HomeMy WebLinkAbout08-13-12 (2)
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J 1505610105
.
REV-1500 ex (pz-„1(rp OFFICIAI-USE ONLY
PA Department of Revenue Pennsylvania County Qx1e Year File Number
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO Box zBO6ot
a
~ - ~a - ~~3
RE
Harrlsbu , PA 17118-O6o7 SIDENT DECEDENT -
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMODYVYY Date of Birth MMDOYYVV
01/23/2012 11/20/1942
Decedent's Last Name Suffx Decedent's Fir st Name MI
Flaccus Robert W
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
FILL IN APPROPRIATE OVALS BELOW
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
~ 1. Original Retum O 2. Supplemental Retum O 3. Remainder Return (Date of Death
Prior to 12-13-82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. f=ederal Estate Tax Return Required
death after 12-12-82)
OD 6. Decedent Died Testate O 7. Decadent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Wilq (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)
Between 12-31-91 and 1-1-95) iAttach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TA%INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
(5701510-3664
Robyn L Cardamone
First Line of Address
245 Winding Way
Second Line of Address
City or Post Office
Camp Hill
State ZIP Code
PA 17011
' N_
REGISTER S USE ONLY,
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Correspondent's a-mall address: fODyn CarOamOne mgmau.cOm _
Under penalties of Derjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowletl9e end belief,
it is true, correct and complete. Declaration of preparer oNer than the personal representative is based on all intormatioc of which preparer has any knowledge.
SIGI.j~T~~O'~~ SON, RES~ I~~F~ ILING RETURN ry `D~T~~ j
ADD~'R[[ESSTPVVW+~ .A...~Ar^/-~. `~ IF
245 Winding Way, Camp Hill, PA 17011
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
150561D1D5 1.505610105 J
,J
15056102(75
REV-1500 EX (FI)
oecedenrs Name: Robert W Flaccus Dec:edent's Social Secudty Number
RECAPITULATION
1. Real Estate (Schedule A).. ........... 1. 0.00
2. Stocks and Bonds (Schedule B) ............... . .. 2. 79,084.03
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 0.00
4. Mortgages and Notes Receivable (Schedule D) ......................... . . 4. 0.00
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 7,576.18
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. 0.00
7. Inter-Vivos Tansfers 8 Miscellaneous Non-Probate Property
34
330
810
(Schedule G) O Separete Billing Requested...... .. 7. ,
.
8.
9 ) ...........................
Total Gross Assets (total Lines 1 throw h 7 6.
.. 417,470.55
9. Funeral Expenses and Administrative Costs (Schedule H) ..... ............. 9.
10. Debls of Decedent, Mortgage Liabilities and Liens (Schedule I) ............... 10.
11. Total Deductions (total Lines 9 and 10) ......... ... ......... ....... ii.
12. Net Value of Estate (Line 8 minus Line 11) .............................. 12.
13. Charitable and Governmental Bequestsl5ec 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.
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers untler Sec. 9116 0
00
(a)(1.2) X 0 0 . 15.
16. Amoun[ of Line 14 taxable
at lineal rate X .0 45
18,359.44
i6.
17. Amount of Line 14 taxable
0
00
at sibling rate X .12 . 17.
18. Amount of Line 14 taxable 0
00
at collateral rate X 15 . 18.
19. TAX DUE .............................. ........... ......... .. ..... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L 1595610205 1505610205
7,130.06
2,352.87
9,482.93
407,987.62
0.00
407,987.62
0.00
18,359.44
0.00
0.00
18,359.44
O
REV-t 500 EX (FI) Page 3
Iluncrinn4'c r`mm~lP}P_ O[~[f rBSS'
Flle Number
DECEDENT'S NAME
Robert W Flaccus
STREET ADDRESS
824 Lisburn Road, Room 106
CITY STATE ZIP
Camp Hill I PA 17011
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments _.. _ _ 17_,440.00
B. Discount 872.00
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) 18,359.44
Total Credits (A+ g) (2) 18,3
(3) 0.00
(4) 0.00
(5) 47.44
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 transfemed .................................................................................... ...._ ^
b. retain the right to designate who shall use the property transfened or its income ..............._..................... ....., ^
c. retain a reversionary interest ........................................................................................................................ ...... ^
^
d. receive the promise for life of either payments, bene0ts or care? ............................................................... _._..
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate considemtion? ......................~................................................................................. ..,... ^
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 Beneficiary designation7 ................._..............._..............................................._............................. ...... ~ ^
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 thle 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
fling a taz 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 benefciaries is 4.5 percent, except as noted in [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 def ned,
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1503 EX+ O-v)
;; ~ pennsylvania SCHEDULE B
~ UFPAPTMEXT OF REVENUE
INHERITANCE TA%RETURN
STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Robert W Flaccus 21-12-0183
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1' Frontier Communications 929.34
2 AKRE Focus Fund Mutual Fund 2,926.35
g Doubline Tolal Return Mutual Fund 20,181.65
q Gabelli Asset Mulual Fund 2,939.11
5 Vanguard FTSE Mutual Fund 3,602.02
g Vanguard GNMA Mutual Fund 11,339.56
7 Vanguard International Mutual Fund 4,729.49
g Vanguard Short Term Mutual Fund 5,955.22
g Vanguard Total Stock Market Mutual Fund 14,897.05
10 Vanguard I Wellesley Mutual Fund 11,584.24
TOTAL (Also enter on Line 2, Recapitulation) ; 79,084.03
If mare space Is needed, insert additional sheets of the same size
REV-1508 EX• (Il-ID)
!!7 pennsylvania SCNED!!LE E
Ril DE°"nT"E"' D` nE°E"°E CASH, BANK DEPOSITS & MISC.
wNERtTnNCE Tnx REruarv PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER
Robert W Flaccus 21-12-0183
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 ichedule F.
[f more space is needed, use additional sheets of paper of the same size.
Re4~4.51G EX+!Ua-09)
Pennsylvania SCHEDULE G
2 oEPnHTMeNTOFxE~eNDE INTER-VIVOS TRANSFERS AND
I"HERB"NCETnx RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF
Robert W Flaccus 21-12-0183
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page thrre of the REV-1500 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INQDDE THE NANE Di iXE TRNYSFEAEE, THEIR REUTIDNSHIP TD DECEDENT AND
THE DnTE Dr TAaxsEEA. annex ncoov Di THEOEEOEOR REnl ssrnTe. DATE OF DEATH
VALUE OF ASSET °~o OF DECD'S
INTEREST EXCLUSION
pinPPUCneie~ TAXABLE
VALUE
t. All items listed below on this schedule were transferred to Robyn L
Cardamone. Robyn is the daughter of Robert W Flaccus
All items listed below were transferred on date of detath because Robyn L
Cardamone was listed as sale primary benefciary on all accounts.
