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HomeMy WebLinkAbout09-02-11COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT.2B0607 HARRISBURG, PA 1 7 1 28-0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT CHADWELL RONALD W 1714 LETCHWORTH RD CAMP HILL, PA 1701 1 -------- fold ESTATE INFORMATION: ssN: 22o-1a-25ss FILE NUMBER: 21 1 1 -0228 DECEDENT NAME: RODGERS DOROTHY E DATE OF PAYMENT: 09/02/201 1 POSTMARK DATE: 09/02/201 1 COUNTY: CUMBERLAND DATE OF DEATH: 12/02/2010 REMARKS: SEAL CHECK# 5359 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 ~ 5219.47 TOTAL AMOUNT PAID: INITIALS: CJ RECEIVED BY: 5219.47 GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS REV-1162 EX111-96) NO. CD 014926 1505610101 EX (oi-io) ~ OFFICIAL USE ONLY Code Year File Number nt REV-1500 C PA Department of Revenue idual Taxes di y ou Pennsylvania ,1 ~ ' ~ ~ ') ~~~' oEO A.ME~. F INHERITANCE TAX RETURN i v Bureau of In PO BOX 28D6oi ' RESIDENT DECEDENT_ r ' Harrisburg, PA i~i28-0601 MMDDYYYY th MMDDYYYY Date of Birth NTER DECEDENT INFORMATION BELOD E Social Security Number to of Dea O ~ ~ ~ O C,~ ~ ~ 1 (~ Z Cp 9 Z O t 2 8 2 '~ ~ , ~ ~ O MI Decedent's First Name ff Decedent's Last Name ix Su ,/1 ~ ~ ~ '~"' ~ o ' !~ G ~" rz 5 MI (If Applicable) Enter Surviving Spouse's I nformation Below Suffix Spouse's First Name Spouse's Last Name E WITH THE AT C E FILED IN DUP Spouse's Social Security Number S I ii THIS RETURN MUST B REGISTER OF W FILL IN APPROPRIATE OVALS BELOW ~ 3. Remainder Return (date of death 2 Supplemental Return prior to 12-13-82) e 1. Original Return O 5. Federal Estate Tax Return Require t Compromise (date of O 0 4. Limited Estate ~ 4a. Future Interes death after 12-12-82) © 8. Total Number of Safe Deposit Boxes 7. Decedent Maintained a Living Trust ~ O 6. Decedent Died Testate of Trust) (Attach Copy O 11. Election to tax under Sec. 9113( (Attach Copy of Will) Credit date of death Spousal Poverty ( (Attach Sch. O) 10 Proceeds Received . ~ 12-31-91 and 1-1-95) ~ 9. Litigation between 1"'} RESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIREf°v7ED Daytime Telep~ne Number • , _x _ COR >~_ ~ ~ ~ fit`- ~~- ' Name , ~ 7 ~~ ~ON~ L17 w C~-{AOwE LL -n _ -; REGISTE#~'OFrWIL SUS QNLY ~ .• _ ~ `~ , !~ ; ~ ~ ~ i^~ -r`t - ~ ;~-ri First line of address =~ ~_ `' ~' Second line of address City or Post Office iw r, v. r 1+t q C1 w ~ r..~~P000ndent's a-mail address: I DATE FILED LLL___------._----' State ZIP Code ~ ~. ~~ o ~ ~ -~ s 2~ ,, ~.