HomeMy WebLinkAbout06-17-111505610140
REV-1500 EX (01-10) -
OFFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN '} .:~
PO BOX 280601 ~ ' ~ 4 ~ ~--~
Harrisburg, PA 17128-0601 RESIDENT DECEDENT _
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
2 1 0 2 6 6 5 7 4 0 4 0 9 2 0 1 1 0 3 2 7 1 9 3 5
Decedent's Last Name Suffix Decedent's First Name MI
H A R T Z E L L S H I R L E Y ~1
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
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 Risturn (date of death
prior to 12-13-8c')
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
^X 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to ta;K under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
R O G E R B I R W I N E S Q U I R E 7 1 7 2 4 9 2 3 5 3
REGISTER OF WILLS USE ONLY ~,
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First line of address ~- ~ ~~° =' --'
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6 0 W E S T P O ~1 F R E T `Z.7
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S T R E E T ~ ~~ ~z.1 ~ _..
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Second line of address ~ ~~'_ v:> ;~ t i-
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City or Post Office DAB ~
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State ZIP Code ---- ~ s ~
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C A R L I S L E P A 1 7 0 1 3 ~' ~,~~ -rt
Correspondent's a-mail address;
Under penalties of perjury, I 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 and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
RS_ON RESPONSIBLE FOR FILING RETURN
E
yS~IGNATURB OF P M GATE
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ADD ESS
317 N• C LE E STREET CARLISLE PA_ 17013
SIGN TURE OF EP E OTHER THAN REPRESENTATIVE DA~E
,~
A RESS -
60 WEST POMFRET STREET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
L 1505610140
Side 1
15056101~41D
J
J 1505610240
REV-1500 EX
Decedent's Name: SHIRLEY M. HARTZELL
Decedent's Social ~;ecurity Number
2 1 0 2 16 6 5 7 4
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 and Notes Receivable (Schedule D) .......................... 4. •
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 5 ~ 8 6 0 9
7. Inter-Vivos Transfers & Miscellaneous N n-Probate Property
(Schedule G) ~ Separate Billing Requested ....... 7. •
8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 5 3 8 6 . 0 9
9. Funeral Expenses and Administrative Costs (Schedule H) .......... ........ 9. 1 2 8 2 . 5 0
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ..... ........ 10. 8 ~ 5 0 • 5 3
11. Total Deductions (total Lines 9 and 10) ....................... ........ 11. 9 6 ~ ~ • 0 3
12. Net Value of Estate (Line 8 minus Line 11) .................... ........ 12. - 4 2 4 6 . 9 4
13. Charitable and Governmental Bequests/Sec 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. - 4 2 4 6 . 9 4
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0 0 0 0 15.
16. Amount of Line 14 taxable
at lineal rate X .045 0 0 0 16.
17. Amount of Line 14 taxable
at sibling rate X .12 0 0 0 17.
18. Amount of Line 14 taxable
at collateral rate X .15 ~ 0 ~ 18.
19. TAX DUE .. .................... .................. ... ..... .. 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610240
150561,0240
0. 0 0
0. 0 0
0. 0 0
0. 0 0
0. 0 0
J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
0 0
DECEDENT'S NAME
SHIRLEY M. HARTZELL _
_ __ _
STREET ADDRESS
1000 WEST SOUTH STREET
CITY
CARLISLE STATE
PA ZIP
17013
Tax Payments and Credits:
~. Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments
B. Discount
3. Interest
0.00
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.
