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Home My WebLink About10-24-12 1505610105 ii 500 EX (oz-u) (FI) REV-~ . eons lvania PA Department of Revenue P y OFFICU\L USE ONLY oE...~~E~.or.E~~~~E Bureau of Individual Taxes PO BOx z8o6oi INHERITANCE TAX RETURN Coun C Year ry ode i- File Number r'y Harrisburg, PA 3128-0601 RESIDENT DECEDENT ~ ~ ~ i ~ a '. ~~ ~ `-`I ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death i MMDDYYYY Date of Birth __ _ MMDDYYYY ', 06/04/2012 06/28/1923 Decedent's Last Name _ Suffix Decedent's First Name _ __ _ MI Mentzer i Anna r (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI _.. -_ - - I ', I i Spouse's Social Security Number - THIS RETURN MUST BE FILED IN DUPLICATE WITH THE _ __ __ ____ __ __________ REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW t~ 1. Original Retum O 2. Supplemental Return O 4. Limited Estate O 4a. Future Interest Compromise (date of death after 12-12-82) m 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death Between 12-31-91 and 1-1-95) O 3. Remainder Return (Date of Death Prior to 12-13-82) O 5. Federal Estate Tax Return Required ~ 8. Total Number of Safe Deposit Boxes O 11. Election to Tax under Sec. 9113(A) (Attach Schedule O) t:ORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name. Daytime Telephone Number __ __ _ David A. Baric, Esquire (717) 249-6873 !, First Line of Address Baric Scherer LLC Second Line of Address 19 West South Street _ __. - _ _ City or Post Office Carlisle _ _ __ _ _ State ZIP Code PA :17013 REGISTER OFJptILLS USE ONL'1r~ CC 33 ` ~ r~ 1.w/ 4 1 .. -.. ~ r N ' `~ - ' ~' % _ ` G C ;°.z -.. ~ -Ti: Q - DATe FIL t.._t v rte ~3 '~~ -~ ~_ ~~-...~~--ryry (,' - !`.' Correspondent's a-mall address: dbarict~baricscherer.com Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIG TORE ~j PERSON SPONSIBLE FOR FILING RETURN ~ I ~ DATE GU,~ (.C ~.r i/t G~.~L.d 2_ " ~-:-~ .ice IC~ ~ a2 ~~12_ 10 arlislfy I~d~N~wville,~A 17241 30 Valley Street Carlisle PA 17013 SP~~ ~j Of F~riaiycrwTi-iFjc'yi'~v FfrPhtESE1VTATIVE ,,,,T~ a3, 19 West South Street, Carlisle, Pennsylvania 17013 / / PLEASE USE ORIGINAL FORM ONLY yn ~- 7 ~~ ~n p -n Side 1 L 1505610105 1505610105 J J 1505610205 REV-1500 EX (FI) Decedent's Social Security Number - __ - __ .. Decedents Name: Anna G. Mentzer RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. ; 0.00 2. Stocks and Bonds (Schedule B) ....................................... 2. i 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00 I, 4. Mortgages and Notes Receivable (Schedule D) ......................... .. 4. ', 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. ', 7,364.00 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. ! 0.00 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property _ ----~""--------- (Schedule G) O Separate Billing Requested...... .. 7. ', 0.00 8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. j 7,364.00 ', 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. , 86,287.45 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............... 10. ~', 0.00 11. Total Deductions (total Lines 9 and 10) ................................. 11. 86,287.45 12. Net Value of Estate (Line 8 minus Line 11) ......................... ..... 12. -78,923.45 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which `-- ---"---- -~ --~ -~ -- -- an election to tax has not been made (Schedule J) ................... ..... 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ................... ..... 14. I 0.00 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 J REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: DECEDENTS NAME Anna G. Mentzer --- -- - - STREETADDRESS 2 West Penn Street CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest (1) 0.00 Total Credits (A + B) (2) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3) Fill in oval on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTfONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred .......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income ............................................ ^ c. retain a reversionary interest .............................................................................................................................. ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurrod after Dec. 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a 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(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedents lineal beneficiaries 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 decedents siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV->So8 EX+ (08-12) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Anna G. Mentrer 21-12-0719 Include the proceeds of litigation and the date the proceeds were received by the estate. Ali property jointly owned with right of survivorship must be disclosed on Schedule F. ~~ ...ore space is neeaeD, use aaamonai sheets of paper of the same size. REV-1511 EX+ (10-09) Pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Anna G. Mentzer 21-12-0719 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Ronan Funeral Home 637.90 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 200.00 Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2• Attorney Fees: Bar1C Scherer LLC 1,500.00 3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant None Street Address City State ZIP Relationship of Claimant to Decedent 4• Probate Fees: 96.50 S• Accountant Fees: 6• Tax Return Preparer Fees: ~• Sarah Todd Memorial Home 609.24 B• Pennsylvania Department of Public Welfare ($31,128.33 class 3) 83,243.81 TOTAL (Also enter on Line 9, Recapitulation) I $ 86,287.45 If more space is needed, use additional sheets of paper of the same size. REV-1513 EX+ (01-10) Pennsylvania SCHEDULE ] DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Anna G. Mentrer 21-12-0719 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1• Lois A. Zeigler daughter 50 106 Carlisle Road Newville, Pennsylvania 17241 2. Doris J. Kems 30 Valley Street Carlisle, Pennsylvania 17013 daughter 50 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. 8, CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS; 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I ~ If more space is needed, use additional sheets of paper of the same size. LAST WILL AND TESTAMENT I, A. GAYLE MENTZER, of 2158 Newville Road, Cazlisle, Cumberland County, Pennsylvania 17013 do hereby make, publish and declare this to be my last will and testament, hereby revoking all wills heretofore made by me. 1. I direct my personal representative to pay all of my debts, funeral and administrative expenses as soon as convenient after my decease. 2. I authorize and empower my personal representative ~to sell any realty and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale therefor, in fee simple, as I could do if living. My representative is authorized and empowered to engage in any business in which I may be engaged at my death, for such period of time after my death as seems expedient to said representative. ~ . 3. I give, devise and bequeath all of my estate of whatever nature and wherever situate to my children, share and share alike, the child or children of any deceased child taking the shaze their parent would have taken if living. 