-allies of perjury, I declare that I have ex~amfn~ed ther than'the personal a~ ~. L©~^ schedules and statements, and to the best or my ~, ~~w~~~y~ e is based on all information of which prepareDATEany know) it is true, correct and compiece. uGac,a.,..,~ ~• ~~-~ SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN j belief, ADDRESS DATE SIGNw ATURE OF PREPARER OTHER THAN REPRESENTATIVE ADDRESS 1505610101 SE Side 1 Y 1505610101 -~~ REV-1500 EX Decedent's Name: RECA U A`TION _ 1505610105 1. Real Estate (Schedule A)... . . 1 2 Stocks and Bonds (Schedule B) .. . 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (~ch Decedent's Socal Security Number ~~~ a $ 2 .~ ~j cf ~ • U (.? ~.~. ~ ~.~ edule Cj .... 3 4. Mortgages and Notes Receivable (Schedule D) ... ~ • ~`"? 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) ~• (~ CJ ...... 5. 6. Jointly Owned Property (Schedule F) S ~ ~ ~ ~ 7 ~/ ~ ~ ~'/ ~:~; eparate Billing Requested ..... . 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 6. (Schedule Gj , ( ~. ® O °-' :: Separate Billing Requested....... 7 , . , 8. Total Gross Assets (total Lines 1 through 7) .. ~ ~ ~ ~ ~ _. 8. ..... 9. Funeral Expenses and Administrative Costs (Schedule H). I ~ 1~ ----~ ~. O ~~, ~j `~' ~ ~•d~i 9. 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule Ij . 7 ~ ~ ' ~` C .... 10. 11. Total Deductions (total Lines 9 and 10). ~ ~!~ o ~' ....... 11. Net Value of Estate (Line 8 minus Line 11) ry 1• J .. ' ~~ 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Sch d ~ ~/ ` ~~ ~ r `j~ 7 ~ ~ 7 e ule J) .. , , . .... 13 . 14. Net Value Subject to Tax (Line 12 minus Line 13) ~ r~ v ~ ~) TAX CALCULATION - S s~ EE jPjgTRUCTIONS FOR AppLICggLE RATES 14. 15. Amount of Line 14 tax bl ~-"'- (~ 7 -°""'-""°---N- a e at the spousal tax rate, or -- transfers under Sec. 9116 (a)(1.2) X .0__ 16. Amount of Line 14 taxable • 15. at lineal rate X .0 ~" 17. Amount of Line 14 taxable ~ ~ 7 ~" 0 7 16. at sibling rate X .12 a ~" ~ ~• ~ ,Z ~ 1 , ~' 18. Amount of Line 14 taxable • 17. at collateral rate X .15 • 18. 19. TAX DUE .......... • ......... 19. ~ I • `~ ~ ~Z' Y " `~' 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT L 1505610],05 Side 2 1505610105 -- ~~~~ Q ~^~.~~ F~ ~ ~ ~- .,,~-~" ~j '~'~~ ~~',~v i 6131.:•.4. ;;OIv1MONWEALTH OF PENNSYLVANIA ~~~'~~"~E,t 10] ~~ ;~1-'era-„ INHERITANCE TAX RETURN .,~~~n~niT nFCEDENT _ FILE NUMoER Zv~l •,- C7 022 ESTATE CF (~ ~ ~~ O ~ ~Y` S "' CJ ~ ~~ ~'` ~ and t date the proceeds were received by tsehedutle F ITEM NUMBER c~ ~ ~~~' ~~ ~~ C~ I dude the proceeds of IdigaUon All property jointly•owned with right of survivorship must be disclosed on c DESCRIPTION - P Sa~:~- s ~ cLOu~ ~ Ps~~-~ 5 © vt N 4 '~ ~ c~s~- .~~, ,~,, o b; I ~ C~ ~G s ~- ~.