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15D561D143 '~I"~' REV-1500 Ex(o,_,o, OFFICIAL USE ONLY PA Depa ment of Revenue pennsylvania County Code veer File Number Bureau of Individual Taxes DErARiMlNr OF REVENUE Po Box. aosot INHERITANCE TAX RETURN 21 10 0 912 Harrisbur , PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFOF~MATION BELOW Social Security Number ' Date of Death Date of Birth 161 34 4800, 08 23 2010 08 03 1941 Decedent's Last Name ' Suffix Decedent's First Name PA.LOVITZ C . (If Applicable) Enter Survi~ring Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security N~Imber THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE O'~/ALS BELOW x^ 1. Original Return ~', ~ 2. Supplemental Return 4. Limited Estate ', ~ 4a. Future Interest Compromise (date of death after 12-122) g Decedent Died Testate I (Attach copy or Wilq ^ ~ p dent Maintained a Living Trust (Alta aG, Gopy of Trust) 9. Litigation Proceeds F~eceived ~ rtv 10. ~°~eenP~Zv-3e19~a d~t,~dataeSQfdeath MI D MI 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT-THIS Name AARON C JA First line of address MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Daytime Telephone Number t1 ESQ 717 234 4121 = s~ 111 NORTB F~20NT STREET Second line of address PO BOX 889 City or Post Office HARRISBURG State ZIP Code PA REGISTER ~1f1~1~S USEaflNLY ~ ' -rrl tV .=. ';_7 .-~ :~~ c_ _._ ., _ nj f'- D r,., DATE FILED Correspondent's e-mail adress: ajackson~tuckerlaw.com Under penalties of perjury, 1 d it is true, correct and complete are that I have examined this return, inGuding accompanying schedules and statements, and to the best of my knowledge and belief, aration of preparer other than the personal representative Is based on all information of which preparer has any knowledge. SIGNATU F PER N RE O IBLE R FILING RETURN DATE Beth D. Pro in /v 27 !/ ADDRESS 164 South Charlott Street Manheim PA 17545 SIGNA PREPARER OTH R THAN REPRESENTATIVE DATE Aaron C. Jackson Esq. !D Z 7 ESS l 111 North Front St ~'eet, Harrisburg, PA Side 1 1505E~1D143 _. _ i ~_ 150561D143 J~ 1505610143 `'>„""' REV-1500 EX`o,_,o, OFFICIAL USE ONLY PA Department of Revenue pennsylvania county cone veer File Number TUCKER' ARENSBERG Attorneys November 23, 2011 VIA FIRST CLASS MAIL Glenda Farner Strasbaugh, Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013-3387 Re: Estate of C. Diane Palovitz, deceased File No. 21-10-0912 DOD: 8/23/2010 Dear Ms. Strasbaugh: Aaron C. Jackson ajackson~tudcerlaw.com Enclosed for filing please find an original and two (2) copies of the Pennsylvania Inheritance tax return in the above-referenced estate. Please time-stamp one copy and return it to me in the enclosed self-addressed stamped envelope. Additionally enclosed is a check payable to "Register of Wills" in the amount of $15.00 representing the filing fee. Should you have any questions, please do not hesitate to contact me. Thank you for your cooperation in this matter. Very truly yours, TUCKER ARENSBERG, P.C. r. , . ~ ~~ ~7 C ~ t~ Aaron C Jackso ~ ~~ ~`~ . - ~~~, Enclosures -"~ ,;~, cc: Beth D. Progin, Executrix (w/o encl.) (via first class mail) ;~ r.~; ~~ HBGDB:123424-1 026396-148361 ` Tucker Arensberg, P. C. 2 Lemoyne Drive Suite 200 Lemoyne, PA 17043 p. 717.234.4121 f. 717.232.6802 www.tuckerlaw.com 1500 One PPG Place Pittsburgh, PA 15222 p. 412.566.1212 f. 412.594.5619 1505610243 REV-15001 EX Decedent's Social Security Number DecedanPsName: P~iOVltz, C. Diane 161 34 4800 RECAPITULATION 1. Real Estate (Sched~ le A) ....................................................................................... 1. 17 0, 0 0 0. 0 0 2. Stocks and Bonds (~ chedule B) ............................................................................. 2. 1 , 2 65.0 0 3. Closely Held Corpor ation, Partnership or Sole-Proprietorship (Schedule C)......... 3. 4. Mortgages & Notes receivable (Schedule D) ........................................................ 4. 5• Cash, Bank Deposit & Miscellaneous Personal Property (Schedule E) ............... 5. 10 , 94 9.97 6. Jointly Owned Prop~ rty (Schedule F) ^ Separate Billing Requested............ 6. nter-Vivos Transfer (Schedule G) ~ & Miscellaneous Imo; Probate Property Se arate Billin R t d U p g eques e ............ 7. 8. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 182 , 214.97 9. Funeral Expenses &Administrative Costs (Schedule H) ....................................... 9. 15 , 615.67 10. Debts of Decedent, I~Aortgage Liabilities, & Liens (Schedule I) .............................. 10. 35 6 , 5 6 9.68 11. Total Deductions (t~tal Lines 9 & 10) ................................................................... 11. 372 , 185.35 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12, -18 9 , 970.38 13. Charitable and Gove mental Bequests/Sec 9113 Trusts for which an election to tax ha not been made (Schedule J) ............................................... 13. 14. Net Value Subject t~ Tax (Line 12 minus Line 13) ............................................... 14. -18 9 , 9 7 0 . 3 8 TAX COMPUTATION - S E INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 t able at the spousal tax ra e, or transfers under Sec. 9116 16. Amount of Line 14 to able 0 . 0 0 16. at lineal rate X .045 17. Amount of Line 14 to able at sibling rate X .12 I'I 0 . 0 0 17. 18. Amount of Line 14 ta~able at collateral rate X .1 0.00 18. 19. Tax. Due ................................................................................................................. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. i Side 2 L 15056]0243 1505610243 0.00 0.00 0.00 0.00 0.0.0 REV-1500 E!( Page 3 Decedent's Complete Ajddress: File Number 21-10-0812 DECEDENTS NAME Palovitz, C. Dian STREET ADDRESS 348 Blacksmith Load CITY Camp Hill STATE PA ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19)'~ (1) 0.00 2. Credits/Payments A. Prior Payments B. Discount 0.00 Total Credits (A + B) (2) 0.00 3. Interest ' (3) q. If Line 2 is greater than Lin~1 + Line 3, enter the difference. This is the OVERPAYMENT. (q) heck 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. (5) Q,QQ ; Make Check Payable to: REGISTER OF WILLS. AGENT. PLEASE ANSWERS THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did deceden make a transfer and: Yes No a. retain he use or income of the property transferred :............................................................................... ^ ^x b. retain he right to designate who shall use the property transferred or its income :.................................. ^ ^x c. retain reversionary interest; or ............................................................................................................... ^ ^x d. receiv the promise for life of either payments, benefits or care? ............................................................ ^x 2. If death occ rred after December 12, 1982, did decedent transfer property within one year of death without receiving ad quate consideration? .................................................................................................................... ^ ^x 3. Did deceden own an "in trust for" or payable upon death bank account or security at his or her death?....... ^ ^x 4. Did deceden own an Individual Retirement Account, annuity, or other non-probate property which contains a b neficiary designation? .................................................................................................................. ^ ^x 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 J ly 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. § 116 (a) (1.1) (i)]. For dates of death on or after J nuary 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)]. T e 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 ar still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after J ly 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 steppe ent of the child is 0 percent [72 P.S. §9116 (a) (1.2)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.3)]. A sibling is defined under Se ion 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rsv-1602 EX+ (11-06) SCHEDULE A r ~ REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Palovitz. C. Diane _ _ 21-10-0912 All real property owned solely or as a tenant In corrarwn nwst be ropoRed at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing twyer and a willing seller, neither bemg compelled to twy or sell, both having reasonable knowledge of the relevant fads. Real property which Is Jolntlyowned with right of survivorehlpmust L» disclosed on schedule F. (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Forrn PA-1500 Schedule A (Rev. 11-08) Rev-1603 FJ(+ (g_98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF FILE NUMBER Palovitz, C. Diane _ _ Z1-10-0912 All property Jointlyowned with right of survivorship must bedisclosed on Schedule F. ITEM NUMBER CUSIP NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 Prudential Common Stock - Account #00028525290 1,265.00 TOTAL (Also enter on Line 2, Recapitulation) 1,265.00 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B (Rev. 6-98) Rev-1508 EX+ Is•seJ COMMONYIEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Palovitz, C. Diane 21-10-0912 Include the pproceeds of litiggation and the date the proceeds were received byy the estatEl. All property Jointlyownedwith the right ofsurvhrorship must be disclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Checking Account -Citizens Bank - #610077-111-3 8.668.71 2 Members First Credit Union -Savings Account #180720-0000 220.42 3 Members First Credit Union -Checking Account #180720-0011 10.89 4 Savings Account -Citizens Bank - #8140-188873 1,050.15 5 2000 Cadillac Seville STS -VIN 1GKS54Y5YU142805 3,000.00 TOTAL (Also enter on Line 5, Recapitulation) I 10,949.97 (If more space is needed, additional pages of the same size) Copyright {c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) REV-1151 Ex+ (10-06) ~HNE R SHE yp( E COM IN RESID NT DEC ~E~RLVANIA ESTATE OF p FILE NUMBER Palovitr, C. Diane _ _ II 21-10-0912 Debts of decedent must be reported on Schedule 1. ITEM DESCRIPTION AMOUNT N M R A, FUNERAL EXPENSES: See continuation schedule(s) attached 8,821.27 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representatives} Street Address City State Zio _ Yearly) Commission Daid 2, Attomev's Fees Tucker Arensberg, P.C. 6,500.00 3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zio Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 294.40 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 15,815.67 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06} SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS