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Home My WebLink About06-29-12J 1505610105 REV-1500 ~ ~oZ_~3, tFt, PA Department of Revenue pertnsylvania OFFICIAL USE ONLY ureau of Individual Taxes H 2~ DlxAI,TMFxT M x[VMDE County Code Year Fde Number IN N r~s~ PA i i28-osoi RESIDENT DECEDENT ~~ / / O ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death. MMDDYYYY Date of Birth MMDDYYYY .:149-40-6993 05/25/2011 07/25/1950 Decedent's Last Name Suffix Decedent's First Name Carano _ MI Sondra L (H Applicable) Enter Surviving Spouse's Information Below - Spouse's Last Name Suffix Spouse's First Name ` N/A MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WRH THE REGISTER OF WILLS FILL IN APPROPRWTE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return {Date of Death O 4. Limited Estate O Prior to 12-13-82) 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Re uired d h q eat after 12-12-82) O 6. Decedent Died Testate O (Attach Copy of Wili) 7. Decedent Maintained a Livin Trust 0 g 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec 9113(A) B t . e ween 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - TNIS SECTION MUST BE COMPLETED ALL CORRESP Name . ONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: - Daytime Telephone Number Jacqueline M. Verney, Esq REGISTERVYILLS USE OM First. Line of Address ~~ ~ ' ~'~? ~_ ~ 44 S. Hanover Street ~3 , . Second Line of Address ,~,~,.} f~a _ ~~-' C, , ` ~ ~ >v - _ ~ ~ x,,, - i-~y -s~j City or Post Office Cti-- .- ~ t - _ ~ - State ZIP Code FILED ~~ i Carlisle `~ FA 17013 . c::> Side 1 L 1505610105 1505610105 ___, _ _ . ._ Correspondent's e-mail address: Under penalties of perjury, i declare that I have examined this return, induding accompanying schedules and statements, and to the best of k it is true, correct and complete. Declaration of preparer other than the personal representative is based on all iMormation of which re re has an~~k ~ a~ ~~~ TURE OF PERSON RESPONSI OR FILING RETURN p ~ y 9e' ' e REV-1500 EX (FI) Decedent's Name: Decedent's Social Security Number 149-40-6993 KEGAPfTUlJ1TION 1. Real Estate (Schedule A) ............................................. L 0.00 c. a~oecs ana esonas tscneauie ts) .................................. ..... 2. 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00 4. Mortgages and Notes Receivable (Schedule Dj ...................... ..... 4. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).. ..... 5. L, 15,863.30 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .. ..... 6. ; 0.00 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property - (Schedule G) O Separate Billing Requested... ..... 7. 0.00 8. Total Gross Assets (total Lines 1 through 7) ........................ ..... 8. ._ ... 15,863.30 9. Funeral Expenses and Administrative Costs (Schedule H) .............. ..... 9. 7,421.20 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule q .......... ..... 10. I _. 14,290.89 11. Total Deductions (total Lines 9 and 10) ............................ ..... 11. 21,712.09 12. Net Value of Estate (line 8 minus Line 11) ......................... ..... 12. -5,848.79 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................... ..... 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ................... ..... 14. + 0,00 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_ 15. 0.00 18. Amount of Line 14 taxable _ _ _ _' at lineal rate X .0 _ 18. 0.00 17. Amount of Line 14 taxable - .- at sibling rate X .12 ' ' 17. ' 0.00 18. Amount of Line 14 taxable .; at collateral rate X .15 18. 0.00 19. TAX DUE .................................................... ..... 19. 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O 1505610205 Side 2 1505610205 1505610205 J REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number Tax Payments and Credits: 1. Tax Dce (Page 2, Line 19) 2. Credits/Payments A Prior Payments ------._- ____ B. Discount 3. Interest (1) 0.00 Total Credits (A + g) (2) 0.00 (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMEM: Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 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 .......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income ............................................ ^ c. retain a reversionary interest .............................................................................................................................. ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a benefiaary 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 is 3 percent [72 P.S. §9116 (a) (1.1) (i)J. 