HomeMy WebLinkAbout02-26-131505611185
-' REV-1500 EX (g2-11)(FI)
OFFICIAL USE ONLY
PA Depadment of Revenue County Code Year File Number
aureeu of Individual Taxes INHERITANCE TAX.RETURN
Po aox zagsot 21 12 1238
Marnsburg, PA tttzs-osot ~ RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Gate of Birth MMDDYYYY
1 1 11102012 05081909
Decedent's Last Name Suffix Decedent's First Name M I
BRAUGHT DOROTHY S
(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 APPROPRWTE BOXES BELOW
® 1. Original Return ^ 2. Supplemental Retum ^ 3. Remainder Return (Date of Death
Prior to 12-13-82)
^ 4. Limited Estate ^ 4a. Future Interest Compromise (date of ^ S. Federal Estate Tax Retum Required
death after 12-12-82)
6. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
^ 9. Litigation Proceeds Received ^ 10. Spousal Poverty Credfl (Date of Death ^ 1 t. Election to Tax under Sec. 9113(A)
Between 12-31-9f 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 Te~hone Numbed ~
~
LOW
ELL R• GATES, ESQ• C w
m
717-7
3]r~Q9600rn ~ o
~
r v m ''`~
z
Q'i r,r rpt
tM
.:a
,,. N ~x:t C:o
First Line of Address T-~ ~. -T, G9 C~
~
' ^` ~'
1013 MUMMA ROAD :.
~:9 }-.a p- ryt
Second Line of Address --1
C.J Ua O
SUITE 100 ~' 't
City or Post Office State ZIP Code DATE FILED
LEMOYNE PA 17043
correspondent'sa•mauaddrau: L•R•GATESaGATESLAWFIRM•COM
Under penaNfes of perjury, 1 declare that I have examined Chia velum, including accompanying schedules antl statements, and to the bast of my knowledge and belief,
it is true, wnect and Complete. Declare[ion of preparar other then the personal representative is based on all Information of which preparer has any knrrMedge.
244-RED HAVEN ROAD J NEW CUMBERLAND, PA 17070
1013 MUMMA ROAD, SUITE 11111 LEMOYNE, PA 17043
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505611185 1505611185
OM464] 3.000 tt~
Estate of Dorothy S. Braught
Executors (Page 1)
Name Annette M. Braught
Address 244 Red Haven Road
New Cumberland, PA 1707Q-
Tax ID 199-26-6752
15D5611285
REV-1500 EX (FI)
Decedent's Sodal Security Number
179-52-5171
oeceaenra Name BRALIGHT DOROTHY S
RECAPITULATION
1. Real Estate (Schedule A) ............ 1. D • D D
2. Stocks and Bonds (Schedule B) ....... . ............. ... 2. D • D D
3. Closely Held Corporation, Partnership or Sde-Proprietorship (Schedule ~), 3. D - D D
4. MoAgages and Notes Receivable (Schedule D) 4. D • D D
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) .. 5. 14 , 2 7 9.16
6. Jointly Owned Property (SCFredule F) ^ Separate Billing Requested g. 1, 4 2 9.4 3
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properly
(Schedule G) ^ Separate BilUng Requested .. . 7. D • D D
6. Total Gross Assets (total Lines 1 through 7) . . ............... . g. 15 , 7 D 8.59
9. Funeral Expenses and Administrative Cosfs (Schedule H) ............ . g, 1 D , 2 3 4.93
10. Debts of Decedent, Mortgage LiabGities, and Liens (Schedule I) , 10. 5D , 78 5 • D 1
11. Total Deductions (total Lines 9 and 10) , ...... . 11. 61, D 19.94
12. Net Value of Estate (Line 6 minus Line 11) , , 12. (4 S , 311.35 )
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) , .. . . 13. D • D D
14. Net Value Subject to Tax (Line 12 minus Line 13) , 14. (4 $ , 311.3 5 )
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or '
transfers under Sec. 9116
(a>(t.z>x.o- D•DD
t5.
D•DO
16. Amount of Line 1q taxable
4
S
DD
at lineal rateX.0
-
D•DD 16. D'
17. Amount of Line 14 taxable
at sibling rate X.12 D•DD 17. D•DD
16. Amount of Line 14 taxable
at collateral rate X.15 D • DD
18.
D • DD
19. TAX DUE ..... ............................. . 19. D . D D
^
20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMEN T
Side 2
1505611285 1505611285
OM/848 3.000
REV-1500 EX (FO Page 3
Decedent's Complete Address;
File Number
,~
~y yG y~~o
DECEDENT'S NAME
T D R TH
STREET ADDRESS -
CITY ~-- STATE ZIP
CAR E
PA 7
Tax Payments and Credits:
1. Tax Due (Page 2, Line i9) (1) Q. QQ
2. Credits/Payments
A. Prior Payments ~ Q , Q I)
B. Discount Q , Q Q
Total Credits (A + B > (2) 0 . p 0
3. Interest
(3) Q . Q Q
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in box on Page 2, Line 20 to request a refund. (q) Q , Q Q
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) Q , Q Q
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Ditl decedent make a Vansfer and'. Yes No
a. retain the use or income of the properly transferred .................
. ^ Q
.
..
b. retain the right to designate who shall use the property transferred or its income ....... ^ ^X
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 properly 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.
Far 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.i) (i)].
Far 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.§8116 (a) (1.1) (li)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements fa disclosure of assets antl
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For tlatesof tleath 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 younyer 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 tlecetlent's lineal beneficiaries is 4.5 percent, except as noted in [72 P.S. §9116(0)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's sialings is 12 percent ]72 P.S. §91 i6(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.
OM48I1 2.000
REV-1502 EX ~ 101-1D)
Pennsylvania
UEPPRTMENi OF REVENUE
INHERITANCE TAX RETVRN
SCHEDULE A
REAL ESTATE
ESTATE OF: FILE NUMBER:
Brauaht S Dorothk 21 12 1238
All real property ownetl blaty or ss a bnant in common must b reported at bir market value. Fair market value is tle6netl es [he price et wiugr progeny
would ba exchanged between a willing buyer and a willing seller, neither being oanpellad to buy or sdl, both heHng reeswrable knoMetlgedthe rNevent tads.
Rql property that la jolMtyowned with rtgM of sunlvorehlp mart ba dkcloaatl on Schedule F.
awesas z.poo If more space is needed, use additional sheets of paper b the same slze.
REV4503 E%+(&12)
Pennsylvania SCHEDULE B
DEPARTMENT OF REVENUE STACKS & BONDS
WHERffANCE TAX RETURN
RESIDENT DECEDENT
Braught S Dorothy 21 12 1238
All property jointly ownetl with right of survivonshlp must be disclosed on Schedule F.
zwaees zooo If more space is nasded, insert addrtronal sneers rn me same s¢e
FEV-0504 E%* (&9B)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR SOLE-PROPRIETORSHIP
Brought S Dorothy 21121238
Schetlule C-1 or C-2 (indutling all supporting information) must be allechetl far each doselµheld eorporationfpannerahip iMeresf dthe tlecedent, other tnan a
sole-proprietorship. Sea inatrudiona far the supporting informaton to be aubminetl fw ed6proprietorships.
ITEM VALUE AT
NUM~BER~ DESCRIPTION DATE OF DEATH
'' INOna
3W48B] 1.000
TOTAL (Also enter on line 3, Recapitulation) I $
more space is needed, insert adtlltional sheets of the same size)
0.00
REV-1507 EX+ (5-98)
SCHEDULE D
MORTGAGES 8 NOTES
ESTATE OF n~o numecn
Brauaht S. Dorothy 21 12 1238
Atl properly~dndycwned wgh dgM o(survivonftip mart he diulosed an Schedule F.
3 WdBAC 1.000 (IT mOfe 9P8Ce W needed, in86K eddllbnel eheet9 0( E8(!ie 8R2)
REV4508 EX+ (l1&1P)
Pennsylvania
!)EPPRYRfrM pF REVENUE
INHERITPNCE TPX RENRN
RESIOEM OECEOENT
SCHEDULE E
CASH, BANK DEPOSITS 8 MISC.
PERSONAL PROPERTY
and the tlale the
ITEM
1. Members 1st Federal Credit Union savings account number
391881-00
2 Members let Federal Credit Union checking account number
391881-05
3 Members let Federal Credit Union investment savings
account number 391881-11
TOTAL (Also enter on line 5; Recapi
2waeAO z.ooo I/ more space is neadeQ use atldilional shoals d pier of the sane aza.
VALUE AT DATE
159.52
70.81
14,048.83
S~ 14
REV-1509 J(+I01-+0!
