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HomeMy WebLinkAbout09-24-12 r ,,,,,~ ~ r 1505610105 REV-1500 Ex tez.,°, (Fq I PA Department of Revenue Pennsylvania- ~ ~- ""- "' - Bureau of Individual Taxes '"`"`" '"`°`""` County Code Year File Number PO BOx 28D6D1 INHERITANCE TAX RETURN Harrisburg, PA 17128-o6D1 RESIDENT DECEDENT ~ ( I ~ GI ~ 1/ Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 220-38-2245 -04!28/2012 09/24/1941 Decedent's Last Name Suffix Decedent's First Name MI Biddinger II Edgar E ' Of Applicable) Enter Surviving Spouse's Information Below Spouse's Last 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 INAPPROPRIATE OVALS BELOW m 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death Prlor to 12-13$2) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a living Trust 8. Total Number of Safe Deposft Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceetls Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-i-95) (Attach SchBtlule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE ANDCONFlDENTIAL TAX INFORMATION 3HW~D BE DIRECTED TO: Name Daytime Telephong Number Peter J. Russo (717)591.1755 REGISTER OF WILLS USE ONLY f+D c~ First Line of Address ~ r"~ f -~ 5006 East Trindle Road Second Line of Address ~ N T.r F, ~ ~' ` Suite 203 . 4~ ~t;~-; -xi City or Post OSice State ZIP Code Dq D`r =~ ~i .y Mechanicsburg PA 17050 ~ "" rv m Correspondent's email atldress: prUSSO@pjrlaW.COm "-- Under penalties ofperjury, I dedarethat (have examined this return, including accompanying schedules and statements, and to me best oY my KnoxAedge arM belief, it is true, coned and complete. Declaration of preparer Omar than Che personal representative i5 based on all information of which prepaner has any knowledge. SIGNATURE OF PE RSO R SPO N SI B LE FOR FILING RETURN 'DATE ~ ~ ~ ~ ~ , ~ ` ~ ~/agJ~~ ~ ~' A RESS NA7 E OF P ARE ER THAN REPRESENTATIVE ~ ~ j aA6Tf `~ ~17 c ~ C~ .. -~i'1 ~_~ .i~Y~ - PLEASE USE ORIGfNAL FORM ONLY Side 1 L 1505t101175 150'1610105 ~ a Lsos61aza5 REV-1500 EX (FI) ' Clecedent s Sodal Security Number Decedent's Name: Edgar E. Biddinger, II ' 220-38-2245 RECAPITULATION 1. Real Estate (Schedule A) ........................................... .. 1. 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 3. Closely Heid Corporation. Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages and Notes Receivable (Schedule D) ......................... .. 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 3,874.82 6. Jointly Owned Property (Schedule F) O Separate Bllling Requested ..... .. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested...... .. 7. 8. Total Gross Assets (total Lines 1 through 7) ......... ....... ..... .. 6. 3,874.92 ', 9. Funeral Expenses and AdministraLve Costs (Schedule H) ................. .. 9. 2,574.66 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I).... ...... . , 10 3,160.85 11. Total Deductions (total Lines 9 and 10) ......... .. ....... ..... .. 11 5,735.51 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. -1,860.69 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which '. an election to tax has not been made (Schedule J) ...................... .. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. •1,860.69 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. 16. Amount of Line l4 taxable at lineal rate X .0,_. 16. '. 17. Amount of Line 14 taxable at sibling rate X .12 -1,825.69 17. 15. Amount of Line l4 taxable at collateral rate X .15 18. 19. TAX DUE . .......... .......... ............. ..... ....... . 19 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTfNG A REFUND OF AN OVERPAYMENT O n Side 2 L 1505b10205 1505b10205 ~ ' ftEV-1500 EX (FIj Page 3 Flta Number veceaenrs ~ompleie F-aaress: DECEDENTS NAME Edgar E. Biddinger, II 101 N. Prince Street, Apt 203 CITY __ __ _. _ _ _. - __ __ _ __ - _... _... PA 17257 lax Payments and Credits: 1. Tax Due (Page 2, Line 19} (1) 0.00 2. CreditsrPayments A.PdorPayments _____. 0.00 B. Discount _~ -~-~--~-~-- Total Credits (A + B) (2) 0.00 3. Interest (3) 090 A. 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. (4) 0.00 5. If Llne 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. „I PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" tN THE APPROPRIATE BLOCKS i. Did decedent make a transfer and: Yas No a. retain the use or income of the property transferred ..................................................................................... ...... ^ b. retain the right to designate who shaft 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 consideration7 ........................................................................................................ ...... ^ 3. Did decedent own an "intrust for" or payable-upon-death bank account or security at his or her death? ........ ...... ^ 4. Did decedent own an individual retirement accoont, annuity or other non-probate property, which contains a beneficiary designation? .................................................................................................................. ...... ^ IF THE ANSWER TO ANY OF THE A80VE 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 tale imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent (72 P.S. §9116 (a) (i.t) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disdosure of assets and filing a tax return are still applicab{e 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 naturel parent, an adaptive 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 benefidaries 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 defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoptbn. ,, REV-[5o8 EX+ (u-io) ~ '" pennsylvania DEPARTMENT OF REVENUE INHERRANCE TAX RETURN RESIDENT DECEDENT SCNED!!LE E CASH, BANK DEPOSITS 8t MISC. PERSONAL PROPERTY FILE NUMBER: Edgar E. Biddinger, II 2012-00611 Include the proceeds of litigation and the date the proceeds were received by the estate. All property lolntly owned with right o/survivorship must be dlaclosed on Schedule F. u umie apace is neeaeD, use a0ol[IDnal sneet5 of paper of the same 512e. ~Cc~rla ~ ,~~ EPISCOPAL TOWERS OPERATING ACCOUNT EST BIDDIN -ESTATE OF EDGAR BIDDINGER '~,v~~"t s ~i4 ~.,., ,~ . ~ nor ~ ~ t_~ ~ .~1il~s C s Wrs. ° e' t. roar ~ z_ ~a~ns, .3a. ex`s, 5-22-12 _ REF RENT * #S 203*REF OVPD RENT 144.00 Date 5-23-12 No. 13670 Total 144.00 i EPISCOPAL TOWERS OPERATING ACCOUNT [aae«stn, Pa. 2316 DAIItY ROAD Fulton Bmk LANCASTER, PA 17601 PHONE (717) 898-2292 5-23-'.l2 ** One hundredforty-four dollars and no cents*****************«*****s*ss******* ESTATE OF EDGAR BIDDII~IGER 1? SABASTAIN WAY CARLISE, PA 17015 VOID AFTER 180 DAYS'" `"'`'< 60-042 313 13670 ****$144.00** Lit SECUflITY iEATUflES INCLUDED. DETAILS ON BACIG LJ B•000 i 36 70~' ~:O 3 i 30 i 4 2 21: O i 50 L 2468n• (s~~~ ~~ ~ ~~~ Q ~s ,,,.~¢-~ ~~ EPISCOPAL TOWERS OPERATING ACCOUNT 2316 DAIRY ROAD Fallon ana Lanwteq Ps LANCASTER, PA 17601 PHONE (717) 898-2292 2-03-12 *' One dollar and 48 cents******«****-**w*«r****r**s***e*s***r*******ra*****r**« EDGAR BIDDINGER SHIPPENBURGTREEI ~2~T. S-203 VOID AFTER 180 DAYS' "" `"~ So-gas "' 13474 ****$1.48** 8 SECURITY FEATUflE51NCLUDED. DETAILS ON BACK. LI ll'OOOi347411' ~:03L30i422~: Oi50 1246811' ~ ~{~ ~~5~~~- ~~~ EPISCOPAL TOWERS SECURITY DEPOSIT ACCT. EST BIDDIN -ESTATE OF EDGAR BIDDINGER :r 5-22-12 REF SECDE #S 203 REF SEC DEP/INT 371.21 Check Ck. Date 5-23-12 No, 1336 Total 371.21 EPISCOPAL TOWERS SECURITY DEPOSIT ACCT. 2316 DAIRY ROAD von ~,ro"'e.. Bo•+az LANCASTER, PA 17601 '+' 1336 PHONE (717) 898-2292 5-23-12 ****$371.21** ** Three hundred seventy-one dollars and 21 cents******************************* ESTATE OF EDGAR BIDDINGER 17 SABASTAIN WAY CARLISE, PA 17015 VOID AFTER 180 DAYS' "" ""`~ 8 SECdBITY FEATUPES INCLUDED. DETAILS ON BACK. 8 a•OOOOi336n• >I:03i30i422t: 9904 88i63ii' ` comcastm Service Details Contact us: www.comcast.com 1-800-XFINITY "il l; i , kJj~"i~c14~k3 i'~'`~ ~f~w~~~ ~tx~(~ El+~~'~ x'sa- 4,r{ +k~k*~, Account Number Billing Data Total Amount Due Payment Due by 09547 340021-04.0 05/21/12 $21.12 No Payment Due Page 2 of 2 Because we had already billed you when the latest changes were made to your account, we have adjusted TV this bill. Listed in this section are credits and/or charges _ FCC Regulatory Fee ,04/28 -06106 -0.08 for these changes. Sales Tax 04/28 -06/06 -0.19 Effective 04!28/12, you removed Digital Sports at Franchise Fee 04/28-- 06106 -6.70 $7.95 per rrroMft and Limited Basic. You removed Totat Taxes, Surcharges & Fees $6.37 Expanded Basic. Effective 06706112, you removed Digital Starter. Adjustments for previously billed services removed 04@8/12 - - - - __~- ._ Digital Sports 04128 -06/06 -10.07 39 days @ $0.2582/day based on a monthly rete of $7.95 Limited Basic 04128 -06106 -26.31 8 days ~ $0.6650/day = -5.32 31 days ~ $0.6771/day = -20.99 Expanded Basic 04/28 - O6J06 -61.11 8 days @ $1.5500/day = -12.40 31 days @ $1.5713/day =-48.71 Adjustments for services removed 06/06H2 Digital Starter 04!28 -06/06 0.01 39 days @ $0.0003/day Total Partial Month Charges & Credits $97.48 s Lobby Hours 339 Baltimore Rd Shippensburg, PA 17257 Mon-Fri 9am5pm, Sat 9am-1 pm 4601 Sm9h St Harrisburg, PA 17109 Mon-Fri gam-6pm, Sat 8:30am~4pm Franchise Authority: PA2575 Borough of Shippensburg 60 West Burd St Shippensburg, PA 17257 Closed Captioning Customers: For assistance call (800)266-2278 or go online for email or live chat at www.comcastcorNsuooort Forwri0en concerns contact NW. Patel, Comcest Closed Captioning O(flce, 1701 John F. Kennedy BWd., Phfia., PA 19103283$ emaN: Closed CaoOonina~Comcest.com fax:(215)286-4700 or o311 our closed captioning Nne (215)286-8000 An administrative late fee of $7.95 will be assessed on accounts not paid within 38 days of the Biling Date of the invoice, and addi0onal late fee wN{ be assessed day 88 of the bNling cycle. To ensure proper credN, refer to the due date on the invoice and allow 5 to 7 days for maNing and processing, if your payment is not reflected on the invoice, N may not have been received by the date the statement was pdnted. 