HomeMy WebLinkAbout02-29-12 (2)1505610140
REV-1500 EX (01-10)
PA Department of Revenue OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 2 1 1 3
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
1 7 9 3 0 5 3 5 3 0 1 1 1 2 0 1 2 0 4 2 6 1 9 2 5
Decedent's Last Name Suffix Decedents First Name MI
Mc DONNELL EVELYN M
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix 5pouse's First Name MI
N / A
Spouse`s Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
Q 1. Original Retum ~ 2. Supplemental Retum ~ 3. Remainder Retum (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Retum Required
QX 6. Decedent Died Testate
~ death after 12-12-82)
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 ,.._,
DAV I D R GE
TZ
ESQ G'.e':a
7 1 7 ~~4 4w~ 8..~
;
REGISTEA~~~USE~ILY f
~ ~ I-rt n ~ r .f ,
.-
First line of address p~~ r- ;
_-
WI X WENGER
&
WE I D N E R
~~_
'- ~ `' ,,
x
~'
-
Second line of address a~ , ~, -.
~ ~ r : ~
=,
rrt
P O BOX 8 4 5 :
r. ~ ~"
~
City or Post Office State ZIP Code DATE FILED
H A R R I S B U R G P A 1 7 1 0 8 0 8 4 5
Correspondent'se-mail address: DGETZC~WWWPALAW.COM
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
enno~ce
10 VICTORIA WAY CAMP HILL PA 17011
SIGNATURE O P ARE O R T AN gR~E/.P.R~ESENTATIVE DATE
nnnaFCC ""-"-+ '
WIX WENGER & WEIDN~R, P.O. BOX 845 HARRISBURG PA 17108
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610140 1505610140
1505610240
REV-1500 EX
Decedent's Social Security Number
Decedents Name: EVELYN M. MCDONNELL 1 7 9 3 0 5 3 5 3
RECAPITULATION
1. Real Estate (Schedule A) ........................................ ... 1. -
2. Stocks and Bonds (Schedule B) ................................... ... 2. -
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3.
4. Mortgages and Notes Receivable (Schedule D) ........................ .. 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 5 7 7 6 • 6 $
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6.
7. Inter-Vivos Transfers & Miscellaneous Nan-Probate Property
(Schedule G) ^ Separate Billing Requested ..... .. 7.
8. Total Gross Assets (total Lines 1 through 7) ......................... .. 8. 5 7 7 6 , 6 $
9. Funeral Expenses and Administrative Costs (Schedule H) ............ ...... 9. 1 5 4 9 4. 0 8
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ....... ...... 10. 1 $ 0 5 9 1 1 7
11. Total Deductions (total Lines 9 and 10) ......................... ...... 11. 1 9 6 0 $ 5 . 2 5
12. Net Value of Estate (Line 8 minus Line 11) ...................... ...... 12. - ~ 9 0 $ 0 $ , 5 7
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ................ ...... 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) ................ ...... 14. - 1 9 0 3 0 $ . 5 7
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2)X.0 _ 0 . 0 0 15.
16. Amount of Line 14 taxable
at lineal rate X .045 0 , 0 0 16.
17. Amount of Line 14 taxable
at sibling rate X .12 0 0 0 17.
18. Amount of Line 14 taxable
at collateral rate X .15 Q 0 0 18.
19. TAX DUE .......................... ..................... ..... ..19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L 1505610240
1505610240
0. 0 0
0. 0 0
0. 0 0
0. 0 0
0. 0 0
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 12 113
DECEDENT'S NAME
EVELYN M. McDONNELL
STREET ADDRESS
10 VICTORIA WAY
CITY STATE ZIP
CAMP HILL PA 17011
Tax Payments and Credits:
t • Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(1) 0.00
Total Credits (A + B) (2) 0.00
(3)
(4)
(5)
0.00
0.00
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred : ...................................................................... ^ 0
b. retain the right to designate who shall use the property transferred or its income; ............................... ^ 0
c. retain a reversionary interest; or ................................................................................................ ^ 0
d. receive the promise for life of either payments, benefits or care? ....................................................... ^ Q
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ^ Q
3. Did decedent own an "intrust for" orpayable-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 i
3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory 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(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1508 EX + (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSItS, 8c MSC.
