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HomeMy WebLinkAbout11-18-11 (2)1505610140 REV-1500 °` ~°'-'°' PA Department of Revenue ~ OFFICIAL USE ONLY Bureau of Individual Taxes Coun Code Year b File Number PO Box 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-°6°1 RESIDENT DECEDENT 2 1 1 1 0 4 2 1 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 7 1 7 0 9 4 0 5 5 0 3 1 1 2 0 1 1 0 4 2 3 1 9 1 8 Decedents Last Name Suffix Decedent's First Name MI W A L K E R H A R P E R L (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS ^X 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death pnor to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required death after 12-12-82) QX 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 tax 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 M A R K T H O M A S E S Q U I R E 7 1 7 7 9 6 2 1 0 0 First line of address 1 0 1 S O U T H M A R K E T S T R E E T Second line of address Clty Or POSt Office M E C R A N I C S B U R G State P A ZIP Code ,.. ~~ REGISTER OK79~ USE O~ ~ ~ '~ -~r+ ms`s - ` ~ r'r-i f ` ~ p ~ ~ --~ v n . ~' C~ C _. ~ •~ ~~ C.~? DA~ FILED ~' 1 7 0 5 5 Correspondent's a-mail address: rmarkthomas[c'~gmaii.com ~1 ." ~ `? ~;~ - r_~ ,_ ~....~ ~_ ~ F7~1 _ -° r-'~ ., r'T'1 .:;n p '.t'1 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 representatlve is based on all information of which preparer has any knowledge. RETURN ADDRESS DGE„1~10AD MECHANICSBURG PA 17050 fl•i EPRESENTATIVE DATE 101 SOUTH MARKET STREET MECHANICSBURG PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 J 1505610240 REV-1500 EX Decedent's Social Security Num ber Decedents Name: HARPER L• WALKER 7 1 7 0 9 4 0 5 5 RECAPITULATION 1. Real Estate (Schedule A) ........................................... 1. 0 . 0 0 2. Stocks and. Bonds (Schedule B) ...................................... 2. 2 5 1 9 4 1. 7 0 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. 1 1 3 3 8 9 . 3 3 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 0 • 0 0 7. Inter-Vvos Transfers 8~ Miscellaneous N Probate Property (Schedule G) ~ S B 1 9 4 eparate illing Requested ....... 7. 4 0 8, 3 8 8. Total Gross Assets (total tines 1 through 7) ........................... 8. 5 5 9 7 3 9 . 4 1 9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9. 3 7 ~ 8 7 . 5 0 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule i) ............. 10. 3 5 3 3. 3 7 11. Total Deductions (total Lines 9 and 10) ............................... 11. 4 1 3 2 0. 8 7 12. Net Value of Estate (Line 8 minus Line 11) ............................ 12. 5 1 8 4 1 8 . 5 4 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... 13. 0 . 0 Q 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... 14. 5 1 8 4 1 8. 5 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 .0 _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 3 7 7 0 3 1. 6 6 17. 18. Amount of Line 14 taxable ' at collateral rate X .15 1 4 1 3 8 6. 8 8 18. 19. TAX DUE ...................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610240 O. o 0 0. 0 0 4 5 2 .4 3. 8 0 2 1 2 0 8. D 3 6 6 4 5 1. 8 3 1505610240 J REV-15Q0 EX Payd 3 Decedent's Complete Address: File Number 21 11 0421 DECEDENTS NAME HARPER L. WALKER STREET ADDRESS 6891 Wertrvilfe Road CITY Enola STATE PA ZIP 17025 Tax Payments and Credits: 1• Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount 3. Interest (1) 66,451.83 Total Credits (A +B) (2) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3) Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 66.451.83 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; ............................... ^ c. retain a reversionary interest; or .....................................................................:.......................... ^ X^ d. receive the promise for life of either payments, benefits or care? ....................................................... ^ X^ 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? ......... ^ X^ 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 p2 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) (i.