HomeMy WebLinkAbout08-17-12 (3)- ~ 1505610140
REV-1500 ~` ~°'-'°'
OFFICUU. USE ONLY
PA DepartrtteM of Revenue
Bureau of Individual Taxes County Code Year Ffle Number
Po B,ox 2eosol INHERITANCE TAX RETURN 2 1 1 2 0
0
Hamslwrp, PA 1712&0601 RESIDENT DECEDENT 4 1
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
2 0 2 3 6 5 6 8 6 0 2 1 7 2 0 1 2 1 2 0 7 1 9 4 5
Decedent's Last Name Suffix Decedent's First Name MI
R I T T E R R O B E R T L
(N Applicabls) ErBer Surviving Spouse's Information Below
Spouse's Laat Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
^X 1.Original Return ~ 2. Supplemental Return ~ 3. Remainder Retum (date of death
pnorto 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Retum Required
death after 12-12-82)
6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Seca 9113(A)
between 12-31-91 and 1-1-95) (Attach S~O) ~;
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX NIFORMA U, OULD BE ~ECTEt~
Name Daytime Teleph Ifnber ~ S;; ~
R O G E R B I R W I N , E S Q U I R E 7 1 7 ~~; 2 ~' S~
-r',
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REGISTE 6G.8 UtiECdLY i~ -~ j-i
3
~ ~
~
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Finn line of address ~
n
W
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I R W I N 8 M c K N I G H T, P C- '~
Second line of address
6 0 W E S T P O M F R E T S T R E E T
City Or Post Office State ZIP Code DATE FILED
C A R L I S L E P A 1 7 0 1 3
Correspondents e-rrlall address:
Under penalties of perjury, I dedare Drat I have examined this return, indudinp axompanyinp schedules end statements, and to the treat of my knowledge and belief,
it is true, Correct and complete. Dedaratlan of praparer otlx9r than the personal representatlve Is based on all infomurtion of which preparer has arty krgwledge.
SIGNATU/~E OF PERSON~iRE3pp,~tt~(~SIBLE /FOR FILING RETURN dpA
/ 1//r~1 . // ( /// t./I/ O~ /i Z-
SIGNATURE
PA 17
/9//~-
TREET CARLISLE
PLEASE U8E ORIGINAL FORM ONLY
L 1505610140
Side 1
1505610140
J
J
1505610240
REV-1500 EX
Decedent's Social Security Number
Decedents Name: ROBERT L• R I T T E R 2 0 2 3 6 5 6 8 6
RECAPITULATION
1. Real Estate (Schedule A) ........................................... 1.
2. Stocks and Bonds (Schedule B) .................................... .. 2.
3. Closely Hekl Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3.
4. Mortgages and Notes Receivable (Schedule D) ........................ .. 4.
5. Cash, Bank Deposits and Miscellaneous Personal Pro )
party (Schedule E .....
.. 5. 3 6 9 6 3. 9 5
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ..... .. 6.
7. Inter-Vivos Transfers & Miscellaneous -Probote Property
(Schedule G) ~ Separate Billing Requested ..... .. 7. 3 4 2 1 0 . 3 8
8. Total Gross Asset (total Lines 1 through 7) ......................... .. 8. 7 1 1 7 4 . 3 3
9. Funeral Expenses and Administrative Costs (Schedule H) ................ .. 9. 1 6 2 8 0. 0 6
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ........... .. 10. 1 9 3 4. 8 6
1 t. Total Deductions (total Lines 9 and 10) ............................. .. t 1. 1 8 2 1 4. 9 2
12. Net Value of E/salr(Line 8 minus Line 11) .......................... .. 12. 5 2 9 5 9 . 4 1
13. Charitpble and Gdvemmental BequestslSec 9113 Trusts for which
an election to tax hae not been made (Schedule J) .................... .. 13. •
14. Net Value SubJscRto Tax (Line 12 minus Line 13) .................... .. 14. 5 2 9 5 9. 4 1
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 74 taxable
at the spousal tax rate, or
transfers under Sec. 9t 16
(a)(1.2)x.o _ 0. 0 0 1s. 0. 0 0
16. Amount of Line 74 taxable
at lineal rate X .0 _ 0 . 0 0 16. 0. 0 0
17. Amount of Line 14 taxable
at sibling rate X .12 1 8 7 4 9. 0 3
17.
2
2
4
9.