1 Ally 24 Month Certifcate of Deposit 29,528,14 100 29,528.1.
2 Ally 18 Month Certificate of Deposit 16,062.34 100 16,062.3
3 Ally Online Savings Account 26,057.34 100 26,057.3
4 State Fann Benefit Management Account 10,169.51 100 10,169.5'
5 Scottrade Rollover IRA Account 248,973.01 100 248,973.0
TOTAL (Also enter on Line 7, Recapitulation) ; 330,810.34
If more space is needed, use additional sheets of paper of the same size.
REV-l.:7t EX+ (LO-09)
SCHEDULE H
pennsylvania
DEaanrmENr or REVENUE
INRERIr^NCET^xREniRN
RESIDENT DECEDENT FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Robert W Flaccus 21-12-0183
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1' Professional Services (less $175 Veterans Benefit) 1,800.00
Equipment and Staff 380.00
Automotive Equipment 637.50
Merchandise 2,110.00
Death Certifcates/Obituary 204.90
Crypt Opening and Closing 1,320.00
Floral Arrangements 238.50
B. ADMINISTRATIVE COSTS:
1, Personal Representative Commissions:
Name(s) of Personal Representative(s) _ _ _ _ _ _ _ _
Street Address
City _ State ZIP
Year(s) Commission Paid; _
2. Attorney Fees:
3. Family Exemption: Qf decedent's address is not the same as claimant's, attach explanation.)
Claimant
Street Address
City _____ __. ____ -_. _._ ____... State __. ZIP
Relationship of Claimant to Decedent _ _ _ _ _ _.... _ _ __ _ _ _
a, probate Fees: 439.16
5, Accountant Fees:
6, Tax Return Preparer Fees:
7.
TOTAL (Also enter on Line 9, Recapitulation) ; 7,130.06
If more space is needed, use additional sheets of paper of the same size.
RN-7.5t2 EX+ ~ l7-NN)
pennsyNania SCHEDULE I
oEaaRTmENr of REVENUE DEBTS OF DECEDENT,
~NNERIT^NCETnx RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
-._ __
ESTATE OF FILE NUMBER
Robert W Flaccus 21-12-0183
If more space is needed, insert additional sheets of the same size.
REV-] 513 EX+ (0140)
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES IS THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS T
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
~ ,' pennsylvania SCHEDULE 7
DEPARTMENT DE Rf NEN11E BENEFICIARIES
tNHERRANCE TA% RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Robert W Flaccus 21-12-0183
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. Robyn L Cardamone, 245 Winding Way, Camp Hill, PA 17011 Daughter 100%
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. § D
If more space is needed, use additional sheets of paper of the same size
COMMONWEALTH OF PENNSYLVANIA
DEPARTMEN( OF REVENUE
BUREAU OF INONIDUAL TA%E6
DEPT. 260601
HARRISBURG, PA 1]128-0801
RECEIVED FROM:
CARDAMONE ROBYN l
245 WINDING WAY
CAMP HILL, PA 17011
eoa
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
ACN
ASSESSMENT
CONTROL
NUMBER
ESTATE INFORMATION: ssN: zoo-36-asio
FILE NUMBER: 2112-0183
DECEDENT NAME: FLACCUS ROBERT W
OATEOFPAYMENT: 04/04/2012
POSTMARK DATE: 04(03/2012
COUNTY: CUMBERLAND
DATE OF DEATH: O1 /23/2012 -
REV-1162 Ex111-98)
NO. CD 015796
AMOUNT
101 ~ 517,440.00
TOTAL AMOUNT PAID:
REMARKS: -
SEAL
CHECK#101
INITIALS: HEA
RECEIVED BY:
517,440.00
GLENDA EARNER STRASBAUGH
REGISTER OF WILLS
TAXPAYER
°ege i of 2
f ro~l~er®
Communications
;_~ 001328
iii I'Id'il'11'I~'II'III'~~1~~~1'~LrJ~~IJrrl'l1~nLinllllllll'~
_~ ROBERT W FLACCUS
~ 245 WINDING WAY
CAMP HILL PA 1701 t
~,omputershare
Computer.trare Trust Company, N.A.
PO Box 43078
Providence, RI 02940.3078
whin USA, US terdlaries s canada 6n no pass
Outside USF~. US territories & Canada 781 575 2382
vm~vi.computershare.comfinvestor
FRONTIER COMMUNICATIONS CORPORATION -Sales Advice
Trade Date: 17 Jan 2012 14:01 (Time) Settlement Date: 20 Jan 2012 Cost Basis Method: FIFO
ShareslUnits Price per Gross Amount I Trading BankinglWire Taxes Other Net Amount
Sold SharelUnit (USD) of Sate (USD); Fees (USD) Fees (USD) Withheld (USD) Fees (USD) of Sale (USD)
186.472024 5.130505 966.96 37.62 0.00 0.00 0.00 929.34
Covered Transaction Total: 14.805964 Noncovered Transaction Total: '173.666060
Covered ShareslUnits Covered Cost Covered Short Tenn Covered Long Term Overall Covered
Sold Basis (USD) GaiNloss (USD) GaiNtoss (USD) GainlLoss (USD)
14.805960 _.._.. _ _.. ____~ 98.72 (22.16) 0.00 (22.16)
PLEASE SEE REVERSE SIDE FOR IMPORTANT DISCLOSURES AND DEFINfTIONS
1 L T R F R O N
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PAGE1
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website - htlp:~'/www.psecu.com 1
~oiNr oweea
ROBERT W FLACCUS
ROBYN CARDAMONE, POA
245 WINDING WAY
CAMP HILL PA 17011-8462
Post Eff Description Amount Balance
O1/O1 ID O1 REGULAR SHARE Beginning Balance 505.89
01/24 Withdrawal via Home Banking Transfer To Share 09 500.00- 5.89
01/31 Payment: Dividend 0.250'k 0.08 5.97
Annual Percentage Yield Earned 0.250 from 01/01/12 through 01/31/12
Based on Average Daily Balance of 376.86
01/31 Ending Balance 5.97
------
------- Dividend YTD: Year to Date
---------------------------------------------------- 0.08
--------
------------
--------
------
Post -------
Eff ----------------------------------------------------
Description -------- -----------
Amount ---------
Balance
O1/O1 ID 02 VACATION SHARE - HEALTH SAVING Beginning Balance 0.00
01/31 Ending Balance 0.00
Dividend YTD: Year to Date 0.00
Post Eff Description Amount Balance
O1/O1 ID 03 CHRISTMAS SHARE Beginning Balance 1.32
01/31 Ending Balance 1.32
Dividend YTD: Year to Date 0.00
------
Post -------
Eff ----------------------------------------------------
Description -------------------
Amount ---------
Balance
O1/O1 ID 09 CHECKING Beginning Balance 4083.71
01/03 Payment: Direct Deposit US TREASURY 303 965.00 5046.71
TYPE: XXSOC SEC ID: 3031036030
CO: US TREASURY 303
01/17 BILLPAYER CHECK 011709 FOR $114.75
WAS MAILED TO HOLY SPIRIT HOSPITAL.