Rsv-1512 FJ(+ (12-0a1 SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA ESTATE OF FILE NUMBER Palovitz, C. Diane 21-10-0912 Report debts incurred by the decedent prior to death that remained unpaid at the data of death, ineludiny unrolmburoedmedical expanses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Boscov Department Store -Credit Card 2,556.22 2 British Petroleum (BP) -Gasoline Credit Card 1.50 3 Camp Hill Commercial Fire Company 376.11 4 Carlisle NeuroCare -Final Medical 65.98 5 Comcast -Utitlities 464.91 6 Culligan -Utitlities 79.60 T GMAC Mortgage -First Mortgage on Real Estate 208,978.87 8 Holy Spirit Hospital -Final Medical 87,011.30 9 Internists of Central Pennsylvania -Final Medical 598.00 10 Keystone Oil -Utilities 291.06 11 Pennsylvania American Water -Utitlities 59.17 12 Pennsylvania Neurosurgery & Neuroscience -Final Medical 60.30 13 Pennsylvania Retina Specialists -Final Medical 64.71 14 PPL Electric Utitlities -Utitlities 124.13 15 Premier Eye Care Group -Final Medical 146.33 16 Premier Ophtalmology Laser 8 Surgery Center -Final Medical 128.42 17 QVC -Credit Card 5,373.01 I Total of Continuation Schedule See attached page TOTAL (Also enter on Line 10, Recapitulation) 356,569.68 (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-08) Rev-1512 E7(+ (6-96) COMMONWEALTHOF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS continued ESTATE OF FILE NUMBER Palovitz, C, Diane 21-10-0912 ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 18 QVC Studio Park -Credit Card 34.98 19 Sears -Credit Card 13,066.41 20 Specialized Loan Servicing -Second Mortgage on Real Estate 29,500.00 21 Spirit Physicians Services -Final Medical 161.98 22 Sunoco - Utitlities 30.00 23 US Bank (Gymboree Visa) -Credit Card 5,643.15 24 Walmart Discover Card -Credit Card 728.00 25 West Shore EMS -Final Medical 1,025.54 TOTAL (Also enter on Line 10, Recapitulation) ~ 358,589.88 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) . SCHEDULE J COMM~~_~Ep [~f~2~1}YANIA N7 ECE BENEFICIARIES ESTATE OF FILE NUMBER Palovitz, C. Diane 21-10-0912 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT ,;Words) ($$$) I TAXABLE OISTRIBUTIONS [include outright spousal ~ distnbutions, and transfers under Sec. 9116 a 1.2 Marc A. Palovitz Son thirty percent of 1308 Carlisle Road residue of estate Camp Hill, PA 17011 Beth D. Progin Daughter seventy percent 164 South Charlotte Street of residue of Manheim, PA 17545 estate Total Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 15 00 cover sheet as a ro riate. NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO'1-Ax IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV'-1500 COVER SHEETI Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08) Estate of C. Diane Palovitz, deceased Estate No. 21-10-0912 Re: PA Inheritance Tax Return List of Exhibits A. Death Certificate (copy) B. Letters Testamentary issued by Cumberland County Register of Wills on September 3, 2010, including Last Will & Testament of the Decedent dated December 21, 1990. C. Real Estate -Legal Description D. Account Valuations E. Debts of the Estate H BGD8:122886-1 026396-148361 10.805 REV (01!07) LOCAL REGISTRAR'S CERTIFICATION OF DEATH ' WARNING: It is illegal to duplicate this copy by photostat or photograph. 'ee for this certificate, $6.00 P 16803973 Certification Number This is to certify that the information here given is correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the .State Vital Records Office for permanent filing. ~-~~ 2Q1 Local Registrar Date Issued 3 RtV 1112006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ~~" CERTIFICATE OF DEATH AcK INtc ISee Instructions and examples on reverse) a..,z ~, 1. Nme d Dsosded (W0. ntldds. bK ed6Q 2 Sr 3. SodY Ssaehy NumMr /. Deb d Dsei (Month, daY, Yrrl 0 Au ust 23 2010 C. Diane Palovitz Female 161 - 34 - 480 s. Ap Iwl 1 Ur,dr 1 l1Ma 1 11 Dab d BMh T. s mama « txen ea Plea d Dee, Grck ar Montlu Osy, Han MMer Fiaeplld: Oher. 1941 Mechanicsburg PA ® ^ ^RaWne• ^oha-sue ^DDA ^N rd lton ust 3 Au 69 , ~r~a„ , U rg e g YB, ~. Ges•y d Da•h Bc Cdy, Sao, Twp. d Death M. FedMy Neer (M Ml Inetltldlon, Qve eheel end numbefl S, Wn DatedaM of Flbpuda Ddgh1 ®No ^ Ye, 10. Recc Amakan IMm, Dlerk. WNU, Mc, Cumberland E. Peansboro Ztrp.' Holy Spirit Hospital M. Pualow~e.h,ae) ( white . 1 t: Deosdars UuY IOM d wodt d one mast d we. Do rot sum 12 Wu Dereded ever h the 13. OrabnYs EduaaOon (Sprdy ody hlpMel grads mnpkled) 11. MaiW Sbhr: Hurled, Never ebrrfed, 15. SundNrp Spew {U wMe, piw mNdm name) •dHl ° fs ww d ONoic Child 1aMdwor~ aMaeadra.nna,ary us. Mn.d FomaeT p,,,,,,,,e,y { semndary (o•tz) CoOeg• (1-a «s«1 P 1W° ~ e Da Care Provider .Day Care ^vr ®Na 12 ~ Divorced " te•°a."daa''"mr"tl^merlsa..c,rxrl'°"n,"r°,:p`°de) °arda~'' Pennsylvania L~w.In°:iOeM 1r~ o.rmdLlrwh Lower Allen T„~, ®Yr 348. Blacksmith Road , . -duelResiderr:e nasml. Urmwtllm De Cumberland T•"i°~i1 nd.^ Camp Hill, PA 17011 ~d ~ 1Tb.Coady ayl~m t& FaMrYe Nmne (FM, midds, bet.,ullhc) t& Moltrra Nur (FhA mNds, mekrt wmene) Herbert Brinkley Irene Osman 20e. bdormrls Nams (Type 1 Pdnq 20L Ham,N`e McWg Adam (Bert atlY / 1s•n, aW, zp pads) Marc A. Palovitz 1308 Carlisle Road, Cam Hill, PA 17011 21e. Herod d Dlepmitlar r ®Grutlon ^ Donetlan 216. Dam d DYPoelan ( M. Y•al 21a Pler d Dipartlr (Nerr d Horsley, a•nrkrY «atha peel 21a Larbfr (CNyllawn, sab, rlp cede! _ ^ 1taY ^ RrriwsllmmSWS ~ w..kaneraDane•nAUOwrMd ^ August 30, 2010 Evans Crematory Schaefferstown, PA 17088 No ^ tMw • r M Metllul Faemherl Coroner Yr ~ 7h. SlQrhn d Da•r •~9 •s ~) 2m. lloawe Mniher 2'k Nure and Adder d Fadtly Inc., P.O. Box 431, New Cumberla d, PA 17070 FS 012 849 L Parthemore FH & CS , _ ~ Corrptets Bane 23x wlYyYq 23a. my , firm d M dnr, deb end pba smW. (SI~a6n rd m•1 236./U~~~j~~a~r Nwriber a SJgrd ~ deY, n•A ptrysldmunal•aMW ddeMhq v~7,~~5'ljL ~a3 ~ / y rrWy ~.• a aexr. Nrrr 24~ red M ~~ by Daam 2S Deb 'f~'M~~a~h dry, y..rl 24. The z0. Wr Gw Madhd E,emMwr 1 Caarw tar s Reran !wr Crwnedm a Dane0on4 ^ ,dro Prariaurrs dsedt ,Q,~ ~ ~I n.. l V Y~B1 CAUSE OF DEATH (5•• In•VUCtlon• • ) r AppnvYneb hbn•t dJ0lbe- dussrs, Muir, a wnplnYaa • tld AreoOP acre! Or deal. 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C~-~9 'Z 9 S y " REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA CERTIFICATE OF GRANT OF LETTERS No . 201 D- 00912 PA No . 21- 10- 0912 Estate Of : C DIANE PALOV/TZ (First, Middle, CasU Late Of : LOWER ALLEN TOWNSHIP CUMBERLAND COUNTY Deceased Social Security No : 761-34-4800 WHEREAS, on the 3rd day of September 2010 an instrument dated December 21st 1990 was admitted to probate as the last will of C DIANE PALOVITZ (Fast, Middle, Last/ late of LOWER ALLEN TOWNSHIP, CUMBERLAND County, who died on the 23rd day of August 2010 and, WHEREAS, a true .copy of the will as probated is annexed hereto. THEREFORE, I, GLENDA EARNER STRASBAUGH Register of Wi I1 s in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters of ADM/N/STRATTON C.T.A, to: MARC A PALOV/TZ and BETH D PROGIN who have duly qualified as ADM/N/STRATOR(RIXJ C.T.A. and have agreed to administer the estate accordir.~g to Taw, all of which fully appears of record in my office at CUMBERLA/VD COUNTY COURT HOUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the .seal of my office on the 3rd day of September 2010. **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) pal.will gmr 12/20/90 - J~ -`~ WILL I, C. DIANE PALOVITZ, of 348 Blacksmith Road, Camp Hill, Cumberland County, Pennsylvania, declare thi~~ to be my last will and revoke any will previously made by me. ITEM I. I give all my automobiles,, and all other articles of personal or household use, together with all insurance relating thereto, to my children, MARL A. PALOVITZ and BETH D. PALOVITZ, provided that they survive me by thirty (30) days. If one of my children does not survive me by thirty (30) days, then I give all my automobiles and all other articles of personal or household use, together with all insurance relating thereto, to the child who does survive me by thirty (30) days. If my daughter, BETH D. PALOVITZ is a minor, my executor may distribute such items to my said child as my executor deems appropriate, and articles which my executor considers unsuitable for a minor may be sold and the proceeds thereof added to my residuary estate. My executor may, without further responsibility, distribute property passing to my minor daughter under this article to my daughter or to any person to hold for my daughter. ITEM II. Provided that my children, MARC A.nPALOVI`~? and --- ----BETH-D: -PALOVITZ- survive me by thirty (30) days, I g~ the 9~sidue ~~~~ ~ .. . Lr) `"i Page 1 of 8 pages. pal.will gmr ~~ 12/20/90 of my estate, real and personal, to my said children. Said funds shall be held IN TRUST and shall be distributed as follows: A. Seventy (70~) percent to my daughter, BETH D. PALOVITZ; and B. Thirty (30~) percent to my son, MARL A. PALOV:tTZ. The share of any child who predeceases me or who dies on or before the thirtieth day following my death shall bey distributed to his or her issue per stirpes living on the thirty-first day following my death and in default of any such then living issue, such share shall be added to the share for my other child. ITEM III. If any beneficiary becomes entitled to an outright distribution of income or principal and is under the age of thirty-five (35), that beneficiary's share shall be distributed to my trustee, IN TRUST, and administered as follows: A. As long as the beneficiary is; under twenty-six (26) years of age: 1. As much of the net income and the principal as my trustee, in my trustee's sole discretion, may from _-_ ----- - - _- - -- - - --- ---==--=time~to-~tiae--think--desirable shal=l" be dstrib~ec7 to my children, MARL A. PALOVITZ and BE'.CH D. PALOVITZ, in such Page 2 of 8 pages. pal.will ' gmr 12/20/90 amounts or proportions as my trustee: may from time to time think appropriate; and 2. Any net income not so distributed shall from time to time be accumulated and added to the principal. B. After my beneficiary reaches twenty-six (26) years of age, he or she shall have the right to withdraw up to one-third (1/3) of the principal of the trust at any time after reaching twenty-six (26) years of age, up to one-half (1/2) of the balance thereof at any time after reaching thirty (30) years of age and the entire balance thereof at any time after reaching thirty-five (35) years of age. Any funds to be applied under this article either shall be applied directly by my trustee or shall bea paid to a parent or guardian of the beneficiary or to any person or organization taking care of