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HomeMy WebLinkAbout05-09-12aJ 1505611188 REV-1500 EX (g2-tl)(FI) ~~ Pennsylvania ORRCIAL USE ONLY PA Dapartmentofflwenup munwrwv.s County Cade Year Flle Number Bureau of lntlividuelTazas INHERITANCE TAX RETURN Po sox zaoeot Harriabarg, PA tlt2a-0801 RESIDENT DECEDENT 27, 11 1355 ENTER DECEDENT INFORMATION $ELOW - Social Sacudty Number Date of Death MMDDYYYY Date of Birth MMDDYYW 09 24 2011 02 06 1924 Decedent's Last Name Bellomo Suff1x pecedent's Rrst Name MI E Florence (If Applicable) Enter Surviving Spouse's Informatlon Below Spouse's Last Name Suffix SPOUSe's Fret Name MI Spouse's Social Secudry Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPADPRIATE OVALS BELOW - ~ 1. Odginal Return p 2. Supplemental Return p 3. Remainder Return (Date of Death Prior to 12-73-82) O 4. Limhed Estate O 4a Future Imerest Compromise (date of (~ 5. 1=ederal Estate Tax Return Required tleazh attar 72-72-62) ~ 6. Decedern Died Testaze Q 7. Decedern Malmainetl a Living Trust B. 'rota) Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trus[) p 9. Litigation Proceeds Received O 70. Spouael Poverty Credit (Date of Death O 71. E=lection toTax under Sec. 97t3(A) Between 12-37-87 and 7-7-95) (Attach Schedule O) CORRESPONDENT -This sectlon must be completed. All Correspondence and Confidential Taz InfarmaLOn Should be Directed to: Name Daytime Telephone Number Robert C• Saidis, Esquire 71'7 243 6222. Rrst Line of Address Saidis, Sullivan & Rogers Second Line of Address 26 West High Street City or Post Office Carlisle gEGISTEa OF W ILLa USE ONLY h.] C[J 1t) ^.~ C1.IT I I~1 ~ii__( 1 ~ti Il~~ r" I ar _. IC3 ~t€FILeo -" -r' _ -': State ZIP Code ~ _., ~~ , ~ = i=~; PA .17013 .., ~'~ correspondents e-mau address: rsaidis(a9ssr-attorneys.com _ Under panaltiee of perjury, I tlaclare that l have azaminetl this return, including aecompsnyingaehadulas and statements, and ~to the beat of my knowletlpe and belief, it is true, comctand complete. Declaration of the preparer stherthan paroonsl nprasentativa is based on all information of wh ich preparar has any knawbtlge. J Carlisle, PA 1701'3 ' PLEASE 115E ORIGINAL FORM ONLY Side 7 1505611188 15[15611188 J i 1 Rev-1500 EX (R) ~ DecedenraNamet Florence E Bellomo RECAPITULATION ~ 1. Real Estate (Schedule A) ...................................... ... 1, 2. Stocks and Bonds (Schedule B) ...... .... ....................... ... 2. 3. Closely Held Corporation, PartnersNp or Sole-Proprietorship (Schedule C) ... ... 3, 4. Mortgages and Notes Receivable (Schedule D) ....................... .. 4. ' 5. I Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) ..... .. 5. ' 6. Jointly Owned Property (Schedule (•~ O Separate Billing Requested .... .. 6. 7. In[er-Vivos Transiers & Miscellaneous Non-Prribaze Property i (Schedule G) D Separate Billing Requested .... .. 7, ' B. I Total Gross Assets (total Lines 1 through 7) .......................... -- .. B, 9. Funeral Expenses and Administrative Costs (Schedule H) ............ ...... B. 3 , 7 5 9 • 8 0 10. Debts of Decedem, Mortgage Liabilities, and Liens (Schedule i) .. ..... ...... 10. 11 D , 411 • B 2 11. Total Deductlons (total uses s and 10) ........................ ...... 11. 1.14 ,171 • 6 2 12. Net Value of Estate (Line a minus Line 11) ....................... ...... y2. D • D D 13. Charitable and GovemmeMai Bequaste/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................. ...... 13. D • D D 14. Net Value Subject to Taz (Line 12 minus Line 13) .....:............ ..... 14. D • D D TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers untler Sec. 9116 1fi. Amount of Line 14 taxable at lineal race X .045 D• D D 1 g. i7. Amount of Line 14 taxable azsiblingrateX.12 D•DO 17. 18. Amount of Line 14 taxable at collateral raze X .15 D • D D 1g, 19. TAX DUE ........................ .... .. .. .. ........ .... ..... . 19. 1505611288 Decedent's Social Secudty Number 140 14 1234 0. OD o•oo D•oD 0.00 828.•00 5,346.58 o.Do 6,174.58 0.00 o.Do o.oD 0.OD o•DD 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1505611288 Side 2 O 1:505611288 J Rev-1590 EX (Fl) Page 3 norndonYe Cnmelete 4ddress' File Number 21 11 1355 DECEDENPS NAME Florence E. Bellomo STREET ADDRESS 11 North Thrush Drive CITY Carlisle STATE PA ZIP 17015 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. Qedits/Paymarns A Prior Paymerns 0.00 B. Discount 0.00 Total Credtts (A + B) 3. Irneresl 4. If Line 2 is greater than Line 1 + Line 3, emer the difference. This is the OVERPAYMENT. FIII in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3Is greazerthan Une 2, enterthe difference. This is the TAX DUE. (1) (2) U.UU (3) 0.00 (a) (s) 0.00 _._. Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN'fHE APPROPRIATE BLOCKS 1. Ditl decedent make a transfer antl: Yes No a retain the use or income of the property transferred .................................... . ^ b. retain the right to tlesignffie who shall use the property transfenetl or its income ............... . ^ c. retain a reversionary iMeres[ .......... . ........................................ . ^ d. receive the promise for life of efther payments, benefits or care? .......................... . ^ 2. If tleffih occuned after Dec. 12, 1982, did decedern transfer property wtthin one year of death wtthout receiving adequate consideration? ...................................... . ^ 3. Did decetlern own an m trust for° orpayable-upon-death bank accourn or security at his or her death? . . ^. 4. Dltl tlecetlern own an individual retirement account, annuity or other non-probffie 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 OFTHE 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 orfor the use of the surviving spouse is 3 percent (72 P.S. Sect. 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 orfor the use of the surviving spouseis 0 peroant [72 P.S. Sect. 9116(4)(1.1 )(Ii)]. The statue does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for tlisclosure of assets and filing a tax Tatum are still applicable even If the surviving spouse Is the only beneficiary. For dates of death on or after July 1, 2000: • Tha tax rate imposed on the net value of transfers from a deceasetl child 21 years of age or younger at death to orfor the use of a natural parent, an adoptive parern or a stepparern of the child is 0 peroent 172 P.S. Sect. 9116(4)(1.2)7. • The tax rnte imposed on the net value of transfers to