01/18 Withdrawal Direct Deposit GREAT COMMISSION 4937.00- 611.71
TYPE: Direct Deb ID: 251615372
CO: GREAT COMMISSION
01/19 BILLPAYER CHECK 011918 FOR $42.55
WAS MAILED TO SPARTAN PHARMACY.
01/22 Payment: via Home Banking Transfer From Share 07 300.00 911.71
01/23 BILLPAYER CHECK 012307 FOR $45.00
WAS MAILED TO HAMPDEN PHYSICIAN ASSOCIATE.
01/23 Check 011709 119.75- 796.96
r~c~~
websiie - http:/'/www.psecu.com 2
JOINT OWPIER
ROBERT W FLACCUS
ROBYN CARDAMONE, POA
245 WINDING WAY
CAMP HILL PA 17011-8462
01/29 Withdrawal Direct Deposit STATE FARM LIFE 13.25- 783.71
TYPE: LOOSF6007 ID: 9LOOSF6007
DATA: INSURANCE PREMIUM
CO: STATE FARM LIFE
01/24 Withdrawal Direct Deposit STATE FARM LIFE 14.25- 769.46
TYPE: LOOSF6007 ID: 9LOOSF6007
DATA: INSURANCE PREMIUM
CO: STATE FARM LIFE
01/24 Payment: via Home Banking Transfer From Share O1 500.00 1269.46
01/26 Payment: at ATM #00003149/PK2595 98.11 1367.57
ATM PNC BANK 1104 CARLISLE RD CAMP HILL PA
01/27 Payment: at ATM #00003464/PK2595 929.34 2296.91
ATM PNC BANK 1104 CARLISLE RD CAMP HILL PA
01/27 Check 011916 92.55- 2254.36
01/27 Check 001961 75.00- 2179.36
01/30 Check 001460 121.09- 2058.27
01/31 Payment: Dividend 0.100 0.28 2058.55
Annual Percentage Yield Earned 0.100 from 01/01/12 through O1/31/1Z
Based on Average Daily Balance of 3310.15
01/31 Ending Balance 2058.55
Dividend YTD: Year to Date 0.26
Number Amount Number Amount Number Amount NLmlber Amount
001460 121.09 001461 75.00 011704* 114.75 07.1916* 42.55
* Asterisk
----------
---------- next to number indicates skip in number sequence
---------------------------------------------------------------
-------------------------------------
-----
-
----
------------
--------
Post -
----
---
--------
Eff Description ------------
Amount --------
Balance
O1/O1 ID 07 MONEY MARKET Beginning Balance 1586.91
01/14 Withdrawal via Home Banking Transfer 33.99- 1554.92
To CARDAMONE, RICHAR XXXXXXXXXX Share 09
01/22 Withdrawal via Home Banking Transfer To Share 09 300.00- 1254.92
01/31 Payment: Dividend 0.300 0.38 1255.30
Annual Percentage Yield Earned 0.3008 from 01/01/12 through 01/31/12
01/31 Ending Balance 1255.30
Dividend YTD: Year to Date 0.38
--- Continued on following page ---
P.O. Box 2554
Cranberry Twp, PA 16066
040449/140141//40449r0000rO00000I215798000 Ot 000000
ROBERT W FLACCUS
ROBYN CARDAMONS POA
245 WINDING WAY
CAMP HILL PA 17011-8462
CUSTOMER STATEMENT
Statement Period
12/21/2011 - 01 /20/2012
Page 1
Customer Care Information
ToU Free 877-247-ALLY (2559)
www.ally.com
Account Type Account Number Beginning Balance Ending Balance
--
24 Month Certificate
pooooooc6082
$2f1,063.13
$29,528.14
18 Month Certificate Ioooooo0c6090 $1Fi,852.48 $16,082.34
Online Savings Account ~ooalocxx9081 _ $;1,499.44 $26,057.33
£ Total Account Balances $50,415.05 $71,867.81
If you only have a Cert~cate of DeposO(CD) account with us, you will receive a quarterly statement. If you have a
saviru~s or dledcing account with us, then we wUl make your statement available for gall of your accounts, including CDs,
monthly by mail or electronically. U you have a CD with electronic transfers, you will receive a monthly statement for any
month an electronic transfer occurs.
Money Magazine nart~d AUy Bank one of the 'Best Banks of 2011' - MONEY(R) Magaarle, 9epL 2011. Why not start
saving more in the rtew year with an AYy Online SavMgs Account? You'll earn rates that are corlsi~rrtly among the
most competitive in the country. To open another account, caU us 2417 ai 877-247-ALLY (255.9) and press 'b" to speak
to a real person or visit us at allybankcom.
The Statement Period is the monthly combined statement cycle detemlined by the oldest opeh account. Any accounts
opened subsequellfly wiU be based on tf19 same mon!ltly cycle. The hrter~t Earned and Days irliormatirsl reflect the
time in the statement period partkxllar to each account.
