HomeMy WebLinkAbout12-17-12
1505610105
(o2-ii) tR7
REV-1500 a I OFFICIAL USE ONLY
PA Department of Revenue pennsylvania
Bureau of Individual Taxes County Code Year File Number
PO BOX 28o6oi INHERITANCE TAX RETURN
L'
Harrisburg, PA 17128-0601 RESIDENT DECEDENT I (42(j
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYM Date of Birth MMDDYYYY
164-30-4479 07/05/2012 11104/1937
Decedent's Last Name Suffix Decedent's First Name MI
Martlew Louise T
(if 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 IN APPROPRIATE OVALS BELOW
(3@D 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death
Prior to 12-13-82)
p 4. Limited Estate O 4a. Future Interest Compromise (date of Q 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 Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9. Litigation Proceeds Received e--% 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
Julianne A. Bishard (717) 343-3712 C=~
C> ~ f rt
REGIST {I OCANILLS U"NLY ~
C>
M -c C->
~ a t-j
First Line of Address ;0 Y> r- t"' n-I r n
' ~ -.7 rj
908 Charles Street ; K C> Z.3 -T7
Second Line of Address , =3
" F
ATE FILED 1..„ gy
City or Post Office State ZIP Code
Mechanicsburg PA 17055
Correspondent's e-mail address:
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"RE OF PERSON RESPONSIBLE FQR FILI URN DAT
ADDRE
4611 Florence Avenue, Mechanicsburg, PA 17055
SIGNATU PREPARER OTHER THAN REPRESEN IVE DATE
ADDRESS
908 Cha Street, Mechanicsburg, PA 17055
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610105 1505610105
d
1505610205
REV-1500 EX (Fl)
Decedent's Social Security Number
Decedent's Name: Louise T. Martlew 164-30-4479
RECAPITULATION
1. Real Estate (Schedule A) 1.
2. Stocks and Bonds (Schedule B) 2.
3. Closely Held 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. 34,401.93
6. Jointly Owned Property (Schedule F) O Separate Billing 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) 8. 34,401.93
9. Funeral Expenses and Administrative Costs (Schedule H) 9. 4,676.70
10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule 1) 10. 2,189.99
11. Total Deductions (total Lines 9 and 10) 11. 6,866.69
12. Net Value of Estate (Line 8 minus Line 11) 12. 27,535.24
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. 27,535.24
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 27,535.24 18
19. TAX DUE 19. 4,130.29
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT COD
Side 2
L 1505610205 1505610205 J
REV-1500 EX (FI) Page 3 File Number
Decedent's Complete Address:
DECEDENTS NAME
Louise T. Martlew
STREET ADDRESS
4611A Florence Avenue
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) 4,130.29
2. Credits/Payments
A. Prior Payments 4,000.00
B. Discount 210.52
Total Credits (A + B j (2) 4,210.52
3. Interest
(3)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4) 80.23
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 QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred ❑ 0
b. retain the right to designate who shall use the property transferred or its income ❑ 0
c. retain a reversionary interest ❑ N
d. receive the promise for life of either payments, benefits or care? ❑ 0
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ❑ 0
3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ❑ 1111111
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? ❑ 0
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 decedent's 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 decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. A sibling is defined,
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
COMMONWEALTH OF PENNSYLVANIA REV-1162 EXIT 1-96)
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT.280601
HARRISBURG, PA 17128-0601
PENNSYLVANIA
RECEIVED FROM: INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 016528
SMITH VERNON E
4611 A FLORENCE AVE
MECHANICSBURG, PA 17055
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
fold
101 $4,000.00
ESTATE INFORMATION: SSN: 164-30-4479
FILE NUMBER: 2112-0824
DECEDENT NAME: MARTLEW LOUISE T
DATE OF PAYMENT: 09/20/2012
POSTMARK DATE: 09/2012012
COUNTY: CUMBERLAND
DATE OF DEATH: 07/05/2012
TOTAL AMOUNT PAID: $4,000.00
REMARKS: VERNON E SMITH
CHECK#104
INITIALS: WZ
SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
TAXPAYER
REV-1508 EX+ (08-12)
pennsyLvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Louise T. Martlew 21-12-0824
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Wells Fargo Bank, N.A. (345), P.O. Box 6995 Portland, OR 97228-6995 13,685.65
Checking Account #1010063129865
2. Wells Fargo Bank, N.A. (345), P.O. Box 6995 Portland, OR 97228-6995 16,216.28
Savings Account #1010080260231
3. Car (2001 Saturn SC2 coupe) - Sutliff Chervolet 13th & Paxton Street, Harrisburg, PA 17104 4,500.00
appraisal date = 8/15/12
TOTAL (Also enter on Line 5, Recapitulation) $ 34,401.93
If more space is needed, use additional sheets of paper of the same size.