IN RESIDENT 0 ~ DENTRN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
EVELYN M. McDONNELL 21 12 113
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION VALUE AT DATE
OF DEATH
1. MEMBERS 1ST FEDERAL CREDIT UNION CHECKING ACCOUNT 340028-11 3,610.85
DOD BALANCE: $3,610.75; ACCRUED INT.: $.10
2. MEMBERS 1ST FEDERAL CREDIT UNION CHECKING ACCOUNT 349768-11 2,078.49
DOD BALANCE: $2,078.49; ACCRUED INT.: $0
3. MEMBERS 1ST FEDERAL CREDIT UNION SAVINGS ACCOUNT 340028-00 82.06
DOD BALANCE: $82.05; ACCRUED INT.: $.01
4. MEMBERS 1ST FEDERAL CREDIT UNION SAVINGS ACCOUNT 349768-00 5.28
DOD BALANCE: $5.28; ACCRUED INT.: $0
VALUATION LETTER ATTACHED
.TOTAL (Also enter on line 5, Recapitulation) I $ 5 776 68
(If more space is needed, insert additional sheets 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
EVELYN M. McDONNELL 21 12 113
Decedent's debts must be reported on Schedule T.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. H. MERRITT HUGHES FUNERAL HOME, WILKES-BARRE, PA g~899.28
2. PATRIOT NEWS, HARRISBURG, PA (OBITUARY) 211.00
3. COOPER'S CATERING, SCRANTON, PA (FUNERAL LUNCHEON) 1 257.35
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s) SHIRLEY KINER
Street Address 10 VICTORIA WAY
City CAMP HILL State PA Zip 17011
Year(s) Commission Paid:
2, AttomeyFees: WIX, WENGER & WEIDNER (ESTIMATED)
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Ciaimant SHIRLEY KINER
Street Address 10 VICTORIA WAY
City CAMP HILL State PA Zip 17011
Relationship of Claimant to Decedent DAUGHTER
4• Probate Fees: CUMBERLAND COUNTY REGISTER OF WILLS
5. I Accountant Fees:
6. ~ Tax Retum Preparer Fees:
7. I CUMBERLAND COUNTY REGISTER OF WILLS -TAX RETURN FILING FEE
8. CUMBERLAND COUNTY REGISTER OF WILLS -INVENTORY FILING FEE
500.00
1,000.00
3,500.00
96.50
15.00
15.00
'TOTAL {Also enter on Line 9, Recapitulation) I $
If more space is needed, use additional sheets of paper of the same size.
REV-1512 EX+ (12-08)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
EVELYN M. McDONNELL 21 12 113
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. HOMELAND CENTER, HARRISBURG, PA 39.86
2. DEPARTMENT OF PUBLIC WELFARE CLASS 3 CLAIM 27,648.22
3. DEPARTMENT OF PUBLIC WELFARE CLASS 5.1 CLAIM 152,903.09
tOTAL (Also enter on Line 10, Recapitulation) I $ 180 591 17
It more space is needed, insert additional sheets of the same size.
REV-1513 EX+ (01-10)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF: FILE NUMBER:
EVELYN M_ Mr•.h(~NNFI I
~~ ~~ ~~~
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS (Include outright spousal distributions and transfers under
Sec. 9116 (a) (1.2).]
1. SHIRLEY KINER Lineal 0.00
10 VICTORIA WAY
CAMP HILL, PA 17011
2. FRANCES LANGAN Lineal 0.00
4403 ROYAL OAK ROAD
CAMP HILL, PA 17011
3. NANCY YALETSKO Lineal 0.00
5019 LINDEN AVENUE
PHILADELPHIA, PA 19114
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:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
~~ nivic aNa~c w nacuCU, we auumonai sneers or paper of the same size.
~~`~~~ i~~ ~xti~r ~~~~~me~~
4 ~
OF ~
~~ __
EVELYIV bICDONNELt y?~ ~ `='''''
1, EVELYN dK'DONNELL, o~ the borough o~ We~s# P.i##~s#on, County ~ ~ N r
~+,'
o~ Luzenne and Conmonwea.Eth o6 Pennsy.~van.ia, do hereby mane, pub.E
.csh N
r p
`-n
and deefane #h.ia to be my Last wtk.~ and Te.etament, hereby nevok-cng
a~.Y pnioa (U.C~.Q.s and Cod.Lei.P.a heretobone made 6y me.
FIRST: 1 d.inect my Exeeu#oa, hene.cnab#ea ,tamed to pay the expeneee
o~ my ~a~st <:f#ne~ and ~uneaa~ ass Boon ass pnac#.Ccab.~e bo.~~ow.i.ng my death.