'Comcast. Account Number Boling Date " Total Amount Due Payment Due by ° 09547 340021-040 05/27!12 .$21.12 No Payment Due Page 1 of 2 Contact rls: wtivw.comcast.com 1-800-XFINITY ~__ J EDGAR For service at: 101 N PRINCE ST APT 203 SHIPPENSBURG PA 17257-1336 News from Comcast You have a credo balance of-21.12 Make no payment ! Our records indicate that you have a credit balance. All credit balances of $1.00 or more wtll automatically be refunded to you. ff your credit balance is less then $1.00 and you would like us to send you a refund, please contact our office by mail or phone with your forwarding address. However, if you are still a customer, this balance will be transferred to your new account. HearinglSpeech Impaired CaI1711 Previous Balance "82.73 Payments - received`by 05/21112 0.00' New Charges -see below -103.85. - aeeTne ronowtngpages mrmt Taxes, Surcharges 8 Fees -97.48:: wrac~unt " - detalls. `-6.37 Y ~ `~''~ Ulf --.... _DetaM.antl.e-B~isscupanwith.your-payment-Please-wAte-yau-e¢eevnt numt~ergryourcheck or-mctt~eq~order. Dorot~sends~dsh: ~.=-. ~.~mcasta Account Number 09547 340021-04-0 Payment Due by No Payment Due 1555 SUZY STREET LEBANON PA 17046-8317 Total Amount Due -$21.12 AV 01 006959 931166 20 A"SDGT I{{II{'I{I{1{111'111'{11{III'{"i{{111111.,..{1.1{11{IIIII.II.I~1 EDGAR BIDDINGER JO ANN SAN6REY 17 SEBASTIAN WAY CARLISLE PA 17015-7677 d 1, i {... d l { {•1"1 {' { 111"1111 { d { L.I L I { 1"I' i l { 1' 111 {' 111 {' { 11 CONCAST CABLE P 0 BOX 3005 SOUTHEASTERN PA '19398-3005 09547 340021 ^4 D 1 OD2112 Amount Enclosed $ Make checks payable to Comcast a 0 s 's s s s COMCAST 1444 SOSY STREET ATTN: LEBAIQO& SDPPORT SERVICES LEBAAOR, PA 17046 - tl~Il~~~ill~~lll~~lllll„III,~IIII~~„III~~1111~11~~111,1~11,~11,1111111 BDGAR BIDDINGER 22329 0342-29-49-3DG 17 S88ASTIAR WAY --- CARLISLE, PA 17014-7677 --- Il~u~rhP~i°9rllh(Plly~(•~pr~glll•~ugl~l'~I~rl'll+ ~omcast. e ~~~cSl~ ~~~,-~.. PAYMENT SU11lMARY CHECKNa 0008881302 pccouNTNO: 09447-34002104 cHECKDaTE: (16/04/12 Dear EDGAR BIDDINGER, The attached check represents a refund for account number 09447-34002104 in the amount of $21.12. If you area Comcast %FIRITY customer and have questions regarding your refund check, you can write us at the address above, call Comcast's toll free customer service number at 1-888-COMCAST (1-888-266-2278), or chat with us at www.comcast.com/'chat. bur representatives are available to assist you 24 hours a day, 7 daps a week. If you are a Comcast Spotlight client or agency, please contact pour local Spotlight office. OEfACHAND RE(AINTNISSfATQAEOR THEATTACHED CHINK IS IN PAYMENT OF YENS DESCRIBEOABOVE IF NOTCORRECi, PLEASE NOTIFY US PROMPRY. NO RECQPi DESIRED. § .. ~~% ~ l~ . INMNAA "y.: s' .. . TBB ~ARR~ `OF 3i$W YORR MBLLOR ' .. ,,. ~ PITTSBURGH, PEARSYLVARIA ~~ irppp8$8L3D2~~' (:04330i6dL': ii3~N7834a` ~M~Bank vvhat§ importa>f~C ly Sprirlg5 Office have any questions, please ar Telephone Banking Center at 1-800-724-2440 Date: Business Date: :012 06/05/2012 11:00 AM fg Deposit $2,195.04 15 Balance: $2,195.04 4331 /05 ~y~,~..c39~+s,~M , > for visiting us today.'"a happy to assist you! hL~~es 3 ~~`'~`n- .~r.na l y~.oo ~. A'"ky~'~"'.~} 3it.K~ ~P~Cw.,4 '•~~r~ Mt Holly Springs Office If you have any questions, pleas: call our Telephone Banking Center dt 1-800-724-2440 Today's Date: Business DatN: 06/13/2012 08/13/2012 Time: 10:06 AM Checking Deposit ****4515 $70.62 Total Balarx:e: $640,66 Available Balance: $619 54 4331/05 10 Co ~~ 2,4« ~,~o~~, 4q,sa Thanks for visiting us today, Me are happy to assist you! I © i~a~N.i ~Y~.~iiii ~what§ in~oatanC Mt Holly Springs Office If you have any questions, please ca'Il our Telephone Banking Center at i-800-724-2440 Today's Date: Busir~ss Date: 07/23/2012 07/23/2012 TiiiE: 11:07 AM ~p.Y sal,iv LD°~ j Checkirlp Deposit F,..r $1,467.50 ****4515 Total Balance: $2,094.68 Avaiilabie Balance: $687.16 4331 /05 81 Thanks for visiting us today. We are happy to assist you! 59$>i~$~S>8>ls~~~~~$~~~ss~>B~ Certificate Number/Mumero de certificado: 24017 300105 233610 s WIN CASHI Take a short survey and let us krww how we're doing. Visa orceM7.800670.7494 TNs Imrifation e~Wiros 7 days from date of receipt. No purchase or trensedlon rogrdrod to enter. IGANE DINERO EN EFECTIVOI Tome una breve encuaste y deienos saber eomo b estemos siMendo. Vts(te o Name al 1.900670-7494. Este irrvitad6n se vence 7 dfas despuES de la fecha mostreda en el rorilm. Ningune compro ni frensacd6n es nacesarta pare partidpar. 81717 Slick(~LeW~'s ~,11~aD Bank.. LISTENING IS JUST THE BEGINNINGT 119E Ml~l ST, ATpt, MNl9Al-/61M71 711i5LiH5 ~ -1915 60-142.313 GATE AMOUNT 07/19/2012 (11717 $1,357.50 ~~ ONE THOUSAND THREE HUNDRED FIFTY SEVEN AND 50/100 DOLLARS KLICK-LEWIS, INC. EDGAR E. BIDDINGER II ESTATE 17 SEBASTIAN WAY CARLISLE PA 17015 G/L# Corltrol# 220A GARD504 648 Amount 1380.00 -22.50 98 FORD TAURUS #WA173511 TITLE FEE SOLD ® GARDEN SPOT A/A s [T5770 EDGAR E. BIDDINGER II ESTATE 07/19/2012 81717 TOTAL 1357.50 81717 e _9 ra n i)'08i7i7n• ~:03i301422~: 0002 87857n` REV-1511 E%+ (SD-U9) ~ ~~ pennsytvania SCHEDULE H DECPRTnENTOrNavE"uE FUNERAL EXPENSES AND t"NERCTaNCErnxREniRN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Edgar E. Biddinger, II 2012-00611 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Ewing Brothers Funeral Home, Inc. 1,625.00 8. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City__-.._.-.__-.__.-______.__-.-._ ___-.-State ___ZIP Year(s) Commission Pald: _ _ _ _ 500.00 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address CitY_._____-__.__--.__.. ._.._.._ _.._-.-.__. .--State---ZIP--.-._--_ Reiationshlp of Claimant to Decedent _.__ 4. Probate Fees: 449.66 5. Accountant Fees: 6, iax Retum Preparer Fees: 7. TOTAL (Also enter on Line 9, Recapitulation) L# 2,574.66 If more space is needed, use additional sheets of paper of the same size. 1~~s.~o ll -~ o o.oo $rew, c.tr.~~l,,,Q rO"~ ~he 'wa 0. ~~J i~q,i ~ -~*oxq C ~t~.~e~ty aeeoy.~' II r!= s +q {L°, e~ E/ck~a,,. F. l3; d a ; ~r Ewing Brothers Funeral Home, It1C. t1VWW.Since1853.com Steven A. Ewing, Supervisor 630 South Hanover St.; Carlisle, PA 17013 Seymour A. Ewing, Deceased Phone: (717)243-2421 Fax: (717)243-7553 E-Mail: admin~since1853.com William M. Ewing, Deceased STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED Charges are onlyy for those items that you selected or that are required. If we are requirrA by law or by a cemetery ar a crematory to use any items, we wrll explain dte reasons in writing below. If you selected a Cuneml that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to ay for embalming you did not approve if you selected arrangements such as cremation or immediate burial. If we charged for embalming we will explain why 6etow. For the Service of: Charge to : Jo Ann A. CHARGE FOR SERVICES SELECTED: t. PROFESSIONAL SERVICES Date of Death. April 28, 2012 Carlisle pq C Basic Services of Funeral Director/Staff .... $ -0- Bathing & Embalming ...................S. -0- Dressing, CaskeOng, Cosmotology etc.......$ -0. SUB-TOTAL OF PROFESSIONAL SERVICES..... :.... At $ -0- 2. FACILITIES/SERVICES/STAFF/EQUIPMENT Basic Use of FarJlity ................. ...8 -0- DocumentPrep/Pernanent Recerding... ...s -0- Obituary Prep/Review ..... . . . ..... .. . g . ~ Facility Usage for ViewingMsitation..... ...s -0- Staff Usage for VlewingMsitation....... ... § -0- Facility Usage for FunereVMemodal..... ...$ -0- Staff Usage for FunereUMemoriai....... ... $ '0' Staff for Graveside/Interment , ...... , , ,$ -0- Equlpmenf/EMre Staff & Time Off....... ...$ -0' Premise Event SUB-TOTAL FACILITIESlSERVICES/STAFF/EQUIPMENT.. A2 8 _0. 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral local ....................... ........5 -p_ Hearse (Casket Coach) Local ....................... ........5 _0_ Safety Lead/Clergy Car Local ........................ ........5 -0- Utiliy-C-ar- __.__ __ ._ Local ........................ ........8 -0- Family Car Local ........................ ........$ -p- Out of Town Transportation Local ....................... ........$ -0- Locel ......................... .......$ -0- ............................ ........$ -0- $ -o- S _n- $ -p- 8 -0. Crematron Um .....................8 ~ (Description)_ $ -0- $ -0- - _ $ -0- TOTAL MERCHANDISE SELECTED ........... B $ -0. C. SPECIAL CHARGES Forwarding of remains to $ -0. (Funeral Home) Receiving of remains from $ -0- (Funeral IHOme) Immediate BUdal ...................$ -0- Direct « ..................$ - - petal Pdce) 1.695.00 OF SPEtaAL CHARGE ....,...-6 1.695.00 D. CASH ADVANCED: a Opening Grave,,,,,,,,,,,,,,,,,, ,,$ _0_ Cemetery Equipment ............. ..5 -0- Cemetery Lot and Deed ........... . .S -0., Sentinel Obituary ................. . .S -0- Patdot Obituary .................. . .S -0. Cert~ed Copies of Death Certificete.. ..S 30.00 Clergy Honorarium ............... ..S -0. Organist Honorarium ............. .. S -0- Cantor/Singer Honorarium ......... ..5 -0- Coroner's Authorization Fee ........ ..8 -0- ~ ....$ Airfare ........................... ~ Altar SBN@re ........ ..............$ -~- Rock Removal Charee g -0- Frederick Newspaper I'FamiN) $ -0- $ -0- $ -0- $ -0. $ -g- SUB-TOTAL OF ADVANCES D S 30 mm basic Use of Facility ....................i -0- ~ . Document PreplPennanent Recording, .....8_,_,=0- Obituary Prep/Review .. . .. . . . . ... . . . : g _ -0- Facility Usage for ViewingNsitation.. , , .. , .s _p_ Staff Usage for ViewingMsitation..........s -0- Facility Usage for FunereVMemodal.......,a -0- Staff Usage far FunerellMemodat ......... $ -0' Staff for Graveside/Intennent ..........