Wells Fargo Combined Statement of Accounts
Primary account number. 1010063129865 ■ June 7, 2012 - July 6, 2012 ■ Page 1 of 4
iarS
DCDPIIDTEF 009506 Questions?
IIIl41111- ii~h4rii~Inllh«ri1119IM1111(ll111111ld111
LOUISE T MARTLEW Available by phone 24 hours o day, 7days a week
4611 FLORENCE AVE APT A 1-800-TO-WELLS (1-800-869-3557)
MECHANICSBURG PA 17055-4391 TTY: 1-800-877-4833
En espanol. 1-877-727-2932
8 1-800-288-2288 (6 am to 7 pm PT, M-F)
Online: weilsfargo.com
Write: Wells Fargo Bank, N.A. (345)
- P.O. Box 6995. _
Portland, OR 97228-6995 0
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You and Wells Fargo Account options e
Keep things simple. Online Statements duplicate your traditional paper bank Acheck Mork In the boxindicatesyou have these
statement and you can access your financial information 24 hours a day from convenientservices with youroccount Go to z
anywhere you have access to the Internet. Reduce clutter and save the welisforgacom orcall the numberabove ifyou have z
environment at the same time. Sign up for and view your Online Statements at questions orifyou wouldlike toaddnewservices.
wellsfargo.com. Online Banldng Direct Deposit Q z
Online Bill Pay Rewards Program z
Online Statements Auto Transfer/Payment z
z
Mobile Banking E] Overdraft Protection Q z
My Spending Report Debit Card C?
Overdraft Service c
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Summary of accounts ~
Checking and Savings
Ending balance Ending-balance
Account Page Accountnumber laststatement thisstatement
Gown Classic Banking` 2 1010063129865 14,733.97 13,685.65
Wells Fargo° Preferred Rate Savings 3 1010080260231 16,215.62 16,216.28
Total deposit accounts $30,949.59 $29,901.93
Primary account number.1010063129865 ■ June 7, 2012 -July 6, 2012 ■ Page 2 of 4
e
Crown Classic Banking®
Activity summary Account number. 1010063129865
Beginning balance on 6/7 $14,73397 LOUISE T MARTLEW
Deposits/Additions 1,074.11 Pennsylvania account terms and conditions apply
Withdrawals/Subtractions - 2,1122.43 For Direct Deposit and Automatic Payments use
Ending balance on 716 $13,685.65 Routing Number (RTN): 031000503
Overdraft Protection
Your account is linked to the following for Overdraft Protection:
■ Savings - 001010080260231
Interest summary
Interest paid this statement $0.11
Average collected balance $14,248.84
Annual percentage yield eamed 0.01%
interest earned this statement period $0.11
Interest paid this year $0.91
Transaction history
Check Deposits/ Withdrawals/ Endingdaily
Date Number Description Additions Subtractions balance
6/12 2125 Check 486.30 14,247.67
6/20 ATMWthdrawa11 06/20MachID6861812000amP -HIIIMalI
600.00 13,647.67
Chesterbrook PA 8047 0006594
6/25 ATM Withdrawal --'06/'2-5-M- ID 68-6-116-1-2-0-0,
861 B 1200 camp Hill Mall 100.00 13,547.67
Chesterbrook PA 8047 0007674
6/27_ US Treasury303 Xxsoc Sec 0627 ] 2 Louise T Martiew
_ _ _ --l07400 14,621.67
7!5 ATM Withdrawal - 07/05 Mach ID 6861 B 1200 camp Hill Mati 800.00 13,821.67
Chesterbrook PA 8047 0009712
7/6 2127 Check
- - _
212 /6 _6_ 'Check-_-_,_________,_____
_ - -
0 1 980
7/6 interest Payrn- ent
13,685.65
- - - 1
Ending balance on 7/6
- -113,685.85
Totals $1,074.11 $2,122.43
The Ending Daily Balance does not reflect any pending withdrawals or holds on deposited funds that may have been outstanding on your account when your
transactions posted. Ifyou had insufficient available funds when a transaction posted, fees may have been assessed.