Statement Period
12/21 /2011 - 01 /20/2012
Page 2
S
a 24 Month Certificate
Summery For: Robert Raccus
Account Number: xxxxxxxx8082
Product: 2-Year Raise Your Rate CD
Customer Care Mhamation
Toll Free 877-247-ALLY (2559)
www.ally.com
Open OMe: 1 110 5 201 0
Maturity Date: 11/1212012
Summary
Beginning Balance
Deposits and Other Credits
Interest Paid This Period
Withdrawals and Other Debits
$29,063.13
$0.00
$465.01
-$0.00
Days In Statemem Period 31
Annual Percentage Yield Eamed 1.61°~
Average Daily Balance Thi;> Period $29,378.14
Interest Paid Year to Data $0.00
Interest Accrued This Period $25.89
Interest Accrued Year to Date $25.69
Ending Balance
229,526.14
Raise Your Rate Summary
Available/Allowed Increases 1/1 Exercised Rate Increases 00
Date of Last Rate Increase
Actiliity
Date Description Credits Debits Balance
12/21/2011 Beginning Balance $29,063.13
12/31/2011 Interest Eamed $465.01 -$0.00 $29,528.14
01/20/2012 Ending Balance 529,528.14
Statement Period
12/21 /2011 - 01 /20/2012
Page 3
~ 18 Montfi Certificate
Summw For: Robert Rectos
Account Number: x7ooocx~oc6090
Product: 18-Month CD Account
Customer Care Mformation
Toll Free 877-247-ALLY (2559)
www.ally.com
Open Date: 11 X052010
Matruity Date: 05/102012
Summary
Beginning Balance
Deposits and Other Cred'Rs
Interest Paid This Period
Withdrawals and Other Debits
$15,852.48
$0.00
$229.86
$0.00
Days In Statement Period 31
Annual Percentage Yield Eamed 1.46%
Average Daily Balance Thi:> Pericd $16,008.19
Interest Paid Year to Data $0.00
Interest Accrued This Period $12.69
Interest Accrued Year to Date $12.69
Ending Balance
518,082.34
Date Description Credits Debits Balance
1 2121 /20 1 1 Beginning Balance $15,852.48
12/31/2011 Interest Eamed $229.86 -$0.00 $16,082.34
01/20!2012 Ending Balance $78,082.34
Statement Period
12/21 /2011 - 01 /20/2012
Page 4
Online Savings Account
Summary For: Robert W Rectos
Accoum Number: ~oooooooc9081
Product: Online Savings
Cardamons POA
Open Date: 10252010
Custaner Care Mfonnation
Toll Free 877-247-ALLY (2559)
www.ally.com
Summary
Beginning Balance $5,499.44 Days In Statement Period 31
Deposits and Other CredRs $20,545.00 Annual Percentage Yield Eeu ned 0.87%
Interest Paid This Period $12.89 Average Daily Balance This; Period $17,549.08
Withdrawals and Oilier Debhs -$0.00 Interest Paid Year to Date $12.89
Ending Balance
$28,057.99
Overdraft Fee Summary This Period Year-to-Date
Overdraft Rams Paid $0.00 $0.00
Overdraft Rems Returned $0.00 $0.00 J
Activity
Date
D~eription
Credits
Debits
4
Balance
12/21/2011 Beginning Balance $5,499.44
12/30/2011 ACH Deposit $929.00 -$0.00 $8,428.44
Requested transfer from ROBERT W
FLACCUS (PENNSYLVANIA STATE
EMPLOYEES CU Checking XXXXXX1800)
01/03/2012 ACH Deposit $19,616.00 -$0.00 $26,044.44
Requested transfer from ROBERT W
~ FLACCUS (PENNSYLVANIA STATE 3
EMPLOYEES CU Checking XXXXXX1800)
~ 01/20/2012 Interost Earned $12.89 -$0.00 $28,057.33 ^,
01/20/2012
~ ErMing Balanee 526,057.33
na.. .. .. _..._. .. .- ~ ._. .. .._.. .._.._... .~ ~ _.d
_,.,. ,... State Farm Benefit Management Account
~~ State Farm Life Insurance Companies
°~°+aspx~Q PO Box 2380
Bloomington, Illinois 61702-2380
Last statement: December 25, 2011 Page 1 of 2
This statement: January 25, 2012 9200769346
Total days in statement period: 31 (0)
Direct inquiries to:
es2-ooo0200-ooo2sss-o 877 734-226:1
ROBERT FLACCUS
245 WINDING WAY State Farm Ilnsurance Companies
CAMP HILL PA 17011-8462 PO Box 23111
Bloomington IL 61702-2316
Account number 9200769346 Beginning balance $10,121.80
Low balance $10,121.80 Total additions 37.91
Average balance $10,121.80 Total subtractions 0.00
Avg collected balance $10,121.00 Ending balance $ 10,159.71
Interest paid year to date $37.91
CREDITS
Date Description Additions
01-25 'Interest 37.91
DAILY BALANCES
Date Amount Date Amount Date Amount
12-25 10,121.80 01-25 10,159.71
INTEREST INFORMATION
Annual percentage yield earned 4.51%
Interest-bearing days 31
Average balance for APY $10,121.60
Interest earned $3'191
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133 East Third Street
Williamsport, Pennsylvania 17701
Funeral Directors
Jeffrey T. & Carl W. Crouse
Telephone (570) 322-4706
TO: The estate of DATE: February 6, 2012
Robert W. Flaccus
TERMS: as per statement of funeral
goods and services selected
FOR FUNERAL EXPENSES OF: RObert W. Flaccus
Professional Services
Equipment and staff
Automotive Equipment: basic
transportation from Camp Hill to Williamsport
Merchandise: Aurora "Spartan" coppertone 18 ga. steel full. couch
casket with belleaire crepe interior
Register Book
Cash Advances: ten copies of the death certificate @ $6.00 Fier copy
ten veteran staus copies of the death certificate
Williamsport Sun-Gazette
'Rain Hi11s Memorial Park - lawncrypt opening & closing
Janet's Floral Creations - three matching baskets, $75.00
each plus sales ta.x
Total
Lycoming County veterans
benefit (if eligible)
Balance
~ ~~~a~~~
,~.~
+~J,7
$ 1,975.00
380.00
445.00
192.50
2,085.00
25.00
60.00
n/c
144.90
1,320.00
238.50
$ 6,865.90
175.00
$ 6,690.90
RECEIPT FOR PAYMENT
GLENDA FARNER STRASBAUGH Receipt Date: 2/10/2012
Cumberland County - Register Of Wills Receipt Time: 09:59:29
One Courthouse Sqquare Receipt No.: 1068729
Carlisle, PA 17Q13
FLACCUS ROBERT W
Estate File No.:
Paid By Remarks:
Fee/Tax Description
2012-00183
RICHARD M CARDAMONE
HEA
PETITION LTRS TEST
WILL
SHORT CERTIFICATE
JCS FEE
AUTOMATION FEE
Check# 1571
Total Received.........
Receipt Distribution ----- ----
Payment Amount Payee Name
210.00 CUMBERLAND COUNTY GENERAL FUN
15.00 CUMBERLAND COUNTY GENERAL FUN
60.00 CUMBERLAND COUNTY GENERAL FUN
23.50 BUREAU OF RECEIPTS & CNTR M.D
5.00 CUMBERLAND COUNTY GENERAL FUN
----------------
$313.50
$313.50
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of Wills
One Courthouse Sqquare
Carlisle, PA 17Q13
FLACCUS ROBERT W
Estate File No.:
Paid By Remarks:
2012-00183
ROBYN L CARDAMONE
CJ
Receipt Distribution
Receipt Date: 2/10/2012
Receipt Time: 10:53:38
Receipt No.: 1068731
Fee/Tax Description Payment Amount Payee Name
INVENTORY 15.00 CUMBERLANIJ COUNTY GENERAL FUN
----------------
Check# 1572 $15.00
Total Received......... $15.00
The Patriot-News Co.
2020 Technology Pkwy
Suite 300
Mechanicsburg, PA 17050
Inquiries - 717-255-8213
CARDAMONE
245 WINDING WAY
CAMP HILL
PA 17011
c~he~latriot~~ews
Now you know
INVOICE
ACCT# NAME
233725 CARDAMONE
233725 CARDAMONE
233725 CARDAMONE
AD ORDER# DATE EDI 1 N ADDTL. INFO.