$ -0- EquipmenVExtre Staff & T(me Off..........$ -0- Premise Event SUB-TOTAL FACILITIES/SERVICES/STAFF/EQUIPMENT.. A2 $ -0- 3. AUTOMOTIVE EQUIPMENT Vehicle to transfer remains to Funeral Local ........................ .......$ -0- Hearse (Casket Coach) Local ........................ .......$ ~ Safety LeadlCletgy Car 1.ocel ........................ ........$ -0- -vtility-Cer- -. ~ _.. _ local ........................ ........$ -0- Family Car Local ........................ ........$ -0. Out of Town Transportation Local ........................ .......$ -0- Local ................... .............$ -0- $ 0 $ -0. SUB-TOTAL OF AUTOMOTIVE EQUIPMENT...........A3 $ -0- TOTAL OF PROFESSIONAL SERVICES, FACILITIES AND AUTOMOTIVE EQUIPMENT .................................... q $ -p- B. CHARGES FOR MERCHANDISE Casket ..............................$ -0- (Descdption) Casket Outer ReceptaGe ......................$ -0. (Descrip0on)_ Outer Cnnta(rnar -V- TOTAL MERCHANDISE SELECTED ........... B $ -0- C. SPECIAL CHARGES Forwarding of remains to 5 _p_ (Funereal Home) Receiving of remains from S -0. (FUnel'al ome) Immediate Buriat ..................S -0- Direct n ......... .. S - - Pedal Pdce} ~ ~ .. ' . 1.695.00 OF SPECIAL CHARGE ..`-. 1.695.00 D. CASH ADVANCED: Opening Greve .................. ..$ -0. Cemetery Equipment ............. ..$ -0- Cemetery Lot and Deed ........... ..$ -0-, Sentinel Obituary . ................ ..$ -0- PatdotObftuary,,,,,,,,,,,,,,,,,, ,,$ .-0- Certified Copies of Death Cerfificate, . . ,$ 3D.00 Clergy Honorarium ............... ..$ -0- Organist Honoredum ............. .. $ -0- Cantor/SingerHonoredum,..,..,.., ,.$ -0- Coroners Authorization Fee ........ . $ '0- Airtare ...........................$ -0- Altar Servers ......................8 -0- Rack Removal Charee $ -0- Frederick Newsoape_r (FamiN) $ -0- $ -0- $ -0- $ -0- $ 'p- SUB-TOTAL OF ADVANCES .................. D $ 70 00 We c(rar~e~ou~or our ~erviges m obtaining: specs a a ante rams/. SUMMARY OF CHARGES: A. Professional Service:>, FacilRies and Equipment and Automotive Equipment ...................... . $. -0- B. Merchandise .................... ..$ -0- C. Special Charges ................. ..8 1.895.00 D. Cash Advances ................. ..$ 30.00 S TOTAL OF ALL SELECTIONS ................. $ 1.725.00 Outer burial centainer .............. . ....S -0- PAID AT TIME OF OR PRIOR TO (Descdption)_Alfemate Container ARRANGEMENTS ........................... $ 0.00 Acknowledgement cerds .. . .. . ... . ..... . .$ _p- BALANCE DUE ................. / $ 7.725.00 Register Book(s) ...................... .$ _p- REASON FOR EMBALMING bl S( ~~ ~/ oc Memorial folders ...................... S. -p- None ~ Q.5 16 RS `~' Prayer cards ......................... $. -0- If any law, cemeury or crematory requirements have required the purehase of any of the items listed above the law or requirement is explained below. Temporary grave marker ................ ~. -0- pouch by crematorium Burial Gothing ........................ $ -0- I agree that I have examined the terms of goods and services seleced above and found them to be coned and axording to the anangements I have requested and 1 adrnowledge a copy of this Statement of Funeral Goods and Services selected. I represent that I have sufficient funds available for payment of total price for goods and services selected. I also agree to make payment of $. 1.725.00 within. 30 days, I agree to be jointty and severelly liable with anyone who signs below. A late charge of 1.5% oar month amounfing to 7 e% per year vaill be applied to the unpaid balance 6aginnin 30 days from the date of this agreement. twill also pay to the Funeral Director all reasonable costspaid by the Funeral Director to collect amounts I owe under t is agreement. Those costs may include attorney's fees, court costs and other costs. Any additional services or merchandise ordered or requested a date//ollf this agreemQment will be considered part of this agreement and the cost t[he~reo/f JD!~fi be rejO'eGfed on the final bill or statement. (Seal) _ ~~] Ur~..,n. ~ .At)v~~ n/~`~.--- - - 7 / ~1CSd 1 (Seal) ~(~~o ~-o~-_ (Purchaser) (Licensed Fune~radU .- ^ ^ Frederick News-Post A ~ ~~ ~~' ~' ~ ~ 351 Ballenger Center Ddve Frederick, MD 21703 ' ~~O ' ~~ Phone: (301)662-1883 Fax: (301)662.'921 Federal I.D. Tax #52-2270563 JO ANN SANGREY 17 SEBASTIAN WAY CARLISLE , PA 17015 ~ _- Acct #: 60028328 Ad #: 00395554 Phone: (717)243-3955 Date: 05/01 /2012 Ad taker: vmar Salesperson: vmar ~ -- Sort Line: BIDDINGER Classification: Description Start Stop Ins. CosUDay 11 Frederick News-Post 05!0212012 05/02/2012 1 65.00 65.00 d~ti~"'"' Sjtli~- ~0.C b ~d f}rm Sa,n9r'e'~/ s Ad Text: Payment Reference: Total: 65.00 Tax: 0.00 Net: 65.00 Prepaid: Total Due 65.00 CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 rope: {rtr-zaas+ee Fax:l71'r)z4o-zees July 13, 2012 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. T0: Ashley R. Malcolm, Paralegal Law Offices of Peter J. Russo, P.C. RE: Edgar E, Biddinger Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Joumai. eaeasasaasaeseaoeeseooasae:=~ eaeaaeaaasaaaaeaasaeaaeseaeeaa aen Advertisement inserted on the following dates: June 29, July 6, and July 13, 2012 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 0.00 Totaf Amount Due $ 75.00 sa:aassaae Payment received by, The Sentinel wrw.cumborlink.eem ~~b aesl ywlYeuc rt!w covr PETER J. RU880, ESQUIRE 0000 EAST TRINDLE ROAD SUITE 100 MECIUWIC8BUR0, PA 17060x327 7n-so1-~76s AD NUA03ER PAGE NO. 411100 1 of 1 SILL DATE SALESPERSON o7ro6t+z wolte START DATE STOP DATE Ot1120M2 07ro4N2 Publludon InsaKiona Rats Not Amourd Groh Amount 3 THE SENTINEL • LEOAL 7 LCiI 5195.18 TOTAL AD CNAROE 5181.19 7 PROOF OF PUBLICATION 01PRF 57.00 3 b10BILE SITE LA082 52.00 Purehaw actor E9LE.BIddingtN PAY THIS AMOUNT 5200.1 t3 5240.19' 'AFTER 07/30N2 Thank you for adtrerOsinp with The SenOnell Deadline for in-column lapel ads is 4:00 p.m. two bwines5 days prior to date of insertion. For quesdons, call (717) 240-7130. THE SENTINEL clo LEE NEWSPAPERS PO BOX 840 WATERLOOIA 80704-0840 oa+oe PETER J. RU330, ESQUIRE 5008 EAST TRINDLE ROAD SUITE 100 MECHANICSSURO, PA 170504327 IMYIA tl1Y1 YnfOn IIIAI YI YyMMr Check 0 ~ Credit Card ^®^®^®o® AOr2 N: EtP. Dato:m m Wms an «emtcaro qrw mYlm dreb oYleea m: THE SENTINEL THE 8ENTINEL clo LEE NEWSPAPERS PO SOX 840 WATERLOO IA 80704A840 Ad Numbs eimnp o.1. o7ros-+2 Amount Due 5 200.+6 THE SENTINEL clo LEt?i NEWSPAPERS PO SOIL 742648 CINCI-tNAT10H 48274.2818 IIII/IIIIIIIIIIIIII/III/MII/IIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIII 21540200000004311500000000000000002401°100©00200168 REV-1.512 E%+ (12-pH) ~ pennsylvania SCHEDULE I OEPA0.TMENTOFgEVENUE DEBTS OF DECEDENT, INHERITANCE TA%REiURN MORTGAGE LIABILITIES Bt LIENS 0.ESIDEM DECEDENT ESTATE OF FILE MUMBER Edgar E. Biddinger, II 2012.00611 Report debts inwrred by the decedent prior to death that remained unpaid at the date of death, Including unrcimbuned medical expenses. ITEM I I VAWF AT OATF 1 Chambersburg Hospital 1,868.53 2. Summit Pain Medicine 85.19 3. Physicians of Rehabilitation, Industrial 8 Spine Medicine, P.C. 190.85 4. Internists of Central PA 207.43 5. Graham Medico{ Clinic, P.C. 37.70 6. Norland Family Practice 11.51 7. PennState Hershey 423.77 e. Summit Physician Service 200.49 9. Chambersburg Imaging Associates, P.C. 31.14 10. Penelec 24.74 tt. Century Link 2107 t2. Parkway Neuroscience and Spine 58.43 TOTAL (Also enter on Line 10, Recapitulation) I ~ 3,160.85 If more space is needed, insert additional sheets of the same size. ' IVIHISC iv tltl:ki.T." pHYHCkI-C l V: / hambersburg~ Hos~rta/ an afa/hbe of /Summa Health 760 E. Washington St. Chambersburg, PA 17201 34931 oaels o101 AMDUNT PAID: $ PATIENT NAME: EDGAR E BIDDINGER ACCOUNT NUMBER: H00044495737 II"'4gPl'IIIII'dIIIhIIHuI,•l'I'I'qu4Pllh11'll"I'ul EDGAR E BIDDINGER 17 SEBASTIAN WAY CARLISLE, PA97015-`7677 f- AID TIDE Notice Date: 06/11/12 Patient Name: EDGAR E BIDDINGER Account Number. H00044495737 Service Date: 02/05/12 Balance Due: $167.31 Your account balance at The Chambersburg .Hospital is overdue and will be .placed with a collection agency if payment is not made within 14-days: it is important that you respond promptly to avoid this overdue account being reflected on your credit history. For your convenience, we offer the option of pa~ent by the major credit cards shown above. Also, payment may be made on ine at www.summitlleaith.org. If you have questions concemi your aaoount or would like to ili-scuss payment arrartgements, please callus at~717) 267-7129, option 2. If payment has been foruvarded or arrangements already made, please disregard this notice with our thanks. SEE BACK FOR ADDITIONAL INFORMATION . IF PAYING BY MASTERCARD. VISA O R DISCOVER FILL OUT BELOW. ^ ® ~ ~ VI&1 ®O~~IER CARD NUMBER - - SECURRY CODE AMOUNTTO 8E CHARGED TD CREDrr CARD EXPIWfr10N DATE SIG TU E - - hl"III'llllurliPrlhlllr'I'Idlr'll'IIIGIIIIIII1111I11'I' CHAMBERSBURG HOSPITAL. 7Ei0 E. WASHINGTON ST. . CHAMBERSBURG, PA 17201-2759 34931`TiV0DA8GK000430 PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT - - 170050I72/Oi) ii®n~~vovii~®s~®~®® MEDICARE K. Has~-ita/ an a/fillate of Summit Heath 760 E. Washington St. Chambersburg, PA 17201 MESSAGE Your account has an outstanding balancibf $167.31; Please make paymentin full today, or call (717) 267-7129 to make payment arrangements to avoid placement with a collection agency. Your account is PAST DUE: -bUMMAKY VF GHAKGtS latwratory S 1356.00 Radiology 8 293, W Respiratory Services 8 156,00 Emergency Room s 2067.00 Respiratory Services s 15.00 Cardiology S 1424.00 Physician Fees -Emergency Room s 319.00 Physiran Fees -EKG s 77.00 PATIENT SERVICE CHARGES s 5707.00 S b An itemized copy of your bill is available upon request. - INSURANCE INFORMATION Primary IDSNrenCe: MEDICARE Policy Number. 