HomeMy WebLinkAbout05-17-13 � 15�561�1�1
R�Y'1.�V V ���a-�ot �,�
OFFICIAL USE ONLY
PA Depadment of Revenue �;Y�?+ania County Code Year Fiie Number
Bureau oFlndividual iaxes INNERiTANCE TAX REFURN
�sox=8a6o� � � a a ��s—
Harrisbura,P4=7iz8-o6oi RESIDENTDECEDENT
ENTER OECEDENTINFORMATION BELOW
08/31/2012 04l14/7947
pecedenPS Last Name Suffiz DecedenYs First Name Mf
Snyder Kenneth R
(if Appiicabie}Enter Survivi�g Spouse's tnfwmztion Beiow
Spouse's Lasz Name SufGx Spovse°s First Name MI
Spouse's Sociat Securiiy Number
7NIS RETURN MUST BE PlLED IN QUP�iCATE WtTN TWE
REGISTER QF W1L�S
FILL IN APPROPRIATE OVALS BELOW
(,� 1. Original Retum p 2.Supplement2f Raturn O 3. Remainder ReNm(date af deafh
pnorto 12-13-82)
p 4.limi[etl Estate O 4a.Future intsrest Compromise(date of Cj 5, Federai Es[pte Tax ftetum Required �
death after 12-12-82}
p 6. Decedent Died Testate O 7. Oecedent Maintainad a Living Trust _0 8. Total Number of Safe Depesit Boxes
(Attach Copy of WiEi) (Attach Copy ot Tmsl)
p 9.Utigation Pmceetls Received O 16.Spousai Paverty Credit(date of death O t t. EieCtion fo izx under Sec.9113(A)
between 1231-91 antl i-1-95) {Attach Sch.O)
CORRESPONDENT- THIS SECTION MUST BE COMPLEiED.ALLCJRRESPONOENCEAND CONFIDENTIAL TAX INFORfAA71UN 3HOUlQ 6E WRECTED T0:
Name Daytime 7elephone Number
Mark W. Allshouse, Esq. {717)582-4004'r; � rn
n w
��srERarmn�isw� Gr
m �' c> � �� '�
s
First iine of address . . . . . . .. . � � n � ?.:.; ,ti�'
4$33 Spring Road ?� u� �' �, �;:r
SeconU line of address � [' ��� � �'�
. .
<��� �� ::;. ;]
� �-� � �,.y
Clty Or Ppst OffiGe SY2t8 ZIP QOdB — DATE�'LEp`r. r,7
.%^ G`)
Shermans Dale PA 17d90
comesponaent�s e-ma�i aaaress: markQchristianlawyersolutions.cam
Under penaities ct puryury,i GeCiara that i have ex8mined thls retum,i�Ci�tling acCOmpanying sChBduies and statemeMS,and to me best of my kn6tY�edge and bElief,
it is irue,carrect antl wmple[a.Dec�aretion af preparer other than the personal representative is based on ali iniortnation of w�ich preparer�as any k�wwwleCge.
SIG�ERS�SP�E POft FILING RETURN ��,�J E/ J
ADDftES5
1321 Fox Hollow Road, Shermans Dale, PA 17090
SIGNATU O PAR O H R THAN REPRESENTATIVE DATE
A00 SS
48 3 Spring Road, Sh rmans Dale, PA 17090
PLEASE VS� ORIGINAL FORM ONLY
Side 1
� 15�56101C11 15t}561�1�]� �
�
_
� 1S�S610105
REV-1500 EX
Decedenfs Sociel Secunty Number
oeceUenPS Name:
REGAPITULATION
t. Real EsYate(ScheduieAJ. ............................................ 1. OAO
2. Stocks and Bonds(Scheduie B) ....................................... 2. 0.00
3. Cbsely Hetd Corporatipn,Partnership or SWe-Proprietorship{SChedu}e C} ..... 3. f}.d4
4. Mortgages and Notes Receivabie(Schedule D).................. ......... 4. 4���
5. Cash,Bank 6eposits and Miscettaneous Personai?roperty{Scheduie E)....... 5. 4,62J.10
6. Joinlly Owned Property{Schpdule F} p Separate Bi3firrg Req�ested ...,... 6. Q.00
7. Inier-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) Q Separate$illirg Requssted........ 7. Q.00
S. Total Groas Assets(total Lines t through 7}............................. B. 4.62$.1d
9. Puneral Expe�ses and AtlmiNstraiive Costs{Schedule H)......,.._........ 9, 7,3$4.31
t0. Debts of DecedenC Mort4age Liablfities,and Liens{Schedule i}.............. t0. 2�,729.$6
11. Total Oeductions{total lines 9 and to)..._ .,.__.................. ... tt. $(I,914.27
72. Net Value of Estate(Line 8 minus Line 11)__.. ............._......... 72. -26,2$5.17
'13. Charitabie and Governmental Bequests/Sec 9119 Trusts for which � � �
an election to tax has not been made{Schedufe,fj ........................ '13. �.DO
14. Net Yalue Subject to Tax(Line 12 minus Line 13j ........................ S4. Q,QQ
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amoun#of i.ine 14 taxable
at the spousai tax rete,pr
transfacs untfer Sec.8116
(a}�t,2)x.0_ 15. O.pO
f6. Amdunt of line 141axable
ai iineai rate X.0_ 18. �.�0
t7. Amaunt of line 14 tazat�le .. .. . .. . . _ .. .. . . . .... .... _.
at sibling rafe X.12 �7, 0.00
18. Amount of�ine 14 taxabie �� -�� - - � �- � � - - � - � �
at coilateral rate X.15 �g, 0.00
19, TAX DUE . 19. . . .. 0.00
. . . .... .. . .. .. ... . .. .. ... .. . .... .. . .. ....... ... � . .. ... ..
26. FIEI IN TNE OVAL IF YOU ARE REaUESTING A REFUND DF AN 4VERPAYMENT p
Side 2
� 15t75610105 150561�01C15 �
REV45W EX Page 3 Flla Number
Deaedent's Compiete Address:
DECEDENT'S NAA4E
Kenneth R. Snyder
SFREETAD�RESS .--..— --- —..—..— —.—..---_.—.—__._�.—.__
175 Lancaster Boulevard
CRY _—__._.'..—_.�.—m —..—.—�.�_—____—.—._.—...— STATE _—__—.—.ZIP — _
Mechanicsburg PA 11055
Tax Payments and Credits:
1. 7ax Due(Page 2,Line 19J (1) Q00
2. CreditslPeyments �� �
A.Pnor Payments ------....________,...--_....__......____...__..___
B.Diswunt ___.__ 0.00
Tatal Credita(A+B j (2} �
3. Inierest
(3) _.� �__0.00
4. lf Line 2 is greater than Line t +Line 3,enter Ne difference, 7his is the 4VERPAYMENT.
Fi�l in oval on Page 2,Une 20 tn request a retund. {4) i�_ 0.4Q
6. If Line t+Une 3 is greater ttsa�r lir�e 2,enter the dl�erence.This is the TAJ(DUE. �j _ �0.04
Make check payable to: REGISTER OF WILLS,AGENT.
P�EASE ANSWER THE FOLLOWING QUESTIONS BY PIACING AN "X"IN THE APPROPRIATE BtOCKS
t. Did decedent make a transfer and: Yes No
a retain the use or income of ttie propetly transferred;..........._..................................._....._............_.................... t� �
b. retain the right to desgnate who shalf use the prnpeRy transferred or its income:._.................._......_..........,.. � �
c. retain a reversionary mterest;or......................._....._............_..........................._......_.......................,....._._....... ❑ �
d. receive the promise for life of either payments,benefts or care?...................._...._............_........................... ❑ �
2. If tleath occurred after Dec.12,1982,6id decedent krensfer property within one year of death
witho�t receiving adequaie consideratian?............................................................................................................_ ❑ �
3. QId decedeni own an°in trust for"'or payabie-upon•death bank account or security at his or her death?.............. ❑ �
4. Did decedent own an individuai retirsrr�t acxou�t,annuity w flther non-prooete property,which
contains a beneficiary dasignaGon? ............................_............................................................._......._....._............ �� �.�
IP THE kNSYYER TO ARY pP THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE�AND FILE IT AS PART OF THE RETURN.
For dates af death on or aftsr Juty 1, a994, and before Jan. i, 1995,the iax rate imposed on the net vaiue of transfers to ar for the use of the surviving spouse is
3 percent(72 P.S.§9118(a){1.1){i)].
For dates of death an or aBer Jan. 1, 7995, the tax rate impossd on the net value of transfers to or for ihe use of the surviving sppuse is 0 percent
[72 P.S.§911fi{a){1.1)(ifj].The sfatute does not exempt a hansfer to a surviwng spouse fran tax,end the sta6atary requirements foi disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is thE only beneficiary.
For datas of death on or after July 1,2400:
. 7he tax rate imposed on the net value of transfers from a deceased child 27 years o(ege or younger at death ta or tor the use of a riatural parent, an
sdoptive parent or a stepparent of the chiid is 0 peroent[72 P,S.§9f 16(a)(1.2}].
. The 2ax rate imposed on the net vaiue qf transfers to or tor the use of the decedenYs lineal beneficianes is 4.5 peraent, except as noted in
72 P.S.§9996(L2)[72 P.S.§911&{a)(1}).
. The#ax rate imposed on the net vaiue of transfets to or for the use of the decedenfs siblings is 12 percent[72 P.S.§9116(a}(1.3)].A sibling is defined, under
Section 9102,as an individua!who has at leasi one parent in common with the decedent,whether by biood or adop6on,
R8V-1608�X+(6-98)
scN��u�� �
COMMOM'VEALTH OF PENNSYLVANIA CfiJ�i, BANK DEPOS#i'S� Ct MI.T..
INHERIFANCE TAX ftETURN PERSONAL PROPERTY
RESIDENTDECEOENT .
ESTATE OF FILE NUMBER
Snyder, Kenneth R. 21-12-0965
Induda the proceeds o(litigaticn and the date the proceeds were receivetl by ihe estate.
Ai!property foinUy-ownad with right nf survivorship must ba dtsciosed on Scheduie F.
�7�M VAIUE AT DATE
NUMBER �ESCRIPTION OF DEATH
1. Members ist Federal Credil Union•savings account#21939-00 i,994.t Q
�. Members 1st Faderal Credit Union•checking account#21939-11 45p.00
3. 1995 Chevrolet Blazer vehiole poor condition 5$5.00
4. 1998 Tayota Tacoma pick-up truck sales price 1,300.00
5. personal property 340.d0
6. 1964 American Standard mobile home-no value-demolished -Estate paid expense of debris removal Q.40
TOTAI(Also enter on Iirte 5,Recapitulationj S d��2���Q
(B more spece is needed,insert additionei sheeis of the seme size)
. . . . _ .—_. ..
REV-;lSll Ex+ (10-09)
�; ���`'x'; pennsylvania SCHEDULE H
�
��1,�` °F�'R�"��°Fa�a�UF FUNERAL EXRENSES AND
`""FR'T""cET^xReT�R" ADMINISTRATIVE COSTS
aesiaenr neceoerar
ESTATE OF fILE NUMBER
Snyder, Kenneth R. 21-12-0965
Oecedent's dehts must he reported an Scheduie i.
ITEM
ttiUMBER DESCRIPTtON AMOUN7
A, FUNERALEXPENSES
f' Noilinger Funera(Home:
a. PmfessiQOaiservices-ctemation 3,Od5.60
b. Merchandise-memorials,register book 175.d0
c. Cash Ativances-deatb certificates,newspaper advertising,clergy,tbwers and tax 691.12
8. ADMINTSTRATIYE C65T5:
1. Personal Representative Commissions:
Name(5)of P2rsonal RepreSentative(s)
Street Address
C�tY�� ���„__. Sta[e�_�ZIP_�_,
Year(sJ Lom�nissian Paid: ---�._i �—_--,�--
2. Atromey Pees;
2,250.00
3. Family ExempClon: (]P decetlent's adtlress is not Che same as[lalmant's,attach explanatlon.J
Claimank
StreetAtldress.�.__. i__ .�.--- --
CitY—__� �_—__.. ^State_...—2iA_
RelationshiR af Cia7mant ta Decedent
4. Probate Pees: g7,�jp
5. Acccuotant Fees:
6. Tax Retum Freparer Fees:
� Cumberiand County Register of Wii�s�filing(ee for inheritznce[ax return 15.00
s. Irwin Law Office-attorney's fees to begin administration of Estate 500.00
S. Cumb�Iand Caw Jouma(-estate advertisirig 75.00
�o. Centra(Penn Business Journai-es[ate advertising 320.00
�t. 2012/2Q13 Schoo!Real Estate 7axes 15.g9
SEE ATTACHED CONTINUATION PAGE 1.2'!8.&8
TQTAL(Also enter an Line 9, Recapitulation) ; 7,184.31
If more space is needed,usa additional sheets of paper of the sgme size.
.. . .. _. _ . .. . . _ .. _. _ . . _ .. ..
Est. Kenneth R. Snyder
No. 21-12-0965
SCH H C4NTlNUATION
Item lVo. Clescription Amount
12 County of Cumberland-Mobile Home Removal Permit $2.40
13 Eric Lepore - demolition of dececienYs mobile hame $600.00
14 RT Carey Trucking, LLC - removal of mobile home debris $616.88
TQTAL SCH H GONTINUATIC?N PAGE $1,218.88
_ .
- _
REV-1512 E%+(1Dq8j
!� � "'�;�'� pennsylvania SCHEDULE I
��� DENARiMENf�PHEVENiIE DEgTS OF DECEDENT�
,""Ea'T^"c:e 1^x aETUR" MQRF6AGE LIABIlTTIE5$c l.IENS
RE5IDENT UECEAENT
ESTATE OF FI1E NUMBE&
Snyder, Kenneth R. 21-12-p965
Report debts incurred bY�e decedeM prior to deaffi that rema7ned urtpaid at tMe date nf deatfs,i�7uding unreimbuned mtdital expenses.
(TEM VAI.UE AT DATE
NUMBER DESCRIPTIQN Of pEATH
i Kinsbury Associates-Iot rent for mobife hame 5189 E.Trindie Road,Mechanicsburg,PA 1,55�.00
2 Sprint-telephone account#829126369 99.98
3. Verizon-teiephone accaunt#717 766-3d76 093 72Y 67.05
4. Pe�nsylvania Amer+can Water-water account#24-0652256-1 58.77
5. PPL Eiectnc Utilities-eiectric utility accourn#00410-8d004 15328
6. Comcast Cabie-cable television utility acwunt#�9547 200962A�-1 169.21
7. Westfieid Insurance-auromobile policy#APV 8548015 111.00
8. Applietl Bank-r.retlit card account#A227093172237103 2,223.90
9. Capital One-aedit card account#4388-6420-6137-0634 538.38
10. Capital One-credi[card account#4121-7416-1857�4029 741.$4
11. Capital One-cretlit card account#4121-7415-3696•2876 2,790.96
12. Blue Mountain Anesthesia Associetes-medical bill account#31663-G 267.9Q
13. DCA of Mechanicsburg, LLC-medical bill account#15118 195.08
1A. Kantor and Tkatch Associates,PC-medicall bill accou�t#SNYKEOdt 356.14
15. Nephrology Associates ot Ce�tral PA,Inc.-medicall bill accounf#6557 188.81
76. Quanwm Imaging and Therapeutic Associates-medicall bil3 accoum#570777 2,3B7.40
17. Associates in Kidney Qiseases,Hypertension&lntensive Care Medicine,L�C-accou�t#162642 131.90
18. PRISM-medicai biii account�06254� 1 d7.74
49_ Alpha Dianostics.LLC -medical bill account# 217691 5.14
20. Cumberland Goadwi!!Fire Rescue Et�S-medical biii account#12-176277 253.75
21. Hampden Tawnship{B�S Emergency}-medical bili account#$506505d601 123.00
22. West Shpre EMS-ALS -medical biH account#1275295A 1,Op7.46
23. Hospitals oP Central Pennsylvania-medical bil�account#1 A0302476 3p4.t p
24. Cadisle Regional Medical Center-medicai biil account�1237821 76.64
SEE ATTACHED CONTINUATION PAGE 9,832.85
TOTAL(Also enter on Line 30, Recapitulation) � 23��29.96
It more spece is needed,insert 8dd1[Ionai sheets of Che same size,
Est. Kenneth R. Snyder
No. 21-12-d965
SCH f CONTINUATiON
Item No. Descriptian Amount
25 Carlisle i2egianal Medicai Center- medical bill account# 1245297 $83.54
26 Spirit Physicians Services, inc.- medica! bill account#75QQ9 $9d0.00
27 Carlisle Physician Services - medical bill account# CPS9529634 $1,143.00
28 Pathaiogy Associates of Central �A - medicai biii account# 336401 $12.51
29 Rivetside Anesthesia - medical biN accaunt#44'145956 $6,$OO.Od
30 Riverside Anesthesia - medical bill account#44143353 $44.25
31 Internists of Centrai PA - medicai bili account# 70326 $221.91
32 Carlisie Mediaa( Group- medicai bili account#28400000411576 $59.88
33 Urology of Central PA- medical bili account# 130774 $175.OQ
34 8peciaf Event Em. Medical Services - medicai bill account# 12-184580 $82.50
35 Cariisle Ent Associates - medicai biit account#677845 $429.29
36 Pinnacle Health Cardiovascular- medical bill account# 131109 $4Q5.59
37 Pinnacie Health Haspitals - medical biii accaunt# 13003792 $275.38
TOTAL SCH. I CONTINUATION PAGE $9,$32.85
REV-1513 E%+ (01-10)
�'�,`�' Pennsylvania SCHEDULE ]
oEPAA�MENr�F aE�tN�E BENEFICIARIES
INHERIiANCE TAX RETIIRN
RES[�ENT DECE�ENT
ESTATE OF: FILE NUMBER:
Snyder, Kenneth R. 21-12-0965
RELA270NSHIP TO DECE�ENT AMOUNT OR SHARE
NUM9ER NAME RND ADDRE55 6F PEft50N(5}RECEtVING PROPERiY 00 Npt I.ist TtuBtee{sJ OF ESTATE
i TAXABLE pI5iRIBUT[ONS[Inciude outright spousal distributions and transfers under
Sec.91i6(a)(1.2).]
f. Kertneth M.Snyder chiid 100°k
1321 Fox Hollow Road,Shermans pale,PA 17090
�
ENTER DOLL4R AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON lINES 15 THROUGH 18 OF REV-I500 COVER SHEET,AS APPROPRIATE.
u NON-TAXABI.E Ot57RIBURONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELEC�ION Tp TAX IS NOT TAKEN:
1.
