HomeMy WebLinkAbout05-14-13 (2) 1505610105
REV-1500 EX(02-11)(FI)
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania
DEPARTMENT OF REVENUE County Code Year File Number
Bureau 02806 Individual Taxes INHERITANCE TAX RETURN �1 '
Ha BOX 280601 G/d
Harrisburg PA 17128-0601 RESIDENT DECEDENT «77"""
ENTER DECEDENT INFORMATION BELOW
Social
06262007 09231946
Decedent's Last Name Suffix Decedent's First Name MI
SEMUTA SUSAN L
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE BOXES BELOW
Q 1.Original Return Q 2.Supplemental Return Q 3.Remainder Return(Date of Death
Prior to 12-13-82)
Q 4.Limited Estate Q 4a.Future Interest Compromise(date of Q 5.Federal Estate Tax Return Required
death after 12-12-82)
Q 6.Decedent Died Testate Q 7,Decedent Maintained a Living Trust 0 8.Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
Q 9.Litigation Proceeds Received Q 10.Spousal Poverty Credit(Date of Death Q 11.Election to Tax Under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule 0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number .
MEGAN WRIGHT 717-443-3044
4tFGISTER OF WIL)_S USE ONbY
w x ryt
M$ �
Oct
25
_D J
First Line of Address Prt = n
--i
116 GREEN LANE DRIVE n ]
Second Line of Address
n � 7
C_ DATE FILED
City or Post Office State ZIP Code
CAMP HILL PA 17011
Correspondent's e-mail address:
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief
it is true correct and complete Declaration of p eparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNAft1 0 I�ERSO�I-RESPONSIBLE FOR FILING RETURN �1
ADDRESS
'`�
116 GREEN LANE DR CAMP HILL, PA 17011
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 1505610105 J
r
�a11
J 1505610205
REV-1500 EX(FI)
RECAPITULATION
1. Real Estate(Schedule A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. NONE
2. Stocks and Bonds(Schedule B). . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . 2. NONE
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C). . . 3. NONE
4. Mortgages and Notes Receivable(Schedule D). . . . . . . . . . . .. . . . . . . . . . . . 4. NONE
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).. . . 5. 190000 . 00
6. Jointly Owned Property(Schedule F) =Separate Billing Requested . . . . . . . 6. NONE
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) =Separate Billing Requested. .. . .. . 7. NONE
8 Total Gross Assets(total Lines 1 through 7) B 190000 . 00
9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . .. . . . . . . 9. 86963 . 00
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1). . . . . . . . . . . . 10. 20345 . 00
11. Total Deductions(total Lines 9 and 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 107308 . 00
12. Net Value of Estate(Line 8 minus Line 11). . . . . . . . . . . . . . . . . . . . . . . . . . . 12. 82692 .00
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 82692 . 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)(11.2)X.0 0 15. 0 . 00
16.Amount of Line 14 taxable
at lineal rate X.o 45 82692 . 00 16. 3721 . 14
17.Amount of Line 14
taxable at sibling rate X . 12 17. 0 . 00
18.Amount of Line 14 taxable
at collateral rate X . 15 18. 0 . 00
19.TAX DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 3721. 14
20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT =
Side 2
L 1505610205 1505610205 J
' REV-1500 EX(F) Page 3 File Number 202-36-5849
Decedent's Complete Address:
DECEDENT'S NAME
SUSAN L SEMUTA
STREET ADDRESS
208 SENATE AVE APT 1015
CITY STATE ZIP
CAMP HILL PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 3721.14
2. Credits/Payments
A.Prior Payments 0.00
B.Discount 0.00
Total Credits(A+B) (2) 0.00
3. Interest
(3) See statement attached
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. (4) 0.00
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 3721.14
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred ....................................................................................... El 0
b. retain the right to designate who shall use the property transferred or its income......................................... ❑ 7X
c. retain a reversionary interest.......................................................................................................................... ❑
d. receive the promise for life of either payments,benefits or care?................................................-................