Summary of checks written (checks listed are also displayed in the preceding Transaction history)
Number Date Amount Number Date Amount Number Date Amount
2125 6/12 486.30 2126 7/6 9.80 2127 7/6 126.33
Primary account number: 1010063129865 ■ June 7, 2012 -July 6, 2012 ■ Page 3 of 4
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Wells Fargo® Preferred Rate Savings
Activity summary Account number. 1010080260231
Beginning balance on 6/7 $16,215.62 LOUISE T MARTLEW
Deposits/Additions 0.66 Pennsylvania accountterms and conditionsapply
Withdrawals/Subtractions -0.00 For Direct Deposit and Automatic Payments use
Ending balance on 716 $16,216.28 Routing Number (RTN): 031000503
Interest summary
Interest paid this statement $0.66
Average collected balance $16215.62
Annual percentage yield earned 0.0596 _
interest earned this statement period $0.66
Interest paid this year $3.79 9
8
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Transaction history
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Deposits/ Withdrawals/ Endingdaily z
Date Description Additions Subtractions balance z
7/6 Interest Payment 0.66 16,216.28 z
Ending balance on 716 _ 16,216.28 Z
Totals $0.66 $0.00 z
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The Ending Daily Balance does not reflectony pending withdrawals or holds on deposited funds that may have been outstanding on your account when your -zt
tmnsoctions posted. Ifyou had insufl'identavailable funds when a transaction posted fees may have been assessed. o
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Customer Appraisal Summary (Draft) Sutliff Chevrolet
y y A
2001 Satum SC2 Base -1 G8ZY12711Z316725 13th & Paxton Streets
Harrisburg, Pennsylvania 17104
Customer Information
Name: LOUISE MARTLEW
You may drive and appraise my vehicle Address: 4611 FLORENCE AVE
nut s
Customer signature
City: ..I kIcHet wl z""Ij r r !t
Manager signature State/Region: Pennsylvania Postal Code•
Email:
Phone (Home):
Phone (Work):
Phone (Mobile):
Vehicle Information
VIN: 1 GBZY12711Z316725 Odometer. 20,966
Year: 2001 Interior Color:
Make: Satum Exterior Color:
Model: SC2 Transmission: Automatic
Series: Base Condition:
Additional Information
Comments:
Extended Warranty: Good Until:
Factory Certification: Time: Odometer.
Vehicle Salvaged: Flood Damage:
Factory Buyback: Odometer Replaced:
Improvements:
Tag or Plate: Tag State/Region: Exp:
Lien Holder: Phone:
Lien Account
Lien Address:
Lien Payoff Good Until: Per Diem:
DMV Fee:
Title in Name of
Title in State/Region of
Salesperson: Chris Walters Appraisal Date: 8/1512012 Est. Recond./Certif.: $600 / -
Appraiser. Chris Walters Good Until: 8/22/2012 Appraisal Amount: $4,500.00
signattue
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
Louise T. Martlew 21-12-0824
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. Myers-Hamer Funeral home (Cremation, Merchandise, Clergy, Newspaper notice etc..) 3,859.00
Food charges for services (payable to Trinity Evangelical Lutheran Church) 258.90
Flowers for service (payable to Peale►'s Flowers) 209.30
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State ZIP
Year(s) Commission Paid:
2. Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 149.50
5. Accountant Fees:
6. Tax Return Preparer Fees: 200.00
7.
TOTAL (Also enter on Line 9, Recapitulation) $ 4,676.70
If more space is needed, use additional sheets of paper of the same size.
~YIYERS-? ~AR-.\'ER FU\ER"~I_ .1-10\-IE..J-i\ C'.
1903NLARFETSTREET
I i T 1 1T i! t I CAMP HILL. PE\XS11\ :kN1A 17011
t 717-737-9961 717-737-1618 ROBERT R\ER
ISISOR
E E E I I Itd SUPERVISOR
- ' 144i PHONE F.-\.\
..s
DUSTIN R. SABER
FUNERAL DIRECTOR
july 24 z 2012
Cremlaiion Package ;;°3 $ 25950.00
Charges for Merchandise Selected
Cremation Container $ 140.00
Cremation Urn 50.00
$ 190.00
= $ 287.00
azz" _ 125.00
' ERS-14ARNER FUNERM. HoN1E. INC.