the beneficiary. My trustee shall have no further responsibility for any funds so paid or applied. ITEM IV. All federal, state and other death taxes-- except generation-skipping transfer taxes--payable because of my death on the property forming my gross estate for tax purposes, whether or _._ _ . _ _ _ __. _-r----------- - ---~- ~ --~-ri6t --it passesVuncTer- this-wll;~shall be paid. out of the principal of my residuary estate just as if they were my debts, and none of those taxes shall be charged against any beneficiary or any outside Page 3 of 8 pages. pal.will gmr (12/20/90 d fund. Any death taxes on future interests shall be paid out of the principal of my residuary estate or the residuary trust whenever my executor or my trustee, in my executor's or my trustee's sole discretion, thinks best. ITEM V. No interest in income or principal shall be assignable by, or available to anyone having a claim against a beneficiary, before actual payment to the beneficiary. ITEM VI. I authorize my executor and my trustee: A. To retain and to invest in a1:1 forms of real and personal property, regardless of (i) any limitations imposed by law on investments by executors or trustees, (ii) any principle of law concerning delegation of investment responsibility by executors or trustees or (iii) any principle of law concerning investment diversification; B. To compromise claims and to abandon any property which, in my executor's or my trustee's opir-ion, is of little or no value; C. To borrow from anyone, even if the lender is an ___ .. ------ - --~ --executor or-trustee--hereunder; and to pledge property as security for repayment of the funds borrowed; Page 4 of 8 pages. pal.wil2 gmr `12/20/90 D. To sell at public or private sale, to exchange or to lease for any period of time, any real or personal property, and. to give options for sales or leases; E. To join in any merger, reorganization, voting-trust plan or other concerted action of security holders, and to delegate discretionary duties with respect thereto; F. To allocate any property received or charge incurred to principal or income or partly to each, witshout regard to any law defining principal and income; G. To distribute IN KIND and to allocate specific assets among the beneficiaries (including amp trust hereunder) in such proportions as my executor or my trustee may think best, so long as the total market value of any beneficiary's share is not affected by such allocation. H. To use administrative or other expenses of my estate as income tax or estate tax deductions or both and to value my estate for tax purposes by any optional metr~od permitted by the law in force when I die, without regard to whether they were paid from principal or income, without requiring adjustments between Page 5 of 8 pages. pal.will gmr 12/20/90 principal and income for any resulting effect on income or estate taxes. These authorities shall extend to all property at any time held by my executor or my trustee and shall continue in full force until the actual distribution of all such property. All powers, authorities and discretion granted by this will shall be in addition to those granted by law and shall. be exercisable without leave of court. ITEM VII. I appoint my brother, RICK E. KLINGER, executor of this will, but if he for any reason fails to qualify or ceases to act, I appoint SUSAN CIBORT executor in h:is place. I appoint COMMONWEALTH NATIONAL BANK as trustee under this will. I direct that: A. Any executor may resign at any time without court approval; B. Any corporate fiduciary hereunder shall receive compensation in accordance with its standard schedule of fees in effect at the time its services are performed; and ~- C. No executor or trustee shall be required to post bond. Page 6 of 8 pages. ' pal.will gmr 12/20/90 ~ . ITEM VIII. If I die before my daughter reaches 18 years o f age A. I appoint IRENE KLINGER guardian of the person of my daughter during her minority; and B. I appoint COMMONWEALTH NATTONA.L BANK as guardian of the estate of my minor daughter over any property that may pass to her other than under this will or a trust of mine. I direct that: 1. Such guardians shall have the same management powers as those granted my executor, may pay or apply principal as well as income for the minor's welfare, comfort, support or education, without court approval, (and if they, in their sole discretion, determine that it is impractical to administer any fund, they may deposit such fund in one or more savings accounts in the minor's name, payable to him or her at majority; the guardians shall have no further responsibility for any funds so paid, applied or deposited); and 2. No guardian shall be required to give bond. ITEM IX. The term "executor" and "trustee" or any pronoun used to indicate the executor, trustee, any other fiduciary or any beneficiary shall be deemed to apply to one or more than one person Page 7 of 8 pages. ' pal.will , gmr 12/20/90 or corporation and to the masculine, feminine or neuter gender, as the case may be. IN WITNESS WHEREOF, I have hereunto set my hand and seal ~ ~ to this m last will this ~ ~1~ da of ~~, ff~ 1990. ~ '~~ ~ " ~ t ~_ ~ ~ (SEAL) C. DI E PALOVITZ SIGNED, SEALED, PUBLISHED, and DECI:,ARED by the above testatrix, as and for her last will, in the presence of us, who thereupon at her request; in her presence and in the presence of each other, have hereunto subscribed our ,ama_s as witnesses. ~ `/J~ \ ~ ../~ ,, ~~.~ lei c~ ~,~/~ ~-~~ ~7 ~e.- J ~ '1 ~ ~ ~ ~~~2C'. "c.~~. L- ~: ~~ ~~~~~ ~ Page 8 of 8 pages. ' pal.will gmr 12/20/90 COMMONWEALTH OF PENNSYLVANIA ) ( ss: COUNTY OF DAUPHIN ) We, C. DIANE PALOVITZ, (r~ jU,ri ~c. rn < ~ . ,~? •Z- , and /~~~ , r,j`t '_1 ~ ,F~~~p/''}~, ,t,j , the testatrix and witnesses, respectively, whose names are signed to the attached or 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 that she had signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the wil:L as witness and that to the best of .our knowledge, the testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. C. DIANE PALOVITZ f W1tneSS ~itness SUBSCRIBED, sworn to or affirmed, and acknowledged before me by the above-named testatrix and by the witnesses whose names - __- ---a .~ t ~~~1. _ .. -___. / ~'--- ~' l , ~~ ~ ` c ary Public ~. JULIE it G 0 ;RE~N•J'~ qY PUBLIC ' FlARRISBURG, DAUPNlN CG`UNTY ~1Y COMMISSION EXPIAEi3 FEB. 22, 1993 !;amber, Ft~~~sy!vard3 f+s:9or ~I Uctaries LEGAL DESCRIPTION All that certain piece or parcel of land, situate in Lower Allen Township, Cumberland County, Pennsylvania, more particularly bounded and described as follows, to wit: Beginning at a point on the Northwesterly side of Blacksmith Road which point is Two hundred eight and seventy-seven one hundredths feeffrom the Northwesterly corner of Allendale Way and Blacksmith Road at the dividing line between Lots Nos. 216 and 217 of the hereinafter mentioned Plan; thence along the Northwesterly side of Blacksmith Road by an arc curving to the left having a radius of Two hundred thirty-seven and three one hundredths feet fifty and thirty one hundredths feet to a point; thence along same South twenty-five degrees fifteen minutes West twenty-seven and forty-eight one hundredths feet to the dividing line between Lots Nos. 215 and 216 of the plan; thence along same North sixty-four degrees forty-five minutes West two hundred seventy-five and fifty-one one hundredths feet to a point; thence north thirty degrees thirty-five minutes twenty seconds East one hundred thirty-eight feet to a point on the dividing line between Nos. 216 and 217 of the plan; thence by same south fifty-two degrees nine minutes twenty seconds East two hundred seventy-four and fifty-two one hundredths feet to a point on the northwesterly side of Blacksmith Road, the place of beginning. Being all of Lot No. Z 16 of Plan of Section 5 of Allendale, Lower Allen Township, dated March 19, 1962, and recorded in the Office of Recorder of Deeds of Cumberland County in Plan Book 12, Page 59, on May 2, 1962, and the Board of Commissioners of Lower Allen Township, April 2, 1962. File ~: 258944 ' 1-Iaving thereon erected a dwelling known and numbered as 348 Blacksmith Road, Camp Hill, Pennsylvania. Under and Subject, to Declaration of Restrictions of National Land and Investment Co. recorded in the Office of the Recorder of Deeds in Cumberland County on June 19, 1962, in Misc. Book 158, Page 243, and utility easements of Bell Telephone Company and. Pennsylvania Power and Light Company of Record, and a Fifteen (15) feet drain easement as shown on the Plan. Being TAX PARCEL No. 13-24-0809-084. PROPERTY ADDRESS: 348 BLACKSMITH ROAD, CAMP HILL, PA 17011-8421 PARCEL # 13-24-0809-084 File #: 258944 ~. Pr ntial """""'AUTO"5-DIGIT 17011 C DIANE PALOVITZ 348 BLACKSMITH RD CAMP HILL PA 17011-8421 357116 S000001253IP000000000 ll~~lllllllll~~~~nllll~llll~llllllll~lllnlt~~lllllullnllll Computershare Computershare Trust Company, N.A. P.O. Bax 43038 Providence Rhode Island 02940-3038 1-800-586-1305 Hearing-impaired 1-800-619-2837 vwvw. computershare.com~nvestor Account Number 00028525290 IN D 5~~.