Total Credits (A + B) (2)
(3)
(4)
(5)
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 : .............................................................. ........ ^ Q
b. retain the right to designate who shall use the property transferred or its income; ....................... ........ ^ Q
c. retain a reversionary interest; or ........................................................................................ ........ ^ 0
d. receive the promise for life of either payments, benefits or care? ............................................... ........ ^ Q
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? ............................................................................... ........ ^ Q
3. Did decedent own an "intrust for" or payable-upon-death bank account or security at his or her death? . ........ ^ Q
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains 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
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 requiremenlls 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, exc~spt 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)]. Asibling is defined, undE
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1509 EX+ (01-10)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF: FILE NUMBER:
SHIRLEY M. HARTZELL 0 0
If an asset was made jointly owned within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A. MARION K. MATTESKY 317 N. COLLEGE STREET NIECE
CARLISLE, PA 17013
e
C
JOINTLY-OWNED PROPERTY:
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET °/a OF
DECE:DENT'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENT'S INTEREST
1. A. 03/2007 M&T BANK -CHECKING ACCOUNT #41645618 10,772.18 50. 5,386.09
ESTATE ADMINISTRATIVE COSTS
TOTAL (Also enter on Line 6, Recapitulation) $
_ 5, 386.09
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (10-09)
• pennsylvania SCHEDULE H
• DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
SHIRLEY M. HARTZELL 0 0
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
B.
2.
3.
4.
5.
6.
7.
City State ZIP
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State ZIP
Relationship of Claimant to Decedent
Year(s) Commission Paid:
Attorney Fees: IRWIN & McKNIGHT, P.C.
Family Exemption: (If decedents address is not the same as claimants, attach explanation.)
Claimant
Street Address
Probate Fees: REGISTER OF WILLS
Accountant Fees:
Tax Return Preparer Fees:
REGISTER OF WILLS
1,200.00
67.50
15.00
TOTAL (Also enter on Line 9, Recapitulation;) I $ 1,282.50
If more space is needed, use additional sheets of paper of the same size. ~
REV-1512 EX+ (12-08)
• pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
SHIRLEY M. HARTZELL 0 0
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimburse~d rrledical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. SARAH A. TODD MEMORIAL HOME -NURSING 3,638.43
2. DEPARTMENT OF PUBLIC WELFARE -CIS #260284625 4,712.10
TOTAL (Also enter on Line 10, Recapitulation) I $ 8,350.53
If more space is needed, insert additional sheets of the same size. ~
REV-1513 EX+ (01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
SHIRLEY M. HARTZELL 0 0
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec. 9116 (a) (1.2).]
1. RODNEY L. HARTZELL Lineal
1916 SPRING ROAD RE=MAINDER
CARLISLE, PA 17013
2. MARION MATTESKY Collateral
317 N. COLLEGE STREET JGINT ACCOUNT **
CARLISLE, PA 17013
** FUNDS FROM JOINT ACCOUNT USED TO PAY SARAH
TODD NURSING HOME AND ADMINISTRATIVE ESTATE
COSTS.
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed, use additional sheets of paper of the same size.
LAST WILL AND TESTAMENT'
of
Shirley M. Hartzell
I, SHIRLEY M. HARTZELL, of South Middleton Township, Cumberland County,
Pennsylvania, declare this instrument to be my Last Will and Testament, hereby expressly
revoking all Wills and Codicils heretofore made by me.
1. I direct my Executrix to pay all of my debts, funeral and administrativeexpenses as
soon as may be done conveniently after my decease.
2. I authorize and empower my Executrix to sell any realty owned by me apt my death,
and not specifically devised herein, at either public or private sale, and to give ;good and
sufficient deeds therefor, in fee simple, as I could do if living.
3. I give, devise and bequeath all of my estate of every nature and wherever situate to my
son, RODNEY LEE HARTZELL, and if he is not living at the time of my death, to MARION K.
MATTESKY.
4. I nominate and appoint MARION K. MATTESKY to be the Executrix of this my Last
Will and Testament; she is to serve as such without bond.
5. I hereby suggest that my personal representative retain the services of Irwin &
McKnight as attorneys in the settlement of my estate.
ACKNOWLEDGMENT AND AFFIDAVIT
WE, SHIRLEY M. HARTZELL, CHERYL L. CLELAND and SHARON L.
