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Home My WebLink About02-01-13IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ,.~ ; N0.21-12-0719 ` z ` ; ~ c , ~ ~° ~, ~ ESTATE OF ANNA G. MENTZER °° ~ w ~~°~ ~" ` a/k/a A. GAYLE MENTZER ~' ~ r- 't ~~ r r~.m ~.. ~;z~a j 2 PETITION UNDER SECTION 3102 `~ ~' ~'' k ~ c',w., s. ~ .. 4... ~.+ OF THE PROBATE ESTATES AND FIDUCIARIES='i f.._. ` ' f.°" ~ a~ CODE FOR THE SETTLEMENT OF A SMALL EST-,PATE ~a ~ TO THE HONORABLE JUDGES OF SAID COURT: 1. Your Petitioners, Lois A. Zeigler, who resides at 106 Carlisle Road, Newville, Cumberland County, Pennsylvania 17241 and Doris J. Kerns, who resides at 30 Valley Street, Carlisle, Cumberland County, Pennsylvania 17013. The Petitioners are the daughters of~ the decedent, Anna G. Mentzer.. 2. The decedent, Anna Gayle Mentzer a/k/a A. Gayle Mentzer, died on June 4, 2012, a resident of the Sarah Todd Memorial Home, 1000 West South Street, Carlisle, Cumberland County, Pennsylvania 17013. 3. Letters Testamentary were issued to the Petitioners on June 28, 2012, by the Register of Wills of Cumberland County, Pennsylvania; no bond was required. 4. This estate is insolvent. 5. The Petitioners have filed a Pennsylvania Inheritance Tax Return although no tax will be due in this insolvent estate. On or about January 21, 2013, the Department of Revenue approved the inheritance tax return as filed in this matter. A copy of the approval is attached hereto as Exhibit «A „ 111J VERIFICATION We verify that the statements made in the foregoing Petition are true and correct. We understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to authorities. Date: ~ Lois A. Z i 1 1~~~~~ Date: Do ' .Kerns NOTICE OF INHERITANCE TAX ~ Pennsylvania BUREAU OF INDIVIDUAL TAXES APPRAISEMENT, ALLOWANCE OR DISALLOWANCE DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION OF DEDUCTIONS AND ASSESSMENT OF TAX - ~~ PO BOX 280601 REV-1547 IX AFP (12-12] HARRISBURG PA 17126-0601 DATE 01-21-2013 ESTATE OF MENTZER ANNA G DATE OF DEATH 06-04-2012 FILE NUMBER 21 12-0719 DAVID A BARK ESQ COUNTY CUMBERLAND ACN 101 19 W SOUTH ST APPEAL DATE: 03-22-2013 CARL ISL E PA 17013- 3445 (See reverse side under Objections) Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALON_6 THIS LINE ---- --~ R_ETA_IN LOWER POR TION FOR YDUR RECORDS E-- _ _ REV-1547 EX AFP C12-12) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE _ _ OR - DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF: MENTZER ANNA GFILE N0.:21 12-0719 ACN: 101 DATE: 01-21-2013 TAX RETURN WAS: C X) ACCEPTED AS FILED ( ) CHANGED APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) (1) 00 2. Stocks and Bonds (Schedule B) (2) . ,00 NOTE: To ensure proper credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule C) C3) .00 submit the upper portion 4. Mortgages/Notes Receivable (Schedule D) (4) 00 of this form with your . tax payment. 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 7,364.00 6. Jointly Owned Property (Schedule F) (6) .00 7. Transfers (Schedule G) C7) .00 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: (B) 7.364.00 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 8 6. 8 7 4 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) .00 11. Total Deductions C11) 86,287.45 12. Net Value of Tax Return C12) 78,923.45- 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) .00 14. Net Value of Ecstate Subject to Tax C14) 78,923.45- NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17 , 18 and 19 will reflect figures that include the total of ALL returns assess ed to date ASSESSMENT OF TAX: . 15. Amount of Line 14 at Spousal rate (15) .00 X 00 = .00 16. Amount of Line 14 taxable at Lineal/Class A rate Ci6) [)0 x 045 = _ 17. Amount of Line 14 at Sibling rate (17) 00 X 12 ,00 _ 18. Amount of Line 14 taxable at Collateral/Class B rate (18) .00 X 15 .00 = .00 19. Principal Tax Due TAX CREDITS: (19) = .00 PAYMENT RECEIPT DISCOUNT C+) DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID TOTAL TAX PAYMENT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. 