SECOND: 1 gave, dewe,ae and bequeath a.~Z o6 my pnopex#y, rtea.~, pea~sona.~
and mixed, o~ a~ha#.aoeven na#une and whene.aoeven e.i#ua#e at the #.ine ob my
death to my hwsband, FRANCIS L. MCDONNELL.
THIRD: In the even# that my hcuband ~hou.2d no# ~surtvtve me, on ~.n .the
event #ha# aye ehou.Cd dLe undea .acceh e~.xcums#aneea ab #o nendea .Ct -impo~.ib.Ye
to deteami.ne who d.Led ~.vc~#, ok .cn the event #hat wee .ahou.~d d~.e w.i#h.in
3-ix#y (6C) days o~ each o#hex,then, .cn #hat even#, I g.lve, dev-use and
bequeath a.~.~ o~ my paopea#y, o~ wha#evek k.cnd and whexeven .~oeated that
I avn a# the time op my death, to my ehE.~dnen, SHIRLEY KINER, NANCY YALETSKD,
and FRANCES LANGAN, .!n equae ehanes, ahaxe and ahane aP.~1ze.
FOURTH: In the event that any o6 my eh~i,2dnen ~shou#d not euxv.Cve me,
but ehou.Cd d.ie buRvLved by a eh.i.Cd oh eh.c.edhen, then the eharte wh.Lch ~sa<.d
eh.i~fd w»u.~d have #aken hexeundea ~ha~.E pa.a~s #o hvs on he-t eh.i.~d on eh-ifdnen
.cn equal .shartea, .share and ~shane a.~.i.ke.
In the event #hat any oh my ch-c.Pdnen ~shou~2d d.ie w~i#hou# ch,i.•ldxen, #hen
the ehaae he ox she wouYd have #aken hereunder, ~sha.Cl pa.ab#o my nema.in.ing
.sunv.iv.tng ch~i.~daen, <n equa4 ahaneo, 4hare and .share a.~~.ke.
FIFTH: 1 nomtna#e, con.a#itute and appoint my husband, FRANCIS L.
MCDONNEL, Exeeu#or o~ #h.us, my La.b# GI.i,LY and Te~s#ament. In the event that
my .aa.id husband ~shouPd not euh.v.ive me, or be unw.e,tt.cng or unab.Ee to nerve gor
any reason, then I hereby nominate, eows#,L#ute and appo~.nt my daughte2, SHIRLEY
KINER ae con#,i.ngent Ezeuctr.Lx o~ th.us, my Last Gl.c,e1 and Te3tamen#.
Ne<then my Ezecuto2 non my cont.Cngent Execu.ttii,x 4ha.~.t be aequ.viced #o
guan~h bond on Sure#.ied .i.n any 1rvc.usdtc.ti.on.
IN UJI7NESS GlHEREO~, I have hereunto set my hand and sea. th.cs
'a' day o4 _- 1986.
'r'-- v". '_.; ~~!" ;~ir %~ .~: ~.-.1~ {SEAL )
V LY ~ NN LL
S~.gned, sea.~ed, pub.~.~hed and deceaxed by the above named Testator,
EVELYN MCDONNELL, ae and boa her La~St Gi~il.~ and Testament, who, at hen
request, ~.n hen presence and ~.n the presence o~ each other, we have hereunto
subscr.c.bed our names as w.~tnesses.
t----- ~,~`~+~
.. re,d.idcng at ~.t.
~-.
-2-
ACKNOWLEINT OF 7ESTA70R
COb4U0NUJEALTH OF PENNSYLVANIA
COUNTY OF LUZERNE SS:
I. EVELYN MCDONNELL, 7ehtat~c.Lx, w~hoee name .us .e.Lgned to the
boaego.cng .i.n~stnument, hav.cng been duly qua.t.LbZed accoad.cng to .taw,
do hexeby acknow.2edge #hat I a<.gned and exeeuxed the boneoo.cng .Lnotieument
as and bon my La,at W.eet and Testament; that I .ai.gned ~.t wtiCP~cng.fy; and
that I s.Lgned .ct as my base and vo.Cuntany act box the purposes thehe.Ln
expressed.
EVELYN NNELL
Swoon on abb.vcmed to and
aehnow.tedged 6ebore me, by
EVELYN AICDONNELL, Testator,
thtby~day ob June, I98b.