0002196038 03/02/12 METRO WEST
0002196038 03/09/12 METRO WEST
0002196038 03/16/12 METRO WEST
ALL CHARGES ARE NET
TYPE OF CHARGE AMOUNT
BASIC AD CHARGE $30.22
BASIC AD CHARGE $30.22
BASIC AD CHARGE $30.22
AFFIDAVIT CHARGE $5.00
TOTAL:
REMITTANCE ADDRESS
The Patriot-News Co.
23794 Network PL
Chicago, IL 60673-1237
Please include the Account # or Ad Order # (above) with your remittance--Thank You
$95.66
NOTE: This Invoice replaces the Order Confirmation which we previously sent with Proofs of Publication
The Patriot-News Co.
2020 Technology Pkwy
Suite 300
Mechanicsburg, PA 17050
Inquiries - 717-255-8213
CARDAMONE
245 WINDING WAY
CAMP HILL
PA 17011
c~he atriot~~ews
Now you know
THE PATRIOT NEWS
THE SUNDAY PATRIOT NEWS
Proof of Publication
Under Act No. 587, Approved May 16, 1929
Commonwealth of Pennsylvania, County of Dauphin} ss
Holly Blain, being duly sworn according to law, deposes and says:
That she is a Staff Accountant of The Patriot News Co., a corporation organized and existing under the laws of the
Commonwealth of Pennsylvania, with its principal office and place of business at 2020 Technology Pkwy, Suite 300, in the
Township of Hampden, County of Cumberland, State of Pennsylvania, owner and publisher of The Patriot-News and The Sunday
Patriot-News newspapers of general circulation, printed and published at 1900 Patriot Drive, in the City, County and State
aforesaid; that The Patriot-News and The Sunday Patriot-News were established March 4thi, 1854, and September 18th, 1949,
respectively, and all have been continuously published ever since;
That the printed notice or publication which is securely attached hereto is exactly as printed and published in their regular
daily and/or Sunday/ Community Weekly editions which appeared on the date(s) indicated below. That neither she nor said
Company is interested in the subject matter of said printed notice or advertising, and that all of the allegations of this statement as
to the time, place and character of publication are true; and
That she has personal knowledge of the facts aforesaid and is duly authorized and empowered to verify this statement on
behalf of The Patriot-News Co. aforesaid by virtue and pursuant to a resolution unanimously passed and adopted severally by the
stockholders and board of directors of the said Company and subsequently duly recorded in the office for the Recording of Deeds
in and for said County of Dauphin in Miscellaneous Book "M", Volume 14, Page 317.
This ad # 0002196038 ran on the dates shown below:
March 02, 2012
March 09, 2012
~~ _ ~ n ~~ ~ March 16, 2012
me th~lfyday,gt%jQlardh, 2012 A. D.
Public
COMMONWEALTH OF PENNSYLVANIA
NoFarlal SeN
Shertie L. Owens, NMary putdk
Lower PakDm Twp., Dauphin County
My Commission 6ryMes Nov. 26, 2015
MEMBER, VENNSYLVANU ASSOCIA7IDN OF NDfAR16
PUBLICATION COPY
Rev 1501 Ea 04/06
NOTE:
(I) File Inheritance Tax Returns in the Register of
Wills Office
(2) Mu Duplicate
Filing Fee
~~, be found at
www c-___cnaT net/row (can be completed on-line and
printed for film-~
INSTRUCTIONS FOR FORM REV-1500
PENNSYLVANIA INHERITANCE TAX RETURN
RESIDENT DECEDENT
A MESSAGE FROM THE SECRETARY
l lrne
IJ"
~ t~~~
~ ,
This comprehensive instruction booklet is designed to provide the information necessary to
complete the Pennsylvania Inheritance Tax Return for the estates of most resident decedents. Our
new format is designed to assist you in fording the appropriate information quickly. A
glossary of terms used throughout the booklet has been added. You will note that the REV-1500
Inheritance Tax Return cover sheet has been redesigned. The use of original forms is
recommended.
As we move toward increasing the use of electronic technology, we will be able to provide better
service through the development of new programs that will allow for faster processing. The
Inheritance Tax Division is committed to providing courteous, timely, and accurate service to the
estate representatives and the survivors of Pennsylvania decedents.
Internet address: www.revenue.state.pa.us
You may also telephone (717) 787-8327, or send a fax to (717) 772-0412.
;,,::~,Y`a5~~gg~~;;,~.,s.~a i ,., - °4`r ti;4 ..4'ag.r,s~'.'~~.,':.+vi ;:.}~ •s S~.i Y~!,~. :~!-,e F~:~,.. ;
ws
PREM UM
MFOICAL BILLING
P.O. Box 312 • Palmyra, PA 17078
Billing Office: (717) 838-6462
3illing For: ARUP K. SARA, M.D.
Robert W Fiaccl-1s
245 Wind inr~ Way
Camp Hili,RA 17011
PATIENT: Flaccl-1s,Raber^t W SEND PAYMENT TO 789 POPLRR
CHURCH RD, CAME' HILL, F`R 172111
Please remove an d return t op portion. Retain bott om for your recor ds.
12/2011 aks Robert W 99^c04 Office Visit New F'atien 5Ei9.42 160.210 421.210
01/20/1' Plan Payment:12uu255 116.27
01/221/1 ' Adj:Insurance Adjust ?,. 73
40.00 advantra copay
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PLEASE SEE REVERSE SIDE FOR ADDRESS OR INSURANCE CHANGES.
ARUP K. SAHA, M.D. ~ • 421. 021
ACCOUNT ANALYSIS TOTAL CURRENT 30-60 61-90 91-120 120 +
INSURANCE BALANCE ~, ~~ (~, 2121 L71, 2121 21, 01~ !Qf, Q11Z1 ICI, Qi21
PATIENT BALANCE 421, QIQt 21, 2121 0, 211ZI QI, 00 421, Q121 QI, 2121 ~ • ~
• 40.00 YOUR ACCOUNT IS OVERDUE RND IS C'DNSIDERED DELINIgUENT
I~HEALTHAMERICA
I Co rpn try Health fore Fl nn
Advantra•
Coven6y Health Cate
Employer Services
2222 Ewing Road
Moon Township, PA 15108
a 154191 AT 0.374 ooooLaes
ROBERT FLACCUS
245 WINDING WAY
CAMP HILL PA 17011-8462
so Isola cov]w.aT22zo12
03/21/2012
ItttIlltltllltL,tttlltltIIIttI.tlLtltllttttltltlLtllltltLtLlll
Deaz ROBERT FLACCUS,
A review of our records has found an error in the payment of some of your claims and as a result you
must pay a higher cost share for certain prescriptions covered under your HealthAmerica Prescription
Drug Plan (PDP) Coverage coverage. We have updated your records and have reprocessed the
prescription claims you filled between 12/27/2011 and 12/27/2011, to reflect the correct higher costs
share as defined by your benefit plan. Please refer to your monthly prescription drug explanation of
benefits (EOB) for more detailed information.