orfor the use of the tlecetlenrs lineal beneficlades Is a.s percent, except as noted in [72 P.S. Sect. 9126(a)(1)]. • The taz rate imposed on the net value of transfers to orfor the use of the decedent's siblings Is 12 paroern [72 P.S. Sect. 9116(4)(1.3)7. A sibling 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+(1T-10) ~"~ pennsylvania SCHEDULE E UEaAPTMEH! OF FEVEIIVE CASH, BANK DEPOSITS, & MISC. INHERITANCETA%RETURN PERSONAL PROPERTY RESIDENTDECEDENr ESTATE OF: ~ FILE NUMBERi Florence E. Bellomo 21 11 1355 Include the proceeds of Ikigation antl the date the proceeds wen: received by the estate. If more space is needed, insert atldltional sheets of the same size .. 1~ it'.. W - . ~.. 4 _ _ ~DI`1ZOIl.. .r Y,' , ~.,. M~r r . " rt s - +` f i i . rM ,,,,,~r ~ wa.!' ~ ~ ~~ ~t h..w.<R .F 56-138' i t , ~ Horizonl0ipe GwarHlgpSlilelA MWpw JeroeY ~"~~ qf'" u Y±' ^v, x^t .~w F+^^'. n AZ.~s - ;,... ",., ~ ry.y ~t aapn Poat4!•t•^'~6'xm,inq,0; ios 1x4o" ,! c ff ~w*i_ 1 _ c ~ _ r .~+~ a '".f!^x. E. .. ...3 •.• :..' _ r>~_' ~, PREMIUM ~2EFllIi1D ACCOUNT., i s' ~ . ~Y .I. =? c.., ., !# . J l ;~ rr'6D 78686rP :D3 1 1D 1D 1 7~: 95D•~~DD 2 21~~~ 2~r' ~, .,. .~. REV-1509 ExH9r-1o) ~ Pennsylvania ~. OEPA9TNENT OF PEYENUE INHERRANCE TAX RETURN RESIDENTDECEDENT ESTATE OF: Florence E. Bellomo If an asset became lolntly awns SURVIVING JOINT TENANT(S) NAME(S) A. Carol B. Mack B. C. SCHEDULE F JOINTLY-OWNED PROPERTY ADDRESS 11 North Thrush Drive Carlisle, PA 17015 FILE NUMBER: 21 11 1355 it must be reportetl on Schedule G. RELATIONSHIP TO DECEDENT Daughter JOINTLY-OWNED PROPERTY: ITEM NUM. LETTER FOR JOINT TENANT DATE MADE JOINT OE6CRIPTN)N OF PROPERTY. INCLUDE NAMEOF FINANCIAL INSTITUTION AND BANKACCTNUMBER OR 6IMILARIDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-M ELD PEAL ESTATE. DATE OF DEATH VALUE OF A66ET %OF DECD'6 INTERE6T DATE OF DEATH. VALUEDF DECEDENTSINTERE6T 1 A 2-10-9 Bank of America Account 0048-8065-7698 joint 10,(193.16 50.0000 5,346.58 with Decedent's daugher, Carol B. Mack TOTAL (Also enter on Line fi, Recapitulation) 5,346.56 If more space is needed, use atldtticnEJ sheets of paper of the same. size. REV-1511 EX+(10-OB) ,6 ~ . Pennsylvania OEVPNTefEM OP NEVENUE INHEflRANCETAx RETUflN flE51DENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Florence E. Bellomo 21 1'I 1355 Decatlent's tlobts must be reported on Sehedtae L ITEM NUMBER DESCRIPTION AMOUM A. FUNERAL IXPENSES: 1 Kulinski Memorials 275.00 8. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Reprasen[ative(s) Street Address qty Stale _ Zip Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City ~ __ State _ Zip __ Relationship of Claimant to Decedent 4. Prebate Fees: 5. Accountant Fees: s. Tax Return Preperer Fees; 7 Cumberland County Register of Wills, filing fees 8 Cumberland Law Journal, legal advertising 9 The Sentinel, legal advertising 10 Saidis, Sullivan & Rogers, reserve for misc. out of pocket expenses 3, 000.00 111.50 30.00 75.00 168.30 100.00 I TOTAL (Also enter on lute 8, Recapitulation) 3,759.80 i, If more space is needed, use additional sheets of paper of the same size. flEV-tet2 E%+It2-DE) ~ Pennsylvania VEPAflIMENT OF PEVEMVE INHERITANCE TAX flEN RI RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER Florence E. Bellomo 21 11 1355 NUMBER DESCRIPTION 1 PA Department of Public Welfare 2 Horizon Blue Cross/Blue Shield, check written prior to, but clearing after Decedent's date of death 3 Cumberland Crossing, check written prior to, but clearing after Decedents date of death 4 Cumberland Crossings, September 2011 statement 5 James E. Holland, CPA, preparation of 2010 income tax returns TOTAL (Also enter on Line 1D, Recapitulation) If more space is neetled, insert additional sheets of the same size. 108,462.52 835.SD 396.45 675.05 42.00 110,411.82 pennsyLvania I DE PA PiMENT OF PUBLIC WELFAaE February 7, 2012 SAIDIS, SILLTVAN & ROGERS CAYLE D SWINDLER 635 NORTH 12TH STREET SUITE 400 LEMOYNE PA 17403 Re: Florence Bellomo CIS #: 230205388 SSN: ###-##-1234 Date of Death: 09/24/2011 Dear Ms. Swindler: Please be advised that the Department of Public Welfare maintains a claim in the amount of X108.462.52 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 ofthls medical expense, namely $31.819.68, 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 $76.642.84, is to be entered as a priority Class 5.1 claim against the estate. Please acknowledge receipt of this letter and advise whethertFle Commonwealth's claim is admitted and when payment may be expected. If the estate :accounting is complete, please provide a copy. If the estate contains real estatE., please provide copies of the deed, the latest tax assessment, and a current apipraisa~,:if;available. Sincerely, t Katie J, East TPL Program Investigator 717-772-6713 717-772-6553 FAX Enclosure Bureau of Program Integrity Division of ThiM Party IJablllty ~ Recovery Section PO box 8486 I Harrisburg, Pennsylvania 17105-8486 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCLLL OPEMTIONS TPLSECiION -CASUALTf UNR PO BDX BIBB HARRISBURG PA 1]tO5d4Bfi January 31, 2D12 STATEMENT OF CLAIM SUMMARY _~F~ I ~JtMEi ~.' Estate of BELLOMO, FLORENCE ~.JIDs~rel,~~~x-,. 230 206 368 a I '+Y .'a ~ 1 r& 1 'C°~i+°Ai ~MF~~aJ~6%~ mq.! Y tA3inHF u~t~~:~LAS$~ '"y ~ 45~~ x 5 u~`~3a4efl'X, n~Ia- 'CLASS^6^1 a e, . w fi>~ -pL; i S, w 1 xTOTA~ ,~ ... t ~'` f~., :t cC r I-~ .C INPATIENT - .OD .00 ~ .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 31,766.66 76,433.BD l08,219A6 DRUG ~ 34.02 208.D4 243.06 Yi,y "©PW ~-~ 5EME : R~I BC7 ~ 619 68 ~ 31 ~ 76 64284 1O8A62.62 . ~ y M s R. . , , CONIMONWEA6TH:OF PENtJSYLVANIA. - DEPARTMENTAR~P.UBLIC WEL`FAR° ~. January 31, 2012 ~~ STATEMENT OF CLAIM .NAME` BELLOMO, FLORENCE ID`? . ~ 230 205 388 UMBERLAND CROSSINGS RE7 COMM LONGSDORF WAY ~RLISLE PA 17013 11/01109 - 11/30109 11115!10 55103144966730001 55103144966730001 5,631.90 5,151.65 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TD DIAGNOSIS 2: 2930 DELIRIUM DUE 7O CONDITIONS PROC CODE : 000000 12/01109 - 12!31109 11/15N0 55103144956760001 55103144966760001 6,819.63 6,366.16 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS2: 2930 DELIRIUM DUE TO CONDITIONS PROC CODE : 000000 01/01110 - 01/31N0 11!29/10 55103274936130001 55103274936130001 5,819.fi3 6,740.88 DIAGNOSI51: 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 2930 DELIRIUM DUE TO CONDITIONS PROC CODE : 000000 02!01/10 - 0212BM0 11/29170 56103274936330001 55103274936330007 