SCHWALM, the Testatrix and witnesses respectively, whose names are signed to the foregoing
instrument, being first duly sworn, do hereby declare to the undersigned authority that the
Testatrix signed and executed the instrument as her Last Will and Testament, that shE; had signed
willingly, that she executed it as her free and voluntary act for the purpose herein expressed, and
that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as a
witness and that to the best of their knowledge the ~restatrix was, at that time, eight~eea~ years of
age or older, of sound mind and under no constraint or undue influence.
S ,R~ZE`I' M. HARTZF~L
~' ~ //
C YL L. CLELA
~(J ~: ~/~
~~'r'7CL.,• .x'.72 ~ x/['~~h >~~ ~~~-_
SHARON L. SCHWALM
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF CUMBERLAND
Subscribed, sworn to and acknowledged before me by SHIRLEY M. HART7,ELL, the
Testatrix herein, and subscribed and sworn to before me by CHERYL L. CLELAND and
SHARON L. SCHWALM, witnesses, this t'='~ day of January, 2007.
,;
3 . ~~~
Public
COMMpNWEALTW OF PENNSYLVANIA
~~I Idtarial Sea!
Roger B. Irwin, Notary Public
Carlisle l3oro, Cumberland County
My Commission Expires Oct. 3, 2008
Member. Pennsylvania Association Of Notarie~~
3
IN WITNESS WHEREOF, I have hereunto set my hand and seal this _~~~ day of
January, 2007.
!~~iI EY M. HART LL
Signed, sealed, published and declared by SHIRLEY M. HARTZELL, tr-e above-
named Testatrix, as and for her Last -Will and Testament, in the presence of us, wllo, at her
request, in her presence and in the presence of each other have subscribed our names as
witnesses hereto.
•, - /'
~.
~~ ,. -
2
M&T
499 Mitchell Road, Millsboro, DE 19966 Adjustment Services
Irwin and Mcknight PC
60 West Pomfret Street
Carlisle, PA 17013-3222
Re: Estate of Shirley Hartzell
Social Security: 210-26-6574
Date of Death: April 09, 2011
Phone 888-`~02~-4349
F ax (302) 934G-2955
May 31, 201.1
.,- -
Dear Sir or Madam:
Per your inquiry on May 26, 2011, please be advised that at the time of death, the above-named decedent had on
deposit with this bank the following:
1. Type of Account Checking Account
Account Number 41645618
Ownership (Names o~ Dale S Hartzell
Shirley M Hartsell
Marion K Mattesky
Opening Date 03/28/07
Balance on Date of Death $10,772.18
Accrued Interest $ .01
Total -- ----------------------------------------------------
$10, 772.19
For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds
please call the Carlisle West 011fice at#717-240-6717. ,
We were unable to locate any safe deposit box for the above-mentioned decedent.
This letter does not include any accounts in which the decxased may have been listed as Power of Attorney, Custodian of Uniform Transfers,
Representative Payee, or Trustee under a Written Agreement
Sincerely,
Tammy Spencer
Adjustment Services
STATEMENT
Sarah A Todd Memorial Home
1000 West South Street
Carlisle, PA 17013
Telephone: (717) 245-2187
Statement Date:05/12/2011
Due Date: 05/25/2011
Amount Enclosed $
Account #: 102054
RE: Shirley M Hartzell
Marion Mattesky
317 N. College St
Carlisle, PA 17013
Balance B/F
03/01/11 RESIDENT INCOME
/01/11 - 03/31/11 Room & Board -Semi-Private
03/01/11
03/02/11 Personal Supplies
Medical Supplies
03/03/11 Medical Equipment Rental
03/09/11 Incontinence Supplies
03/15/11 Beauty & Barber
03/31/11 Personal Laundry Services
03/31/11 Cable Television
03/31/11 Cable Television
/01/11 - 04/30/11 Room & Board -Semi-Private
04/01/11 RESIDENT INCOME
04/08/11 Cable Television
31 266.00 -8,246.0
-7 .55 -10.9
-133 1.26 -177.4
-46 19.54 -884.1
-5 12.45 -53.6
-1 18.00 -18.0
-1 30.00 -30.0
1 24.75 24.7
-1 24.75 -24.7
30 266.00 -7,980.0
1,345.6
1 24.75 24.7
1~~~~
i
.,,..