, 0
2, if death occurred after Dec. 12, 1982,did decedent transfer property within one year of death
without receiving adequate consideration?................_........_...._...._....._._....._........_................_.............._..... ❑
3. Did decedent own an"in trust for"or payable-uponAeath bank account or security at his or her death?_.......... ❑ 0
4. Did decedent own an individual'retirement account,annuity or other non-probate property,which
contains a beneficiary designation?_...................._........_........................._..._._..._............_............................ 0 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving
spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of
assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 PS.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is
defined,under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-1737-4 EX+(6-08)
Pennsylvania SCHEDULE E, PART 1
DEPARTMENT OF REVENUE MISCELLANEOUS
INHERITANCE TAX RETURN PERSONAL PROPERTY
NONRESIDENT DECEDENT
ESTATE OF FILE NUMBER
SUSAN L SEMUTA 2007-00756 (PA#21-07-0756)
Part 1 must include all tangible personal property having its situs in Pennsylvania. Examples of tangible personal property are
jewelry,furniture, paintings, etc.All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
Complete Part 2 on reverse side ONLY when the proportionate method of tax computation is elected.
ITEM
NUMBER DESCRIPTION VALUE AT DATE OF DEATH
1. CASH AT DATE OF DEATH 0
2 CASH PROCEEDS FROM LITIGATION SETTLEMENT-FUNDS NOT RECEIVED UNTIL MARCH 190,000
OF 2013 AND DEPOSITED IN INTEGRITY BANK
PART 1 TOTAL
$ 190,000
PART 2 TOTAL
From reverse side. $ 0
TOTAL Also enter on Line 5 Recapitulation) $ 190,000
(If more space is needed, use additional sheets of paper of the same size)
REV-1737-7EX+(6-08) SCHEDULE [
pennsylvania DEBTS OF DECEDENT Use Schedule 1, Part 2,ONLY for
DEPARTMENT OF REVENUE r proportionate method of tax computation.
INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS
NONRESIDENT DECEDENT
ESTATE OF FILE NUMBER
SUSAN L SEMUTA 2007-00756 (PA#21-07-0756)
Part 1 must include mortgage liabilities, liens and taxes against the Pennsylvania realty that were due and
owed as of the date of decedent's death.
Complete Part 2 ONLY when the proportionate method of tax computation is elected.
OBLIGATIONS
ITEM
NUMBER DESCRIPTION AMOUNT
1.
TOTAL PART 1 $ 0
PART 2—ALL OTHER DEBTS OF
ITEM
NUMBER DESCRIPTION AMOUNT
1. MEDICAL EXPENSES 20,345
TOTAL PART 21 $ 20,345
TOTAL Also enter on Line 10 Recapitulation). 20,345
(If more space is needed, use additional sheets of paper of the same size)
REV-1511 EX«(10-08)
Pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX
RESIDENT DECEDENT RETURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
SUSAN L SEMUTA 2007-00756 (PA#21-07-0756)
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERALEXPENSES:
1. FUNERAL EXPENSES 3,978
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions: 2,500
Name(s)of Personal Representative(s) MEGAN WRIGHT(FORMERLY MEGAN MARTIN)
Street Address 116 GREEN LANE DR
city CAMP HILL State PA zip 17011
Year(s)Commission Paid: 2013
2. Attorney Fees: 79,000
3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 105
5. Accountant Fees: 1,050
6. Tax Return Preparer Fees:
7. MISCELLANEOUS LEGAL&PUBLICATION FEES 330
TOTAL(Also enter on Line 9, Recapitulation) $ 86,963
If more space is needed, use additional sheets of paper of the same size.
ESTATE OF SUSAN L. SEMUTA
SUMMARY OF LITIGATION PROCEEDS AND DISBURSEMENTS OF ESTATE
SSN: 202-36-5849
File No. 2007-00756, PA File No. 21-07-0756
Grand Summary
Settlement Proceeds 190,000.00
Lawyer Fees (79,000.00)
Funeral (3,978.00)
Medical (20,344.51)
Legalfees (435.33)
Accountant's fee (1,050.00)
Administrator's fee (2,500.00)
Net Proceeds per client 82,692.16
ESTATE OF SUSAN L. SEMUTA
SSN: 202-36-5849
REGISTER OF WILLS ESTATE NO. 2007-00756
PA FILE NO. 21-07-0756
FORM REV-1500, PAGE 3
STATEMENT REGARDING INTEREST COMPUTATION
The estate had no assets until litigation proceeds were received on March 21, 2013.The litigation
proceeds were placed in a non-interest bearing bank account. Since the estate produced no income, let
alone income equal to the rate of interest provided by law, the estate computed its interest assessment
at the rate of net income produced by the property,a zero rate of return.