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 tfte net value of transfers to or for the use of the decedent's lineal benefiaaries is 4.5 percent, except as noted in [!2 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+ (ii-1o) p~nnsylvania SCMEpVLE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Sondra L. Carano 21-11-0777 Indude the proceeds of litigation and the date the proceeds were received by the estate. Ali property jointly owned with right of survivorshia must be disclosed on Sehedule F. If more space is needed, use additional sheets of paper of the same size. Jun 2712 06:21 p 941 Grsenspring Road Balances Paid this F 3 0. 717-776-7863 Earned Paid Year-To-Date ~ v.vs Paid Last Year 'The interest earned and the interest paid may differ d pending on when interest is credited to your account. OverdraftlReturned item Fee Summary Fee descrlptton Total OverdraR Fees Tota! Returned Item Fees Checks Posted Check # Date Pald Amount Reference 2334 _.05106 - 5371.00 _ 970¢48+~~__ 2335 051~i $12.00 970547995 4 Check(s) Posted =:589.50 An asterisk (') indicates a skip in sequential check numbers. Account Activity Date Descrtption 04-27 Beginning Balance 04-27 US TREASURY 303 XXSOC SEC 042711 Tota! for this statement period $0.00 So.oa Check # Date Paid p.4 0.01 $0.' Total year to date s35.ao So.oo Amount Reference ~/16 -~37 ~-- 13.50 _ 9726868Q0.- 995052' p5/23 Si 73 00 993645460 An (E} indicates check was wnverted to an electronic item. Additions 5ubtractforrs Balance S5 194 54 __ A SSA $625.00 $5,819.54 04-27 CHK CARD PUR 125750 GAMESTOP GAMIESTOP#65 -~---'" ~`--~-" -- - MECHANICSBtJRGPA - ~ $274.40 _ ~ $5,545.14 04-27 CHK CARD PUR 238126 V1fALMAI~T WALMART#2574 ~•"-~ --__. _ CARLISLE PA ~ $266.83 __ 55,278.31 04-27 CHK CARD PUR 036474 RATTER'S RUTF'ER'SFAR w. "-- -"'-'--`--- •---- --- CARLISLE PA 546.14 $5,232.17 04-27 CHK CARQ PUR 13'E9i3 HESS 3835 HESS38357 ~••- ----" --- --.-.------?~_-..------ __ _CARUSLE PA 519.39 _ -$5,212.76 04-28 CHK CARD PUR 375942 9EST BUY BEST BtJY ~`~ --- - '-~ ~- MECHANICSBURGPA $36.19 $6,176.59 04-29 US TREASURY 220 TAX REF 042911 '-`--------- ---~-- __ 4 - IR5 - $2Q4.00 ~• $5,380.58 04-29 CHK CARD PUR 362589 HESS 3835 HESS38357 - " ---°°------- _ CARLISLE PA ___ $50.00~~- _ $5.330.59 • 0429 CHK CARD PUR 439858 ALSPIZZA ALSPIZZA?,tVD - --.----. _-- ~---- __ MEC HANICSBU RGPA $~~~ -- ~~- _ $5,304.53 04-29 _ _ CHK CARD PUR 363974 HESS 3835 HESS38357 '---- --- _-- ~- _ CARLISLE PA 522.18 - $5,282.35 04-29 CHK CARD Pl1R 377190 CHICKFiL CHICKFIL A# ---W------ "- '--" _ ~ . 0 MECHANICSBURGPA S 12.65 ~-- ---~ 55,269.70 04-29 CHK CARP PUR 366664 TACOBELL TACOBELL244-'- ~-~ ------ - -~~- `"-"--- ----- CARLISLE PA -- $5 47 - $5,264.23 1xr~rtier. r~/'~/ 18914.?.it / i SONDRA L CARANO Account # 2891034955 Jun 2712 06:21 p 941 Greenspring Road r (1 ~ "' Account Activity (Cont. for Acct# 2891034155) Date Description 05-02 US TREASURY 312 XXCIV SERV 050211 717-776-7863 p,5 Additions Subtractions eafance F 3355924 W CSF ~ $970.00 36,234.23 05-02 SOVER IGNBANK CASH RVi/RDS PRGRM ----_...--_'-_ .-_-- ._-._ . - _ MAR 11 REWARDS ---_..---_._-- $0.25 .--.....__--__ _ 56,234.48 05-02 CHK CARD PUR 659146 GUIDALAW GUIDALAWOFF - HARRlSBURG PA 5100.00 $g 1~3,q,48 05-02 CHK CARD PUR 696776 AUTOZONE AUTOZONE#18 - - - ° •~-- - CARLISLE PA $87.14 56,047.34 05-02 CHK CARD PUR 805013 AYAJAPAN AYAJAPANESE --- "`-- CARLISLE PA 576.02 $5,871,32 05-02 CHK CARD PUR 688221 GIANT 611 GIANT6112~ ---•~-"- - `---- -• -- - •-_. CARLISLE PA $71.85 $5,899.47 05-02 CHK CARD PUR 690258 GIANT 611 GIANT6112 ~ -" •••-•-- - _ CARLISLE PA $~•~ $5,869.47 05-02 CHK CARD PU 605997 HESS 3835 HESS38358 ''` CARLISLE PA $11.24 $5,858.23 05'03 ATM ASH W/i? 688993 M&TBANK M8T6558CARLI ~ MECHANICSBURGPA $2'40.00 55,618.23 05-03 CHK CARD PUR 070637 GAMESTOP GAMESTOP#6 _ 5 MECHANICSBURGPA 547.69 55,570.54 OS-03 CHK CARD PU~089204-VyALMART WAL(btART#2574 - CARUSLE PA $29•~ $5,541.54 Q5-03 AUTp DRAFT' SENT TO 00431130221 05-04 CHK CARD PUR 988529 CARLISLE CARLISIEREN `- 510.00 $5,531.54 CARi.IS1.E PA 578.44 $5, '4 3105 05-04 CHK CARD PUR 205380 SHEETZ SHEETZ -~•- '-- -° ---- -• CARLISLE PA $43.69 55,409.41 05-05 CHK CARD PUR 180423 VERIZOtJ•O VERi20N`ON~ ••-- - . . 800-483.3000 TX ^ 5677.00 . _.__ $4,')32:41- 05-05 CHK CARD PUR 435509 MICROSOFT MICROSOFT' - - --•- - - -~~- 08003865550 WA •- 519.99 -$4,712.42 05-05 CHK CARD PUR 452125 WA ART WALMART#1886 ~ -- ~ _ MECHANICSBUR PA $19.00 • 6g~4242` 05-06 CHECK •• 233q '---`-. --_.