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 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, except as noted in 72 P.S. §9116(1.2) (72 P.S. §9116(x)(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(x)(1.3)]. Asibling is defined, undo Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1503 EX + (6-98) COMMONWEALTH OFPFTINSYLVANIA STOCKS ~ BONDS INHERITANCETAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER HARPER L. WALKER 21 11 0421 All property jointly-owned with rlgM of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEAT ~• NC Investm t 91 C H en s, umberland Parkway, Mechanicsburg, PA 17055-5676 Acct No 8613-3134 , . . m Equity Diversified Div. Investment Fund, 6126.3210 shares @ $12.67 per share 77,620.49 2• NC Investments, 91 Cumberland Parkway, Mechanicsburg, PA 17055-5676 Act No 8613-3134 , . . ederated Bond Fund A Shares, 14738.4340 shares @ $9.25 per share 136,330.51 3. NC Investments, 91 Cumberland Parkway, Mechanicsburg, PA 17055-5676 Act No 8613-3134 , . . ederated Bond Fund B Shares, 1852.9820 shares @ $9.29 per share 17,214.20 4• NC Investments, 91 Cumberland Parkway, Mechanicsburg, PA 17055-567 6 Act No 8613-3134 . , . . ederated PA Muniapal Fund A Shares, 2025 shares (a.~ $10.26 per share 20,776.50 TOTAL (Also enter on line 2, Recapitulation) I S (If more space is needed, insert additional sheets of the same size) REV-1508 EX + (8-98) ' ~ SCHEDULE E . COMMONWEALTH OF PENNSYLVANIA CASH, SANK DEPOSITS, & MISC. '" ~s o~ o ~ o~~" PERSONAL PROPERTY ESTATE OF FILE NUMBER HARPER L. WALKER 21 11 0421 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointty-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. NC Bank, Checking Account No. 5070086375 26,026.95 1 Cumberland Parkway echanicsburg, PA 17055 2. NC Bank, Savings Account No. 5000960549 2,295.54 1 Cumberland Parkway echanicsburg, PA 17055 3. embers 1st FCU, Savings Account No. 5736-00 5.00 . O. Box 40 echanicsburg, PA 17055 4. embers 1st FCU, Certificate of Deposit No. 5736-40 50,812.15 . O. Box 40 echanicsburg, PA 17055 5. embers 1st FCU, Certifipte of Deposit No. 5736-42 32,707.42 . O. Box 40 echanicsburg, PA 17055 6. 010 Federal Income Tax refund 1,190.00 7. '-lighmark (insurance refund) ~ 352.27 TOTAL (Also enter on line 5, Recapitulation) ~ S (If more space is needed, insert additional sheets of the same size) REV-1.510 EX+ (08-09) ' ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESiDENi DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER HARPER L. WALKER 21 11 0421 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. NUM ER DESCRIPTION OF PROPERTY ~~DTMA~~ oTRnrrs~.A~a~c,~HA~c~oFT~HE~®w~RE~a~TE~D VALUEOFA SET o~NTER SD'S EXCLUSION oFaaPUCaeu:~ TAXABLE VALUE 1. ransamerica Life Insurance Company, Annuity No 02CBT059527 116,454.92 00.00 0.00 116,454.92 . O. Box 3183, Cedar Rapids, IA 52406 -Estate was beneficiary (Net was $104,252.50, fed. & state taxes were taken out) 2. Ilstate Life Insurance Company, Annuity No. AC1099384A 26,914.95 00.00 0.00 26,914.95 . 