~~~~~ ~, v . ,~, u V' b 9 vi ~l 1~'l 0 y S ~~1 u ~c~ ~~~~~ W~ ~~'`~y ~~~ ar~i r~~«r~ ~t~~r ~- ~D , 0 ~ 1 sa, ~ VALUE AT DATE OF DEATH .j ', 25 is~.oo ~~ t~ ~oS, ou s so. Q ~ i CTAL Also enter on Ilne 5, Recapitulation] S (If more space Is needed, insert additional >heets of the same size) RE'~.'-~510 EX= (OS-OG1 ^ ~. -~ ~uI~'_._c~ pEPARTid N OF R`t~ENUE INHERITANCc TAX RETURN ~ s ~~ ~ ~' ~ 'j ;~ 3 ~3.. i" ~ m r RESi~tivi ~~..",~ -_-- ------ n F"sLE i`.IUi~B~R 2. ~ ~ ` ... ~~.,. ow_1 snn .c ves. ~~ ~:c~ '.~~ ~'~~ _~^~..~3a,~y'. [.,1~ hFV EN UE oERaaT~~ENi o INHERITANCE TAX RETURN RESIDENT DECEDENT EST;ATt ~F ~ d r ~~~ ~~ ~~, ,~v Ct% i '' ~1 nn SchE:dUle I. ~oeir Decedenti's dents m N""` NUMBER A, FUNERAL EXPENSES: ~ ~ S S o c i q~~ I. I ~ ~ q~ t O~^ Ah Gr FILE i~UtilgcR ZU ii -v02Z~ AMOUNT Fetes ~~ ~3~".00 B I ADMINISTRATIVE COSTS: - ~ Personal Representative Commissions: i Name(s) of Personal Representative(s) Sheet Address State ZIP ----- City Year(s) Commission Pald: Z Attorney Fees: 3 Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) - Claimant _ Street Address State ZIP ~-- City P.elationship of Clalmant to Decedent q Probate Fees. ~, Accountant Fees: 6 Tax Return Preparer Fees: 7. 7C~Tp~L (Also enter on Line 9, P.ecapitulation) I ~ ~ ~, If more space is needed, use additional sheets of paper of the szme size. 6 '. r ~~,~ DEPAR ~=~~ OF EVFNLE IHERiTANCE TAB RETURN ID RESIDENT DECEDENT t y •~0 ~~~ 9 ~ ~' UGC'"~~~5 t f ESiAiE On ~ ~ p she decedent prior to death that Report debts incurred by `~ .i-M DE NUMBER r ~ 1. FILE [~lU1yi3ER .ZU ~ ~ ~ ~ (~ Y' ~ enses. ed unpaid at the date of death, includln9 unrel~sed medVALUE AT DATE OF DEATH - -~ ---~ co,~~,;ras1 I 2_ ooo. RCS P.EV-1513 EX= !.O1- ~ 0; ,~, .r-, n ~ }~ 7-'f,„~ c' ~ ~ c E ~~ p_pnR f~~ElvT 0. ~EVENLE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE 0` ~ ~1 ~. ~ (~ C 1(~ S G r ~~~ , NUMBER I NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [lnduseC 9196t(a) (lsz) jistributions and transfers under 1. but ~N, (~~gG'wC~~1 , ~ ~~ ~'.~ ~~0~~ Caw~~p ~;~'1 ~ pP~- FILE NUM5E2: ~~;~ ._~U2'2~ AMOUNT OR SHARE RELATIONSHIP TO DECEDENT OF ESTATE Co Not List TrusteeO_ ~ ~~a~a Sd~ F TER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPP,IATE. _N iI I NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKER ; B. CHARITABLE AND GOVERNMENTAL DISTRIBU (IONS: GTAL OF PAST Ii - EiV I ER TOTAL NON-TAXABLE DISTRI6UTI0~J`~0~ LoINpE Pe OFtRE saris 00 OVER SHEET. $ If more space is needed, use addltun ("I U) 234-84'if: ~;"orns'~urg~~ P.O. Boxb1013 B00 237-?3~!~3 (Plationwi~~'} Harrisburg, PA 11106-1013 ~ } PLEASE NOTE: BASED ON IRS CRITERIA THIORTANTUNAX RETURN DOCUMENTAN IMP 1 AV 0.335 oor~'~Ep 8073XXXXXX 00003400 sTresa~-+T ~E ~° ~n~~~~~n~~~~~nu~~~u~~~~i~~u~~~~~nn~~~i~~~~~~~~n~~~~~ atom DOROTHY E RODGERS 12011 123110 APT 411 820 LISBURN RD - --- CAMP HILL PA 17011-7106 PAGE 1 _ TRASH g~C~ P~~' F-NANCE FEGBaR A/iAbU1F1• _..