaid, was established
December 13,1881, since which date THE SENTINEL has been regularly issued in said
County, and that the printed notice or publication attached hereto is exactly the same as
was printed and published in the regular editions and issues of
THE SENTIlVEL on the following day(s):
Mazch 31, Apri17 and Apri114, 2011
COPY OF NOTICE OF PUBLICATION
f >
J a : r ~. v 'a
Eby t~ int I.eturii of;AdmMi.hstlori on d
ice a. ttxi~tt, rn., o.neia~a: We.ol Damp t
sielld County, PMneylyMiS, have bNn grarda
utrator. , „ ; dr
N tlnrtore indebnsd ro s.a.s4+s.r..equ.vu
tl. artd ttra.r hwr,a ruu d.xn. w ~.... ,,...
Affiant further deposes that he/she is not
e e.ate of ~ interested in the subject matter of the
wt3orougn ` "'•~'`'' ~ aforesaid notice or advertisement, and that
I ro Me undersigned
'~ ~ ;all allegations in the foregoing statement as
I to meice immediate to time lace and character of ublication
im Ma same, duty ~ i p p
:4,~ west : ; are true.
Wr~Ipbtratora, . ~ : ;.;
Sworn to ands scribe before me this
Zl~d~ ~ ~D~ Zo ~ t
Notary Public
My commission expires:
NOTARIAL SEAL
BAMBI ANN HECKENDORN
Notary Public
CARLISLE BOROUGH, CUMBERLAND CNTY
idy Commission Expires Jan 27, 2014
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, PA 17013
Tele: (717) 249-3188 Fax: (717) 249-2888
April 15, 2011
Cumberland Law Journal is published every Friday by the Cumberland County
Bar Association and is designated by the Court of Common Pleas as the official•legal
publication for Cumberland County and the legal newspaper for publication of legal
notices.
TO: Gerald J. Brinser Esquire
Maurice R. Logan, Jr. Estate
RE:
Legal advertisements must be received by Friday Noon. All legal advertising
must be paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on the following dates:
April 1, April 8, and April 15, 2011
Advertising Cost $ 75.00
Proof of Publication $ 0.00
Second Proof Request $ 0.00
Payment received $ 0 .00
Total Amount Due $ 75.00
Payment received by
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16, 1929), P. L.1784
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
ss.
Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and
State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law
Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid,
was established January 2, 1952, and designated by the local courts as the official legal
periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly
issued weekly in the said County, and that the printed notice or publication attached hereto is
exactly the same as was printed in the regular editions and issues of the said Cumberland Law
Journal on the following dates,
viz:
__ April 1, Apri18, and April 15, 2011
Affiant further deposes that he is authorized to verify this statement by the Cumberland
Law Journal, a legal periodical of general circulation, and that he is not interested in the subject
matter of the aforesaid notice or advertisement, and that all allegations in the foregoing
statements as to time, place and character of publication are true.
SUBSCRIBED before me this
_ l~
Notary
Logaa, Illfaurlee R., Jr., deed.
Late of Camp Hill Borough.
Administrator. Berwyn P, Logan,
443 W. High 3t., Apt. 208, Eliza-
bethtown, PA 1'7022-3141. NOTARIAL SEAL
Attornry: Gerald J. Brinser, Ee- DEBORAH A COLLINS
`p1CE' Notary Public
CARLISLE BOROUGH, CUMBERLAND COUNTY
My Commission Expires Apr 28, 2014
15 of April, 2011
10/05/lOrr 99221 Hospital Admission-Low C 785.4 187.00 19.39
11/03/10 Plan Payment:21228 77.54-
11/03/10 Adj:MediCare Write 90.07-
01/19/11 Plan Payment:no ck 0.00
got new address
~W-_ `
3q•--I1
Stay Warm!!
Call with questions
VASCULAR ASSOCIATES,
PROVIDER/ VASCULAR ASSOCIATES, FOR BILLING 717-763-0510
PRACTICE NAME INQUIRIES, CALL
' AN ASTERISK APPEARS ON ACCOUNT LOGAMA-00 DATE OF LAST ~~~~~ N I PAYMENT 9BEEOPON
CHAROES FILED FOR INSURANCE NUMBER PAYMENT DUE DATE
Over 30 Days I Over 60 Days I Over S+0 Days I Over 120 Days I PLEASE PAV This
CURRENT
cR THE CLOSING DATE WILL APPEAR ON YOUR NEXT STATEIIiENT I~~~~~~~~a~~~~~~a^
Pleaac maUyourpayment and this paym~,., ,...._ -.,~~ envelope.