-_~_,•-- _ -- - ~ ` 05-06 CHK CARD PUR 445031 CV MART CV IIAART •-- - Op '- 3371. '--•---- $4,322.42 NEW KINGSTOWNPA 54.00 34,282.42•- 05-06 CHK CARD PUR 586257 GIANT 600 GIANT6005 - MECHANiCSBURGPA $38•~ 34,243.76 05-06 CHECK 2335 05-06 CHK CARD PUR 455283 HESS 3835 HESS38357 '---•-"- - ------•- ' $12.00 _ ~ 54,231.76 CARLISLE PA $11.24 $4,220.52 05-06 CHK CARD PUR 597937 MICR050FT MICROSOFT° - -~' -- 08003865550 WA 59.99 54,490,58` 05-12 CHK CARD PUR 377325 LOWES#01 LOWES#01710 ---'--• `~'-'--------- CARLISLE PA 5105.94 _ $4,104.59- 05-13 POS RETURN 022384 AUTOZONE AUTOZONE#18 "- ' L--- CARLISLE P A $92 47 ---- __.._ 54,197,00 _ 05-13 POS RETURN 021801 AUTOZONE AUTO 8 v`--•- O Z NE#1 CARLISLE PA $50.43 - "--"- - - 4 247 43 5 05-13 CHK.CARD PUR 551289 GIANT 800 GIANT6005~ `--'" • - MECHANICSBURGPA $9394 S 4,153.49 05-13 CHK CARD PUR 386756 KMART 042 KMART04275 ~---° '"----" MECHANICSBURGPA 549.37 34,104.12 05.93 •CHK CARD PUR 364995 HESS 3835 HESS38357 -" -- CARLISLE PA ^ $30.01 $4,074.11 05-16 CHK CARD PUR 657074 MICROSOFT MICROSOFT' - `- -~ -- -• 08003865550 WA $19.99 54,054.12 05-16 CHECK 2337 513.50 $4,040 62 " page .i of 4 ?391034155 Jun 2712 06:23p 941 Greenspring Road Account Activity (Cont. for Acct# 2894Q34155j bate Description 05-16 CHK GARO PUR 657633 AAICRL?SOFT MICROSUFT` 717-776-7863 p,6 Additions Subtractions Balance _08003885550 WA $4.99 54,035.Es 45-18 llGl U7111T1E'S ~NLIIdE PMT 114518 _ CKF07i90fi103POS $70.00 _ $3,855,63 OS-18 CHK CARD PUR 108152 AISPIZZA AI.SPIZZAAND ~"-"-' MEGHANICSBURGPA 529.08 53,336.55- 05-19 CHK CARD PUR 326872 AUTOZONE AUTOZdNS#1d'-- ._""""-~~"""'-'-~`-'------- _ CARLISLE PA 5315.45 N3~,621.10 05-19 CHK CARD•PUR 190407 BUTTER'S RUT'FEi2'SFAR -'~_-~----"~.-~'------._.-'-._~_._...~ ..._..--.- CARLISLE PA •-_,__~,~,__ 525.00 __.~_~..~_ °s3.596.iC 05.19 --- CHK CARD PUR 190509 BUTTER'S BUTTER'SFAR~~----"•""""_~~---°---•--• ----- •~ CARLISLE PA -------_._.__, 516.98 _...____._-____._, 53,573.12 08.23 ^CHK CARD PUR 744073 itRONROMUF MOh1ROMUFFLE CARLISLE PA 5577.17 ss,ool.~5 .. 05-23 SS _.- µ""-'_._. -_._..__.__-•----_._._____....~ _ ATM CASH W/D 450464 M&TBANK M&TRUTTER' ~_T~___..._ •~ .. . CARLISLE PA _~ $250.00 ' S2 151.55 05-23- 'CHECK 985052 -_..-__._..._._____._._........___---.--....,...___.-__._..-------.--_._._______ __. 05.23 • CHK CARD pUR 907656 BUTTER'S RUTTER'SFAR --'T•"-_._.,_..-.__..._.~___,_„__ $173.00 ____..• ______ .__ X2.578.95' ._.__.,_. CARLlSLH PA S30•~ ______y 52,5413.11 05-23 CHK CARD PUR 749500 HES5 3835 NESS58357 ~--~'- --- ~ "--"~'--"-"-'""-__._...___._..._ .___ ~ CARLISLE PA ___. _.,--._._.._T 525.00 ~.___._____,•,. 52.523.1 i 05-23 CHK CARD PUR 750276 HESS 3835 HE5S38357 '-~~- -- CARLISLE PA 519-84 S2,503.2i OS-25 US TREASURY 308 X>(SOC SEC 052511 -~-'• -`-_--" - -'---- ---- `~__ A SSA 5510.00 __....__ __ __ 53,013.27 1N CASE OF (:;RRORS OR pU~:S'1'IONS ABUU'l~ YOElR 1?LEC7`fZUN1C'TRANSI=IRS ;':1E.[. Y(JUR (a5'rt:JMkl( SGRVtCI C'F..N'1'!:R 11'1• fl IE NUM!!i;f2 51101~'N UN 1'FIE .(.OL' QP Y(?l.!K S7 A'i'tihff'i`i'I' (:1R tl:'KI'!'G 1't:! t'Flh' F}Akf~ ft:Jl2 [)11131'1 CARI)1SSUFS: I~(.)!2 ;11.1.. U")l If-:R lSS(iI:S: Srtrerci5n Liank lrnereien 4iank Attn: C:ud I)isppulcs T'ctntt MA I !vlli3 02 Ct~ Attn: CI'ient Rclatinns P.(~. Ciux R31(K!2 ! tN ~ ! -(~ R I rioStten !4tA 02383-10()'_ 1'.(). I:iCJ`( 126th Itf•:AI)IN(a, PA 1'1612-2G4t5 Please citntatn us i1'yuu think your statement or reu:ipt i.. wrong ar il'vou weed aJditional inl'nrnratiuu abc!ur a trrnstcr nn the sta!cntrnt or n:.~cipt. We must hear fnmt you rta later than Gl) days a11cr tte sent yr>u t!tr Fltiti"I' suttemenr rat which thr rrxor apprarrJ. • •i'ell us your nantr. and account numher• • [:hscritx; rhr rrror er d,r ,ransrrr that ~•oa :u'e ansurr abonl and cnplain as cfe:n'I} a~ ttxr • •I c(I us the dollar amcumt of the suspected rrrnr. 4,n whp you tx;liece there iti an r,•ror pr wh~• you nrcd littylnr infcrrtnatron. H';•ou tell us urslh•. we may rcgoirr putt ur send your cumplaim ur gtrestitm to writing within 111 business day's. Wr will prttmptty investigate the multrr and call or write to you with an answrr within It) busint•s Bats (1(! raiendar da}s in ABassr,rhasens). If uc nerd morn time. >.r mtty lake up to y i days to investigate ~•oar cnntplaint nr question. If the do, u•o will cr,tdit tour account within this IU-dot period fix nc~ am<xtnt you think is in cmtr, co you :vi El h:rvc i6c ,ise of the mrnrcc dunnir the tirttr ;r utkrs us to complete utrr im cstiN:trinn. If we yy1;'y,?u Ir, pot your complaint or yuestiort in writing and we do not receive it within ~i Q bnstrress Jay,, we nun' chottse not to credit t t!ur account. T~nren•ttrs immlcing rx;tt acccxtnls, point ul'snlcpurchases or litrei!;n transactions. we m:n~ take ap to 9f1 dnps m invcvi};arr ~r„rr con,plaim or yuestian. For new act:nunts. ur ntay take up to :.0 business dots to credit pour nrcur.utt li?r dtc ant<xnu r,tu think is in cr7nr. tk'e n~ili till you the resuhs o1 tx,r invrstie:alirnt within 3 hnsinrss dot s after <arnptetine our investicnt!on. tl ttc dreid~ 8tere was no error. ur wilt ,rod y,w a written explanation. You stay ;tsk Fnr copies of Ihr documents we useJ in our ince:as;aiion. Important ial'ornralion shoal pour Sovereign orbit Card 'Chr mttvorks thtttugh which srnne nt'vtKu Sovereign Ckhit Card purchase; are proc~~ascd hate ltenun allotting nten:hanLy to prrcess ytwr purchsisc u•iihrntt either a signatun: or a f IIV. If`yott art: not reymrct) (o enter }our I'!h when ynu nt;tke ~ purchase, t•nar purchase m:rt be processct! either thnxtgh the Visa neheork or Ntruugh the ST:1R rn• NYCh networks. l l'ynur l>un-hasc is pra;cssedaU,roueli S`I•:1R or ?