~ .. CFrANta~'~ _. cN~1ss7R CIMARfiE _ _. _.._. TAANS/'~TIQN upp.taN '.arm .:. ~ -__--- - _ .~. _ _._. . _ .. 2 5 5 ...... rx~ .. - ... _. _ _... . - ... _ . REGULAR SHARES BEGINNING BALA . p 00 12/01 ID O1 12/31 , ENDING BALANCE _ --~=a=== = ____-__°_- END YTD: YEAR TO DATE - __=__=__~______________ 2862.34 DIVID __=_------ BALANCE 34 12/b1 ID 04 CHC=CKTNG BEGINNING. 142.62- 669.72 12/0:] CHECK ..'04044:3, 1076.00 3745. 2 , 12 O1 CHECK 000442 DIRECT DEPOSIT US TREASURY 303 12/03 PAYMENT: TYPE: SOC SEG I0: 3031036030 207 . D0- 3538 • 72 ~~. US TREASURY 303 0:..3.0 '3~39.QZ ' 12/06 CHECK 000464 AYt1ENj : I?I.VIDENA 0 . ]<.00%~ lOi FROM 12/01/10 O , THROUGH 12/31/10 %31 ~x . P YIELD EARNED ANNUAL PERCENTAGE BALANCE OF 3,502.69 3539.02 BASED ON AVERAGE DAILY 2 76 12/31 ENDING BALANCE 'pIUIDEND YTD: YEAR TO DATE AKOUNT AM033NT AMDIINT NI~MeER ' '' Nt~M$f R KuM~~R 207.00 AMOUNT K~MBER 50.00 000464* 62 000443 NUMBER SEQUENCE 142 - ____ _____- _ - ______________ _ 000442 . SKIP IN INDICATES ___ --- NEXT TO NUMBER - ---- ___° ___ 0.00 --___ .- , * ASTERIS K _ --- _--__ _____ __ ____ - 00 0. 1D MONEY MRRRET~EGINNiNG BALANCE 07'. 0.00.. 12/01 12/31 . ENDING BALAN _ _ _ ____ YEAR Td DATE T _ -_ _-- ____ ___________________ r _ D: Y DIVIDEND _ _ --------------= ----------- BALANCE -~ --___---- 966.06 1973.42 __ ___ E BEGINNING 50-60 MONTH IRA I I 7.36 12/31/10 12/01 ID 410 4 /O1/1 IDEND FROM 1 PAYMENT. DIV EARNED'4.50~ 0 THROUGH 42 197.3. 12!31 ANNUAL PERCENTAGE YIELD 12/31 ' ENDING BALANCE URE UN O1i.02/14 ICATE WZLL GERTIF 87.09 : 60 F1UNT1i IRA DATE NONTAXABLE DIVIDENDS YEAR TO ________________ 13.00 - IRS WITHHOLDING YEAR TO DATE _ _ _______ _____ _________ ____ ________ o.aD __ ---- - - ONTRIBUTIOMS 2.76 ____ TOTIiL CItRRENT YEAR IRA G YTD: YEAR TO D RE 87.09 TOTAL DIVIDEND TO DATE Y p ~ NONTA 13.00 TOTAL YEAR TO DATE ITHHOIDING IRS N TOTAL ~L J O~ ~ p O Y ~ r n Z ~ z O °- Z ~ 11 0 Y O ~ Y ~ Q ~.: ~ ~ 2 O +'3 `r co m o ~ o d 0 0 O O O - ~~,.+~ ~~ m ~ Q ~ ~n ~~ C 1 ~ O 0 0 ~ ~ ~.~r. X O O `- I"" X -Ef3' x x X X ?l Y X d O ~ W J Q c, w U `~ ~ ~ Q w ~ v ~ o ~ T m ui _ ~ ~ ~ ~ O ~ CD p o ~ ~ ~` ti a ' ~ c rc `., ~ c o y_, *k , p l y o ~ ~ uJ Q v w o ~ z m ~ 4 '~' ~ c_J") ~. Z F~ ~' rc ~PENNSYLyANIA, INC. ~~V~J ~~ '• r er, Supereisor ~ ~ Far 717-S~i1-9943 ' Shown E. ~~+ P 00-7..0-8..21. • Uec 3 ~ 2~7.~Ii 1 sD 12 :~ t3 1,.~ 5 i~onaid Chadwel! ~ ~ _~~, ~e~cnt~~ortirl Roast u ~ 'Its' "1 ~~ t. a.n~i~ r='- L ' - Dorothy ~,stella Kocigers - 'Deceased ;;~~;Cl!~~ Gt-f.