5,25fi.44 4,937.49 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DllE TO DIAGNOSIS 2: 2930 DELIRIUM DUE 70 CONDTIONS PROC CODE : 000000 03/01!10 - 03/31/70 11/29/10 55103274936630001 65103274836530001 5,819.63 5,648.02 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO . DIAGNOSIS 2: 2930 DELIRIUM DUE TO CDNDITIONS PROC CODE : 000000 04/01/10 04!30110 12113110 55103425009760001 b51034260D9760001 b,631.90 5,415.73 DIAGNO5151 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSI52: 2930 DELIRIUM DUE TO CONDITIONS PROC CODE : 000000 OS/01!10 - 05/31/10 12!73/10 55103425010030001 55103425D100300D1 6,819.63 6,619.24 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2: 2930 DELIRIUM DUE TO CONDITIONS PROC CODE : 000000 D6/O7/10 - 06/30/10 12/13110 55103425010100001 65103425010100001 3,128.80 2,702.26 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2: 2930 DELIRIUM DUE TO CONDITIONS PROC CODE ; 000000 .~ - ~~ ;:. . ~.. ~~ GOMMONWEALTNsOF PENNSYLVANIA 2; -. ~- >~: ~.: WELFARE ` ~ ~ DEPARTMENT OF,PUBLJC', . ' January 31, 2012 ` STATEMENT OF CLAIM NAME.: BELLOMO, FLORENCE •I~'~,,":~' 230205388 UMBERLAND CROSSINGS RET COMM LONGSDORF WAY PA 17013 09/01110 - 09!30710 10/77M7 6511296430376DOD1 ._.55112854303760001. . . 5,631.90 DIAGNOSIS 1 : 56400 CONSTIPATION, UNSPECIFIED DIAGNOSIS 2: 2930 DELIRIUM DUE TD CONDITIDNS PROC CODE : OOOOOD 10/91/10 - 10131110 11!21111 55113194314620001 55113194314820001 6,819.63 DIAGNOSIS 1 : 66400 CONSTIPATIDN, UNSPECIFIED DIAGNOSIS 2: 2930 DELIRIUM DUE TD CONDITIONS . PROC CODE : OOD000 11/01/10 - 11!30/10 11!21111 66173194314530001 b81131843145300D1 6,106.30 DIAGNOSIS 1 : 58400 CONSTIPATION, UNSPECIFED DIAGNOSIS 2 : 2948 DTHER PERSISTENT MENTAL DISORDERS DUE TO PROC CODE : 000000 12!01/10 - 12131/10 17!21111 55113194314fie00D1 65113194314690001 6,308.81 DIAGNOSIS 1 : 66400 CONSTIPATION, UNSPECIFIED DIAGNOSIS 2 : 2948 DTHER PERSISTENT MENTAL DISORDERS DUE TO PROC CODE : 000000 01/01/11 - 01/31/11 12119/11 55113474310680001 55113474310880001 6,308.61 DIAGNOSIS 11 5849 ACUTE KIDNEY FAILURE NOS DIAGNOSIS 2 : 2930 DELIRIUM DUE TO CONDITIONS PROC CODE : 000000 02/01/11 - 02128/11 12!19/11 55113474310880001 65113474310890001 5,698.28 DIAGNOSIS 1:5849 ACUTE KIDNEY FAILURE NOS DIAGNOSIS 2 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO PROC CODE : 000000 03/01!11 - 03131117 12119/11 55113474311010001 66113474311010001 6,308.81 DIAGNOSIS 1 : 5849 ACUTE KIDNEY FAILURE NOS OIAGNDSIS 2 : 2948 OTHER PERSISTENT MEN7AL DISORDERS DUE TO PROC CODE : 000000 04/01/11 - 04130!11 01116/12 55120124272450001 55120124277450001 6,105.30 DIAGNOSIS 1:43491 CEREBR ARTERY OCCLU, UNSP DIAGN05152: 2930 DELIRIUM DUE TO CONDITIONS PROC CODE: ODOODO -~ 4,794.43 6,45246 - 5,254.33 5,452.4fi 5,19299 4,fi23.71 6,192.99. 5,436.25 _ ~ -COMMONINEALTH:OF PENNSYLVANIA: ~ - - - ~ .[7EPARTMENT:OF:PUBLIO VJE~FARE ~ ~' January 31, 2012 ` STATEMENT OF CLAIM :NAMES; BELLOMD, FLORENCE ID'%:ii": 230 20b 368 CUMBERLAND CROSSINGS RET COMM 1 LONGSDORF WAY ' PA 17013 06!01111 - 06/31N1 D1I16N2 55120124272A60001 65120124272460001 6,306.81 6,639.95 DIAGNOSIS 1:43491 ~CEREBR ARTERY OCCLU, UNSP - DIAGNOSIS 2: 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO PROC CODE: 000000 06/01111 - 06!30111 01116!12 65120124272630007 66120124272630001 6,106.30. 