STATE OF PENNSYLVANIA SHORT CERTIFICATE
COUNTY OF CUMBERLAND
I, GLENDA FARNER STRASBAUGH
Register for the Probate of Wills and Granting
Letters of Administration in and for
CUMBERLAND County, do hereby certify that on
the 10th day of August, Two Thousand and Seven,
Letters of ADMINISTRATION
in common form were granted by the Register of
said County, on the
estate of SUSANL SEMUTA late of EASTPENNSBORO TOWNSHIP
(First,Middle,Last)
in said county, deceased, to MEGAN MARTIN
(first,Middle,Last)
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 10th day of August
Two Thousand and Seven____
File No. 2007- 00756
PA File No. 21- 07- 0756
Date of Death 612612007
S. S. # 202-36-5849
Register Of Wills I
JJJ
Deputy
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
r
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,PENNSYLVANIA
IN RE: ORPHANS' COURT DIVISION
MEGAN MARTIN (Now MEGAN WRIGHT) REGISTER OF WILLS
Administratrix of the Estate of
SUSAN L. SEMUTA ESTATE NO. 2007-00756
Petitioner
ORDER AUTHORIZING SETTLEMENT OF
UNDERINSURED MOTORIST CLAIM
AND NOW this / .r - day of � Z'ZC4,, 2013, Petitioner is hereby
—authorized-io-settle-the Underinsured-Motorist-Claim-for-SUSAN-.-SEMUTA—against-all---
parties and sign Releases for any claims against GEICO INSURANCE COMPANY for the sum
of Qne Hunched Five 'thousand ($105,000) Dollars.
,s --I xc j
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Judge
Distribution List:
Bratic & Portko LLC, 101 South US Route 15, Dillsburg, PA 17019
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SUSAN SEMUTA,
Plaintiff
V. UNDERINSURED MOTORIST CLAIM
GEICO INSURANCE
Defendants
SETTLEMENT STATEMENT
TOTAL RECOVERED: $ 105, 000.00
PLUS MEDICAL BILL RESERVE FROM THIRD PARTY
SETTLEMENT CREDITED TO THIS ACCOUNT: $ 45, 192 .95
LESS : Attorney' s Fees $ 42 , 000 . 00
(Per contingent fee agreement)
LESS : Costs Incurred $ 264 . 58
(Itemized Below)
LESS : Dept of Welfare Lien $ 4 , 657 . 35
LESS: Medical Bills (see Attached List) $ 13 , 146 . 60
BALANCE TO ESTATE OF SUSAN SEMUTA $ 90, 124 .42
COST INCURRED:
DATE PAYEE/DESCRIPTION OF COSTS AMOUNT
10/5/07 Cumberland Legal Journal - advert Estate $ 75 . 00
10/5/07 The Sentinel - advertise Estate $ 174 . 58
3/6/13 Register of Wills - File Pet . to settle $ 15 . 00
TOTAL $ 264 .58
Acceptance and negotiation for payment of the check
made payable to the Estate of Susan Semuta in the net amount set
forth herein above, shall constitute satisfaction and acceptance
of such amount as the net recovery in this case .
Any outstanding medical charges which are not set forth
above as being protected by this office, or benefits which have
not been assigned directly to this law firm, are solely the
responsibility of the client .
This document also authorizes Dusan Bratic, for me and in my
name and stead to endorse the check and draft which may require my
endorsement arising from payment under the full and final release,
executed by me, and to remit the proceeds thereof, in accordance
with this distribution settlement sheet .