B. CHARITpBLE AND GOVERNMEMAL pISTRIBUTI0N5:
1.
TOTAE OF PAR7 II—ENTER TOTAI NQNdAXABI.E DISTRIBUTTOP{S ON ISNE 13 OF REV-1506 C6VER SHEET. $
If mpre spare is needed,use additional sheets qf paper of the same size.
.
S�
m
MEMBERS 1n
P6D8RALCRSDTT UN[ON
REGU�AR 3AVINGS ACCOUNT:
Accou�t NumbedSu�x 21939-00
Date Account Estabiished 10/01/1974
Principa(Batance at Date of Death $1993.83
Accrued Interest to Date of Death $0.37
Tatai Principai and Accrued lnterest $1994.14
Name of Joint Owner Nane
CHEGK4NG ACCOUNT:
Account Number/Suffix 21939-11
4ate Accaunt Estabiished 03l25l1982
Principal Balance at pate of Death $450.p0
Accrved interest ta Date of Qeath �0.00
Total Principal and Accrued Interest $450.00
Name of Jaint t)wner Nane
MEMBERS 1SS FEDERAL CREdiT UNION
Tess��l��
Lending Insurance Support 5pecialist
Sept�mher 48, 20i2
Estate of: KENNETW R SNYDER
Uste of Death:88/31/2012
8ocial Securily Number: 166-38-0305
5000 Louise Drive • P.Q.Box 40 � Mechanicsburg,Pennsylvania 17d55 • (80d}283-2328 • w�vwmamberslst.org
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SJ GaRYrigMC 2013 NAC}ASC.AII SYights Reserved s .
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Holtinger Funeral Home &Crematory, Inc.
Eric L. Hollinger,Supernisor
August 31,2012
Kenneth Snyder
1321 Fox Hollow Rd.
Shermansdale, PA 17090
The Funerel Service for Kenneth R.Snyder:
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,AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
Professional Service-Cremation Package C. $ 3045.00
Merchandise-Memorials, Register Book 175.00
ATTHETIME FUNERALARRANGEMENTS WERE MADE,WEADVANCEDCERTAIN PAYMENTSTOOTHERS
AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES.
Cash Advances
Death Certiflcates(lOX 6.00) 60.00 �
Dauphin County Coroner Fee 25.00 � \ � '�
Sentinel 117.34 �j
Patriot News 204.78
Minister 125.00 � �'
Flowers &Tax 159.00
Total Charges J $3911.12
Current Balance: $3911.12
Sot NORTH BALTIMORE AVENllE • M011NT HQLLY SPRINGS.PENNSYLtlANtA t 7065 • (717)486-3433 • FAX(7 t 7) a86-34 t 5
www.hollingerfuneralhome.com
tRW/M LAW QFFICE
ss savr�r rmr sr�er
HAR4LD 5.IRWIN, I 1 I CARL/SLE,PL�NNSYiVAN/A 17013 71�-2d3�090
PFIONE
www.iminlSwoffice.com 711-2a392op
e-mail: invinlawolflce�gmaiLcom Facs��n�
September 14, 2012
KENNETH M SNYDER
EST OF KENNETH SNYDER
1321 FfJX HOLLOW RD
SHER�AAANSDALE PA 17094
<>t><><><>t,�K>G!G>t>tJG>K>G>t><><><><><><>+k>+C>�C>{�<><><><>+C>C><>CT
RE: Professionai SentiCes
Clffice canferenae; preparation of Estate
Information Sheet; preparation of Petitlon
for Letters of Administration; fiting of docs
at Courthouse; draft Praecipe for withdrawai
and entry of appearance; ietter ta Kenneth M. Snyder:
Attarney Feas $508.09
Probate Fees Advsnced 87.50 _
Tatai Amaur�t Due $597.54
THANK YOU!
GUMBERI.AND LAW JOURNAL
32 St?UTN BEDFORD STREET
CAR�lSLE, PA 17013
Tele; (717)249-8186 Fax:(71�249•2863
Octaber 26, 2012
Cumberland Law Joumal is published every Friday by the Cumberland County
Bar Associatian and is designated by the Court of Common Pleas as the officiai legaf
publication for Cumberland Gounty and the lega! newspaper for publication of legal
fiQxICBS.
TQ: Marit W. A4{shause, Esquire
f2E: Kenneth R. Snyder Estate
Legai advertisements must be received by Friday Noon. A!I legal advertising
must be paid in advance. Make all checks payable to: Cumberland Law Jaumal.
Rdvertisement inserted an falEowing dates:
4ctaber 12, October 19, and Ockober 26, 2012
Advertising Cast $ 75.00
Proaf af Publication $ D.00
Second Proof Request $ O.Q4
Payment received $ 75.04
Tota! Amount Due $ 4.Q0
8ecky H. Morgenthai, Executive Director
I N V O I C E
7504 Paxton Street .
JOU R NAL Harrisburg,PA 77104 1022/2012
M U LT I M E p I A T.717-236-4300
F.717-236-6803 ORDER#: 85658
www.journaimu{timedia.com TERMS: Net 30 Days
---------- INYOICE TO----�--�- ---------- ADVfRTISER---�---
Christian Lawyer Solutions, LLC Christian Lawyer Soiutinns, LLC
Acopunts Payable
4833 Spring Road
Shermans Dale, PA 17090
INYOICING:AdveRiser
DESCRIPTION OP CHARGES COST � CREDIT � BALANCE
PUBI.iCATtOh; CLA5SIFIED/CENTRAL PENN BUS.JRNI.
COVER pATE: t0I1912012 THEME: CLASSIFIEp ADICENTRAL PENN BUSINESS JOUR
RATE GARD:
OESCRIP178N 8F AD:
Legal listing: Estate flf Kenneth Srryder
REP(3}:
MARKSUNDAY
SIZE: LEGAI LISTING, pAOE: 320.00
CQLOR: B&W 0.00
SPACE SU6dQ7AL: 320.00
• BALANCE DUE: 326.�6
PAYABI,E TO: �,',@��� j � ����}�; 09754
MithaelLet�peqTreasu ex 3 � � MUNICIPrWTY'HVrqtlenlwp. BILLNO:Mi54
T30 S.SW�9 ttitl Raad HWrs'^u'ae Reverse
MeUieniCBb!X9,PA17{f50 w�� � � � :757-73T-0822 PRbPERiY:33KI14GS8URY BttL6ATE:1t5t20iz
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ruu.scHOO�nreTn�c o.uo a+s.ee s�s.se
THISTAXISDUEANGPAYABLE•YOl1AREXER86YRE0UES7ED ���STEnoCFRaT
TOMR%EPAYMENCTHEREOF. L���^�`p�pT
TN(AMOUNTpUE FiS. f15.B9 E�'+.29
uaeiaonoreswre areinx iasv�x i�n:
SNYDER,lCENNETH
5�99 E TRINOIE RD LCYT 33 NO CNECKS ACGEPTED AFTER pEC ,20t2
MECHANICSBURG.PA t?65C-3859
� S82"s $523 $5.23
o���au� �x on r w+v+z �nnwnw+.w
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MQBR.E HONdE REMOVAL PERMIT $2.00 — ,�����
�
Please Print ar Type This permit �f��������������^� �
DATE ,�l�!�. PARCEL NLTMBER �/ J
L(3CATION 4R PARK � LOT 1�iUMBER J I�C�S
OWNER'S NAME ` ��'��.
A1VD ADDRE3S �� � i ��� �
TAXE3 DUE .��5..�_._ YEAFt �.�� IvIAHE ��'cr�r.. .�i��� }/�
SIZE f� �`5 SERIAL # �.��� 'j f�
DATE LTI3IT IS TO BE 3]���ED �Q I,��)�,�,. .
*k*M4�k+k�k+k*#�k�k�k�k�k�k�k#�k+k�k+R�k�k�k'+k�k�k�FA��k'h�k+ktk�k*k#fF�kM#�kA:�k*+t�kek4k�k�k�k:i:k+k�sk#�ki�'+k#�k+k M��k+k#4#�k#8&�k:k i:+k�k�k#*+k�k:k�k
IF MOBILE HOME IS BEING SOLD:
NEW OWNEFC$NAME
AND AI7DftESS _
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qWNER QF LAN'D
TOWNSHIP AND LOCATICiN
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PARK NAME
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se**s*:��*�r**+x*��ax�+e:e*.*r*:�m*r�*a��xa�:+*.aa�s*wwa�r�*�«+���:*��s**�*x���r�*w*rr:wr��e�rr:sw�+*r*s
IF MOBILE HOME IS BEING TRADED,PLEASE PROVIDE INFORMATIpS3 ON NEW MOBII,E
' HOME:
YEAR MAKE 9IZE
SERIAL # Y PRIGE $
3?k s 4+F�k##x�ks#�I:t tw»ris�w�kk+r:k�P+R+k�k�k�k*8*b�P'+k*�kaN�rt�k�kts�k�k�kY��ai�wA�R:r%:k4+:%�wrt�k�A�k#vsrt�kp�x�k+l�t+ks�k+w+kY�+ksMM+k
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TAX COLLECTOR'S SIGNAfiURE
Dietribution: LVhite-Owner Green-AesessmentOflice Ye73aw-AssessmentOf}Ice Pirilc-TaaCollector
I1/15/2012
I Eric Lepore was paid $600.00 Dollars to demolish Kenneth R. Snyder's
Trailer at 5169 E. Trindle Road Lot 33 Mechanicsburg, PA 17050 . On
October 15�' 2012 By his son Kenneth M. Snyder .
j1'
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STATEMENT �A�E �
KINGSBURY ASSOCIATES
C/O D.L.PAGAN
P.p.BOX 718 Account No. Date
MECHANTCS&IJRG,PA 17455 33SNYDER , ]2124112
(91'�791-1201 FX:(717)791-1218
Tatal Amount Due
1,550.00 .
ESTATE OF R:ENNETFI SNYL7ER $
KINGSBURY MHI'-LOT 33
S 169 E.TRINDLE ROAD
MECHANTCSBURG,PA 17050
Please cut at dotted Une and retum with your payment
.....-----°......°-----......._-�---.......-'--................._......-------.....----.........-----....------'----........------.....--------°---------°'--_._----
��� w ��
E Currcnt � 31 -b0 51 -90 , � saai ltmaant t'tue
310.00 310.00 310.00 620.Op 1,550.00
KINGSBURYASSOCIATES ��]� YOU
P4 B4X 7951
SHAWNEE MISSION KS 66207
SpC�nt .
#BWIIKCfX
#OOQO 482912$369 B 3# {#9i2
AB Oi 0382Y2 8Yt7p H 12? A
KEt1N�rx gqypER Aecountlnformation
5169 E 7RINDLE RD 1.0T 33
MEt�1ANICSBtlRG PA 17Q54-3559 A�o4uM� 8291263�a.�12
AetouM DW: .96
liqli�ll��ll�lldh���rp�uu�p�hhd�p��r�hy�yllhu�� " �
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Your requesf is complete
On behalf pf Sprint, please accept our candolences tor your loss. Per yaur request, aanunt
829126389 has besn cancelled.We have applied the appropriate adjustments and waived all
associated early tarminati�n fees.M unpaid balance remains o�the eccaunt. ��
Piease maii your payment today to the address below, referencing the ar,count number on your ���
payment to ensure proper credit, if you prefer,you may call us at 1-800-45660"70 to discuss M�ke yar dw�dc payaWe
your payment optians wfth a FinaRCe Services Representative. 6o Spintand mail itwlp�
fhem�ort beirnr��e
Sprfnt utilizes NCO�'" as an oukside collectioo agency that specializes in estate and probate ��
matters.7hey may contact yau if further corcespondence Is required. p��pw:
�8.99
Sincarely.
Pat R.
Sprint Credit Compliance
Note:7'hk astterls sn attempt to caNect e detit osred ta Sprint AnyinYOrmabm o6fained w�6e usedforMUtP�F�B�Y•
Cradtt Coaqiiluwu Hows ot Clpatatbn
Maxfay-Friday:8 a.m.�5 p.m.Centrat Tpne
IMPORTANT:TO INSURE PROPER CREDIT,PLF.ASE RETURN THIS LOWEit PORTI6N TOGETHER WITH YOUR REMI7TANCE.
Account IMortnation
KENt+iETH SNYDER I �N�: 828�28��
fi169 E 7R{NQLE i2p LQT 33 k ���: �.�
MECHANICSBURG PA 17050
PO 8C1X 54977
LOS AN�ELES CA 90654-09T7
III'll����llu����ll�'�'�IIII��Ju��������1�u�u�In�b�J���p
829�26369 �i1C1L106d00 OI]��p99980 Ot]Od099987
I
Accoum Numher oue Date Amoum Due
�\/� 777 76fr3476 1093�!72Y Upon fleceipt $67.05
ver�Zon � �
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f b f � JYMII���Wr: 9��i1��.
t�.�� �`: '�! �,;� r" �.T�� KENNERINSNYDER
�. ��i + x � t Phme: 717-7663476
Yl {\l � F .5 . � '
f
,,„�,�.,7po�Yb�c�►+11 x e: Aa:oum Summary
, `"rr%'�.;, idi{��;T `` Previous Belance $67.64
L.�:.V� \ ti...f Y '.� f :..�. . .. _ ._ _._. . .. . . . . .
, -.�.,. . , , ..:,.. v„ ,. . .:., . .::: No PaymeM Received $.00
'3`�," .;, ` ! � .. BilalaFoMUrd . . _ . .. . - S67O1
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Moving?Call Verizon H.,,,q,,,�
Call 1-888-476-9691 belore you move.We'll help . CWrem Actrvtty . . . .. . . -$3.�
set up your IMemet,N and Plwne tor your new _. _ . . . . . .__.__. .._._._ .
addresa You can be up and nnning in no time!DOMT Taxes,Fees and Other Charges -52.96
WM!And he sre to ask A FiOS is available in your . __ . _. _ . . ___ ___ .... --
area.Serviceavailabiliryvaries OUierProvideB . _ .__ . . . $8.31
. _ . . . ---__.._ ---_ ___._. . ___. .
ToYI Nrw qwga -589
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iretilulion to dedud ihe emoiad ot your mwithlY bGl fran ia�mn���.c�eB w�m a�aimag�n i-soo-sia-eaos rn.
the aaoum arociated with your ericloeed check aM
aend paymem Nrecty to veAZOn.To dleoontlnue
Aulomatic Peymem,call Verizort Plesee keep a copy ot
- thisaWiaimtbn.
� P�mtum remtt alip with peymem.
Ta erroll inAUtometic PeymeM�Sipn eM dete bebwJ
Accoixd Number. 717 766-3476 093 72Y
. Charyes Due: PM�se Pay Now
AmomrtDw: �87.06 091912
ar+�wwq Wwe i wirynn�ir�w nwwwa rw Make dbac vef�ebk to Verlmn
rtceptEMMromECanElYO�sel � �❑.❑�
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00000117 01 AT 0.374 VPC263110001 XX
KEMETFI fl SNYDER
51 W E 7PoI�LE f�LOT 33
MCHNCSBR6PA 170W-3659 �I��II�IuIII'IIII�nnu6l�luJl��d�1�16��I�1���Idquryl�I
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LEHIGN VPLLEY PA 18002-8000
117717�76634760932�280211499999100000067645UOOOD06705800000
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nao��ra�s���bb��uvuu4�r�__-- _
� PennsylvanlaAmerlcarrW�f��er 24-0652256-1
PO Box 371412
Fittsburgh, Pa. i5250-7412 AMOUNT DUE �5�� T�
For Service To: 6i6S E Trind{e Rd LT 33
DUE DATE Jan 29, 20i3
AMOUN7 PAID
I�p��t�l�hhi{11����Ilili�hi.����r1{hldu„�,�,'l��ry.,.q�
o3aire t as a.a�s z�7zna�lztfloz+z2 �ae �NcESCn.
KENNETH SNYDER �
1321 FOX H(aLLOW RD PENNSYLVANIA AMERiCAN WATEF
"— SHERMr�NS DAIE PA 1'7090-8829 pd 80X 3714f 2
PITTSBURCaH, PA. i525d-7di2 i1b9 E
,t,�.��„�,�����m,��i�t1►1j��1�41���1h1111��t�Ety�.,t.�,��.�� er Service
:nt, and
Please rhectc here ro add H26Help to OHrers conh+butian fo ywrr;;rcmthlY t�f! �d
w to cherige your sdoress or te7ephorte number,and pr/nt u�fwmation an reverse side.