No y <c
:ale ' .. .. . _
-3-
AFFIDAVIT OF WITNESSES
CO~+~'.lONWFALTN OF PEUNSI/LVANIA
COUNIY OF LUZFRNI: SS:
,,
,~- ~ /~ I- -
~~'%Il~7.#7 ',~~<9h~/!I. and ~. .- scs`
the w.itne~s.ae~s whoae name,a ane .aubbenibed to .the %oaego.ing documen#, 6e,cng duty
qua.C.iS.ied aeeond.eng to taw, do depose and say .that we were pnehent and .aaw
the Te.atatic.cx ~s-ign and execute the <nstnument as hex Last W-i.P.f and Tehtanrer~ct;
that .ahe ~si.gned .it w.i.P~-ingly and that ehe executed ~..t a.~ hen 6nee and vo.~untaxy
act boa the puapoeee thene.cn exp~ce~s.aed; and each ob u~ <n the hean.cng and
a.ight ab the Tebta#n.tx .a-i.gned the W.i.P.C a,a w.Ltne.aae~s; and that to .the 6e.at
ob oux know~@edge, the Tedtatie.ix wa.a, at .that time, e.ightee (18) oa mope
yeaa~s o4 age, ob .eound mind and undue not eowsxica.int o2 undue .inb.fuenee.
~°` ~"
Swokn oa a6b.inmed to and
aefznow.eedged bebone me, by
.:~ - ~,~ anyd
i !/'ci ~ th.c~ /~~
day o6 June, 1986.
Notaay P .cc
-4-
MEMBERS 1st
FEDERAL CREDIT UNION
REGULAR SAVINGS ACCOUNT:
Account Number/Suffix 340028-00 349768-00
D-ate Account Established 09/26/2008 02/20/2009
Principal Balance at Date of Death $82.05 $5.28
Accrued Interest to Date of Death $.01 $.00
Total Principal and Accrued Interest $82.06 $5.28
Name of Joint Owner None None
CHECKING ACCOUNT:
Account Number/Suffix 340028-11 349768-11
D-ate Account Established 09/26/2008 02/20/2009
Principal Balance at Date of Death $3,610.75 $2,078.49
Accrued Interest to Date of Death $.10 $.00
Total Principal and Accrued Interest $3,610.85 $2,078.49
Name of Joint Owner None None
M B 1sT FEDE~~~~L~~C~~RQQEDIT NIO
.Danielle .Kline
Lending Insurance Support Specialist
February 2, 2012
Estate of: EVELYN MCDONNELL
Date of Death: 01/11/2012
Social Security Number: 179-30-5353
5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 wwwmemberslst.org
~~~ Po
R
3 °- m Q
m m n ~
m
° ~ < D
1 ~ z ~
m m O Z
C D T ~
D _~ ~ o
D ~ a m
m
~ N ~
fi ° ~ !ZA
a ~
D D
• : O O
• a ~
' D D
m m
O
D : :
~ ~ O O O
~ ~ ~ ~ ~
D n ~ N. O
° mp c
~~
° mx~~
_ ~
~ O ~+
~ ~
g m g
W A
1 n~
i
n ~ O D -a o 0 oc0 m ~ ga
. ~ ~ m~
~ ° Q c S ~° to ~ w O m o~° T -° ~ O ~' ~ ~ ~ m ~ "° o
~- ~o~.z °.~ ~ ~ -~ ~o ay~o ° zom~ m z m C ga~ .,°~.^ .