DATED this 70 day of L VV' 2013 .
nA I
Witness 14egan Wright Administratrix
Estate of Susan Semuta
SUSAN SEMUTA MEDICAL BILLS DUE
BILLS W/LETTERS OF PROTECTION
Dr. Avraam Karas - Surgery 2004 $ 8, 500 . 00 reduced to $5, 000 . 00
Mensana Clinic - Dr. Hendler $2 , 995 . 74
Dr. Michael Kaplan $ 150 . 86
Dr. Reginald Davis reduced to $5, 000 . 00
TOTAL MEDICAL BILLS $13 , 146 . 60
SUSAN SEMUTA, IN THE COMMON PLEAS COURT OF
Plaintiff DAUPHIN COUNTY,PENNSYLVANIA
V. CIVIL ACTION NO. 2005-CV-3817-CV
HEMA N. BHATT and
NAREN B. BHATT JURY TRIAL DEMANDED
Defendants
SETTLEMENT STATEMENT
TOTAL RECOVERED: $ 85, 000.00
LESS : Attorney' s Fees $ 34, 000 . 00
(Per contingent fee agreement)
LESS: Costs Incurred $ 2 , 807 . 05
(Itemized Below)
LESS : Loans to Client $ 3 , 000 . 00
(Itemized Below)
TOTAL TO CLIENT BEFORE
MEDICAL BILL REIMBUSEMENT: $ 45, 192.95
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
COST INCURRED:
DATE PAYEE/DESCRIPTION OF COSTS AMOUNT
01/7/04 Chart One - Medical Records $ 30 . 20
03/14/05 Penn Rehab Associates (Dr. Vialago) $ 300 . 00
Consultation - Records Review
05/20/05 Mensana Clinic - Medical Records $ 25 . 30
06/16/05 Penn Rehab Associates - Report $ 125 . 00
08/04/05 Richard B. Brown M.D. - Records $ 19 . 00
08/04/05 Chart One - Medical Records Dr. Ameigh $ 72 . 73
08/04/05 Chart One - Medical Records Hbg Hosp. $ 30 . 20
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DATE PAYEE/DESCRIPTION OF COSTS AMOUNT
08/04/05 Chart One - Medical Records Pinnacle $ 69 . 93
08/04/05 Avraam Karas, M.D. - Records $ 53 . 50
08/04/05 Pinnacle Health - Dr. Davis Records $ 72 . 25
08/04/05 Camp Hill Police = Accident Report $ 15 . 00
08/04/05 Penn Rehab Associates - Records $ 39 . 08
08/11/05 Sourcecorp - Records Hershey Med $ 26 . 45
08/15/05 Sourcecorp - Records Hershey Med Palmyra $ 33 . 75
08/23/05 Mensana Clinic - File Review & Report $ 350 . 00
08/31/05 Penn State Hershey Med. - Bill copies $ 15 . 00
09/07/05 Prothonotary - filing fee $ 105 . 00
09/07/05 Sheriff Dauphin Co. - Service fee $ 65 . 75
09/14/05 Family Med Center - Mtg w/Dr. Davis $ 200 . 00
05/23/06 Reginald Davis M.D. - Mtg $ 187 . 50
06/13/06 Richard B. Brown M.D. - Records $ 40 . 00
07/13/06 Rehab. Med. Team - Records $ 20 . 76
07/13/06 Sourcecorp - Records Hershey Med $ 50 . 01
07/28/06 UPS - Overnight mail to Dr. Hendler $ 17 . 17
08/03/06 UPS - Overnight mail to Atty Youman $ 23 . 32
11/21/06 Filius & McLucas - Depo of S Semuta $ 153 . 52
12/05/06 Lucinda Hoffman - Depo of Defendants $ 166 . 63
3/27/07 Avraam Karas M.D. - Report $ 500 . 00
TOTAL $ 2, 807. 05
Acceptance and negotiation for payment of the check
made payable to Susan Semuta in the net amount set forth herein
above, shall constitute satisfaction and acceptance of such amount
as the net recovery in this case.
Any outstanding medical charges which are not set forth
above as being protected by this office, or benefits which have
not been assigned directly to this law firm, are solely the
responsibility of the client .