Please be advised that because of the reprocessing of these prescription claims, you have a balance of
$100.12 due upon receipt of this letter. This amount reflects the difference between your previous cost
share and the new, higher cost share under which your covered prescriptions should have been filled.
If you would like to speak to us about a payment plan, or have questions concerning how your balance
was determined, please contact C~rstomer Service at 1-888-736-9115 (TTY'/TTD 711
Telecommunications Relay Services), 8AM to 8PM, 7 days a week, your local time. Ctirstomer service is
available in English and other languages.
This letter pertains only to your Medicae prescription drug plan benefits. Thank you for your attention to
this important matter.
Sincerely,
Customer Service Unit
A Coordinated Care plan with a Medicare Advantage Contract
Advantra HMO and PPO products are offered by HealthAmerica
Y0022 2011 7013. 737 File and Use: 01/15/2011
STMDIIiD LETIER TEMPLATE - 3]91UlM6 - RMa Cowan PCP]H CnV]9ana.RTP Onn0~a85 / nn002nf3
Reprocessed Claim
Adjusted Cost Share Amount Due
RX Prescription Pharmacy Date of Original Adj. Amount
Number Name Service CosYShare Cost Due
(Paid at Share
Pharmac
1027670 NAMENDA SPARTAN 12/27/11 $11.08 $111.20 $100.12
PHARMAC
Y
Total $100.12
Amount
Due
A Coordinated Caze plan with a Medicaze Advantage Contract
Y0022 2011 7013 974 File and Use: 04/20/2011
srumano ~arerar'ure - anio-eso- - wns course o000000o r aoooooox
Please detach here and mail with payment.
Member Name: ROBERT FLACCUS
_ Member ID Number: 802061688*O1
Amount Enclosed: $
Please make your check payable to Coventry Health Care, Inc. and write yoiu member ID number on
your check. Please do not send cash.
Mail this portion with your payment to:
Coventry Health Care, Inc.
PO Box 280068
East Hartford, CT 06108-9998
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STANDARD LETTER TEMPLATE - 37910640. - RMS covl99 0oooooao / ooDOOO01
UriOLY
PITAL
The Spirit o{ Caring
.. ..-
We have received the explanation of benefits
from your insurance company(s) and have
applied whatever payments and/or adjustments
are appropriate. Please make payment for the
balance due $50.00 OR take advantage of a
15% prompt payment discount and remR $42.50
on or before 04/21/2012.
41483751
ROBERT W FLACCUS
824 LISBURN RD
CAMP HILL PA 17011-7102
Patient Name: Flaccus ,Robert W
Statement Date: 03/22/12
Service Date(s): D1/10/12
Account Number: 41483751
Medical Record Number. 681781
Ins. 1: GEISINGER GOL
Ins. 2:
Ins. 3:
Ins. 4:
Here are two convenient ways to make
payment:
1. Call Customer Service at 717-763-2138
to make payment by credR card.
2. Mail tearoff coupon below with payment
using the enclosed self-addressed
envelope.
Previous Balance: 4.00
Total New Charges: 44, 932.00
PaymeMSlAdjustments: 44, 882.00-
Account Balance: 450.00
Please Pay This Amount: $50.00 OR
Discounted Amount of $42.50 if paid on or
before 04/21/2012
Please call Customer Service at 717-763-2138
to add or make cerretxions to your insurance
information, or to make arrangements for a
payment plan. If you are unable to make
payment, please contact the Financial
Counselor's Office at (717) 763-2885 to discuss
financial assistance options.
Please Note: Your physicians wiA bill separately for professional services.
Make Checks Payable To: Holy Spirit Hospftal
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ADDRESS SERVICE REQUESTED ~_F1..
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RQBERT W FLACCUS
824 LISBURN RD
CAMP HILL PA 17011-7702
Acnunt Number.
41483751 Annum Due:
50.00 Pay only
Puiena ISmc
ROBERT W FLACCUS $42 50
if jail b Q4121i2Qi^a
^ ~ ^ ~ ^ ~ ^
Cara Number. C1M1 No:' e+m. Dam
~>nunc Amomt 7ua:
'The C1/12 No, k required to prams your payment. M N the lest 3 lipid on the
beck otyour credit card, M your sigmture. For Anrmt mN holders, C i~ the 4d~C
number on the fraM of your card, shove CIe card number.
Ir..lll.lm,rlll..l.,rl.ll
HOLY SPIRIT HOSPITAL
P.O. BOX 822183
PHILADELPHIA,PA 19182-2183
000041483751001000000050000010073500000001130000007500000004250042120129
Lower Allen Township
Emergency Medical Service
2233 Gettysburg Road • Camp Hill, PA 17011
Phone (717) 975-7575
Tax# 23-6005253
CC
INVOICE
INVOICE #: 1220028
DATE: 03/16/12
BILL TO:
ROBERT W FLACCUS
824 LISBURN RD APT 106
CAMP HILL, PA 17011
PATIENT: ROBERT W FLACCUS
ACCOUNT#: 10042885201 TRIP#: 1220028 DATE OF SERVICE: 01/10/12
PATIENT PICKED UP: 824 LISBURN RD (17011)
PATIENT TAKEN TO: HOLY SPIRIT HOSPITAL
DESCRIPTION OF ILLNESS/INJURY:
PATIENT TRANSPORTED FOR (780.39), (456.9), (780.8)
DESCRIPTION UNIT COST QTY. AMOUNT DUE
A0429 600.00 1.0 600.00
A0425 14.00 3.4 47.60
***ENTIRE CLAIM WAS APPLIED TO THE DE UCTIBLE.**
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All Delinquent Accounts Will Be Re orted To Th C;redit Bu aus.
Collection Costs Will Be Added To All Delinq ent Invoic s.
COMMENTS: NO PAYMENT RECEIVED FROM YOUR INSURANCE SUBTOTAL 647.60
PAYMENT FOR SERVICE IS DUE BY 09-16-12 AMOUNT
PAID 285.00
PLEASE RETURN SECOND COPY WITH YOUR PAYMENT THANK YOU TOTAL 352.60
(Checks maybe made payable to Lower Allen EMS)
Terms: Net 30
Lower Allen Township
Emergency Medical Service
2233 Gettysburg Road • Camp Hili, PA 17011
Phone (717)975-7575
Tax# 23-6005253
^o
INVOICE
INVOICE #: 1220028
DATE: 03/16/12
BILL TO:
ROBERT W FLACCUS
824 LISBURN RD APT 106
CAMP HILL, PA 17011
PATIENT: ROESERT W FLACCUS
ACCOUNT#: 10042885201 TRIP#: 1220028 DATE OFBERVICE: 01/10/12
PATIENT PICKED UP: 824 LISBURN RD (17011)
PATIENT TAKEN TO: HOLY SPIRIT HOSPITAL
DESCRIPTION OF ILLNESS/INJURY:
PATIENT TRANSPORTED FOR (780.39), (458.9), (780.8)
DESCRIPTION UNIT COST QTY. AMOUNT DUE
A0429 600.00 1.0 600.00
A0425 14.00 3.4 47.60
***ENTIRE CLAIM WAS APPLIED TO THE DE UCTIBLE.**
All Delinquent Accounts Will Be Re orted To Th Credit Bu aus.