~l'C'f. <lif(crcnt term.+ appip sad ticxt will not tx eligible f'or the rights and protccUOrts available through b ica. Please sec your 1 crs,,nial 17rposit Acavuu !'.grrcmcm ti?r more inl'rtim:ltion. l~n~:c a q~'-! _'.gy,'r13M , ; Jun 27, 12 06:24p 941 Greenspring Road 717-776-7863 p,g Total Control A.ccount'~ Account Na. 4060953778 May 201 I Statement Period From 5/01111 To 5131/11 Page 1 of 1 SH•009A28•TCA1PA01 SONDRA CARANQ Customer Service: 295 WALNUR' LN (800) 638-7283 CARLISLE pA 17075-7820 MetLife plays a role as a responsible corporate citizen by supporting green initiatives in the communities where our employees live anti work. For exarnpie, all 14 of MetLife's U.S, owned and/or operated buildings are Energy Star certified, earning us recognition by the Environmental Protection Agency as an Energy Star Leader. And Newsweek magazine ranked MetLife among the top 50 of the largest 500 companies in its annual green issue, making us the highest ranked insurer on the list. To learn more about MetLife's tradition of corporate contributions and community involvement, please visit us on .Line at.www.metlife.cam. TCA SETTLEMENT OPTION EFFiECT/VE ANNUAL YIELD 0..50°,% AS OF 05131/99 Account Summary 1~ginni~tg 8~aii~ut-ee $13.007.14 Interest Checks $4.&8 Other $t2,850.00- $157.14- Ehd#rrg ~:Baiar+c $0.00 Year To, Data 1n13et~ast $28 21 Yeah Ta ~a~ ~i~cral T~t~t,Wi~ttteid .; . ... ,_ _ . $0.00 REV-1511 EX+ {1®-09) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Sondra L. Carano 21-11-0777 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Hoffman-Roth 219 N. Hanover St Carlisle, PA 17013 5,556.28 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City __.._ __.....------_ _....... - -.__ _ State ZIP Year(s) Commission Paid: Z• Attorney Fees: 1,500.00 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• Probate Fees: 111.00 5. Accountant Fees: 6. Tax Return Preparer Fees: ~• .Advertise Letters Sentinel-$178.92 + Cumberland Law Journal $75.00 253.92 TOTAL (Also enter on Line 9, Recapitulation) ; 7,421.20 If more space is needed, use additional sheets of paper of the same size PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Tackie Cox, Sales Director, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SEIV'TINEL, a newspaper of general circulation in the Borough of Cazlisle, County and State. aforesaid, was established December 13,1881, since which date THE SE1VT'IlVEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regulaz editions and issues of THE SQL on the following day(s): Tul ly 5, Tuly 22 and Tuly 29, 2011 COPY OF NOTICE OF PUBLICATION -- - , ADMMII$THATOA NOTlCE.; ` ~~dminislrAtlon onlt+e~~ fate of SONDRA L CAAANO, late ~ the otMidtibaeicF~priandCounty; Pennsylvania, deceased, grehted'4odhe undersigned. Ap peri(nowit~ themselvts to-tie Indebted to said'Eatate will make mediately, enA thgse having claims wul present them for ~.- . Tront Anderson, Administrator c1o Jacqueline M. Verney 44 South Hanover Street ` Carlis{e, PA 19013 Ja~quelinelul. Verney, Attorney Affiant further deposes that he/she is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of publication e. / f Sworn My commission expires: before me this NOTARIAL SEAL BAMBI ANN HECKENDORN Notary Public CARLISLE BOROUGH, CUMDERLAND CNTY I~Ay Commission Expires Jan 27, 2014 Notary Public PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regulazly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regulaz editions and issues of the said Cumberland Law Journal on the following dates, viz: _ July 22 July 29 and Au>;llst 5 2011 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. Cuaao, Soadra L., deed. Late of Middlesex Township. Administrator: Trent Aaderson c/o Jacqueline M. Verney, Es- q~0. 44 South Hanover Street, Carlisle, PA 17013. Attorney; Jacqueline M. Verney, Esquire, 44 South Hanover Street, Carlisle, PA 17013. SWO1~T TO AND SUBSCRIBED before me this 5 of August, 2011 ~~~~.~= NOTARIAL SEAL DEBORAH A COLLINS Notary Public CARLISLE BOROUGH, CUMBERLAND COUNTY My Commission Expires Apr 28, 2014 CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717) 249-3166 Fax: (717) 249-2863 August 5, 2011 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Jacqueline M. Verney, Esquire RE: Sondra L. Carano Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Joumal. Advertisement inserted on following dates: July 22, July 29, and August 5, 2011 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director The Sentinel www.eumbarlink.com ~~G CApIAE SFIPPHJ58tAtG ffitltY COIHJTY JACQUELINE M. VERNEY 44 SOUTH HANOVER STREET CARLISLE, PA 17013 717 243.9190 AD NUMBER PAGE NO. 399025 1 of 1 BILL DATE SALESPERSON 07/29J11 woifc START DATE STOP DATE 07H5/11 07/29H 1 ~ 399825 ~ ADMINISTRATOR NOTICE