-1i2G i_:> i }^. e C ;, i:r ema t i on ram ~j l~ia?. zonwide Uuaranteeteco~on ~,rogram r~nJ Q r l C1V;' 1 Cl. ? `l` 1" 8. t1 e 1 ~~~w~i~_~L, Sr~~Gr~L t~Hx~z~.~~s ~KUrt~:~:~1iJ1VH1+ ~~kltili(:~5 t;_ 5tai=~ ~'Llrleic^..? iti reCtGr S yPl_`/:L.~rS US 1)_r?~:Sln~~;/LU~111eT.1zln~ j~ienlUrlal `..SerViCe es rx ;;tai= nor , Service ~~ ~' '. ,_ ~_or Llemoria_~ ;~ r. a y ~ ~~. ,~~t~t = amen` ~ ramify ~tewrnq ,T. _.<.lace 1L Cremation t~! 1,.,he5~,~ ~ ~zc,' t;~e ~ L~~ ~-2zmains <;,r„~ r~c>rsadruinc, of Cr~_lr~at..> ~t.x : ~ o~ ~;remated Ke.mains ;,mac°,clla~ ueiivery rema r.en t~ema i ns ,~ - .: r _. n ~; c~ r -- ~,,~~1 r~,__, ~'it~7r r;SSiCJi\l~.L S~K~ 1.C;~'S ~u~~tN ~'i~l`1' ~1.;~~ s _ ~; e nl < <r:~.i V e h ;. c i e _,~~.r; i.:.ar; Clergy Gar ~_•:i, i ~,' Car ~,~~;~?''1~1, ,~U'.l'C`:`~!Q'1`iV~ .;(~)t11.L'Mlt `1-' Sa. _5~a5.m(~ S1 F 595 . (tl~d included $85.~~ $85.~~ ~~ nc 1 tided ~~ . ~?G ENNSYL~ANI~1, INC. RATION SER j SERVICES '(~F P r sU e~,sor p~~G~ ~>~~s ~jj'~~ ~"~~1~N -~i-99`x? • Shawn h. Carpe > P V~ • Harrisburg, PA 17109 • 1-800"7~0-8?>> ~ Fay ~4~~~ • 0 ~~~ ~~yG~ 4100 Jonestown Road ppE~1'NSYLVA`~t~' 11238 LL5 llec 3 , 2~:~~d ~G27a i ~ Chadwe 1 i r `,eLC1~t'Grtn L~.OaC;. L: cc^. Illj=> 1-i 1 1 ~ F N ~ I '. r ~} .y ~. to i?odgers ~ deceased L'~orotny Este 1 _ "' y_4r595.mm ;~~'~:C;1 a~, CHARU~S ~~i,..PGt Cremation Procfram y~ ~3~•;_~orlwicie Uuaranteetection Yr°g~`am ~1,595.~~~ t~~Gr ! C1t:.* i ~e `I'rave i Pro ~i'U'1'A1~; t';~C~~_L C:til-~i~GES ;.nclucied -~.t;ri:~.s~iviv~L S~~~runerai ll~rectar ~. .~t.af•x. .~e1:~'. ~ "yes "r ~iriy~ jCc~smet~Zinct MenlGrial Service r.ies c~ Stafz for ;, ;ce " r for ~viemorial ,erv_ ~..: , _ r; ,,.;cu i ~nlen ~.~,~ view~nq ,-, vatie ! ~~ ~'ami iy ~7e Cremation n;' a8`~ ~~ ~~ , ~~IC~ alnatc:c~ ~~ema i -~ ~-~c, i r'c7~v4Cxrcx ~',iematecr remains. ersot7~- ~ Ue 1 Ivery _> ,<-~ ,,. ~~r;.n~t o~ ~~-'emate~~. i~.emalns -- 585.~~ viC~ti 'i'i~`.LA.'„ ~r~~7H'ts5:?1~JIVLaL SEK -rncluded ... ~ ~_ '_ ~a1" /C~iergY ~•ar ~~ , ~(~ ~: s. r , ft} 3-1llY 1 X Service Vehicle ~tl:tiANll1-5E Nl Eook register tremor i a ~ ~=ar`~s `1'nanx You Cards Package itemembrance Container AiternatiVe d Contain Gantainer ^, Cardboar Vault urn ~u-rial Flag Case Ve,.erans Memorial Marker t;ravej ~~:r ~~,,e i.~t~?n a ng . uipment ~ ~votice ~ C?er ~~ae~;~s?~a ivewspajie1 !notice ve~ts;~a.per Notice ~:,ier~1Y ~, rtonl~~raanis~t/~ol°lst ~ ~ Glucled ; ~ ,.~ • ~~.n~~_r c!~ ~ n ~L~.Om x~ sowers rova_ ~_;rematarY Gnarge t ~'ee oi°aner A~~ ate ic ~ ~,• ~(~ .3~D . , Cert i .. ;:ounty ;~~11~ iZl?l1 -) ~ eS '~~ Deat~ CASH ADVANCED ITF.NYS ' Ai, 'I'O'I SUMMAKY ~ Charges Sg!;.~~ ;;peciaa Services fessional $rp.~D~ pro ~zomot ive Equ-ll~ment ~r S~ „ ~~ _ Merchandise advanced Items $55.