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Customer Account Informatlon Bllling Summary
fror S�vice To: KENNETH SNYDER Prbr 8aiartce--^-----�-- lppt
5185 E Trindle Rd L7 33 Pnor Water Ba/�nce $125.25
/lccount Number:240652258-1 F'aym�ts pnar fo Jan OB,2013. Thanlcsi .dd
Premise Num�er: 240885154 Totat Qrior baianca,3an 09,2(313 125.25
Ad�ustments.—__
Bllling Ps�Nad& Meter Informat►an Bilp�g Error-Adj Res -63.09
Billing dete: Jan 09,2013 QS{G Charge-/laij Res -1.44
Lt Chrg Alhvd-Atlj Res -3.9 2
PenRa Surcharge-Adj Rea •�2
Rate Type: Residerntiai Ta#at edjustrt�Ms,Jan 48,2073 -68.48
-----AMOUNTDUE---------- $56.77
Water Usage Gom{�arison
�b Montl�+y usapo fi hune�d gedions�_.__
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Messages #o you Erom Pennsylvania Amsr(cao Water
"Any pnrtron of ttte watsr charges which is not peid as of 2104J13 wilt bs subject to a 1.60%pe�atty.
'The due date perfaMs to current ctrarges only.My past due balance shauld be paid immediately. $�
� 'Aanroximatety 4.5?percent;or$3.12 of State taxes are includsd in your current bill.
-•- f-� �.r%.���m<nr.Surcharqe(STASj has decrsrased from O�e fo-.!5%.
._._�..,...,h naoG�n:i 48%.
_ _
� /+� Questions7 Piease ,j� Visit us oniine at Adjusted Final Bill Page 1
�"""''�";''�:•�' 1,,/J cpntact us By Nov 6. - l.J
��� :,,. _���Pg` pplelectrtc.com
•:'� (1-80CM3d2-5775) " d � z "
.eu�m++ouwm.. �... M-F�Samto5pt11 0041fY80004 NOa 6, 2012 1a,,.«?;n
our Electric llsage Prafile Biiling Summary {Bliling detaits on bedc}
}�tp; Balance as af Oct 15,2012 $145.18
°N SNYDER Charges:
t69 E TR1Np�E RD UNiT L33 ToYa4 IDT Energy Charges $1.28
IECHANICSBURG, PA 17050 Total PPL Electric Utilities Charges $5.82
teter.79132�4
TptalCharges 5153.28
iis sectiOn hplp5 yoU UnderStand YOUr year-LO,-YeaF " ="a' " .�.„���. ,:� �. '� .
ect�ic use by momh. Meter readangs are actual unless Accourn 9alance $153.28
therwiSe npted.
�Zp» �zp12 �pc��d PPL Electdc Utliities'price to compare for your rate is 7.907 cents per kWh
efFective 9/1/2012 to 11J34j2012. For a list of wpptier offers,visit
30 � papowerswkch.com ar www.op.state.pa.us.
zs
�p Yeur Message Center _
is
• The$146.18 baiance inciudes$3.38 in prior iate
payment charges.
3a • IDT EnergY Customer Senrice hours wffi be 8am tu 7pm
5 Monday through Friday starting June 3,2012.
• WRh pa eries5 bitiing,yp u can receive and pay}rour
p a � ht n ki s � a S o N D PPL Electrfc Utlifti85 bills Ortliri2.The p[OceSS f5 ff22, 8
nnoncns quick,convenient and secure.Ta Iearn mare or sign up,
visit pplekctric.com.
• information about appiience energy use and tips an
saving energy are avaNable through the Energy ubrary
on our Web site,ppieMctric.com.
Sep 2012 12 15 2 74f • Keep iight buSbs and flxtu�es ctean. Dust aod dirt absorb
Sep 2Qii 31 348 11 fi7F ��Bht and can reduce iight output by as much as haif.
�
� P�yment Methods �
Sep 10 AdJusted 44454 ✓� Oniine at: �By phpne:l-8003d2•5775 �
Aug 24 Actuai 4qd3g V pR�electr[c.com or call BIIIMatrlx(service fee applies) �
at i-�672-2413 to pay using Visa, �
12 Days kWh 91Ued 15 MasterCard, Discover or debit c8rd.
� By MBfI: Cprrespondence 5hould be sent to: �
Oct 2Q31-Sep 2012 3617 gp1 2 H°rth 9th Street Customer Services
CPC-GENNi 827 Hausman Rpad �
Oct 2010-Sep 2011 4b43 387 ��entow�,PA 18201-1175 Allentown,PA 1$1Q4-9392 �
Uther fmpprta�t 3nformation on the back of this bill�
`';:`;r= � Retum this part in the envebpe I I -
pp� •y
s" provided wikts a check payable
'�' to PPL Electric Utilities. 00410-$OOQ4 Nov 6, 2Q12 $15328
x.�.cae uurw..
,0.mount Enctoaed:
AV 01 007943 549618 33 A`"5DGT �❑�❑�❑❑
�IIIh611�11��'1���1��19��II���If��I�I�IIIII'��I�I�'������I����
KEN SNYDER PpL ELECTftiC UTiL{TIES
5t69 E 7RINDLE RD UNiT L33 2 N4RTk 8TH STREET GPGGENNI
MECHANiCSBURG,PA 170'',�0-3681
AL.LENTOWN, PA 1810'f-1175
t�n,��,�,�litl�Ihili��uE4�ih���i�ii�11����y4��lli���i��{il
1 590000153289000L1153284 0041080UU4
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� ���CC! C�St, f----------_ - --____-----..__l
� Account Number 09547 20U962-01-1 �
� Billing D8t2 10/1M12 �
Unpaid 8alance �169.21 -Due Nuw
T�Amo�f Due $168.21
Page t of 2
Canffict us:�www.camcast.com�717`-5�10-89dQ ___ _�
KEN SNYDER � " ' � '
P�evi0a8 Baienoe 18:4,27
Fa�senrice�: Paymer�s-recx�tved by 1i'�9di12 O.U6
5163 E TRINDLE RD APT 33
MECHANICSBUFtG PA 17p50-3659 llnpald Balauce 'Due Now 788.2'1
�`����`�it� ' ��� !
News #rom Comcast
we regr�i�s�g ya,as one a�a,r subscx;bers. tk,r � �
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records indicate thaa�t ttre fmai baiance sha�m above is . . • . : .
now due.Your prompt paynieM�appredated.My
outstanding equipment must be r�umed to our office �
within 7 deys. Piease c�us�1-SW-C4MCAST ar�r a
time shouid you wish to reconnect yaur serviCe. °
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NearinySpwaeh impaired Ca117N
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Detach and enckaee lhla carafn wiG�yau peyrn�t.FMease wrl[e yaur e�wimt number'an your check or rnon�ry atler.Do not aentl ce�ah.
(comcast. A�°°�"��,� ��'��.�,-'
Payment Due by Due Now
�s�suzrs�Er Totsi Amaur�t Due 5163,21
EEBANON PA 1744&8317
AV Oi Ot8i0A 953488 54 A••snGr Amount EnClosed S
��'�!'�'�1�'ll"�1�1���4ryslrl'1�'IIItIIj����rlli��lnl�ill����E� t�k8 d1eCkS pOyeble to ComCest
KEN SNYDER
5189 E TRINpLE RD APT 33
MECHANICSHUR6 PA 17050-3559 11��'��131�6��1!{Iil:i�ls�l�l��tii••�1�i'1�1l�"��ti�'•11����1��
COXGLST fJ49LE
P 0 BOX 3008
SpUTHEASTERN PA 19398-30p6
t]954? 2U0962 01 � 0 �16921
_ _ _ _
/ WesifiNd Biili� Contxt 4nformation
Billing Customer Service: 7.Spp.552.9134
�� W E S T F I E L D Monday - Friday 7;00 -6:Op EST
I x 5 U R A N C E Pay-by-Ph�me: f.800.766.9133, Access cadem5 digit zip cade
S�anng Knowledge.Builtlirg TrusC Pay dnlina: www.westfeidinsurance.cam
- One Park Circle, PO Box 5001, Westfield Center pH 44251
111voiC@ �dte: September 25, 2072
INSURANCE 1NVti10E ACCOtlNT NUMBER
KENNETH R SNYpER �ast Payment 3700325094
7321 fQX H4LLON RD S77 83 AtNOUNT DuE
SHERMANS DALE PA t7096-8829 Ju�y O5, 2012 � $111,00
TO PAY IN FULI
For policy questions call:
R T DUNN INS INC 5111.00
DUE DATE
MECHANICSBURG PA 17055
T17.766.0770 . t�bo6er 10, 2472
P�� � DURATtON PAY POLICY AMdUNT
OP RouCY PtAN BAUiNGE DUE
Perspllal Auto(s)
Poliqy; APV 8548075 08-09-12 to 49-17-12 Monthly $101.00 � ���:$70�1�.00
Pre�iu� due on canceited poticy
Installment Fee � $10.00 �$70.00
TOTAL S��i.00 Syt�.00
� W E S T F I E L D Parr�eENT CouQON 37-as28 Changes ta address
:� PNUa wriN your�ccauM num6ar on your ohxk.
INSURANCE NAME
For billinp quaatbns call 1,800.552.9111
:f. Shanng Knowtedge.Builtling TrusC � �
� �� ADORESS
.. . CITY,STATE ZIP
KENNETH R SNYqER
1321 FOX HOI.�OW RD —
SHERMANS DALE PA 17p90-S829 ACCOUrrr NUhtsert 3760325094
AMQUNT DUE $711.00
Ta Pnr iw Fuu. $1 t t.00
�ipqqiu���p����npnlldllilP��i������������qa�hrrr� DIJE DATE oGCObe��z
Westfieid Insurance Payment Processing AMbUNT ENCL43ED
PC} Box �t11566 See revsne sitle for future payment scheduie.
Louisvilie KY 4029a1566
37D0325C1940Q1D��012�12�925t]�013�ZCI�S
BANKCARDCENTER I�Appl/+�dB'ank� � �P�SECHECXlFTHEftE1SAC4ANpEOFAODBE55
AhtD PFIQYI�THE INF4Rh9AT10N ON THE BACK.
� P��x,,,�o ..._.-- �Ink• v�s�
WILMINGTON,DE 1985p-71�0
�AUVr,
Mryd
MINIMUM PR5TDUE PAVMENT NEW /iMOUNTYOU °�'� ,�
ACCOtlNTNUMBER re
PAVMENT DUE AMOUNT pUE OATE BALANCE ARE PAYING �,
$28L00 $234.00 70127l72 32,223.90 d227 0931 7223 7103 $
FOR PR�MPT CREQiT,MAII.PAVMENT TO IOCATION
BHOWN BELiJW.PAVMENT IN ANY OTHER WAV MAV
DELAV CqE�ITING VOUR AQCOUNT UP T6 5 DAYS.
MAKE CHECK PAYABLE TO:
APPiIED BAtsC ����I��I�1���1�I��1'Id1��11��p���t�1,lE1�y��11rIi1l�t1i�1'�tti
PO BOM 1�12o KENNETk R SNYDER
WILMINGTbN� DE 19a86-7120 5164 E TRINDLE RD LOT 33 ic'16u
') i 'it) , t ' � (�� ��, ' `��i� !"� � ` , MECNpN2CSBURG PA 17050-3659 qio9
I t n� � il �ll iltl� �1 ��i� �i111 1 � i ��I 1�
422709317223710300C128100002223900
H„ pI.E.ASEOETACNTHEABOVEPORT�PtAF#IRETUf�it7WITNYWRPAYMEN'fT4EWSUFiEPROPEFtCFED1T.REFAWIOWERPORTi6NFORYWFtRECOitOS.
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Summary of Account Acliviq Paymenl Information
Previous Baiariee $2,�8.90 . New Balarxe $2,223.9b
Paymenis - 50.00 Minimum Peyment pue $281.00
Qiher Credits � $0.90 Payment Due Date 10/27/2072
Purchases + �.�Q LatePayma�tWt'rNny:
Castr Adv�s + �.aQ If we do rn7t receiva yuur rt�imum pa}arent by tt�e data Iisted�ie.
Fws Cfiarpad + 376.00 you may have to pay a Iate fea up fo$35.
II1�Nel�CM191pBd i E0.00 . .
New Balarite $Z Z23 9p Minimum PaymeM WarMnp: �f
Making onry the minimum paymmnt wiU inorease the amount af INereat
Credt Lfmit 52.158.OQ You pay�d the i�ne at takes to roPaY Yaur balsrice.AnY eddiUarei
Availeble Credit ryqNc emamis added io you�account belarxe during ihe biiflng period
Statement Closing Date 10/02@012 shouki be included with your minimum peymant emaunt tp meet the
Days in Billing Cycle sp v�ron s�h�a�ia�s�u���a nei�,. +ith the
�5�� Vf you make no YoU Wi�pay att ihe Md you wiM ���
Call Custorrwr Service 1-484-840-2706 addHionai chargee baiarwe shown on erxf up payi�g
lost or S�M�n Credit Card 7-900-5565878 usinp this cerd and thia etatement in an estimaled
each monih yuv pay... about... total of...
oray ttre mi�imtan .Of th18
peyment 5 years 52,224
note that
asz ay�rb az,zaa W�
tf you woutd Iike inhxmati�n ab�wt credit cauns�ir�serv�es.
tali i-87731&-6322
Please aend blllirre inquides arW oorrespondence ro:
Pc7 80X 77125 WI�MINGTCNI,DE i9854-7125
Tronsaotlons
Tnro 6ab P�e Dets Hatrrvnaa NEmmWr Dascrl�iai IN Transaction Or Cradit Amount
Faw
OBN4 09N4 MCNTHLYMAINTENANCE FEE WII.M DE i5.00
TdTAI FEE$W R THIS PEHIOQ 16.Q0
rrna.at anrgw
10N2 10/02 Intarest Charge on Purchases 0.00
14102 1 OPo2 interest Charge on Cash Advances Q.00
TOTAL INTEREST FOR Ttii3 PERIQ4 0-�
I �
Nt7TICE:SEE REVERSESIDEfORIMPORTANTINFORMATION,
5564 6i82 +176 7 7 2 121962 2% Pape 1 ef 2 3541 317'8 CTS2 011`i55l4 14160
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---- __ __ www.capitalone.com � __ _ _ seP os-aa os zo�zTsaoa m -- _,
��/ Gustomer5ervice1�800•955-7070 YS ��9�Y� ' ,
��!' �^�..� , .
i MINIMUMPnVMENTWAeNING:IfyoumakeonlytheminimumpaymenteaKhpeiwrd,you i
i � wilk payy mwe in irterest and it mnN Wke y4u langa m p»y off your haiance Foreimipk: .
� �sa Platlnum XMXX-XXXX-XXXX-OB34 i Payment Amount Exh Period if No ApproRima[e Time tq Pay OfF ExGmatrtd �
i
' NEW$AUWCE P�§E;Yt�v9(2PJ€S�Ay!vl€Ni pii€ i)64d� �daian�chaz�esarehsade Statementsaiante rotaicaat �
I ___.___ .._._.. - ---___,.._.. __. . '
'� $53$.38 Minimum Payment 7 Years �f673 '
S92.ua no,raz,zfFSZ I) __�...__W . �—. _�._...__ ..
If yrou would hke mFormetlon atwut credit munseling services,csil i-SB8�326-gl155 1
o I
-'= ' °"�'�"'�� tATEPAYkd€NTt4ARNiNG_ifvmdonotaReiveyaurmin{mumpeymen[hyYnsrd�dYe 1
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: Credrt Umrt $600.00 Cash Advance Credit�mrt.$600.00 j Ynu may have to pay a Iste Fre of up tn$35.W and your APRS may be increazM uptoMe
� i i � PCnairyAoROf29.40%. �
, �Availa6le Credit:$61.62 Available Credittor Cash Advances:861.00�
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� i Previous Baiance PaymenCS and Gedits �ees and Interest Charged TrensaRions New Baiance +
-v _._ __.__�__.._ ___-_----- ^ - --� �'
� � 5574 93 � - � _�S36 5S � } � S4.Q0 �� ,{. � 54,f36 i ... �� _3538.� .. r
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: ( , . , r mpn .� Y V� t i C ••�n3 ':-'-' or� V��e)�: u x'S.ot ir�;�n
. ) rTRAN5ACT10N5 -�-- -�1 I Help is Available. j
, ! PAYMENTS,CRfDtTS&ADIUSIAdENTSFORKENNETH&SNYAER�tl834 ( ; t��y, ��� � L�� (����. � ,
; ��, i �3 SEP PAST DUE FEEAOlUSTMENTNT (525.06i ,) (, �I � � �I j �
� ; 2 OS SEP INTfRES7 CHARGE:CASH AQ4TMENT {571.50) � � �i
'i 3 OS SEP INTERESi CHAftCrE'.PURCHASED)USTMENT ($0.051 i ,
j Call 1-800•955-6600 and a spetially Yrained agent will
i � � be happy Co help you check your balance and make payments. j
� FEES i
�, Tota!�ee�ihJs Petlod qp_p6 � .
:. . .._...___.....___.,....—.__ ___ _.__.._�.�.-.__�_ . ._._..�
INiEREST CHAlIGED
' � INTERE57 CHARGE CA�CULATION
, Total interest ThiS Period $6.6P ---'-___.._�.__.__'_'_'... _.____,.__
j Your Mnual Perantage Rak(APR)is the annual interest rak on your a�urR
TDTAlS YEA[t TO DATE
� Total Fees This Year 50.D0 � 7ype of Balanu Annual per�ntage Ba7ance Subpct ta Interest Chazge
� Tota:IntereR ThiF Year �gg.53 Rate(APR) Interest Rak
� Purchases _-�W"����" 22.9�°b D�..I��._ E0,00 SO.OD
' I Cash AGraaces I 249tl96 D SO.OQ I SO.UD
I P,L,p,F=Variable Rate.See rsverse of page 1 fir details
�.___-_--------._.--...----�.—_.—..�__—__.__.._-_.____...__-_._---i
PIEASE FETURN PORTION BELOW WITH PAYMENT OR l6G ON 70 W W W.CAPITALONE.COM 70 MAKE Y6UR PqYMENT ONIINE.