220382245A F PLEASE REfAM THIS PORTION FOR YOUR RECORDS. PLEASE PORi1fNi YYfrH YOUR PAYMEfrT Hospital ~ an aRNFate or SummitHealN 760 E. Washington St. Chambersburg, PA 17201 - ACCOUNT SUMMARY Statement Date Nay. 11, 2012 Date(s) of service 02/05/12 - 02/05/12 PatientNeme EDGAR E BIDDINGER GUareOtOr - EDGAR E BIDDINGER Account Number H00044495737 Patient Service(:harges 8 5707.00 Total Transfers S O.oo Insurance Payments 8 -G42.10 Adjustments S -4897.59 Patient Payments S 0.00 Balance Due S 167.31 Amount Due S 167.31 Data DUe. June 10, 2012 - AUESTIONS If you have questions regarding your bill, please contact us by calling: (717) 267-7168 (Insurance-related questibns) (717) 267-7129 (Patient payment questions) If a payment plan is necessary, please tall to set up an agreeable arrangement. office hours: B:00 AM to 6:00 PM Monday -Thursday 8:00 AM to 4:30 PM Friday 8:00 AM to Noon Saturday Our business office is located at: 760 East Washington St. Chambersburg, PA 17201 You may pay your account online at wwwsummithealth.oro. ~ _ ...SEE BACK FOR ADDITIONAL INFORMATION AMOUNT PAID: PATIENT NAME: ED~R BIDDINGER ACCOUNT NUMBER: H0004f1495737 nsoe otol II'Illllgll'Illullltllyld'lllyll'll'lhlllldllllfllgl66t EDGAR E BIDDINGER 101 N PRINCE S7 APT 203 SHIPPENSBURG, PA 17257-1336 IF PAYING BY MASTERCARD VISA OR DISCOVER FILL OI1T BELOW. CARD NUMBER SECUflITY CODE AMOUNT TO BE CHARGED TOCREDI CARD EXPIRATION TE S GNATURE wuveoo Id"lII'1116u'Idh'f411h"I'nP"II'911t114hhulllPl' CHAMBERSBURG HOSPITAL 760 E. WASHINGTON 8T. CHAMBERSBURG, PA 17201 Make check payable to Chambersburg HospRal aasar•noovvzsLOOOZrs 11~I,i1~~~1~~111~I~IB~®A9 ~® t~m~~~~°3$l~":. MESSAGE f'IOSD~a1 ~ We received payment from your insuranceoompanyi Tha remaining balance isyour ,,, snare or / summn Hearin respon ,ibigly: Please pay in full within 30 days. Questlons, call (717) 760 E. Washington Si. Chamhersburg, PA 17201 267-7129. You may pay online at wwwsummitflealth.org/paymybill. - SUMMARY OF CHARGES Room 8 Board S 3885.00 Pharmacy S 552.02 SuppNes 5 170.55 Laboratory s 797.00 Radiology S 6(18.00 Anesthesia S 1%.00 Physigl Therapy s 374.00 Emergency Room 8 2574.00 MRI s 2063.00 Phartnecy S 575.70 Recovery Room S 678.00 Observation or Treatment Room s 7963.00 Physician Fees -Emergency Room s 287.00 PATIENT SERVICE CHARGES S 20802.67 An item¢ed copy of your bill is available upon request - INSURANCE INFORMATION Pdmary IrISUrenCe: MEDICARE Policy Number. 220382245a PLEASE RETAIN THNi PORTION FOR YOUR RECORDS PLEASE OEfAgI AND RENRN THIS POHf10NYYIm YOUR i H~p~a, an 4fl4nare or Summk Heald, 760 E. Washington St. Chambersburg, PA 17201 AMOUNT PAID: PATIENT NAME: EDGAR E BIDDINGER ACCOUNT NUMBER: H00044796845 04883 0101 Ilrllllllll'IIII'1111111'rlrlll"1llllllllll"I"ill'IIII'IrI11J EDGAR E BIDDINGER 101 N PRINCE ST APT 203 SHIPPENSBURG, PA 17257-1336 - ACCOUNT SUMMARY SlatementDate dune ot, 2012 DBte(S)Of.SBfViCe 03/12/12 - 03/15(12 Patient Name EDGAR E BIDDINGER Guarantor EDGAR E BIDDINGER Account Number H00044796845 Patient Service Ctoarges s 2oao2.67 Total Transfers 8 D. 00 Insurance Payments s -3826.76 Adjustments 8 -15781.99 Patient Payments S 0.00 Balance Due S 1794.52 Amount Due 8 7794.52 Date DUe duly 01, 2072 - 61UESTIONS If you have questions regarding your bill, please contact us by calling: (717) 267-7169 (Insurance-related questions) (717) 267-7129 (Patient payment questions) If a payment plan is necessary, please call to setup an agreeable arrangement. Ofice hours: 8:00 AM to 6:00 PM Monday -Thursday B:OO AM to 4:30 PM Friday B:00 AM to Noon Saturday Our business office is boated at: 760 East Washington St Chambersburg, PA 17201 ~ You may pay your account online at wwwsummithealth.ore. SEE BACK FOR ADDrr10NAL INFORMATION IF PAYING BY MASTERCA RD. VISA OR DISCOVER FILL ~ JT BELOW. cnRD ~ ~ rn~scaER CARD NUMBER SECURITY CODE AMOUNiTO BE CHARGED TO CREDR CARD EXPIRATION DATE SIGNATUR h1,a91iN16mGplrplpllrrlrllprrprgllruhlllnl)Ilrlr CHAMBERSBURG HOSPITAL 760 E. WASHINGTON SL CHAMBERSBURG, PA 17201 Mak® check payable to Chambersburg Hospital aassianLassHxaooozoT I®111®1~1~®®®~®®®11 '® HosPi~ an affiliate or Semmk Hearth 760 E. Washington St. Chambersburg, PA 17201 - SUMMARY OF CHARGES MESSAGE Youraccount has a PAST DUE balance of$96.69. Please make payment today, or call (717) 267-7129 to make payment arrangements to avoid placement with a . collection agency. You may pay online at wwwsumm'itheatih.org/payrnyblll Phamtacy S 3.ao Radiology S 439.00 Emergarwry Room S 942.00 Pharmacy S 6.50 Physician Fees -Emergency Room s 186.00 PATIENT SERVICE CHARGES s 1577.30 An itemized copy of your bill is available upon request. - INSURANCE INFVRMAIIVN Pdmary IRSUrenCe: NEDICARE Pogcy Number. 2203822459 PLEASE RETAIN THNi PORTON r-0R YOUR RECORO.S r PLPABE DETAd1AND RETURN TFDS PORTION WRiI YOUR PAYMFM .~ HaBp~ an affiaate of Semmtt NealM 760 E. Washington St. Chambersburg, PA 17201 AMOUNT PAID: PATIENT NAME: EDGAR E BIDDINGER ACCOUNT NUMBER: H0004A757854 ]9086 0701 IP111111,Ihq,1i,I111P11'1111111111111111111111.1,L11111'll° EDGAR E BIDDINGER 17 SEBASTIAN WAY CARLISLE, PA 17015-7677 - ACCOUNT SUMMARY i Statement Date .tune 08, 2072 '~, Date(s) of Service 03/04/12 - 03/04/12 Patient Name EDGAR E BIDDINGER GUarenfOr EDGAR E BIDDINGER Account Number N00044757854 Patient Service Charges - $ 1577.30 Total Trensfere s 0.00 Insurance Payments S -351.88 Adjustments s -1128.73 Patient Payments s o.oo S 96.69 Balance Due r - ~ Amoun~ t pue - :- S ~ ~ 96.69 Date Due ~ July 08, 2012 - AUESTlONS If you have questions regarding your bill, please contact us by calling: (717)267-7169 (Insurance-related questions) (717) 267-7129 (Patient payment questions) If a payment plan is necessary, please call fo setup an agreeable arrangement Office hours: 8:00 AM to 6:00 PM Monday -Thursday 8:00 AM to 4:30 PM Friday 8:00 AM to Noon Saturday Our business office is boated at 760 East Washington St ~ Chambelsburg, PA 17201 You may pay your account onlne at wwwsummititeakh.arg, SEE SACK FOR AGDITIONAL MFORMATION IF PAYING BY MASTERCARD VIS OR DISCOVER FILL OUT BELOW. RCMD CARD NUMBER SECURITY CODE AMOUNT TO BE CHARGED TO CRE IT ARD EXPIRATION DATE SIGNATURE a,a~,a 111,~I~I,Illllut11111,µlpll„I,Itll„llegthtudthnlltrh CHAMBERSBURG HOSPITAL 760 E. WASHINGTON ST. CHAMBERSBURG, PA 17201 Make checkpayable to Chambersburg Hospital 34837+TISORKYJ0000897 ~i~B~-~/"~U/" M E SSAG E ~'-,~ HOSf-/taI Youraccount hes a PAST DUE balance of $37.62. Please make paymentioilay, or arrrwre of Summit Hnah call (717)267-7129 to make payment alrangemeMs t0 evOkl piaCBment with a 760 E. Washington St. Chambersburg, PA 17201 collection agency. You may pay online at wwwsummitheafih.org/paymybill - SUMMARY OF CHARGES Physical Therapy s 762.00 PATIENT SERVICE CHARGES S 762.00 a I An Itemized copy of your bill Is available upon request. - INSURANCE INFORMATION Primary IDSUrenCe: MEDICARE Policy Number. 220382245A PLEASE NETAIN THIS PORTION FOR YOUR RECORDS PLEASE OETAl91 ANU flEiURNTH~ PORRUN WRH YOUfl PAYMIM iHosf-/taI an aNNJate of SummttFkelth 760 E. Washington St. Chambersburg, PA 17201 AMOUNT PAID: PATIENT NAME: EDGAR E BIDDINGER ACCOUNT NUMBER: H00044603124 1M703 0101 111111'llllllllllllllll~tltltlll~l'Il'llellrllldll'Itll'llllelrl EDGAR E BIDDINGER 101 N PRINCE ST APT 203 SHIPPENSBURG, PA 17257-1336 - ACCOUNT SUMMARY StalBmant Date June 04, 2012 Date(s)ofService 02/20/72 - 03/21/12 PaGentName EDGAR E BIDDINGER Guarantor EDGAR E BIDDINGER Account Number x00044603124 Patient Service Charges s 762.00 Total Transfers s o.oo Insurance Payments s -150.48 Adjustments E -57.90 Patient Payments s 0.00 Balance DUe 8 37.62 Amount Due - .5 37.62.1 Date DUe July 04, 2012 - 61UESTIONS If you have questions regarding your bill, please contact us by calling: (717) 267-7169 (Insurance-related questions) (717) 267-7129 (Patient paymarit questions) If a payment plan is necessary, please call to set up an agreeable anangement. Office hours: 8:00 AM to 6:00 PM Monday -Thursday 8:00 AM to 4:30 PM Friday B:OO AM to Noon Saturday Our business office is located at: 760 East Washington SL Chambersburg, PA 17201 You may pay your account online at www.summffhealth.om. _ ._ SEE BACK FOR ADDITIONAL INFORMATION IF PAYING BY MASTERCARD. VIS~I O R DISCOVER FILL T BELOW. t ''' ncaao "~-~ v~uA -~ [-n CARD NUMBER SECURITY CODE AMOUNT TO BE CHARGED TO CRED CARD EXPIRATION DATE SIGNATUR (dtr111tIIIIuIrldhrP1f14trlrnl~rrlli11~1t11hhhn111rir CHAMBERSBURG HOSPITAL 760 E. WASHINGTON ST. CHAMBERSBURG, PA 17201 Make check payable to Chambersburg Hospital 34831 •T10GMG7 511000483 ®®®{1®1®®I~~II~f®1191 HosPital- anaalaateof Summa Health 760 E. Washington St. Chambersburg, PA 17201 - SUMMARY OF CHARGES MESSAGE A payment of $25.00 is due within 30 days .according ro your contract. You may pay yqur account in fu6 at any time. Questhms, caN _(717) 267-7129. Online: payment can be made at wwwsummfthealth.org/paymybill. Pharmacy S 614.55 Laboratory s 7847.00 RadiOlOgy S 3669.00 Emergency Room s 1945.00 Cardbiogy s 2761.00 Pharmacy S 495.62 Cardbrogy s 200.00 Observation or Treatment Room s 973.00 Physician Fees -Emergency Room 8 .319.00 Physician Fees -EKG s 72.00 PATIENT SERVICE CHARGES s .12896.77 An item¢ed copy of your bill is available upon request. - INSURANCE INFORMATION Primary lOSUraOCa: MEDICARE Policy Number. 220382245A L PLEASE RETAIN THIS PORTKIN FOR YOUR RECORDS r PLEASE DETACH AND pETURNiHai PONr10NW17HYWpPAYMENT .