19,668.25
11,422.25
11,411.32
11,233.85
10,349.73
10,296.06
10,278.06
10,248.06
10,272.81
10,248.06
2,268.06
3,613.68
3,638.43
Current 1-30 Days 31-60 Days 61-90 Days Over 90 Days Amount Due
.00 24.75 1,370.37 2,243.31 .00
~.v ~ ~. rr~ ~ i-~u~ ~ as vv~ lJrv17 RGI.Clr 1 DV 1 IVV LJ11 CR
THE 25TH OF THE MONTH ***** Please remit the LAST AMOUNT
your statement. Include the ACCT# from the statement on the MEMO
of your check. Payments after 5/9/11 do not reflect on statement.
NOTE: ** LATE PAYMENTS ARE SUBJECT TO A 1.25°/a LATE CHARGE PER
A $10.00 FEE WILL BE CHARGED for RETURNED CHECKS **
Shirley MHartzell -Account #: 102054
Sarah A Todd Memorial Home
1000 West South Street
Carlisle, PA 17013
Telephone: (717) 245-2187
Statement: Date: U5/12/2011
Duey Date: 05/25/2011
SARAH A. TODD MEMORIAL HOME
1000 West South Street, Carlisle, PA 17013
(717) 245-2187 • (717) 245-9733 -FAX
www.ucc-homes.org
May 25, 2011
Marion Mattesky
317 N. College Street
Carlisle, Pa. 17013
Re: Shirley M. Hartzell, # 102054
Dear Mrs. Mattesky,
The account for Shirley Hartzell is now past due. We recommend your immediate aittention in
this matter. Please forward the total amount due of $3,638.43 by June 15, 2011.
If this payment is not received by the stated date, please contact me to establish a meeting time to
review your options. If payment is not received or arrangements made within the al-ove
mentioned deadline, I will be referring this account to our legal counsel.
Thank you for your prompt attention in this important matter.
Sincerely,
,~
Mary Jane Walker, NHA
Executive Director
A program of service for the older person sponsored by United Church of Christ Homes
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF PROGRAM INTEGRITY
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-8486
June 9, 2011
~~ _
IRWIN & MCKNIGHT LAW OFFICES '~ "'~ `~`"
ROGER B IRWIN ESQ ~ ~. ~r~'~' ->. i,' .,;.' ,,r ,
WEST POMFRET PROFESSIONAL BUILDING ~ ~~'~~ '°' ~,I"' .'""
;, ~;,; - .
60 WEST POMFRET STREET -~~"
CARLISLE PA 17013-3222
Re: Shirley Hartzell
CIS #: 260284625
SSN: ###-##-6574
Date of Death: 04/09/2011
Dear Mr. Irwin:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $4,712.10 against the above-mentioned estate. `Phis
claim is for restitution of medical assistance granted on behalf of t:he
decedent for which the Probate Estate is now responsible to reimbursE~ 1.he
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 $4,712.10, 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 $.00, is to be entered
as a priority Class 5.1 claim against the estate.