This document also authorizes Dusan Bratic, for me and in my
name and stead to endorse the check and draft which may require my
endorsement arising from payment under the full and final release,
executed by me, and to remit the proceeds thereof, in accordance
with this distribution settlement sheet .
DATED this day of June, 2007 .
Witness Susan Semuta
BRATIC AND PORTKO LLC
Attomeys at Law
101 OFFICE CENTER, SUITE A
101 SOUTH U.S. ROUTE 15
DILLSBURG, PENNSYLVANIA 17019
DUSAN BRATIC, ESQ. (717)432-9706
STEPHEN K. PORTKO, ESQ. (7 17)432-2533
FAX (7 17)432-9220
March 21, 2013
Dr. Avraam Karas
5601 Loch Raven Blvd., #404
Baltimore, MD 21239
RE: Susan Semuta
Dear Dr. Karas:
Enclosed please find a check in the amount of$5,000 in full settlement for your services
to Susan Semuta.
Thank you for your consideration.
Ve truly yours,
z;
Dusan Bratic
DB/rsr
Enclosure
Dr.Avraam Karas
5601 Loch Raven Blvd.,#404
Baltimore, MD 21239 3+21/2013 ( - ,1
(410)323-4041 ! '1
SUSAN L.SEMUTA
646 SECOND STREET sEMS0000
HIGHSPRE, PA 17034
Date Document De ption Case Number Amours
Previous BaSanw: 0,00
Patient: SUSAN L. SEMUTA Chart* SEMSUOOO
Case Description: TOS L CS 2 Date of Lest Payment: 311512010 Amount: 0.DO
61812004 0406080000 CONSULTATION OV LEVEL 5 4420 350.00
71112004 040608MOO COMMERCIAL PAYMENT 4420 -350.00
5111/2005 05052 }0 MEDICAL COPY SERVICE 4420 53,E
814/2005 0506280000 AT1Y PAYMENT 4420 -53,50
3115/2010 1003150000 COMMERCIAL PAYMENT 4420 0,00
8125/2004 1309130000 NEUROLYSIS BRACHIAL PLExUS 4420 2,500.00
8/25/2004 1303130000 EXCISION 1ST&10R CERV RIB 4420 3,500.00
8/25/2004 1303130000 ARTERY&VEIN REVISION OR EXPLORATt 4420 1,500.00
8/25/2004 130313MW SCALiENECTOMY ANT, MID ABERRANT 4420 1,000.00
3/2012013 1303200000 COURTESY REDUCTION PER OR KARAS 4420 -3,500.00
The Estate of Susan L. Semuta 60-1878/313 1003
Megan C. Wright, Administratrim
116 Green Lane r.
Camp Hill, PA 17011
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BRATIC AND PORTKO LLC
Attorneys at law
101 OFFICE CENTER, SUITE A
101 SOUTH U.S. ROUTE 15
DILLSBURG, PENNSYLVANIA 17019
DUSAN BRATIC,ESQ. (717)432-9706
STEPHEN K. PORTKO, ESQ. (717)432-2538
FAX (717)432-9220
March 21, 2013
Dr. Nelson Hendler
2145 Easy Tahquitz Canyon Way, Suite 4
Palm Springs, CA 92262
RE: Susan Semuta
Dear Dr. Hendler.
Enclosed please find a check in the amount of$2,900 in full settlement for your services
to Susan Semuta.
Thank you for your consideration.
Ve t my yours,
C G�
Dusan Bratic
DB/rsr
Enclosure
Nelson Handler,MD,MS
2145 Easy Tahquitz Canyon Way,suite 4
Palm Springs,CA,922622
Dusan Bratic, Esq
101 South US Route 15,
Dillsburg, PA 17,019
RE: Susan Semuta
3/10/13
Dear Mr. Bratic:
In reviewing my records, 1 find that there are two outstanding bills pertaining to Susan Semuta.
Earlier, I send a bill for$900,which you already have, and payment is outstanding-
Below, please find another bill which is also outstanding:
Review extensive medical file, review literature&medical journal for current assessment re:ALS, prepare
extensive report-$2,000.
Total outstanding: $2,900.
Please remit payment to the address above.