~~ Cash ;;i!~ `i'Ca'1'~-ism .~, vu ..~-- iJty-, 51,735.~~ $ Cd , vJ tD L~1~ -:~~35 . (D~ llate Lec ~ ~ S~ . ~~) $(D . 0@ $55.~~ - iV'i' Nit1Y NUT Ft.lr~L~;t;'I' ALi, I~1~'t~Sk'1=.L'~,t~ C~iAl~GES ~ _. ~-~~ WEST SHON A E SUITE 281 205 GRANDVIE CAMP HILL, PA 17011 Phone #: (800) 367'0512 Federal Tax ID: 23-2463002 pAT-ENT NAME: DOROTHY RODGERS CALL NUMBER: 1021707A DOROTHY RODGERS 1714 LETCHWORTH RD CAMP HILL, PA 17011-7528 -:~- ~~a: N REVERSE SIQ'<'. MDEN INSURANCE: MEDICARE B AL BLUE CROSS MDIP CAPIT DATE OF CALL: 1112712010 820 LISBURN RD APT 411 FROM: HARRISBURG HOSPITAL TO: ACG®UNT SUMNlAH~' 1001.62 TOTAL CHARGES: 0.00 PAYMENTS/ADJUSTMENTS: 1001.62 PLEASE PAY THIS AMOUNT: DETACH ALONG PERFORATION AND RETURN `~ UuN P1R CEAyMENT QUANTITY _______---- DESCRIPTION OF CHARGE 967.62 ALS EMERGEN4 24) VEL 1 ANGIOCATH EKG ELECTRODES (1) EXTENSION SET 8" NEEDLELESS GLUCOSE BLOOD OP SITE SALINE PREFILLED SYRINGE A0999 1 '0 6.72 A0394 1 '0 0.80 A0396 4'0 12.52 A0394 1 '0 7.08 A0394 1 '0 1.92 A0394 1.0 2.56 A0394 1.0 DES RC IPTION OF PA_~ NT Denied by Medicare PAYMENT DATE RECEIPT 1211712010 AMOUNT 967.62 6.72 3.20 12.52 7.08 1.92 2.56 Total Charges 1001.62 AMOUNT 0.00 0 00 Total Credits _ _ ~ - , ,, _ _ ,. AMOUNT PAID: _ CALL NUMBER: 1021707A 01!0312011 ?ATIENT NAME: RODGERS, DOROTHY E ACCOUNT IS PAST DUE! Send your payment now or contact THIS our office to make payment arrangements. X1001.62 C _ 01 C 9(15 rRpNI1VIFW A~/F CIIITF 944 (`eMD Ltll ~ oe 47fl44 WFST SH(1RF FM ~ r- Rlr~.~ A H1vw... ---- QUANTITY __.._ ~iwn _.._. _--- - 867.62 DESCRIPTION OF CHARGE g67,62 6.72 S0207 1 A 6 72 8.00 ALS EMERGENCY LEVEL 1 A0394 1,0 0.80 12.52 ANGIOCATH (14-24) A0396 10.0 12.52 1.92 EKG ELECTRODES (1) " NEEDLELES A0394 1.0 1.0 1.92 6 2.56 EXTENSION SET 8 p0394 1.0 2.5 EFILLED SYRINGE O A0394 SALINE PR ------ DESCRIPTION OF P Denied by Medicare RECEIPT F~AYMENT DATE 11130!2010 9 3499 --~ Total Char es -~_ ApgOUNT 0.00 I _ Total Credits .~ ~. PATIENT NAME: RODGERS, DOROTHY E CALL NUMBER: 'I O23 ZO oA rocessed by Mediicare or other Primary - A claim was P - ~ ~ our supplemental insurance. insurance and thew; h you insurance carrier or remit e follow up AMOUNT PAID: Q 00 $999.34 Pleas payment. 17011 LS 205 GRANDVIEW AVE SUITE 211 CAMP HILL' PA WEST SHORE EMS A File Number rtEV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME - ~ ~; ~,~ /;, (~ _~~ • J ,.:, t~ ~ ~; STREET ADDRESS ~ I I ~, lj ~` ~ S ., Z ~-%' cirr ~, ~{ i11fO ~\ ~ \ ~ Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) ~_~ 2• CreditslPayments _ - - q. Prior Payments .~--''-'. g. Discount 3. Interest This is the OVERPAYMENT. reater than Line 1 + Line 3, enter the differuest a refund. 