8
8
18. Amount of Line 14 taxable
at collateral rate x .15 3 4 2 1 0. 3 8
18.
5
1
3
1.
5
6
19. TAX DUE .................................................... ..t9. 7 3 8 1. 4 4
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVEttPAYMENT
Side 2
L 1505610240
15D5610240
REV-1500 E~( Pape 3
Decedent's Complete Address:
File Number
21 12 0410
DECEDENTS NAME
ROBERT L. RITTER
STREET ADDRESS
103 THIRD STREET APT D _
CITY
BOILING SPRINGS STATE
PA ZIP
17007
Tax Payments and Credits:
~ • Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments 6,500.00
B. Discount 31S.C~
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fiil in oval on Page 2, Line 20 fA request a refund.
(1) 7,381.44
Total Credits (A +g) (2) 6,500.00
(3)
(4) 0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is The TAX DUE.
(5) SSIo- ~/c/ 88x-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 transferred : ............................................................ .......... ^
b. retain the right to designate who shall use the property transferred or its income : ...................... ......... ^ X^
c. retain a reversionary interest: or .............................................................
.......................... ^
.........
d. receive the promise for life of either payments, benefits or care? .............................................. ......... ^
2. If death occurred after December 12,1962, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................. ......... ^ ^X
3. Did decedent own an 'in wst for' or payable-upon~eath bank account or security at his or her death? ......... ^ ^X
4. Did decedent own an individual retirement account, annuity or other non~robate property, which
contains a beneficiary designation? ......................................................................................... ......... ® ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(x)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(x)(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(x)(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 E1(+ (11-10)
' pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, 8 MISC.
PERSONAL PROPERTY
ca ini c ter: PILE NUMBER:
ROBERT L. RITTER 21 12.0410
Include the of litigation and the date the proceeds were recened by the estate.
All owned wNh rlpM of eurvhoohlp mutt ba dkclosed on ScheduN F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. WESTERN NATIONAL LIFE INSURANCE COMPANY 18,037.35
ANNUITY CONTRACT W236704
2. SOVEREIGN BANK -CHECKING ACCOUNT #0571111149 11,176.60
3. 2006 CHEVY COBALT 7,750.00
TOTAL (Also enter on Line 5, Recapitulation) I S
If more space h needed, insert additional sheets of paper of the same size
REV-1510 Fa(+ (pg.09)
' pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON•PROBATE PROPERTY
ESTATE OF FILE NUMBER
ROBERT L. RITTER 21 12 0410
This scfredule must be completed and flied ff the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TD DECEDENT AND
THE PATE OF TRANSFER. ATTACHACOPY OF THE DEEP FOR REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET
% OF DECD'S
INTEREST
EXCLUSION
pF~ppucnetPl
TAXABLE
VALUE
1. PRUDENTIAL FINANCIAL 34,210.38 100.00 34,210.38
ANNUITY CONTRACT E1129993
BENEFICIARY: JOKE F. REMY
TOTAL (Also enter on Line 7 Repapftulation) ~ S 34 210 38
If mole space is needed, use additional sheets of paper of the same size.
REV-1511 FX+(10-09)
' Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ROBERT L. RITTER 21 12 0410
DecadeM'f debts must be roported on Schedub I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
t. EWING BROTHERS FUNERAL HOME, INC. 7,918.37
2. WESTMINSTER CEMETERY -OPENING/CLOSING GRAVE 1,826.00
3. ST. PAUL'S EVANGELICAL LUTHERAN CHURCH -FUNERAL LUNCHEON 186.65
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)o(PersonalRepreseMative(s) JOKE F. REMY
street Address 103 THIRD STREET
Cary BOILING SPRINGS state PA Zlp 17007
Year(s) Commission Pafd:
2,500.00
2. AMY Fees: IRWIN & McKNIGHT, P.C. 3,000.00
3. Family Exemptlon: (If decedents address is not the same as daimaM's, attach explanation.)
Claimant
Sheet Address
Ctiy State ZIP
Relationship of Claimant to l~cedent
4. Probate Fees: REGISTER OF WILLS 151.50
5 Arxountant Fees:
6. lax Retum Proparer Fees: PATRICIA A. ROSENDALE, CPA 375.00
FINAL FIDUCIARY TAX RETURN
7. REGISTER OF WILLS -FILING FEE 30.00
8. CUMBERLAND LAW JOURNAL -ESTATE NOTICE 75.00
9. THE SENTINEL -ESTATE NOTICE 189.54
10. SOVEREIGN BANK -DATE OF DEATH VALUATION 20.00
11. REGISTER OF WILLS -SHORT CERTIFICATES 8.00
TOTAL (Also enter on Line 9, Recapitulation) ~ ;
1
If more space is needed, use additional sheets of paper of the same size.