Thank you for your consideration,
Sincerely,
�Nelson Hendler, MD
The Estate of Susan L. Semuta
Megan C. Wrigght, Administratrb 60-1975/313 1002
116 Green Lane Dr.
Camp Hill, PA 17011
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BRATIC AND PORTKO LLC
Attorneys at Law
101 OFF[CE CENTER,SUITE A
101 Souni U.S. ROUTE 15
DILLSBURG,PENNSYLVANIA 17019
I)USAN BRATIC,ESQ. (717)432-9706
STEPHEN K. PORTKO, ESQ. (717)432-2538
br.vicnortkMa�wl,aiin FAX (717)432-9220
March 21, 2013
Elvetta E. Knox. Claims Agent
PA Dept. of Welfare
Division of Third Party Liability
Casualty Unit
130 Box 8486 717-705-8150
Harrisburg, PA 17105-8486
717-772-6613
RE: Susan Semuta
CIS4: 190145784
Incident Date: 09/17/2003
Dear Ms. Knox:
Enclosed please find a check in the amount of$4,657.35 in full payment of the claim for Susan
Semuta.
Thank you.
�Very (ruly yours,
Dusan Bratic
DB/rsr
Enclosures
2013 1 02P Third Party LiabiIitX, ,„,-AvA„ No. 5521 P. 3
6URH1J0PPR00WI fGAET
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Momh 11.2013
STATEMENT OF CLAIM SUMMARY
F E: SEMUTA,SUSAN
10014S784
UPDATE TO PREVIOUS SOC DATED 0710312007
MEDICAL 'USUAL CHARGES AMT APPROVED
PREVIOUS SOC 130.746.55 110,031.07
CURRENT 60C .00 AO
PRIOR REIMBIADJ (107,969.22)
TOTAL 1a0,748,65 $041,6S
CASH PERIOD COVERED DOLLAR AMOUNT
PREVIOUS SOC 03106104 - 03131/06 2,61630
CURRENT SOC
TOTAL 2.616.60
REIMBURSEMENT TO DPW 4,667.39
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN- 23-6003113
The Estate ofSusan L. Semuta, 60.1e7SM13 1001
Megan C. Wright,1 AdminlStratnx
116 Grecn Lane Dr.
Camp Hill, PA 17011
PAT TO THE
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irn1001us 0:0313187871: 220103414211
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BRATIC AND PORTKO LLC
Attorneys at Law
101 OFFICE CENTER, SUITE A
101 SOUTH U.S. ROUTE 15
DILLSBURG, PENNSYLVANIA 17019
DUSAN BRATIC, ESQ. (717)432-9706
STEPHEN K. PORTKO, ESQ. (717)432-2538
FAX (717)432-9220
March 21, 2013
Dr. Reginald Davis
PERSONAL & CONFIDENTIAL
Neurosciences
6535 N. Charles St., Suite 600
Physicians North Pavilion
Baltimore, PA 21204
RE Susan Semuta Date of Service 10/9/2005
Dear Dr. Davis:
The family of Susan Semuta received a small settlement arising out of an accident
case. You were kind enough to provide emergency services and they wanted to send
you something, realizing it is not what was billed. Hopefully you will find this acceptable.
hope this letter finds you well.
Ver .truly yours,
usan Bratic
The Estate of Susan L. Semuta
Megan C. Wrigght, Administratrix 80-1878/313 1005
116 Green Lane Dr.
Camp Hill, PA 17011
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Keystone Financial Solutions, P.C. Invoice
A Certified Public Accounting Firm Date
47 Marchwood Road 05/10/2013
Suite 2G
Exton, PA 19341-1835
Bill To:
Estate of Susan L. Semuta
c/o Megan Wright, Administrator
116 Green Lane Dr.
Camp Hill, PA 17011
Terms
Due on receipt
Date Description Amount
05/10/2013 Accounting services related to the finalization of the estate 1,025.00
We appreciate the opportunity to provide this service. Total
$1,025.00
Payment due upon receipt of invoice. Payments received 15 days payments/Credits $0.00
after invoice date will be charged a$25 late fee and will be charged
an additional $50 late fee every month thereafter. Balance Due $1,025.00
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