Pennsylvania
OFPARTMENi OF RE4ENVE
INMERITgNCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF:
FILE NUM
Braught S Dorothv 21 12 1238
p an asset becameJdMy owned wltltln one year dthe decedent's tlate of rbath, H mwt t» reported on Schedule Q
SURVNWG JOMlTTB~ULM(Sl N9N£(S) I AOgiESS _ - --- I RflATpNStQT00EC8JErn
A Braught, Annette M
SCHEDULE F
JOINTLY-OW NED PROPERTY
244 Red Haven Road, New
Cumberland, PA 17070
JOINTLY OWNED PROPERTY:
Daughter
Ir~
tJ~~Bj u:TfER
GIXi JgNT
TENAYi b1TE
t'A9~ I
JLVNT ~~pN~F~py~iy
NCLUCE INEE(F FlINNL41L IN6iILUTIMAXDBAX(ALCWM'NLAbER CP BIMUR
ICEMIfYINGMJA6ER. AtTAG1DEED KN JpMLV XELO PEAL EBTATE.
~TE~~TM
VALLE OF ASSET %OF
iJec~vFxrs
MB=EST 097E OF OFATFi
VALUEOF
OFS.~BJI'S tVfEREST
1 A 8/28/2004 Sovereign Hank checking
account number 1681735665 2,858.85 50.0000 1,429.43
TOTAL (Also enter on Line &, Recapitulation) S 1 , 429.43
avxsgE z.ooo If more space is needed, use additional sheets a paper of the same size.
REV-1510 EX+(OB-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDEM
SCHEDULE G
INTER-V1VOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
Braught S. Dorothy 21 12 1238 _
This schedule must be completed and filed if the answer to any of quesFOns 1 through 4 on page three of the REV-1500 is yes.
ITEM
NUMBE DESCRIPTION OF PROPERTY
wxu~rrE waneorrremwaren~, nEia a¢Anorr*Pre cec~mAfO
7\f MIECG lR1J'KHi AiTHF1ACGPY OF TIE DEED FOq REpL E6TATE.
DATE OF DEATH
VALUE OF ASSET
%OF DECD'S
INTEREHT
EXCLUSION
FAPVIJ(ABLE
TAXABLE
VALUE
~ None
TOTAL (Also enter on line 7, Recapitulation) $
I(more space is needed, use additional aheata M paper nF the same Size.
9WIBAF 2.000 '
REV-1611 EX+(1608)
pennsylvania
DEPPRTh£M OF REVENUE
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
Br u ht S r h 11121238
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
~, Ewing Brothers Funeral Home, Inc. (funeral bill) 1,400.59
Total from continuation schedules .
8. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name{s) of Personal RepresentativE(s) a„no7•rc M. Hraug};t
Street Address 244 Red Haven Road _
Ciry New Cumberland State PA ZIP 17070
Year(s) Commission Paid: 2013
2. Attorney Fees:
3. Family Exemption: (If decedents address is not fhe same as daimant's, attach explanafia~.)
Claimant .__
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees:
5. Accountant Fees:
6. Tax Return Preparer Fees:
7.
1 Patriot News (estate publication notice to
creditors)
(Total from continuation schedules .
859.74
2,500.00
5,000.00
123.50
151.10
200.00
10
awasnc z.coo If more space is needed, use additional sheets of paper of
Estate of: Braught S. Dorothy
Schedule H Part 1 (Page 2)
Item
No. Description
2 Westminster Cemetery (grave marker)
3 Georges' Flowers (funeral flowers)
21 12 1238
Amount
723.00
136.74
Total (Carry forward to main schedule) 959.74
Estate of: Braught S. Dorothy 21 12 1238
Schedule H Part 7 (Page 2)
2 Cumberland Law Journal (estate publication notice to
creditors) ~ 75.00
3 Updegraff s Ruhl (personal income tax preparation
for deceased 2012 taxes) 125.00
Total (Carry forward to main schedule) 200.00
REV4512 E%~(tt~OFI)
pennsylvania
OEPPRThENl OF REVENUE
INHERITANCE TAX RETURN
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
FILE NUMBER
Brauaht 3 Dorothv 21 12 1238
Report debts incurred by the decetlent prior to death that remained unpaid at the date d death, Including unraimbursed medical exparrees.
BW48AH 2.000 If more space is needed, insert addhbnal streets of the same srze.
REV-1513E%t (01-1 D)
pennsylvania
OEPAR1hEM OF REVENUE
INHERRANCE TAX RETURN
RESIDEMDECEDEM
SCHEDULE J
BENEFICIARIES
FILE NUN~ER:
)MBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I TAXABLE DISTRIBUTIONS[Indude autdght apouael diffiri6uaons entl venskls under
Sac. 9116 (a) (1.2).]
r. Annett® M. Braught
264 Red Haven Road
New Cumberland, PA 17070
P.TIONSHIP TO DECEDENT
Do Not Llat Trustee(s)
Daughter
ENTER DOLIAR AMOUNTS FOR DISTRIBLRIONS SHOWN PROVE OM LINES 18 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
(( NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CI~ARITABLE Ate C-AVERNMEMAL DISTRIBURONS:
1
awasAl s.ooa
II -ENTER TOTAL NON-TA)CAtlLt uIS I r
It more space is needetl, use
SHEET
AMOUNT OR SHARE
OF ESTATE
0.00
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat ar photograph.
i•c Ihr Chic u•rtitiL.nc. F6.U0
P 1888'~~~0
_ ___ __
Cu ul(cutian tiuluhcr
I hn i> to Lcrtift th:a the inR)rmaliun here given is
col rc~al~ rup(cd (ilno an rniginai ('cnifiealc of 1)ea0
doh tiled s(ith me .)~ Local Regiauar. TLe urigina
cerhL case Lt itl he Inr)vnrded to the Slate Vila
ttcculds (NCicc ti)r pcrmtinent tiling.
L~hn~v~~~ N i 2012
__~ _ -
t seal Regiar.u llule Issued
Type/p ~~m COMMONWEALTH OL PENN3VLV4NIq•DEPggTMENT OF HEA LTNVITgLgFCOROS
Poi ~g,n"` CERTIFICATE OF DEATH state FmN
D o.aenra LPHaI rvame fFi : Mltlme, L.n, sgmx) z. ]« s. soeln securlN N mb.. of oa.M (MO/Dav/Yq tsp.x Mol
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NOVa[Iber l0, 2072
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G\nnberlanC4 He. Realtlenc. (Zip COde) J
Lu NO. tleced.nt llvetl wlMln limbs eT ~ )_ 1 ctty/bo,0.
9.EwlIn VS Irma esi 30. MerlhlSh[us at Tlma q(MeU Merded Wltlowe 1.]urWVlnH 3pnuse'a Neme(II wIEe,BHe name prior tOflyt mer<leHe)
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13. Fetner'a Name (Firs[, Middle, Lea49ulxa) 13. Mo<n e!'a Neme Plbr W Glrrt Manle{e (Pilot. Middle. Lif[)
Milton C_ Souder Sarah Albert
i<.. In(bm..nra N....e tae. Raalonsblp to D.ceaen< lac.m M.IxN gdarea isn.a<e Nomb a ]t.<
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21. Oac.den['s Sfn81e Rece ]elf-MSIHnatlOn - Cn.ck ONLY ONE to Intllexte what tm dOCeden< coOalOered nlmself or FeYUI( to be. 33 e. Oecetlent's Vsual Occupation - Intlkeh <Ype n( work
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LAST WILL AND TESTAMENT i~ ^
DOROTHY S. BRAUGHT < ~~/
I, DOROTHY S. BRAUGHT, now of 1414 Bryn Mawr Road, Carlisle,
Cumberland County, Pennsylvania 17013, do publish and declare
this to be my Last Will and Testament, hereby revoking all other
prior wills and codicils made by me.
FIRST: Family Background and A~DOintment of Executor.
(A) Family and Background Information. I am married to
HAROLD J. BRAUGHT. I have not been previously married. The
child of our marriage is ANNETTE M. BRAUGHT. Throughout this
Will, HAROLD J. HRAUGHT will be referred to as "my husband" or
"my spouse" and ANNETTE M. BRAUGHT will be referred to as "my
child." The word "issue" will include any children as well as my
other descendants.
(H) ADPOintment of Executor. I appoint as my Executor and
successor Executor (all hereinafter referred to as Executor or
Executor(s)) under this Will, the following named persons or
corporations to serve without bond and without being required to
account to any Court:
Executor: My husband, HAROLD J. BRAUGHT.
Successor 8xecutor: My daughter, ANNETTB M. BRAUGHT.
Second Successor Executor: My granddaughter, DEBRA
ANN HERSHEY
(C) Inter Vivos Trust. The inter vivos trust agreement
referred to in this Will is entitled "THE BRAUGHT FAMILY
IRREVOCABLE TRUST," DATED P~~t1~kI~YC-- ~--' by and between HAROLD
J. HRAUGHT and DOROTHY S. BRAUGHT, as Settlors, and HAROLD J.
HRAUGHT, DOROTHY 3. BRAUGHT, and ANNETTE M. BRAUGHT as Co-
Trustees, as now in effect or as may hereafter be amended.