REV-15126X+ (12-OB)
' Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
w~n~c yr FILE NUMBER
ROBERT L. RITTER 21 12 0410
Report dells Incurred by fhe dacedettt prior to death that remained unpaid at the date of death, Including unreimbureed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. HOLY SPIRIT HOSPITAL -MEDICAL 65.00
2. ~PA DEPARTMENT OF REVENUE -INCOME TAXES
3. YELLOW BREECHES EMS INC. -AMBULANCE
4. IWEST SHORE EMS -AMBULANCE
TOTAL (Also enter on Line 10, Recapitulation) I S
If more space is needed, insert additional sheets ~ the same size.
125.00
100.00
1,644.86
REV-1513 EX±(01-10)
Pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
ROBERT L. RITTER ~~ , ~ AAA A
~~ v~~v
RELATIONSHIP TO DECEDENT
AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Ust Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outrigh(spousa;distritwfionsancl transfers under
Sec.911i6 a)) 1.2).
1. JOKE F. REMY Collateral 34,210.38
103 THIRD STREET APT D PRUDENTIAL ANNUITY
BOILING SPRINGS, PA 17007
2. DOLORES R. BASHORE Sibling 3,749.81
139E PATRICK ROAD 1/5TH REMAINDER
PALMYRA, PA 17078
3. NANCY ONEILL Sibling 3,749.81
3612 CANTERBURY ROAD 1/5TH REMAINDER
HARRISBURG, PA 17109
4. BONNIE R. BEITLER Sibling 3,749.81
3800 KENTON LANE 1/5TH REMAINDER
HARRISBURG, PA 17111-1757
5. WILLIAM F. RITTER Sibling 3,749.80
1317 HUNTER STREET 1/5TH REMAINDER
HARRISBURG, PA 17104-1754
6. GARY RITTER Sibling 3,749.80
1112 BOWER ROAD 1/5TH REMAINDER
SHERMANS DALE, PA 17090-8808
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 T HROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET, j
it more space Is neeaeD, use aaaroonal sheets ~ paper of the same size.
WESTERN ~ NATIONAL
Life Insurance C o m p o ~ y
April 27, 2012
ROGER $ IRWIN
WEST POMFRET PROFESSIONAL BLDG
60 W POMFRET ST
CARLISLE PA 17013
P.O. Box 871
Amarillo, Texas 79105-0871
1.800.424.4990
~~c~u
MAY 0 3 2012
1RWIN Z McKNIGHT
LAW OFFICES
Re: Annuity Contract W236704
Contract QwnerRobert L. Ritter, Deceased
Dear Mr. Irwin:
The Internal Revenue Service (IIt5) requires reporting of all death benefits for federal estate tax purposes.
Please note that Form 712 is only prepared for regular life insurance contracts. Since this contract is an
annuity held with Western National Life Insurance Company, the Form 712 is not applicable consequently
we are unable to issue it for this annuity.
As such we are providing the requested information in an alternative format. Listed below is the relevant
death benefit information for the above-referenced annuity contract.
Tax Deferred
Contract Owner's Nam s : Robert L. Ritter
Cost $asis $17 528.47
Accumulated Value as of Date $18,037.35
of Death on 2/17/12:
Proceeds made payable to
Robert L. Ritter Estate
Mr. Irwin, after a thorough search of our records, we can find no other policies in the name of Robert L.
Ritter.
We appreciate the opportunity to assist you. Should you have any questions, please contact our Client
Care Center at 1-800-424-4990.
Sincerely, ~ ~
~^'
Yvonne Salmon
Annuity Claims Departrnent
Soverei n REG~~~~®
g R 2 e 2p12
~-~' _...
Court Ordered Processing 1 Decedents -
April 24, 2012
841005 -Boston, MA 02284
Roger B. Irwin
Law Offices
Irwin 8~ McKnight, P.C.