~ B ~ Reminder Regarding the Sales Facility at Computershare As of the close of the market on August 31, 2010, you owned 25 shares of Prudential Financial, Inc. Common Stock valued at $1,265.00. This letter is being sent as a reminder of the terms of the Sales; Facility offered by Computershare, Prudential's Transfer Agent. There are three options for selling your shares. • By calling 1-800-586-1305 (For hearing-impaired, call 1~-800-619-2837). • By going online at www.computershare.com/investor. • By mail, by signing the form below or submitting a signed letter of instruction. The market value will fluctuate until your sales transaction is completed and the actual sales price is determined. A check will be mailed to you within t:wo weeks of the sale. The proceeds will reflect an $11.00 transaction fee and an 8¢ fee for each share sold. Selling your shares will not impact any policy or contract you own with Prudential. To sell all of your shares, sign the form below, detach this portion and return in the envelope provided. Sale Authorization Form for your Prudential Financial, Inc. Shares. This program is voluntary. Should you decide to sell all of your shares, sign in the box(es) below and return in the envelope provided. Additional information is listed on the back of this form and in the Sales Facility Term Sheet provided. All persons listed must sign exactly as named above Signature for sale only Please sign inside box Additional signature if needed Please :>ign inside box I (we) agree to the Sales Facility Term Sheet included in this mailing. . IINIO~I~~~~IIII~I~NI~ Date (mm/dd/yyyy) 00028525290 I N D CDIANEPALOVnZ 00028525290 5UCF PRU 002CSP0003 0183TG 100917_PRU_PRODUCT_I_DOMESTIC_I/35711N35711G/i12 ~R Ce~~~ens ~~1'i~ 1-888-910-4100 Call Citizens' PhoneBank anytime for account information, current rates and answers to your questions. Checking continued from previous page Description Deposit Benefit Payments Pensions 100802 000000253400612 Deposit US Treasury 303 Soc Sec 081110 Other Withdrawals (continued) Date Amount Description C DIANE PALOVITZ Check # 0000004524 Green Checking 08/10 54.00 NglIns Group 12 Chk Pmt 100810 610077-111-3 Check # 0000004557 08/16 100.00 Scheduled Transfer 6140188873 08/16 50.00 Scheduled Transfer 6140188873 So4e~Re E I. Total For Total This Period Year-To-Date Total Overdraft Fees .00 193.00 Total Insufficient Available Funds .00 429.00 (Returned Item) Fees Deposits & Additions Date Amount 07/28 250.00 08/02 380.15 08/03 7,464.46 08/11 741.00 Daily Balance Date Balance Date Balance 07/27 1,363.04 08/04 8,384.23 07/28 1,367.04 08/05 8,297.23 07/29 1,071.04 08/06 8,224.23 07/30 1,003.11 08/09 .7,902.23 08/02 933.55 08/10 7,523.25 08/03 8,398.01 08/11 7,905.33 MEMO Account Statement OF 6 ~~~ , Beginning July 27, 2010 through .August 24, 2010 n Total Withdrawals 1,245.94 n Total Deposits & Additions 8,835.61 n Current Balance 6,668.71 Date Balance 08/12 7,844.71 08/13 7,423.71 08/16 7,273.71 08 18 $q3„ ~ 6, 668 .J 1 --Reminder: As of August 15, 2010 a new federal regulation will change the way your account works today. As detailed in the insert you received in your July statement, with current Standard Overdraft Practices, Citizens Bank, at our discretion, may authorize and pay transactions that cause overdrafts including ATM and everyday debit card transactions. However, effective August 15, 2010 we wilt decline your ATM and everyday debit card overdrafts unless you ask us to include them in the Standard Overdraft Practices on your account. If your account was opened July 1, 2010 or later, your Standard Overdraft Practices preference was made during account opening and is effective immediately. At Citizens Bank you have a choice for how you would like us to handle your ATM and everyday debit card transactions. If you haven't already done so, and you wish to give us the authority to pay ATM and debit card overdrafts on your behalf, you may provide your consent by using one of these three convenient options: call us at 1-866-211-2921, log on to online banking or visit your local branch. While you can make and/or change your decision at any time, to retain this service without interruption we must have your authorization before August 15th. If you prefer that the bank does not pay ATM and everyday debit card overdrafts on your account, there's no action you need to take. Beginning August, 15th, any overdrafts on ATM and everyday debit card transactions will be declined. For more information on this new regulation visit citizensbank.com/overdraft-regulation. By providing you with information about this new federal regulation and how it impacts your account, Citizens Bank remains dedicated to helping you bank on your terms. Member FDIC Q Equal Housing Lender ~~ Send Inquires to: Statement of Accounts 5000 Louise Drive PO Box 40 Mechanicsburg, PA 17055 May 25 , 2010 thru Jun 24, 2010 www.membersl st.org Main Switchboard: (800) 283-2326 EZCaII: (717) 697-4372 or (800) 283-4372 Account Number: 160720 ® TDD: (717) 697-5312 or (800) 283-2328 ext. 532 TeleBranch: (800)237-7286 MEMBERS 1St Balances at a Glance FEDERAL CREDIT UNION CheCking : 10. 9 7s7 i av 0.335 787_787 Savings: 220.42 I~~~III~~~III~~~~~~II~~~III~~I~~I~~I~~I~I~~~II~I~~II~~I~~~II~I Certificates: C D PALOVITZ Loans : 0.00 348 BLACKSMITH RD Money Management: 0.00 CAMP HILL PA 17011-8421 Swipe 5 YTD Reward : 0.00 ~' Page : 1 of 1 Your aggregate balance as of June 1st is $x!31.11. An aggregate balance of $2,500 and having 3 ;products will place you in the Silver MLR level. Weve made it easier for you to manage your accounts online! See the enclosed insert for more details. CHECKING ACCOUNTS 0011 -CHECKING May 25 Balance Fon~vard Jun 24 Ending Balance i SAVINGS ACCOUNTS 0000 -REGULAR SAVINGS Date Transaction Description .Additions Subtractions Balance May 25 Balance Forward i 220.36 May 31 Deposit Dividend 0.300% ~ .' 0.06 220.42 Annual Percentage Yield Eamed 0.320'/a from 05/01/2010 through 05/31/2010. ,r Jun 24 Ending Balance `~ _. _._ 220.42 _ - --- YTD SUMMARIES ,;~ TOTAL DIVIDENDS PAID t 0000 REGULAR SAVINGS 0.29" ~' 0011 CHECKING 0.00 i ~,' _. ~' ~ -> Total Year `To Date': Dividends Paid ~F` ";, 0.29 NOTE: Totel,mcliides closed shares _. ~-, Don't forget about our new `Member Loyalty Rewards Program. The more products you have with us, the more benefits you'll receive. Ask an associate for details or visit our website at www.members1 st.org for details. ~~ Account Statement ~~ Citizens Bank 1-888-910-4100 © of 6 Call Citizens' PhoneBank anytime far account information, current rates and answers to your questions. Beginning Juty 27, 2010 r through August 24, 2010 Savings ~. s u ni tN a R r C DIANE PALOyITZ Balance Calculation Balance Statement Savings 6140-188873 Previous Balance 750.12 Average Daily Balance 915.66 Withdrawals .00 - Interest Depositr & Additions 300.00 + Interest Paid .03 + Current Interest Rate .039'° Current Balance 1,050.15 ~ Annual Percentage Yield Eamed .04% Number of Days Interest Eamed 29 Interest Eamed .03 Interest Paid this Year .08 TRANSACTION DETAILS Deposits & Additions Date Amount Description 08/02 50.00- Scheduled Transfer 08/02 100.00 Scheduled Transfer 08/16 50.00 Scheduled Transfer 08/16 100.00 Scheduled Transfer Interest Date Amount Descriptoon 07/30 .03 Interest Daily Balance Previous Balance 750.12 n Total Deposits 8 Additions 300.00 n Total Interest Paid .03 n Curtent Balance 1,050.15 Date Balance Date Balance Date Balance 07/30 750.15 08/02 900.15 08/16 1,050.15 NEWS FROM CITIZENS --Citizens Bank is here for all your borrowing needs. Whether you are consolidating debt, making home improvements or paying off student loans, Citizens Bank has great rates that can help you with a variety of borrowing needs. Take advantage of flexible repayment terms and no closing costs on home equity Lines or loans. Or, for those of you who are purchasing a home or refinancing your mortgage, get 1/8% off your rate when you have a Circle Gold Checking account and your payment automatically deducted. See a banker today or call 1-888-567-1518 and discuss your borrowing options. -We all have savings goals. Whether it's a new home, a child's education, retirement or being prepared for unexpected expenses, Citizens Bank makes it easy and rewarding for you to start saving. Creating an emergency savings account can prepare you for unexpected events and help you reach your savings goals. No matter what you're saving for, we have a great savings solution. Ask your banker about what savings accounts and programs are right for you. We also offer money market accounts and CDs with competitive rates and the peace of mind of FDIC insurance. For more information or to open a new account, visit your local branch today or call 1-888-821-3900. Member FDIC. See a banker for FDIC coverage amounts and transaction limitations. --Give help. Give hope. Be Inspired. Please join us in saluting our new Champion in Action at citizensbank.com/community. Memher FDIC 1~ Fqual Housing Lender 'Heilmfin, Dawn From: Jackson, Aaron Sent: Thursday, June 02, 2011 9:24 AM To: Lupe Palovitz Cc: Heilman, Dawn Subject: Re: Vehicle Hi Lupe, Thanks for your email. I am actually on a short vacation, but I have contacted Dawn and she will be contacting you. We will simply draft a Bill of Sale for the vehicle and Dawn will get it to you so that it can be executed. It is essentially just a receipt for the sale. Thanks, Aaron Sent from my iPhone On Jun 2, 2011, at 9:16 AM, "Lupe Palovitz" <lpalovitz(cr~Lgraystonetowerbank.com> wrote: Good Morning, Aaron: I hope that this message finds you well... I am following up on a few phone calls from a couple of weeks ago, both my husband and I had spoken with Dawn regarding the sale of the vehicle, and how we would go about it. I advised her that the Blue Book is $4,100 and that we were offered $3,000 becau:;e there is some maintenance needed at this point (new brakes, oil change, and front tires). I really do not want to keep the potential buyer on hold too much longer, so would you be able to let me know how we can go about making this transaction. I look forward to hearing from you at your earliest convenience. My contact inforniation for the office is listed below, or my mobile number is (717) 805-4716. /~1~c.~.~e. ~~~~ - ~ 0 ~ ~~ i f c~.L se v~ ~l f ~ d ve~~~e ~-7 S V~~ -1c~ (~KS5~~5~U~ya~S Warm Regards, 1 Ur}-~m e ®~ .. ~r - Lapa PaBavifz f Loan Operations Analyst I t d U ~ ~~ <image001jpg> Graystone Tower Bank ~~ S.bI~Q~ 1828 Good Hope Road 1 HSBC Retail Services P.O. BOX 5244 CAROL STREAM, IL 60197-5244 S~f~~l, 09/06/2010 ~~~~~ C DIANE PALOVITZ 348 BLACKSMITH RD CAMP HILL, PA 17011-8421 .~., =~ ACCOUNT NUMBER: 0000000000003823679 CURRENT BALANCE: 52,556.22 MINIMUM AMOUNT DUE: 5171.00 RE: BOSCOV'S Dear C DIANE PALOVITZ: -= In case you .were not aware, HSBC Retail Services reports account conditions to the three major credit bureaus (Trans Union, Equifax & Experian) on a regular basis. These reports may remain a part of your credit history for up to seven (7) .