4. I nominate and appoint Doris J. Kerns and Lois A. Zeigler to be the co-personal representatives of my estate, to serve without bond. 5. I suggest that my personal representative retain the services of Harold S. Irwin, III, Carlisle, Pennsylvania in the settlement of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this~day of July, 1996. y,,,,J~~.L~~ '- `/ I (SEAL) A. GAYLE ME TIER Signed, sealed, published and declared by the above-named person as and for a last will and testament, in our presence, who at said person's request, in said person's presence and in the presence of each other have hereunto set our names as subscribing witnesses. ~~~ ,,,;~ ACKNOWLEDGMENT AND AFFIDAVIT WE, A. GAYLE MEN17,ER, HEATHER A. BARBOUR and AMY S. IRWIN, the testatrix and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her last will and that she had signed willingly, and that she executed it as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the will as a witness and that to the best of their knowledge the testatrix was, at that time, eighteen years of age or older; of sound mind and under no constraint or undue influence. ,~ ~ ~ ~n A. GAYLE NTZER A.BARBOUR r -~. COMMONWEALTH OF PENNSYLVANLQI COUNTY OF CUMBERLAND :ss: Subscribed, sworn to and acknowledged before me by A. GAYLE MENTZER, the testatrix herein, and subscribed and sworn to before me by HEATHER A. BARBOUR and AMY S. IRWIN, witnesses, this ~ day of July, 1996. pennsylvama DEPARTMENT OF PUBLIC WELFARE July 10, 2012 O'BRIEN BARK & SCHERER DAVID A BARK ESQUIRE 19 W SOUTH ST CARLISLE PA 17013 Anna Mentzer CIS ~`: 02 SSN: ###-##-4673 Date of Death: 06/04/2012 Dear Attorney Baric: Please be advised that the Department of Public Welfare maintains a claim in the amount of 583,243.81 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely 531,128.33, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely 552.115.48, is to be entered as a priority Class 5.1 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, ~ rl ~~ " f'~ , ~.h. Elizabeth M. Wilson TPL Program Investigator 717-214-1868 717-772-6553 FAX Enclosure cc: Lois A Zeigler 106 Carlisle Rd Newville PA 17241 1/Zat3 Bureau of Program Integrity ~ Division of Third Party Liability i Recovery Section PO Box 8486 ~ Harrisburg, Pennsylvania 17105-8486 COMMONWEALTH OF PENNSYLVANIA BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY RECOVERY SECTION PO BOX 8486 HARRISBURG, PA 17105-8486 July 6, 2012 STATEMENT OF CLAIM SUMMARY NAME Estate of MENTZER, ANNA ID 360 246 516 MEDICAL CLASS 3 CLASS`5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 31,099.01 52,081.63 83,180.64 DRUG 29.32 33.85 63.17 REIMBURSEMENT TO DPW 31,128.33 52,115.48 83,243.81 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE. EIN - 23-60031 t3 Page 1 of 8 r I COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE July 6, 2012 STATEMENT OF CLAIM NAME MENTZER, ANNA ID 360 246 516 SARAH A TODD MEMORIAL HOME INC 1000 W SOUTH ST CARLISLE PA 17013 DATE OF SERVICE'. PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES' AMOUNT APPROVED 01/18/11 - 01/31/11 10/31/11 55112994586540001 55112994586540001 1,856.77 1,890.09 DIAGNOSIS 1 : 43822 HEMIPLEGIA AFFECTING NOND DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PROC CODE : 000000 02/01N1 - 02/28/11 10/31/11 55112994586550001 55112994586550001 4,478.83 4,545.47 DIAGNOSIS 1 : 43822 HEMIPLEGIA AFFECTING NOND DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PROC CODE : 000000 03/01/11 - 03/31/11 10!31111 55112994586530001 55112994586530001 5,040.70 5,114.48 DIAGNOSIS 1 : 43822 HEMIPLEGIA AFFECTING NOND DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PROC CODE : 000000 04/01/11 - 04/30/11 11/07/11 55113054502800001 55113054502800001 4,853.41 4,833.01 DIAGNOSIS 1 : 43822 HEMIPLEGIA AFFECTING NOND DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PROC CODE : 000000 05/01/11 - 05/31/11 11/07/11 55113054503400001 55113054503400001 5,040.70 5,019.62 DIAGNOSIS 1 : 43822 HEMIPLEGIA AFFECTING NOND DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PROC CODE : 000000 06/01!11 - 06/30/11 11/07/11 55113054504130001 55113054504130001 4,853.41 4,833.01 DIAGNOSIS 1 : 43822 HEMIPLEGIA AFFECTING NOND DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PROC CODE : 000000 07101/11 -.07/31/11 05/07/12 55121254628000001 