0. Box 660191, Dallas, TX 75266 Net was $28,914.95, federal taxes only taken out) -Estate was beneficiary 3. etLife, Annuity No. 9200562960 51,038.51 00.00 0.00 51,038.51 .O. Box 10366, Des Moines, IA 50306 not sure if taxes were taken out) -Estate was beneficiary TOTAL (Also enter on Line 7, Recapitulation) ~ S 194 408 38 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+(10.09) ' Pennsylvania DEPARTMENT OF REVENUE. INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND .ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER HARPER L. WALKER 21 11 0421 . Decedents debts must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Gingrich Memorials (cemetery inscription) 160.00 2. Rev. Robert Bishard (funeral service) 200.00 3. Myers Funeral Home, East Main Street, Mechanicsburg,PA 17055 7,450.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Edith Shelley Street Address 305 Sample Bridge Rd City Mechanicsburg State PA ZIP 17050 Year(s) Commission Paid: 2. 3. Attorney Fees: R. Mark Thomas, Esquire 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 4• ~ Probate Fees: 5. 6. 7. 8. AccourHant Fees: Tax Return Preparer Fees: Richard Sgrignoli Pennsylvania Department of Revenue (2010 tax return) Death Certificates 15,000.00 13,990.00 544.50 200.00 138.00 105.00 TOTAL (Also enter an Line 9, Recapitulation) ~ 3 If more space is needed, use addifional sheets of paper of the same size. REV-1512 EX+ (12-08) ' ' ' iiennsylvania SCHEDULE 1 DeanRn~ewT of REV~ue DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES, ~ LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER HARPER L. WALKER 21 11 0421 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. era Care 1,000.00 5 South Houcks Road, Suite 101 arrlsburg, PA 17109 2. olden Living Center -West Shore 2 296 37 . O. Box 644407 ittsburgh, PA 15264 3. ames R. Hardy, M. D. 237.00 TOTAL (Also enter on Line 10, Recapitulation) I S If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) • ~ ~ Pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENG~~C~ A o'Cc INHERITANCE TAX RETURN G /1R G~7 RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ueocec ~ ~niei irrc RELATIONSHIP T.0 DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Indude o~gMspousal distributions and transfers under S 91 i6 ec. (a) (1.2).j 1. Neff Walker, Jr. Sibling 3992 Geveland Highway Dalton, GA 30721 2. Richard P. Walker Sibling .2455 East Blanche Drive Phoenix, AZ 85032 3. Ruth E. Foltz Sibling 286 Ridge Hill Road Mechanicsburg, PA 17050 4. Edith A. Shelley Sibling 305 Sample Bridge Road Mechanicsburg, PA 17050 5. Raymond B. Martin, Sr. Sibling 801 North Hanover Street, Room 235 Carlisle, PA 17013 6. David P. Martin, Sr. Sibling 2332 South Market Street Mechanicsburg, PA 17055 7. Florence L. Martin Williams Sibling 61 Shoreline Drive Florence, OR 97439 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OFPART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S 0.00 If more space is needed, use additional sheets of paper of the same size. avg. ~s. 20>> 3:33PM PNC INVESTMENTS kem0er NNAA anR SIPC March 28, 2011 Edith A Shelly 12E: Estate of Harper L 'W'alker Date of Death Valuation Date of Death: March 11, 2011 Dear Mrs. Shelley: No, 4985 P. 1 The bate of Death Value for securities held by Hazper L 'Walker in his PNC Investemnt Account Number 8613-3134 is as follows: 6126.3210 shares Aim Equity Diversified biv: Inv Fund @ $12.67 per share 14738.4340 shares Federated Bond Fund A Shares @ $ 9.25 per share 1852.9$20 shares Federated Bond Fund B Shares @ $ 9.29 per share 1~ ~ a'~ ` a~ 2025 shares Federated PA Municipal Fund A Shares @ $10,26 per share p~U~S r CHoused in this account there were- annuities The Date of Death Valuation