5-rr
G t ~Y 19033 MARKET STREET
t t i ! TP7 C.4-NIP HILL, PENNSYLVANIA 17011
ROBERT H. HAR.NER
717-737-9961 717-737-418 SUPERVISOR
PHONE FAX
DVSTI\ R. BAKER
FUNERAL DIRECTOR
July 27, 2012
Mr. Vernon E. Smith
4511 Apt A Florence Avenue
Mechanicaburg PA 17055
Ten Corrected Certified Copies for Louise Martlew $ 60.00
t
~A///
Glenn E. Ludwig. M.DiN: Nancv R. Easton. 'X4. Div.
I\'I"EKI\i SENIOR P:\tiTOK TRINITY ASSISTANT PASTOR
John H. Frock, M.Di\: Gu~S. Edmiston. Jr.. D.D.
ASSOCIATE r:\srOR Evangelical Lutheran Church SU- PPORT PASTOR IN RESIDENCE
July 23, 2012
Ms. Elizabeth Boyer
61 Old Mill Road
Dillsburg, PA 17019
INVOICE
Charges for the Louise Tozer Martlew Funeral Meal:
Total cost of meal $258.90
Total amount due $258.90
If you have any questions about this invoice, please feel fee to call me at the church.
Thank you,
Paul Hensel
Financial Administrator
2000 Chestnut Street, Camp Hill, Pennsylvania 17011
PHo E 717.737.8635 e FAx 717.730.9297 • E-MAIL trinluth@Lrinitycamphill.org o WEBSITE wwrvtrinitycamphill.org
MTrack your expenses... 0 TAX-OEOWnaLE rcat 0~7
0 Clothing 0 Food 0 Transportation
0 Credit Card 0 Utifi ies 0 Mortgage
i 0Entertainment 0Insurance 00ther.
- ;
SALA~
FORWARD
ll S _ , , _ TFA STEM -
-wow
OTHER
BALANCE
FORWARD
For added security, your name and account number do not appear an this copy. NOT NEGOTIABLE
Shop
Peal er ` s Flower
Date: 07/1912012 Terminal: 2
Time: 03:07:50 PM Session: 6734
rachel
Payment
Account Number: 0149179
Account Name: Martin Tozer
Balance Due (7/19/2012): $ 209.30
Payment Amount: $ 209.30
New Balance Due (7/19/2012): $ 0.00
Amount Tendered: $ 0.00
Change Due: $ 0.00
Send flowers.... Just Because!
Print Date: 07/19/2012
Print Time: 03:07:50 PM
RECEIPT FOR PAYMENT
GLENDA FARMER STRASBAUGH Receipt Date: 7/27/2012
Cumberland County - Register Of Wills Receipt Time: 12:12:31
One Courthouse Square Receipt No.: 1070786
Carlisle, PA 17Q13
MARTLEW LOUISE T
Estate File No.: 2012-00824 -
Paid By Remarks: ULIANNE A BISHARD
Receipt Distribution
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 90.00 CUMBERLAND COUNTY GENERAL FUN
WILL 15.00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 16.00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN
Check# 2092 $149.50`'. O
Total Received......... $149.5 0
A~-
tE YOUR DUPUCATE CHECKS IN YOUR CHECK BOX. O~
99Tractt your expenses. ❑ w-DaDucnas_E nEm
0 Clothing 0 Food 0 Transportation
0 Credit Card 0 Utilities 0 Mortgage
0 Entertainment 0 insurance 0 other -
rr7
THIS ITEM
BALANCE
OTHER
BALANCE '
FORWARD
'
.d security, your name and'accnunt number do not appear on this H. you SPY NOT NEGOTIABLE
REV-1512 EX+ (12-08)
j i pennsylvania SCHEDULE I
zy DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Louise T. Martlew 21-12-0824
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Rent (Walker Realty) - *1/2 of full amount paid 347.50
2. Water (PA American Water Company) - *112 of full amount paid 27.48
3. Electric (PPL) - *1/2 of full amount paid 228.78
4. East Pennsboro Ambulance Services-6/24/12 transport 330.11
5. Golden LivingCenter- West Shore (room hold) 173.50
6. Golden LivingCenter - West Shore (copay charges) 75.00
7. West Shore Ambulance Services 1,007.62
8.