pdi nm~m s'~'S m ~•~r~ir O ~'~~~~fO~~ ~~c~0~~ 8: °D
m g ~ ~ ~ m ~ m m ~ ~ ~ ~ '" `- $ : m tNr1 q~ ern
N 1Q ~ ° b a f. 3
n ~ n -i
~ a v ~ ~c ~gm O ~~~~~. ~ m~~7~v
n ° m T O ~ m ~ ~ ~jm0 nai o~°e3'~~gTa~': ~ s ~'~ZD
~ ~ ~ ~ { o ~ a~ a ~ ~ ~, ~ ~~~
m a 4a3 R° 32 °~G
!~ 3 0' rq 3 ON
Q ~~°~ D ~ fcdNtn
o ~oag3• T ~g',,Dn
N N N N N N N N N N N N N N N N N N ~' ~~ C m N N ~i
O y~
~~ ~
~ N
B °° !~
o~ ^~
~ ~o
ll1 N L! N ill N N N N N N N •
J !-' N W
~ O W N
O ~P °1 °
O O O O
O O O O
O O O O
x Am N•J~O ~'O m ~~SQS D ~ ~ ~ O T
c m2 0 °< ° ~j A m,,, c
q ~ ~. a S rp ~ m m o ~ m •~ ~• H (] ~ U] ~ 3 ~ ~ ~ ~ ~d g ~ 3 ~ O °
~ 4a= ° ~ ~ m ~ z a~ga8. ~ '~ rn ~ m Q. ~ ~ ~ ~ ° ~ ~ o ° ~ '~ s ~ N j 7~GJ
y a~o o -_ ~~ cou m o~,~~o c c n $~ ~ .. Z O~~~° a ~ O~ m< o ~ N
i3 c e a4 O a °~ m m 33 ~
~ ~ `- ~ 3 ^ m -< ~ ,~ ° ~ N ~ g ° ~ Si a ro rt rn m m o ~+ ~ ~ O
A ~ ~ : ~ - ~' c m =~ s -~ m ~ ri a' .:~ O ~ ° 'a ~' ~ a A 3 m < 9' 47
w ~M - v ~~~C~s~ ~° O ain ~ ~ ~ fi ~ c ~' n ~ ~ ~ Dim y;~
~ ~. g "' ~mg~'~ m a0o c° W N Q r ~ ~ 3r I t=i y3 xx
r
. ~ Qa '~VO~S-~ .c m ~m ~ f~! Y > on ~~..
~ LS o°wOm w p m$ tS ~ ~
g ~ °° ~m x
m
~ m ~~~~~0 3 m m Rt $ ~n
n I~ S't° r-~ 3 ~ to ~ ~ ~ ~ z
(] N m ~~ 2' 3 O N N N N N N N N N in os vi an v+ m p ~~ P1
O m ~- N
'~' ~ C d c°~~c °$- ? W m~ c 7 r O lfi N U1 Ul ~O N O D_ v F--' ,.
~x n 3. S ~ ~~~X-• Lt r o 0 0 o N o o ~° to o 0 0 ~~
~ s ~ z
F; 0 s ~~ X00--~ m ~ °~- o o ~ o o o N o 0 0~ 70~
~, ,~ 3 m°n,~a,.. = n oo ~ o O owooon~
~.+. x rn-3mm~$ m N N
'C1 p W ~ a~°~ S o ~• C •i ~ N N~ tt F-l
~ ~ = m c ~r a' 3•.~ m ~ O ~' ~t N
~ ~F-'a~ '$ fv_amp...- _ ~ N iP o 4
r "v ~ ~ ~,~.m a ° ~ O o su
~ N~ g o~ m W? ~ O O N ~ m ~
.. f... n O O C O W ~ i
r 'm w t7~ ?~ ~ ~. 'ti ~ O I Q1
° o m~ T ~• ° ~ N N 7 K
~ a a4 g~3 { ~ ~ I
rR ~ r' a =i W ~ t° ~ D
a ~ m --~r•`~3 ~ ao o ~
0'-' lp l0 D lP tQ OD
o w m O ~ a•f0 r 10 SN l° °1 iN
s ii ? 7 m ~O• ~ N ~ N < O
° ommS O W W N
o ~ ~ N
°p _ .
.. _ _ :. • ~ ~ - ' Of.~Y ~'Cf•IG~ DY YG16EY5". - ~ .
~fl ...9
.... .. a.,..,,.
~.:,~ .. .
• -! w
Party Name: ~ '
.Date Bc Time: - (~ ~ - - ~ ~. .
Appetizers: - ~ - ~ ~ ~ .
~Entree.'s: at $ ~ ~~ $
at $ ~ - X07
... .. at$ -. $ _
... - .Total. Entrees:
...
Cake:-
.
~
..
~ ~ _
Nan :Alcoholic.Punch _ Gallons. - ~ ~ ~ $ ~ - .. - -
Non-Alcoholic Drinks: ~- ~ $
_ ... ~ . 6~lo P.A. Sales Tax: -- $• ~ ~ ,
-
Bar (G~neraQ ~ ~ ~ . ~ ~. • ... $
Party Package:.. :Persons ~ :.at- ~ _ _ . $ ~ - .
.Bartender: ' ..... ~ $ . .. .
Deposit. ~ ~ ~ .. ~ $
Miscellaneous Costs: ~ ~ ~ .. ~ ~ -..._.. .. - - $ `..-
Balance Due: ~ - ~ ~$
Payment: ~ Cash . ~ - ~ • ~ .
^Credit Card - - ~ • -
. Check # _ ~~ ~ ~~ .. -
. _ _ . .~1 MC /VISA .