(Ijyou are paying jor muhYple accounts with one payment, plea,,e incluae al! payment stubs.)
Summary Statement of Services (Detail on Reverse Side)
Account: Logan, Maurice R (324329) ~ Due Date: March 18, 2011
Program: Consult-Older Adult Statement Date: March 3, 2011
Admit Date: 06/15/2010 Previous Statement Balance: $42.86
Discharge Date: Payments Received Since Last Statement: $0.00
~ /\~- Total New Charges: $0.00
Q ~ ~/~~ Amount You Now Owe: $42.86
FINAL NOTICE
Previous attempts to have you settle this account have failed. Your account will be referred to Collections in Fifteen (15)
days.
To prevent this action, remit payment in full or contact our office at (717) 270-2413, option #2 or toll free 800-932-0359
Ext 2413, option #2, Monday -Friday 8:00 AM - 4:30 PM
Self Pay Financial Counsellor
Patient Accounting/Philhaven
Thank you for choosing Philhaven for your healthcare services.
135-164
• r ^ "ice,: PO Box 550 Mt Grefia, PA 17064 ;Phone (888) 302-4710 Ext. 2413 or (717) 270-2413
~l~l~, Vel4 Business Office Hours: Monday through Friday 8:00 am - 4:30 pm
A~wpewj ~ tiestig'ad wiakxcc
WEBT BHORE PATHOLOGY 2129"38162665
PO BOX 60 z;r~re±eevronT=_
PITT8BURGiH PA 15230-0060 02/24/2011
Temp-Return Service Requested ~ _„
J,f f~ .-I '
PHL4"26"38162685 ~ 3,~i?
1~D571.7~OTH0000588.J07D1Q.024218 024071 2129 /
MAURICE R LOGAN JR
~.nAi)UNT DUE .~h+i::a~r E~~C_c E~
s2so.oo
MAKE CHECK PAYABLE AND REMIT TO:
I VIII "III VIII VIII VIII VIII IIfII VIII VIII VIII VIII VIII IIII' IIIiI I
MAURICE R LOOAN JR tVIII IIIIIIIIIIILIIIIIII11111IIIIIVIIIVIIIVIIIVIIIIiIIIILII
w 4837 E TRINDLE RD WEST SHORE PATHOLOGY
MECHANICSBURO PA 17060 PO BOX 80
PITTSBURGH PA 16230-0080
IIII II LIII III II IIJIIII II IIIL ~ILIIIJIIII II IILIIIIII IIIIII II IIIIILLIIIIL IILIII II III VIII III IIIIIIIIIIIIIIIII I/L1111
i~i~~~i~n~~~~~~~i~~~i~w~~~i~~iw~~~~w~u~i~~iw~~i~~
MI_MOIV 7
RECEIPT RECEIPT INS. PAT.
DATE PATIENT DOCTOR CPT4 DESCRIPTION CHARGE FROM INS. FROM PAT. ADJ. BAL BAL
10/OS/10 Maurice Vahora 99222 INITIAL HOSPITAL CARE $154.00 $105.10 522.62 $0.00 $26.28
10/06/10 Maurice Vahora 99232 SUBSEQUENT HOSPITAL CARE 573.00 555.70 53.38 $0.00 $13.92
10/07/10 Maurice Vahora 99232 SUBSEQUENT HOSPITAL CARE $73.00 $55.70 $3.3e $0.00 $13.92
10/08/10 Maurice Vahora 99232 SUBSEQUENT HOSPITAL CARE S73.00 $55.70 63.38 $0.00 $13.92
10/09/10 Maurice Vahora 99232 SUBSEQUENT HOSPITAL CARE 573.00 555.70 53.38 S0.00 $13.92
10/10/10 Maurice Vahora 99232 SUBSEQUENT HOSPITAL CARE $73.00 555.70 $3.38 $0.00 $13.92
10/11/10 Maurice Vahora 99238 HOSPITAL DISCHARGE DAY $100.00 554.69 $31.64 $0.00 $13.67
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1 '
J
CURRENT 30-60 DAYS 60-90 DAYS 90-120 DAYS OVER 120 DAYS TOTAL ACCOUNT BALANCE
~~DUE FROM PATIENT ~~
S0.00 50.00 50.00 S0.00 S109.55 5109.55 ~I 5109.55 ~~
Thank You For Your Payment. For &Iling Questions, Please Call: (717) 972-4490.
r ~C~c ~~ ~a~ yee ara oared directly to the patient because a copay, deductible is due or your claim vdas denied by your
insurance company. It is the patient's responsibility to provide current insurance information (see reverse side).