TOTAL (Also enter on Line 10, Recapitulation) $ 2,189.99
If more space is needed, insert additional sheets of the same size.
00870 11-24
Office AU # 1210(8) PERSONAL MONEY ORDER SERIAL 6798001686
ACCOUNT#: 4861-509800
Purchaser: VERNON E SMITH
Purchaser Account: 1000630083518
Operator LD.: pa00286o July 05, 2012
PAY TO THE ORDER OF ***WALKER REALTY***
***Six hundred ninety-five dollars and no cents*** **$695.00**
WELLS FARGO BANK, N.A. NOTICE TO PURCHASER-IF STOP PAYMENT IS PLACED ON THIS VOID IF OVER US $ 695.00
3205 TRINDLE RD INSTRUMENT, WELLS FARGO BANK MAY IMPOSE A WAITING
CAMP HILL. PA 17011 PERIOD BEFORE ISSUING A REPLACEMENT OR REFUND. NON-NEGOTIABLE
FOR INQUIRIES CALL (480),-a4-3122
Purchaser Copy
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r 00024113433880000000000000000514
Pennsylvania American Water 24-1139338-8
Po Box 371412 AMOUNT DUE NO PAYMENT
Pittsburgh, Pa. 15250-7412
For Service To: 4611 1/2 Florence Ave APT A DUE DATE CREDIT
AMOUNT PAID Credit: Do Not Pay
11111'IIIIIiIiI"II'II'llill'illil'llll'I'i'IIII'illl'IlPlilll'I return this •
027961 1 AT 0.371 3861/27961!00'3961 113 1 NCOZ33 Please VE SMITH AND LOUISE T MARTLEW 1 Payable to the • •
4611 FLORENCE AVE APT A PENNSYLVANIA AMERICAN WAT
MECHANICSBURG PA 17055-4391 PO BOX 371412
PITTSBURGH, PA. 15250-7412
II'illl'III'"IIIIIIIII'll'III'IIIIIIIIlIlI'Illliilllll"lIIIyL,
E I Please check here to add H2O-H to others contribution to your monthly big
or to change your address or telephone number and print information on reverse side.
-
Customer Account Information Billing Summary
For Service To: Ve Smith and Louise T Martlew ------Prior Balance--------
4611 1 /2 Florence Ave APT A Prior Water Balance $54.95
Account Number: 24-1139338-8 Payments prior to Aug 20, 2012. Thanks! -54.95
Premise Number: 24-0378742 Total prior balance, Aug 20, 2012 .00
-----Adjustments------
Billing Period & Meter Information Over Estimate - Adi Res -18.20
' - Billing Period: Jul 10 to Aug 15 (36 da • ) DS1C Charge - Adj Res -.15 ys Total adjustments, Aug 20, 2012 -18.35
(Text re- ac Ling on a o , 2p1"2"!- -------Current Water Charges
Rate Type: Residential Service Charge 16.50
DSl - PAWC Charge 0.83% .14
Meter readings in current billing period: Total water charges, Aug 20, 2012 16.64
Meter Number N090978319 is a 5/8-inch meter.
Present-actual 24700 -----AMOUNT DUE------------
Last-estimate 24700
'Meter Changed Jul 12, 2012. Credit Amount: Do Not Pay
Meter Number H012004258 is a 5/8-inch meter.
Present-actual 2400
Last-estimate 2400
Gallons used 0
Water Usage Comparison
50 Monthly usage in hundred gallons.
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c.uJlurnLr ALA;UUrn In►ur►►►ili►ul► an►►ng oumrnary
' For Service To: Ve Smith and Louise T Martlew --------prior Balance------------------------ -
4611 1/2 Florence Ave APT A Prior Water Balance $98.80 .