LETTERS OF AD 10 PUBLIC NOTICES 32 ' 2 cols Publication Insertions Rate Net Amount Gross Amount 3 THE SENTINEL -LEGAL 3 LGL 6169.92 TOTAL AD CHARGE S1g9.92 3 MOBILE SITE M082 62.00 3 PROOF OF PUBLICATION 01PRF 67.00 ~~+~ Order Est.S.L.Carano PAY THIS AMOUNT $178.92 $214.70' *AFTER 08/23/14 THE SENTINEL .. Thank you for advertising with The Sentinel! Deadlin, fi*~ c/o LEE NEWSPAPERS in-column legal ads is 4:C' •~in~^~ ~+• PO BOX 540 date of insP~^~ Fr WATERLOO IA 50704-0540 REV-1512 EX+ (12-Q$) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILTiTES 8F LIENS -_ ESTATE OF FILE NUMBER Sondra L. Carano 21-11-0777 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unretmbursed medkal expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1• Pinnade Health Hospital P.O. Box 2353 Harrisburg, PA 17105 2. Pinnade Health Emergency 6880 W. Snowville Rd #210 Bricksville, OH 44141-3255 3. Moffitt Health ~ Vascular Group 1000 North Front Street Worm~ysburg, PA 17043 4. Pinnade Health Cardiovascular 1000 North Front St. Wormleysburg, PA 17043 5. West Shore EMS -Carlisle 205 Grandview Ave Suite 211 Camp Hill, PA 17011 6. .Silver Spring Ambulance P.O. Box 726 New Cumberland, PA 17070 7. :Quantum Imaging & Theraputic Assoc P.O. Box 62165 Baltimore, MD 21264 8. Assodated Cardiologists 856 Century Dr. Mechanicsburg, PA 17055 9. Carisle Regional Medical Center Alexander Spring Road Carlisle, PA 17013 TOTAL (Also enter on Line 10, Recapitulation) ~ ~ __ __ If more space is needed, insert additional sheets of the same size. 8,166.50 684.00 6.00 325.00 1,007.42 971.00 36.00 75.00 3,019.97 14,290.89 PINNACLEHEALTH HOSPITALS SONDRA CARANO 295 WALNUT LN CARLISLE PA 17015-7820 Accaur~t Summary :i Statement Date: 06/02/11 Service Date(s): 05/25/11-05/25/11 Account Number: 1103197x5 Primary Diagnosis Code: 427.89 ir~~t~ranc~ Information Ins. 1: fns. 2: Ins. 3: Ins. 4: important IV'IeSSage Finanaal Aid is Available For Those Who Apply And Qualify. Customer Service Can Assist You Wdh This Process. For Account Information, Please Call (717) 230-3717 or 1-80003-6064 for Out of Area Calls. If payment has been sent, please disregard. Pay online at: http://www.pinnaclehealth.org/biifpay! Total Charges: 18,166.50 Payments/Adjustments: _ . 0 0 Account Balance: 08,166.50 Patient Balance: 08,166.50 Please Pay This Arrrt: ;i8,1ge,60 Contact ~.1 For questions, call our Billing Help line at: 717-230-3717 for local calls or 1-800-603-6064 for Out of Anew. Customer Service Hours: Mon-Wed-Fri 7:00 AM to 4:00 PM Tues-Thurs 7:00 AM to 6:00 PM Please Nb[+e: Your physlcisn wiM blN separaf~ety far professional serv/ces. Make checks Payable To: PinnadeHeafth Hospitals linl~~a~l~~l~®~t^ PtrmacleHealth Haspitais PO Boz 2353 Haarrlaburg PA 171 U5 CMdc Yes N ~rarr awnee er ieMwesee ielonnetiee ^ hn diMNe/. Pisses ~ eYewpe ee Yedc. NreiYer. Pleeee Aewws: Carano Sondra Due Now ^ ^ ^ ~: sH..wr.: J-waMe • TYe CWt NseNer ie tlr ItlR ~ /i/Me ee tlr YseY of varr etitt ea w ..e....:........ 00003033 001 0.53 SONDRA CARANO 295 wAI.NUT w CARLISLE PA 17015-7820 I~~~III~.~I.~.Illl~~~~l~l~~tl~-I PINNACLE HEALTH HOSPITALS P.O. BOX 2353 HARRISBURG, PA 17105-2353 0000011031978500000816650000000007 P.O. Box 2353 Harrisburg, PA 17105-2353 4> PINNACLEHEALTH 06/05/11 SONDR.A CAR.ANO 295 WALNUT LN CARLISLE PA 17013 PATIENT NAME SONDRA CAR.ANO ACCOUNT NO 110319785 DEAR SONDRA CARANO Pinnacle Health Hospitals is proud of its mission to provide quality care to all in need, 24 hours a day, 7 days a week, 365 days a year. If you are uninsured, Pinnacle Health provides financial Discounts from 40~ family of 4 with a a discount of 100$ account balance to nothing. aid to patients based on their income level. to 100 are offered. For example, a household income of up to $53,000 receives of billed charges, which takes their zero. In this case, the patient owes Patients wishing to apply for charity care or financial assistance must complete the Financial Aid Application provided on the back of this letter and submit the required application documentation as noted on the form. The completed Financial Aid Application is to be forwarded to Credit & Collections, P.O. Box 2353, Harrisburg, PA 17105-23.53. When the application is received the staff will review and determine if the application is complete and the documentation supports charity care or financial assistance eligibility. After we have received all the necessary documentation, you can expect to be notified of our final determination via telephone or by letter within 2 weeks of receipt. The determination of charity care will be effective for 6 months from the date of approval and will be re-evaluated at the request of the patient/responsible party. Please note that it is important that you act upon this immediately as your account will continue through the collection process if you do not complete and submit your