for the annuities will be sent directly from the city .Companies. ~--~ Please feel free to contact me if Y can be of fiukher service to you. Sincerely, Charles E Little, CFP, VP Financial Advisox• CEL/dhp The rriforrrrarlon contnlned herein has been oblalnedfrom sources eve believe la be reelable bur do trot gur-ralrtee it to be /rccrrrole, correct, complete or ttniely, a~lB shrtll not be tesparsible for ilfe resells obtnlned from iPs rrse. PNClnvestmenis LLC Memher of The PNC Financial5ervices ©roup 91 Cumberland Parkway Mechanicshurg Pennsylvania 17055-5G76 vuww.pnc.com Imporant Inveslmenls lnlormafan: BroKerape and insurance produces ara: Nok FDIC Insured • Nok Bank Guarapleed • May Lose Valor Securities and brokerage services arc providetl M PNG ImeslmeMs PLC, memoer fINRA and SIPC. Mnuilios and other insurance produces are offered by PNC Insvranoe Services, LLC a Goensed insurance agency. 'IRAN~AIV~RICA a LIFE INSUAANCH COMPANY Transamerica Life Insurance Company 4333 Edgewood Road NE PO Box 3183 Cedar Rapids, Iowa 52406-3183 July 08,.2011 ESTATE OF HARPER L WALKER EDITH ARLENE SHELLEY EXEC 305 SAMPLE BRIDGE RD MECHANICSBURG PA 1.7050 RE: Annuity Number(s) 02CBT059527 - Dear ESTATE OF HARPER L WALKER: ~. A check for $104,252.50, representing the full and final death benefit payment for the above listed Non-Qualified tax deferred annuity has been sent. Next January, .you will receive a Form 1099-R reporting this distribution. as follows: Gross Distribution: $116,454.92 Taxable Portion: .$61,012.07 Federal Withholding: $6,_101.21 State Withholding: $6,101.21 Transamerica Life Insurance Company does not give legal, tax, or accounting advice. You may wish to consult your own attorney, accountant, or tax advisor with questions or specific points of interest to you. Any additional questions regarding this annuity can be directed to the Annuity Service Center at 1-800-553-5957. A Transamerica-Life Insurance Company representative will gladly assist you with any questions you may have regarding this annuity and help you meet your financial goals. RE: Allstate® Advantage. Plus # AC1099384A The check amount of $26,914.95 represents the net proc s of yo annuity as of 05/OM11. Gross Annuity Value as of 05/04/ $27,683.27 $27,683.27 Gross- Withdrawal Amount $27,683.27 27 683.27 Less Federal Income Tax Wi Iding $768.32 Check Amount. $26,914.95 Remaining Annuity Value as of 05/OM1~- $0.00 ~~ As required. the taxable amount of this distribution will be reported t~the_ Internal Revenue Service on Form 1099R~A copy of this form will be mailed to you by January 31 of the next year. . ~---~_ If you have any questions; please contact your representative or call Allstate Life Insurance Company at 1-800-755-5275. If we can be of any service in the future, we would again. welcome the opportunity to assist you in reaching your long-term financial goals. ._ _ `~ ~ \~ . ~? 1 ~\~ ~,\ `Y C88FLL3T.N01 1 NYLR1666 HARPER L WALKER ESTATE 305 SAMPLE BRIDGE RD MECHANICSBURG, PA 17050 Date: 05-26-2011 Customer Service 1-800-343-8496 Check No: 060929310 .~ / Contract No: 9200562960 % Claim Proceeds Gross Payment 51,038.51 ~~ ~` ti ~ C"' ~~ ~~ \ ~~~ ~\ `~ asera~care August 4, 2011 Edith Shelley 305 Sample Bridge Road Mechanicsburg, PA 17050 Dear Ms. Shelley: This letter is to confirm the verbal agreement made for you to pay $1000 toward the outstanding balance of Harper Walker's account. As discussed, once the payment is received there will be no further collection attempts to secure the remaining balance. Should you have any additional questions, please do not hesitate to contact me. Sincerely, anon Shoff. Executive Director Asera.care Hospice Harrisburg 75 South Houcks Rd., Ste. 101. Harrisburg, PA 17109 Phone:. 