~ years. Having a past due history or being presently delinquent `_ could influence the decisions of other creditors in the future. In order to prevent further. late charges and a possible negative report to the credit bureaus, we request that you send your payment in the amount of 5171.00 immediately. You can take advantage of our check-by-phone program. Call our toll-free number 1-800-365-2026. Collection Department, HSBC Retail Services WE ARE REQUIRED BY LAW, IF APPLICABLE, TO NOTIFY YOU THAT WE ARE ATTEMPTING TO COLLECT A DEBT, AND ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. Please include this portion of the letter with your payment or correspondence to ensure prompt attention. C DIANE PALDVITZ ACCOUNT NUMBER: OOOOD00000003823679 PAYMENT AMOUNT: 5 $ SEND T0: a HSBC Retail Services, PO BOX 4144, CAROL STREAM, IL 60197-4144 0 o Questions ab out credit scores, credit reports, or how lenders make credit decisions? Visit Yo u'rMoneyCounts.com for answers to t hese questions and more. You'll also find useful tools, tips and articles - YourMoneyCounts.com is your online guide to financial and credit education. L805 by ® Manage your account online: additional contact information www.chase.coMbo conveniently located on reverse side ACCOUNT SUMMARY Account Number: 4227 6510 1027 3893 Previous Balance $1.50 New Balance $1.50 OpeninglClosing Date 06/18/10 - 07/17/10 Total Credit Line $400 Available Credit $3gg Cash Access Line $120 Available for Cash $120 PAYMENT INFORMATION New Balance $1,50 Payment Due Date 08/14!10 -- Minimum Payment Due $1.50 Late Payment Warning: If we do not receive your minimum payment by the date listed above, you may have to pay up to a $39.00 late fee and your APRs will be subject to increase to a maximum Penalty APR of 29.99%. This account is closed and not available for new transactions. If there is a balance please continue to make payments by the due date. BP REBATES SUMMARY Previous Rebate Balance $0.00 Redeem fur a BP Gift Card, a check made -$0.00 Rebates Due-tv Expire-- - ---------- -- --------- ---- --- --payable-to-you-ora-dona[ion-tathe----- --- -- __-- Conservation Fund. 2010 Totals Year~#-Date Total fees charged in 2010 $51.00 Total interest charged in 2010 $0.00 Year-to-date totals reflect aft charges minus any refunds applied to your account on or after January 31, 2010. INTEREST CHARGES Your Annual Percentage Rate (APR) is the annual interest rate on your account. Annual Balance Accrued Balance Percentage Rate (APR) 5ublect 7o Interest Interest Type 30 Days In Cycle Interest Rate Charges Charges Purchases 27.24% (v) $0,00 $0.00 $0.00 Cash Advances 2724% v () $0.00 $0,00 $0.00 (v) ~ Variable Rate Please see Informatiori About Your Account section for the Calculation of Balance Subject to Interest Rate, Elnnual Renewal Notice How to Avoid interest on Purchases, and other important information, as applicable. s~.Q ~ z. 0001007 FIS33337 D 11 000 N Z 17 10/07!17 X 0330 PL570413 Paga 1 or 1 00287 MA MA 13867 19710040110461308701 P.O. Box 3268 Shirecnans~town, PA 17011 September 20, 2010 Sc V,~~ i 3 L~~III~~~III~~~~t~IL~~tILJt~f~~I~tLI~~~II~I~rII~~L~~ILI 000174*********"**"*****AUTO**ALL FOR AADC 170 C DIANE PALOVTIZ 348 BLACKSMITH RD CAMP HILL, PA 17011-8421 Commercial Acceptance Company Accounts Receivable. Maalagement Phone: (717) 901-4557 (800) 690-3857 Extension: -- CLIEP+TT-NAME AGENCY CLIENT-# TOTAL-PAID BALANCE CAMP HILL FIRE COMPANY NO 588601 0949083 $.00 $376.11 TOTAL: $.00 $376.11 YOUR ACCOUNT WITH THE ABOVE CREDITOR REMAINS EXTREMELY DELINQUENT. Because you have refused to cooperate and pay your debt, your account has been set for final review. If you intend to avoid additional collection activity, payment in full ar suitable arrangements must be made with our office within five (5) days of receipt of this notice. This communication is from a debt collector. This is an attempt to collect a debt and any information obtained will be used for that purpose. The representative assigned to your file is: CORNERSTONE/MEMORIAIL at Extension -- Your may now pay your bill online at our secure site, www.paycac.com. You will need to enter your agency number. For security reasons, credit card payments will not be processed without the security code from the back of the card. f.1~AST'r.:RC.4R0 ~ q~ X 1~`~ VISA CARD hlUPABER CVV2 CODE AMOUN7 SIGtJATURE • Account Number EXI? DATE Bill Date $376.11 588601. 09/20/10 C DIANE PALOVTIZ Remit payment to: P.O. Box 3268 Shiremanstown, PA 17011 REF STATEMENT This is a statement for professional services rendered C Diane Palovitz by your physician. You may receive a separate bill r' from the hospital for its services. 09/07/2010 SC ~. ~ C Diane Palovitz 348 Blacksmith Road Camphill PA 17011 r~ • 08/23/2010 08/23/2010 08/23/2010 09/03/2010 09/03/2010 Carlisle NeuiroCare 220 Wilson Street Suite 210 Carlisle, PA 17013 717-249-8283 r • • • Claim:20001, Provider: Mohammad Ismail, MD Facility: Holy Spirit Hospital 99291 CRITICAL CARE, FIRST HOUR Humana Payment ~I Humana Adjustment Your Balance Due On These Services ... 3Ei9.00 153.! 149.1 r • • ~ • PAY THIS 09/07/2010 C Diane Palovitz 15586 AMOUNT 65.98 MAKEEHE~ ~ Mohammad Ismail PAYABLE TO: ••• ~- e We are pleased to offer you the option of check payment. ~omcast, Contact us: .`~ www.comcast.com 717-540-8900 Account Number 09547 221624-01-2 Billing Date 09/07110 Unpaid Balance $290.79 -Due Now New Charges $174.12 -Due 90101/10 Total Amount Due $464.91 Page 1 of 2 C DIANE PALOVITZ Previous Balance 290.79 For service at: Payments - receive+~ by 09/07/10 0.00 348 BLACKSMITH RD CAMP HILL PA 17011-8421 Unpaid Balance- IDue Now , 290.79 New Charges -Due: by 10/01/10 174.12 NEWS ffOfTl COC71CaS~ see 6elowfor-liore information Total 'Amount Due $464.9'1 Disconnect Warning: Payment for services received is "` now seriously past due. All past due charges must be paid immediately. Failure to comply may result in disconnection of services without further notice. Thank you for your prompt payment. For your convenience, we now accept regular and automatic monthly credit card payments and direct debit. HearinglSpeech Impaired Call 711 Sca~~ 4x l 5 6 XFINITY TV" 92.84 XFINITY Voice 62.17 Other Charge; & Credits 7.95 Taxes, Surch~irges & Fees 11.16 ' Total New Charges _ , ~ $174..:12 Detach and enclose this coupon with your payment Please write your account numher on your check or money order. Do not send cash. ~Q~C~S{; Account Number 09547 221624-01-2 ` Payment Due by Due Now 1555 SUZY STREET LEBANON PA .17046-8317 AV 01 004840 623828 12 A"SDGT 11~,111,111,,,1'~~I~I~I~I„11111,,,~~'1'1~'II~J,I~"~II'~I~~~~„ C DIANE PALOVITZ 348 BLACKSMITH RD CAMP HILL PA 17011-8421 1„.1.,1,~1,~IIII11~~~'~~'11'11,I111111'~1'~~'I~1'~~~~Ill"~I'I1 COMCAST CABLE P 0 BOX 3006 SOUTHEASTERN PA 19398-3006 09547 221624 D1 2' 7 046491 Total Amount Due $464.91 Amount Enclosed $_ Make checks payable to Comcast ° I PRESORTED ~ WATER CONDITIONING, INC. i ~ 1 2 WATE FORD DR MECHANICSBURG PA 1 7050-823 I "'' ~- " ~ ~' 017H15Eff~.Sfis~LASS NhKID .. ~ ,~.'~~' ~ ---~-ppgTAGE P~jD (71 7) 697-065 ~ '~~ `~''" w $0 J 28Q ~ . Vl i~.' ~" = PE910112010 ~ L ~ , • s 7 -~ - , I AMT. 78.44`ACCT. 101783>p~E 79.60 FINANCE CHARGE 09 01 1.16! Did you know you can ;pay your balance by pphone? Call Mon to Fri ~ 8:00 to 4:30 for 'from ~ , ~details 1-800-427-9287.: I TO: DIANE PALOVITZ ;348 BLACKSMITH RD 09/16/1Q~ 79.60~CAMP HILL PA 17011 i ANN PEAC. RATE GAILY PERIODIC RATE MIN. FINANCE RATE ACCOUNT # 18X 0.0499 0.75 1017831. ~ FlN. CNG. ON ~ UNPD. PREV. BAL ILU ATE NEW LA CE Jl„1,,,11,1 I l li i 1.16 78.44 '9 ~h fib" ~ , , ,,, , ,,, ,. ~, I S~~R ~ ~ . ~~.29, j August 1, 2011 } PHELAN HALLINAN & SCHMIEG, LLP 1617 JFK Boulevard, Suite 1400 Philadelphia, PA 19103 215-563-7000 Fax: 215-568-7616 MARC A. PALOVITZ, in capacity as Co-Administrator eta and Devisee of the Estate of CAROLE D. PALOVITZ A/K/A C. DIANE PALOVITZ 1308 CARLISLE ROAD CAMP HILL, PA 17011-6102 R1;: GMAC MORTGAGE, LLC, AS SUCCESSOR IN INTEREST TO HOMECOMINGS FINANCIAL, LLC, 348 BLACKSMITH ROAD, CAMP HILL, PA 17011-8421 Dear Sir or Madam, Please be advised that this notice is being sent to you pursuant to the requirements of Federal law. Phelan Hallinan and Schmieg, LLP is a debt collector attempting to collect a debt. Any information we obtain may be used for that purpose. If you have previously received a discharge in bankruptcy, this correspondence is not and should not lie construed to be an attempt to collect a debt, but only enforcement of a lien against property. Under Pennsylvania law, a state court foreclosure action is in rem only, meaning against the property, rather than for a personal money judgment. The amount of the debt as of 12/02/2010 is as follows: Principal Balance $208,978.87 Interest $5,697.07 07/01/2010 through 12/02/2010 Late Charges $960.87 Property Inspections/Property Preservation $22.50 Escrow Deficit $94.81 TOTAL $215,754.12 Interest and other items will continue to accrue. If you would like to pay the debt, please call our fi.rm's Foreclosure Resolution Department at 215-320-0007, x1230 or by email to fcresolution@fedphe.com for an up to date q>,.tote. Your original creditor was MORTGAGE ELECTRONIC REGISTRATION SYSTEMS, INCORPORATED AS A NOMINEE FOR HOMECOMINGS FINANCIAL, LLC (F/K/A HOMECOMINGS FINANCIAL NETWORK, INC.), 9 SYLVAN WAY, SUITE 100, PARSIPPANY, NJ 07054. The mortgagee of record is DEUTSCHE BANK TRUST COMPANY AMERICAS AS TRUSTEE FOR RALI 2007QS4 . They are your creditor. Your Mortgage Servicing Company is GMAC MORTGAGE, LLC, AS SUCCESSOR IN INTEREST T'O HOMECOMINGS FINANCIAL, LLC. Unless you dispute the validity of the debt or any portion thereof within thirty (30) days after receipt of this notice, the debt will be assumed to be valid by our firm. If you notify our *Phelan Hallinan &Schmieg is a PA Limited Liability Partnership Phelan Hallinan &Schmieg PC is a New Jersey Professional Corporation office in writing within thirty (30) days after receipt of this notice that the debt or any portion thereof is disputed, we wiii obtain and provide you with verification of the debt by mail. The law does not require us to wait until the end of the thirty (30) day period following first contact with you before commencing a foreclosure action. Accordingly, a separate complaint in foreclosure may be filed and served on you. Even though the haw requires a response within twenty days of service of the com la'nt, a judgment will not be entered against you for a period of thirty days aft e complaint to assure your opportunity to dispute the validity of the deli'' Very Tyti~y Yours Lawrence T. Phelan, Esquire rands allinan, Esq ' Daniel G. Schmieg, Esquire Michele M. Bradford, Esquire Judith T. Romano, Esquire Sheetal R. Shah-Jani, Esquire Jenine R. ,Davey, Esquire Lauren R. Tabas, Esquire ~'ivek Srivastava, Esquire J;ay B. Jones, Esquire Peter J. Mulcahy, Esquire Andrew L. Spivack, Esquire C:hrisovalante P. Fliakos, Esquire Joshua I. Goldman, Esquire urtenay R. Dunn, Esquire Allison F. Wells, Esquire William E. Miller, Esquire Melissa J. Schemer, Esquire Phelan Hallinan & Schmieg, LLP Lawrence T. Phelan, Esq., Id. No. 32227 Francis S. Hallinan, Esq., Id. No. 62695 Daniel G. Schmieg, Esq., Id. No. 62205 N[ichele M. Bradford, Esq., Id. No. 69849 Judith T. Romano, Esq., Id. No. 58745 S;heetal R. Shah-Jani, Esq., Id. No. 81760 Je;nine R. Davey, Esq., Id. No. 87077 Lauren R. Tabas, Esq., Id. No. 93337 Vivek Srivastava, Esq., Id. No. 202331 Jay B. Jones, Esq., Id. No. 86657 Peter J. Mulcahy, Esq., Id. No. 61791 Andrew L. Spivack, Esq., Id. No. 84439 Jaime McGuinness, Esq., Id. No. 90134 Chrisovalante P. Fliakos, Esq., Id. No. 94620 Joshua I. Goldman, Esq., Id. No. 205047 Courtenay R. Dunn, Esq., Id. No. 206779 Andrew