Collection Costs Will Be Added To All Delinq ent Invoic s.
COMMENTS: NO PAYMENT RECEIVED FROM YOUR INSURANCE SlJBTOTAL 647.60
PAYMENT FOR SERVICE IS DUE BY 04-16-12 AMOUNT
PAID 295.00
PLEASE RETURN SECOND COPY WITH YOUR PAYMENT THANK YOU TOTAL 352.60
(checks may be made payable to Lower Allen EMS)
Terms: Net 30
Statement of Account
HAMPDEN PHYSICIAN ASSOCIA TES
3456 TRINDLE ROAD
CAMP HILL, PA 17011
Account No. Pa e #
FLACCU0000 1
~ ROBYN CARDAMONE Date
345 WINDING WAY
CAMP HILL, PA 17011 ~ 01/19/2012
Date For Description Ref Charges Credits
10/13/2011 ROBERT ASSISTED LVG/R-HOME L2 53658 123.09
Copay $15.00
01/12/2012 ROBERT Primary Insurance Payment 53658 -74.52
1229642
01/12/2012 ROBERT Insurance Adjustment 53658 -33.57
1229642
10/28/2011 ROBERT ASSISTED LVG/R-HOME L2 53673 123.09
Copay $15.00
01/12/2012 ROBERT Primary Insurance Payment 53673 -74.52
1229642
01/12/2012 ROBERT Insurance Adjustment 53673 -33.57
1229642
11/11/2011 ROBERT ASSISTED LVG/R-HOME L2 53702 123.09
Copay $15.00
01/12/2012 ROBERT Primary Insurance Payment 53702 -74.52
1229642
01/12/2012 ROBERT Insurance Adjustment ~~,~~
1
1229642 53702 -33.57
9
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0 - 30 Days 31 - 60 Days 61 - 90 Days 91 - 120 Days > 120 Days
Current
Past Due
Past Due
Past Due
Past Due Balance Due
$15.00 $0.00 $15.00 $15.00 $0.00 $45.00
Notes. PLEASE MAKE CHECKS PAYABLE TO: Account No. We Accept
VISA, Mastert;ard, DISCOVER and American Express
HAMPDEN PHYSIC IAN ASSOCIATES FLACCU0000
Credit Card #:
Thank you for your payments. Billing questions,pl call 717-635-2073.
Exp. Date: __ Payment Amt.
Please remit in full or call for payment arrangements.
Cardholder Name
Signature:-
SPARTAN PHARMACY
3526 Brownsville Road
Pittsburgh, PA 15227.
Ph. (412) 885-4700
STATEMENT OF ACCOUNT
001398
STATEMENT DATE: 12/31/11
PAYMENT DUE UPON RECEIPT
Robert Flaccus
c/o Robyn Cardamone
245 Winding Way
Camp Hill, PA 17011
PLEASE DETACH HERE AND RETURN TOP PORTION WITH YOUR PAYMENT
S PARTAN-PHARMACY Ph. 0412) 885-4700 ____. _..... _. __. _ _. _. __. _.
~.
~ . ~
******** PATIENT FLACCUS, ROBERT
824 LISBURN RD.
12/09/11 1025037 Rf#O1 Qty=0060 ACETAMINOPHEN 500 4.99
12/11/11 1026626 Qty=0030 EXELON 9.5 MG/24HR PATC 12.50
12/17/11 1025368 Rf#O1 Qty=0015 MIRTAZAPZNE15 MG 2.50
12/19/11 0000034 november payment
12/20/11 1027211 Qty=0527 POLYETHYLENE GLYCOL 335 2.50
12/24/11 1027403 Qty=0030 VITAMIN D3 5,000 UNIT C 3.99
12/27/11 1017261 Qty=0030 SENNA LAXATIVE TABLET 4.99
12/27/11 1027670 Qty=0060 NAMENDA 10 MG TABLET 11.08
######## PATIENT TOTAL $ 42.55
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42.55 ~ ~ ~ ~~
CDPPENT 30 DAYS PAST DDE 80 GAYS PAST DUf 90 DAYS PAST DDE OVEF 90 DAYS POST Dl1E
ACCOUnt UU13y8 SLrtIL llaLe 1Z/31/11 KOberL b'1 aCCUS
•168.14 ~ 42, 55 + ~0 .00 = 210.69 - 168. :L4 =
• ~ ~
~ ~
42.55
aaxoo~
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
STRETCHER VAN -1 Way Transport T2005 1.0 108.75 108.75
Transport Van Mileage S0209 3.3 3.74 12.34
t\ ~~~`Z
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Total Char es
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT --
EE $31 00 $121.09
-
'iETURNED CHECK F -
PATIENT NAME: FLACCUS, ROBERT W CALL NUMBER: 2Y5655W AMOUNT
01/19/2012
IMPORTANT MESSAGES:
ASSISTANCE.
THIS SERVICE IS NOT COVERED BY MEDICARE OR MEDICAL
WEST SHORE EMS -BLS 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011-1708
Please return to:
HOLTGATE PODIATRY, PLLC
PO BOX 415
LEMOYNE, PA 17043
ROBERT W FLACCUS
624 LISBURN ROAD, APT 106
CAMP HILL, PA 17011
Bill To:
ROBERT FLACCUS
824 LISBURN ROAD, APT 106
CAMP HILL, PA 17011
Feb 07,2012
Amount Enclosed
Check Number
Account#: PT00000552
STATEMENT
Account #: PT00000552
Sr.No. Serv. Date Description Provider Charges Pat.Bal.
1 01/10/2012 CHARGES:11719 Trim Non-Dyst. Nails Holtz, Peter 40.00
HEALTH AMERICA PAID: 0.00
PATIENT RESPONSIBLE: 40.00 40.00
Patient Balance Note: Expenses incurred after coverage terminated.
Current Over 30 Over 60 Over 90 Open Credit
Patient: 40.00 0.00 0.00 0.00 0.00
Please make check payable to Holtgate Podiatry, PLLC and send with top part of this statement.
Please call (717) 731-1933 if you have any questions about this statement or amount due.