1 4388642467370634 OS D53838402504QR92007
A���� Account Number:4388-642d-6137-0834
__Due Date � Pttw 8atanQ Mi�imum!sayment Amouo[Endou6 Take advantage. I�kQ �Q��Q�.
.,.__.__.r_._. .--------
Nav 02,2d12 � � $538.38 �92.po Manage yaur accaur�t anline
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_____.._--__...1 ,-----��_...�, �,__�_.._.._ � �...._�__--� atwww.capitalone.com
PI FASE NAY A(LEASi �
rias�aMOUNx • Make payments
• fteview account information
• Manage your account in privacy �
KENNETH R SNYDER �+i°a
5169 E TRINDLE RD LOT 33 '+b0616
t4ECNAHZ{SBURG, AA 1765�-3659 tapStal Qne 8a�k tUSA}, N•A�
�h������������Jlll��l'I"11lIL��I���II�d��l��l�l�l�������lll1 Charletts�,3NC32e272-1�G3
idflP�i����uhi�h�IdP�+��lin�i��lh��lll��l��ll(i►hi�inl
P�pase make checks payahie to Capitel One Bank(USA),N.A,and meii wtth this coupan in the encfosed envelope.
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.. Page i of 2 � . .
�+ Custamer Sprvicc f-800�903-3637 ��.� SeP.08-Oct,05.2012 3p Days irt&IFng Cyde
i•'�/ ' www.capitatoae.com .- . .. -.._ . . .__ _ _.... ._.._....
= k . .t ,�w :; �n.�n ,}r,l;�',•fiG�,�t ,�x5�w'ri'f.b�a.�. �y�, w�='+�y�',� MINIMOMVAYMFNTWaNNING:IfyoumakeunlytheminlmumpaymenCea[hpniod,yau
?Fx2^n'c"R ��%�.> "`�".'.� ..
wi{i pay mpre�n in{�res;and±{y�(ki{ake}rou tpnge(o pay 6(F pour baar.ce.�areurryk:
� ��V�Sd PI81]OUIII XXXX XXXX-RX7(X�4029 � payment Amount Each Period if No Appraximate Time[o Pay Off Estimi�led
Nf W BAtAP7CE . . , . _. . . ' nadition�rnazqes are aAaae seatemenc e�ar,ce ioGM cRSt �
"' ' . .._ _ . __.
- $747.84 � .� Minimum Paymen[..... . �. . . ...4 Vears . .�. .37,�p � .
i
�
�� � � ifyouwoultllikemformationaboutcreditcaunseMgzervices,cail7�888d2b�e0i5..
� �' . -- . .. . . . ..__.. __ . .. .._._.. . . �• tA7EPAYMENTWARNING:ifvmtbano}receivepourm;nimumpry�mpypyrdurdaip.
� CrediLLimit:8800.00 Ca5hAdvanceC1pditlimit:$800.00I youmayhaveropayalatefeeofuproE35.00andyourAPRSmaybeincreazeduptothe �
� ' �� � ➢enatyA°8afP9ap5a,
4 ' 'Available Credii:858,16 Available Credit for Cash Advences�.$58.16 �, �
'� . . . . . ... . .. _. ... .. ..... . _ . . .. . �
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� ' Previous Baiance payments and Credits fees aod tnterest Charged 7ransaction5 New Balance '
m _ ._ _ _ . __. ____
37879] i - i f40.Q7 �� i t � SO.M3 , } 50.69 i - . . , .
N � , ' � , . S7At.84
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p � Re�walNotice-YO�riit20i2biiiwtillncludeyoar$39.00annualmemberhipfee. � � ���p �� A�a��ab��. .
�' ' The reverse of this pdge explains how you may dpse your account and avoid Ibis fee. . �, �
84th sides oE this paqe pmvide ifiportant in^ormation a6out your rateis}and how your j ' 1 u st p i c k u p t h e p h o n e, '
_ , interest chargp is calculated. �;�
$ � . . . ... 'I � :
a �7RANSACTIONS Ca11 1_gpp-g55-660�and a specially trained egent will
v PAYMENTS,CREDITS&ADIUSTMENTS FOR KENNETH R SNYDfR#C079 ' � �
1 03 SEP PAST pUE FEf ADIUSTMENTNT ($ZS,pp) i I bB IIdPpY t0 h2�P YOU CI1BCk YAUf bd�2f1C2 dfid R18k2 pdYrtIQ0I5.
: 2 DSSER iNTERERLHAR6FCA5HAGV7MENt ($5,7�� - _
3 OS SEP INiEA85T CHARGE�.PURCHASEDIUSTMENT (59.36) � �� �
,� I .. _.. . ..._ ._ _ .. _ .
.__ ... . _. . . ___. . .._. .
-0 ' INTEftEST CNARGE CALCULATkON
i _ . . - _ __._ ._. . ___ ___.__ .
FEES Your Annual percenWge Rate fAP�is Nre annual interest rate on your aa'nunt.
to,ai Fees This Penod $O.Oa j Anrtuai Percentage Balance 5ubjett to
' 7ype pf 8alance Rate U47R) Intecest Rate Interest Charqr
- INTERESTtHARGEp j _,.,._._ , .__ ... __
� iotal lnterest This Period $0.00 ! Purchases I 22 9�°k D I $0 00 SO q0
� � Cash Advances ( 24 90%R � b0.00 � f0�
Transactions continue on page 2 � P,L,D,F ���� Variable Rate.See re�xrse of page 1 for details
.. . __ . .... . . __._. . ._.. .... ._.._. ._ .._ _...'
PLEASE RE'IURN PORTION BELOW WITH PAYMENT OR LOG ON TO WW W.CAP{Sp�QNE.CQM TO MAKE YOUR PAYMENT ONLINE.
-�� 1 4121741b18574Q24 OS 07418444250�0101Q02
`j�p�'7""G. Account Number: 4721-7A16-1857-4029
Due oate New Baiance .r Amount Endosed ���,� advantage. Take eantrol.
_
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Nov o�,207 2 ;; $7a1�84 i 1 , �j � 1 Manage you�account onl9oe
;
_ , _ _ _ ; _. _ at www.capitalone.com �
f • Make payments
• Review accaunt information
• Manage your acmunt in privacy a�
� KENNETH R SNYDEft Ni°s
5169 E 'fRINDLE RD LOT 33 �ez54D
t1ECHdNICSBi1RG, pA 1705Q-3659 tepiYdl Qn@ BanK tUSAF. N�A.
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Please make cheeks payable to Capkal One Bank(USA},N.A.and mail with this coupon in the endosed env�lope.
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� CusGwner iervice i-800-903•3637 i �p 72-Oet 27 2412 3d Days m B�iing Cyde : ,
�� � www.capitalone.com ' ---. ___..� __._ _____
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- MINIMUMPAYMENTWARNING:IfyoumakeoMytheminimumpaymenteaKhpe+od,pu '
vdli pap rtvre in inte�est�d it will t�e pau Iongex to pap off}mu:h�az�ce.Gor�aanple:
� VE50 PI3�tltlei X7(XX�X7tXX-XXXx�3876 p�yment Amount Exh Period if No Appro�rimate Time to pay DtF Estlmaed �
rl NEW BALANCF MiNIMUM PAYMENT DUE UATE i hdditio�al thargas nre Made statement ea�ance iatalcost ,
__._— _.____. .,.._ _ — . _.�_ ,
$2,794.96 � M�nfmum Paymmt iz rears 5s.esa
� 5244AU Nov 18,.Q12 � -- �-
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' �Credrt lAmtt:$2,7pp.p0 Casfi Advana G¢drt i�m�i:52,700Dg YQU may have ro pay a late Fee of uR to 535.00 and your APRS may be increased uptothr
fl ) i j PanaitY APN af 74.a0%.
� �i �Availabie Credit 80 06 __ � __Avaitabie Credit for Cash Advances�86A6�i,
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a i Previous Balance Papme�ts and Credits Fees a�d Interest Charged Transactians New Balance
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� ' PAYMENTS,CREDITS�AD7USFMENTS FOR KENNETM R SNYDER�f2&78 4 '
$ ; [
i Call 1-80q-955-6600 and a specially trained agent will �
� j ' be happy to help you check you�kralance and make payments.
PEES (
i TQtai FeeS This Period 50.00 � ,
� INTERfSTCHARGED � ...,.._....- '-..."'_--�_..�_._.._�._..._------,__.__._ ....,�
� � Totai Interestihis Periad SG.OQ
� � 1NTERFST CHARGE CALCUTATION_`..--------_..._—�.
% TO7AL5 YEAR TO pATf Your Mnual Percentage Raffi WVN is the anrtual interest rate on your awount
� lotal Fees This Year 454.00 pnnual Permntage 9alance Subject to
��� Total Interest This Year S35t.98 Type of Balance ���,R} �ii�� intercst thuge
. .------°---------_ _ ._..____._
Purchases ; 77.9D%D 30.00 �i SO.pO
CashAdvances i 23.90°bD I 50.00 � f0.q0
I I� P.l,D,F=Varia6le flate.See�everse of page i(ur details
PLEASE RETURN POFTION BELOW WITM PAYMENT qR LOG ON TO WWW.CAPITALONE.COM TO MAKE VOUR PAYMENT ONIINE.
1 412174153b462876 21 27909b4DT3�00244003
R��p� " AccountNumber:4721-7475-3696-2876
Oue Dak New Balance Mmimum Papment Amou�rc Eirclaud
— ---, , __ _ . ___ .__—.\ ._� _�, Ta e a vantage. Take control.
Nov i B 2012 � $2,790 96 � ( $244.p0 ~ . Manage your accourrt pnline
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KENNfTH R SNYDfR N109
5Y69 E TRTNDIE ftD LOT 33 s3Z�s°
MESHANICS9URG, PA 17050-31,59 CapiCal One Benk (IJSA7. N�A•
�Ii���.Nid���r�111E�1������11��"'t�'•tll�i�Et'�'�3fE�hI�lEE1� Charlptic?yNC�28272-1083
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Please make checks paya6le to Capita(One Bank(USA),N.A,and mail with this zoupon in the enelosed envelope.
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BLtTE MBUIdTA�CN AH€STFIESIA ASSOC ����RD USiNG iAR GAYMENT ` '—
PO BOX 947 w.�.,c`� m�a ❑
CAAM$ERSBUI?G, F?A Z7201-0947 . Ma�«+�aao �
UIIDNIIMBER � Sf(URITYCO�E
RETURN SERUTCE REQUESTED aewnme �xauxr IXP.p1iE
. $7A?EFIENT 6ATE --PAYTHIS AMOUNT �� ACCOUNT N0.
CHA22—$MA
{$00}$27-3§�58 7�49i0 I2Jb1J12 267.9 31663—G
OAM—YPM CnRiiGESANOCRE6ST5MADEAF:EASTpiE�.1eN� SHt�NAMdUNT�
IJ�TE WILI APP�qR�N NF%T 6T11lEMEM. PAID HERE
RDpRESSEE: � MAKE CNECKS PAYABLE/REMITTO:��
25194
KENNETH R SNYDET2 $LUE �UHTAIH ANE5TFIESIA ASSOC
1321 FOX HOLLOW RD PO $OX 947
SHERMANS DALE. PA 17090-8929 CHAMBERSBURG, PA 17201-0947
p,rrldllih�u���IP�drIlydP�hd�����y�dlP�Pu��ll� os4e9 ��i��lu��i��q��ulnP4mhihi�r�Illdh�y����hunPlll�
�Please check hox if above addre6s is incorrect or insurance PLEASE DETACH ARO RETUBN TpP PORTION WITH
_ information has changed,and irWicate cfia`pg{sj on�averse sWe. �� YOUR PAY�ENTlN ENCLOSED ENVEI.OPE
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OB(O7/12 01922 .ANES NOM'INVASIVE I►�fA6I�P16fRltQIA7TON:THER 36E?.4q. 267�.94 6ANA�'SESDL
08It5{12 � Dexr4at NGVZ7A� SpLUTIUNS � �� .361�� �AI.EXANDER�.�SF"It�PNG ���:RD
OB/28/12 Deh:Fai HEALTH Ai�`R'SCA ..
09I8S7I52 ' Paymert#� HEALTH�t�#!£RSGA. .. � ,D4�.. . . � � . .. .
09/20/f2 Deductlb7 HEpLTH A►IERIGA. � 26?.9d-��� � � � �
44f20/12 �� HEAtTti AMERICA Afls3tlSTMEtr13. . . . � � $82,.t0-� . � � �
Piease PaY 267.9q
BLUE MOUN7AIN ANESTHESSA A5SOC
YC7UR ACC6UNT IS PAST DUE.PLEASE SENO YOUR PA'YMfNT WITNIN t4 p0 BOX 947
DAYS OR THE ACCOUNT WILI BE FORWARDED TO COLLECTIONS.IF CHAMBERSBURCa, PA �7207-09a7
YUU HAVE ALREADY SENT!N YOUR PAYMENT,P�EASE pt$RECaAitt?.
(800)827-3459 X4950
$AM-4PM
sTarEMEr�r
SEE REVERSE SIDE FOR IMPORTANT BILtING INFORMATION ��zea
eus o�ro� wm.sn eex �aawr� zrau.v.nw
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7075
DCA af Mechanicsburg,LLC Fac.�ity: 204 "
12p S.Filbert Street Statemeat Date: Q4/1212Q13 '� •.
Mechauicsburg PA 17055 Dne Date: OS/12/2013
Accaant Namber: 15118
AmonntDne: $195.p6
� �
Questions:(214)736-2'7b9
MAKE CNECK PAYABLE&REMfT TO:
03D63
�In,llf��9I�d111t��d1ldtl��1��d�.fil�'����Itdii��iu��1�lI �dl'U+II1r0�t'I'1��'�Ithlt��6����'9I��"IItdl�Ipn��II1L
Snyder,Kenneth i?CA of Meehanicsburg,LLC
S I69 E Trindle Road Lot 33 PO Box 713 i 5$
Mechanicsburg PA 1'7050-3659 Cincinnari OH 45271-3158
O P4EASE GHECK 80X IF ABOVE ADOqF$ IS INCARRECT ry�MDI pTE CHANGE5 ON @ACK. DETACH HER AND REiURN TM$TOP POflTipN WITH YOUR PpYMENT
USAENAL7-03A3l14�0009POJ1�828dtl1�o0136&NW307o-7076 ` � USINGTHEqETURNENVELOPEENCL08ED
FRQM T�tLI CLA1M AND DESCRIPTION CHARGES PAYMEN7'S ADJLiSTMENT5 BALANCE
b&/tN12 08l21/t2 387088-InCeater 520,635.05 51,111.80 $19,328.19 5195.Ob
BALANCE DiTE: $195.06
Q[7ESTIONS: (214)'736-2769 ACCOUNT NiJMBER: 1511$ FACII,ITY:DCA of MecLantes6urg,LLC
usr�wn�iosaae�a0000000aioseasmi�oo�asa aoow�o-�o�s
_ _
:RE"�?T^' �'AYMENTS ACCEPTE6 IN OFFICE-CALL pi7}231-8343 T6 MAKE CREDIT CARD PAYMENT-BIL�ING QUESTIONS CALL THE BILLING OFFICE
KANTOR and TKATCH ASSOC., P.C. Staterrent Date Chart Nurrber� Page
205 SQUTH FRONT S7REET 11/28/2012 SNYKE001 2
HARRISBURG, pA 17104-1B19
Make Check nd Pa �
Payable&Se yment Ta:
KANTOR and TKATCH A3SOCIATES, P.C.
205 SOUTFi FRC}N7 STREET-$th FLOOR
HARRISBURG,PA 17104-1619
KENNETH SNYDER ����ngt�estloesCsll:EKG.MHMGAlBILG.INGSHNiCE
Bitling OiFCe 7eNaphone Number:717564-0564
1522 FOX HOLLOW RD TOLLFRR�::9-87T-337�4&t3
SHERMANS DALE, PA 17090 FaxNumber:717-564-3735
Fnter Am�unt�f Payme�t 3 Gheck# Doctors Office Aceepts
�� Credit Card Payments
�H�� Okice Phone#:(717)231-8343
08t14/12 99232 H4SP SUB CARE IEVEL 2 106.p� -52.45 -44.29 9.26
"' Cq INSURANCE AMOUNT DUE
Patient: KENNETH SNYDER Chart Number: SNYKE001 Services ProHded ak w+RR�sBURG HoSPfI"AL-PD
Amount Paid by Paid By
Qates Procedure Procedure Charge lnsurance Guarantor Adjustments Remeinder
08/30/12 99254 HOSP CONSULT LEVEL 4 270.44 4.00 0.00 210.�
Merrt�er Respons&siCrty.please remit payment upon receipt of statement.
Patient: KENhtETH SNYI7ER Chart Number: SNYKE001 Services Pra�dedat: HEALTHSOUiHMC-B5
Amount Paid by Paid By
Dates Procedure Procedure Charge Insurance Guarantor Adjustments f2emainder
48/17/12 99222 NOSP INIT iNPT LEVEL 2 225.00 -98.41 -1p9.22 17.37
" COINSURANCEAMOUNTDUE
08/21/12 99232 HOSP SUB CARE LEVEL 2 106.q0 -52.45 -44.28 9.26
Merst�er R�nsib�ity.Ptease�emit payrrent upon�eipt of statemetit
CQILECTiON STATUS
.. _—..� . •---°—•._.—_
Past Due 30 Day Past Due 60 Days Past Due 90 Days ue
0.00 329.51 0.00 356.14
ACCOUNTS "PAST DU8 60 DAYS"WILL BE SENT TO COLLEC710N UNLESS
PAYMENT Af2RAPfGEMENT IS MADE WI7H THE BILLING OFFtCE: 71i�64-0564 Gnarc Nu oo�
IF PAYMENT HAS 9EEN MA�E RECENTIY, PLEASE�ISREGARD TH15 STATEMEN7,THANKYOU 32434
0
""NOTICE: TO ALL Cp PAY 8e SELF PAY PATIENTS""
IF Yt7Ut POLICY IiB�URE3 A 40-PAY AMOU+tT 8 IT IS NOT PAID AT TFETIME OF OFFIGE VISIT
ONLY t-CqUR7E5Y STA'fEhEttT W ill BE SENF 64R CQ-PAY&3HLF PAY°AtiENT$. 1GCQUNT Wtl�BE SENT TQ GO�IECTfON WI7HOU7 FURTHER NOTICE.