C. Bramblett, Esq., Id. No. 208375 Allison F. Wells, Esq., Id. No. 309519 1617 JFK Boulevard, Suite 1400 One Penn Center Plaza Philadelphia, PA 19103 215-563-7000 258944 DEUTSCHE BANK TRUST COMPANY AMERICAS AS TRUSTEE FOR RALI 2007QS4 1100 VIRGINIA DRIVE P.O. BOX 8300 FORT WASHINGTON, PA 19034 Plaintiff v. MARC A. PALOVITZ, IN HIS CAPACITY AS CO-ADMINISTRATOR CTA AND DEVISEE OF THE ESTATE OF CAROLE D. PALOVITZ A/K/A C.DIANE PALOVITZ 1308 CARLISLE ROAD CAMP HILL, PA 17011 BETH D. PROGIN, IN HER CAPACITY AS CO-ADMINISTRATOR CTA AND DEVISEE OF THE ESTATE OF CAROLE D. PALOVITZ A/K/A C.DIANE PALOVITZ 164 SOUTH CHARLOTTE STREET MANHEIM, PA 17545 Defendants ATTORNEY FOR PLAINTIFF COUR:T OF COMMON PLEAS CIVIL DIVISION TERN[ NO. fly- 6ap2g C/v/L TPr~'y- CUMBERLAND COUNTY T'RUE~COPY;F,ROM RECORD M TeatlmonY }"~ ~~-unto sef my hand ~hts ~-~- °r ~ ~,~tisle~Y c~"1~~~ ~'' ~`S~/ ~~r ~~j CIVIL ACTION -LAW COMPLAINT IN MORTGAGE FORECLOSURE JVe hereby certify the Nithin to kle a true any, ;orrect copy of the ~rigirlal filed of r9C©cd File #: 258944 HMI # TYPE OF DATE OF 81LL DATE OF BILL PREY BILL F I~1A /2'.' ;' 1~~ INS. 4J ~ I PFITIENT NAME FEi # 23-f 512747 PATIENT NUMBER SEX AGE I ADMISSION DATE I DISCHARGE DATE I DAYS PAGE ® ~ - I3IRTH-DATE r Hose. ael03141 (_ C.O.B. INSURANCE COMPANY NAME GROUP NUMBER POUCY NUMBER GUARANTOR C L) I ANE F ALO;J I T? ]. HUMANA [tC]LI7 5476 i 1 SGC NAME 34S IiLACF~SMITH RC7AL7 DAMP HILL FA 17011 AND ADDRESS CLr'1RbC T7:MOTHY A n _ _ / AMOUNT OF PLEASE RETURN THIS PORTION WITH YOUR PAYMENT. `G,~GWI+~ ~~~ PAYMENT ~ -- DATE POSTED DESCRIPTION OF HOSPITAL SERVICES SERVICE CODE TOTAL CHARGES EST. COVERAGE INS. CO. N0.1 EST. COVERF~GE INS. CO. N0.2 EST. COVERAGE INS. CO. N0.3 EST. COVERAGE INS. CO. N0.4 PATIEN AMOUN ~~IMrh Y of GHAR~JES ~~<c I TENBI `si~AYS@ ~iG4. aG b31^c. GG 631. aG ~p~c MI TE 2aA4`S~ 1448. Qc~ 289h. as 2896. G{? Y°<C I TEhdS:C 3D,~,~r'SL 1884.00 5652. a0 5652. Oct PHAi:ih1ACY 250 $b74. 80 8674. SG MS`S SUPPLIES 270 9289.50 5289.50 LADORATt7RY 300 x.3762.00 137b2.0a LAX ;~-R,AY 320 3744. Qa 3?~-4.00 LT SGAN 3S0 11245.00 1ic4S.00 OR SER~,,`ICES 3bG 4Gig.00 40113.00 BLOOD P Ri?C ESS 390 462. GO 462. 00 I MAO I h•IG SFR V 402 ~ 2302.00 2302.00 RESPIRATORY SV 4ia 9493.00 9493.00 PHYSICAL THPY 420 902.QO 902.00 SPEECH THERAPY 440 62G.00 62G.00 EMERGENGY ROOM 4S0 if3G8.00 1oG8.OG CAR.~7IOLOGY 4B0 3285.00 32135.00 EK.G/EGG ?30 1332. as 133'2.00 EEG 740 764.00 764,Qa OGC 1"HERAFY 45n.00 450.00 3UL'-TpTAL OF" CHARGES J CJ~CL~~ 7a1 i . 30 X37011 . 30 4 ti 5 ` K i t k .. (f"' +1 FEDERAL IDENT. N0.23-1512747 T O T A L S 7a i 1.30 X01 i. 30 _ PATIENT NuMeER REFER ALL QUESTIONS TO THE PLEASE SEND PAYMENT TO: 37797c71' BUSINESS OFFICE pt~ Asa-2~sa. HOLY SPIRIT HOSPITAL PAY THIS AMOUNT 0 ADDITIONAL PATIENT 81LLING MAY 8E NECESSARY R 503 NORTH 21 ST STREET CHARGES NOT POSTED WHEN THIS BILL WAS PR. OR IF INSURANCE CARRIERS DO N07 PAY ANY P," CAMP HILL, PA. 1 701 1-2288 THE AMOUNTS SHOWN UNDER ESTIMATED INSU COVERAGE. INTERNISTS OF CENTRAL PA ' 108 L'OWT'HER STREET LEMOYNE, PA 17043 09/08/10 44878 10.00~ Forwarding Service Requested _MC _VISA `Disc Security Card~~ Code _ ~--. S i gn _ Exp _/_ 30971 `~ C `-'I 1 ---~ l ESTATE OF C. DIANE PALOVITZ INTERNISTS OF CENTRAL PA 348 BLACKSMITH RD 108 LOWTHE;R STREET CAMP HILL PA 17011-8421 LEMOYNE, PA 17043 •• -•- • • MESSAGES EXPLAINED - BELOW '`'`~ PLEASE PAY UPON RECEIPT. FOR BILLING QUESTIONS CALL ;174-1366 BETWEEN 10 '~"~~` --- ~** AM AND 4 PM AND CHOOSE BILLING. EFFECTIVE 3/1/10 THERE WILL BE A *"* ~`** LATE FEE ADDED TO BALANCES OVER 60 DAYS OLD. **''` ~c ~c ~c ~c ~c ~c 3c ic:'c :c ~:'c:'c:'c is ~c ~.c:'c:ti ~c ~c:'c ic:'c:Y is ~c ic:Y:Y :4:'c 4c is ~c ~c 4c ~c ~c 4c ~c:'c ~c ic:t:~:'c ~c is :c is ~: ~c ~c:'c:Y:'c is :t:4:::c:Y:::'c:'c'c ~c:'c is ic:Y ~c :r:'c ir:'r:c is :::c ;c:: Insurance Charges pending to Prv: 806.00 Ins Pay/Adj against Ins pending 103.29 -114.71 588.00 06/10/10 1 15 OFFICE VISIT EST LEVEL 1 99211 V58.61 :25.00 06/28/10 HUMANA GOLD Payment 8.70 07%O8%1Q Credit CardgPayment 10.00 -6.30 0.00 07/01/10 1 15 OFFICE VISIT EST LEVEL 4 99214 272.4 1:30.00 07/01/10 Credit Card Payment 10.00 07/26/10 HUMANA GOLD Payment 88.58 07/26/10 Accept Assign Adj. -31.42 0.00 08/13/10 1 3 L OFFICE VISIT EST LEVEL 1 99211 V58.61 25.00 09/08/10 HUMANA GOLD Payment 9.11 09/08/10 Accept Assign Adj. -5.$9 10.00' L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make payment. DATE LAST PAID AMOUNT • - ~ • . ~ • - • ~ • c - -- ~.~fjj[N 07/01/10 20.00 10.00 0.00 0.00 0.00 0.00 588.00 0.00 598.0 INTERNISTS OF CENTRAL PA HAKE 108 LOWTHER :STREET HECK ~AVAeLEro: LEMOYNE, PA 17043 l ~P1 10.00'' Ph: (717)-774-136 PAT~~ 1-C. DIANE PALOVITZ PRV~~ 3-TYNDALL, JAMES A. , ti. D. Acct~~: 44878 PRV~~ 15-VISWANATHAN, PRATHEFiSH, Date: 09/08/10 Page 1 of 1 24 HOUR EMERGENCY SERVICE STATEMENT ACCOUNT NO. PAGE CLOSING DATE 06/30/2009 3740 1 STATEMENT DIANE PALOVITZ (A) AC BR 348 BLACKSMITH ROAD CAMP HILL PA 17011-8421 ~' C_ ~ ~ U Please detach and mail with your remittance. KEYSTONE OIL P. O, Box 157 • Camp Hill, PA 17011 Phone: (717) 737-3451 PA5 5 8 5 • Heating Oii • Air Conditioning • Oil Burners • Heat Pumps • Water Heaters • Service Contracts DIANE; PALOVITZ (A) AC E!R 348 E3LACKSMITH ROAD CAMP HILL PA 17011-8421 Pay Online zit www.keystone~oilproducts.com ~ AMOUNT ENCLOSE 'REFERENCE DATE - DESCRIPTION ~ AMOUNT Prior Balance 288.94 PERCENTAGE RATE S FINANCE CHARGE IS COMPUTED ON FINANCE TO AVOlDADDITIONAL FINANCE CHARGE Acct # PERIODIC ANNUAL THIS AMOUNT CHARGE PAY BALANCE BEFORE K374G 1.50 18.00 2.15 07/31/2009 291.09 STATEMENT DATE CURRENT 30 DAYS 60 DAYS 90 DAYS • 06/30/09 -176.72 145.86 321.95 0.00 KEYSTONE OIL • P. O. BOX 157 • CAMP HILL, PA 17011 PHONE (717) 737-3451 UOQ2406542478QO1]QOQt]QaQQQ59Z7Q18 Pennsylvania American Water PO Box 371412 Pittsburgh, Pa. 15250-7412 For Service To: 348 Blacksmith Rd 017608 1 AV 0.335 16061176061001606 069 1 PCLSQZ IIIIIIIIIIIIIIIIIIIIIIIlIII1tI11111111111t11111111111111t11111 C DIANE PALOVITZ 348 BLACKSMITH RD CAMP HILL PA 1 70 1 1-842 1 S~ .~ Pennsylvania American Water PO Box 371412 Pittsburgh, Pa. 15250-74 i 2 11111111111111111(IIIIIIIIIt111111111111'11111111111 Please check here to add H2O-Help to Others contribution to your monthly bill or to change your address or telephone number, artd print Information on reverse side. Customer Account lniormatron ~ Blllln 'Summer 9 Y For Service To: C Diane Palovitz --------Prior Balance-------------- 348 Blacksmith Rd Prior Water Balance Account Number: 24-0654247-8 'Payments prior o Sep OB, 2010. Thanksl Premise Number: 24-0386240 Total.prior balance,: Sep 08, 2010 -------Current Water Charges------ BIII1ng Period & Mefer lnformaflon Sertrice charge Billing Date: Sep 08, 2010 Water Volume ($.007890 x 2,600) Billing Period: Aug 04 to Sep 02 (29-days) STAS PAWC Water 0.45% Next reading on/about:' Oct. 05, 2010 DS! =PAWC Charge 0.96% - Rate Type:. Residential ; Total water charges, Sep 08, 2010 Meter readings in current billing period: --AMOUNT DUE ------ Meter Number N087701117 is a 5/8-inch. meter. , Present-actual 13900 Last-actual 11300 Gallons used 2600 ~ . Water Usage Comparison..:- - Monthl~ usage in hundred gallons- J . $25.19 .00 25.19 13.00 20.51 .15 .32 33.98 ~I $59.17 MAKE CHECKS I?AYABLE TO: Pennsylvania Neurosurgery Neuroscience 4310 Loridonderry Road Suite 202 Harrisburg, PA 17109-5329 ScQ.~2<-Px ~- i 2 STATEMENT ADDRESSEE: ~n~~~~~n~~~n~en~~ni~~n~~~~~n~~ Palovitz, C Diane 348 Blacksmith Road Camp Hill, PA 17011 USA Please check box it above address is incorrect or insurance information has changed, and indicate change(s) on reverse side. DATE ~ DESCRIPTION OF SERVICE 08/16/10 ENCOUNTER 57014 FOR C WITH POWERS MD, STEPH MESSAGE: _ - - --- - STATEMENT DATE PAY THIS AMOUNT ACCOUNT NBR 09/13/10 $60.30 ~ 11682 SHOW AMOUNT PAID HERE REMIT T0: Pennsylvania Neurosurgery Neuroscience 4310 Londonderr~r Road Suite 202 Harrisburg, PA 17109-5329 PLEASE DETACH ANC) RETURN TOP PORTION WITH YOUR PAYMENT (717) 920-7664 -~ $39.41 $39,41 `. I ID. STEPHEN K PLEASE PAY THtS AMOUNT ~»>»» $60.30 i ~-- ----- ' ----- ' INSUR 'PATIENT _` J AMOUNT BALANCE BALANCE ~ BALANCE ~'t57 d0. - $39.41 ** PAYMENT DUE UPON RECEIPT * THANK YOU ** STATEMENT PAGE: ~ ~~ _ • • PENNSYLVANIA RETINA SPECIALISTS, PC 08/27/10 24553 220 GRANDVIEW AVENUE SUITE 200 CAMP HI]:.L, PA 17011-1740 64.71* Return Service Requested ~~ 8548 `MC --VISA -Disc Card~~ _ _ Sign Security Code _ Exp _/_ ESTATE OF C DIANE PALOVZTZ 348 BLACKSMITH ROAD CAMP HILL PA 17011-8421 PENNSYLVANIA RETINA SPECIALISTS, PC 220 GRAND'JIEW AVENUE SUITE 200 CAMP HILL, PA 17011-1740 MESSAGES EXPLAINED ~ BELOW ~ • ^ • • ~ ~ ~~~~ ' ~ ^ X11 / L3S LCTI *** P'lease Pay -Amount Due Now From Patient- See Red B ox Thank You. ~'`** Sc~c~Y a'cit* Pa ent due u on recei t. If ou have uestions re g u 3c~'c:c ardin our billin , g ~c~c;c lease call o r Billin Department at (717) 761-86 88 or toll free at *"* (800) 6 33-8688. *"* icy'c~c~:JCS'cic~c~c~'c~c~c ic9c~c~'c~cic~c~c~tic~'c~c~.:'cic~cic9c~c3c~cic~cic~c~'cic~'c~'cic*~Fic~'r~'c~'c~k*~'c::~'chic „:c~c*ic4cic~cic~c~c~'c~c~';is:c~F~'c~cic~c~c~'c~'c~c;'c~c~c Balance Forward: 11.51 11.51 Insurance Charges pending to Prv; 1298.00 . Ins Pay/Adj against Ins pending 468.30 -829.70 0.00 04/19/10 1 4 L BEVACIZUMAB 1.25MG/0.05ML J9035 250.50 100.00 05/21/10 HUMANA - GOL Payment 0.00 08/23/10 HUMANA - GOL Payment 46.06 08/23/10 Accept Assign Adj. -42.43 11.51' 07/22/10 1 4 L EYE EXAM EST PATIENT 92014 362.83 1.30.00 08/23/20 HUMANA - GOL Payment 79.12 08/23/10 Accept Assign Adj. -20.88 30.00- 07/22/10 1 4 L BEVACIZUMAB 1.25MG/0.05ML J9035 362.83 ].00.00 08/23/10 HUMANA - GOL Payment 46.76 08/23/10 Accept Assign Adj. -41.55 11.69 L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make payment. DATE LAST PAID AMOUNT - • - ~ • - . ~ • • ~ • - ~ . . _. i~iFT1.1:1Ft~~ 00/00/00 0.00 53.20 11.51 0.00 0.00 0.00 0.00 0.00 64.7 PENNSYLVANIA RETINA SPECIALISTS, PC 1AAKE 220 GRANDVIEW AVENUE SUITE 200 HECK ~AYABLETO: CAMP HILL, PA 17011-1740 PAT~~ 1-C DIANE PALOVITZ PRV~~ 4-BANACH,MICHAEL J, MD ' '~ ~ ~ rI 64.71_ Ph: (717)-761-86 Acct~~: 24553 Date: 08/27/10 Page 1 of 1 PPL Electric Utilities Electric Service For_ C DIANE PALOYfTZ 348 BLACKSMITH RD CAMP HII..L PA 17011 Questions about this bill? Please contact us by Sep 17 at1-800-342-5775 (1-800-DIAL-PPL) or write to: Customer Service 827 Hausman Rd Allentown, PA 18104-9392 www.pplelectric.com Electric Use This graph shows your electric use over the last 13 months. Types of Meter Readings: Actual Adjusted Estimated Customer (~ ,~~~ .`,-~~., ..-- •._ ~. ~~~ '•'` '• .