1505610105 500 ex toZ_,1, IFt, REV-~ . PA Department of Revenue Pennsylvania OFFICIAL USE ONLY ~F/.ggEMFHTOEqEYENY! Counly Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN I -- ------_- PO BOX 28o6oi , Harrisburg, PA 1~>,z8-0601 R ESIDENT DECEDENT j ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY __ 195-16-4673 ~ 06/04/2012 ~ ~-- 106/28/1923 Decedent's Last Name J Suffix Decedent's First Name MI _---- --- , Mentzer __ __ , Anna ~ G ~ (If Applicable) Enter Surviving Spouse's Information Below S pouse's Last Name __ ------- Suffix Spouse's First Name MI _ ll II - -- - - -__ _J ~ _~l -- -- ------- _J - 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 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) ~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 4 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A} Between 12-31-91 and 1-1-95) (Attach Schedule 0) CORRESPONDENT - THIS SECTION MUST 8E COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name _ _ _ Daytime Telephone Number David A. Boric, Esquire (717) 249-6873 First Line of Address Boric Scherer LLC Second Line of Address 19 West South Street City or Post Office Carlisle _______ State PA ZIP Code ~ 17013 REGISTER OF WILLS USE ONLY C'7 ~, v _ ~` ~ ~7 - r-` 7 `.:. ~ `~ DATE FIC-EDt-•' 7'?r .T7 ~ r; ,.. ~~ C,.' ~ : i' _; -_r .I t=~ f• -., r-, _~ - ^ t' _l :~ `'J ' ~;~ r- ~~ -~, _~: r~ --; ...o .. __ - _...----------- _ ---- y -v Correspondent's a-mail address: dbarici~bariCSCherer.COm Under penalties of pery'ury, I declare that I have examined this return, including accompanying schedules and statements, and to the hest 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. SIGIytgTURE OJj PERSON Ft;ESPONSIBLE FOR FILING RETURN ~j /) //" narF 10 arlisl d!Nr~wvill A 17241 30 Valley Street, Carlisle, PA 17013 SI O A TH RftPRESENTATIVE p T ~~ DRESS 19 West South Street, Carlisle, Pennsylvania 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610105 1505610105 15056102175 REV-1500 EX (FI) Decedent's Social Security Number decedent's Name: Anna G. Mentzer i 195-16-4673 RECAPITULATION - ----- 1. Real Estate (Schedule A) ............................................. 1. I ----------0.00 .. 2. Stocks and Bonds (Schedule B) ....................................... 2. ! ~ 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. I 0.00 j' 4. Mortgages and Notes Receivable (Schedule D} ........................ ... 4. ~ 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).... ... 5. I 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 throw h 7 ( s ) ........................... .. s. 7, i 364 00 I 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. ~ 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 Side 2 1505610205 1505610205 O fc~V-1500 EX (FI) Page 3 Decedent's Complete Address: File Number DECEDENTS NAME Anna G. Mentzer STREET ADDRESS -- 2West Penn Street CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 2. B. Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) Total Credits (A + B) (2) (3) (4) (5) 0.00 Make check payable to: REGISTER OF WILLS, AGENT. .,i 1 , ~ *~ ~` ~! ~. ;"'~'~"ip~•~~+~ktn rr '~ i 'R ~x.. ~ n; r ,a. 4 ac ~- ~u. ~:;~~nam~..•,1~~a~$~.s3.~~~ e~e~w!memmas ems. ~~'~°~~~,.:~r'~S"~,~x,.,~T',,,,,,~,._ a~~C"s'~`~•~''i~3adt~an PLEASEANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred ................................................................................... ....... ^ b. retain the right to designate who shall use the property transferred or its income ...................................... ...... ^ 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 consideration? ............................................................................... 3. Did decedent own an "in trust for" orpayable-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 oftransfers 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 far 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 JuYy 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)]. 