Account Number: 24-1139338-8 Prior Balance Other $20.00
Premise Number: 24-0378742 Adjustments 20.00
Payments prior to Jul 13, 2012. Thanks! -139.00
Billing Period & Meter Information Total prior balance, Jul 13, 2012 - .20
_$illing Date: Jul 13, 2012 ------Current Water Charges----------
Billing Period: Jun 08 to Jul 10 (32 days). Service Charge 13.75
-
l~lexr readtng--o-nTaEiout: Aug a9, 2iU f2-Y Water Volume ($.009101 x 4,500) 40.95
Rate Type: Residential DSI - PAWC Charge 0.83% 45
Total water charges, Jul 13, 2012 55.15
Meter readings in current billing period:
Meter Number H012004258 is a 5/8-inch meter. ----------AMOUNT DUE $54.95
Present-estimate 4600
Last-actual 100
Gallons used 4500
Water Usage Comparison
Monthly usage in hundred gallons.
t + 1
77 + 77
2 J A S O N D J F M A M J J 2
0 i u e [ v C a b a p a u u 0
1 9 p y n I 2
'=Estimate
Messages to you from Pennsylvania American Water
Any portion of the water charges which is not paid as of 8107,112 will be subject to a 1.5091o penalty.
Approximately 4.57 percent or $2.52, of State taxes are included in your current bill. j
Effective July 1, 2012, the Distribution System Improvement Charge (DSIC) increased from 0.32% to 0.83%,
This charge funds the replacement of water distribution facilities.
*Have you recently changed your primary phone number? If you have, please update your account information online
using My H2O Online at www.amwater.com1myh2o or callus at the number below so that we can update our records. ;
An annual water quality report (Consumer Confidence Report) was provided to you earlier this year. Copies can
be obtained by contacting our Customer Service Center or by also visiting our website. Landlords / businesses
schools and other groups are asked to share this water quality information with water users at their location who
may not receive a bill and therefore did not receive a copy of this report directly.
i
001555'001555 NCDWN2 TATt 1 12
Customer Service & Emergencies 1-800-565-7292 (24 Hours)
For Hearing Impaired Customers TDD 1-800-300-6202 (24 Hours)
Visit Us online at: www.pennsylvaniaamwater.com
RAWt00AM7931 A1M 24981
STORE YOUR DUPLICATE CHECKS IN YOUR CHECK BOX.
your expenses... ❑TAX-DEDUCTIBLE ITEM 135
((Track
❑ Clothing ❑ Food ❑ Transportation
{ ❑ Credit Card ❑ Utilities ❑ Mortgage
❑ Entertainment ❑ Insurance ❑ Other: ti
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3
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SHEMIN'=' I
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STORE YOUR DUPLICATE CHECKS IN YOUR CHECK BOX.
I 0CTrack your expenses... ❑ TAX-DEDUCTIBLE ITEM 138
❑ Clothing ❑ Food ❑ Transportation
f ❑ Credit Card ❑ Utilities ❑ Mortgage o-
f ❑ Entertainment ❑ Insurance ❑Other:
BALANCE
FORWARD
THIS ITEM I
f, BALANCE
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OTHER
BALANCE
FORWARD j
SIMON a, -M,
For added security, your name and account number do not appear on this copy. NOT NEGOTIABLE
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Please Remit Payment To:
East Pennsboro Ambulance Service Inc
Billing Office 12-164255 8/8/2012 $330.11
PO Box 726
New Cumberland, PA 17070-0726
QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 717-214-6020 Email: info@ambulancebillingoffice.com
Date of Service: 6/24/2012 20:59 Please visit our website to provide insurance or make payment, and
Patient Name: MARTLEW, LOUISE T. for additional payment options and frequently asked questions:
From: GOLDEN LIVING CENTER - WEST SHORE www.ambulancebillingoffice.com
To: Holy Spirit Hospital
•
We billed this claim to your insurance company, however, they have applied all or a portion of the bill to your
deductiblelco-insurance. Please remit payment. Thank you.
6/24/12 BLS Emergency Transport A0429 1.0 850.00 850.00
6/24/12 Mileage A0425 0.2 9.00 1.80
6/24/12 Adjustment - Insurance -494.44
8/08/12 Adjustment - Insurance -27.25
Total 851.80 -521.69 0.00
DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT.