~ Hosf-ital an aRiAafe of SunnnH Healh 760 E. Washington St. Chambersburg, PA 17201 AMOUNT PAID: PATIENT NAME: EDGAR E BIDDINGER '~Y" ACCOUNT NUMBER: H00042415786 ~oarae oroi Illllllallllldllllrlllll'I'llll'Ill'1411"11111"nlllhll{II'1 EDGAR E BIDDINGER 101 NORTH PRINCE ST APT 203 SHIPPENSBURG, PA 17257-1336 - ACCOUNT SUMMARY Statement Date Nay 21, 2012 Date(s)ofService 06/22/17 - 06/22/77 Patient Name - EDGAR E BIDDINGER GUeranror EDGAR E BIDDINGER Account Number x00042415786 Patient Service Charges s 12996. t7 Total Transfers S 48.62 Insurance Payments S -1855.34 Adjustments s -10486.06 Paient Payments, S -225.00 Balance DUB 9: 378.39 Amount Due ~ - s.. 378.39 Date-0ue June 20, 2012 - 61UESTIONS If you have questions regarding your bill, please contact us by calling: (717) 267-7169 (Insurance-related questons) (717) 267-7129 (Patient payment questions) If a payment plan ti; necessary, please cal{ ro set up an agreeable artangement. Office hours: 8:00 AM ro 6:00 PM Monday -Thursday 6:00 AM ro 4:30 PM Friday 8:00 AM ro Noon Saturday Our business office is located at: 760 East Washington St. Chambersburg, PA 17201 You may pay your account online at www.summifhealth.org. SEE BACK FOR ADDITIONAL INFORMATION IF PAYING SY MASTERCARD VIS ~R DISCOVER FILL ~ T BELOW. ~TEflCARD ~ -~ p CARD NUMBER SECURf1Y CODE AMOUNT TO BE CHARGEDTO CRED CARD EXPIRATION DATE S GNA RE fi5a026a {di111'I~IInr614'IhPh"I'uP"Il~lhl'1111114u~111'1' CHAMBERSBURG HOSPITAL 760 E. WASHINGTON ST. CHAMBERSBURG, PA 17201 Make check payable to Chambersburg Hospital 3493t•TIAOKGW300D443 ®®N®IYIf®NBf®B®Ild 51D0lIT PAIN MEDICINE .785 5TH AVE STE 3 CHAMBERSBURG, PA 17201-1282 RETURN SERVICE REQUESTED (800)827-3458 R4950 SAM-4PM ADDflESSEE: 13788 EDGAR E BIDDINGER 101 N PRINCE ST APT 203 SHIPPENSBURG, PA 17357-1336 hd'hlPl'ulhl'Ih'dulllpullu'I'rllllppl"I'I'pugl G6286 I ]Please check hoE if a Infarmadan has than 99221 09/12 99231 16/12 16/12 12/12 99232 16/12 16/12 14/12 62311 12/12 12/ 12 14/12 99144 12/ 12 12/12 14/12 77003 12/12 IncarNG or insurance e change(s) nn mversa sitle. **SerVices For BIDDINGER, EDGAR E** OIEIX ('ARD USING FOR PAYMENT c x.anea O Ya4' ^ ^ ^ RASTERCMD y~gp DISCOVER AMER E%P.. GRDNWIBRt SR]RR1 CeaE SNNANRE. ANBUNf ' _ STATEMENT DATE: :. PAYTHIS AMOUNT :` -'. ACCOUNT NO. >r CHAM-PMFC 5 19 12 85.19.__ 3706-G CHARGES AND CFlEDITS MADE AF1'C-n BTATEG1EtJi~ SHOW AMOUNT DATE l91LL APPEAp ON NE:.T e4ATErdENL PAID HERE ~~ MAKE CHECKS PAYABLE / REMR TO: SID+IIIIT PAIN MEDICINE 785 5TH AVE STE 3 CHANBERSBURG, PA 17201-1282 '1'lllllllludlll'11111'll'11111111'11161iII'I'lllllll'llllll PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT IN ENCLOSED ENVELOPE INITIAL HOSPITAL CARE/DAY 30MINUTES -156.00' 19.:16 TLMOTHY SEMPOWSKI. Payment NOVITA$ SOLUTIONS.' 76.65'- 112 N SEVENTH -ST: MEDICARE ADJUSTMENT 60. 19= 5650 HOSPITAL CARE/DAY 15 MINUTES 180.00 7.48 EWA MALINOWSKI Payment NOVITAS SOLUTIONS 29.93- 112 NSEVENTH S7 MEDICARE ADJUSTMENT 142.59- ' 5850 HOSPITAL DARE/DAY 25 MINUTES 270.00 13.68 EWA MAIINOWSKI Payment NOVITAS SOLUTIONS 54.71- 112 N SEVENTH ST MEDICARE ADJUSTMENT : 201 .61- 5650 HOSPITAL CARE/DAY 25MINUTES 27000 13.68 ALI YDUSUFUDDIN Payment NOVITA$ SOLUTIONS. - 54.71- 112 N SEVENTH ST MEDICARE ADJUSTMENT 201.61- NJX DX/THER SBST EPIDURAL/SUBARACH LUMBA 790.00 17.12 ALI YDUSUFUDDIN Payment NOVITAS SOLUTIONS 68.48- 112 N SEVENTH ST MEDICARE ADJUSTMENT 704.40- MODERATE SEDATION PHYS PERF DX/THER 5VC 450.00 8.20 Payment NOVITAS SOLUTIONS - 32.82- MEDICARE ADJUSTMENT 408.98- FLUORO NEEDLE/CATH SPINE/PARASPZNAL OX/T 180.00 5.87 Payment NOVITAS SOLUTIONS 23.47- Please Pay YOUR ACCOUNT IS PAST DUE. PLEASE SEND YOUR PAYMENT TODAY TO SUMMIT PAIN MEDICINE 785 5TH AVE .iTE 3 - AVOID.ANY FURTHER ACTION. IF YOU HAVE ALREADYSENT YOUR ~ CHAMBERSBURO„ PA 17201-1282 PAYMENT, PLEASE DISREGARD THIS STATEMENT. THANK YOU. (800)827-3458 X4950 8AM-4PM STATEMENT SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION I37e6 ttx slwr wu-w rm uonaw srxa . v.nn ' 85.19 PHYSICIANS OF REHAEi1LiTAT10N,lNDUSTRIAL & SPINE MEDICINE, P.C. ;..;'_'_ STATEMENT `,, ~.ra ~anuuaie::~~oa:vum •a :u ~onuonaerry noae mlcnael r, ~upmacu, M.U. STATEMENT DATE PAGE P O Box 2028 Bloom Bld Suite 106 Willi IIA A R J M . . g. am , . o r., .D. Mechanicsburg, PA 17055 Harrisburg, PA 17109 William A. Pomilla, M.D. 216112 / 12 'L12 (717) 691-3755 (717) 561-4242 Lisa A. Eaton, PsyD www.pdsmdrs.com Bil4ing Dept: {717) 591-4415 Tax I.D. #25-1651500 Please retain this portion of statement for your records. NUMBER 06141 c (MNSACTIDN DATE INV.ND. POS. PATIENT DR PROCEDURE DESCRIPTION OF SERVICES DIAGNOSIS AMOUNT ?14/i//i0 C EDGAP, AFL 99E3O /U HOER VISIT, LEVEL 2 7993 120.00 !14/;='5/10 G EDGRR FL 9`~'c'31 !U HOSF' VISIT, LEVE=L 1 7993 11ZIC.0Ql ?14/46/i0 C EDGAR FL 99231 /U HOSP VISITS LEVEL 1 7993 1O2.211P 95114/12 EDGRR FL 4121 EDICRRE DISRLLOW 64.59 rJ5/14112 EDGAR FL '121 RYMENT-MEDICARE ^c9.93 95/14/10 EDGAR FL 421 EDICRRE DISALLDW 64.59 ~I5/14/1O EDGAR FL 10 RYMENT-MEDICRRE 09.93 95/14/10 EDGAR FL 421 EDICARE DISALLOW 1421.40' X5/14/12 EDr,RR FL 10 RYMENT-MEDICRRE 51.88 95/14/12 EDGAR FL 40 EDICRRE DISALLOW 107.22 §5/14/12 EDGRR FL 121 AYMENT-MEDICARE 1219.42 941::6!10 C EDGRR AFL 9O8Oa. ~5YCH DIRG INTER~IEGI EX 32190 250.021 'I4/c7/1O C EDGRR FL 9923'c' /U HOSP VISIT, LEVEL 2 7993 122.210 94/$8/12 C EDGRR FL 99031 /U HOSP VISIT, LEVE',L 1 7993 102.00 'J5/15/12 EDGAR FL 421 EDICARE DISALLOW 131.53 95/15/12 EDGAR FL 10 'RYMENT-MEDICARE 94.78 §5J15/12 EDGRR FL 40 EDICRRE DISALLOW 721.20 95/i5/ii' EDGRR FL 10 'RYMENT-MEDICARE 25.44 ?15115/10 EDGAR FL 40 EDICRRE DISALLOWd 53.61 95/15/10 EDGRR FL 10 'AYMEf+JT-MEDICARE 54.71 ~LEA'~E C L 1 4405 4JI FI GlUE8TION5 P TWEEN 8x30 AM-4 PM 'ELL US I ' WE AR MEETI G OUR NEEDS: www.Prismdrs.com =RIENDLY REMI D R! YOU R OUNT I5 PR AT DUE. PLER5E REMIT 9RLANCE. HAN : Y U,. 16$.61 22.24 ACCOUNT 4 AGE TOTAL AMOUNT y 190.85 CURRENT - OVER 90 DAYS - OVER 00 DAYS OVER 90 DAYS OVER 120 DAYS ANALYSIS WE PLEASE DETACH AND RETURN THIS PORTION WRH YOUR REMITTANCE ACCOUNT NO. 2161412 EDGAR E BIDDINGER 101 N PRINCE ST RPT2O3 SHIPPENSBURG.PA 17257 216/12/12 .. 9 1921. 85 PLEASE MAKE YOUR CHECK PAYABLE TO PRISM. y.;(~IANS OF REHABILITATION, INDUSTRIAL & SPINE MEDICINE, P.C. STATEMENT ancaster Boulevartl 4370 Lontlontlerry Roatl Michael F. Lupinacci, M.D. B STATEMENT DATE PAGE ox 2028 Bloom Bldg. Sui[e 706 William A. RoIIA, Jr., M.D. - ~echanicsburg, PA'17055 Harrisburg, PA 17109 William A. Pomilla, M.D. 06/ 12/ i c 01 (777) 691-3755 (777) 561-4242 Lisa A. Eaton PsyD www.p~rismdrs.com , Billing Dept: (717) 597-4415 Tax LD.825-7657500 Please retain this portion Of statement for your records. ACCOUNT ~ NUMBER 06141 ~. TRANSACTION DATE ~INV.NO. POS. PATIENT DR. PROCEDURE DESCRIPTION OF SERYICES DIAGNOSIS AMOUNT ~REVIQUS SRLRNCE 22.24 94/18/12 C EDGRR FL 99231 -/U HOSE' VISIT, LEVEL 1 799..?, 10^c. 00 94/19/12 C EDGRR FL 99232 -/U HDSP VI5IT, LEVEL 2 7993 122.00 44/20/12 C EDGRR FL 99232 /U HO5P VI5IT, LEVEL ~ 799' X2.00 95l03f12 EDGRR ~iFL 4121 EDICARE DISALLOW 107.22 95/09/12 EDGAR FL 10 'RYMENT-MEDICRRE 1149.42.' 95/¢19/12 EDGRR FL 414 MEDICARE DISALLOW 64.59 45l09/1c EDGRR• >'IFL 10 RYMENT-MEDICRRE ^c9.93 94/21/12 C EDGAR FL 9923]. /U HDSP VISIT, LEVEL 1 7993 1142.121@ 94/22/12 C EDGRR FL 991:31 -/U HOSP VISIT, LEVEL 1 7993 1142.021 94/?.~/12 1; EDGAR FL 99231 /U HOSP VISIT, LEVEL i 7993 10'c'.00 44/24/12 C EDGRR FL 99232 -/U HOSE' VISIT, LEVEL [ 7993 122.021 95/'11J12 EDGAR FL 42! IEDICARE DISALLOW 70.20 4'5{11/12 EDGRR FL 10 RYMENT-MEDICARE 25.44 45/11/12 EDGRR F 40 EDICARE DISALLOW 118.20 95/11!12 EDGAR FL 10 'RYMENT-MEDICRRE 84.64 ?15/11/12 EDGRR F 40 EDICRRE DISALLOW 64.59 45/11/12 EDGAR FL 10 RYMENT-MEDICRRE 29.93 94/14/12 C EDGAR F 99231 fU HOSP VISIT, LEVEL 1 7993 10.00 94/15/12 C EDGRR ~1FL 99231 /U HDSP VISIT, LEVEL 1 7993 102.00 94/16/12 C EDGAR FL 99^c32 /U HOSG VI^a IT, LEVEL 2 7993 122.00 ,ONTINUED ON NEXT PRGE ACCOUNT AGE TOTAL AMOUNT y CURRENT OVER 30 DAYS OVER 60 DAYS OVER 00 DAYS OVER 120 DAYS ANALYSIS DUE PLEASE DETACH AND RETURN THIS PORTION WTfti YOUR REMITTANCE D ACCOUNT NO. ~• 5 PLEASE MAKE YOUR CHECK PAYABLE TO PRISM. fERNISTS OF CENTRAL_PA 108 LOWTHER STREET LEMOYNE, PA 17043 Forwarding Service Requested EDGAR E BIDDINGER 101 N PRINCE ST APT 203 SHIPPENSBURG PA 17257 INTERNISTS OF CENTRAL PA 108 LOWTEER :iTREET LEMOYNE, PA :L7043 ~..e. ~ ~ 04/21/12 1 17 L HOSPITAL SUBSEQUENT CARE 99232 414.00 97.00. 05/23/12 Medicare Payment. 05/23/12 Accept Assign Add. 04/22/12 1 17 L HOSPITAL SUBSEQUENT CARE 99232.414.00 97.00 05/23/12 Medicare Payment 05/23/12 Accept Assign Adj. 04/23/12 1 3 L HOSPITAL SUBSEQUENT CARE 99232 414.00 97.00 05/23/12 Medicare Payment. 05/23/12 Accept Assign Adl. 04/24/12 1 3 L HOSPITAL SUBSEQUENT CARE 99232 414.00 97.00 05/23/12 Medicare Payment 05/23/12 Accept Assign Adj. 04/25/12 1 3 L HOSPITAL SUBSEQUENT CARE 99232 414.00 97.00 05/23/12 Medicare Payment. 05/23/12 Accept Assign Adl. 04/26/12 1 3 L HOSPITAL SUBSEQUENT CARE 99232414.00 97.0() 05/23/12 Hedicare Payment 05/23/12 Accept Assign Adj. 04/27/12 1 3 L HOSPITAL SUBSEQUENT DARE - 99232-4i4r00 97,00- OS/23/12 Medicare Payment 05/23/12 Accept Assign Adj. 46.50 -38.87 11,63* 46.50 -38.87 11.63* 54.71 -28,61 13.68* 54.71 -28.61 13.68* 54.7E -28.61 13.68* 54.71 -28.61 13.68* _.__ ___s _ _._. 54.71 -28.61 13.68* L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make payment. 00/00/00 I 0.00 I 207.43 I 0.00 f 0.00 I 0.00 I 0.00 INTERNISTS OF CENTRAL PA w cK 108 LOWTHER STREET ~avaaieTO: LEMOYNE, PA 17043 PAT~~ 1-EDGAR E BIDDINGER PRV~ 3-TYNDALL, JAMES A., M.D. PRV~~ 17-SWEENEY, ALAN J., M,D, 0. .~ ~ ~ 207.43* Ph:(717)-774=1366 Accts/: 69655 Date: 05/25/12 Page 2 of 2 INTERNISTS OP CENTRAL PA 108 LOWTHER STREET LEMOYNE, PA 17043 05/25/11: I 69655 Continued Forwarding Service Requested 28475 EDGAR E BIDDINGER 101 N PRINCE ST APT~203 SHIPPENSBURG PA 17257-1336 _MC _VISA _Disc Card{ __ ..