West Pomfret Pofessional Building
60 West Pemfret St
Carlisle, PA 17013-3222
RE: Estate of Robert L. Ritter
Date of Death: 02/17/2012
Dear Roger B. Irwin:
Per your request, enclosed please find the account information as of the date of death
for the above-named decedent. For your information, accrued interest is not included in
the date of death balance.
Please feel free to contact me if I can be of any further assistance.
Ve truly yours,
~~
Nicole o
Specialist
617-514-5189
D
Sovereign Bnnk
ESTATE OF Robert L. Ritter
SOCIAL SECURITY #: 202-36-5686
DATE OF DEATH: February 17, 2012
Account #: 0571111149 Type: Checking Open date: 3/19/1993
In the name of: Robert L Ritter
Date of Death Balance: $11,176.60
Int.(YTD) from 1/1/2012 to 2/9/2012 $0.17
Accrued interest to date of death: $0.03
Other Info: Account closed on 04/11/2012 for $11,176.78.
Account #: 4539571729 Type:
In the name of: Robert L Ritter
Balance Due on Death:
Ynt.(YTD) from
Accrued interest to date of death:
Other Info:
Line of Credit
$0.00
to
Open date: 7/31/2010
Page 1 of 1
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.~,• .~ ~ uuvltblAl
sue- Annuities Services
yt~~ P.O. Box 13467
.. Philadelphia, PA 19176
e~iiea u~amnr
amo
Premier Retirement B Series
Aslnuity Statement
October Oi, 2011 through December 31, 2011
ROBERT LEE RITTER
103 3RD ST.D
BOILING SPRINGS, PA 17007
Pagc 1 of 7
Financia{ Professional:
EDWARD M. TAYLOR
LPL FINANCIAL CORPORATION (BA)
75 STATE ST
BOSTON, MA 02109
Contract Number: E3129993 Type: IRA .Contract Issue Date: 10/ 18/2010
,Owner Name(s): Robert Lee Ritter Annuity Date: 01/01/2041
'Annuitant: Rabert Lee Ritter
Please review your statement and contact us within 30 days if you find any information you believe to be inaccurate, Note that any
livuig benefit or death benefit values qou may have are shown in the "Your Benefit Detail° section of this statement, if you do not see a
lxneflt that you selected, please cott~ct us.
Your Portfolio
Your Atsauity Activity
Beginning Account Value
Purchase Payments
Withdrawals
Contract Fees and Charges*
Investment Performance
Ending Account Vttatte**
Year-to-Date
$36,408.71
.UO
:00
($382.34)
($1,815:99)
IC34,210.38
Sisnce Issue
.00
$35,347.01
.00
($382.34)
($754.29)
1r34,Z10.38
• "Contract Fees and Charges- re8eds certain teas end ohatges including, but trot NmNed to Contingent Deferred Sales Charge (CDSC), damtx tees, annual
makdsnance lees, or other benefit tees ar charges, a applkatrle ar Imposed dudtrg the psrbd covered W this statement as of thle statement dale,
" "Ending Account Vslue is your value prbr to the application of any Surrender Charge (CDSC), Market Value Adjuskranl (IJNA) and arty tther Fees and Clarges that
may be applioabb to your ennu9y rb.
Benefit Summary
Highest Daily Lifetiase(BM) 6 P1ns
Estimated Protected Withdrawal Value(PW~
Estimated Annual Income Amount
PWV Cumulative Stcp-ups***
Date of last Step-up
Past performance does not guarantee future
results. PWV is separate from yew Account
Value and not availattk as a llanp slgtt.
Please refer to the "Your BerxHN l>BtaN" aectlon on
the next page for addMbnal information regardk7g
your benefN.
"" PW V CumutaNve step-ups - TM totet number of thnes the PWV locked In a Mghest daily value prior to teking the that LNe11me WNhdravval under the bsneil skrce the
alfedWe data of your benefit. Step-ups pertain only to your PW V and not your Account Value, as your AceouM Value is subJeq W variation each business day lased on
the imroalment perfomancs of yen hrdividuai fund allooa8ons.
Agent ID N B7PPXQ Office t ZJIXY
00848 8730969007120 0122 00002f000t7
,, Ewing Brothers Funeral Home, Inc.