6,436.26 DIAGNDSI51: 2846 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNDSIS 2 : 4292 ASCVD PROC CODE: 000000 07!01/71 •. 07131!11 09/19/11 69112444023010001 69112444023010001 6,308.81 6,633.76 DIAGNOSIS 1:2848 OTHER PERSISTENT MENTAL DISORDERS DUE TD DIAGNOSIS 2 : 2930 DELIRIUM DUE TO CONDffIONS PROC CODE: 000000 08101111 - 08!31/11 09M9111 20112444273320001 .20112444273320001 b,308.81 6,633.76 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 4389 UNSPECIFIED LATE EFFECTS PROC CODE: 000000 09!01111 - 09124/11 10124/11 20112764323290001 20112764323290001 4,660.73 4,006.66 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2: 4388 UNSPECIFIED LATE EFFECTS PROC CODE : 000000 RRD~/IDERSl16 TCj7JiL:~ CUMBERLAND CRDSBINGS RET COMM 120,826.86 108,219.46 ~n~" eR"~"r"Y~1`1~'"'"'.;4r q~~ '~ F y ' ' : 03 100777740 0050 , , . : ., y:: i l., :i '~.~'COMMONWEAL°F.H•OF PENNSYLVANIA ~ ~ :`k ' ~:~DEPARTM=WT O-F.PUBLIC~,WECFARE - January 31, 2012 STATEMENT OF CLAIM ~IJAME~. BELLOMO, FLORENCE 1D~~ . 230 205 388 >NTWUING CARE RX S 2ND ST PA 17074 11/02/09 - 11!02/09 12728109 25093375666730001 25W3375686730001 43.67 ~ 2Z.21 DIAGNOSIS 1 : D NDC CDDE: 50466Q69150 RISPERIDONE 0,6 MG TABLET - ATARACTICS•TRANQUILIZERS 11!16109 - 11!16!09 12/28/08 2509337b687540001 25093375687640001 107.60 9720 DIAGNOSIS 1 : 0 NDC CODE : 00085128801 NASONEX b0 MCG NASAL SPRAY TOPICAL NASAL AND 0T1C PREPARATIONS 11!30109 - 11130/09 12/28/08 25083355740540001 25083355740540001 41.76 fi.33 DIAGNOSIS 1 : 0 NDC CODE : 002282057SD LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS - 11!30109 - 11130/09 11128/09 26093375fi88020DD1 25093375688020001 216.03 - 1.42 DIAGNOSIS 1 :.D NDC GODE: 62856024690 ARICEPT 10 MG TABLET - PARASYMPATHETIC AGENTS 11!30109 - 11/30109 12128/09 25093376689080001 25093375689080001 101A6 '1.37 DIAGNOSIS 1 : 0 NDC CODE : OD456202001 LEXAPRO 20 MG TABLET - PSYCHOSTIMOLANTS ANTIDEPRISSANTS 19/30!09 - 11/30109 12!28/09 25093375689470001 25093376689470001 99.32 1.A3 DIAGNOSIS 1 : 0 NDC CODE ; 00456321060 NAMENDA 10 MG TABLET - MISCELLANEOUS 12130109 - 12130/08 01!25/10 25093845646320001 25093645646320001, 39.76 6.10 DIAGNOSIS 1 : 0 NDC CODE: 00228205750 LORAZEPAM D.5 MG TABLET ATARACTICS-TRANgUILIZERS 01130110 - 01!30110 03101110 25100306266730001 25100305266730001 39.76 6.10 DIAGNDS151 : 0 NDC CODE: 00226201750 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANgUILIZEP,:: S ~ - .GOMMONWEALTkFOF PcNNSYLVANW ~ •I '=~ ~~DEPARTMENT OF?PUBLIGVJELFARE - January 31.2072 ` STATEMENT OF CLAIM NAME' BELLDMD, FLORENCE 'ID ~ ~_ 230 206 388 CDNTINUING CARE RX 2H S 2ND ST PA 17074 07126/10 - 02l26H0 03!22/10 251006!5497130001 25100575497130001 39.76 6.10. DIAGN05151 : 0 ~ ' NDC CODE: 00228205750 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 03129!10 - 03/29H0 04126H0 25100885593670001 26100886593870001 29.76 6.33 DIAGNOSIS 1 : 0 NDC CODE: 00228206760 LORAZEPAM 0.6 MG TABLET - ATARACTICS-TRANgUILIZER:i 04/29110 - 04!29110 05!24110 26101185356050001 26101196365050001 39.76 6.33 DIAGNOSIS 1 : 0 NDC CODE : 00228205/50 LORAZEPAM O.b MG TABLET ~- ATARACTICS-TRANQUILIZER:: 05f31H0 - 06!31/10 08!28110 2510151526822DDD7 .25101515258220001 39.76 6.33 DIAGNOSIS 1 : 0 NDC CODE : 00228206750 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANOUILIZERa - 06l01H0 - 06101!10 06!28/10 25101525269850001 25101526269850001 5.68 5.49 DIAGNOSIS 1 : 0 NDC CODE: ~ A09D4323392 CALCIUM 600+ VIT D 4DD TABLET - ELECTROLYTES 8 MISCELLANEOUS NUTRIENTS 09/10HD - 09/10110 10104/10 25102635623280001 25102635623280001 30.81 5.85 DIAGNOSIS 1 : 0 NDC CODE: 00228205750 LORAZEPAM 0.6 MG TABLET - ATARACTICS TRANQUILIZER:. 11/09/10 - 11/09/10 12/06110 25103135358670001 25103136358670001 21.87 5.23 DIAGNOSIS 1 : D NDC CODE : 00226205750 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 12/09/10 - 12/09/10 01/03/11 25103435276460001 25103435275460001 21.87 5.23 DIAGNOSIS 1 : 0 NDC CODE : 00228205750 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERP. i 1 ,. _ '~- ~ -, _'^" .-.~~,:: COMMONWEALTH OF'RENN$YLVANIA ~ ~ ~ '' .` ~ -' - ~~ =:OEAARTMENT~OF~PIJBLIC.WELFARE January 31, 2012 ° - STATEMENT OF CLAIM ~NAME;a BELLOMO, FLDRENCE .ID":,'~~~ 230205388 INTINUING CARE RX 5 2ND 5T PA 17074 D1/03!71 - 01103!17 01!37/11 25110035692230001 25110036692230001 21.87 5:01 -_ DIAGNOSIS 1 : 0 NDC CODE : 00226205750 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILRERl6 01!27/11 - 01/27111 02!21117 26110275268460001 25110276268460001 21.87 5.01 DIAGNOSIS 1 : 0 NDC CODE : 00228205760 LORAZEPAM 0.5 MG TABLET - ATARACTICB-TRANQUILIZERi ' 02/201N - 02120!11 03121!17 25110615352910001 25110515352310001 21.87 6.07 DIAGNOSIS 1 : 0 NDC CODE: 00226206760 LORAZEPAM 0.5 MG TABLEL - ATARACTICS-TRANQUILIZERSi 03176111 - 03/76!11 04/11/11 - 25110755437900001 251107654379DDOOT 21.87. 4.96 DIAGNOSIS 1 : 0 NDC CODE : 00228205750 LORAZEPAM OS MG TABLET - ATARACTICS-TRANQUILZERS 04/09111 - 04109111 05/09111 25110995239320001 25110995239320001 21.87. 4.96 DIAGNOSIS 1 : 0 NDC CODE : 00226205750 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANgUILIZER:i 05/03/11 - 05/03/11 05130/11 25111236674430001 25171235674430001 - 23.87 4.96 DIAGNOSIS 1 : 0 NDC CODE: 00226205750 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUIIIZER:t 06101/11 - 06/07111 06!27!11 25111625551410001 25111526651410001 23.87 4.96 DIAGNOSIS 1 : 0 NDC CODE : 00226205760 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZER:{ 07/06/11 - 07195/11 08l01N1~ 25111865674310001 25711866674310001 23.87 4.92 DIAGNOSIS 1 : 0 NDC CODE : 00378232105 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS ~ j I 1 .. .COMMONWcALTH OF PpNIU5YL3VKNIA' DEPARTMENT OFPUBLIC WELFARE January 31, 2012 STATEMENT OF CLAIM :NAME' SELLOMO, FLORENCE iID-.. ~'' 230 205 388 CONTINUING CARE RX 28 5 2ND ST- EWPORT PA 17074 ~r+D,4i');EyOFhS,L:R~QE ,~~{?aDiAf:. b~IGINA:4(:RJ4eY~i§{c ~i-~ADdtN,Sj1'p,(5~{C*f~q~5l7AL+~Ofi1ARCES'~ 9MO~II~TBfRP.R@1I,ED'. to J <wh. 08/02/11 - 08/02!11 OBR9/11 25112146282680001 25112145292680001 23.87 492 DIAGNO5151: 0 NOC CODE : 00378232106 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 08/11111 - 08/11!11 09!06111 26712236333060001 25112235333060001 11.63 9.30 DIAGNOSIS 1 : 0 NDC CODE : 00713016612 ACEPHEN 660MG SUPPOSITORY - NON-NARCOTIC ANALGESICS ";y~" ~~~'~~ bµ1D~@~ifl?71tAL 1P~2 CONTINUING CARc RX 1,144.86 243.06 , ,"` ~~t•~h` 24 100731447 0011