Please acknowledge receipt of this letter and advise whether they
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,
Tina M. Wise
TPL Program Investigator
717-214-1204
717-772-6553 FAX
Enclosure
- -
~,:~
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION -CASUALTY UNIT
PO BOX 8486
HARRISBURG PA 17105-8486
June 7, 2011
STATEMENT OF CLAIM SUMMARY
NAME Estate of HARTZELL, SHIRLEY
ID 260 284 625
MEDICAL CLASS 3 CLASS 5.1 TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 4,613.07 .00 4,613.07
DRUG 99.03 .00 99.03
REIMBURSEMENT TO DPW 4,712.10 .00 4,712.10
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN - 23-6003113
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
June 7, 2011
STATEMENT OF CLAIM
NAME HARTZELL, SHIRLEY
ID 260 284 625
SARAH A TODD MEMORIAL HOME INC
1000 W SOUTH ST
ARLISLE PA 17013
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES I AMOUNT APPROVED
03/01/11 - 03/31/11 05/18/11 20111384020480001 20111384020480001 4,460.:37 4,460.37
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS
PROC CODE : 000000
04/01/11 - 04/09/11 05/18/11 20111384020470001 20111384020470001 152.'TO 152.70
DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING
DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS
PROC CODE : 000000
PROVIDER SUB TOTAL SARAH A TODD MEMORIAL HOME INC 4,613.07 4,613.07
03 100777455 0001
June 7, 2011
STATEMENT OF CLAIM
NAME HARTZELL, SHIRLEY
ID 260 284 625
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
MILLENNIUM PHARMACY SYSTEMS INC
5020 RITTER RD
STE 110
NIECHANICSBURG PA 17055
DIAGNOSIS 1 : 0
I T DATE I VKIh11VHL I.KIV I ADJUSTED CRN I USUAL CHARGES I AMOUNT APPROVED
03/01 /11 - 03/01 /11 05/11 /11 25111315667360001 25111315667360001 8.92 .09
DATE OF SERVICE PAYMEN
NDC CODE : 63304062410 FUROSEMIDE 20 MG TABLET - DIURETICS
03/01/11 - 03/01/11 05/11/11 25111315667530001 25111315667530001
DIAGNOSIS 1 : 0
NDC CODE : 00378180301 LEVOTHYROXINE 50 MCG TABLET - THYROID PREPS
03/01 /11 - 03/01 /11 05/11 /11 25111315668730001 25111315668730001
DIAGNOSIS 1 : 0
NDC CODE : 00591024005 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
03/02/11 - 03/02/11 05/11 /11 25111315668870001 25111315668870001
DIAGNOSIS 1 : 0
NDC CODE : 63481068403 VOLTAREN 1% GEL - ANTIARTHRITICS
03/04/11 - 03/04/11 05/11/11 25111315669060001 25111315669060001
DIAGNOSIS 1 : 0
NDC CODE : 00597001314 COMBIVENT INHALER - BRONCHIAL DILATORS
03/29/11 - 03/29/11 05/11/11 25111315672530001 25111315672530001
DIAGNOSIS 1 : 0
NDC CODE : 00378180301 LEVOTHYROXINE 50 MCG TABLET - THYROID PREPS
03/29/11 - 03/29/11 05/11/11 25111315672780001 25111315672780001
DIAGNOSIS 1 : 0
NDC CODE : 63304062410 FUROSEMIDE 20 MG TABLET - DIURETICS
04/07/11 - 04/07/11 05/11/11 25111315673420001 25111315673420001
DIAGNOSIS 1 : 0
NDC CODE : 50458092550 LEVAQUIN 500 MG TABLET - URINARY ANTIBACTERIALS
14.06 1.10
17.41 5.01
42.71 9.50
204.;19 45.00
10.(14 1.22
7.10 ,80
116.62 25.71
• COMMONWEALTH OF PENNSYLVANIA ~•~• _..~___-~~Y r
• DEPARTMENT OF PUBLIC WELFARE
June 7, 2011
STATEMENT OF CLAIM
NAME HARTZELL, SHIRLEY
ID 260 284 625
MILLENNIUM PHARMACY SYSTEMS INC
5020 RITTER RD
STE 110
ECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
04/07/11 - 04/07/11 05111 /11 25111315673700001 25111315673700001 9.96 4.39
DIAGNOSIS 1 : 0
NDC CODE : 00591024005 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
04/08/11 - 04/08/11 05/11/11 25111315673630001 25111315673630001 30.20 6.21
DIAGNOSIS 1 : 0
NDC CODE : 00054040444 MORPHINE SULF 100 MG/5 ML SOLN - NARCOTIC ANALGESICS
PROVIDER SUB TOTAL MILLENNIUM PHARMACY SYSTEMS INC
24 001887261 0008 461.61 99.03