800-551-4466 Fax:. 717-541-4470 www.aseracare.com I 1677542309 ~II~ ~~ en living centers WEST SHORE 04/01/2011 ~~ ' r~* 6,989.48 -4,693.11 HARPER WALKER -2,287.48 03/04/11 . 03/04/11 MASK,NON REBREATHER,AD Z 03/04/11 03/04/11 HUMIDIFIER, 6FOML FRE-F 1 03/04:/11. 03/04/11 CANNULA,ADULT,OXYGEN,7 1 0 3 / l6f 11 FAYMENT 03/01/11 03/10/11 ROOM CHARGE 10 03/01/11 03/31/11 REV LAST MO RC -31 STATEMENT QUESTIONS ABOUT YOUR BILL? (866) 325-5606 ~ 002854230.90001 4.72 3.38 0.7E 2,239..03 6,941..00 00 ~ 8.89 -2,287.48 When returning home: patients often require ongoing care that family members cannot easily provide. In these cases. AseraCare Home Health is an ideal solution. Visit homehealth.aseracare.com for more information. . Thank you for choosing Golden LivingCenters. 04/15/2011 ._ ;~!.R ~~Y.t7Ul3BlLL(J~1f~1.V~~~v ~fde~ifiv~"~" svm ;~k ~~ ~ ~„~~ OUNT:DItE Y~" d• ~. .~~. ,~:~ 8.89. ---_--~~DETACH HERE AND~RETURN BOTTOM PORTION VIFITH YOUR PAYMENT FOR TIMELY PROCESSING~~--_~ GOLDEN LIVINGCENTER -WEST SHORE CIO NORTHEAST BILLING OFFICE. 1500 ARDMORE DRIVE, SUITE 101 PITTSBURGH PA 15221-4466 Check box if address below is incorrect or insurance information has changed. Indicate changes on reverse side. 00286'423090001' HARFER'wALKE,R .~ . .~ , 04/01/11 04/19/11 8.89 Cnec?c beta IC pay by Crata cart ant enter C2C'I cart nlc'maRCn ba1CW. ^ VISA ^ MASTERCARO ^ DISCOVER CARD NUMBER CVV CCDE' ZIP CCDE CARDHOLDER NAME EXP. DATE 51GNATURE AMOUNT ...- v.. ~~~a z o nnea~::6a numcar uaua~.y wuna cn [nB OaiCK CI yCUr CrlC:t Ci'E. Please Make Check or Monay order Payable To: EDITH SHELLEY GOLDEN LIVINGCENTER -WEST SHORE 305 SAMPLE BRIDGE ROAD P.O. BOX 644407 MECHANICSBURG PA 17050-1632 PITTSBURGH PA 15264-4407 1049970028542309300010401201100000d89D0000000001 I~~1755942309~II~ golden living centers WEST SHORE STATEMENT QUESTIONS ABOUT YOUR BILL? (866) 325-5606 . _ ,- .. .. ~ 3 ! K s - ~~~ ~ 0/01/2011 HARPER WALKER 0.029423`050001 E . . 8.99 0.00 -8.84 0.00 0.00 DAuTE/PE1~IC~EI C`Qj/,,ERED ~;~~~Cf,C~f1(~kT,AC_TI~X4T~~° , * ' T`~/D1~ _ ;~C~Fi?~RGE~ ,"RAYM ~1`G~ 04/11/11 ~FAYMENT _g.8c When returning home, patients often require ongoing care that family members cannot easily provide. In these cases, AseraCare Home Health is an ideal solution. Visit homehealth.aseracare.com for mare information. Thank you far choosing Golden LivingCenters. ~,~ ~ , ~ ~ ,~;~ ~ - N w ,~ ~~ > ,.,~ ~ r ~~~ ~ r ~r~t~ J?~gYMENT >. , MAILY£?UR PAYMENT USING THE COUPON BELOW c ~.~- ~,~ .>~U~ pq~~E ~ ~~ 0 5 / 15 / 2 011 ~ ~ g : a A"MOUNT pllE PAY YOUR BILL ONLINE AT wwwgo(den(iving cam ~ ,_a r - ~ ~' ~ ~ ~s ~ ~~ 0.00 x.v DETACH HERE AND RETURN BOTTOM PORTION WITH YOUR PAYMENT FOR TIMELY PROCESSING GOLDEN LlVINGCENTER -WEST SHORE CIO NORTHEAST BILLING OFFICE 1500 ARDMORE DRIVE, SUITE 101 PITTSBURGH PA 15221-4466 Check box if address below is incorrect or insurance information has changed. Indicate changes. on reverse side. EDITH SHELLEY 305,SAMPLE BRIDGE ROAD MECHANICSBURG PA 17050-1632 i 2 0028~42305000i ' HARP&R WALKER o~/O1/11 oG/lE/11I o.ool' Chet<hete to pay Oy GreCtl CarC ant enter C:eCa cart ~nlCtmaLGn DelCW. ^ VISA ^ MASTERCARD ^ DISCOVER CARD NUMBER CVV CCDE' ZIP CCDE CRRDHCLDER NAME ~ EXP. DATE. S13NATURE AMCUNT I ae 1. V V ccce e a t!1•eeC ~ t n;i7lCer JEJa"y fcJ nC Cn lne CdCK Cf yca' C'eC'! qK Please Make Check or Money Order Payable To: .GOLDEN LIVINGCENTER -WEST SHORE P.O. B OX 644407 PITTSBURGH PA 15264-4407. 104997002854230930001050120110000000QD0.000000002