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. Tax Due (Page 2, Line 19) CreditslPayments A. Prior Payments _ REV-i5o8 EX+ (o8-iz) Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDVLE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Anna G. Mentzer 21-12-0719 Include the proceeds of litigation and the date the proceeds were received by the estate. Ai" property joinNy owned with right of survivorship must be disclosed on Schedule F. it more space is needed, use atlditional sheets of paper of the same size. REV-1511 EX+ (10-09) ~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS 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: I' 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: Z• 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 5. Accountant Fees: 6• Tax Return Preparer Fees: ~• Sarah Todd Memorial Home 609.24 s. 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 DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE ] BENEFICIARIES 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. Kerns daughter 30 Valley Street Carlisle, Pennsylvania 17013 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. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: L 50 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I # If mare space is needed, use additional sheets of paper of the same size. LAST WILL AND TESTAMENT I, A. GAYLE ~ MENTZER, of 2158 Newville Road, Carlisle, 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 share 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. .~ ._ ~..~ti,(~ (SEAL) A. GAYLE 1VIE R' 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. :. , ~;L, ACKNOWLEDGMENT AND AFFIDAVIT WE, A. GAYLE MENTZER, 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. ~,~ ~ A. GAYLE NTZER G~~ BO/R A. BARBOUR r ~ /1 ~. _ C^ AMY S. IR COMMONWEALTH OF PENNSYLVANLI :ss: COUNTY OF CUMBERLAND Subscribed, swop 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, 18996. penns~Evania DEPARTMENT OF PUBLLC WELFARE July 10, 2012 O'BRIEN BARK & SCHERER DAVID A BARK ESQUIRE 19 W SOUTH ST CARLISLE PA 17013 ~: Anna Mentzer CIS #`: 602 6 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 $83.243.81 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 $31,128.33, 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 $52,115.48, 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, Elizabeth M. Wilson TPL Program Investigator 717-214-1868 717-772-6553 FAX Enclosure cc: Lois A Zeigler 106 Carlisle Rd - - - -- - - Newville PA 17241 _ _, :~~~~~~ Bureau of Program Integrity ~ Division of Third Party Liability ~ 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 8466 HARRISBURG, PA 17105-6466 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 - 23-6003113 Page 1 of 8 I 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 02/01/11 - 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 10/31/11 55112994586530001 55112994586530001 5,040.70 5,114.48 DIAGNOSIS 1 : 43822 HEMIPLEGIA AFFECTING NOND DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PRO.C CODE : 000000 04!01/11 - 04/30/11 11!07111 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 07/01/11 - 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 08/01M 1 - 08/31!11 05/07112 55121254628610001 55121254628610001 5,040.70 5,270.72 DIAGNOSIS 1 : 43822 HEMIPLEGIA AFFECTING NOND DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PROC CODE : 000000 Page Z of 8 I . .. ' ' COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE ~. July 6, 2012 STATEMENT OF CLAIM -NAME MENTZER, ANNA I D 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 GHARGES AMOUNT APPROVED 09/01/11 - 09/30/11 05/07112 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 05/21112 55121374500010001 55121374500010001 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : T843 APHASIA PROC CODE : 000000 12/01/11 - 12/31/11 05121/12 55121374499310001 55121374499310001 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 7843 APHASIA PROC CODE : 000000 01/01/12 - 01/31/12 06/18/12 55121654397310001 55121654397310001 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 7843 APHASIA PROC CODE : 000000 02/01/12 - 02/29/12 06/18/12 55121654397970001 55121654397970001 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 7843 APHASIA PROC CODE : 000000 03/01/12 - 03/31/12 06!18/12 55121654398660001 55121654398660001 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 7843 APHASIA PROC CODE : 000000 04/01/12 - 04/30/12 06/04/12 20121354023720001 20121354023720001 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : T843 APHASIA PROC CODE : 000000 Page 3 of 8 4,833.01 5,019.62 4,995.52 4,622.30 4,995.52 4,956.51 5,003.11 5,195.39 5;399.45 5,000.17 5, 399.45 4,956.51 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 20121664027580001 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 ~ of 8 i- .i L~ 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 03l02/i1 - 03!02/11 04/18/11 25110815604890001 25110815604890001 DIAGNOSI 9.96 4.40 S1. 