55121254628000001 5,040.70 5,270.72 DIAGNOSIS 1 : 43822 HEMIPLEGIA AFFECTING NOND ' DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PROC CODE : 000000 08/01/11 - 08/31/11 05/07/12 55121254628610001 55121254628610001 5,040.70 5,270.72 DIAGNOSIS 1 : 43822 HEMIPLEGIA AFFECTING NOND DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PROC CODE : 000000 Page 2 of 8 COMMONWEALTH OF PENNSYLVANIA .DEPARTMENT OF PUBLIC WELFARE July 6, 2012 STATEMENT OF CLAIM NAME MENTZER, ANNA ID 360 246 516 SARAH A TODD MEMORIAL HOME INC 1000 W SOUTH ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 09/01/11 - 09/30!11 05/07/12 55121254629290001 55121254629290001 4,853.41 5,076.01 DIAGNOSIS 1 : 43822 HEMIPLEGIA AFFECTING NOND DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PROC CODE : 000000 10/01/11 - 10/31/11 05/21/12 55121374497930001 55121374497930001 5,049.62 5,225.39 DIAGNOSIS 1 : 43822 HEMIPLEGIA AFFECTING NOND DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PROC CODE : 000000 11/01/11 - 11/30/11 05/21/12 55121374500010001 55121374500010001 4,833.01 5,003.11 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 7843 APHASIA PROC CODE : 000000 12!01/11 - 12/31/11 05/21/12 55121374499310001 55121374499310001 5,019.62 5,195.39 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 7843 APHASIA PROC CODE : 000000 01/01/12 - 01/31/12 06/18/12 55121654397310001 55121654397310001 4,995.52 5;399.45 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 7843 APHASIA PROC CODE : 000000 02/01/12 - 02/29/12 06/18/12 55121654397970001 55121654397970001 4,622.30 5,000.17 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 7843 APHASIA PROC CODE : 000000 03/01/12 - 03!31/12 06!18/12 55121654398660001 55121654398660001 4,995.52 5,399.45 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 7843 APHASIA PROC CODE : .000000 04/01!12 - 04/30/12 06/04/12 20121354023720001 20121354023720001 4,956.51 4,956.51 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 7843 APHASIA PROC CODE : 000000 Page 3 of 8 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC' WELFARE July 6, 2012 STATEMENT OF CLAIM NAME MENTZER,ANNA iD 360 246 516 SARAH A TODD MEMORIAL HOME INC 1000 W SOUTH ST CARLISLE PA 17013 DATE OF`SERVICE - PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 05/01/12 - 05/31/12 06/14/12 20121664021580001 20121664021580001 5,148.04 5,148.04 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 7843 APHASIA PROC CODE : 000000 PROVIDER SUB TOTAL SARAH A TODD MEMORIAL HOME INC 80,678.77 83,180.64 03 100777455 0001 Page 4 of 8 COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF PUBLIC'WELFARE July 6, 2012 STATEMENT OF CLAIM NAME MENTZER,ANNA ID 360 246 516 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 17055 DATE OF SERVICE PAYMENT DATE OR{GINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 03/02/11 - 03/02/11 04/18/11 25110815604890001 25110815604890001 9.96 4.40 DIAGNOSIS 1 : 0 NDC CODE : 00591024005 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 07/11/11 - 07/11/11 08/08/11 25111935320290001 25111935320290001 9.96 4.37 DIAGNOSIS 1 : 0 NDC CODE : 00591024005 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 09/05/11 - 09/05111 10/03/11 25112485250250001 25112485250250001 4.22 4.22 DIAGNOSIS 1 : 0 NDC CODE : 00168001431 HYDROCORTISONE 0.5% CREAM - GLUCOCORTICOIDS 09/05/11 - 09/05/11 10/03/11 25112485250260001 25112485250260001 9.44 7.58 DIAGNOSIS 1 : 0 NDC CODE : 51672201602 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 09/29/11 - 09/29/11 10/24/11 25112735813550001 25112735813550001 14.92 4.68 DIAGNOSIS 1 : 0 NDC CODE : 00591024005 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 09/29/11 - 09/29/11 11!28/11 25113025226020001 25113025226020001 .50 .50 DIAGNOSIS 1 : 0 NDC CODE : 00904770480 ASPIR-LOW EC 81 MG TABLET - NON-NARCOTIC ANALGESICS 10129!11 - 10/29/11 12/26/11 25113335443950001 25113335443950001 .52 .52 DIAGNOSIS 1 : 0 NDC CODE : 00904770480 ASPIR-LOW EC 81 MG TABLET - NON-NARCOTIC ANALGESICS 11/26/11 - 11/26/11 12/26/11 25113305273100001 25113305273100001 9.44 7.Og DIAGNOSIS 1 : 0 NDC CODE : 51672201602 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS Page 5 of 8 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE July 6, 2012 STATEMENT OF CLAIM NAME MENTZER, ANNA I D 360 246 516 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 17055 DATE OF SERVICE.. I PAYMENT DATE I ORIGINAL CRN I ADJUSTED CRN I USUAL CHARGES I AMOUNT APPROVED 11/29/11 - 11/29/11 01/23/12 25113635229490001 25113635229490001 .50 .50 DIAGNOSIS 1 : 0 NDC CODE : 00904770480 ASPIR-LOW EC 81 MG TABLET - NON-NARCOTIC ANALGESICS 12/29/11 - 12/29/11 02/27/12 25120295234550001 25120295234550001 .52 .52 DIAGNOSIS 1 : 0 NDC CODE : 00904770480 ASPIR-LOW EC 81 MG TABLET - NON-NARCOTIC ANALGESICS 01!03/12 - 01/03/12 02/06N2 25120095841180001 25120095841180001 17.41 4.86 DIAGNOSIS 1 : 0 NDC CODE : 00591024005 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 01/17/12 - 01/17/12 02/13/12 25120175318960001 25120175318960001 9.44 7.62 DIAGNOSIS 1 : 0 NDC CODE : 51672201602 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 01/23/12 - 01/23/12 03/05/12 25120395564560001 25120395564560001 17:41 .86 DIAGNOSIS 1 : 0 NDC CODE : 00591024005 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 01/29/12 - 01/29!12 03/26/12 25120605232330001 25120605232330001 .52 .52 DIAGNOSIS 1 : 0 NDC CODE : 00904770480 ASPIR-LOW EC 81 MG TABLET - NON-NARCOTIC ANALGESICS O7J07/12 - 02/07/12 03/26/12 25120605238430001 25120605238430001 1.02 1.02 DIAGNOSIS 1 : 0 NDC CODE : 00904582460 VITAMIN D 1,000 UNIT TABLET - FAT SOLUBLE VITAMINS 02/29/12 - 02/29/12 04/23/12 25120895223940001 25120895223940001 .49 .49 DIAGNOSIS 1 : 0 NDC CODE : 00904770480 ASPIR-LOW EC 81 MG TABLET - NON-NARCOTIC ANALGESICS Page 6 of 8 >- COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC;WELFARE July 6, 2012 STATEMENT OF CLAIM NAME MENTZER,ANNA ID 360 246 516 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 17055 DATE OF SERVICE.. PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 02/29/12 - 02/29/12 04/23/12 251208952=698(1~r 251398952269°^^^" 1.34 1.34 DIAGNOSIS 1 : 0 NDC CODE : 00904582460 VITAMIN D 1,000 UNIT TABLET - FAT SOLUBLE VITAMINS 03/29/12 - 03/29/12 05/28/12 25121205235910001 25121205235910001 1.43 1.43 DIAGNOSIS 1 : 0 NDC CODE : 00904582460 VITAMIN D 1,000 UNIT TABLET - FAT SOLUBLE VITAMINS 03/29!12 - 03/29/12 05/28/12 25121205236340001 25121205236340001 .52 .52 DIAGNOSIS 1 : 0 NDC CODE : 00904770480 ASPIR-LOW EC 81 MG TABLET - NON-NARCOTIC ANALGESICS 04/29/12 - 04/29/12 06!25/12 25121505550450001 25121505550450001 .50 .50 DIAGNOSIS 1 : 0 NDC CODE : 00904770480 ASPIR-LOW EC 81 MG TABLET - NON-NARCOTIC ANALGESICS 04/29/12 - 04/29/12 06/25/12 25121505558280001 25121505558280001 1.39 1:39 DIAGNOSIS 1 : 0 NDC CODE : 00904582460 VITAMIN D 1,000 UNIT TABLET - FAT SOLUBLE VITAMINS 05/10/12 - 05/10/12 06/11/12 25121385485040001 25121385485040001 g,44 7,62 DIAGNOSIS 1 : 0 NDC CODE : 51672201602 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 05!29/12 - 05129/12 07!02/12 25121585238740001 25121585238740001 .17 .17 DIAGNOSIS 1 : 0 NDC CODE : 00904770480 ASPIR-LOW EC 81 MG TABLET - NON-NARCOTIC ANALGESICS Page 7 of 8 i- COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE July 6, 2012 STATEMENT OF CLAIM NAME. MENTZER,ANNA ID 360 246 516 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 17055 DATE OF"SERVICE ~ PAYMENT DATE I ORIGINAL CRN I; ADJUSTED CRN I USUAL CHARGES I AMOUNT APPROVED 05/29/12 - 05/29/12 07/02/12 25121585238770001 25121585238770001 .46 .46 DIAGNOSIS 1 : 0 NDC CODE : 00904582460 VITAMIN D 1,000 UNIT TABLET - FAT SOLUBLE VITAMINS ,PROVIDER SUB TOTAL MILLENNIUM PHARMACY SYSTEMS INC 121.52 63.17 24 001887261 0008 Page 8 of 8 C`~~.~ ~~~~ x~