- _ _ Sign INTERNISTS OF CENTRAL PA 108 LOWTHER STREET LEMOYNE, PA 17043 Security Code _ Exp _/_ •• •~• e e *** PLEASE PAY UPON RECEIPT. FOR BILLING *** AM AND 4 PM AND CHOOSE BILLING. *** LATE FEE AD~ED* TO BALANCE OVER ~~ DA 04/13/12 1 17 L NOSPITAL INITIAL DARE 2 05/23/12 Medicare Payment 05/23/12 Accept Assign Adj. 04/14/12 1 17 L HOSPITAL SUBSEQUENT CARE 05(23/12 Medicare Payment 05/23/12 Accept Assign Adj. 04j15/12 1 17 L HOSPITAL SUBSEQUENT CARE 05/23/12 Medicare Payment 05/23/12 Accept Assign Adj. 04/16/12 1 17 L HOSPITAL SUBSEQUENT CARE 05/23/12 Medicare Payment 05/23/12 Accept Assign Adj. 04/17/12 1 17 L HOSPITAL SUBSEQUENT CARE 05/23/12 Medicare Payment 05/23/12 Accept Assign Adj. 04/18/12 1 17 L HOSPITAL SUBSEQUENT CARE 05/23/12- Medicare Payment 05/23/12 Accept Assign Adj. 04/19/12 1 17 L HOSPITAL SUBSEQUENT CARE 05/23/12 Medicare Payment 05/23/12 Accept Assign Adj. 04/20/12 1 17 L HOSPITAL SUBSEQUENT CARE 05/23/12 Medicare Payment 05/23/12 Accept Assign Adj. 00/00/00 I 0.00 /AKE INTERNISTS OF CENTRAL PA :HECK '-` 108 LOWTHER STREET ~nvas~Ero: LEMOYNE, PA 17043 CALL 774--1366 BETWEEN 10 *** 3/1/10 THERE WILL BE A *** 99222 414.00 167.00 97.Ob -36.19 26.16* 99232 414.00 97.00 104.65 46.50 -38.87 11.63* 99232414.00 97.00 99232 414.00 97.00 99232 414.00 97.00 99232 414.00 99232 414.00 99232 414.00 46.50 -38.87 11.63* 54.71 -28.61 13.68* 54.71 -28.61 13.68* _s _ 471" -28.61` 13.68* 97.00 54.71 -28.61.. 13.68* 97.0(1 46.50 -38.87 11.63* PAT~~ 1-EDGAR E BIDDINGER PRVJJ 3-TYNDALL, JAMES A., M.D. PRVJJ 17-SWEENEY, ALAN 7., M.D. ., , Continued Ph;(717)-774-1366 AcctJJ: 69655 Date: 05/25/12 Page 1 of 2 GRAHAM MEDICAL CLINIC, P.C. 100 SOUTH HIGH STREET NEWVILLE, PA 17241-1409 05/15/12 ~ 250704 37.70* 27728 EDGAR E BIDDINGER C/0 JOANNE SANGREY 17 SEBASTIAN WAY CARLISLE PA 17013-7677 _MC _VISA Disc Card/~ Sign GRAHAM MEDICAL CLINIC, P.C. 100 SOUTH HIGH STREET NEWVILLE, PA 17241-1409 Security Code _ Exp _/_ -_ L _ _ ---- _ *** Pl *** PL *** ~ *** }}''0 ie***,4a'eie 03/16/12 1 04%11%12 05%03%12 1 05/03/12 e Payy -Amount Due Now From Patient- See Red Box Thank You. *** 103AY UPON RECIEPT, IF BILLINGS QUESTIONS PLEASE CALL 717-776-3114 ~~~ AY RE~EIVE 2 STATEMENTS FROM US WE ARE CONVERTING 'IO A N~W SY~TEM *** ***** *************************~******** **********e*****.**** ********** 3 L INT NURSING EVAL/MANAG CO 99305 733.13 150.00 Medicare Payment 99.44 Accept Assign Adj. -25.70 24.86* 1 L SUB NURSING CARE EVAL/MAN 99308 733.13 75.00 Medicare Payment 51.38 Accept Assign Adj. -10.78 12.84* s L-The 'PLEASE PAY' DATE LAST PAID AMOUNT 00/00/00 0.00 includes unpaid co-pay or co-ins. Please make payment. • • ~ • •~ ~ ~ 12.84 24.86 0.00 0.00 0.00 0.00 , , , ; 0.00 37070 ace HecK GRAHAM ME 100 SOUTH DICAL CLINIC, P.C. HIGH STREET ,~ ~ A ~rneLeTO: NEWVILLE, PA 17241-1409 37.70* Ph: (717)-776-3114 PATS 1-EDGAR E BIDDINGER PRV// 1-TOWNSEND, JAY A., MD Acct~~: 250704 PRV/~ 3-ROBISON, CAROL R., DO Date: 05/15/12 Page 1 of 1 NORLAND FAMILY PRACTICE - PAGE 1 OF 1 " 3106 PHILADELPHIA AVE STATEMENT NO "AMOUNT DUE CLOSE DATE CHAMBERSBURG, PA 17201-8938 (717) 264-3644 ST2121320149N0 11.51 05/11/12 Address change, indicate below AMT PAID $ FOR CREDIT CARD PAYMENT: EDGAR BIDDINGER VISA/MC CARD # _ 101 NORTH PRINCE STREET EXP DATE APT 203 SIGNATURE SHIPPENSBURG, PA 17257 < - DETACH HERE -> Statement of: EDGAR BIDDINGER NORLAND FAMILY PRACTICE "-Scat-cfi(@nt-77umb~r-~'ST212Y32014~9NP- ~------~--- -------330G-PHILA~nELPHI-A-AVE---- .----. Stmt Closing Date: 05/11/12 CHAMBSRSB~URG, PA 17201-8938 TOTAL INSURANCE PATIENT DATE * LOC DOCTOR DESCRIPTION AMOUN2 BALANCE BALANCE NF0000094227 EDGAR E BID OTHER 03/02/12 NFP Buchanan PAC EST PT - OFFICE VISIT 90.00 03/19/12 ADJ MEDICARE -32.45 886075764 03/19/12 PMT MEDICARE -46.04 886075764 TOTAL 11.51 11.51 t~4~ 11i;15S_E_? 1nii =i ~.t ~'IUIh=~ i•9• '. * ITEMS MARKED WITH AN ASTERISK HAVE BEEN BILLED TO YOUR INSURANCE COMPANY PATIENT BALANCE: 11.51 INSURANCfi BALANCE: 0.00 TOTAL BALANCE: 11.51 PLEASE PAYBALANCE DUE. PATIENT .TOTAL CUREENT 30 DAYS AGED BALANCES: 11.51 60 DAYS 90 D71YS 120 DAYS+ 11.51 PEi~1N~STATE; HE[~>HE~I l~'f~ilt®n ~~. Hershey l~Zedicat Center ACCOUNT # 17462730 D4ro7/12 To D4rn2/12 PERFORMED BY: ROBERT E HARBNJ611 MD D1ViSIW OF lER PLACE OF SVC: IF~ATIENF 04!07!12 63047.60 733.13 LMN% N FACETX/FORAM 1 LVL 7711.00 04/24/12 MEDICARE PAYlRiNltl 872.35- 04/24/12 MEDICARE CDNFRACiUAL AD.IIE 6620.56- D4/24/12 BALANCE TRANSFERIE 218.D9 ' PERFOiBffD BY: .ASIAIA 6 TILE ND D1V OF DIAL RADmIOGY 04/07n2 7101D26 Y72.83 CHEST 1 VIEN >;;,OD t 04/26/12 MEDICARE PAYMENI3E 6.94- * D4/26/12 MEDICARE COMRACTUAL AD.HI 74.32- ~ D4/26/12 BALANCE TRANSFER* 1.74 PERFORMED BY: PAUL KALAPOS !~ DIV OF DIAL RADIDLOGY 04/07n2 7215826 724.02 MRI LUMBAR SPINE UlAENN ENN 107E.00 * 04/2b/12 MEDICARE PAYMENIt: 91„ 28- :1 04/26/12 MEDICARE CtlIFRACiUAL AD.k: 457.9D- * D4/26/12 BALANCE TRANSFER:1 22,8E PERFORMED BY: PAOMA4Q % OHAA MD OIY DF tdiESFHESIp 04/07n2 63D47.AA 733.13 16 ANES PROC IN LUMBAR REGIO 2144.DD ^ 04/26/12 MEDICAAE PAYMENT'II 274.82- a D4l26/12 MEDICARE CONFRACi11AL dD.i>E 18~.48- ~ D4/26/12 BALANCE TRANSFERI~ 6g,7D n ~ PERFORMED BY: DEBORAH L AOLBRETiE MD ELECTIlOPHYSIOLOGY ~ 04/07/12 9301D 79€.31 2 EC6 ELECFROCARD INIERP 194.OD ~-05/!4/-12- ---- -- _- - MEDICARE PAYMENi~ -- ---- --- _-- - 13:34-- _- _--- ^ 05/14/12 MEDICARE CONrRACTi)AL AD.i>E 177.32= - ~ 05/14n2 BALANCE TRANSFER:1 ; ~ ~ , PERFORMED BY: ROBERT E NARBAUGH 1® DMS70M OF IR * D4/07n2 99223.57 733.13 IFU:TIAL xDSPITAL CARE 643.00 ~ 05nb/12 MEDICARE PAYtRiNI~I x,50_ ~ D5/16/12 MEDICARE CDNFRACTUAL AD,61 451.12- ~ 05/16/12 BALANCE TRANSFERI: 3B,~ PERFORMED BY: PAUL KALAPOS ND DIV DF DIAG RADIOLOGY 04/Q8/12 72131E6 V58.89 CT LUMBAR SPINE UNEI0IAIICE 527.00 # 04/27!12 MEDICARE PAYMENf3e ~,4b- * 04!27/12 MEDICARE CONFRACiUAL ADS 47g,~- 11 D4/27n2 BALANCE TRANSFER:E 9.61 PERFORMED BY: DAVID C MAN -m VASCULAR SURGERY D€/04n2 9397D26 78E3 dJRLEX SCAN EV - L'DMPLEFE 347.00 € 04/27/12 MEDICARE PAYFffNItl 26.36- * 04/27!12 MEDICARE CONFRACfUAL AD.Ati 313.72- R D4/27n2 MEDICARE CONFRACTtlAL AD.9E 0,~ ^ CHECK BOX AND ENTER ANYADDRFSS OR INSURANCE CORRECTIONS ON BACK ipaxv4:uES7wNS, PLEASE colvrAC7: N3HlNC PATIENT FINANCIAL 3ERVICE3 FFfl TAY IA ~! 9C1AC7MnC _ ~ STATEMENT OF PHYSICIAN SERVICES P~IVRS~G~TE ~~~,~$~~~~~`~' ~~ Nlilta~n ~. I~ershey IFAMY QUESTIONS. PLEASE CONTACT: EA~A~R3E Blt)pINGER 101 N PRINCE STREET SHIPPENSBURG PA 17257-1336 ACCOUNT # 2076087 PERFORMED 8Y; dNJIC NADUZI JTAEIDO:RC MD IIIAGIW6 ID 20 D4110/12 4330626 429.3 TTE M/DOPPLER i COLDR FLD 1175.00 ~[ 04/30112 MEDICARE PdYMENT~I 50.54- * 0413D/12 MEDICARE CtyVTRACTUdI ADJI: 1111.82- ~ D4130112 BALANCE TRANSFER* 12.64 PERFORMED BY: SANSAM 6 KAIJEICAR 10) DN OF DIAL RADIOLOGY 04/10/12 7210026 805.4 SPINE LUMBOS ANT/POST LAT 94.OD >& D5/OU12 MEDICARE PAYMENfIf 9.14- ~ D6/OL12 MEDICARE CONTRACNAL ADJI: 87.57- ~ 0510]/12 BALANCE TRAhBFE1dI 2.24 PERFORIffO BY: JOHN J ZURLD MD DN DF INFECT' DLS & EPIDM ~ TY-/10/12 99221.60 733.13 INIITAL IiDSPITdL CARE 365.00 ~ 05/24/12 MEDICARE PAYFDiNTN 77.42- ~ 05/29112 MEDICARE CONIRAUNAL ADJN 266.22- * 06129/12 BALANCE TRAI6FER+: 19.36 PERFORlffD BY: T THOMAS ZdONARIA MD DN DF DIAL RADIDLOGY 04/1L12 7210026.77 805.4 SPIAff LUlBOS AMf/POST LAT 99.DD ~ 05/01/12 IffDICARE PAYMENT31 4.14- * 05/01/12 MEDICARE CONTRACTUAL ADJaE 87.57- ~ 05/D1/12 BALANCE TRANSFERS 2.24 PERFORMED BY: SANSAM 6 KAIffICAR FB DN DF DIAS RADIOLOGY u. D4/11/12 7210026 805.4 SPINE L1R806 ANf/POST LAT 44.00 05/DL12 MEDICARE PAYMENTN 9.I4- ~t~,51D1/lY~, _ - IgDIt:ARE CONIRACNAL ADJN ~ 67.57- ~ 05/01/12 BALANCE TRANSFERI: - _" _ - 2.29 PERFORMED BY: PAfR:LA L BRIAN MD DN OF OIA6 RADIOLOGY y D4/11112 73D3026 719.41 SHOULDER COMP >2YIE16 83.90 N 05/01/12 MEDICARE PdYMEMN 7.81- ~ D5/D1/12 MEDICARE Ct><!i'RACNAL AD.PE 73.24- * D5/Bi/12 BALANCE TRANSFER:[ 1.95 PERFOIMED BY: JOIN J 2URIA MD DN OF INFECT DIS A EPIOl1 * 04/1L12 99232.60 T33.13 DAILY ItOSPITAL CARE 224.D0 :[ 05/29/12 MEDICARE PdYMENTI: 54.7I- IE D5124112 MEDICARE CdAi'RACNAL ADJN 160.61- * 01;/29/12 BALANCE TR#NSFERiE 13.68 BALANCE: EDGAR E BIDDINGER 5493.77 I: INDICATES NEM FINANCIAL ACTIVITY SINCE LAST BILL. #Dl1e ME HAVE NDT RECENED YaJR PAYMENT' IN FULL. YOUR ACCOIA~IT IS PAST DUE. PLEASE SEND PAY1031f >~BIATELY. IF PAYMENT' NAS BEEN MADE, THIA~K YOU AND DISREGARD THIS BILL. STATEMENT a+T~ 05!29172 IAST STATEMENT a+TE~ 0412M12 'ENNSTATE HERSHEY Milton S. Hershey ®MediCal Center IF ANY QUESTIONS, PLEASE CONTACT: EDGAR E BIDDINGER APT 203 101 N PRINCE STREET SHIPPENSBURG PA 17257.1336 ACCOUNT # 2078087 YLt6'St fi:lt: IU ACCP TUUN A4Z.UJr1I 4lJRNCNfa WR PULIC APPLY YOUR PAYMENT TD TIB: OLDEST OUTSTANDII6 BALANCE. STATEMEtI! DATE: 05/29/12 LAST STATEMENT w-Te 04!24!12 TMANC YOU FOR USING 16INC PHYSICIANS 6'ROUP TOR YOUR PNYSICIAN SERVICES. IF Yq! NAVE ANY QUESTIONS REGARDING TIDE BILL, PLEASE CQITACT US AT 7I7-531-5069 OR SOD-254-2614a BE111EE1~1 S:ODAM Ate 5:3081 MONDAY TIBmIlsM NEONESDAY OR BE'DR:EN 8:DOAM AND 4:3DPM TNIRZSDAY AND FRIDAY. P O 00 I ~- aeee GUARANTOR RESPONSIBILITY 77 8 of 3 I _ IMPORTANT: PLEASE OETACN ANO RETURN ROTTOY PORTfON OF STATEMENT NfTH YOUR PAYYEN7 STATEMENT DATE GUARANTOR RESPONSI&LTM MItRMUM PAYMEN Bra osr2sriz s 42a.n s 42a.n MSHMC PHYSICIANS GROUP BIWNG SERVICES P O BOX 854 HERSHEY PA 17033.0854 I...II.1.I...1111111..I..Iffliff1111It,llf~ll.II.11f.11.ll.l.l Mail MSHMC PHYSICIANS GROUP ro: MSHMC PHYSICIANS GROUP PO BOX 643313 PITTSBURGH PA 15264-3313 OFFICE USE OMLY HC: FBBO 101 N PRTNCE STREET SHIPPENSBURG PA 17257-1336 FOR CRmfi CARD PAYMENT, PUiASE FlLL IN INPDRMATION BEIOM CNELK ONE I I' I ~ I I I' I I' I I I I AA/C CARD NUMBER EI(P DATE -VISA -DISC CARDHOLDER NAME (PRINT) 00002076067 uP 0000000000042377052912 00000768 03 EDGAR E BIDDINGER APT 203 CREDIT CARD SIGNATURE r MSHMC PHYSICANS CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BAIX I ~ SUMMIT PHYSICIAN SERVICES 785 5TH AVENUE, SUITE 3 CHAMBERSBURG, PA 17201-4232 05/08/12 I -98505 Continued Address Service Requested ~ 29389 i ESTATE OF EDGAR E BIDDINGER 101 NORTH PRINCE ST _ APT 203 SHIPPENSBURG PA 17257-1336 ,MC -VISA -Disc _AmerExp Security Card~~ __ Code _ Sign Exp _/_ SUMMIT PHYSICIAN SERVICES 785 5TH AVENUE, SUITE 3 CHAMBERSBURG;, PA 17201-4232 Insurance Charges pending to Prv: 248.00 248.00 02/05/12 1 140 ECG MONITOR/REVIEW/INTERP 93227 785.1 74.00 02{20/12 Medic DEDUCT Payment 0.00 02/20/12 12 Accept Assign Adj. l P - 25 5 -48.15 0 00 03/01/ ayment Check Persona .8 . 