630 South Hanover Street
® Carlisle, PA 17013-
(717)243-2421
February 27, 2012
Joice F. Remy
103 Third St., Apt. D
Boiling Springs, PA 17007
The Funeral Service for Robert L. Ritter
We sincerely appreciate the confidence you have placed in us and witl continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF T1~lE SERVICES, FACILITIES, AU'fOMOTIV E EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING TFIE FUNERAL ARRANGEMENTS.
1. PROFESSIONAL SERVICES
Basic Services of Funeral Director/Staff $1200.00
Bathing & Embalming $895.00
Dressing, Casketing, Cosmetology etc. S25U.00
2. FACILITIES/SERVICES/STAFF/EQUIPMENT
Basic Use of Facility , $130.00
Document Prep/Pennanent Recording, $250.00
Obituary PrcplRevic+v $75.00
Facility Usage for Viewing/Visitation , $300.00
Staff Usage for ViewingNisilation, $300.00
Facility Usage for Funeral/Memorial $300.OD
Stan Usage for Funeral/Memorial , $300.00
Sta1T for Graveside/Interment Service , $100.OD
3. AUTOMOTIVE EQUIPMENT
Vehicle to transfer remains to funeral Home, $275.00
Hearse (Casket Coach) $275.00
Safely Lcad/Clergy Car $125.00
Utility Car . $125.0U
FUNERAL HOME SERVICE CHARGES 54900.00
SELECTED MERCHANDISE:
PC I Xs Lt. Copper 18G Steel Casket , $1325.00
N12 Guardian in Capper w/setup $1395.UU
Acknowledgementcards, $ID.00
Register Book(s) $40.00
Memorial k~ldcrs , $75.00
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THAT YOU HAVE SELECTED $7745.00
Cash Advances
SentinclObituary+v/Photo $176.95
Patriot Obituary w/i'hoto. $302.92
Certitied Copies of Death Ccrtilicatc $36.00
Clergy Honorarium $125.00
Flowers. $132.50
T07'AL CASH ADVANCES AND SPECIAL CHARGES . S773.37
Total
Total Cost . $8518.37
~~j v C ~~
v
!- SUB=TOTAL $851837 ~ r ~~ ~ V~
INITIAL PAYMENT! DISCOUNT /CREDITS 100.00 = Yr~'J r '~ Ply
TOTAL AMOUNT' DUE 58418.37 f~'~ 3 ~! a `ZOO;
Thaunpaid balance over 30 days is subjected to a Li0 % service charge per month - 18.0000 °h per annum. "' ~~' . Cld L
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~` ~~~~~~.3~
View Check Image
Susquehanna
Doing what counts.
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DETACH dLnNf. PFAFP1Ad7'/AIU d~In arrr~au eer..e .~u~-u awv-~r~rr
DEBCRIP'170N OF CFiAROE QUANTITY UNIT PRICE AMOUNT
NSS 0.9% 1000cc Bag A0394 1:0 3.48 3:48
OP SITE A0394 1.0 1.92 1.92
STYLET / A0422 1.0 7.96 7.98
Total Charges 1644.86
DE3CRIPTKIN OF PAYMENT RECEIPT PAYiNENT PATE AMOUNT
Denied by Insurance - HIGHMARK -FREEDOM E 03106!2012 0.00
Total Credits 0.00
':'!.SASE ~~~?! T!-il`= !titllt~E_pl`~~ ih9'tiF^PtY1- ~84~ i.;f-%~~~t l;Fr~~Ec~7 -.,.
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PATIENT NAME: RITTER, ROBERT CALL NUMBER: 1203a~ AMOUNT PAID:
04!28120"12
Mari'+•'a'~l?`i!/N,~~ G Fvit s~f-~i s'i:: This account is now PAST DUE!! Payment must be received
WITHIN 10 DAYS. Collection process will begin.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011-1708
.^, r'h,ajC ~/~~:~ ~?-11.^" iYl.h~NG~?.pfd ~i ^•:''.j ~.'{'!.:'- rit Yr ;, ~..~~ F'~ : .._.Nr,, .., +.
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PATIENT NAME: RITTER, ROBERT CALL NUMBER: ~ 2.~~1~ AMOUNT PAID:
04/2612012
nrwoE=t irr'~~9~+'i ~Udl?~ Sn~;;~-<~ Thls account is now PAST DUEIi Payment must be received
WITHIN 10 DAYS. Collection process will begin.
WEST SHORE EMS -CARLISLE 205 GRANDVIEW AVE SUITE 211 CAMP HILL, PA 17011-1708