SECOND: _Funeral_aad Last illness Expensess Taxes.
(A) ExDenaes of Funeral and Last Illness. I direct my
Executor to pay my funeral expenses and the expenses of my last
illness from my estate. In addition, my Executor may notify th
Trustee of the Trust described in Paragraph FIRST (C) of any s~
expenses and my Executor may accept reimbursement from such //
Trustee.
LAST WILL AND TESTAMENT
OF
DOROTHY 3. HRAUGHT
PAGE 2
(B) Taxes. I direct my Executor to pay any and all estate,
inheritance, succession, legacy, transfer and other death taxes
or duties, by whatever name called, including any and all
interest and penalties thereon, imposed under the laws of any
jurisdiction by reason of my death upon or with respect to any
and all property included in my gross estate for the purpose of
such taxes, whether such property passes under or outside of this
Will. without any apportionment otherwise required by law and
without being prorated or apportioned among or charged against
the respective devises, legatees, beneficiaries, transferees, or
other recipients of any such property or charged against any
property passing or which may have passed to any of them, I
direct that any taxes so paid shall be charged against my
residuary estate. My Executor shall not be entitled to
reimbursement for any portion of any such taxes from any such
person. The foregoing provisions of this Article SECOND shall
not apply to such portion or portions of said taxes, interest and
penalties which may be required to be paid, or are actually paid
or reimbursed, by the Trustee of the Trust described in Paragraph
FIRST (C), above.
THIRD: Tangible Personal ProDertY. Except for those
excluded below and those items enumerated in the Letter of
Instruction, I bequeath all my tangible personal property,
including but not limited to clothing, jewelry, heirlooms,
furniture, household furnishings, personal effects, motor
vehicles, and all other similar articles, which I own, and
insurance thereon, to my spouse, HAROLD J. BRAUGHT, if he
survives me. Tangible personal property shall not include:
any and all property used by me in any business, (2) cash on
or on deposit in banks, (3) stock or securities, (9) any type
evidence of indebtedness, and (5) any life, health or accident
insurance policies.
If my spouse, HAROLD J. BRAUGHT, does not survive me, I
leave such tangible personal property to my daughter, ANNETTE M.
BRAUGHT, per stirpes. If there is any disagreement as to
distribution, I direct my Executor to make such distribution.
The decision of my Executor shall be final and binding. Any
items not selected or any items which my Executor considers
unsuitable for my child may be distributed or sold in the sole
discretion of my Executor and, if sold, the net proceeds
therefrom shall be added to the residue of my estate. Any
article allocated to a minor may, as my Executor deems ad ble,
~,.~~/.~
~/ S
items
the
(1)
hand
of
LAST WILL AND TESTAMENT
OF
DOROTHY 3. HRAUGHT
PAGE 3
either be delivered to the minor or to any person to safeguard on
behalf of the minor.
Notwithstanding any other provisions in this Article THIRD,
I may leave a separate, dated and unsigned Letter of Instruction,
which I shall place with my Will, containing directions as to the
ultimate disposition of certain of the property bequeathed under
this Article THIRD, and such Letter of Instruction shall
determine the distribution of such items.
FOURTH: Residuary Estate. I devise and bequeath all of the
rest, residue and remainder of my estate, real, personal and
mixed, of whatever nature and wherever situated to which I am
legally or equitably entitled, to the then-acting Trustee(s) of
the Trust described in Paragraph FIRST (C) of this Will, to be
held, administered and distributed pursuant to the terms thereof,
as the same may be amended from time to time. By this devise and
bequest of my residuary estate I hereby exercise all Powers of
Appointment I possess at the time of my death except any power of
appointment which i possess under the Trust described in
Paragraph FIRST (C) of this Will.
FIFTH: Powers of Executor. In addition to the powers and
duties as may have been granted elsewhere in this Will, but
subject to any limitations stated elsewhere in this Will, the
Executor shall have and exercise exclusive management and control
of the Estate and shall be vested with the following specific
powers and discretion, in addition to the powers as may be
generally conferred from time to time upon the Executor by law:
(A) in the management, care and disposition of the Estate,
the Executor shall have the power to do all things and to execute
such instruments, deeds, or other documents as may be deemed
necessary or proper, including the following powers, all of which
may be exercised without order of or report to any Court:
(1) To sell, exchange or otherwise dispose of any
property at any time held or acquired hereunder, at public
or private sale, for cash or on terms, without
advertisement, including the right to lease for any term
notwithstanding the period of the Estate, and to grant
options, including any option for a period beyond the
duration of the Estate.
(Z) To invest all monies in such stocks, bonds,
securities, mortgages, notes, choses in action, real to
~~~
LAST WILL AND TESTAMENT
OF
DOROTHY S. HRAUGHT
PAGE 4
or improvements thereon, and any other property as the
Executor may deem best, without regard to any law now or
hereafter enforced limiting investments of fiduciaries.
(3) To retain for investment any property deposited
with the Executor hereunder.
(4) To vote in person or by proxy any corporate stock
or other security and to agree to or take any other action
in regard to any reorganization, merger, consolidation,
liquidation, bankruptcy or other procedure or proceedings
affecting any stock, bond, note or other security.
(5) To use attorneys, real estate brokers, accountants
and other agents, if such employment is deemed necessary or
desirable, and to pay reasonable compensation for their
services.
(6) To compromise, settle or adjust any claim or
demand by or against the Estate and to agree to any
rescission or modification of any contract or agreement
affecting the Estate.
(7) To renew any indebtedness, as well as to borrow
money, and to secure the same by mortgaging, pledging or
conveying any property of the Estate.
(B) To retain and carry on any business in which the
Estate may acquire an interest, to acquire additional
interest in any such business, to agree to the liquidation
in kind of any corporation in which the Estate may have an
interest and to carry on the business thereof, to join with
other owners in adopting any form of management for any
business or property in which the Estate may have an
interest, to become or remain a partner, general or limited,
in regard to any such business or property and to hold the
stock or other securities as an investment, and to employ
agents and confer on them authority to manage and operate
the business, property or corporation, without liability for
the acts of such agent or for any loss, liability or
indebtedness of such business if the management is selected
or retained with reasonable care.
(9) To register any stock, bond or other security in
the name of a nominee, without the addition of words
indicating that such security is held in a fiduciary
i "_'~
LAST WILL AND TESTAMENT
OF
DOROTHY 3. BRAUGHT
PAGE 5
capacity, but accurate records shall be maintained showing
that such security is a Estate asset and the Executor shall
be responsible for the acts of such nominee.
(H) Whenever the Executor is directed to distribute any
Estate assets in fee simple to a person who is then under twenty-
one (21) years of age, the Executor shall be authorized to hold
such property in Trust for such person until he/she becomes
twenty-one (21) years of age, and in the meantime shall use such
part of the income and the principal of the Estate as the
Executor may deem necessary to provide for the proper support and
education of such person. If such person should die before
becoming twenty-one (21) years of age, the property then
remaining in trust shall be distributed to the personal
representative of such persons estate.
(C) In making distributions from the Estate to or for the
benefit of any minor or other person under a legal disability,
the Executor need not require the appointment of a guardian, but
shall be authorized to pay or deliver the same to the custodian
of such person, to pay or deliver the same to such person without
the intervention of a guardian, to pay or deliver the same to a
legal guardian of such person if one has already been appointed,
or to use the same for the benefit of such person.
(D) In the disbursement of the Estate and any division into
separate trusts or shares, the Executor shall be authorized to
make the distribution and division in money or in kind, or both,
regardless of the basis for income tax purposes of any property
distributed or divided in kind, and the distribution and division
made and the values established by the Executor shall be binding
and conclusive on all persons taking hereunder. The Executor may
in making such distribution or division allot undivided interests
in the same property to several trusts or shares.
(E) The Executor shall have discretion to determine whether
items should be charged or credited to income or principal or
allocated between income and principal as the Executor may deem
equitable and fair under all the circumstances, including the
power to amortize or fail to amortize any part or all of any
premium or discount, to treat any part or all of the profit
resulting from the maturity or sale of any asset, whether
purchased at a premium or at a discount, as income or principal
or apportion the same between income and principal, to apport~?n
the sales price of any asset between income and principal, tfb /
treat any dividend or other distribution of any investment
<' ,~
LAST WILL AND TESTAMENT
OF
DOROTHY S. BRAUGHT
PAGE 6
income or principal, or apportion the same between income and
principal, to charge any expense against income or principal or
apportion the same, and to provide or fail to provide a
reasonable reserve against depreciation or obsolescence on any
assets subject to depreciation or obsolescence, all as the
Executor may reasonably deem equitable and just under all the
circumstances. If the Executor does not exercise the above
discretionary power, the cash or accrual allocation shall be in
accordance with Chapter 81 of Title 20 of the Pennsylvania
Consolidated Statutes, or the corresponding provisions of
subsequent state law.