application for the above assistance or call to establish other payment arrangements. Should you have any questions, you can call our Customer Service Department at 717-230-3717. Sincerely, HCI # PINi~7ACLE HEA~,TH HOSPI'T'ALS TYRE OF BILL DATE OF BILL DATE OF PREV. BILL p _ ~ _ , $~x 2 3 5 ~ - - - vA 1 ~ FINAL 06 02 11 ' HAR,RLS$URG~; , PA -717~ 2 ~~=;3717;-- ~' `' 17105 2~~3~ _ s . ~ ~.x, INP. ~ ~ ,; . ~ ~'Ei #$~ : 25177$644 , 'BIRTH=I3A~'E HosP.i ;- ~~ . . ~ - 0~J25f5fl $ I PATIENT NAME PATIENT NUMBER aex AGE ADMISSION DATE DISCHARGE DATE DAYS( ' CARANO SONDRA 110319785 60 OS 25 11 05 25 11 .:GUAF2~ PSI - {7i'~}'766w 7358 - 1 r~. GUARANTOR SONDRA CARANO NAME 295 WALNUT LN AND CARLISLE .PA 17013 ADDRESS ~. }. ,,,, ~~ ~ ~r h `SON W#i'H YOUR DATE P C E V SE E HOS I TA S CES CODE CHARGE INSURANCE COMPANY NAME °~ R POLICY NUMBER ,. ... ... s7, r :~ ~ ~ ~~t ~~~ MOUNT OF ~. QAYMENT ~r ~+« -~ PAYMENT .~, .~. .......... .. EST.COVERAGE EST. COVERAGE EST. COVERAGE EST. COVERAGE PATIENT S INS. CO. NO. 1 INS. CO. N0.2 INS. CO. NO.3 INS. CO. N0.4 AMOUNT DETA L OF CURRENT CHARGES, PA ENTS AN ADJUS (15/25 - 001 CRITICAL CARE 742709 610.00 05/25 004 IV INFUS HYDR 742732 440.00 05/25 001 THER/PROPH/DI 742747 176.00 05/25 001 THER/PROPH/DG 742747 176.00- 05/25 00.2 THER/PROPH/DI 742747 138.00 05/25 001 CRITICAL CARE 742756.. 305.00 05/25 001 CBC & AUTO DI 011507 69.00 05/25 001 CBC & AUTO DI 011507 69..00 05/25 001 CK 011517 46.00 05/25 001 PTT 011518 43.00 05/25 001 POTASSIUM 011520 27.00 -05/25 001 PROTHROMBIN T 011521 43.00 05/25 001 CKMB 01160.3 71.00 0.5/25 001 BASIC METABOL 011703 86.00 05/25 001 TROPONIN I 011705 65.00 05/25 001 B NATURIETIC 011707 166.00 05/25 001 CBC AND MANUA 011707 05/25 001 CBC AND MANUA 011707 57.00 05/25 001 CBC AND MANUA 011707 22.00 05/25 001 CHEST 1 VIEW 731450 123.00 05/25 001 PORTABLE 731761 189.00 )5/25 003 ATROP 1MG SYR 735009 73.20 )5/25 001 DILT 50MG VL 735040 9.40 )5/25 008 EPI 1MG 1.5 S 735045 120:40 )5/25 001 MG 1GM VL 735079 3.95 )5/25 001 ONDANSET 4MG 735099 2.40 )5/25 001 MOXIFLOX 400M 735484 99.00 )5/25 001 MOXIFLOX 400M 735484 99.00 )5/25 002 SOD BICA 8.4~ 735701 46.10 )5/25 001 MS 2MG SYR 735719 6.80 )5/25 001 MS 2MG SYR 735719 6.80 15/25 001 DOPA 400MG PM 735730 44.05 15/25 001 AMIOD 150MG A 735737. 6.40 NT NitiABEA " PLEASE REFER TO PATIENT ADDITIONAL PATIENT e NUMBER ON ALL INQUIRES FOR ANY CHARGES NC AND CORRESPONDENCE WAS PREPARED OR IF NOT PAY ANY PART C UNDER ESTIMATED INSI 610.00 440.00 176.00 176.00 138.00 305.00 69.00- 69.00 46.00 43.00 27.00 43.00 71.00 86.00 65.00 166.00 57.00 22.00 123.00 189.00 73.20 9.40 120.40 3.95 2.40 99.00 99.00- 46.10 6.80 6.80 44.05 6.40 flINNACLE HEALTH EMERGENCY 6880 W. SNOWVILLE RD #210 BRECKSVILLE, OH 44141-3255 CUSTOMER SERVK:E PFIONE: 1 (877y &16-7929 CUSTOMER SERVICE HOURS: 8:00 -.6:00 Mon -Fri Eastern TO MANAGE YOUR ACCOUNT ONLINE, PLEASE VISIT US AT: hops:l/serviceportai.rrieddata.com I~Ilrllll~rir~lhll~nrl~lln4111~1vl~nllll~~llllllhlllll SONDRA CARANO ~' .t 295 WALNUT LN CARLISLE PA 17015-7820 ~ P A Y NI G B Y CR EOfI' CARD, Fitt. pUT BELpW ®® ~ ~ ~ ~ ~ ~ ~ ^VIBA® ^IIA978iCr1RD® ^OIaCOYBI® ON6tE7~. CNbNUrI YUBT ~ SH:URRY CODE FIIDY ~~~ NINE AtRAMfANi ON TNECMD S!. AIpIt,R STATEMENT BATE PAY THIS ARIOUNT ACCQIJNT N0. 06/03/11 5884.00 PH1 1041785 CHARGES AND CREDITS MADE AFTER STATEMENT DATE WILL APPEAR ON NEXT STATEMENT. SHOW AMOUNT PAID HERE 90.10 ~ MAKE CHECKS PAYABLE / REMIT TO: ^B>_ PINNACLE HEALTH EMERGENCY DEPARTMENT SERVICES, LLC PO BOX 8500-55168 PHILADELPHIA, PA 19178-5168 ~r~lll~l~rrr~lll~~~il~~l~~l~lr~~~ll~llr~l~~lrrl~~ ^ Please check box'd above address is incorrect or insurance .. .... .. STATFMFNT PLEASE DETACH AND RETURN TOP PORTION WITH Imunlluuwl n as c~wlryw, nlm nwmxus taWmye~s/ url rever se swe. YOUR PAYMENT IN ENCLO SED ENVELOPE • 0511 23 FRONKO l1AD 458.9 99291 CG EIM CRITICALLY ILL/INJ 478.00 05/25/11 23 RALD FRONKO MD 458.9 98292 CC E/M CRITICALLY ILL/1NJ 206,00 L.~ ~..~ p . ~'- Z `~ ~ U ~ ~ l5 'PLACE OF SERVICE: 21. INPATIENT 22.OUTPATIENT 28. EMERGENCY ROOM STMT DATE 0-30 DAYS 31-60 DAYS 61-90 DAYS OVER 90 DAYS 06/03/ 11 684.00 .00 .00 .00 PATIENTS NAME LOCATION OF SERVICE ACCOUNT NUMBER SONDRA CARANO HARRISBURG HOSPITAL PH1 1041785 ;684,00 PLEASE VISIT US AT: MtpsJ/servkeportadmeddata.com CUSTOMER SERVICE PHONE:1 (877) 848-7929 CUSTOMER SERVICE HOURS: 8:00 - 6:00 Mon -Fri Eesbsm PLEASE PAY YOUR PERSONAL BALANCE PERSONAL BALANCE: 5684.00 INSURANCE BALANCE: 5.00 WORKERS COMP. BALANCE: 3.00 PINNACLE HEALTH EMERGENCY DEPARTMENT SERVICES, LLC PO BOX8500-55188 PHILADELPHIA, PA 19178188 I~~r~~~~~~~ STATEMENT SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION ~ . a i ~ ~ MOFFITT HEART & VASCULAR GROUP .06/24/11 178637 1040 NORTH FRONT STREET • WORMLEYSBURG, PA 17043 ~ - ~ 6.00* Forwarding Service Requested MC _VISA _ Disc Security _- Card~~ Code - -. Sign _ Exp _/ 33520 ESTATE OF