.. . _ . . . _ _ . _.
NEPHRdLOGY RSS(JC OF CEN PA(NC IF PAY NG BY REDR H FILL Olff BELQW•CHECK CARD TYPE USED FOR PAYMENT
PO BOX 517
,/� HAZLETUN, PA 1$201-0517 OTEp''-AF'0 P1a^_
ARD NUMBER� ^ CVY2 C�OE EXP.DRTE
IGFIRTUBE
NACP
G� NACP 6557
Page: 1 /2
01/18/13 $ 198.91
O�QOD�0226
,�id�����Pl��rl���h�lr�^tdhl����i���li�^Ur�hl���l�l�! �ake checks Payable and Mail #o:
KENNE7H SNYDER NEPHROLOGY ASSOC OF CEN PAINC
1321 FC1X HOLLQW R6 PO Bt?X 597
SHERMANS DALE, PA 17090-H829 HAZLETON, PA 18201-0517
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�Pieaase chedc bac it aorne infamatiwr is incorrect w tt�+eurarrce"vn«matlon nas �Please detaah atuf retum the top porfio�with your paymerrt.i
chsngeE and indicate change(s)on reveise aide.It you have ques6ons please pqYMEN7 pUE UPON RECElPT
conact us az (800)4S0$208.
PATIENT NAME: ICENNETH SNYdER,65b7 OFFtGE: NEPHROLOCY ASSOC OF CEN PA tNC
OBt011t2 PATEL ESRD 3RV 2-3 VSTS P MO 20+ 3pp,pp �264.g8 0.00 35.14 2
08/03N2 ROTHMAN SUBSEQUEN7 HOSPITAL CARE - 13t}.00 -116.72 4.OQ . 13.2&
OB/04/72 PATEL SUBSECIUENT HOSPITAL CARE 134.00 -116.72 0.00 1328
OBl05It2 SU6SEQt1ENT HOSPITA�GARE 130.00 -1'l8.72 p.D6 1328
0$/O6N2 MITAL HEMODIALYSIS ONE EVALUATION 750.OQ -139.80 Q.W 10.20
08107/i2 SUBSEClUENT HOSPITAL CARE 95.00 -85.74 O.pO 9.26
0&l98t12 HEMODIAIYSiS IN+IE EVALUATION 150.D6 -239.80 0.06 10.20
08I09/12 SUBSEQUEN7 H09PITAL CARE 95.0� -85.74 Q.00 928
08t10t12 HEMOpiALYSIS ONE EVALUATION 150,00 -139.80 p.00 1020
0$/1tN2 PATEL SUBSEQUENTHOSPITAlCARE 85.OQ -85.74 4.� 9.2&
08112i12 SUBSEQUENT HOSPITAL CAR[ 95.00 -65.74 0.00 9.26
0&13t12 HEMO�IAIYSiS ONE EVALUA7fON 150.00 -i39.88 0.�0 10.2d
08/14/12 SUBSEQUENT HOSP�TAL CARE 95.OQ -85.74 D.QQ 9.28
0$12Bt32 ROTHMAN HEMODiALY9IS CNE EVALUATION 15p,00 -133.80 Q,00 10.20 2
IR31TfAL H6SPITAL Cp,RE 1A5.00 -127.63 O.W 17.37 . 2
08/30l12 SUBSEGIUENT HOSPITAL CARE 95.p0 -85.74 O.qO 9.26 2
Td7AlS: $2,t55.00 $'1,956.Q9 $0.� $198.91
MESSAOES pND fNSURANCE EXPLANA710N CODE DESGfiIpTfONB
Inmurance�cn Cotlees: . .
2 CdnaUtatxe Amalyd - . . . .
INSURANCE INFORMATION ON PILE:
COMPANY PO�ICY# GROUP# EFFECTIVE �TATEMEPIT PLEftSE
DATE PAY
PRIMARY HEALTHAMERICAASSURRNCE 85065454601 10QOQ'10015 01/18/13 $'I98.S1 '
SECONDARY
. ._. .. _ . .. . . . . . . .
.. _ . _ . .. . .- �PAYkHieYY�MASiE.t�aROdi OISOOYER %LOUteELOw .
/ DO NOT fi�'\D PAYMENTS TCl THIS A�3Dl2ESS N�� Q���n(�1 ❑oiscwven�
l Dcpt. 1968� - ��,�
/ P/'y.O,1,Bos 37.79�1 j
1/UM1S� PA I��Y76 ��_�� ^- gqaNI�YCQ1EfH0'M
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For bi0ing questions call: (717)932-5955 � �� � � �
ar: {8?7)932-5955 9II3I2012 Cantinued 570777
Fax: (717)932-4856 `
OffSCeHour.>: 8:44APA-4:30PM cna�snr�cnmRSranoea�RSrA�a�ewr SHOWAkiOUNT,�
To pay your bill online and registerforeSta#ements, DATEWILLAPPEAPONNE%T5fATEMENf P/��D HERE
please visit us at: www.qita.com �MAKE CHECKS PAVABLE/REMIT 70:��
(EPl1��11�I�.��I���I��d.�1���qI(�lt�dli�j'I�������IIII�II��II ias�o.z
Quantum lmaging and Therapcutic Associates
� KENNETH R SNYDER P4Bos62365
� 175 LANCASTER BLVD. . Baltimore, MD212fi�-21G5
� MECHANICSBllR6 PA 17055-3562 („�,1f��11����I�I1���I�tIn1�I„��I�II���1�EuI������IdGn1
� Please check 60!�if above atlUress is incm�ect or insu�ance �+S�.�T��� PIEASE UETACH ANp HETUpN TOP POR'f10N WrtH
�ntanl8tion h2s chariged,and Intlica�change(el m�mverae�de. f�=i1�if11�w Y{R�S RAYMENT�i FNCLOSED ENi+H.�PE
Patie�t: KENNETH R SNYdER
Accou�rt:5707TY > id�dered At:CAR.
rac m
� Gotie �A Charge '" Ad'ustments Balanca
7/14P2412 71M0 CHEST SING�E VIE1Al',Fftt'3I�'1`!�l-,. 38A0 36:00
7J19/2012 718'16 C4fE3T'SNflt�l.�VIEW�RONT14i. 38.00 38.00
7/78fZ012 7107Q �HF.ST 5�9�ttFE1AY"Fl�t!!l�tTAF. 36.fl0 38.00
7J17J281Z 71010 GHEST"StTi�iLEV1EtiAt FRC�N1'FAL 36.00 36.00
7l1AJ2Q12 70d56 C7 SCAid 8t2JlItU 1iYNt)EhDNTRAST 'F98.Q0 188.f�Y
7/18/2012 71010 G}IEST 511+lC#I.,E VtEW�RCINTA� 38.00 36.p0
7/18l2Q12 T1010 CMEST SINC�Rl.E WIEW FR0INTA� 36:04 36.00
7/142012 71010 CHEST SIAIGi�E VIE1N FRONFA� 38.00 36.p0
7120l20/2 T1014 Ct1ES7 BtNtiLE ViEY$fR(iMT'A4 38.4Q 36.08
7/2212012 71p10 CHESTSINCiLEVIEUVFRONTAL 36.00 36.110
7J2112Q12 71014 CFFEST SiNt3tf VIEW PROPtTA�, 3$.60 38.Od
7/23/2012 71010 CHEST SINC3LE VIEN!FRONTAL 36.00 38.Q0
712$t2Q12 7}016 CHFSF SiN{3t.E V1EW FRONTA� 36.06 38.80
7/16/2012 36886 INSRTN OF NpN-TUNNELED CVC s 5 YRS 373.00 373.00
7116t20/2 7706� f�UORO t3U1DMCE FOR CVA P�GMTtREPLCN{N 82.00 82.06
7/16/2012 76937 US GUID VASC ACCESREQ EVAL VESSEL PA 318.00 316.ClQ
712At2612 38558 INSR7N TUNAlELD CYGW748UBCUT PORT>5 550.00 950.00
7/31/2p12 71010 CHEST 5lNCilE VIEW FRONTAL 38.00 38.OQ
8Jtt�12 71Qt8 CHEST StNC3LE VIEW FRONTAL 36.00" 36.00
8/2f2012 71035 CHES7 pECUBfTUS 52.40' 52.tM .
_8/2J20t2 7�0'18 GtIES7 SIN{iLE ViEW FRQNTAL 38.00" 36.00
8%2l2012 7'IC135 CHEST pECUBiTU3 52.00* 52.U4
8/2/2612 79010 CHEST SINf3LE WIEW FROMTA� 38.00* 36.00
8!2/2012 71035 CHEST DECUSITUS 52.�I" 52.SHI
SY.#l2012 77010 CHEST SWOLE V(EW FRONTAL 36.00" 36.00
8!4l2012 71Q10 CHEST 5lN4LE VtEW FRQNTAL 36.�` 36.06
8/5/2012 71010 CHEST StNGLE VIEW FRONTAL 38.00" 36.00
8fll2012 71010 CHEST SINOtE VIEW FRONTA� 36.OQ' 38.U0
8/Sl2012 36568 INSRTN TUNNELp CVCW/O SUBCUT PORT y8 95p.00" 950.00
St8l2412 770Q'1 �LUORd GUIDIVCE FOR CVA P�CMTIREPLCPAN 82.00• 62.00
BAI.ANCE DUE Contioued
PAY BY
THIS ttCCC3U�I+tF�14tAN6E GSYOUR. �. For biiting questians call: (717}932-5955
PLEASE REl�r PdAYMtEi!�T tN fU�4�t`G�W,L"C&►R or. {877)932-5955
oFFFCE IP PkYMEN3.AF�i'Ai�![3E�!tiBAMi�/fiR Fax: (717)932-d858
IN8URANCE INFORt�iIII�N is NL�E5SA1t`Y. Office Hours: 8:OQ RM-4:30 PM
Thase chargea shavrn vvlth an"*"irtdFcat�s pendi�ng insnrarn�: Ta pay your bitl online and register far eStatement
STATEMENT piease vis'rE us at www.qita.com
C � �� SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION
ras�o.a
-
DO NOT SE�'D PAXMENTS Tf1 THIS ADDRES5 — ��PAVIMG@YVIS�.MA$iFPCMDOR OISCOVElIyFiLLOIffBELOW —��
D� L 196R7 � Cl+na+��1 �M.s�cr.�o��� Gmscoven�i '��
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Q'�,l(5` �(� ��1�4�'} �JtRiilOIDEPHYME �—� J�—� MISiMpUIIEHpIGII
���(`y�'pI' �III �@I� !^`--_—.�— IfN N`IX�qNY�ENNRd --
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For biiling questions caii: (�17}932-5955
or: (877}932-fi955 9113/2012 $236Z00 57O777
Fax: (717}932-4856 —` "`
Office Hours: 5:00 AM - 430 PM CMANGESAND CpEDITS MAOE AFTEF STI+TF.M'cry' SHOW AMOUNT y�
DATE WILL AFVEAR ON NE::T SiAiEMER^�. PAID HERE "7
To pay your biii oniine and register for eStatements, '
piease visit us at: www.qita.com �MAKE CHECKS PAYABIE 1 REMFT TO:�
Quunlum [maging and Thcrppeulic Associalcs
,K:�.r KENNETH R SNYDER P08oxb2IG5
65"� 175 LANLASTER BLUD Baltimore, MA 2126�t-2t�i5
`�'�` MECHAhICSeURG PA b7Q55-3562 �„I�I�uI���L1��In,I��1�dd���ILIl���66dh�ddd�.��!
L��ill���l(1����(d�JJ���11��LLJt����1�II�„LIJ�J��ti
P�ase cMCic baz it ffipve atltlress is incorrect m irceurance + , pIEASE DEfACH AND HETURN TOP P4NnON Wfflf
intprtnctlon heg crys�ped.imq IMicate r.hange(s�on rererse altle. � Y6UH PAYMEM M ENCLOSED ENYELOPE
Patient: KENNETW R SNYDER
Account:870777 Services Rendered At;CAR
Dete C� Deecript[en C�� " Ad'usmtmen#s Balance
$/9/2012 76937 US GUlD VA3G ACCESREQ EYAt VESSEL PA 318.80' 318.00
8f9/2012 99744 CONS SED>5 YRS Ot1?19T 30�tN�tTEB 296.�' 296.d0
8lf412Q12 7102Q CHEST 2 VIENtS PA&LkTERAL 45.�3* 45.p0
&f7l2Q12 71Q10 Cf1EST SINGtE VREW fRt?FdTAL 36.84' 38.00
8130lZ012 7l420 CIiEST 2 ViEWS PA 8 LAT@RAL 45.d0' 45.00
$!29l2412 71014 CHES7 StNtiLE VIEW FR4NTAL 36.00• 38.00
CurreM 31 -88 61 -90 S1 -120 Qver 120 BALANCE DUE 52367.00
0.00 2367.00 4.00 0.40 0.00 PAY BY �r6ae Upon Receipt
HIS ACCOUNT BALAMGE ISYOUR RESPOtd3lBiLiTY. For billing questions call: {717}932-5955
LEASEREMIT PAYI�tENT IN FULL OR CALL OUR or: {877}932-5955
�FFiCE IF PAYMENT,Al2R111HGEMENTS ANplOR Fax: j79"7}932-d$58
aSURANCE MFORMATIdN IS NEGE33ARY. 4�ce Hours: $.00 AM-4:30 PM
hose aharges ahown wfth an"""Indicale pending insurance. Ta pay your biii oniine and register for eSta#ement
STATEMENT p�ease visit us at: www.qita.com
������������ SEE REVERSE SIDE FQR fMPORTANT BtLLiNG INFORMATlON
t98T0-4
Assoceates^n K%dney Qiseases, kiypertenf.ian
_ � '�x�RS,Y� �a« ��d,���e, ��� STATEMENT
_ 890 Poplar Church Rd Ste 2048
_ Camp Hill PA 17011
Billing Questians: (8fi6) 263-�721
Billing Fax: (941)355-52$p
- Appointments: (7�7) 695•p394
� *****�**•****""AI�T�**MIXED AADC 8d0 AA 577-1/1 P4 T3 MAKE CHECKS PAYABtE AND MAILTO:
L��III���III„�Id��II���Ld�I��L��LII�L���LL�dI�dIJ a„ssoclArESINKIDNEVDISenSe$,rnPERTENTION&
Ksnneth R Snyder INTENSNEGAREMEDIC�IE,LLC
1321 Fox Hoilaw Rd ��PU+RCHURCtit2DSTE264B
Shermans Dale PA 17p90-8829 CAMPHILLPA1701i
�FLFABF p1EGN B04 R�BOV@ MORE%I$INCQR11ECi pt IN911MNCE ������
�xrww�nox rw cwevarn,u10�xoK�re cruew[s w xevense woe 10/28/2012 •*102642 137.80
_-�._...____-_--_�..______._-_..____-_�.--._-__--_._-�_-__
tum P n � Y t
467084$ 7/24/201 98232 SUBSEGUENT FpSPITAL CARE 80.Op -52.45 0.00 -18.2 9.4E
4810548 7/2BI207 98232 Sl185ECUENT HOSPITAL CARE 80.pp -32.45 0.00 -18.2 9.2E
1Q848 7128I2dt 98232 -St�SEQUENT HUSAITAL CARE 80.00 -52.45 O.QO. -18_2 8.2E
48745d8 7I28128t 99232 51JBSEQU6M #iDSP2TAL CARE 80.04 -$2.45 0.00 -18.2 9.2E
4382�40 7/22/201 88232 SUBSEQUENT HOSPITAL CARE SO.Q4 -82.45 0.00 -18.2 9.2E
43823d0 7/23/201 99232 SUBSEQUENT HOSPITAL CARE 80.Od -52.45 0.00 -18.2 9.Yf
4320372 7/18/201 99232 SUBSEQUENT FqSP27AL CAflE BQ.pp -52.45 0.00 -l8.2 8.2E
4520312 7tt912G1 99232 �785EQUENT F�SPSTAL CARE SO.00 -52.45 O. -t8.2 8.2E
4320312 7J2p1201 59232 Si185EQUEHT Fq5P2TAl CARE 80.00 -62.A5 0.00 -18.2 9.2f
4320312 7/21/207 99232 SUBSEQ6IENT HOSPITAL CARE 80.44 -92.45 0.00 -78.2 8.2E
4128722 7/17/201 90935 HEMDDIALVSIS, ONE EVALUATION 130.EW -59.81 0.00 -81.9 Y0.2(
4068828 7l78l201 ) 99291 CRITICAL CARE, PIitST HOUR O�O.IyO -184.9t O. -2Q5.9 29.it
�
� i
Analysis OfAccountBalance
Z 0,2
:: „� 131 . 90
to uavs trom w�cetot 7�nkyouforsetectingAssaaatesit�KidneyDiseases,Hypertentian&intetuive
��n� �far,��rrr.tlie �ta�af: CareMeGiar�,LlCfaryaure,^.entheafthcareneeds.l'hisstatementre�ts
your most recent charges,as well as the balance now due.Patient balance is due
Associates in Kidney Diseases,Hypertentio� in full upon presenTatlon ofthis statement.As a courtesy,we have billed your
8 intensive Gare Medici�e, CLC i����mPany.Anyd�argesdeniedar�atpaidbyyourinsurencecompany
898 Poptar Church Rd Ste 204B wiii be trarts€erred to patient respo�tsit�lity.If you trave questions as fo how yaur
Camp Hill PA1T011 insurancepaidorelectednottopay,pleasecalltheinsurancecompanydirectly.