(F) If at any time the total fair market value of the
assets of any trust established or to be established hereunder is
so small that the corporate Trustee's annual fee for
administering the trust would be the minimum annual fee set forth
in the Trustee's regularly published fee schedule then, in
effect, the Trustee in its discretion shall be authorized to
terminate such trust or to decide not to establish such trust,
and in such event the property then held in or to be distributed
to such trust shall be distributed to the persons who are then or
would be entitled to the income of such trust. If the amount of
income to be received by such persons is to be determined in the
discretion of the Trustee, then the Trustee shall distribute the
property among such of the persons to whom the Trustee is
authorized to distribute income, and in such proportions, as the
Trustee in its discretion shall determine.
(G) Except as otherwise provided in this Will, when the
authority and power under this will is vested in two (2) or more
Executors or Trustees, the authority and powers are to be held
jointly by the Executors or Trustees, respectively. A majority
of the Executors or Trustees may exercise any authority or power
granted under this Will or granted by law, and may act under this
Will. Any attempt by one such Executor or Trustee to act under
this Will on other than ministerial acts shall be void. The
action of one such Executor or Trustee under this will may be
validated by a subsequent ratification of the act by a majority
of the Executors or Trustees.
SIXTH: Rights and Liabilities of Executor.
(A) No bond or other security shall be required of any
Executor.
~.S'~S~
LAST WILL AND TESTAMENT
OF
DOROTHY S. BRAUGHT
PAGE 7
(B) This instrument always shall be construed in favor of
the validity of any act or omission by any Executor, and any
Executor shall not be liable for any act or omission except in
the case of gross negligence, bad faith or fraud. Specifically,
in assessing the propriety of any investment, the overall
performance of the entire Estate shall be taken into account.
(C) Each Executor shall be entitled to receive reasonable
compensation for services actually rendered to my estate, in an
amount the Executor normally and customarily charges for
performing similar services during the time which he/she performs
the services.
SEVENTH: Spendthrift Provision. No beneficiary shall have
the power to anticipate, encumber or transfer his or her interest
in the estate in any manner other than by the valid exercise of a
power of appointment. No part of the estate shall be liable for
or charged with any debts, contracts, liabilities or torts of a
beneficiary or subject to seizure or other process by any
creditor of a beneficiary.
EIGHTH: Tax Elections.
(A) in determining the estate, inheritance and income tax
liability relating to my Estate, the Executor's decision as to
all available tax elections shall be conclusive on all concerned.
If the Executor joins with my spouse in filing income tax
returns, or consenting for gift tax purposes to having gifts made
by either of us during my life considered as having been made
one-half by each of us, any resulting liability shall be borne by
my Estate and my spouse in such proportions as they may agree.
In accordance with IRC Section 2632 (a) and without regard to
whether a Federal estate tax return is actually filed, my
Executor shall allocate so much of the Federal Generation
Skipping Transfer (GST) exemption amount as will fully exempt any
generation skipping transfer which may occur under this Will.
(B) The Executor may, in its discretion, determine the date
as of which my gross estate shall be valued for the purpose of
determining the applicable tax payable by reason of my death.
(C) The Executor may, in its discretion, decide whether all
or any part of certain deductions shall be taken as income tax
deductions (even though they may equal or exceed the taxable
income of my estate and whether or not claimed or of benefit o
my estate's income tax return) or as estate tax deductions a
~~.,5~- .
LAST ATILL AND TESTAMENT
OF
DOROTHY 3. BRAUGHT
PAGE 8
choice is available; and in the event that all or any part of
such deductions are taken as income tax deductions, no adjustment
of income and principal accounts in my estate shall be made as a
result of such decisions.
NINTH: Definitions and General Provisions.
(A) Survival. Any beneficiary who dies within sixty (60)
days after my death shall be considered not to have survived me.
(B) Captions. The captions set forth in this Will at the
beginning of the various articles hereof are for convenience of
reference only and shall not be deemed to define or limit the
provisions hereof or to affect in any way their construction and
application.
(C) Children. As used in this Will, the words "child" and
"children" shall include persons who are legally adopted and the
issue of said persons, whether born in or out of wedlock, so long
as any person born out of wedlock is acknowledged in a written
instrument executed by the one of their natural parents who is a
descendant of mine to be the Child of said descendant. The word
"issue" shall include descendants of all generations including
adopted persons. A posthumous child shall be considered as
living at the death of his parent. The birth to me or the
adoption by me of a child or children subsequent to the execution
of this Will shall not operate to revoke this Will. Except for
discretionary distributions which may be made unequally among a
group of persons and distributions pursuant to a valid exercise
of a power of appointment, in making a distribution to the
children of any person, the property to be distributed shall be
divided into as many shares as there are living children of the
person and deceased children of the person who left children who
are then living. Each living child shall take one share and the
share of each deceased child shall be divided among his then-
living descendants in the same manner.
(D) Code. Unless otherwise stated, all references in my
Will to section and chapter numbers are to those of the Internal
Revenue Code of 1986, as amended, or the corresponding provisions
of any subsequent federal tax laws applicable to my estate.
(E) Other terms.
genders, and the use of
includes the other.
',,5;!3
~;
The use of any gender includes the other
either the singular or the p'••-'~'
LAST WILL AND TESTAMENT
OF
DOROTHY 3. BRAUGHT
PAGE 9
(F) Powers of Appointment are Exercised. By this Will I
exercise any and all Powers of Appointment which I possess at the
time of my death except any power of appointment which I possess
under the Trust described in Paragraph FIRST (C), above.
IN WITNESS WHEREOF, I, DOROTHY S. BRAUGHT, the Testatrix,
have to this my Last will and Testament, typewritten on ten (101
pages, including the Acknowledgment and Affidavit, set my hand
and seal this ~_ day of `71 ~r~lrri/ 1995.
DOROTHY 3". BRAUGHT'
r
Signed, sealed, published and declared by the above-named
Testatrix, as and for her Last Will and Testament, in the
presence of us, who have hereunto subscribed our names at her
request, as witnesses hereto, in the presence of the said
Testatrix, and in the presence of each other. Each of us further
declares that a or she believes the Testatrix to be of sound
mind and m The preceding instrument consists of this and
nine (9) h consecutively numbered typewritten pages including
the Ack w~dgment and Affidavit.
nt name)
:,
;) ~ /
~~~ i ~ ~~
residing at rCrnwlU~ Q~
residing at ~~.1'.c,~r~r~-.~-_c-~~:~,-~~z,~
J
(print name)
ACKNOWLEDGMENT AND AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF ~(.vr'lz:~-~~~'~^~- ,
The Testatrix and the witnesses whose names are signed and
subscribed to the attached or foregoing instrument, being first
duly sworn and qualified according to law, do hereby acknowledge,
depose and say to the undersigned authority, that the Testatrix
signed and executed the instrument as her Last Will in the presence
of the witnesses; that she signed it willingly or willingly
directed another to sign it for her; that she executed it as her
free and voluntary act for the purposes therein expressed; that
each of the witnesses were present and saw the Testatrix sign and
execute the instrument as her Last will; that each subscribing
witness in the hearing and sight of the Testatrix signed the will
as witnesses; 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.
witness
Sworn to or affirmed, subscribed to, and acknowledge, before
me by the above named Testatrix and witnesses, this o~^ day of
,'
J,
~=
of ry Pub is
My Commission Expires:
Notarial Seaf
Linda Lee Gates, Notary Public
Shiremanstown Boro, Cumberland County
My Commission Expires Oct. 9, 1999
n Member, Pennsylvania Association of Notaries
-. Y n
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SHORT CERTIFICATE
I, GLENDA EARNER STRASBAUGH
Register for the Probate of Wills and Granting
Letters of Administration in and for
CUMBERLAND County, do hereby certify that on
the 29th day of November, Two Thousand and
Twelve,
Letters TESTAMENTARY
in common form were granted by the Register of
said County, on the
estate of DOROTHYSBRAUGHT late of CARL/SLEBOROUGH
/Fi/st, Midtlle, (esU
in said county, deceased, to ANNETTEMBRAUGHT
and that same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the
seal of said office at CARLISLE, PENNSYLVANIA, this 29th day of November
Two Thousand and Twelve.
File No.
PA File No.