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Page 1 of 1
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Total: 40.00
Amount Due: 40.00
THANK YOUI
Lower Allen Township
Emergency Medical Service
2233 Gettysburg Road • Camp Hill, PA 17011
Phone (717) 975-7575
Tax# 23-6005253
^o
INVOICE
INVOICE #: 1120855
DATE: 12/09/2011
BILL TO:
ROBERT W FLACCUS
824 LISBURN RD APT 106
CAMP HILL, PA 17011
PATIENT: ROBERT W FLACCUS
ACCOUNT#. 80206168801 TRIP#: 1120855 DATEOI=SERVICE: 10/28/2011
PATIENT PICKED UP: 829 LISBURN RD (17011)
PATIENT TAKEN TO: HOLY SPIRIT HOSPITAL
DESCRIPTION OF ILLNESS/INJURY:
PATIENT TRANSPORTED FOR (780.97)
DESCRIPTION UNIT COST QTY. AMOUNT DUE
A0929 600.00 1.0 600.00
A0425 14.00 3.4 47.60
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All Delinquent Accounts Will Be Re orted To Th Credit Bu aus.
Collection Costs Will Be Added To All Delinq ent Invoic s.
COMMENTS: BALANCE DUE AFTER INSURANCE PAYMENT SUBTOTAL 647.60
PAYMENT FOR SERVICE IS DUE BY 01-09-12 AMOUNT
PAID 522.60
PLEASE RETURN SECOND COPY WITH YOUR PAYMENT THANK YOU TOTAL 125.00
(~necrcs may oe maoe payao~e ro ~owerHUen tna~~
Terms: Net 30
WEST SHORE EMS -ALS y~ ''olscovea a
205 GRANDVIEW AVE ~ ~ f
CAMP HILL, PA 17011-1708 ON REVERSE SIDE
~.ST .SHO~ Phone #: (800) 367-0512. Federal Tax ID: 23-2463002
EMERGENCY MEDICAL SERVICES
PATIENT NAME: ROBERT FLACCUS INSURANCE: GEISINOER GOLD HEALTH REJ
NONE
CALL NUMBER: 120O616A DATE OF CALL: 01/10/21)12
FROM: WOOD;i AT CEDAR RUN
ro: HOLY SPIRIT HOSPITAL
ACCOUNT SUMMARY
ROBERTFLACCUS
824 LISBURN RD 70TAL CHARGES: 1017.26
CAMP HILL, PA 17011 PAYMENTS/ADJUSTMENTS: 0.00
PLEASE PAY THIS AMOUNT: 1017.26
DETACH ALONG PERFORATION AND RETURN STUB WITH PAYMENT
PLEASE PAY THIS AMOUNT -INVOICE DUE UPON RECEIPT ~
RETURNED CHECK FEE - $31.00
Total Credits 0.00
x1017.26
PATIENT NAME: FLACCUS, ROBERT W CALL NUMBER: 1 ZOO616A AMOUNT PAID:
02/16/2012
IMPORTANT MESSAGES: A claim for this invoice amount was denied by your insurance
carrier. Balance is your responsibility -please remit ~L Q ' Z
.~
payment to our office. ~ 7
WEST SHORE EMS -ALS 205 GRANDVIEW AVE CAMP HILL, PA 17011-1708
SPARTAN PHARMACY
3526 BROWNSVILLE ROAD
PITTSBURGH, PA 15227
RETURN SERVICE REQUESTED
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130001 MB 0.404 [31100 to 60
- rtrtrtrtrtrtrtrtrtrtrtrtrtrtrtrtMIXED AADC 400
- ROBERT FLACCUS
GO ROBYN CARDAMONE
- 245 WINDING WAY
- CAMP HILL, PA 17011-8462
~I~I~
PAYMENT IIY:
CHECK ^ MASTERCARD O VISA Q D15COVER O AMERICAN EXPRESS ^
'3d Di R number on bark of card
a um er ~xpuaUCn ate
rgnaturc um r
SPARTAN PHARMACY
3526 BROWNSVILLE ROAD
PITTSBURGH, PA 15227
PLEASE RETURN TOP PORTION WITN YOUR PAYMENT AND KEEP BOTTOM PORTION FOR YOUR RECORDS
SPARTAN PHARMACY
3526 BROWNSVILLE ROAD
PITTSBURGH, PA 15227
412-884-5650
SPARTAN
P H A R M A C Y
Statement Date
ov3v2o12
Account Number
001398
Amount Due
$ 54.74
STATEMENT Pa e1Df1
Statement Date Account Number
Ov3ll2012 001398
GATE Rx NUMBER OTY DESCRIPTION AMOUNT SALES TAX ITEM TOTAL
PATINNT: ROBERT FLACCUS
01/08/2012 0001025037 60 R7Y102 Qty=0060 ACETAMINOPHEN 500 4.99 .00 4.99
07/09/2012 0001027212 1 Qty=0001 TRH.YTE WITH FLAVOR PAC 7.00 .00 7.00
OL16/2012 0001025368 15 Rfg02 Qty=0015 MHtTA7.APINE 15 MG 4.76 .00 4.76
01/16/2012 0001028596 1 Qty=0001 BOOST ENERGY DRINK-VAM 30.99 .00 30.99
O1f19/2012 0001027211 527 RtYg11 Qty=0527 POLYETHYLENE GLYC 7.00 .00 7.00
01/24/2012 DECEMBER PAYMENT , p
~~ 42.SSCR .00 42.SSCR
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PAYMENT DUE UPON RECEIPT
$ 54.74
Owr 30 Owr W Over 90 Ovar 720 Owr 150
AMOUNT DUE
vices 9aunw Chagas This Month Finance Charges Total Charges Payments 8 CreElb $ 54.74
$ 4255 + $ 54.74 + e $ 97.29 - ~ $ 4255
RXAA SPARTAN2 S VPl ]M296RP 111NR1 e)M2111212RR£S In Rn
Statement of Account
HAMPDEN PHYSICIAN ASSOCIATES
3456 TRINDLE ROAD
CAMP HILL, PA 17011
ALACCUOOOO Pa 1e #
ROBYN CARDAMONE ~te
345 WINDING WAY
CAMP HILL, PA 17011 02/01/2012
Date For Description Ref Charges Credits
12/09/2011 ROBERT ASSISTED LVG/R-HOME L2 53789 123.09
Copay $15.00
01/20/2012 ROBERT Primary Insurance Payment 53789 -74.52
1233254
01/20/2012 ROBERT Insurance Adjustment 53789 -33.57
1233254
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0 - 30 Days 31 - 60 Days 61 - 90 Days 91 - 120 Days > 120 Days
Current
Past Due
Past Due
Past Due
Past Due Balance Due
$o.oo $15.00 $o.oo $o.oo $o.oo $15.00
Notes. PLEASE MAKE CHECKS PAYABLE TO: Account No. we Accept
VISA, MasteTard, DISCOVER and American Express
HAMPDEN PHYSICIAN ASSOCIATES FLACCU0000
Credit Card #:
Thank you for your payments. Billing questions,pl call 717-635-2073.
Exp. Date: _ Payment Amt.
Friendly reminder. Your Bill is past due. Cardholder Name
Signature:-
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