I
STORE YOUR DUPLICATE CHECKS IN YOUR CHECK BOX.
i 001rack your expenses... ❑ TAX-DEDUCTIBLE ITEM 102
❑ Clothing ❑ Food ❑ Transportation
❑ Credit Card ❑ Utilities ❑ Mortgage
f ❑ Entertainment ❑ Insurance ❑ Other:
FORWARD I
r BALANCE
y
x DEPOSIT
1 OTHER
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FORWARD
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IIIIIIIIIIIININIIIIIIIIIIIIIINIIIIINIINIIIIIIIIIIIII STATEMENT
1788244941 golden living centers QUESTIONS
OUT
YOUR BILL?
(866) 325-5606
WEST SHORE
STATEMENT DATE PATIENT NAME ACCOUNT NUMBER
08/01/2012 LOUISE MARTLEW 00285449410001
PREVIOUS BALANCE NEW CHARGES PAYMENT ADJUSTMENTS NEW BALANCE
173.50 0.00 -173.50 0.00 0.00
DATE/PERIOD COVERED ACCOUNT ACTIVITY QTY/DAYS CHARGES PAYMENTS ADJUSTMENTS
07/11/12 PAYMENT -173.50
When returning home, patients often require ongoing care that family members cannot easily provide.
In these cases, AseraCare Home Health is an ideal solution. Visit homehealth.aseracare.com for more information.
Thank you for choosing Golden LivingCenters.
MAIL YOUR PAYMENT USING THE COUPON BELOW PAYMENT 08/15/2012
DUE DATE
-OR-
PAY YOUR BILL ONLINE AT www.goideniiving:COm PLEASE PAY THIS AMOUNT DUE
` • 0.00
DETACH HERE AND RETURN BOTTOM PORTION WITH YOUR PAYMENT FOR TIMELY PROCESSING- - -
i ACCOUNTNUMBER PATIENT NAME
GOLDEN LIVINGCENTER - WEST SHORE '00285449410001 LOUISE MARTLEW
C/O PATIENT ACCOUNTING- ADM OFFICE
1000 FIANNA WAY ell-LING DATE DUE DATE AMOUNTDUE AMOUNT ENCLOSED
FORT SMITH AR 72919-2263 08/01/12 08/15/12 0.00
Check here to pay by credit card and enter credit card information below.
❑ VISA ❑ MASTERCARD ❑ DISCOVER
Check box if address below is incorrect or CARD NUMBER CVV CODE'
❑ insurance information has changed. Indicate CARDHOLDER NAME EXP. ZIP CODE
DATE
changes on reverse side.
SIGNATURE AMOUNT
The CVV code is a three-digit number usually found on the back of your credit card.
Please Make Check or Money Order Payable To:
JULIANNE BISHARD GOLDEN LIVINGCENTER - WEST SHORE
908 CHARLES STREET P.O. BOX 644407
MECHANICSBURG PA 17055-3942 PITTSBURGH PA 15264-4407
1049970028544941100010801201200000000D0000000008
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IINIIIII~IIIIIIIIIIIIInIIIIIIhIIIIIIII~~I~IIIIIIIIIII STATEMENT
1776644941 golden
l
living centers QUESTIONS YOUR BILL?
(866) 325-5606
WEST SHORE
STATEMENT DATE PATIENT NAME ACCOUNT NUMBER
09/01/2012 LOUISE MARTLEW 00285449410001
PREVIOUS BALANCE NEW CHARGES PAYMENTS ADJUSTMENTS NEW BALANCE
0.00 0.00 0.00 75.00 75.00
DATE/PERIOD COVERED ACCOUNT ACTIVITY QTY/PAYS CHARGES PAYMENTS ADJUSTMENTS
08/30/12 COPAY-RC 75.00
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When returning home, patients often require ongoing care that family members cannot easily provide.
In these cases, AseraCare Home Health is an ideal solution. Visit homehealth.aseracare.com for more information.
Thank you for choosing Golden LivingCenters.
MAIL YOUR PAYMENT USING THE COUPON BELOW PAYMENT DUE DATE 09/15/2012
-OR- AMOUNT DUE
PAY YOUR BILL ONLINE AT www.goldenliving.com
75.00
DETACH HERE AND RETURN BOTTOM PORTION WITH YOUR PAYMENT FOR TIMELY PROCESSING
STORE YOUR DUPLICATE CHECKS IN YOUR CHECK BOX.
OKTrack your expenses... ❑ TAX-DEDUCTIBLE ITEM ~ 03
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