Expiratl~on :.. .
i'F Di.~/tSiAw o f CCO~E~'S SCR foDd FbusE ~Ot N. WRSYIiwgtOwAi/Cwtct SC1~RwtOw-P.4 YSSO~ ,•
RECEIPT FOR PAYMENT
GLENDA FARNER STRASBAUGH Receipt Date: 1/26/2012
Cumberland County - Register Of Wills Receipt Time: 14:29:50
One Courthouse Square Receipt No.: 1068548
Carlisle, PA 17613
MCDONNELL EVELYN
Estate File No.: 2012-00113 ---
Paid By Remarks: KINER HENRY R
HEA
------------------- ----- Receipt Distribution
-----
--------
-------
----
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST
WILL 30.00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE
JCS FEE 15.00
8.00 CUMBERLAND
CUMBERLAND COUNTY
COUNTY GENERAL
GENERAL FUN
FUN
AUTOMATION FEE 23.50
-------
5_00 BUREAU OF RECEIPTS
CUMBERLAND COUNTY & CNTR
GENERAL M.D
FUN
Check# 5531 ---
---
$81
50
Total Received..... .
.... $81.50
pennsylvania
DEPARTMENT OF PUBLIC WELFARE
February 7, 2012
WIX WENGER & WEIDNER PC
DENISE B WILLIAMSON LEGAL ASST
508 N SECOND ST
PO BOX 845
HARRISBURG PA 17108-0845
Re: Evelyn Mcdonnell
CIS -# : 590221711
SSN: ###-##-5353
Date of Death: 01/11/2012
Dear Ms. Williamson:
Please be advised that the Department of Public Welfare maintains a claim in the
amount of $180.551.31 against the above-mentioned estate. This claim is for restitution
of medical assistance granted on behalf of the decedent for which the Probate Estate is now
responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective
August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the
Department's itemized statement of claim.
A portion of this medical expense, namely $27.648.22, was incurred during the last
six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of
the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the
claim, namely $152,903.09, is to be entered as a priority Class 5.1 claim against the
estate.
Please acknowledge receipt of this letter and advise whether the Commonwealth's
claim is admitted and when payment may be expected. If the estate accounting is
complete, please provide a copy. If the estate contains real estate, please provide
copies of the deed, the latest tax assessment, and a current appraisal, if available.
Sincerely,
~ Y~
Nathan L. Snyder
TPL Program Investigator
717-772-6266
717-772-6553 FAX
Enclosure
Bureau of Program Integrity (Division of Third Party Liability ~ Recovery Section
PO Box 8486 ~ Harrisburg, Pennsylvania 17105-8486
COMMONWEALTH OF PENNSYLVANIA
BUREAU OF PROGRAM INTEGRITY
DIVISION OF THIRD PARTY LIABILITY
RECOVERY SECTION
PO BOX 8486
HARRISBURG, PA 17105-8486
February 7, 2012
STATEMENT OF CLAIM SUMMARY
NAME Estate of MCDONNELL, EVELYN
I D 590 221 711
MEDICAL CLASS 3 CLASS 6 TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 27,626.32 152,866.29 180,492.61
DRUG 21.90 36.80 58.70
REIMBURSEMENT TO DPW 27,648.22 152,903.09 180,551.31
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN - 23-6003113
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 7, 2012
STATEMENT OF CLAIM
NAME MCDONNELL,EVELYN
ID 590 221 711
HOMELAND CENTER
1901 N 5TH ST
HARRISBURG PA 17102
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
07!01108 - 07!31/08 03/02/09 55090564307850001 55090564307850001 5,512.11 4,128.27
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
08/01/08 - 08/31!08 03/02/09 55090564307860001 55090564307860001 5,512.11 4,128.27
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
09101/08 - 09!30/08 03/02/09 55090564307870001 55090564307870001 5,334.30 3,949.80
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
10/01/08 - 10!31/08 03/23/09 55090774026320001 55090774026320001 5,512.11 3,926.77
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
11/01/08 - 11/30/08 03/23/09 55090774026630001 55090774026630001 5,334.30 3,754.80
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
12/01/08 - 12!31/08 03/23/09 55090774026980001 55090774026980001 5,512.11 3,926.77
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
01/01/09 - 01/31/09 04/13!09 55090974242110001 55090974242110001 5,512.11 4,048.45
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
02/01/09 - 02/28/09 04/13/09 55090974242450001 55090974242450001 4,978.68 3,498.80
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