08/09!10 .93926 DUPLEX ARTERIES L 400.00 .00 .00 .00 400.00
I
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TOTAL 400.00 .00 .00 .00 400.00
PATIENT NAME: MAURICE LOGAN JR AMOUNT DUE: 6400.00
Please ca11800-786-8015 option 2 between hours of 8:00 AM and 4:30 PM EST. MAIL PAYMENT TO:
BILL IS FOR PORTABLE ULTRASOUND ADS
PO BOX 62510
BALTIMORE MD 21264-2510
~~~~ 1138-MXRSTM-927594942849971-P; 4419419-1-681; 31251520.1; 1
These charges are billed directly to the patient because a copay, deductible is due or your claim was denied by your
insurance company. It is the patient's responsibility to provide current insurance information (see reverse side).
08/06/10 f 73660 TOElTOES MIN 2 VI 32.00 .00 .00 .00 32.00
Q0092
08/06/10 SET UP FEE X RAY 24.00 .00 .00 .00 24.00
I
R0070
08/06/10 TRANSPORT X RAY 2 132.50 .00 .00 .00 132.50
I
09/20/10 ! 72100 SPINE LUMBOSCRAL 50.00 .00 .00 .00 50.00
09/20/10 ~ 72220 SACRUM/COCCYX MIN 43.00 .00 .00 .00 43.00
09/20/10 I Q0092 SET UP FEE X RAY 48.00 .00 .00 .00 48.00
09/20/10 I R0070 TRANSPORT X RAY 1 275.00 .00 .00 .00 275.00
TOTAL
604.50 .00
.00 .00 604.50
PATIENT NAME: MAURICE LOGAN JK
Please call 800-786-8015 option 2 between hours of 8:00 AM and 4:30 PM EST.
THIS BILL IS FOR PORTABLE XRAY SERVICES
AMOUNT DUE: 5604.5'
MAIL PAYMENT TO:
Mobilex USA
P.O. Box 17452
Baltimore, MD 21297-1452
n~~~+~~ 1138-MXRSTM-927609-942674969-P:4419630-1-2391; 31251699-1; 1
ACCOUNT # 1108728
I ~- IF ANY QUEST10N5, PLFJI3E CONTACT:
03121/Il
03/24/11
E 04/06/lI
E 04/14/11
E 04/25/11
04/25/11
E D4/25/11
PATIENT
sTATEYENr
~T~ 05/05/11
twsT sTATE~ENr
a-TE~ 03/31/11
FED TAX ID #251857035
15756300
PERFORMED BY: JAY A ZDSERMANN MD PENN STATE CHILD HEALTH
PLACE OF SVC: OP PHYSICIAN
99204 433.11 OUTPATIENT VISIT NEM ADM 314.00
MEDICARE PAYFEMs D.OD
IEALTNAMERICA PAYMENT~E 0.00 0.00
Lri806201
PERFORMED BYs FRANK G LYNGH MD INTERVENTIONAL
PLACE OF SVC: ~ PFKSICIAN
94243 433.11 OFFICE OR ER CONSULTATid~l 249.00
NEALTNAMERICA PAYMENTS 34.32-
IEALTHAMERICA CDNT ADJE~ 174.68-
IE DEDICATES NEN FINAtArIAL ACTIVITY SINCE LAST BILL.
OTTER CHARGES BILLED TO YOUR DASURANCE COMPANY. 859.00
IF YQ! NAVE ANY QUESTIONS ABOUT THE AIpWF YOUR DASURAt~CE
COMPANY PAID, CONTACT THEM DIRECTLY. FOR ANY OTTER QIArSTIQNS
REGARDING YOUR BALANCE, PLEASE CONTACT OUR OFFICE. IF PAYMENT
HAS BEEN MADE, THANK YDU AND DISREGARD THIS BILL.
PLEASE NOTES TO KEEP YOUR ACCOUNT CURRENT, OUR POLICY IS 1'O
APPLY YD>RAt PAYMENT iD THE OLDEST OUTSTANDD~6 BALANCE.
THANK YOU FDR USDr6 MSIlR; PHYSICIANS GROUP FOR YOUR PHYSICIAN
SERVICES. IF YOU NAVE ANY QIAESTI08 REGARDING THIS BILLS PLEASE
CONTACT US AT 717-531-5069 OR 8D0-254-2619, BEiIEEN B:DDIW ND
5:30PM MONDAY THAOU611 iR:DNESDAY OR BE11iEEN B:OOAM At0 4:30PM
THARSDAY AND FRIDAY.