~ Summary Page Page 1 ,. _: _.:::<~'cralrB~ILAccti~~uFhsmbrx= ;; 58"790-91009 wh~aasl~-ui~or ;- ..;. Balance as of Aug 27, 2010 $0.00 Charges: Total llOMII~TION ENERGY SOLIJTION5 Charges$111.00 Total PPL ELECTRIC UTILITIES Charges $13.13 Total Charges $124.13 .: a~'I'h~.~X.mosu~. lz;~.a~er ~, ~.7, ~©~~':::: .. r .::....:..... ~1~~#; Account Balance $124.13 ~~ ~ i~. 72 60 48 36 24 12 0 KWH -Average Per Day Meter Reading Information Metgger #98980084 Ju1286 Actual 17530 29 Da s KWH Billed 1908 Average -Aug 2009 2010 Te~m~~~pperature KW ~ P D 75F 60 76F I 66 H ~ er ay ~ Yearly Use: Total Average Use Monthly Sep 2008 -Aug 2009 13700 1142 Sep 2009 -Aug 2010 11774 981 ASONDJFMAMJJA 2009 Months 2010 Other important information on back -1 Rehun this part to address below with a check payable to PPL Electric Utilities Coxporation ~.. ~#~-$r~ ~'iccbtu~t 3~igg~g#` .....:.: ......: _#"1~a~ :>~a.. ~ ....: ....:. Y 3~a A:,~AiusC......: 58790-91009 Sep 17, 2010 $124.13 Amount Enclosed AV 0'I 004491 151656 20 A"5D6T ^ ^ ^' ~~ ^ ^ ~ ^ C DIANE PALOVTIZ 348 BLACKSMITH RD CAMP HILL PA 1 70 1 1-8421 PPL ELECTRIC UTIL,TIIES 2 NORTH 9TH STREET RPC~rENNI ALLENTOWN PA 18101-1175 ilfultili~.lillll,l~l~li~~lllumi~~iul~l~li~imll~~~~ii~gii 1 ~200001241320~00124137 5879~91~~9 v PREMIER EYE CARE GROUP 92 TUSCARORA STREET HARRISBURG, PA 17104 /" ~ . ~.~ C DIANE PALOVITZ 348 BLACKSMITH ROAD CAMP HILL, PA 17011 Total Due:: $ 146.33 Minimum Payment Due: $ 146.33 Payment Enclosed $ Make Cheeks Payable to Premier E:ye Care Group Credit Card Payments: Amount Paid: $ Visa [_] MC [_] AmEx [_] Disc [_] Card # Exp. Date;: / / Last 3 Digits # Back of Card Signature: STATEMENT OF ArCOLTNT - ArCT #: 155396 - !' DT-P.N~: PP_LnV?T? ---------------------------------------------------------------------------------- Please detach and return the above portion with your payment. Patient Statement of Account - Date: 09/01/2010 C DIANE PALOVITZ Services Provided at Premier Eye Care Group - Tax Id 25-1?11473 SVC DATE DR. CPT SERVICE PERFORMED ICD9 CHARGE INS PMT PT. PMT ADJUST BALANCE 02/Z4/10 BARTF 92012 EP INTERMEDIATE OP366.19 108.00 ~~0.14 21.49 36.37 .00 HUMANA.DED/COINS./,COPAY DUE 02/24/10 BARTF 92136 IOL MASTER 366.19 200.00 ~i0.31 21.56 128.13 .00 HUMANA DED/COINS/COPAY''DUE 03/26/10 BARTF 66984 ECCE W IOL OR IOL:36.6.-,19 1898.00 474.32 56.951220.40 146.33 HUMANA DED/COINS/COPAY DUE $- 5-~0 ~ j~,~ "`cw- TOTAL' BALANCE : -v"`~ ~ 1:4 6 . 3 3 TOTAL INSURANCE PENDZNCT; ~~.~ 00 PATIENT `DUE: ~ r?s a~,; ~y' 1}46 33 PAYMENTS ON.~ A000UNT s~° t °` ,.,~ Q;O TOTAL PATIENT POR -3. ~ ~ {~ :3:3 ~,.awF'~i~ ° I j I :„ ,1 x~ ~ x S~ :: ~ cm, ~~ ~. `.OF PATIEIJr I +~ ~ CE' - y 0 Days 90:x, a , ~, ~~'~Q~'bays 180'Days+• Current 30~ DaAsIN6 `;~ , _ ~r3 ~ ~ + -. : 00 - --.00 ~,. 00 = '+ OQ~ X4.6 ~ 3 ~< --00 --00 ~'` PT`S- MAK~ING:_°PYMTS` ON'_ACCT ~;;~~~ , -'Tf you have questions regarding the balance: due, please call our office at 717- 234-•2413. PO Box 51 S Middletown PA 1 70 57-05 1 8 RETURN SERVICE REQUESTED Date Our Acct # Amt Owed 9/2/10 350173-2E $128.42 350173-2Fi-001 391974812 Ill1111llllinlllllll~~~lllllllllln~lllllri~llhlllrllillr~~l C Diane Palovitz 348 Blacksmith Rd Camp Hill PA 1 70 1 1-842 1 Sc~~hG~e L l (a PEERLESS CRI~DIT SERVICES, INC. Phone (717)702-2003 Fax (717) 702-2007 PEERLESS CRED][T SERVICES, INC. PO Box 518 Middletown PA 170:17-0518 I~~~III~„Ills,..I,I~I~~~nll,~~~I~i~~~~lll~~l,~~~!lI~~I~I~~~N IF PAYING BY CREDIT CARD, COMPLETE ALL, SIGN AND RETURN. CHECK CARD USING FOR PAYMENT ~ ~ ~ VISA MASTERCARD CARD NUMBER PLUS 3 DIGIT SECURITY CODE (on back otcard) EXP. DATE CAROHOIAER NAME CARDHOLDER SIGNATURE AMOUNT "'Detach Upper Portion and Retum with Payment"' Our Account #: 350173-2E Responsible Party: C Diane Palovitz Creditor Account # Regarding Amt Owed Ophthalmology Surgical 123101 128.42 Dear C Diane Palovitz: This letter has been sent to you by a debt collection agency. Our client has hued our office to collect your overdue balance. Unless you notify this office within 30 days after receiving this notice that you dispute the validity of this debt or any portion thereof, this office will assume this debt is valid. If you notify this office in writing within 30 days from receiving this notice, this office will obtain verification of the debt or obtain a copy of a judgment and mail you a copy of such judgment or verification. If you request this office in writing within 30 days after receiving this notice, this office will provide you with the name and address of the original creditor, if different from the current creditor. This is an attempt to collect a debt. Any information obtained will be used for this purpose. All communications from this office now and in the future will be attempts to collect a debt. We ask that you resolve this matter. Please respond to our office. Sincerely, ~• ~a~dty ** Duect your questions to: Peerless Credit Services (717) 702-2003 ** ** Payment should be made directly to our office. ** ** Please contact our office if you would like to pay with Check By Phone. ** 3SDPEER01001 ~9®P Checks by telephone, please call for details. (717) 702-2003 Peerless Credit Services, 'Inc. • PO Box 518 • Middletown PA 17057-0518 • Phone (717) 702-2003 • Fax (717) 702-2007 ovc ~$ DIANE C PALOVITZ Account Number 173 9381 6487 Summary of rAccountActivity Previous Balance - Payments + Fees Charged + Interest Charges ~' ~~: ~ ~~ ~ ~ r ""'{ $5,703.97 $486.00 $39.99 $115.05 New Balance $5,373.01 Credit Limit $4,500.00 Available Credit OVERLIMIT Statement Closing Date 08/13/2010 Days in Billing Cycle 31 ~~ N Visit us at www.gvc.com Customer Service: 1-800-367-9444 ~'aY.!Pent Infatma~ton ~ .. ~„Yf+ ~4 r,~'~~ t~ ;<; New Balance $6,373.01 Minimum Payment This Period $269.00 Amount Past Due $78.00 Total Minimum Payment Due $347.00 Overlimit Amount $873.01 Payment Due Date 09/07/2010 Late Payment Warning: If we do not receive your minimum payment by the date listed above, you may have to pay a late fee up to $35.00. Minimum Payment Warning: If you make only the minimum payment each period, you will pay more in interest and it will take you longer to pay off your balances. For example: If you make ro „ '-NoU-wIN payoff; ~ ,~nd,yqu (iwlfend ~ddldonal.charges ' ~ t ~~t~a~baianpe?~ ~~ ~~2 h rJp'paymgan ' using this card shown on this-~ '"estlmatedtotal „ .end each man~h r~~ ', state~sn~t y ~' # 3 ~'~N sir of 4Mft r ~~ Y0µ Pay ialioUt ~ ~~Y~ ~ s , , x~ r z Only the minimum 11 years $9,031.00 payment If you would like information about credit counseling services, call /-877-302-8775. rT dr~tlSaCtl6[I Si,mmary Nu9I uk`.~sW~P~"it ~ .c.~`~~~t+u . t~a`?'"'f'[~~ ive:; : ha .rdi c~~li,Vik+'f:~~'Fefi~(~1'~.~1~'~!t i N «~ Tran Date Post Data Order Number Item # Description of Transaction or Credit PAYMENTS AND CREDITS 07/18 07/18 PAYMENT -THANK YOU 07/27 07/27 PHONE PYMT-THANK YOU ALPHARETI"A GA TOTAL PAYMENTS AND CREDITS FEES 08/13 08/13 LATE FEE TOTAL FEES FOR THIS PERIOD INTEREST CHARGED 08/13 08/13 INTEREST CHARGE ON PURCHASES TOTAL INTEREST FOR THIS PERIOD "`~, ,r'~u a~k+y i *rld'9Y1' !!(({{701D,Tokafs YeaC>to Date~~t6 `~~'+ f~u~l~'~;fk° ,,,~ ?tiA. AC'i ~~i~if SF} M14r,~1. ,:k'Y .. .k.:"+r +'r:^~i Y ~'l YrFfi. Total Feas Charged in 2010 $79,98 Total Interest Charged in 2010 $361.29 Amount ($200.00) ($266.00) ($486.00) $39.99 $39.99 $115.05 $115.05 QVC ~r ~~ l C. Diane Palovitz ~. 348 Blacksmith Rd Camp Hill, PA 17011 Dear C. Diane Palovitz: I~ customer service ;September 13, 2010 We need to alert you that one or more Easy Pay installment is past due on your QVC customer account and must be paid immediately. Please take action now to authorize payment of the past due amount to another major credit card, or to make other payment arrangements. For your convenience, you can make updates at QVC.com in Order Status. Just sign in, then look for the Easy Pay orders that are past due, indicated by a notice in red. Click the "Pay" link to access the Edit Pay Method view. You cane then update expired credit and debit cards or add a new card that needs to authorize successfully to fulfill payment: Please take care of all orders that indicate they are past due. If you cannot use our website, it's critical that you call Customer Ser~~ice at 800.367.9444 between lam and lam Eastern Time. Check /money order payments can be made payable to QVC and sent to PO Box 2254, West Chester PA, 19380. Include your QVC Customer Number and phone number on the check. Please pay all outstanding Easy Pay debt and / or other payments due today to avoid having your shopping privileges revoked. Thank you for your prompt attention. Sincerely, /~c ~~ Dan McDermott, Senior Vice President Customer Services Total Amount Due: $34.98 QVC Studio Park West Chester, PA 119380-4262 J 800.367.9444 I q~ic.com ' 'Estate Information Services, LLC 2323 Lake Club Drive Suite 300 Columbus, OH 43232 csxaxe infnrmaxion services, llc. Hours: Mon-Thu Sam-9pm and Fri Sam-Spm EST Deceased Account Collection Agency Toll Free: (877) 347-2484 Phone: (614) 322-2758 Fax: (614) 322-2761 www.probate-care.com 9 lll~lnllllllll~llll~ll~lll~lllilruln~l~lll~lllllllll~lnlli~ AARON JACKSON, ESQUIRE 111 N Front St PO Box 889 Harrisburg, PA 17108-0889 RF: Estate O£ C DIANE PALOVITZ Creditor Name:Citibank NA Account Type: SEARS GOLD MASTERCARD Account Number:************1524 Dear Attorney AARON JACKSON, ESQUIRE: 11 /03/2011 Amount of Debt: $14,177.84 Reference #:2851374 Our office recently presented an estate claim on behalf of Citibank NA in the above referenced estate. In an effort to encourage prompt liquidation of the estate's obligation, we have obtained permission from Citibank N.A to accept the sum of $6,876.25 on or before 11/18/2011 as settlement of the debt. A.1099-C may be issued to the Estate of C PALOVITZ as a result of this settlement. Please consult an independent tax advisor of your own choosing if you desire additional information regarding tax consequences which may result from this settlement. If you decide to accept this offer, please mail the estate's payment, along with the: attached coupon to Estate Information Services, LLC., PO Box 1730, Reynoldsburg, OH 43068-8730, or you may visit our website at http://www.probate-care com/paymment if you wish to process your payment electronically. If you have any questions regarding this offer, please feel free to contact us at the toll free number listed above, and you will be connected to the legal assistant handling this account. Estate Information Services, LLC is a debt collection company. This is an attempt to collect a debt from the assets of the estate of C PALOVITZ and not from the assets owned by your client personally; any information obtained will baz used for that purpose. Your client, personally, is not required to pay any of the debts from the estate of C PALOVI7Z. Sincerely, ESTATE INFORMATION SERVICES, LLC • ~ t 8' t ~ Cut along this line- Please Make Check Payable To: ®a®~ Citibank NA estate infnrmarinn srrvicrs, lie. Mail Payment To: Estate Information Services, LLC. Debtor Name: C PALOVITZ PO Box 1730 Reference #:2851374 Reynoldsburg, OH 43068-8730 Amount Due: $6,876.25 ~~ 8742 Lucent Blvd. SLS \\~~ Suite 300 1 Highlands Ranch, CO 80129 Specialised Loan Servicing, LLC 1-800-3i5-4SLS (4757) + 0296994 000001226 09SL02 0916945 GARGLE PALOVITZ 348 BLACKSMITH RD CAMP' HILL PA 17011-8421 ~~~Ill~~~lll~~~~~~ll~r~ill~~l~~l~~l~~i~l~~~ll~l~~ll~~l~~~ll~ Property Address: 348 BLACKSMITH RD CAMP HILL.PA 17011 MON I iiLY MORTGAGE STATEMENT Statement Date: 08/09/10 Account Number: 1004427004 Payment Summary Payment Due Date: 09!01!10 Current Payment: $251.98 Past Due Payments: $0.00 Escrow Payment: $0.00 Am,ort Fee Payment: $0.00 Optional Ins. Payment: $0.00 Outstanding Late Charges/Fees: $0.00 Suspense Balance: .