02/15/12 1 155 L OFFICE VISIT EST LEVEL 3 99213 427.69 111.00 03/20/12 Medicare Payment 54.16 03/20/12 , Accept Assign AdJ. -43.30 13.54* 02/15/12 1 155 L ELECTROCARDIOGRAM COMPLET 93000 427.69 98.00 03/20/12 Medicare Payment 14.44 03/20/12 Accept Assign Adj. -79.95 3.61* 02/16/12 1 137 L X-RAY RNEE COMPLETE 73564 726.61 127.00 03/13/12 Medicare Payment 33.32 03/13/12 , Accept Assign AdJ. -85.35 8.33* 03(07/12 1 51 L OBSERVATION CARE HIGH SEV 99220 427.89 260.00 04/20/12 Medicare Payment 139.83 04/20/12 Accept Assign Adj. -85.21 34.96* 03/0$/12 -f 1~ L ~ SUISSQUSNT ~OB~ERV~~ON-C`A- "99226 427:.89 " 184:OU " _ -_ ~_ ___. __...__ _~ __._ ___ ;. 04/20/12 Medicare Payment 78.95 04/20/12 , Accept Assign Adl. -85.31 19.74* 03/09/12 1 10 L SUBSEQUENT OBSERVATION CA 99226 427.89 184.00 04/20/12 Medicare Payment 78.95 04/20/12 , Accept Assign Adl. -85.31 19.74* 03110/12 1 10 L SUBSEQUENT OBSERVATION CA 99226 427.89 184.00. 04/20/12 Medicare Payment , 78.95. DATE LAST PAID AMOUNT • ~ • . ~ • , ~ • ~ . . r 03/01/12 ~ 25.85 SUMMIT PHYSICIAN SERVICES ., ~ cHelcK 785 STH AVENUE, SUITE 3 PAYABLETO: CJ3AMBERSBURG, PA 17201-4232 Continued PAT~~ 1-EDGAR E BIDDINGER PRV~~ 10-DHAR,SANJAY, M.D. PRV// 51-TAHIR, PSHTIWAN A, M.D. PRV~ 91-MADARAS,LASZLO I, H.D. PRV//137-LUTTON, JEFFREY S, M. D. Ph:(717)-263-9555 Acct//: 98505 Date: OS/O8/12 Page 1 of 2 SUMMIT PHYSICIAN SERVICES OS/O8/13! 98505 785 5TH AVENUE, SUITE 3 CHAMBERSBURG, PA 17201-4232 200.49* Address Service Requested ESTATE OF EDGAR E BIDDINGER 101 NORTH PRINCE ST APT 203 SHIPPENSBURG PA 17257-1336 _MC -VISA -Disc _AmerExp Security Card/k __ ~ _ _ Code _ Sign Exp _/_ SUMMIT PHYSICIAN SERVICES 785 5TH AVENUE, SUITE 3 CHAMBERSBURG, PA 17201-4232 •• ••• • MESSAGES EXPLAINED - BELOW 04/20/12 Accept Assign Adj. -85.31 19. 74* 03/11/12 1 10 L SUBSEQUENT OBSERVATION CA 99225 427.89 123.(10 04/20/12 Medicare Payment 54.90 ~ 04/20/12 Accept Assign Adj. -54.37 13. 73* 03/12/12 1 91 L HOSPITAL SUBSEQUENT CARE 99232 427.89 153.00 04/20/12 ~ Medicare Payment 54.71 04/20/12 • Accept Assign Add. -84.61 13. 6$* 03/13/12 1 91 L HOSPITAL SUBSEQUENT CARE 99233 427.89 179.00 04/20/12 Medicare Payment 78.51 04/20/12 Accept Assign Adj. -80.86 . 19. 63* 03/14/12 1 41 L HOSPITAL SUBSEQUENT CARE 99232 427.89 153.00 04/20/12 Medicare Payment 54.71 04/20/12 Accept Assign Adj. -84.61 13. 68* 03/15/12 1 91 L HOSPITAL DISCHARGE DAY 99239 427.89 201.00 04/20/12 Hedicare Payment 80.46 04/20/12 , Accept Assign AdI. -100.43 20. 11* - _ -_... _ . .-y -- - L-The 'PLEASE PAX' includes unpaid co-pay or co-ins. Please make payment. DATE LAST PAID AMOUNT • ~ • • • , 03/01/12 25.85 175.01 25.48 0.00 0.00 0.00 248.00 0.00 448,49 MAKE SUMMIT PHYSICIAN SERVICES , , ,, , (NECK 785 5TH AVENUE, SUITE 3 7ArAeLE TO. CHAMBERSBURG, PA 17201-4232 200. 49* Ph:(717)-263-9555 PAT{ 1-EDGAR E BIDDINGER PRV~~140-SAFI, ARSHAD M, M.D. Acct/J: 98505 PRV//155-LEWIS, GARY W. M.D. Date: 05/08/12 Page 2 of 2 ~~, ,_, 25 PENNCRAFT AVENUE SUITE E CHAMBERSBURG, PA 17201-1686 HENRV T. CHING, M.D. (717) 263-1383 DAVID fl. BRILL, M.D„ FACR, FAGNP FAX (717) 263-7434 MICHAEL E. SHIVERS, M.D. EDWARD W. LAMPTON, JR., MD., FACfl GEORGE GALANIS, M.D. AMIR R. BATOUII, M.O. PATIENT: EDGAR E BIDDINGER LocarloN: CHAMBERSBURG HOSPITAL ROBERT S. PYATT JR., M,D. FAGR, PRESIDENT T. TOE TH4NE. M.D. PETEq J. W. FANG, M.D. ~PHIUP J. SABRI, M.D. NITEEN N. SUKERKAR, M.D. ANN E. LEWANDOWSKI. M. D. H45038833 EDGAR E BIDDINGER 100 N PRINCE'ST APT 203 SHIPPENSBURG, PA 17257 H4503S833 . ~. 05/07/12 16.82 ~~6-TSErAG`R HERE ~ TO ASSURE PROPER CREDIT PLEASE WRITE YOUR ACCOUNT NUMBER ON YOUR CHECK AND RETURN UPPER PORTION WITH REMRTANGE. o~ MEDICARE HAS PAID THEIR PART OF YOUR BILL. PLEASE CALL US WITH YOUR SECOND- ARY INSURANCE OR PAY THE BALANCE DUE. H45038833 04/06/12 72128 04/06/12 72131 OS/_D4112._ 02DIl~ ACH- 86243428 OS/04/12~ 0295 EDGAR E BIDDINGER CT LUMBAR SPINE UNENHANCED urrurrtA R ~EDZCARE-PAYMENT--- 194.00 -~-6~ :-3-1- LIMIT OF ALLOWANCE WRITE OFF CHAMBERSBURG IMAGING ASSOCIATES, P.C. 25 PENNCRAFT AVE. CHAMBERSBURG, PA 1 7201-1 686 -303.87 io: ..o c. IRS # 23-2192005 ' 25 PENNCRAFT AVENUE SUITE E CHAMBERSBURG, PA 17201-1686 ROBERT 5. %~ AI JR., .D. F;:C3. ==35 ~=iJT HENRY T. CHING, M.D. T 1JE. t.1.D. (717) 263-1383 DAVID R. BRILL, M.D., FACR, FACNP Fc ER.,., .FANG.': -. FAX (717) 263.7434 MICHAEL E. SHIVERS, M. D. _'-' L!P J. SAEiRI. l:.::. EDV/ARD W. LAMPTON, JR., M. D., FACR NI i EES; fi. E! EKE RXR.:• ~ GEORGE GALANIS, M.D. A;.;p; E. __.;; ~,..; C;~ilS{~,,.. r.. AMIR R. BATOULI, M.D. PATIENT: EDGAR E BIDDINGER LocnnoN: CHAMBERSBURG HOSPITAL. H44796845 ° EDGAR E BIDDINGER H44796845 101 N PRINCE•ST APT 203 SHIPPENSBURG, PA 17257 05/03/12 114.32 _ _. __ _. R DETACH HERE TO ASSURE PROPER CREDIT PLEASE WRITE YOUR ACCOUNT NUMBER ON YOUR CHECK AND RETURN UPPER PORTION WITH REMITTANCE. d/ r - - I ,_. 1 i '~ ~~_ • THIS BALANCE IS PAST DUE. PLEASE PAY PROMPTLY OR CALL US WITH INSURANCE INFORMATION IMMEDIATELY. THANK YOU H44796845 EDGAR E BIDDINGER 04/03/12 0200 HIGHMARKfMEDICARE PAYMENT 57.28 __ACH-. 8612.611Q___-.~ 04/03/12 0295 ~ LIMIT OF ALLOWANCE WRITE OFF ~~ X169.40 CHAMBERSBURG IMAGING ASSOCIATES, P.C. 25 PENNCRAFT AVE. CHAMBERSBURG, PA 1 7201-1 686 IRS # .?3-2192005 B"Cf 1~JGL Bib Based On: Estimated Metw Reading, Final Page 1 P72 ~nr~Ctaw.x Bill, Prorated Bill - May 21, 2012 Billing Period: May l5 to May 16, 2o12 foradays - Account Number: 100 074 006 139 BIII Far: EDGAR E BIDDINGER ~^1a U ' '~` ~1~~~ ~ "'' `-' STEVENSON BLD - •` - - 'F ~'"g.`" ~F`. 101 N PRINCE ST AP7 203 Due Date: June 11, 2012 SHIPPENSBURG PA 17257 _ ,..~ - - - :: r 'gym"- To repod an emergenq w an outage, ca0 24 hours a day 1A68.5444877. Fw CuslomerSarvice, call 1800545-7741. Fw Payment Options, call 1~800~982-4848. Fgy your biN aMirre at www.hrsleitergycwp.com BKI issued hy: Pertetec, Fb Box 16001, Rearing F'A~1961&6W1 Your curtenl PRICE i0 COMPARE to genera0on and transmission hom Perrelep is listed belax. Fw you W save, a supplier's Wke must be taxer. Shndard Residentlal -0001555092- 7.50 cents per KWH Customer reserves the right to shop for an electric supplier. Your bill includes $0.16 in PA lazes, of which 80.10 is PA grass receipts lax. Genereticn prices and charges are set by the electric genere9on supplier you have chosen. The P+d>lic UIiN9es Commission reguates drsfrbution prices and services. The Federal Enwgy Regulatory Commission regulates transmission prices and services. be found on back SOC 400 300 200 YQO A-Actual E-Estimate Average pally Use (fO~IN) Average Daily Temperature last 12 Months Usre (KWH) Avenge Monthly Use (KWH) C-Cuslamw N-No Usage M~' lacy 12 11 28 58 .. ~ ~ 4 3,530 294 PO BOY 1Bt101 A~ Reading, PA 19812.6001 Prevbus Balance PaymenislAdjuslments BaWnce al BIIlilrg on May 21, 2012 KWH Rearing (Estimate) KWH Readmg (Estimate) Wtren wnla:aug of Castanet Number. Rata: Slentlard Re UeWUIl Service Support Charge Nan•Utility Generation Charge Small Meter Charge Slate Tax Surcharge Cumnt Consumptbn Bill Charges fallowing. 22.00 0.00 12 KWH x 0.074950 O.B 1.q 12 KWH x 0.041687 0.5 12 KWH x 0.000500 0.0 12 KWH x 0.009030 0.1 0.1 -0.C 2] Retum this part with a check or money order payable to Penelec Amount Paid lllrgrlhl4hiP9yWlrLll~lt.lili(,l.uillt'Iridtrrirrflr 00019818 01 AV 0.347 EDGAR E BIDDINGER B7EVENSON BLD 101 N PRINCE ST APr209 6HIPPENBBURG pA 17257-0990 Amount Due Due Date 006 139 $24.74 Jun 11, 2012 PENELEC PO BOX 3867 AKRON OH 44309-3687 Illdllllll.lll...r_u_rr . , ..... ._._ ~~~ CenturyLink~ I~ ~~ P.O. Box 1319 Charlotte, NC 28201-1 31 9 Accoum Name: EDGAR E BIDDINGER Page: 1 of 4 Accoum Number: 313589090 Bill Date: May 22, 2012 COr1tACt NUrrlberS CUrr6rlt ChafQ@S $UtllmerV Detail Page Pay Online vrvvw.centurylink.com/myacoount ® CeMuryLink Packages 3 0.00 Pay by Plrorre 1-866-712-1996 Customer Service 1-BOo-~ae-3600 Customer Service Hours Mon-Fd 8 am. 7 p.m. Repair Service 1~aoo-~6Basoo Visit us online vmw.cenWryGnkcom DISCOUMa Previous Balance Payments Zx AdJs Past Due Current Charges Amount DUe Date Due 35.67 ~ 13,74 CR I 21,93 ~ 0.88 CR I 21.U7 I Jun.15,2012 ff f Jusi a friendly reminder that your account is past due. If you have already made your payment, thank you for bringing your account up to data. i '7 a a B The Due Bata en Thie Bill Applies to Current Charpea~nly_ __ _ .. ___ - - "`PLEASE FOLD, TEAR HERE AND RETURN THIS PORTION WITH YOUR PAYMENT"" PLEASE REMIT PAYMENT TO: IIIII'I~II~l1~I111~111~I~I11i11~1111~1~11i11111111~111111II'Ill~l CenWry~nk P.O. Box 1319 Chadotte,NC 28201-1319 Account Number: 3 CenturyLink Local Services WA - g.oo ® Centurylink Long Distance Services 4 1 .os Late Fees Total Current Charges 2.77 CR 0.25 0.86 CR 313569090 F D gsaal2 Amount Due By Jun. 15, 2012 AB 01 242831 93754 8 952 A EDGAR E BIDDINGER 17 SEBASTIAN Way CARLISLE, PA 17015-7677 h'il'tl'PI'I'III{,{Igq~p~l,p~,.l,lglhldtllrllllll'hlil 21.07 FOR CHANGE OF ADDRESS OR PAYMENT AUTHORIZATION: Please check here and complete reverse. Thank You. 000031356909020000000021931000000000052212000000210725000000 .e~-i . ~j~` CenturyLink~ Service Categories Past Due Basic Services. 15.64 Other services 6.29 All Services 21.93 Accoum Name: EDGAR E BIDDINGER Accoum Number: 313569090 Allocation of charges: Page: 2 of 4 Bitl Date: May 22, 2012 Current Month 2.17 CR 1.31 0.86 CR Total Due 13.47 7.so 21.07 Failure to pay Basic charges may result in the disconneofion of those Services.