Page 1 of 8
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 7, 2012
STATEMENT OF CLAIM
NAME MCDONNELL,EVELYN
ID 590 221 711
HOMELAND CENTER
1901 N 5TH ST
HARRISBURG PA 17102
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
03/01/09 - 03/31/09 04/20/09 55090974242850001 55090974242850001 5,504.05 4,031.45
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
04/01/09 - 04!30/09 05/18/09 20091214186550001 20091214186550001 5,354.10 3,881.50
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
05/01/09 - 05/31/09 06/15/09 20091524118820001 20091524118820001 5,532.57 4,059.62
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
06!01/09 - 06/30109 07!20109 20091824097250001 20091824097250001 5,354.10 3,881.15
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
07/01109 - 07/31109 11/08/10 55103064234880001 55103064234880001 5,532.57 4,122.24
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
08101109 - 08131/09 11108/10 55103064235240001 55103064235240001 5,532.57 4,122.24
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
09/01/09 - 09/30/09 11/08/10 55103064235670001 55103064235670001 5,354.10 3,941.75
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
10/01/09 - 10/31/09 11/15/10 55103144231570001 55103144231570001 5,532.57 4,179.28
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
Page 2 of 8
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 7, 2012
STATEMENT OF CLAIM
NAME MCDONNELL,EVELYN
ID 590 221 711
HOMELAND CENTER
1901 N 5TH ST
HARRISBURG PA 17102
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
11/01/09 - 11/30/09 11!15/10 55103144231930001 55103144231930001 5,354.10 3,996.95
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
12/01/09 - 12/31/09 11!15110 55103144232380001 55103144232380001 5,532.57 4,179.28
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
01101/10 - 01/31/10 11/29/10 55103274232110001 55103274232110001 5,532.57 4,481.80
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
02/01110 - 02/28110 11129110 55103274232660001 55103274232660001 4,997.16 3,897.88
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
03101!10 - 03131N0 11/29110 55103274232870001 55103274232870001 5,532.57 4,472.50
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
04/01/10 - 04/30110 12/13110 55103424151590001 55103424151590001 5,354.10 4,336.16
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
05/01110 - 05/31/10 12/13110 55103424152000001 55103424152000001 5,532.57 4,529.54
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
06!01110 - 06/30110 12113110 55103424152390001 55103424152390001 5,354.10 4,336.16
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
Page 3 of 8
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 7, 2012
STATEMENT OF CLAIM
NAME MCDONNELL,EVELYN
ID 590 221 711
HOMELAND CENTER
1901 N 5TH ST
HARRISBURG PA 17102
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
07/01110 - 07/31!10 10/17/11 55112844199700001 55112844199700001 5,532.57 4,664.08
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
OS/01/10 - 08/31110 10117111 55112844200080001 55112844200080001 5,532.57 4,664.08
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
09/01/10 - 09/30/10 10/17/11 55112844200510001 55112844200510001 5,354.10 4,466.36
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
10/01/10 - 10/31/10 10124111 55112924129370001 55112924129370001 5,532.57 4,526.44
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
11/01/10 - 11/30/10 10124/11 55112924129780001 55112924129780001 5,801.40 4,858.16
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
12/01/10 - 12/31/10 10/24!11 55112924130170001 55112924130170001 5,994.78 4,526.44
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
01/01/11 - 01!31!11 10/31111 55112994127940001 55112994127940001 5,994.78 4,816.79
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
02/01/11 - 02/28/11 10/31111 55112994128230001 55112994128230001 5,414.64 4,210.25
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
Page 4 of 8
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 7, 2012
STATEMENT OF CLAIM
NAME MCDONNELL,EVELYN
I D 590 221 711
HOMELAND CENTER
1901 N 5TH ST