$0.00 Tonal Amount Due: $251.98 Account Summary Principal Balance': $29,500.00 Escrow Balance: $0.00 Interest Rate: 10.250% Interest Paid to Date: $2,015.84 Ta:Kes Paid to Date: $0.00 'This principal balance does not re flect the total amount required to pay your loan in full - IMPORTANT NOTES • Specialized Loan Servicing is committed to courteous and responsive service, accurate and I;imely handling of your payments and simple, direct answers to your questions. • Specialized Loan Servicing is pleased to offer a quick and easy way to make your mortgage payment. You may now sign up for our Automatic Payment Drafting by calling our Customer Care Center. Simply contact a customer care associate by calling 1-800-315-4SLS (4757) during our regular business hours, Monday through Friday, 6:00 am 40 6:00 pm MST. • 1Me are pleased to announce that you may now access your account information on line at w~nrw.sis.net 24 hours a day regardless of account status! You may also use our 24-hour automated information system for up to the minute information about your account. For questions regarding this statement, to make a payment or general account information please call our Customer Care Center at 1-800-315-4SLS (4757) associates are available to assist you JNonday througlh Friday, 6:00 am to 6:00 pm MST. TDD 1-800-268-9419, Monday through Friday, 8:00 am to 5:00 pm MST. Thank you for your business! TRANSACTION SUMMARY Date Description Total Interest Principal Escrow/ Impound Late Charge Fees/ Advances 08/09!10 Mortgage Payment 251.98 251.98 0.00 0.00 0.00 0.00 ... - -. - _. ...,. IF PAYING BY M<~STERCARD, DISCOVER OR VISA, FILL OUT BELOW. MAKE CHECKS PA YABLE TO: SP P ~ a CHECK CARD USING FOR PAYMENT ~~ D ~ a IRIT HYSICIAN STERCARD ISCOVER ~-~ A ~`~~ SERVICES INC CARD NUMBER SIGNATURE CODE . A SERVICE OF HOLY SPRIT HEALTH SYSTEM SIGNATURE EXP. GATE 205 GRANDVIEW AVE ~~{~~~ SUITE 210 3838-MHSH STATEMENT DATE PAY THIS AMOUNT ACCT # : CAMP HILL, PA 1 701 1 -1 708 . ~ oioi 09/10/10 $161 .98 0358 Tax ID # 25-1766971 SHOW AMOUNT PAGE: 1 PAID HERE .__ '.: _.. 3000( lnllll~lrln~lllulll~llll(~~fllllr~lln(I(Illl~ll(llll~~ll~ll C DIANE PALOVITZ 348 BLACKSMITH ROAD CAME' HILL, PA 17011-8421 ~-~ sue. ~ 2 ~. r7 Pleasa check bax if address is incorrect or insurance U information has changed, and indicate change(s) on reverse side. hNlllflhllullhl~l~l~~rl(llllllllillllll~rllf~ll(I~Innll~ SPIRIT PHYSICIANS SERVICES !NC 205 GRANDVIEW AVE SUITE 210 CAMP HILL, PA 1 701 1-1 708 3836-MHSH•SOZOTEP14001465 STATEMENT PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT RECEIPT RECEIPT INS. PAT. DATE PATIENT DOCTOR CPT4 DESCRIPTION CHARGE FROM INS. FROM PAT. ADJ. BAL BAL 08/20/10 C Diane Rao NID 99291 CRITIrnT• CARE, FIRST HOUR $331.00 $153.94 $111.08 $0.00 $65.98 08/21/10 C Diane Rao I~ 99291 CRITICAL CARE, FIRST HOUR $331.00 $153.94 $111.08 $0.00 $65.98 D8/22/10 C Diane Rao I~ID 99233 SUBSEQUENT' HOSPITAL CARE $110.00 $70.04 $9.94 $0.00 $30.02 Thank yo for your romp payment. CURRENT 30-60 DAYS 60-90 DAYS 120 DAYS 90 OVER 120 D Y T T - A S O AL ACCOUNT BALANCE DUE FROM PATIENT S 161.98 50.00 50.00 80.00 50.00 S 161.98 ' ~~ $161.98 i~ Thank You For Your Payment. For Billing Questions, Please Call: (717) 972-4490. I~~1I~IB~1~1Ilti~IN~1~I~Il~~~l~~It~ Cardmember Service PO Box 108, St Louis, MO 63166-9801 mbank. September 15, 2010 <~ C~ ~--- DIANE PALOVITZ 348 BLACKSMITH RD CAMP HILL, PA 17011-8421 Account No: 4013988870038133 Balance: $5,761.29 Amount Due: $497.00 Dear DIANE PALOVITZ ***IMPORTANT CARDMEMBER ALERT - WE ARE. HERE TO HELP*** IS EVERYTHING OK? We haven't heard from you and are concerned that 30 days have gone by without receiving your credit card payment. We understand that the current economic conditions have affected our cardmembers, and want you to know that we have special payment assistance programs available to help. DID YOU KNOW - Our payment assistance programs have already helped thousands of our valued customers find a solution to their financial challenges. Your account is now past due and unfortunately, we will report your account as delinquent to the national credit bureaus unless payment is received. We don't want this to happen. Please call us today at 1-800-676-4060 to discuss your options or visit us online at www.usbank.com to see if you qualify for one of our special programs . Sincerely, Collection Department Cardmember Service 1-800-676-4060 This is an attempt to collect a debt. Any information obtained will be used for that purpose. L8618 __- i --- y N Walmart' CAROLE D PALOVITZ Visit us at walmartcom/credit Discover' card Account Number: 6011 3100 9645 8950 Customer :iervice: 1-866-611-1148 Summary of Account Activity, , ,~ , •, ~ r ~~ ,~Paymeht Irtforr~ration -' „~ ` ~ ~>! ~~~~?,~~ ~'; Previous Balance $671.45 New Balance $728.00 + Fees Charged 539.00 Minimum Payment This Period $64.00 + Interest Charges 517.55 Amount Past Due $64.00 New Balance 5728.00 Total Minimum Payment Due $128.00 Payment Due Date 09/17/2010 Credit Limit $1,170 Late Payment Warning: If we do not receive your minimum Available Credit $0.00 payment by the date listed above, you may have to pay a fate Cash Advance/Quick Cash Limit $240 fee up to $35.00. Available Cash $0.00 Minimum Payment Warning: If you make only the minimum Statement Closing Date 08!2512010 payment each period, you wilt pay more in interest and it will Days in Billing Cycle 31 take you longer to pay off your balance For example a f jf you fnakl3 note , Youw(Il pay,Aoff kf'Ar;dfyoi~{yrll~`end~~, .,.additlo(ial charges~x << r+the balance ~~~~~ pup payt~g ~I+~~,ni using this card~~ ~, shgwn,'on this ~~! est(~atadtofat ~U~~r and each rnontGl~~~~~ ~~:lstatementirn ~'; of~~r~.~'~;~~~~' ~L 1, g ~ yiou payR i.~+~~ ~ )~1 about ~t t~v~,'rz"a~ .~. ~?'c~a ~[[n`{`~~r~~zx,, Only the minimum 7 years $1,486.00 payment If you would like information about credit counseling services, call 1-877-302-8775. ~..2~. ~ a ,i ~I, ~ .. CastrNe 9 'I10 L1~51 sr'~'-'(~}.~'ioi~j.ni ~w`_Y,i"`,..ah.lF~ ,~,C•~9h EarnecitSumrtlary;~t , ,...:', '„ t~~!7#?~~~E~,Mt§s.:~ r q u~ .d.uY!~Y,`a,,!i,4r+tJ~?J.r d.WMdIa,FX;&,n r4~.ar~ +~e Previous Balance $0.00 Earning cash back with the Wahmart® Discover®r (+) Earned This Period $0.00 is easy! Simply use your card everywhere = Balance $D.00 Discover® is accepted. Remember every time you earn just $10, you 'will receive a check in your billing statement -it's automatic. Tian Post Date Date Reference Number Description of Transaction or Credit Amount FEES 08!17 08117 LATE FEE $39.00 TOTAL FEES FOR THIS PERIOD 539.00 INTEREST CHARGED 08/25 08/25 INTEREST CHARGE ON PURCHASES $17.55 !, 08/25 08/25 INTEREST CHARGE ON CASH ADVANCES $0.00 TOTAL INTEREST FOR THIS PERIOD $17.55 ~tta~.1:~ ~'~zl~y~ u~~~°~:'"~,~:~~201tl, Toj~alsyyXeaY..To~;,~0atea~~aka'~>~tsr~~6r~rs< Total Fees Charged in 2010 $78.00 Total Interest Charged in tot 0 $55.49 ;. ;;lptere§t, Char a Calcufatio~ ,~ x .f , ya, ; ... r ., k~1. ~`~.~ " ...} y. ,.,. s :.., .. . . , g .,.:. ., i.. ,.w. ...F. 1. w., ~...,4wy~ .._ .. _.,r ~.Ff....: L:_- .,.~' . ~~.: J.ui~O x~n!; ~~. ~M f• § Pr ° - ~- Your Annual Percentage Rate (APR) is the annual interest rate on your account. Type of Balance Expiration Date Annual Percentage Balance Subject To Interest Charge Rate interest Rate Regular Purchases NA 29.90% $691.12 $17.55 (Continued on Next Page) PAYMENT DUF BY 5 P M (ETON THE DUE DATE NOTICE: We may convert your payment into an electronic debit. See reverse for details, Billing Rights and other important information. 544 0005 BGI~ 1 7 22 100825 F D PAGE 1 of 3 621 1lltl0 A252 O1CtH54U4 61430 WEST SHORE EMS -ALS ~ ~ - 205 GRANDVIEW AVE SUITE 211 /~!'~.~ ' CAMP HELL, PA 17011 /~~~~ `~~ ~) Phone#: (800) 367-0512 Federal Tax ID: 23-2463002 EIv1ERCsENCY IvIEGiC:\L SER`ICF PATIENT NAME: C DIANE PALOVITZ PATIENT NUMBER: 93737 REJ CALL NUMBER: 1014964A NONE INSURANCE: DATE OF CALL: 08115/2010 TIME OF CALL: 04:37 PM CALLER: 1014964A FROM: 34;6 BLACKSMITH RD TO: HC)LY SPIRIT HOSPITAL C DIANE PALOVITZ 348 BLACKSMITH RD REASON(S) ALTERED MENTAL STATUS CAMP HILL, PA 17011 FOR ~„ S ~ TRANSPORT SST . -~ ~ INVOICE DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT ALS EMERGENCY LEVEL 1 A0999 1.0 967.62+ 967.62 20GTT TUBING A0394 1.0 14.72 14.72 ANGIOCATH (14-24) A0394 1.0 6.72 6.72 EKG ELECTRODES (1) A0396 4.0 0.80 3.20 EXTENSION SET 8" NEEDLELESS A0394 1.0 12.52 12.52 GAUZE PADS A0382 1.0 0.20 0.20 INF CONTROL GLOVES {PR) A0382 1.0 1.00 1.00 GLUCOSE BLOOD A0394 2.0 7.08 14.16 NSS 0.9% 1000cc Bag A0394 1.0 3.48 3.48 OP SITE A0394 1.0 1.92 1.92 Total Charges 1025.54 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT Denied by Insurance - HUMANA GOLD CHOICE 09/13/2010 0.00 - Total Credits 0.00 PLirASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ---~- $1025.54 RETURNED CHECK FEE - X31-00 DETACH ALONG PERFORATION AND RETURN STUB WITH PAV'MENT AMOUNT DUE 1025.54 PATIENT NAME: P.ALOVITZ, C DIANE CALL NUMBER 1014964A AMOUNT $ PATIENT NUMBER: 93737 BILLING DATE: 09/16/2010 ENCLOSED A claim for this invoice amount was denied by your insurance VISA carrier. Balance is your responsibility -please remit, . V/sa MasTe eaGd' - AND MASTER CARD ACCEPTED WEST SHORE EMS -ALS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011 s ~ M ~. o ~ ~* r O '~ r N ~ t.f) N ° a, ~ ° ~~ ~ ~~ aa~spN .~ ~ „ _~ ',t~~:.: ~'~'~ L.1 _ G c~'~ J a k_t_: C~~~ F-- - ..~ - = 1 C; ..- ~ ~ - - `~ - ; ~~ ~; cL- _ ,. : _ ~ ,_,` L ' ~= .~ _ i_,~ .~:_ _~ U =. C'') O n r ~ y r V T ~/ N ~; ~° o tiQ W o (~ ~ F'~ d U '' 1J~ o J N N v- O L ~_ •~ N ~U ~`~ a ~ coo ~~~r.. o ~, r- a~ U o ~~~a ~~o~i '~l~U N ~ ~ C RS cJUOU v