Date of Death
S.S. #
2012-01238
21- 12- 1238
11/10/2012
179-52-5171
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
PA REV-1500
SCHEDULE E
CASH, BANK DEPOSITS &
MISCELLANEOUS PERSONAL
PROPERTY
st
MEMBERS 191
P~ERAL CREDIT UNION
REGULAR SAVINGS ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Interest Accrued 01/01/2012 - 11/10/2012
Name of Joint Owner
391881-00
07/30/2010
$159.52
$0.01
$159.53
$0.31
None
J
CHECKING ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Interest Accrued 01/01/2012 - 11/10/2012
Name of Joint Owner
INVESTMENT SAVINGS ACCOUNT:
Account NumberlSuffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to pate of Death
Total Principal and Accrued Interest
Interest Accrued 01/01/2012 - 11/10/2012
Name of Joint Owner
Estate of: DOROTHY S BRAUGHT
Date of Death: 12/11/2012
Social Security Number: 179-52-5171
391881-05
07/30/2010
$70.81
$0.00
$70.81
$0.10
None
391881-11
0713012010
$14,048.83
$0.35
$14,049.18
$8.67
None
MEMBERS 1sT FEDERAL CREDIT UNION
~.2D
Tessa L Klugh
Lending Insurance Support Specialist
December 11, 2012
5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 •_ (800) 283-2328. • wwv~memberslst,ore
Sovereign Bank
ESTATE OF Dorothy S Braught
SOCIAL SECURITY #: 179-52-5171
DATE OF DEATH:
November 10. 2012
Account #: 1681735865 Type: Checking Open date: 8/28/2004
In the name of: Annette M Braught or Dorothy S Braught
Date of Death Balance: $2,858.85
Int.(YTD) from 1/1/2012 to 10/15/2012 $0.26
Accrued interest to date of death:
Otherlnfo:
$0.02
Page 1 of 1
ra x~v-isoo
SCHEDULE H
FUNERAL EXPENSES and
ADMINISTRATIVE COSTS
Ewing Brothers Funeral Home, Inc.
630 South Hanover Street
Carlisle, PA 17013-
(717)243-2421
November 13, 2012
Annette M. Braught
244 Red Haven Rd.
New Cumberland, PA ] 7070
The Funeral Service for Dorothy S. Braught
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUT OMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
I. PROFESSIONAL SERVICES
Basic Services of Funeral Director/Staff _ $]200.00
Bathing & Embalming $895.00 -
Dressing, Casketing, Cosmotology etc. $295.00
2. FACILITIES/SERVICES/STAFF/EQUIPMENT
Basic Use ofFacility . $200.00
Document Prep/Permanent Recording, $325.00 -
Facility Usage for Viewing/Visitation, $150.00'
Staff Usage for ViewingNisitation, $150.00
Staff for Graveside/Interment $125.00'
3. AUTOMOTIVE EQUIPMENT
Vehicle to transfer remains to Funeral Home, $295.00
Hearse (Casket Coach) $295.00
Utility Car , $135.00 '
FUNERALHOME SERVICE CHARGES $4065.00
SELECTED MERCHANDISE:
0293 Gold Blend Gray 20G Gasketed C $1625.00'
Acknowledgementcards, $10.00•
Register Book(s) _ $40.00
Memorial folders , $85.00-
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THAT YOU HAVE SELECTED $5825.00
Cash Advances
Opening Grave, $2068.00'
Sentinel Obituaryw/Photo $208.02-
PatriotObituary $189.17•
Certified Copies of Death Certificate $36.00-
Clergy Honorarium $]00.00•
TOTAL CASH ADVANCES AND SPECIAL CHARGES . $2601.19~~
Total
Total Cost , $8426.19
SUB-TOTAL
INITIAL PAYMENT f DISCOUNT J CREDITS
TOTAL AMOUNT DUE
The anpaid balance over 30 days is subjeMed to a 1.50 % service charge per month - 15.0000 % Der annum.
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GE~tGES' FLOWERS
ate: 11/14/2012
ime: 02:59:13 PM
4
Terminal: 2
Session: 2590
PAYMENT
ccount Numher: 0012365
Account Name: ANNETTE M BRAUGH7
Balance Due (11/14/2012): $
Payment Amount; $
New Balance Due (11/14!2012): $
Amount Tendered: $
Change Due: $
Thank You For Your Business!
~rint Date: 11/14/2012
rint Time: 02:59:13 PM
0.00
136.74
-136.74 ,~
0.00
0.00
RECEIPT FOR PAYMENT
-------------------
---------------
GLENDA FARNER STRASBAUGH
Cumberland County - Register Of wills
One Courthouse Square
Carlisle, PA 17013
BRAUGHT DOROTHY S
Estate File No.: 2012-01238
Paid By Remarks: CJM BRAUGHT
FeefTax Description
Receipt Distribution
Payment Amount Pay
PETITION LTRS TEST
WILL
SHORT CERTIFICATE
JCS FEE
AUTOMATION FEE
Check# 3000
Total Received.......
60.00 CUM
15.00 CUM
20.00 CUM
23.50 BUR
5.00 CUM
----------------
$123.50
$123.50
Receipt Date: 11/29/2012
Receipt Time: 08:26:42
Receipt No.: 1072210
ee Name
BERLAND COUNTY GENERAL FUN
BERLAND COUNTY GENERAL FUN
BERLAND COUNTY GENERAL FUN
EAU OF RECEIPTS & CNTR M.D
BERLAND COUNTY GENERAL FUN
e dtC10t-1~ews Order Confirmation
Now you know
AO Order Number Customer Pavor Customer
0002248854 GATES, HALBRUNER 8 HATCH, P. C. GATES, HALBRUNER 3 HAT
Sales Reo. Customer Account Pavor Account
aleeds 41052 41052
Order Taker Customer Atldress paver Address
aleeds ATTN: Traci Hilferdirtg,1013 M UMMA ROAD,SIJITE ATTN: Trail Hilferding,1013 MUMMA ROAD,SUITE
Lemoyne PA 17043 USA
Order Source Lemoyne PA 17043 USA
Phone Customer Phone paver phone
717-731-9600 717-731-9600
PO Number
Spatial Pdcfia
Ordered By Norte
traci
customer Pax
Customer EMeU
t. h iNerding Qgateslarvfirm.oom
Tear Shasta Proofs Affitlavita
0 0 1
Invoice Taxt
Matarlais
Net Amount
$151.10
Pavttrent MaMod Pavmem Amount
$0.00
81intl Box
Tax Amount
$C.00
Amount Due
$151.10
jghlAmount
E151.10
Ad Number Atl Tvoe Ad Size
0002248854-01 Legal Liners :1.0X20 Li
Protluc0on McMOd produetion Notes
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Product Information PlacemenUClassification Run Datea
Run Schedule Invoice Text SoR Text
PNCO::FuIIRun 840W -Metro West Legals 211212013, 2119/2013, 2/26/2013
ESTATE NOTICE LETTERS OF TESTAMENT, ESTATENOTICELETTERSOFTESTAMENTAF
# Inse Cost
3 $138.60
Online::FullRun 840W -Metro West Legals 2112/2013, 2/19/2013, 2/26/2013
ESTATE NOTICE LETTERS OF TESTAMENT. ESTATENOTICELETTERSOFTESTAMENTAF
#Inserts
3 $7.50
2/11/201312:38:56PM 2
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, PA 17013
Tele: (717) 249-3186 Fax: (717) 249-2883
January 11, 2013
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.
TO: Lowell R. Gates, Esquire
RE: Dorothy S. Braught Estate
Legal advertisements must be received by Friday Noon. All legal advertising
must be paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on following dates:
December 28, 2012, January 4, and January 11, 2013
Advertising Cost
Proof of Publication
Second Proof Request
Payment received
Total Amount Due
$ 75.00
$ 0.00
$ 0.00
$ 75.00
-------------
$ 0.00
Becky H. Morgenthal, Executive Director
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16, 1929), P. L.1784
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
ss.
Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and
State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law
Journal, a legal periodical published in the Borough of Cazlisle in the County and State aforesaid,
was established January 2, 1952, and designated by the local courts as the official legal
periodical for the publication of all legal notices, and has, since January 2, 1952, been regulazly
issued weekly in the said County, and that the printed notice or publication attached hereto is
exactly the same as was printed in the regulaz editions and issues of the said Cumberland Law
Joumal on the following dates,
December 28.2012 and January 4, and January 11, 2013
Affiant further deposes that he is authorized to verify this statement by the Cumberland
Law Journal, a legal periodical of general circulation, and that he is not interested in the subject
matter of the aforesaid notice or advertisement, and that all allegations in the foregoing
statements as to time, place and character of publication aze true.
r~r
Szatr`ht, Dorothy 8., deed.
Late of the Borough of Carlisle.
Executrix: Annette M. Braught,
244 Red Haven Road, New Cum-
berland,PA 17070.
Attorneys: Lowell R. Gates, Es-
quire, Gates, Halbruner, Hatch &
Guise, P.C., 1013 Mumma Road,
Suite 100, Lemoyne, PA 17043.