-Basic SSivice cons(sts-ofiocal phone service, interstate access charge, telttccrmmunicaflons relay surcharge, emergency 911 surcharge, installation and other fees. Please contact CenturyLink regarding any questions or problems with your bill before the due date. A rate schedule, an explanation of how to verify the accuracy of your bill and an explanation of :spec'rfic charges can be obtained free of charge by calNng the cusomer service number listed on the firs[ page. Effective July 3, 2012 CemuryLink will begin collecting an Access Recovery Charge as a way to recover the costs of providing access to the telephone network This surcharge has been tbmbined with the Subscriber Line Charge on your bill. The surchazge has been authorized by the Federal Communications Commission (FCC) and will be $.50 for consumers. If you have questions or concerns regarding tfie Access Recovery Charge, please contact CenturyLink at 1-855-234-1901. Effective July t, 2012, Add'Rionai Listing w)tl increase from $3.25 to $3.50. Akemate Number, Cross Reference and Extra-line will increase from $2.25 to $3.00. Pay-per-use feature Repeat Dial and Return CaA will increase from $1.25 to $1.50 per use. We value you as a customer and look forward to continuing to serve your communication needs. If you have any questions, please contact, customer service at the number listed on this bill. CaA 8-1-1 before you dig, it is the law. As warmer weather approaches, so do plans for construction projects. But before you sink that shovel or backhoe into your property, it is important to check what utility lines might ba lying just bekwv the sod. Digging into underground telephone, electric, gas or water lines can disrupt service to your area or could cause serious injury; and you cattld be charged substantial floes for causing damage. For peace of mind, please call 8-1-1 at least two days before digging up your property. This is a free service. _ ___._.._._.~._._ P.O. Box 1319 Charlotte, NC 28201-1319 Immediate Billing Address Changes Call 1-000-780-9500 313569090 EDGAR E BIDDINGER 17 SEBASTIAN Way CARLISLE, PA 17015 Address In(onnafion Changes New Address City Work Phone ( ) Effective Date State Zip Phone ( ) MONTHLY AUTOPAY AUTHORIZATION FORM I authorize CenWryLink W cfrdrge my MasterCard, Visa, Discover, Amakan Express, sav,rres or ckmg account monthly for any accrued balance on the blQYlg acceunt listed below. (Wa reserve the right to revoke this if bards eppmwl is dented) Checking Accoum # (Wdte your billing rwcount number on a voded check or copy of a vcided check end anachJ i, Savings Accoum # (Write your billing eu;eeunt number on a voided deposit skp and attach.) Credit Card ^ pebR Card Exp Date; MasterCard Visa ~ Discover ^Amedcan Express S~natare required Date Pl~ae continue to pay your bill until notified on your statement that autopsy is active. Account Number a~-i~ - „` CenturyLinkTM P.O. Box 1319 Charlotte, NC 28201-1319 Account Name: EDGAR E.BIDDINGER Page: 3 of 4 Account Number. 313569090 Bill Date: May 22, 2012 Important Notices and Information CenturyLink works every day to bring you solutions that best meet your total communications needs. Stop in and team more about our value pricing that wilt help you reduce your household expenses when you bundle all of your services with CenturyLink. You can also pay your bill and check out our newest products and services ar your bcal GerituryLink Customer Experience Center. Visi[ www.ceMUrylink.cont/stores to find the bcation nearest you. Notice about elecVonic check conversion When you provide a check as payment, you authorize us to use information from your check to make aone-time elecVonic fund transfer from your account or to process the payment as a cheep; transaction. CeMuryLink offers convenient aftematives to mailing your payment each month. Simply go to centurylink.conr/myaccount to make aone-time payment orto set up recurring payments from your bank account. LATE FEE REMINDER: Late fees may be charged each month for any eligible unpaid balances not paid in full by the due date listed on your bill. The methods for cak:ulating late fee amounts vary by state and product. For more information you may access Terms and Cond'ttrons, and Tariff materials at http://www.centurvlink.com/Pages/AboutUs/Legal/Tariffs/displayTariffLandingPage.html?rid=tariffs, or CenturyLink customer service at the phone number indicated on this The United Telephone Company of Pennsylvania, LLC DBA CenturyLink CenturyLink should be notrfied within 90 days after the CenturyLink Bill Date of any billing discrepancies on your slalemeM. FREE Enro{hrreM! With CeMuryLink's My Account service, you can update your Ibilling information, view and pay your bill and much more. Visit us online at www.centurylink.coMmyaccouM. • ~ ~ ~ Adjuabnents Preferred Customer Discount / 717377-9327 5.00 Remove 1 Pty ResMence Une From MAY 0.5 To MAY 21 / 717-477-8321 1 n.20 CR Remove Ecoramic Features Pack From MAY 05 To MAY 21 / 717-477-9321 3.39 c2 Remove Non-Published Non Usted Res From MAY 05 To MAY 21 / 717377-~J321 2.13 cR -Remove SubscriberUne~Charga=lnterFromMAY-0.5-To'MAY-2Y/717.477-9321-- -- --~'~ ~-~~- 3.c2T.~ ~ Total Payments and Adjustments 13.74 CR ~ ,~. Economy Peek Bundle Package Charges o.os Promotional Discount 2.17 cs Package Charges Auer Discount 2.17 Ck Subtotal Package 2.t7 ck Total Package 2.17 CR s c 's F i 's ~"'u Vii,` CenturyLink~ P.O. Box 1319 Charlotte, NC 28201-1 31 9 Account Name: EDGAR E BIDDINGER Page: 4 of 4 Account Number: 313509090 Bill Date: May 22, 2012 • pecurring Charges Prorated Bonus 30 From APR 22 To MAY 04 o.ai Total For 717-477-9321 0.67 Total Recurring Charges 0.67 Taxes, Fees and Surcharges PENNSYLVANIA Interstate Gross Receipts Tax o.03 PENNSYLVAN1A~InlrastateGrossReceiptffiTax._._ ._._.-_. .- _-- - ..-o:oz- -----~. PENNSYLVANIA Sales Tax o 05 Universal Service Fund Surcharge O.o9 Total Taxes, Fees and Surcharges Long distance service provided by Embarq Communkxifons, Inc. dlb/a CenturyUnk Communications, using the trade name Cen[uryLink o.ta PARKWAY NEDROSCIENCE AND SPIN 17 WESTERN MARYLAND PKWY SDITE HAAGER.STOWN, III/ 21740-5971 ADDRESS SERVICE REQUESTED SA565003 58337 7256337 ~ADDRESSEE~ >36340 2057282 001 092096 JOANN SANGRSY 17 SEBASTIAN WAY CARLISLE PA 17015-7677 Page Statement Date Due Date Office Phone Number Account # Patient Balance Show Amount 1 06/15/12 06/30/12 (301) 797-6369 829070 58.6k3 Paid Here $ 7P-IB88atd1BCIlE004811d.113BTflVB159.SIdBlO ._-_- _-- - STATEMENT--- --- _ - --r~E•ruRNt~+isPaRTkeN-wir+k-PArt~e im0tate address a Insurance Ctleng6s Date ICPT 8 Reason Explanation of Activity Charges & Insurance Payments & Patient Debits Pending Credits Amount Patient: Edgar E Hiddiager Departments Neurosurgery. Voucher: 550130 03/10/12 99223 - lest Soap Care Pr D 70 N 281.00 05/29/12 886317756 Nedicare Payment -153.50 05/29/12 886317756 Nedicare Adjustment -89.12 05/29/12 886317756 Nedicare Transfer This represents tha Co-Insurance amount due. Please remit payment. ---- Visit Total 38.: Voucher: 441200 - 04/03/12 99214 Office outpt Est 25 Nia 142.00 04/24/12 368204828 Nedicare Payment .0.00 05/08/12 886241247 Nedicare Payment -80.20 05/08/12 886241247 Nedicare Adjustment -41.75 05/08/12 886241247 Nedicare Transfer Thies represents the Co-Insurance amount due. Please - remitrpaymei3c. _ ,. - _..-. .. ---- Visit Total 20.1 ~~,~va ..~.psg It`s°~~a~ CHECK CARD USING FOAPAYMEM MASTERCARD V/S~ V^ISA ® ~DISCOVEN AMERICAN.E%PRESS CARD NUNBER VEflIFICATIONC CARDHOLDER NAME EXP. DATE SIGNATURE AMOUNT ~~~MR ror~ PARKWAY FIEUROSCIENCE AND SPIN 17 WESTERN MARYLAND PKWY °= NAGERSTOFR( MD 21740-5471 Ldd~ldll//d11,111L~:ddl~l/~IL,:II:dIIJ,:LL.::dll •~,1.,• PARRIPAY NEDAOSCIENCE AND SPIN 17 DIEBTEAN NARYI;AND PR9PY 3IIITE NAOERST0/7N, ND 21740-5471 Account Numbers Office Phone Nfumber: BZ9071 (301)797-638! Your account is past due. Please remit payment upon receipt of this statement. 36340 2057282 038341036341 00001Kg001 9209612 Patient Balance: 58.4: szos6s5 .,.. REV-1513 EX+ (OS-30) ~I1tlB ~ pennsylvania ~~*~> DEPARTMENT OF REVENUE INHERRANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 7 BENEFICIARIES ESTATE OF: FILE NUMBER: Edgar E. Biddinger, II 2012-00611 RELATIONSHIP TD DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do No! List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. ~ Jo Ann B. Sangrey Sister ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 (:OVER 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. 100 ~~ LAW OFFICES OF PETER J.RUSSOr.c. PETER J. RUSSO, ESQUIRE PAUL D. EDGER. ESQUIRE THOMAS D. GOULD. ESQUIRE ATTORNEYS AT LAW ASHLEY R. MALCOLM, PARALEGAL DEREK M. STROUPHAUER, PARALEGAL Friday, Seutember 21, 2012 Glenda Farner Strasbaugh, Register of Wills Register of Wills and Clerk of Orphans Court Cumberland County Courthouse One Courthouse Square Carlisle, PA 1'7013 RE: Estate of Edgaz Biddinger Deaz Farner Strasbaugh, Enclosed herewith, please find one (1) original and two (2) copies of tYie Revenue 1500 as well as check number 2857 in the amount of Fifteen and 00/100 ($15.00) Dollars as payment for the requested filing fee. Kindly file the original, time-stamp the remaining copies, and return a copy of same to our office in the self-addressed, postage pre-paid envelope I have provided for your convenience. Thank you for your attention to the enclosed. If you should have an;y questions or concerns, please feel free to contact our office. truly yours, ~ erek M. Strouph er, Paralegal /dms Enclosures 5006 EAST TRWDLE ROAD, SUITE 203, MECHANICSBURG, PA 17050 PHONE: (717) 591-1755 EAX: (717) 591-1756 ~O a q M ~~ ti rn a ~ o `° ~~ r m o"co LLh0 ~ O ,_ ~L O ~ ~.. I L7 L1am~.... V v„ N ~ c r. L1_ i ~ ~ J u. -~'~ c' J -' `-~C1 !;~:f s '`nom ~ . }~~ ~ ~ c_.~ y U w o m y ~ o o ~ ~bU' ~ ~ ~ ,~ ~ o ~3~ o~ ~ ~ a o~~a W „ :. ai m °'U,'" ~ m s~ ~~~a~ ~aUOU s m c ~ ~ ° --~ ~~ a ~ W '? qn