Billing pupstions: (866?263-0121 Forquestionsregardingyouraccountnotrelatedtoinsurance,pleasecallour
Biili�g Fax:(S44}355-528Q tk�siness ofHce{868}263�4t2a,Mar�dBy-��day beM�een 9:tk3 am and 4:30 pm.
AppointmBMs: {Tt7) 695-6394 Thankyou!
s�nvsi
_ _ .
'MYSI�:IANS C1F HEMABI�,�,TR.TION, INDUSTRIAL&SPiNE MEDlCINE, P.C. STATEMENT
75 Lancaster Bouievard 4310 londonderry Road Mic�aei F.�upinacci,M.D. STATEt�tENT DATE PaGE
'.O.Box 2028 Bloom Bidg.Suite 106 Willlem A.Rollt,Jr.,M.D.
Aechanicsburg,PA 17055 Harrisburg, PA 17109 Williem A. Pomilla,M.D. a^-,,,!/iZt,°.j/1,� 01
7t7}691-3755 (717)561-4242 �9sa A.Eaton,PsYD www.prismdrs.com
3illing Dept:(717)591-4405 Tax I.D.ri25•1651500 ACCOUM ry
PleeBe�9taln thi3 pORi0f1 Of 8tAMmO�t fOf you�I'9COfdS. NUMBER ijlEi�'"-'.J�F 1
I6ACTION DA7E INV.Np. POS. PATIENT DR. PRp4"EDURE DESCHIpT70N OF$ERVICES DIAGNCISI5 AMOUNT
REV I I�US BflLFiNCE f v77. 7k
?ASE CR � 5 1— 4�D5 WI H UESTIONB B TWEEN 8:30 fiM-4 F'M
_L US I ° WE AR '" MEETF C� DUR IVEEDB; www. prismdrs. com
ZS RALA CE IS UERDUE dPM1t�T RRYM 'F WI�.L AVOID
_LECTSp �'k CE URES. �l.E SE CONTRCT US NpW.
i Q�7. 74 �� �� 107. 74
t�r �aeoATS �ae�uArs oat�eovwrs ov�na��rs �Yes o�E
PLEASE DETACH AND flETURN THIS PORTION WI7H VOUR flEMITTANCE
ACCOUNF NQ.
@62541 �
0CI05t13
KENNETH R SIVYDER
1321 FOX HOL�OW RD f 107. 74
SNEftMflNS DA�.E, Ps� 17C9`3�IJ
PLEASE MAKE YOUR CHECK
PAYABLE TO PRISM.
IF GAYINO BY MA81'FACAR0.DIBCOVER,YIBA ORAM[ItlCAN ODREB&FLLLQUT!lLOW.
�-.PHA DIACINQSTTCS LT.0 CHECNCAR6 USINQ FOR PAYMENT
�445 EAST PARK DR.. �w n:rKhno � q �� �u�.�ww,mr�eea
SUTTE 102 "
HARRISBURG,PA171I1-28U4 �.*oaE—'---"—"—'--'—"�" a..wtc
35346
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iziiana 217691
289 010t pAGE: 1 pf 1 ' ��'
$5.i4
6580.588(PC��
w��ADDR@SSEE:�� �III� REMITTO; �II���
�I��I����qiihhmldnitll�it���nd�ii�mi�r�ln��l�d��ll� I�Iunlh���n�ili��p���I��PPrrilu�d��p,�dqqu���uii
KENNETH R.SNYDER ALPHA DIAGNOSTICS LLC
5169 E TRINDLE RI} 94S EAST PARK DR.
LOT 33 SLTIT'E 202
MECHANTCSBURG,PA 17050-3659 HARRI5BURG,PA 17111-2804
353-0b•T070XBF6COD6691
Q Please check box 'rf incorrect or insurance information has changed, and indicate change(s) on reverse side.
r
!(4 �GETl1�tt NB�AMR RESLIRN l'QR PQRTFt�t VMITM Y01lEi Px►Y#AENT +�
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If yon have any questions or cpacems aboixt you ststement please call 1-800-420-9729
osnsnz KE1v1VE'i'A Chest 2vw�;w/obllqUe views '71022 786.50 ADXPA 40.00 237
Fatient: 3NYDER,KEIVNETFT R-217691
Servicing Provider:ALPHA DIAfixNOS'TTC LLC
09l11l2012 Advantra Z2.85
Coordination of benefits needs updated
1dJ23/2012 Advantra 14.38
Balance Dne reflecta the Ca-Insurance
08/24/12 I�NNE�1'H Cheat 2vws;w/ob$Qae views 71422 786.05 ADXP'A 44.04 2.57
Parient: SNYI7ER,KENNETH R-217691
Serviciug Providet: ALPiiA DIAGNCtiSTIC LLC
Q911 1120 1 2 Advantra 22.85
Coordinaiion of benefita needs updated
10/29l2oi2 Advantra 14.58
Balance Due reflecta the Co-Ineurance
MAKE YOUR A�A������� SEf REVERSE SiDE
CHECKS * '�5 EAST FARK DR. � {F AN tNSURANCE
PAYAB4.E TO SUI1E IQ2 MESSAGE APPEARS ����4
I�fARR„{SBi3RC� PA T7i11-2$U4
COMMENT5:
Batanee is seriousiy past due
23 7691 � � 5�.14 �
, .
I��I��r�1�1/�r�/1!
41ea5a Remit PaYment?a�� � .. ... . . . . � . � .
�
CumberEand Gaadwiil Fire Rescue EMS
Si1}ing Office 12-178277 1124l2013 $253.75
PO Box 726
New Cumberiand, FA 17070-072&
QUESTZONS ABOUT TMIS BILL? Phone: $77-214-6Q18 Espanol: 866-724-4114 Fax: 717-214-6020 Email: info@ambulancebillingoffiqe.com
Date of Sefvice: 81'i12072 12:55 PleBSe vi5it our website to prqvide insurance or make payment, and
Patient Name: SNYDER, KENNETH R. far additional payment opkions and frequently asked questions:
From: Carlisie Regionat Medical Center www.ambulancebiilingaffice.com
To: PinnacleHealth Hospitals
•
"*THIS IS AN UNRE50LVEl?BILL"*Your account has now been trartsfemed to our Coltection& Credit Deparement.
**IMMEDI�f TE ACTItJNIS NECESSARY**
'_`� �- -. .. ��::. ' �:�a '
8/01/12 ALS Emergency Tran5port-Lev 1 A0427 1.0 1,401.75 1,401.75
8/01i12 Mileage Ad425 24.0 12.08 289.92
14131112 Payment -1,437.92
Total 1,691.67 O.QO -1.437.92
QETACH AND RETURN 84TTOM PpRTtON WITH YOUR PAYMENT.
..."' ""'.,.-„ "4...�.... "."" .�.-..�" "n""' ,."""... �..,-,.��.�__�. .
We��t paWner�k�In Wtl bY'c�k."`aroiAt�Cafd ar�NlCtrtink Pisave Aaka Ur,�F 1hrYdOW't�i:
a�deauce�on.wea�e ma�sa�y�wr pewyment etswce neww � Cumberlartti Caocnlw�fi F`w+e
and flll In requ{red Inibrmatlon,fp other 8rrar�ements are R�us EMS
necessary,piease caii Us at 877 2i4-l401$,
12-176277 $ 253.75
� y� � c�cery�ar
Credit Card: C7 MAS7ERCARD ❑VISA ❑AMERICAN EXPRESS ❑DISCOVER Amount Paid:
Please make any corrections to address below.
_. _... __._ _ __'____ _._ .._ .. ... . . . . _ . .
" ` ` To the Estate of
�— ._,_---_
e�earontc chenc oeauct�on -•� KENNETH R. SNYDER
Please send a volded cheek OR provitle In(ormaflon below: �t+��_v..,�.. '�•3•L� F�X(„�fl�L�w R�}.
-.--.. ____ ____
SHERMANS DALE, PA 17090-8$29
�,. .,�,_ � �•, ��,rE,�
*Retumed checks—YOU wili be re5pan5ibie far aii incurred bank feCS permissibk untler state taw.
� HAMPAEN TOWNSHIP INVQICE #: 12p1860
230 SQUTA SPQRTING HSLI, RdAD
MECHANICSBURG, PA 1705d DATE: 11{27J2012
(717) 761-5343
TAR # 23-6050136
PATISNT: KENNE2'H 9NYI?ER
BILL TO:
KENNETH SNYDER
5169 EAST TRIN��LE ROAD
LOz 33
MECHANICSBURG, PA 17�56
ACCQUNT #: 85C65p54601 CONTROL �: 1201660 DATE OF SERVICE: p8/29/2012
PATIENT PICKED OP: LANCASTER BLVD MECHANICSBURG, PA 17d553
BATIENT TAKEN TO: HARRISBURG HOSPITAT,
3t natice SOf33J2412 2nd notice i1�28j2102
DE$CRZPTIO;: •::ZT CO3T'—QTY. AMOUNT I7UE–
BLS EMERGENCY 20I2 Ap429 700 . 00 1 .0 700 .00
MILAGE 2012 A0425 15 .04 &.0 120 .Od
Commeats: SECOND NOTICE - PLEASE SEND PAYMENT OR SUSTOTAL 820 .00
INSUBANCE INFORMATION. PAYMENTS CP.N ALSQ BE AMOUNR'
CHARGED. THANK YOU PAID 697 .0�
THANK YOU. TOTAL 123 .00
✓
WEST SHORE EMS - ALS (oiscaveR
�; 245 GRANDVIEW AVE � ,�
°�.�IC� CAMP HILL, PA 17011-170$
`�°� Pflone#: (800} 367-U512 Federat Tax ID: 23-2463002 �REVERSE SIDE
Vi�T SHORE
PnT1�r Narae: KENNETH SNYdER �w5uqnrlCe: ��TH AMERICA NMI
MEDICARE 6 �pyg�
CALL NUMBER: '�2��2J�/� pATE OF CALL: ���9t2D12
�oM: ACUTE REMA&HOSPITAL
70: HARRISBUFtG HOSPITAL
ACGOUNT SUMMARY
KENNETH SNYDER
5169 E TRINDLE RQ LOT 33 ToTA6 CMARGES: 7007.46
MECHANICSBURG,PA 17p50 PAYMENTS/ADJUSTMENTS: 0.00
PlEA3E AAY TNI3 AMOk7NT: "1007.4$
DETACH AlONG PERFOFATlpM ANB RETURN STUS WlTN PAYMEM7 _
Totsl Gredits O.fl4
P4EA3E PAY THIS AMOUNT-INVOICE DUE UPON RECEIPT —► $7007.46
RETURNED CHEGK FEE-$31.Od
PAr1ENT NAME: SNYDER,KENNETH R cnu Nua�s�a: 7215295A AMOUNt pA�p:
09/17/2012
IMPORTANT MESSAGES: A claim for this invoice has been sent to your insurance.
Payment may be made to you. Please remit payment to us.
Thank you.
WEST SHORE EMS-AL3 205 GRANDViEW AVE CAMP HILL, PA 17411-1788
o �,'[L�,4�—
� ❑Visa
� HO$PITALISTS OF CENTRAL PENNSYLVANIA � � �MasterCard
' P4 84X 62722 Gard Number �""""� Exp.Dm
I e BALTIMORE, MD 212642722
� Card Holder Name Signature
� m
, ^ FORWARQING SERVIGE REQUESTED
� tatement ete Pay Thb Amount eouM
� 12/OB/7Z 904.10 14d902478 - N4f!
� Payrt�ent ShawAmouM� � Bji
� 12/27/12 P d H e
�
� I11I'I11+�I�'1'I�I��"111I"I'I"I'I'I'II'I„"I'I'lY1'���,pryleg by crsdit aerd your neUpt wiii b�irom GloAei H�eith Menegem�nt S�rvk��.
� lliYtilti}4ftM 'f '1 HOSPI7ALISTS OP CENTRAL PENNSY�YANIA �
� a�� FoR a�ac �7a Po sox sz�aa
avuxa
� 6Al.TtMQRE, MD 212$4P722
SNYDER,KENNETN R
� 1321 FOX HOLLOW RD
' SHERMANS DALE PA 17090-8829
(]Piaase oheak ii adCress ar insuranse lnfarmatian
Is Incarrect and aomplete form on back. PLEA5E DETACH AND RETURN TOP PORTION WttH YOUR PAYMEN7
a��o�,�� #: 14Q302476! Piease Pay: �13Q�.1 U au� �$��: 12i27/12
P qments
Dete Descri tion Amount Ad�ustmenta
BAiANtE FORWARD lAST STATEMENT 36.42
07/16/12 99233 SUBSEQUENT HOSPITAL CARE LEVEL 20Q.pq
09/13/12 IN6N TNSURANGE 6ENIED 0.00
1Of31f12 SNCK INSURANCE CHECK -95.93
10/31/12 INWO INSURANCE WRITE OFF -$7.14
97I17/12
07/19/12 99291 CRITICAL CARE E/M 1050.OQ
49l13j12 INON INSURARCf DENiED 0.00
10;31/12 INCK INSURANCE CHECK -927.51
1Oj31/12 INWO INSURANCE WRITE OFF -311.63
or�zariz 99241 CRI7ZCAl CARE EfM 354.40
09/13/12 INDN INSURANCE pENIEU 0.00
1Oj31f12 ZN{K INSURANtE CNECK -209.2d
10/31/12 INWO INSURANCE WRITE OFP -103.88
07J21/12 94291 tRITICAI CARE E/M 350.Op
09/13/12 INDN INSURANCE QENZED 4.00
10/31/12 INCK INSURANCE CHECK -209.2p
1OJ31l12 INW4 INSt3RANCE WRZTE 4FF -id3.88
07/22/12 99291 CRITICAL CARE E/M 350.00
08J13j12 INDN ZNSURANCE pENTEO O.dO
10/31f12 INCK INSURANCE CHECK -209.24
10/31/12 INWO INSURANCE WRITE OFF -ip3.88
07l23f12 49232 H4SPI3AL DAIIY YISIT 150.04
09/13/12 INDN INSURANCE DENIEp 0.00
16J31j12 ZNtK ZNSURANCE CHEtK -6b.$5
A Ward About Your Accouot
BALANCE DUE UPON RECEIPTI
BAIANCE fS DE#.34UENT AN[}MAY BE GONSIDERED FOR COLLECTIONS.
T4tal NOw DUe 30a.10 �
Maks CheCka HOSPiTALISTS 4f CENTRAL PEHNSYLVANIA For Biiling QU$$t�OfiB {'i8��
Peyeble Ta: PO BOX 82722 {888) 610-$322
BAl.TtMORE, MD 212842722
PAGE 1 OF 2
P�Iifl-�5
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REC O�NA�L
Hcnitn� ccnTCa
� { •' • � • • ' •
Patient Name Kenneth R Snyder � pp��ne at www.carlislermc.com
Account Number 1237821 {availabis 24t7)
Date of Service June 04, 2412 �
Ssrvice Type Outpatient �Y P�one-71]-96d-1680
insura�ce Name Fieaikhamerica
Name of Insured Kenneth R Snyder �By credit card -campleta section betow and return
Policy Number 85065054801
Arnount Due From You $7&.64 (� gy�teck-retum sectian beiow with c�eck
($ • • � • •
Amount due from you is$76.64 as of 10l2212012 for The charges listed below da n refled the discount that
Outpafient perfortned on June 04,2012. you and your insurance company received.
Lab 76.8d
Totai Charges $76,64 TOTAL CHARGES $78.64
Discwunis/Rdjustments G�ven . $Q.04
Insurance Payrnents Received $0.4d
Amount You Paid $O.OQ
Amount Due From You $76.64
���� '� � 3269-HMASTMT-1491 72 7-1 314SBA202-P,6709015-1-523:32728334-t;t
'tl�s amount shown on this stabma�rt is oubf+andin�at thia 4�mr.lfour prompt
i►aymerrt wtI!bs greetiy appreclaited.
`t-
FOPt CR@6R CARp PAYMEFR,PtEABE FlLL WT 8EL8W...
°.�a� � °��R v��►° i� °�
� RII4F 381 Alexander Spring Rd. °""°"`"^eER e"'.
R�C(��C Carlisle,PA 17415 �
BIGNANRE 9ECORRY CODE
PATIENT NAMB STATEIAENT DATE DATE WE
Kenneth R 5nyder Eatate 10l22(2012 UPON RECNPT
Patient Financial Serv+ces:
ACCOUNT NUMBER AMpUNT bUE �UIOUNT PAYINR
�,u..,_ 717-560-1680 7237821 $T8.B4 `,_
:{.'7y� ❑CheckbaxrfeedressberowisincartactwchangeaanaMaicatncnergels;onbsck. B5a04&tlPCZ�
i�� RFMt7 TX1S PAYMEAt7 STtt6 70:
eao o,o, KENNETH R SNYDER ESTATE CARLISLE REGIONAL MEDICAL GENTER
1321 FOX HOtLOW RD PO BOX 261442
SHERMANS QALE, PA 1?490-$829 ATLANTA,GA 3{33$4-1442
Ill��t�dll�ll��l�I��+'���I����I�I��1�N�����i1�1�uI�i'IIllt�n� f I���lii�f t�l�I�i�t�Inllilll�+iti�Itlli�I���tii�t��1�NII�1�Ili)
�U0�01237$2100D�OOOZ664KENNETHRSNYDERESTATE 8
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\� ` R,EG�It�Nt�L�
�'—•�"�NfDI[nL CENTL0.