0 NDC CODE : 00591024005 IORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 07/11/11 - 07/11/11 08/08/11 25111935320290001 25111935320290001 DIAGNOSIS 1 : 0 NDC CODE : 00591024005 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 09/05/11 - 09/05/11 10/03/11 25112485250250001 25112485250250001 DIAGNOSIS 1 : 0 NDC CODE : 00168001431 HYDROCORTISONE 0.5% CREAM - GLUCOCORTICOIDS 09/05/11 - 09/05/11 10/03N1 25112485250260001 25112485250260001 DIAGNOSIS 1 : 0 NDC CODE : 51672201602 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 09/29/11 - 09/29/11 10/24/11 25112735813550001 25112735813550001 DIAGNOSIS 1 : 0 NDC CODE : 00591024005 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 09/29/11 - 09/29/11 11/28/11 25113025226020001 25113025226020001 DIAGNOSIS 1 : 0 NDC CODE : 00904770480 ASPIR-LOW EC 81 MG TABLET - NON-NARCOTIC ANALGESICS 10/29/11 - 10/29/11 12/26/11 25113335443950001 25113335443950001 DIAGNOSIS 1 : 0 NDC CODE : 00904770480 ASPIR-LOW EC 81 MG TABLET - NON-NARCOTIC ANALGESICS 11/26/11 - 11/26/11 1 2/26/11 25113305273100001 25113305273100001 DIAGNOSIS 1 : 0 NDC CODE : 51672201602 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS Page S of 8 ..COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC INELFARF 9.96 4.37 4.22 4.22 9•~ 7.58 14.92 4.68 50 .50 52 .52 9•~ 7.08 ;1~ COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF PUBLIC WELFARE July 6, 2012 STATEMENT OF CLAIM NAME MENTZER, ANNA fD 360 246 516 MILLENNIUM PHARMACY SYSTEMS INC 5020 RITTER RD STE 110 MECHANICSBURG PA 17055 DAl"E OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CFfARGES 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 DIAGNOSIS 1 : 0 NDC CODE : 00904770480 ASPIR-LOW EC 81 MG TABLET - NON-NARCOTIC ANALGESICS 01/03/12 - 01/03/12 02/06/12 25120095841180001 25120095841180001 DIAGNOSIS 1 : 0 NDC CODE : 00591024005 LORA2EPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 01/17/12 - 01/17112 02!13/12 25120175318960001 25120175318960001 DIAGNOSIS 1 : 0 NDC CODE : 51672201602 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 01/23112 - 01/23/12 03/05/12 25120395564560001 25120395564560001 DIAGNOSIS 1 : 0 NDC CODE : 00591024005 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 01/29/12 - 01/29/12 03/26/12 25120605232330001 25120605232330001 DIAGNOSIS 1 : 0 NDC CODE : 00904770480 ASPIR-LOW EC 81 MG TABLET - NON-NARCOTIC ANALGESICS 02/07/12 - 02/07/12 03/26/12 25120605238430001 25120605238430001 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 DIAGNOSIS 1 0 NDC CODE : 00904770480 ASPIR-LOW EC 81 MG TABLET - NON-NARCOTIC ANALGESICS Page 6 of 8 52 .52 17.41 4.86 9.44 7.62 17:41 .86 .52 .52 1.02 1.02 .49 .49 r ~ ~~ ' COMMONWEALTH OF PENNSYLVANIA i DEPARTMENT OF PUBLIC WELFARE Jufy 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 PAYMENT BATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 02/29/12 - 02/29/12 04/23/12 2512^v8iJ5.226x^$^^wvT~542Bo9522&9°^^^' 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 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 DIAGNOSIS 1 : 0 NDC CODE : 00904770480 ASPIR-LOW EC 81 MG TABLET - NON-NARCOTIC ANALGE5ICS 04/29/12 - 04/29/12 06/25/12 25121505550450001 25121505550450001 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 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 DIAGNOSIS 1 : 0 NDC CODE : 51672201602 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 05/29/12 - 05/29/12 07/02/12 25121585238740001 25121585238740001 DIAGNOSIS 1 : 0 NDC CODE : 00904770480 ASPIR-LOW EC 81 MG TABLET - NON-NARCOTIC ANALGESICS 1.43 1.43 .52 .52 .50 .50 1.39 1.39 9.44 7.62 17 .17 Page 7 of 8 .~ ,- - COMMONWEALTH OF PENNSYLVANIA L DEPARTMENT OF PUBIC 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 APPROVEI 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