4. If Line 2 is 9 e 2, Line 20 to req Fill in oval on Pag Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. 5• If - ZIP -1 (0 ~% .STATE n y~ 17 C) 1 i - r~-7 ~ 21~.~'`~ (1) _ - Total Credits (A + f3) (2) (3) (4) (5) ___-•-- J--- o- i ~'Z~~•~7 k a able to: REGISTER OF WILLS, AGENT. Make chec p Y ., r=°~ BY PLACING AN "X" IN THE APPROPRIATE BLOCK Yes PLEASE ANSWER THE FOLLOWING QUESTIONS ~ . ... ^ 1. Did decedent make a transfer and: ro ert transferred :........................ a. retain the use or incomge of the p P y ro ert transferred or its income;...••~••~~•••~ ••~"'~"'~" ~" ~ •~ ~•• b. retain the right to desi Hate who shall use the p P Y • interest; or ............... . . c. retain a reversionary a menu, benefits or care? ~•••~•••~•""'~~~ ear of death ~' d, receive the promise for life of either p Y ro ert within one y [] 2. If death occurred after Dec. 12, 1982, did decedent transfer p P Y uate consideration? ..•~•••~•~~~•••~~•'~ ' " ~ ~ ' without receiving adeq aable-upon-death bank account or :security aot ei~orvhhcheath?.•~~••~ •••~•~ ^ or other non-probate p p Y. ......... . 3. Did decedent own an "intrust for" or p y ......................... . 4. Did decedent own an individual retirement account, annul ULE G AND FILE IT AS PART OF THE RETURN. contains a beneficiary designation EABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEO for the use of the surviving spouse IF THE ANSWER TO ANY OF TH nd before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or °`~ - ~~ ~ ~ ~~ souse is 0 perc~ For dates of death on 16aae(1 ANC)] 1994, a n im osed on the net value of transfers to or for the use of the surviving t 72 P.S. §91 () tax and the statutory requirements for disclosure of assets 3 perce [ 1gg5, the tax rate p souse from t a transfer to a surviving p For dates of death on or after Jan. 1 ~ souse is the only beneficiary. [72 P.S• §9116 (a) (1.1) (ii)]' I cable event the surviv ngp p arent filing a tax return are still app ~ child 21 years of age or younger at death to or for the use of a natural p For dates of death on or after July 1, 2000: 9116 a 1 2 ercent, except as Hots • The tax rate imposed on thent of the child s 0 percent [72 P Sc§ased( )( )] ado tive parent or a steppa ansfers to or for the use of the decedent's lineal beneficiaries is 4.5 p p 13 A sibling is defined, ~ osed on the net value of tr ercent [72 P.S. §9116(a)(• )]~ The tax rate Imp 72 P S §g116(a)(1)]. blood or adoption. 72 P.S. §9116(1.2) [ ed on the net value of transfers to arent m commontw th the decedent) whether by The tax rate impos Section 9102, as an individual who has at least one