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Patient Name Kenneth R Snyder � pnline at www,cadistermc.com
AcCOUrrt Num6er �24529� (available 24/7)
Date of Service June 2fi,2012
Sarvice Type Outpatient � �Y Pnone-71'7•96p-168p
insurance Name Healthamerica
Name of Insured Kenneth R Snyder �By credit card-complete section below and retnm
Policy Number 65065054601
Amount Due Prom You $83.54 ��Y��-�tum section beiow with c�eck
tilJ • • � � . . . �
Amount due from you is$83.54 as of 10/22/2012 for The charges Iisted below do not reflect the disc�uni that
Outpa#ient perFarmed on Juna 26, 2d12. you and your insurance company received.
Lab 83.54
Tota!Charges $83.54 707AL CHARGE5 S83.54
Discounts/Adjustments Given $0.00
Insuran�Payments Received $O.dO
Amount You Paid $O.QO
Amount Due Fram You 583.54
���'..� � 3269-HMASTM7-1491721•i314$84321-P;8709016•7-524:32728334-t;1
The artwaunt shown on thls staYam�rM is aukshndMp at lhis#�ns:Yarc prompt
p�ynrNnt wiii bs 9�h+$PP*��•
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F6R GRFAIT CARD PAYMENT,Pt€A56 FIX.1.AUT Bd.4W.._
� OHTL'RCCAD O DIBCOVF.R �J�N N�.SA � �Mk'%
�R�'�y,�. 361 Alexander Spring Rd. °""°"u"'eER �.
ECIOT�W. Cadisie,PA 17015 �
&GNATIIRE SECURRY CpOE
PATI@NT NAME STA7EMENT 6ATE DATE DUf
Kenneth R Snyder 10/22/2012 UPON RECEIP7
� PB�I@Clf FR18I1C18I S81YIC98: ACCWNTNUMBER AMpU11TOUE NAdUNTPAYHiB
��� 717-960-1680 1245297 5�.54 '—
❑cr�cirr,orxmw,�ss to-row rs;.�orm«orzna�eea�d v�rate cha,g,te�on c«a.
REM/T TH/S PAYMENT STUB TQ: ssnaen�aczl
�xs3� 070� KENNETH R SNYDER CARLISLE REGIONAL MEDICAL CENTER
1321 Ft?X NOL�4W RD PO BOX 281442
SHERMANS DALE, PA 17090-8829 A7l.AN7A,GA 30384-1442
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GAR�NUMBER SIC3NqTURE CODE
ASII2V[�OFHOLYSPfRTf SHSYSTFM _...._..—_._..,__—...
2q5 GRANpVIEW AVE sicNnruae exa.on.e
�"�•'y� Sl11TE 210 3838-NNiSH
°Cr��� CAMPHILL, PA 17011-1708 STATEMENTDATE PAYTHISAMOUNT ACCLk
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09/13/12 $100.00 5009
52]94 pt07
SHOW AMQUNT@
PAGE: 1 � PAID HERE W
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KENNETN SNYDER SPIRET PHYSICIANS fiERVPCES INC
5169 E TRINDLE RD tOT 33 205.GfiANDVIEW AVE
MECHANICSBURG, PA 17�5fl-3659 SUITE210
CAMP HILL, PA 77011-1708
3898-MHSH*S7.W W8EHZ00080�
("(Pleeae chbck ho�t If edtl�ass is incorcect or&�suronce STATEMENT p�q$E DETACH AN6 f4ETURM TOP PORTION WITH YOt�t PAYFr�M
u�formetion hes cha�ped,and ir�aicate changeis)on raverse side. ,
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RECEIPT RECEIPT !N&. PAT.
DATE PATIENT DOQTOR CPT4 DESCRIPTION CHARiiE FROM INS. FHOM PAT. A6J. BAL BAL
08/02/12 Aennekh Pennpck 93680 US CAAOTZD DUPLEX SILATER $100.00 �0.00 �0.00 $100.Op
�
CUflpENT 30-84 DAYS 84�0 DAY$ 80-120 DAYS OVEH 72d pAYB TOTAL ACGOUNT BALANCE -
DUE FRBM PATIENT
$100.00 $0.00 $0.00 $0.00 $0.00 $700.00 $100.00
Thank Yau Fpr Your Payment. For Bllling Questions, Please Cell: (7171 972-4490.
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CMEpt CARD UStNG �((--��
FOR PAVMENt �� � � ��
CARLISLE PHYSICIAN SERVICES CAPD NUMBER nrnouNr
IJEPART'MENT 2124
P.O.BOX S 1�7 SI�NATURE 3 tlipA VIN�t EXP�ATE
BIRMINGHAM,AL 35246-2124
10/08/12 CPS9529634 1,143.p0
�"f� �t���"������t���l� Please send payment to:
***********************AUTO**3-DICrTT 170 CAI2LISLE PHYSICIAN SERVICES
KENNETH SI3YT?ER DEPARTMENT 2124
1321 PDX HdLLOW RD � P.O. B4X i 1407
SHERMANS DALE,PA 17090-8829 BII2MINGHAM, AL 35246-2124
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PATIBNTlNYC: IQMIlTH�NYOfR FAGLLRYNIIYE:CANLIBLEI�OWNAI.YEpCALL'EN7ER
. . . . . .. .. . _ . .
07/14/12 MIEICLEY $FffiR6HNCY AEPT VISIT - DR 1,082..Q0 1,062.00
48j49j12 PAYMBNT - ZNSURAt7{:8 0.00
09/07/12 $AYMENT - INSURANCE 0.00
01ji4j12 MZBRLEY ECG-ROUTiN& Wj12 L$ALSS; I 61,00 61.00
OB/09/12 PAYMENT - INSURANCE 0.40
08f07j12 PAYMENP - INSURXI7CE 0.00
This is your Emage�y Room Physician's bill which is sepaiate£rom your hospitai bi22. Your insurance company has pracessed yaur claim
and the balance is now your xesponsibility.
YQtJR PAYMENT IS NOW PAST DUE.
�����j� CUHH@lIBAlANCE
36DAY8 EG6AY86CY�1
1,143.00
CP39529634 0.04 1,243.6Q 0.00
� * * 2nd Attempt � * �
COREQCi6N EN LA MFORMqCION DEL SEQURO: Pa Mwr de pyyeemoe w�ip Ce k W�ala E9 ppuro m6tlid5. IMipUB ai al8pum M6dloo 68 prbnMo o aMUntlaAa.
4FFICE FIQt7RS:8AM-$PM MC}N-THtTR,and 8AM-bPM FRI Pap dnline>ffiecunmc Statemenis,Download Ivie3ical Records,
and Ou-line Accaunt Informafion all available now
Toll Free: 877-358-0145 with PaymentsMD PaNent Poital.
Ga ro hupsJtportai.paymenismd.comlapollomd
Para preguntas,por favqr Ilame al: 866-8533802 t",,et your medical hisYUry today with Patient Health Services Report
At www.paymentsmdcom.
�
pq�pLQ�,+y p�q�pp�r�qy You may pay your b�l onUne at hitpa//pay.inaWmed,comlPATHOI.OGYASSOCIATES
��.�/J��/� iMW19�YYINOII WI�MCWO.ILL01R�iOM
DO NOT SB.NU PAYMENTSlC4RRESP01'tDENC.'E T4:
Dept 13844 PO Box 1259 .��_._._ Q��
flaks,PA 19456 @'�'""
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For biliing questions call: 717-652-6105 2ll5120i2 $12.51 ,T, 33b4dI
Fa�t: 717-652-2165
Office Hours: Mon -Fri 7:OOam to 5:Odpm ���i��T �
PAtD HERE
Persanat&Carfide�rtial
rnP�il�Pl��rdllh�ll��r���y�n��l���l�h�rd�l�l�i�uin +� MakeG?udFsPayabXefio
� KENNETH SNYDER Pathol4gyAssociatesofCentralPA
� 1321 FOX H8LL6W RD 4520UmanLiepasitRd
„ SNERMANS DAIE PA 17�90-8829 ��8,PA F7111-2920
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�•*��u�romon�a R�w��raym�t#�*
Patie�st Name: KENNBT�i SNYDER
Services Rendered At: Pinnaele H�pital
Account#: 336401
BALANCE: $12.51
PAY BY: PAST DUE
**�'IMPORTAI�TT***
You may pay yoar b�71 oniine at https://pay.instamed.comJPATHQLOGYASSOCIATES
Your accoum is PAST DUE.Perbaps you have overlooked this balaace? Remember credit is one pf your most
valuabie assets. To pruteet your oredit,send payment in fuTt,or, camact our office im¢nediately to make satisfactory
Pa}nneaE anao$�neats•
PLEASE CALL: 717-652-6105
Pathol �y Associates of Central PA
4�!520 Union Depasit Rd
Harrisburg, PA 17111-2910
Please contact our offioe for fiuther details nn yaur account.
���,�,��r���� ,�_�
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�MAKE CHECKS PAYAB�E TO: � DATE 10H7/2012
RIVERSiDE AhlESTHESIA gALANCE DUE $6$4d.00 44105956
1 RUTHERFORD ROAD STE 101 SH4W AM4UNT
HARRISBURG PA 17109 DUE UPON i2ECEIPT pAID HERE
ADDRESS SERVICE REQUESTED
.. � FAYSYMkit "�-:� � � �
Card Numtaer: �
BILLlNG QUESTIONS: MONDAY THRU FRIDAY Exp Date (mm/yy): Signature Code:
PLEASE PHONE:(877}222-d217 Signature:
HOURS: 9:OOAM -B:OOPM EST
ADDRESSEE: ❑�� ❑ V►SAi p rj��
—. �,��b�lrl��P.�I11���nE1�1�4Ei��I��Iry.t��hP�yh{.����h REMITTO;
��. 000003p0]00069tl2]3]31Y090BBt921--T12AA1D6B6�B53�STMT1
KENNETH R SNYDER
1321 Fox Hollow Rd RIVERS.IDE ANESTHESIA
Sherrr2ans dale PA 17090-8829 1 RUTHERFORD R4AD STE 10i
HARRISBURG PA 17109
E-mail: Customer.Service@AnesthesiaLLC.com PAGE: 1 of 1
❑Please check box if aGOVe address is inqorrect or insurence � pLEASE DETAGN AND RETURN TdP PORTIQN WITH YOUR PAYMENT
ortormation has cnangetl,and indiwte change(s)fln reverse side.
KEEP TNIS PORTIOM f�R YOUR flEGtlRO&
IMPORTANT - Bil! for Anestt�es�a and(or Pain Management Services
If you have already paid this balance, please disregard this biil. If indicated insurance information is i�corract or
missing please submit using form on reverse side. if you receive the insurance payment, ptease forward tp the
abave address. Payment submitted with restrictive natation is subject to review. 'Your account is still outstanding,
please remit payme�t in fuit.
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PRtMARY INSURANCE
HEALTH AMERICAlCLAIMS
P4 BOX 7089 LC?NLtOtd KY 44742
POLICY: 85Q65054601 GROUP: 100401Qb15
812t2412 3655fi INSRTIdN NON-TUNNLD CNTRI.LY 1N 480.d0
8/2I2072 36820 ART CATH/CANNULAT SAMPLING MON 340.QQ
8/912012 76937 US GUID VA5C ACSS PTNTL ACSS S 100.00
-- -- -
8/2I2072 93813 ECHO REAL-TfME TRAKSESOPH;PLC 200.04
8/7J2012 93503 IN3ERTION&PLCMT FL,OW DIRECTED 1000.00
8(9l20l2 TO TRAGKING ONlY -506.00
9i11/2072 NR NO RESP TQ REQUE3TED INFO 5800.00
81Tt2012 3320fi Anasthesla Servlce 14U6A0
9H112012 NR NO RESp TO REQUESTED INFp 1000.04
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1 RUTHERFORd ROAp STE 101 $6800.00
HARRISBURG PA 171p9 —.--
�. �� PATIENT:44108956
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� MAKE CHEGKS PAYASLE TO: � t}ATE 11/2172012 nCC6uNT r�unes�R
RIVERSIDE ANESTHESIA BALANCE DUE $44.25 44143353
1 RUTHERFdRD ROAD STE 101
HARR}SBUF2G PA 17109 Di1E UPON RECEIPT SH4W AMOUNT
ADDRESS SERVICE REQUESTED PAID HERE
PAY BY tAAIL.
Card Number. ��� �
BILL.ING QUESTIONS: MONDAY THRU FRIDAY Exp Date(mm/yy): Signature Code:
PLEABE PHONE:{$77)222.4217 Signature: f
HOURS:S:OOAM•6:OtlPM EST �,�___,
�' � `.:J
RDDRE3SEE: ❑ ❑ �/!SA ❑i
� P�I��.��q�l.yilllllihlur��,.�hi�,n,�l.�.�d�l�„llll���li REMiTTO:
�� 00080200fa00I243Zt951YWpe92931—YtIDEECPF33A335TMT1
KENNETH R SNYDER
1321 Fox Hollow Rd RIVERSIDE ANESTHESIA
— Sherma�s Dale PA 17090-8829 1 RUTNERFdRD ROAD STE 101
— HARRISBURG PA 17109
E-maiL Gustomer.Service@�lnesthesiaLLC.com PAGE: 1 of 1
❑Please check box if above atldress is incarrect or insurance � p�,EASE DETACH AND RETURN TOP P�RTION WITH Yq�R PAYMENF
mfprmatipn has chznged,antl indicate change{s)on reverse sitle.