Lisa arie Coyne, Edltor
SWORN TO AND SUBSCRIBED before me this
11 day of Januar~2013
,/~
`` Notary f'
NOTARIAL SEAL
9EBC(sAH A COLLINS
No;ary Public
GARUSLE BOROUGH, CUMS[RLAN~COUNTY
My Commission Expires Apr 2f3, 2014
UPDEGRAFF & RUHL
CERTIFIED PUBLIC ACCOUNTANTS
4330 CARLISLE PIKE
CAMP HILL, PA 1701 1
(717) 763-8038
EiN: 25-1869799
Ms. Dorothy S. Braught (Confidential)
c/o Ms. Annette M. Braught
244 Red Haven Road
New Cumberland, PA 17070
STATEMENT AS OF FEBRUARY 20, 2013
For the year ending December 31, 2012:
Preparation of Federal Income Tax Return
INVOICE: 4486
Total Amount Due
$125.00
P~}~~ ~./i51-3
CK ~ 3030
p.~'`rJ BY'
7{+~.c..
PLEASE RETURN THE COPY OF THIS INVOICE WITH YOUR PAYMENT.
_s. '
A. M.'9RAUGMT
' PH 717242x2952`
' 244 ~ED,jiA,VfsN ROAD
NEW.CUFII~RLANO, FA 97070 .-.
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~:23i38224i~: 2i8ii45g68~~' 3030
PA REV-1500
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES
and LIENS
Pennsylvania
DEPARTMENT OF PUBLIC WELFARE
December 28, 2012
GATES HALBRUNER HATCH & GUISE P C
LOWELL R GATES ESQUIRE
1013 MUMMA RD STE 100
LEMOYNE PA 17043
Re: Dorothy Braught
CIS #: 391108196
SSN: ###-##-5171
Date of Death: 11/10/2012
Dear Attorney Gates:
Please be advised that the Department of Public Welfare maintains a claim in the
amount of 348.019.42 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 322.345.26, 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 325.674.16, 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,
~~ ~~~
Desiree D. Havasi
Claims Investigation Agent
717-772-6961
717-772-6553 FAX
Enclosure
Bureau of Program Integrity I Dlvlsion of ThUtl Party Liability I Recovery Sectlon
PO Box R466 I Harrisburg, PennsyNanla 17105-8486
COMMONWEALTH OF PENNSYLVANIA
BUREAU OF PROGRAM INTEGRITY
DIVISION OF THIRD PARTY LIABILITY
ftE00VERV SECTION
PO BOX 8486
HARRISBURG, PA 17IDSdg86
December 24, 2012
STATEMENT OF CLAIM SUMMARY
NAME Estate of BRAUGHT, DOROTHY
ID 391 108 196
MEDICAL CLASS 3 CLASS 5.1 TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 22,315.50 25,636.46 47,951.96
DRUG 29.76 37.70 67.46
REIMBURSEMENT TO DPW 22,345.26 25,674.16 48,019.42
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN - 23-6003113
_ Pane 1 of 6
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
December 24, 2012
STATEMENT OF CLAIM
NAME BRAUGHT, DOROTHY
ID 391 108 196
FOREST PARK HEALTH CENTER
700 WALNUT BOTTOM RD
CARLISLE PA 17013
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
10/01/11 - 10131/11 05/21112 55121374100670001 55121374100670001 6,537.28 3,751.96
DIAGNOSIS 1 : 95901 HEAD INJURY, UNSPECIFIED
DIAGNOSIS 2 : 0
PROC CODE : 000000
11/01/11 - 11/30/11 05/21/12 55121374100680001 55121374100680001 6,326.40 3,545.39
DIAGNOSIS 1 : 95901 HEAD INJURY, UNSPECIFIED
DIAGNOSIS 2 : 0
PROC CODE : 000000
12/01/11 - 12/31/11 05/21H2 55121374100690001 55121374100690001 6,537.28 3,751,95
DIAGNOSIS 1 : 95901 HEAD INJURY, UNSPECIFIED
DIAGNOSIS 2 : 0
PROC CODE : 000000
01/01/12 - 01/31/12 06/18/12 55121644162290001 55121644182290001 fi,537.28 3,770.10
DIAGNOSIS 1 : 95901 HEAD INJURY, UNSPECIFIED
DIAGNOSIS 2: 0
PROC CODE : 000000
02/01/12 - 02!29/12 06/18/12 55121644182340001 55121644182340001 6,115.52 3,351,68
DIAGNOSIS 1 : 95901 HEAD INJURY, UNSPECIFIED
DIAGNOSIS 2 : 78723 DYSPHAGIA PHARYNGEAL PHASE
PROC CODE : 000000
03/01/12 - 03/31/12 06/18/12 55121644183210001 55121644183210001
DIAGNOSIS 1 : 95901 HEAD INJURY, UNSPECIFIED
DIAGNOSIS 2 : 78723 DYSPHAGIA PHARYNGEAL PHASE
PROC CODE : 000000
04/01/12 - 04130/12 10/29/12 69122794022910001 69122794022910001
DIAGNOSIS 1 : 95901 HEAD INJURY, UNSPECIFIED
DIAGNOSIS 2 : 78723 DYSPHAGIA PHARYNGEAL PHASE
PROC CODE : 000000
05101!12 - 0 5/31/12 06!25/12 20121534301220001 20121534301220001
DIAGNOSIS 1 '. 95901 HEAD INJURY, UNSPECIFIED
DIAGNOSIS 2 : 78723 DYSPHAGIA PHARYNGEAL PHASE
PROC CODE : 000000
_. Pane 7 of F _
6,537.28
6,290.70
6,500.39
3,770.10
3,695.29
3,784.98
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
December 24, 2012
STATEMENT OF CLAIM
NAME BRAUGHT, DOROTHY
ID 391 108 196
FOREST PARK HEALTH CENTER
700 WALNUT BOTTOM RD
CARLISLE PA 17013
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
06/01/12 - 06/30/12 07/30/12 20121854027550001 20121854027550001 6,290.70 3,575.29
DIAGNOSIS i : 95901 HEAD INJURY, UNSPECIFIED
DIAGNOSIS 2 : 78723 DYSPHAGIA PHARYNGEAL PHASE
PROC CODE : 000000
07/01/12 - 07/31/12 OS/27H2 20122144304450001 20122144304450001 6,500.39 3,809.98
DIAGNOSIS 1 : 95901 HEAD INJURY, UNSPECIFIED
DIAGNOSIS 2 : 78723 DYSPHAGIA PHARYNGEAL PHASE
PROC CODE : 000000
08/01/12 - 08/31/12 09/24/12 20122474167680001 20122474167880001 6,500.39 3,784.98
DIAGNOSIS 1 : 95901 HEAD INJURY, UNSPECIFIED
DIAGNOSIS 2' 78723 DYSPHAGIA PHARYNGEAL PHASE
PROC CODE : 000000
09/01/12 - 09/30/12 10/29/12 20122764039940001 20122764039940001 6,290.70 3,575.29
DIAGNOSIS 1 : 95901 HEAD INJURY, UNSPECIFIED
DIAGNOSIS 2 : 76723 DYSPHAGIA PHARYNGEAL PHASE
PROC CODE : 000000
10/01/12 - 10/31/12 11/26/12 20123064130140001 20123064130140001 6,500.39 3,784.98
DIAGNOSIS 1 : 95901 HEAD INJURY, UNSPECIFIED
DIAGNOSIS 2 : 78723 DYSPHAGIA PHARYNGEAL PHASE
PROC CODE : 000000
PROVIDER SUB TOTAL FOREST PARK HEALTH CENTER 83,464.70 47,951.96
03 101867397 0001
Paoe 3 of 6
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
December 24, 2012
STATEMENT OF CLAIM
NAME BRAUGHT, DOROTHY
ID 391 108 796
GUARDIAN LONG TERM CARE PHARMACY
123 BRUBAKER RD
BROCKWAY PA 15824
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
10/11/11 - 10/11/11 04/16/12 25120605315850001 25120805315850001 7.20 4.90
DIAGNOSIS 1 : 0
NDC CODE : 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS
11/05/11 - 11105/11 04/16/12 25120805317500001 25120805317500001 7.20 q.90
DIAGNOSIS 1 : 0
NDC CODE : 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS
11!15/11 - 11H5/11 04/16/12 25120805318210001 25120805318210001 7.20 .90
DIAGNOSIS 1 : 0
NDC CODE : 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS
12/12/11 - 12/12/11 04/16/12 25120805319000001 25120805319000001 7.20 4.90
DIAGNOSIS i : 0
NDC CODE : 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS
01/12112 - 01/72/12 04/16/12 25120805319390001 25120605319390001 7.20 4.90
DIAGNOSIS I : 0
NDC CODE : 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS
02/13/12 - 02/13112 04/16/12 25120805319960001 25120805319960001 7.73 5.30
DIAGNOSIS 1 : 0
NDC CODE : 63323004401 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS
03/09/12 - 03/09/12 04/16/12 25120805492290001 25120805492290001 7.73 5.30
DIAGNOSIS 1 : 0
NDC CODE : 63323004401 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS
03/12112 - 03N 2/12 04/16/12 25120805493180001 25120805493180001 7.73 1.30
DIAGNOSiS 1 : 0
NDC CODE : 63323004401 CYANOCOBALAMIN 1,000 MCGIML - WATER SOLUBLE VITAMINS
Panes 4 of fi
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
December 24, 2012
STATEMENT OF CLAIM
NAME BRAUGHT, DOROTHY
ID 391 108 196
IUARDIAN LONG TERM CARE PHARMACY
23 BRUBAKER RD
BROCKWAY PA 15824
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
O4/12N2 - 04/12/12 OSI07/12 25121035429820001 25121035429820001 7.73 5.30
DIAGNOSIS 1 : 0
NDC CODE : 63323004401 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS
05/74/12 - 05/14/12 O6/11N2 25121355353400001 25121355353400001
DIAGNOSIS 1 : 0
NDC CODE : 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS
08/13/12 - 06/13/12 07/23/12 25121775515880001 25121775515880001
DIAGNOSIS 1 : 0
NDC CODE : 63323004401 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS
07172/12 - 07!12112 08/06/12 25121945686660001 25121945686660001
DIAGNOSiS 1 : 0
NDC CODE : 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS
08!07/12 - 08/07/12 09/03/12 25122205630820001 25122205630820001
DIAGNOSIS 1 : 0
NDC CODE : 51991060401 VIT D2 1.25 MG (50,000 UNIT) - FAT SOLUBLE VITAMINS
08/14/12 - 08114/12 09/10/12 25122275240730001 25122275240730001
DIAGNOSIS 1 : 0
NDC CODE : 63323004401 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS
09/13/12 - 09/13/12 10/08/12 25122575252760001 25122575252760001
DIAGNOSIS 1 : 0
NDC CODE : 63323004401 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS
09/20/12 - 09/20/12 10/15/12 25122645393160001 25122645393160001
DIAGNOSIS 1 . 0
NDC CODE 51991060401 VIT 021.25 MG (50,000 UNIT) - FAT SOLUBLE VITAMINS
- Pane S of F _
7.20 4.90
6.16 3.62
7.20 2.90
13.89 3.74
8.16 3.62
8.16 3.62
13.89 3.74
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
December 24, 2012
STATEMENT OF CLAIM
NAME BRAUGHT, DOROTHY
ID 391 108 196
GUARDIAN LONG TERM CARE PHARMACY
123 BRUBAKER RD
IROCKWAY PA 15824
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
10113112 - 10H 3/12 11/12112 25122875286860001 25122675286860001 6.16 3.62
DIAGNOSIS 1 : 0
NDC CODE : 63323004401 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS
PROVIDER SUB TOTAL GUARDIAN LONG TERM CARE PHARMACY INC 141.74 67.46
24 102290870 0001
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DO NOT SEND PAYMENTS TO THIS ADDRESS
Dept. 19687
P O Box 1259
Oaknuu~~asaBB.uu, P a''Aa''fnNf~~uuuu''1I194~~~~5ad„q„q'ary6aa~a~BII IBnB~I~1a' N
~1~ ,1111 ~Irll X~nl ~~nnl ~P~ ~I
For biifing questions call: (717)932-5955
or: (877)932-5955
Fax: (717)932-4856
Office Hours: 8:00 AM - 4:30 PM
To pay your bill online and register for eStatements,
please visit us at: www.gita.com
Illllrllrrllrl~~~lll~ll"II'~Irrr1"IIII'I'li'~~I~'~~I.Ilirlrll~l teeTat
,,..,.,, DOROTHY S BRAUGHT
244 RED HAVEN RD
NEW CUMBERLAND PA 17070-3173
[] Please check box iF above address is Incorrect or insurance
information has changed, antl indicate change(s) on reverse sitle.
Patient: DOROTHY 3 BRAUGHT
Account: 10887
K P~YINa YY M611. AN47FaQAnG OR OYCOVFII. RLL Our BFLOw
SBA ® ^MAereRrwo ® ^olsowen
m.wre xr um
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SECUPnYCWEFgpA
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sraTeMel+r ogre IPgv nna Aslouert aeeouHr ro.
1/14/2013 Continued 10887
CHARGES AND CREDITS MACE AFTER STATEMENT SHOWI AMOUNT
GATE WILL APPEAR ON KENT STATEMENT. PAID HERE
~~ MAKE CHECKS PAYABLE ~ REMIT TO: ~~
Quantum Imaging and Therapeutic Associates
P O Box 62165
Baltimore, MD 21264-2165
I.rlrlrrrflrrlilrllrrrlrrlrrlrlrrrlirflrrrlLl,rllrrrfrlrllrrrl
PLEASE DETACH AND RETURN TOP PORTION WITH
_ _ YOUR PAYMENT IN ENCLOSED ENVELOPE
Services Rendered At: HOLY SPIRIT IMAGING OUTPATIENT CEN
pate Cie Description Cha a Payments
-9 Ad ustmeMs Balance
1/25/Y011 73030 SHOULDER MIN 2 VWS 38.00 2.03
2/182011 PMT CAPITAL BLUECROSS 10.17
2/182011 CR Adjustment CAPITAL BLUECROSS 25.83
6!22!2011 PMT CAPITAL BLUECROSS -10.17
6/22/2011 CR Adjustment CAPITAL BLUECROSS -25.83
8/12!2011 PMT MEDICARE-NOVITAS SOLUTIONS 8.14
8/12/2011 CR Adjustment MEDICARE-NOVITAS SOLUTIONS 25.83
3/20/2011 71010 CHEST SINGLE VIEW FRONTAL 36.00 1.75
5/2/2011 PMT KHP SENIOR BLUE 8.77
5/2/2011 CR Adjustment KHP SENIOR BLUE 27.23
9/20/2011 PMT MEDICARE-NOVITAS SOLUTIONS 7.02
920/2011 CR Adjustment MEDICARE-NOVITAS SOLUTIONS 27.23
1/42012 PMT CAPITAL BLUECROSS -8.77
1/42012 CR Adjustment CAPITAL BLUECROSS -27.23
3/18/2011 78588 PULMONARY PERF IMGPART W VENTILATIO 193.00 10.65
522011 PMT KHP SENIOR BLUE 5323
522011 CR Adjustment KHP SENIOR BLUE 139.77
7/13/2011 PMT MEDICARE-NOVITAS SOLUTIONS 42.58
7/132011 CR Adjustment MEDICARE-NOVITAS SOLUTIONS 139.77
1142012 PMT CAPITAL BLUECROSS -53.23
1142012 CR Adjustment CAPITAL BLUECROSS -139.77
3/182011 74020 ABDOMEN LATERAL DECUBITUS 57.00 2.63
522011 PMT KHP SENIOR BLUE 13.13
522011 CR Adjustment KHP SENIOR BLUE 43.87
7/132011 PMT MEDICARE-NOVITAS SOLUTIONS 10.50
7/132011 CR Adjustment MEDICARE-NOVITAS SOLUTIONS 43.87
1/4/2012 PMT CAPITAL BLUECROSS -13.13
1/42012 CR Adjustment CAPITAL BLUECROSS -43.87
3/1812011 72170 PELVIS AP 34.00 1.90
522011 PMT KHP SENIOR BLUE 9.50
522011 CR Adjustment KHP SENIOR BLUE 24.50
BALANCE DUE Continued
PAY BY
THIS ACCOUNT BALANCE IS YOUR RESPONSIBILITY. FOr billing quesllDnS Cell: (717)932-5955
PLEASE REMIT PAYMENT IN FULL OR CALL OUR or: (877)932-5955
OFFICE IF PAYMENT ARRANGEMENTS AND/OR Fax: (717)932-4856
INSURANCE INFORMATION IS NECESSARY. Office Hours: 8:00 AM - 4:30 PM
To pay your bill online and register for eStatement
STATEMENT please visit us at: www.gita.com
IVIIINVIINtl1111111~~~11191~I~~IW~~~~~ SEE REVERSE SIDE FOR_IMPORTANT BILLING INFORMATION_ ----
DO NOT SEND PAYMENTS TO THIS ADDRESS
Dept. 19687
P 0 BOx 1259
Oaks, PA 19456
IIIII ~~ VIII IIN IINI ICI ~I III IV ~I III
For billing questions call: (717)932-5955
or: (877)932-5955
Fax: (717)932-4856
Office Hours: 8:00 AM - 4:30 PM
To pay your bill online and register for eStatements,
please visit us at: www.gita.com
.~ DOROTHY S BRAUGHT
244 RED HAVEN RD
NEW CUMBERLAND PA
6 PAYING ~'/ NEA YAMiRC11RD ON DMDDVER, RLL OUTlEIDW
ors, ® ^NAaD:RCNIC ~ ^DlscaaN
cuo m.na
PMITCMGMttOEPMMIC MAST iNLWpEa pelT
SELUflRY CCQE FflPM
a,~~~~
STATEMENT-0ATE PAY THIS AMOUNT ACCOUNT NO.