SONDRA L CARANO MOFFITT HEART & VASCULAR GROUP 295 WALNUT LANE 1000 NORTH FRONT STREET CARLISLE PA 17013-7820 WORMLEYSBURG, PA 17043 ~• •~• ~ ~ MESSAGES EXPL.AiNED BELOW.... _ ` *** Paqq Account Balance Immediately to Avoid Collection Agency!!!!!! *** *** PLEASE CALL 717-731-0101 X3014 WITH CURRENT INSURANCE COVERAGE *** *** Thank you for your prompt payment. -Please call 717-731-8315 with any *** *****~~~~~*~**x******************************************************************** Ins/Collection Chrgs pending to Prv: 4035.00 Pay/Adj against Ins/Coll pending 476.00 0.00 3559.00 04/24/09 1 18 OFFICE VISIT EST LEVEL 3 99213 414.01 75.00 05/20/09 - GATEWAY HEAL Payment ~ 34.50 05/20/09 HMO/PPO Adj. -36.50 02/16/11 GAIL GUIDA Payment 4.00 0.00 09/23/09 1 18 L OFFICE VISIT EST LEVEL 4 99214 414.01 120.00 03/11/10 MEDICAL ASSI Payment 48.42 03/11/10 Accept Assign Adj. -65.58 6.00* 04/05/11 1 17 PROGRAM EVAL, ICD SINGLE 93282 427.1 145.00 04/05/11 Courtesy Adj. -29.00 04/05/11 Check-Personal Payment 116.00 0.00 L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make payment. -DATE LAST PAID AMOUNT ~ . ~ ~ • 04/05/11 116.00 0.00 0.00 0.00 0.00 6.00 145.00 3414.00 3565.00 MAKE MOFFITT HEART & VASCULAR GROUP ~ ~ I ~I ~ ~ ` ~ , CHECK 1000 NORTH FRONT STREET ~ArAS~Ero: WORMLEYSBURG, PA 17043 6.00* Ph:(717)-731-0101 PAT~~ 1-SONDRA L CARANO PRV~ 17-RADTRE, NANCY, MD, FACC Accts/: 178637 PRV~/ 18-MYERS, LOUIE, D0, FACC Date: 06/24/11 Page 1 of 1 ~ ~ i1 i ~ 1 PINNACLEHEALTH CARDIOVASCULAR INST, INC 06/24/11 178637 1000 N FRONT-ST-(MOFFITT HEART &VASC) WORMLEYSBURG, PA 17043 -- 325.00* Address Service Requested _MC -VISA -Disc Security Card~~ Code _ Sign Exp _/ 33503 ESTATE OF SONDRA L CARANO PINNACLEHEALTH CARDIOVASCULAR INST, INC 295 WALNUT LANE - 1000 N FRONT ST (MOFFITT HEART &VASC) CARLISLE PA 17013-7820 WORHLEYSBURG, PA 17043 :~ •• ~~: •. e - •t CAGES EXPWNED ~ BELOW -- -- -- *** Paq Account Balance Immediately to Avoid Collection Agency!!!!!! *** *** PLEASE CALL 717-731-0101 X3014 WITH CURRENT INSURANCE COVERAGE *** *** Thank you for your prompt payment. Please call 717-731-8315 with any *** 05/25/11 1 70 CRITICAL CARE FIRST HOUR 99291 786.09 325.00 325.00* DATE u-s~r PaD AMOUNT • ~ • • • ~ • 00/00/00 0.00 325.00 0.00 0.00 0.00 0.00 0.00 0.00 325.00 PINNACLEHEALTH CARDIOVASCULAR INST, INC ~ ~ , it , ~ MAKE CHECK 1000 N FRONT ST (MOFFITT HEART &VASC) aArae~Ero: WORMLEYSBURG, PA 17043 325.00* Ph:(717)-731-0101 PAT~~ 1-SONDRA L CARANO PRV~~ 70-MARTIN, ROBERT, MD, FACC Acct: 178637 Date: 06/24/11. Page 1 of 1 . ..~, ~ w ~,..~ WEST SHORE EMS -CARLISLE asco~ . ~ ~* 205 GRANDVtEW AVE SUITE 211 ~~ CAMP HILL, PA 17011 oN REVERSE SIDE ~~~+ ~ Phone #: (800) 367-0512 Federal Tax ID: 23-2463002 PATIENT NAME: SONDRA CARANO CALL NUMBER: 1109955 SONDRA CARANO 295 WALNUT LN CARLISLE, PA 17013 INSURANCE: DATE OF CALL: 05/25/2011 PRIV NONE FROM: 295 WALNUT LN TO: HARRISBURG HOSPITAL ACCOUNT SUMMARY TOTAL CHARGES: 1007.42 PAYMENTS/ADJUSTMENTS: 0.00 PLEASE PAY THIS AMOUNT: 1007.42 DETACH ALDNG PERFARdTIAN dNA QCT! /O/u cri ~Q wrru nw wr.~r DESCRIPTION OF CHARGE QUANTITY UNIT PRICE _ AMOUNT ALS EMERGENCY LEVEL 1 A0999 1.0 967 62 ANGIOCATH (1424) A0394 1.0 . 6.72 967 62 6 72 EKG ELECTRODES (1) A0396 10.0 0.80 8 00 EXTENSION SET 8" NEEDLELESS A0394 1 0 12 52 , INF CONTROL GLOVES (PR) A0382 . 1 0 . 1 00 12.52 GLUCOSE BLOOD A0394 . 1.0 . 7.08 1,00 7 08 OP SITE A0394 1.0 1.92 1 92 SALINE PREFILLED SYRINGE A0394 1 0 2 56 . . , 256 Total Charges 1007.42 DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOI~~ Total Credits 0.00 PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT -- RETURNED CHECK FEE - $31.00 :1007.42 PATIENT NAME CARANO, SONDRA L CALL NUMBER: 1109955 AMOUNT PAID: 06/09/2011 IMPORTANT MESSAGES: THIS INVOICE IS YOUR RESPONSIBILITY. Please forward this itemized statement to your Ins Carrier and MAKE PAYMENT DIRECTLY TO US. Pieaae include Invoice Numbers on your check. WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011 Please Remit Payment To: Silver Spring Ambulance & Rescue Assn Bitting Office P.O. Box 726 New Cumberland, PA 17070 QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espafiol: 866-724-4114 Fax: 717-214-6020 Email: iM`o~ambulancebllliny0}/ice.~m Date of Service: 5/25/2011 1217 Please visit our website to provide insurance or make payment, and Patient Name: CARANO, SONDRA L. for additional payment options and frequently asked questions: From: RESIDENCE www.ambulancebillin office.com To: Harrisburg Hospital (Pinnacle) 9 '`Pleasaread~tJuahill~,r~~~rts,~onsa~flil~~w"33'e3sizv~~sn3duce`t~,fvron'on~'rle~brgot: Pleaseptd~ideyvur -. ~ , ~. .. insurance informal/on fl>a the back o. f'ths bill or remit pa~m~nt, Tlictrik~ u, ` Yo 5/25/11 Basic Life Support Emergency A0429 1.0 600.00 600.00 5/25/11 Mileage A0425 21.4 15.00 321.00 5/25/11 Oxygen A0422 1.0 50.00 50.00 Total 971.00 0.00 0.00 ----^------DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT. .'I~A6~C~ygr+~r*'h fuA b~,d'fdrtf.