HARRISBURG PA 17102
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
03101!11 - 03/31111 10131/11 55112994128530001 55112994128530001 5,994.78 4,816.79
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
04/01/11 - 04/30/11 11/07111 55113054125130001 55113054125130001 5,801.40 4,436.41
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
05!01111 - 05/31/11 11/07/11 55113054125520001 55113054125520001 5,994.78 4,632.65
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
06/01/11 - 06130/11 11/07111 55113054125880001 55113054125880001 5,801.40 4,436.41
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
07101/11 - 07/31/11 08!15/11 20112134213180001 20112134213180001 5,994.78 4,543.99
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
08!01111 - 08/31111 .09/19111 20112444104700001 20112444104700001 5,994.78 4,543.99
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
09/01/11 - 09130/11 10/24111 20112764119320001 20112764119320001 5,887.20 4,350.61
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
10!01111 - 10/31/11 11/21111 20113054162800001 20113054162800001 6,083.44 4,632.65
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
Page 5 of 8
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 7, 2012
STATEMENT OF CLAIM
NAME MCDONNELL,EVELYN
ID 590 221 711
HOMELAND CENTER
1901 N 5TH ST
HARRISBURG PA 17102
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
11!01111 - 11130!11 12/19/11 20113354113150001 20113354113150001 5,887.20 4,436.41
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
12/01111 - 12/31111 01/30112 52120184291610001 52120184291610001 6,083.44 4,632.65
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
01101112 - 01/11/12 02/01/12 20120324230860001 20120324230860001 1,962.40 486.02
DIAGNOSIS 1 : 56211 DIVERTICULITIS OF COLON
DIAGNOSIS 2 : 0
PROC CODE : 000000
PROVIDER SUB TOTAL HOMELAND CENTER 236,737.21 180,492.61
03 000757594 0001
Page 6 of 8
1
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 7, 2012
STATEMENT OF CLAIM
NAME MCDONNELL,EVELYN
I D 590 221 711
BROCKIE PHARMATECH
209 N BEAVER ST
YORK PA 17403
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
07112108 - 07/12108 11/10/08 25082875521540001 250$2875521540001 5.87 5.87
DIAGNOSIS 1 : 0
NDC CODE : 00182108211 ANTI-DIARRHEAL 2 MG CAPLET - ANTIDIARRHEALS
03/16109 - 03/16/09 04113/09 25090755249750001 25090755249750001 6.59 6.06
DIAGNOSIS 1 : 0
NDC CODE : 00904772512 ANTI-DIARRHEAL 2 MG CAPLET - ANTIDIARRHEALS
06101/09 - 06/01/09 06/29/09 25091525246330001 25091525246330001 6.59 6.06
DIAGNOSIS 1 : 0
NDC CODE : 00904772512 ANTI-DIARRHEAL 2 MG CAPLET - ANTIDIARRHEALS
04/09/10 - 04/09/10 05103/10 25100995254600001 25100995254600001 4.80 4.80
DIAGNOSIS 1 : 0
NDC CODE : 00904772512 ANTI-DIARRHEAL 2 MG CAPLET - ANTIDIARRHEALS
09102110 - 09/02/10 09127110 25102455396370001 25102455396370001 14.01 14.01
DIAGNOSIS 1 : 0
NDC CODE : 00067399830 LAMISIL AT 1% CREAM - ANTIFUNGALS
11119!11 - 11/19/11 12/19/11 25113235313140001 25113235313140001 9.66 9.66
DIAGNOSIS 1 : 0
NDC CODE : 00713016550 ACEPHEN 650 MG SUPPOSITORY - NON-NARCOTIC ANALGESICS
12/13/11 - 12/13/11 01/09112 25113475331720001 25113475331720001 10.18 8.12
DIAGNOSIS 1 : 0
NDC CODE : 00904772512 ANTI-DIARRHEAL 2 MG CAPLET - ANTIDIARRHEALS
Page 7 of 8
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 7, 2012
STATEMENT OF CLAIM
NAME MCDONNELL,EVELYN
ID 590 221 711
BROCKIE PHARMATECH
209 N BEAVER ST
YORK PA 17403
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
12!23!11 - 12!23/11 01/16112 25113575568700001 25113575568700001 10.18 4.12
DIAGNOSIS 1 : 0
NDC CODE : 00904772512 ANTI-DIARRHEAL 2 MG CAPLET - ANTIDIARRHEALS
PROVIDER SUB TOTAL BROCKIE PHARMATECH
24 100750872 0009 67.88 58.70
Page 8 of 8
Statement
HOMELAND CENTER
1901 N FIFTH STREET
HARRISBURG, PA 17102
Telephone: (717) 221-7900
Statement Date: 02/01/2012
SHIRLEY KINER
10 VICTORIA WAY
CAMP HILL, PA 17011
Re: EVELYN MCDONNELL
Account Nr: 2259
Date Description Days Rate Charges Payments
Quant
---------------------------------------------------------------------
Balance
BALANCE FORWARD 1,650.38 1,650.38
01/12/12 PAYMENT 1,650.38 .00
01/01/12 RESIDENT INCOME 39.86 39.86