1/14/2013 Continued 10887
CHARGES AND CPEDITS MADE AFTEfl STATER9ENT
DATE WILL APPEAfl ON NExT STATEft9ENT. SHOW AMOUNT
PAID HERE
~ MAKE CHECKS PAYABLE / REMR TO: s_
Quantum Imaging and Therapeutic Associates
P O Box 62165
Baltimore, MD 21264-2165
],7070-3173 Irrlrlrrrlirrl~lrllrrrlrrlrrlrlrrrllrllrrll,lrrllrrrirlrilrrrl
I.,rIllrrrlllrrrlrrrlllrlrrrlllr,rlllr,rlrrlllrlrrl,Irrlrrllrl
] Please check box if above address is incorrect or insurance , PLEASE DELACH ANO RETURN 70P PORTION WITH
mtormation has change4 and intlirate change(s) on reverse sitle. YOUR PAYMENT IN ENCLOSED ENVELOPE
_ _ _ . _
Patient: DOROTHY S BRAUGHT
Account: 10887 Services Renderod At: HOLY SPIRIT IMAGING OUTPATIENT CEN
Date Code Description Charge ~ u~ments Balance
7/13/2011 PMT MEDICARE-NOVITAS SOLUTIONS 7.60
7!13/2011 CR Adjustment MEDICARE-NOVITAS SOLUTIONS 24.50
1/4/2012 PMT CAPITAL BLUECROSS -9.50
1/4/2012 CR Adjustment CAPITAL BLUECROSS -24.50
3/18/2011 71010 CHEST SINGLE VIEW FRONTAL 38.00 1.75
5/2/2011 PMT KHP SENIOR BLUE 8.77
52/2011 CR Adjustment KHP SENIOR BLUE 27.23
7/132011 PMT MEDICARE-NOVITAS SOLUTIONS 7.02
7/132011 CR Adjustment MEDICARE-NOVITAS SOLUTIONS 27.23
1/42012 PMT CAPITAL BLUECROSS -8.77
1/42012 CR Adjustment CAPITAL BLUECROSS -27.23
3/18/2011 72125 CT CERV SPINE WO CONTRAST 238.00 10.10
522011 PMT KHP SENIOR BLUE 50.49
5/2/2011 CR AdjustmeM KHP SENIOR BLUE 187.51
7!132011 PMT MEDICARE-NOVITAS SOLUTIONS 40.39
7/132011 CR Adjustment MEDICARE-NOVITAS SOLUTIONS 187.51
1/42012 PMT CAPITAL BLUECROSS -50.49
1/42012 CR Adjustment CAPITAL BLUECROSS -187.51
3/18/2011 73564 KNEE COMPLETE 4 OR MORE VIEWS 48.00 2.37
522011 PMT KHP SENIOR BLUE 11.85
522011 CR Adjustment KHP SENIOR BLUE 34.15
7/132011 PMT MEDICARE-NOVITAS SOLUTIONS 9.48
7/132011 CR Adjustment MEDICARE-NOVITAS SOLUTIONS 34.15
1/42012 PMT CAPITAL BLUECROSS -11.85
1/42012 CR Adjustment CAPITAL BLUECROSS -34.15
3/18/2011 70450 CT SCAN BRAIN W/O CONTRAST 198.00 8.35
522011 PMT KHP SENIOR BLUE 41.77
522011 CR Adjustment KHP SENIOR BLUE 156.23
7/13/2011 PMT MEDICARE-NOVITAS SOLUTIONS 33.42
7/132011 CR Adjustment MEDICARE-NOVITAS SOLUTIONS 156.23
1/42012 PMT CAPITAL BLUECROSS -41.77
1/42012 CR Adjustment CAPITAL BLUECROSS -156.23
BALANCE DUE Continued
PAY BY
THIS ACCOUNT BALANCE IS YOUR RESPONSIBILITY. For billing questions call: (717)932-5955
PLEASE REMIT PAYMENT IN FULL OR CALL OUR or: (877)932-5955
OFFICE IF PAYMENT ARRANGEMENTS AND/OR Fax: (717)932-4856
INSURANCE INFORMATION IS NECESSARY. Office Hours: 8:00 AM - 4:30 PM
To pay your bill online and register for eStatement
STATEMENT please visit us at: www.gita.com
WYnYtVIIIVWVIII~I~IIVWIIWllNVIIIII SFF pFVFGRE SIQF Fr]R IMRAFFTANT RII 1 ING INEORMGTI[]N _ __
DO NOT SEND PAYMENTS TO THIS ADDRESS
Dept. 19687
P O Box 1259
Oaks, PA 19456
InI~II~~N1~f~l~l~1N~l~l~lll~l~ll
For bllling questions call: (717)932-5955
or: (877)932-5955
Fax: (717)932-4856
Office Hours: 8:00 AM - 4:30 PM
To pay your bill online and register for eStatements,
please visit us at: www.gita.com
IF PAYING BY VILA Y114T91CARD GR GROGVER, FlL~ OU{9{LOYf~D
OaeA ~ ^su9TeRC,wG ® ^DlaeovFn Imo' Ib'
tlMMI~lNI PO, qIE 1 OUM
IIIWTCMp10lA P MUST INGLpE301GIT
SECUflT'CODE FPOM
a~~x~~~
STATEMENT DATE PAY T}11S AMOUNT ACCOUNT NO.
1/14/2013 $50.18 10887
OHApGES AND CREDITS MADE AFTEp STATEMENT SHOtN~ AMOUNT
DATE WILL APPEAp ON NEXT STATEMENT, PAID MERE ~P
~ MAKE CHECKS PAYABLE ! REMIT TO: ~~
Quantum Imaging and Therapeutic Associates
,,,,fix DOROTHY S BRAUGHT POBox62165
244 RED HAVEN RD Baltimore, MD 21264-2165
NEW CUMBERLAND PA 17070-3173 I„I,Inrllnl,I,Ilurlr,Iulrlurllrlln,ITlullurlrl,llml
I.„Ilt,,,lllr„I.„111,,,,,Ilr,r,111rI,l,rll„Ir,l~l„I,~II,I
(] Please check hox It above address is Incorrect ar insurance
information has changed, and intlicate change(s) on reverse side.
_.
Patient: DOROTHY S BRAUGHT
Account: 10887
Services Rendered At: HOLY SPIRIT IMAGING OUTPATIENT CEN
d
~
Date Code Description Charge p
us
lments Balance
3/18/2011 73080 HUMERUS 35.00 1.75
5/12011 PMT KHP SENIOR BLUE 8.75
522011 CR Adjustmert KHP SENIOR BLUE 26.25
7/132011 PMT MEDICARE-NOVITAS SOLUTIONS 7.00
7/132011 CR Adjustment MEDICARE-NOVITAS SOLUTIONS 26.25
1/42012 PMT CAPITAL BLUECROSS -8.75
1/42012 CR Adjustment CAPITAL BLUECROSS -26.25
3/18/2011 93970 US DUPLFJC EXTREM. VEINS BILAT 275.00 8.90
522011 PMT KHP SENIOR BLUE 34.51
522011 CR Adjustment KHP SENIOR BLUE 240.49
7/132011 PMT MEDICARE-NOVITAS SOLUTIONS 27.61
7/132011 CR Adjustment MEDICARE-NOVITAS SOLUTIONS 240.49
1/42012 PMT CAPITAL BLUECROSS -34.51
1/42012 CR Adjustment CAPITAL BLUECROSS -240.49
Current 31 - 60 61 - 90 91 -120 Over 120 BALANCE DUE E50.18
50.18 0.00 0.00 0.00 0.00 PAY BY Due Upon Receipt
THIS ACCOUNT BALANCE IS YOUR RESPONSIBILITY. For billing questions call: (717)932-5955
PLEASE REMIT PAYMENT IN FULL OR CALL OUR or: (877)932-5955
OFFICE IF PAYMENT ARRANGEMENTS AND/OR Fax: (717)932-4856
INSURANCE INFORMATION IS NECESSARY. Office Hours: 8:00 AM - 4:30 PM
To pay your bill online and register for eStatement
ST/~TEMEIJT please visit us at: www.gita.com
N~III~IIIBIII~IIHIII~~~u11011~111111W1111 SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION_
®~ 5~ PLEASE DETACH AND RETURN TOP PORTION WITH
YOUR PAYMENT IN ENCLOSED ENVELOPE