~"ti t~rQ of e~anic" x4ed~a l~7ce C.]iecfc Pb~abTe ~'o~ ct+ec3c~It~eHon. P4eex Indlcett Yot~'Puj'fnet~i Ci-ofcC btlaw .. ~u. ---. , -~ , -, _ ..,~.:, " and tillln-regalred information. If-r~ther.arrangernentsar~-- StlVer,Spfirlg,AmbUlattce &, necessary, please tafi us at 87T-n+t=cross. Rescue Assn" a - a o Credit Card: ^ MASTERCARD ^ VISA ^ AMERICAN pEXPRESS ^ DISCOVER I ~ ~ ~ ~ ~ ~~~ ~ ~~~ Card Numoer Please make any corrections to address below. Name on Cara Expiration Electronk Check Dedudk~n Please send a voided check OR provide information be/ow• `- Bank Routing Number Checking Account N ber Signature SONDRA L. CARANO 295 WALNUT LANE CARLISLE, PA 17013 *Retumed checks -You will be responsible for all Incurred bank fees permissible under state law. DO NOT SEND PAYMENTS TO THIS ADDRESS Deft. 19687 P O Box 1259 Oaks, PA 19456 I~~~~®~~'~~~~~ For billing questions call: (717)932-5955 or. (877)932-5955 Fax: (717)932-4858 Office Hours: 8:00 AM - 4:30 PM ~ ~A~q ~ alA~7aAt:ARD OR OACOY61. R.L OUT YELO'Y1 ~ ^weTar,~no ® ^o~eoo+rER ...~,. wsrNauDesaort s~unnr coos ~ ercu of c1wD STATEMENT t?/ITE PAYTINIS AMOUNT AG>;OtiN'r NQ. 6/6/2011 $36.00 131092 CHARGES AND CREDITS MADE AFrER STATEMENT DATE WILL APPEAR ON NEXT STATEMENT. SHOW AMOUNT PAID HERE ~ MAKE CHECKS PAYABLE /REMIT TO: ~ I I I11 ~ 11 ~ 1~ 1111"11' 1 1 1 1 1 l' 1 1 1 l' 1' i l l l' I I I"1111111f111' 1' 1 1 1 l' 1 1 1 es7o-1T0 ~ntum Imaging and Therapeutic Associates SONDRA L CARANO P O Box 62165 ' 295 WALNUT LN Baltimore, MD 21264-2165 CARLISLE PA 17U15-7820 I~~I~I~~~11~~1~1~11~~~1~~1~~1~1~~~11~11~~~1~1~~11~~~1~1~11~~~1 ^ Please check box ff above address is incorrect or insurance ~ PLEASE DETACH AND RETURN TOP PORTION WITH Information has changed, and indicate change(s) on reverse side. ~ YOUR PAYMENT IN ENCLOSED ENVELOPE Patient: SONDRA L CARANO Account: 131092 ~ Services Rendered At: HARRISBURG HOSPITAL Date C de Description - - Charge Ad uystm~eMs 5125/2011 71010 CHEST SINGLE VIEW FRONTAL 36.00 Current 31 - 60 61 - 90 91 -120 Over 120 BALANCE D UE 536.00 36.00 0.00 0.00 0.00 0.00 PAY BY July 06, 2011 THIS ACCOUNT BALANCE IS YOUR RESPONSIBILITY. For billing questions CaIL• (717)932-5955 PLEASE REMIT PAYMENT IN FULL OR CALL OUR or: (877)932-5955 OFFICE IF PAYMENT ARRANGEMENTS AND/OR Fax: (717)932-4856 INSURANCE INFORMATION IS NECESSARY. Office Hours: 8:00 AM - 4:30 PM Tax ID: 251792806 STATEMENT I~i1~Ir11M~~1^Il~lrelll SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION ASSOCIATED CARDIOLOGISTS, P.C. 858 CENTURY DRIVE MECHANICSBURG, PA 17055 RETURN SERVICE REQUESTED Billing Phone: 717-591-7122 Billing Fax: 717-591-7153 Office Hours: Mon-Fri 8:00-4:00 F-~rnowvw-onwsrt~c~ ~uo~ur~a,ow a~.A ® o~~ ~~ •""TM~ tYxrsTwauDeaDart aFa~anr cooE Fnw ~~~ STATEMENT DATE PAY iHL4 AMOUNT ACCOUNT f+t0. `` 06/13/2011 $75.00 288265 CHARGES AND CREDITS MADE AFTER STATEMENT DATE WILL APPEAR ON NExT STATEMENT. SHOW AMOUNT PAID HERE ~~ MAKE CHECKS PAYABLE / REMIT TO: ~~ "'llil'I"11'11111'11111111111'il'I'1'II'lll'li'llllllll""1111 ea714~2 SONDRA CARANO 295 WALNUT LN ASSOCIATED CARDIOLOGISTS, P. C. CARLISLE PA 17015-7820 856 CENTURY DR MECHANICSBURG PA 17055-4505 I~~~III~~~lll~~~~l~l~~i~l~~l~~l~l~l~ll~~~~l~l~l~l~~l~l~~ll~r~l ^ Please check box if above address is incorrect or insurance information has changed, and indicate change(s) on reverse side. PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT IN ENCLOSED ENVELOPE .DATE OF PROCEDURE... SERVICE CODE PROCEDURE DESCRIPTION DIAGNOSIS CHARGE CREDIT BALANCE xcxxxxxx xxx-- xx :xax=-=cxx==xcxxsx=-zxxc=xx. xx~zxc=xx xxxxxsxx xxx:xxxx xxsxa:: 05/25/11. 93010 ECG INTERPRETATION/REP 786.50 25.00 .00 25.00 05/25/11 93010 ECG INTERPRETATION/REP 427.89 50.00 .00 50.00 AMOUNT DUE $75.00 STATEMENT I~~II~I~~~N1~~I1~ SEE: REVERSE SIDE FOR IMPORTANT BILLING INFORMATIGN 06/26/2012 13:58 FA% 717 7764362 618 Spring PhaT'nlacy Inc f~J.004 The Law does of ,Aiichel! D. B~uhrn 8~ Aeeo~ciates, LtC :~~orney~.~tt Law . 2222 T®~orr~ f~ltw~ Ife 1$~ Sherman, Tesas.t5090 Ca~9isle Regional Meelical COrrter 3f3N~iA~ 1. ~ARANO Z5A6989 . 85&9417`55 118` 3f~.94 April 7, 2011 `-`'Fh~nt~1 ~r.'`' , REV-1513 EX+ (O1-10) Pennsylvania SCHEDULE ] DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAx RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Sondra L. Carano 21-11-0777 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. Trent Anderson 941 Greenspring Rd Newville, PA 17241 son 1 /4 2. Wayne G. Anderson, Jr. 33 Springview Rd Apt 3, Carlisle, PA 17015 son 1 /4 3. TinaMarie Hetfier 297 Walnut Lane, Carlisle, PA 17015 daughter 1/4 4. Matthew J. Anderson 297 Walnut Lane, Carlisle, PA 17015 son 1 /4 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ; If more space is needed, use additional sheets of paper of the same size.