IIEEP THI$PqHTlON P�R YOUR flfC�NOS
(MPORTANT - Bill for Anesthesia and/or Pain Management Services
I if you have already paid this balance, piease disregard this bill. If indicated insurance information is incorrect ar
m�ssing ptease submit using form an reverse side. lf you receive the insurance payment, piease forward to the
above address. Paymenk submitted with restrictive notation is subject to review. **' This is your LAST AND FINAL
notice, please pay the balance in fuii. *°`
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PRIMARY INSURANCE
HEALTN AMERIGAtCLAiMS
PO BOX 7089 LqNDON KY 4Q742
I POLICY: 85065054601 GROUP: 1000010015
(
9f11f2012 NR NO RE$P TC!REQllE3TED INFO 100Q.40 '
70N3/2012 FtQ NEED INS INPO SUBMIT FORM -1000.00
'10t1312012 T� 7RANSFER 1000.d0
10/31/2012 CA COMMERCIAL ADJUSTMENT -705.00
16131t2012 CC APPLIEO TO COINSURANCE dd.25
10/31/20i2 CP COMM6RCIpL PAYMEKT -250.75
'1'l/5/2012 AT AUTO TRANSFER Fi20M PATIENT 7p •1000.00
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� 1 RUTHEF2FORd RdAD STE 1Q1 $44.25'
HARRISBURG PA 17109 . T�
��. • PATIENT:44148353
..._.._�._----
-�_,_,,� �� • � � • • 1
INTERNISTS IIF CENTRAL PA 04/OSj13 ' 70326 $
108 LOWTHER STREE2
, �
LEMpYNE, PA 17043
221.92*
Forwarding Service Requested MC VISA _Disc Security
Card� , � � � Cade
� Sign Exp _/_
�ESTATE OF KENNETH R SNYDER
5169 E TRINIILE RQAB LOT 33 . INTERNISTS OF CENTRAL PA
IiECHANIC3BURG PA 17454 108 LOitTHER STREET
LEMOYNE, PA 17043
• •• , •
�.._.,_.. _.....�. �,_�._.�__ ____.�_.�...__...:.___.�__.�_._...___.^._.��_.--....__
ME86AOESEXPWNEO ��-BEL41M
� • � • • � • � �
10/03/12 Medicare Payment O.pO
14J30112 HEAI.TFi At�RI Payaent fi1.04
18J30I12 Acce t Assi Adj. -25.19 10.77*
08/22/12 1 2 HOSPITA� SUBSE�UENT CARE 99232 421.9 97.04
SOJ03J12 Hedicare Faqment d.00
10/30/12 IiEALTH AtiLRI Paywent 61.04
i4J34J12 Accept Assiga Adj. -25,19 20.77*
08/23/12 1 2 L HOSPITAL STJBSBQUENT CARE 99233 421.9 130.00
lOftl3fi2 Hedicare Payaent 0.00
1dj3U112 HEALTH AMERI Payment 87.59
10/30/12 Acc•pt Asai�n Adj. -26.45 15.46*
osi2al�2 1 2 HOSPZTAL SUBSEQUEKT CARE 99232 421.9 97,00
10/03/12 Medicare Paymeat 0.00
1OJ30J12 HEALTH AMERI Papment b1.44
10/30/12 Aeeept Assign Adj. -25.19 10.77*
OS/25J12 I 2 HOSPITAL St3BSEqUEtiT CARE 99232 42i.9 47,00
idj03j12 Hedicare Paymexit O.OU
10/30/12 FlEALTH A2SERI PaymenY 61.fl4
10J3dJ12 Acca t Assign Adj. -25.19 10.77*
08/26/12 1 2 HOSPITA� SLTBSERUENT CAItE 94232 421.9 97.00
id103112 tfedicare Payment 0.00
10/30/12 13EALTH AlfERI Psyment 61.Q4
1QJ34j12 Accegt Asaign Adj. -25.19 10.77*
08J27/12 1 2 H09PITAL 3IIBSEQIENT CARE 99232 421:9 97.00
1Of43/12 Msdicsre Psy�eat d.t�
10130/22 SEALTH APtElki F�yment b1.�
io/sol�z n��mpt n..��n a��a��. -zs.i4 ia.��*
os/2sf�2 1 2 H45PZTAL $IIBSEQu�NT CARE 99232 421.9 9'I.UO
10/03/12 Medieare Payment O.OQ
lOJ3QJ12 HEALTH A2�RI Payment 61.04
io/3o/i2 Aecept Assiga aa�. -as.ig io.��*
L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Flease make payment,
DA7E LAST PY1R.? AIIpIMtf �
00/40/00 0.00 0.00 O.Q4 U.OQ 0.00 221.91 U.Q6! O.Q4 221.91
A��� INTEB2IZSTS OF CENTRAL PA . , , ., , �
He^cic ' 108 LOiiTHER STREET
°YAB1-�TOi LE2t0YHE, PA 27043 22I.91*
Ph: (717)-7�4-13b6
PAT� 1-KHNNHTH R SNYDER P$Y� 2-MIGHAEL L. 6LLiGK, 2i.D. Acct�: 70326
PAq� 12-RATNASAt4Y, PAIRICK, ?S.D. Dat�s 04/QS/1S
Pags 2 of 2
_ _ _
_
�F PAVMG BY MASTERCARD,DISCOVER OR VISA,FiL�ou�ne�uw. �
CHECK CARD USING FOR PAVMENT
� O STERCARp - D❑ISCOVER O V�ISA
CenVal Penn Management Group CARDNUMBER WVCODE MAOUNT
1600 Cloister Drivee '
Lancaster, PA�7UO� I51 NA UPE EXP.DATE
���
� ' 3 ATEMENT DATE PAV 7HIS AMOUNT ACCT.#
12/O6/12 $59.88 00280000000t 1576
06042 0202 SHOW AMOUNT —�
PAID MERE
853712�PC
� Pleaee Merk bmc M adCreae�incarrecl or Inwrenca InMmatlon Ms chenpeQ enA inAkate
tlienges m revme eltle
� ADDRESSEE: - �� REMIT TO: ��
Snyder, Kenneth R CARLISLE MEDICAL GROUP, LLC
5169 E Trindle Road PO BOX 281651
Lot 33 ATiANTA, GA 30384-1651
Mechanicsburg, PA 17050 I��'�'��������I'��II'�"��II���'�'I���'���I��I"���1��""'�I'�"
0028�0�00001157600059881206127
�
. Pbeae�detach and retum top portlon with your paymeM �
Date Desaiption qmp�M �nsurance Patient Line Item
Bai�nce Balance Balance
07/19H2 ENCOUNTER 55385 FOR KENNETH WITH
PARVIZ MD,3HEtKH SHEHZAD
07H9/12 99232-SUBSEQIfENT HOSPITAL CARE $129.00 $12.37
08/02172 Payment LB Commerdal(PR227(Infortnation $0.00
Provided By PatieM Insuffic))
� 08/02l12 AdJustment PPO(PR227(Informffiion Provided $0.00
By Patient Insuffic))
� 09H?112 Paymerrt LB Commercial $0.00
09/12/12 Payment LB Commeraal(N179(Add'I Info $0.00
Requested From Member))
09/12/12 AdJustment PPO $0.00
10I25/12 AdJustmeM PPO(PR2(Coinsurance Amount)) -$46.51
10/25/12 Payment LB Commercial(PR2(Coinsurance -$70.12
Amount))
07/23/12 99232-SUBSEQUENT HOSPITAL CARE $129.00 $12.37
08/02/12 AdJustment PPO(PR227(Infortnetion Provided $0.00
By Patient Insuffic))
OB/0?J12 Payment LB Commercial(PR227(Infortnation $0.00
Provided By Patient Insuffic))
09/12112 Payment LB Commercial(N179(Add'I Info $0.00
Requested From Member))
09/12/12 Adjustment PPO $0.00
09/12/12 Payment LB Commercial $0.00
10/25/12 AdJustment PPO(PR2(Coinsurence Amount)) -$46.51
MeSSBge: TOTAL ACCOUNT
For Biiling Inquiries Please Call 717-519-1550 BALANCE
559.88
PAYMENT DUE UPON RECEIPT-THANK YOU
NIlYAl11YR}I$yNY ..,, .....nt.. .roenn-..n.ne�nn�o o.co1�n09_1A0�'19AdQRdIL9• 1
�/' � r • i
Uro2ogy Of Central PA 09j27/12 130�74 �
P4 Box 458
Camp Hill, PA 17001-0458 �
175.04*
Address Service Rcquested MC VISA Diac �AmerExp Security
Card� _ � ' _ Code
Sign Exp �/,
4831
ESTATE OF KENNETH R SNYDER Urulogy Of Central PA
5169 E TRINDLE RD LOT 33 PO Box 458
HECHANICSBUitG PA 17050-3659 Camp Hill, PA 17001-0458
s •
--__________...�.____.__. _...._._.__.m___...._.._...�...�..._---_._..__.._._..__._..._.__.�__�._____,`.._.....__..�...�.. ._._...._.._______
MESS�1tiES E)(Pi,Jdti�,p �,ELOW
, � s � . � y
*** PAY ON-LZNE AT WWfi UR�L�(; OMJP�Y $�M ***
**�f*ie**i�irir4r***ir*�tie***at�t�***ir*�t����e�**** *�# ****�rair*�t&*******#te***ir*ir**ir***#*******ir
08J17J12 1 23 OFFIGE VISZT AtEW LEVEL 3 99203 599.71 175.d0
09/17/12 HEALTfi AMBAI Payment 0.4Q I75.4Q*
)aTEUlBT'P� ANOUNF �.
ao/ooloa o.oa i�s.00 o.00 o.00 o.00 o.00 o.oa o.00 izs.00
Urclagy Of Cantral PA • � •� � �
�cK PO Box 45$
�r�e�ero: Camp Hill, PA 17p01-U458 275.00*
Ph: (717)-724-4684
PAT� 1-RENNETH R SNYDER PRV�� 13-OWENS, R. $COTT, H.D. Acct�: 130774
Date: 09/27/12
Page i af I
Please Remit QaymentTO�.� .. . . .. . � . � . . .
Speciai Event Emergency Medicai Services
Billii�g Office 12-184b$0 1?J812012 $82.50
PO Box 726
New Cumberland, PA 17070-0726
QUESTION5 ABOUT THIS BILL? anone: 877-214-6018 Espafioi: 866-724-4114 Fax; 737-214-6020 emaii: info�ambulancebillingoffice.com
Qate af Service: S114t2Q12 48:12 Please visit aur website to provide +nsurance pr make payment, and
Patient Name: SNYCIER, KENNETH R. for addikional payment options and frequently asked questions:
From: PinnacieHeatth Hospitais www.ambulancebii�ingoffice.com
To: NEAL7HSqUTH MECHANICSBURG REHA
•
**THIS IS AN LTNRESOLVED BILL"*Your account has now been transferred to our Collection cg CreditDepartment.
#*IMMEI}L4TEACfifC3NZSNECESSriRY*"
.- • . •
8114/12 Wheelchair Van Transport A0130 1.0 60.00 6Q.OD
$t14712 Mileage S0209 9.0 2.50 22.50
Fofat 82.50 O.dO d.00
DETACH AND RETURN BOTT6M PORTION WFTH YOUR PAYMENT.
"".... _......_.._..,,. -.-...... """'. ",._,.�._ �.,...."' ""'� ,-r-^,� ��
.VYtl a�pt PbY'�!n f�np'hY dYwk,*C�eMt�tatd iN'�k # �Se�J�IeI�€.!"is�t A2lyN6k'iif
citeck xie:ducHbn P18aiae iti�e your��ettt#+WtB 4etow � �j�{�,1t�tt�t�BCg8t1Cy
and flli i�requked Infur�matlon.I(other awrangements nre ��i�4�e���nC
necesSary,piea�cali us at 8T7-2i+{-8038.
12-184580 $r 82.5Q
� y'�' � ���
l`!��J
Credit CaM: ❑MASTERCARD CI VISA ❑AMERICAN EXPRESS ❑DISCOVER Amount Paid:
Please make any correctipns tp address below.
_...... _—....___. .... . _ .._ .__ ..—....._
` ' To the Estate of
Eiectronic CHe�k Detluction �� ���� ',•�.) KENNETH R. SNYDER
Please seno a widee check pR p�oNde in/armatian belaw: �_v.-_� �321 F{�X y��L{��lj R�.}.
---- --_ _ _ _
SHERMANB DALE, PA 17090-8829
,., � ,.. ; �-.., ��_�
*ReNmed checks—YOO wili bc resGOnsibie for a1i incurtcd bank fEes permi5s16ie under SCaie Vaw.
_
P.O. Box 140p65 000ia7
t�rash��tte,'rtv3721a C C'APlTAIACCOUNTS
I ������� 866.854.5359(phone)•800.296..i317(far)
,� � �
z
�u����y�r���xiu������rnu�Eu��ii���nu������������u�����
39723"**AUTO•"MIXED AADC 3S0 T)ate: 12/21J2012
Kenneth R 5nyder 5
51b9 E Trindte Rd Account: 677805
Mechanicsburg PA ]7Q50-3G61 Clien#:Carlisle En#Associates
Balanoe: $429.29 settie for$343.43
Settlement OiTer
C1ear Kenneth R Snyder:
We are pieased ta offer the above listed settiernent on behaif af aur client,Carlisle Ent Associates.This offer is good for 10
days from the date of this letter. We are not obligated ta renew this offer.
By ciearing up this deiinquent obligation,any negative credit reporting with the 3 national credit bureaus to reflect your
updated payment activity.
**"tf payment arrangements are necessary,you may reach us totl free at 866.$54.5359 or explore options online at
www.c ital6i!{�y.com***
This communieation is an attempt ta coClect a debt by a debt eoilectqc Any infarmation obtained will be used for that putpose.
Pay by phone at 866.854.5359 Direct all paqments to Capital Accaunts
SEE REVERSE SIDE FOR IMPORTANT INFORMATION
RETURN BdTTOM PORTION WFIEN PAYING BY MAIL
Kenneth it 3nyder Visa[ ]MasterCazd( ]AMEX[ ]Discaver( ]
5169 E Trindle Rd Card Holder Name:
TvEechanicsburg PA t 7050 Card Halder Sign�ture:
fR6DIT CARD NO.:
1��1����� DOCiC�CIOCI�C�C�C���C�LJ�
EXPtRATION DAtL: PAYMENT AMOUN'P:
❑0�❑ $
I�iP��9�1'il'I��I.Iq�i��i��I�����„�I�I��������II�'I�fi18II��� Account Number : 677845
Capitat Accounts Amount : $429.29 settle far$343.43
PO Box 140065
Nashville TN 37214-0065
SL7_04
. . . . . .
PINNACLEHEALTH CARDZqVASCULAR INST, INC Qljl$/13 131109 $
1000 N FRqNT ST �
WORMLEYSBURG, PA 17043-1034
405.59*
Addresa Strvice Requested HC VISA _Dise Security
Card� _ _ _ _ Code
Sign Exp �/i
ESTATE OF RENNETA M SNYDER
2321 FOX HOLL041 RD PIId1VACLEAEALTH CARDiOVASCULAR INST, INC
�SHERMANSDALE PA 17090 lOQO N FRONT ST
WORHLEYSSURG, PA 17043-1q34
• � •� • • r
--_._.___...._._...._..._....__._. ....__..._..__................------------.....-- _ -- ---°-._._..--------_....---_---._.._-......_....._.:__......_._..___......_-..._._.....--°-._.....- .._ --
MESSAGE$EXPLAINED � 8EL4W
� ' ' - � • • • � r• � •
S1JOlJ12 fIEALTH At�RI Payment 4.05
11/O1/12 Accapt Assign Ad . -64.24 0.71*
U$J02J12 2 207 L Dt3PPLER ECHO LZtiITF.�f 93321 424.1 35.00
08/27/12 HEALTH AMERI Paym�nt O.QO
04(1$/12 IiEALTH At1ERI Paysent O.i10
11/O1/12 HEALTH At�RI Paymont 8.40
i1f41/12 Accept Assi Adj. -25.22 l.k$*
08/03j12 1 19 L HOSPITAL SIIBSE�UENT CA1tE 99232 424.0 90.00
U8/27f12 HEALTH A2�R Paysaent 0.04
o�tr$!iz HEkLTH Al�RZ Paymont 0.00
11/O1/12 HEALTH AtSERI Payment 74.53
11J41J12 Aecept Assign Adj. -2.32 13.1i*
08/04/12 1 19 L HOSPITAL SUB58QoENT CARE 99232 424.0 90.Od
08J27J12 HEALTH AtiERE Payment 4.00 '
09/18/12 HEALTH AMERI Fayment 0.00
11J01J12 FIEALTH AMI:RI Payment 74.53
1FJ01/12 Acce t Asas n Ad -2.32 13.15*
08/07/12 1 6 L IxSERT �ACEMAtC�R ATI�IAL & 33208 424.Q l075.04
ostisfiz $EALTK At�SERi Payaisnt o.ao
10/25/12 HEALTH At�RI Payment 600.43
14jZ5J12 Accept Assign Ad -368.61 ldi.96*
08/29/12 1 5 L HOSPITAL CONSULT IN�TIAL 99253 786.05 140.00
Q9f2$/12 FIfiALTH AMERZ Payment 0.00
10{25j12 IiEAI.Tfi AIiERI Payesnt 119.00 21.00*
08/30/12 1 5 L HOSPFTAL 5UBSEQUEHT CARE 99233 7$6.05 120.Q4
14125Ji2 EEALTH AtSERT Paysont 10z.00 18.00*
08/31/12 1 5 L HOSPITAL SUBSEQUENT CARE 99232 �86.05 94.Otl
a911811z xEat2H At�ttT Paqmeat O.dO
10/25/12 TiEALTH AHERI Payment 74.53
1OJ25J12 Accept Assign Adj. -2.32 13.15*
L-The 'PLEASE PAY' includes unpaid co-pay or co-in�. Please make payment,
ATE LAST PAID AMOUNT
00/00/40 0.00 0.00 0.00 405.59 0.00 0.00 6Q0.00 0.00 1005.54
� PINNACLEHEALTH CARDI4PASCULAR INST, INC . , ., a �
ecK 1000 N FRQNT ST
,AeL�*°: wo�LE�ss�c, PA i7aas-ios4 �os.sg*
Ph: (717)-73I-0101
PAT�� 1-AENNETH t4 SNYDER PRV� 17-RADTRE, NANCY, 19�, FACC Acct�: 131209
PRV� 19-HAINI, BRZJESHWAR, I�ID, F Date: O1/18/13
PRY� 78-WALSH, TIMOTHY, 241, FACC Page 4 af 4
PRV��207-SKOTNICRI, ROBERT A, L10,
� _ . _
, . . . -
P1 N NACLEHEALTH Y4UR ACGOUNT t8 CURRENTLY DUE.
� YQUR PROMP7 Ai'7ENTION WOUtd BE
NOSPITALS t3RA7EFUl.LYAPPRECIATED.
Financial assisCanca is aveilabie forthe anit�surect
or undeAnsured who apply and qualiCy. For more
information, please cell or see our website at
www.pinnacieheafth.org/billpay.
KENNETH SNYDER porAc�aurrt infarmatiorr,
t32i FOX HOLLtSW RD ptease Cali Customer Service {7`97}230-3717 ar'
SHERMANS DAIE PA t709d-8829 1_800-8f13-9464 for Out of Area Calls.
See detaiis pn the back of this statemerlt.
tf paymerrt has tseen sent, piease disregarcl.
Pay an19�at:
htlps:!lhillpay.pinnaclefuastth.org
� • .
Pa6e�ri Name: 5nyder,iCenneth Totai Charges: t214,519.58
Stateme�pate: 72J31/12 Payments/Adjustmerits: #214,244.20-
Service Dffie(s): 08/01H2-08/14112 AsxouM Balance: �275.38
Accourk Numbe+r. +soosrasa Patierrt Balance: t275.38
Primary Di�nosis Code: 996.81 Please Pay This Ami: Sz75.38
. , .
ins. 1: MEDECARE A .Eip For questions, cali our Biiiing Help line at:
Ins.2: HEALTH AMEft1C .Op 717-230-37i7 for local cafl�or
Ins.3: 1-800-803-8084 for dut of Area.
ins.4:
Customer Service hiours:
Marr-Wed-Fri�:t30 AM ta 4:80 PM
Tues-Thurs 7:AU At�l io 5:00 PM
l�lease No!'e: Yow pd�ysipen will biN separ�atety for professiona!servicas_
Make Ch9dcs Paysbie Ta: PinnBdeiis8ith Hospitsts �°�p'""�� T °"""�""^"10p��
�nr:
.�_ $
i�lt�■M�I�NN���lII�� 3n .r Kenneth u RerRi
�� ���H��� ❑ a�o 0
Pi? Bou 2353 ,�,.
Hariisburg PA 1�iD5
slam.n: Au+eun[
❑ CMet iw itY��HtYr M iMam14 iRfenMHSn
k1�Wln�d. MrrmWrehMryrleaMet wTMCW2MdmMrNtMbcYSiplaaa�MbtlaF7�tMttaM.M7arVf��
�QUU1727 001 0.53
KENNETH SNYDER
ta21 Pax Hotlow RD t��dllnd���8iim.l«Ld6�1
SHERMANS DALE PA i7090-8829 PIh1NACLE WEALTti HOSPI"fALS
P.O. 80X 2353
fiARRIS$URC,, PA 77145-2353
II�QOD1300372R200UOBd27538ttt3C1�Q0[101
_ _
_
`�,{tl S T/q�
LAWYER � �
Sa�UT�6�s 4833 Spring Road � Shermans Dale,PA 17090 •p. 717.582.4006• f. 717.582.7476
e. mark@christianlawyersolutions.com • i. christianlawyersolutions.com
May 17, 2013
Register of Wiiis
Cumberland County Courthouse
One CauRhouse Square, Ftoam '€42
Carlisle, PA 17d13
Re: Esta#e af Kenneth R. Snyder
No. 21-12-0965
Dear Sir/Madam:
Enciosed please find the ariginal and two copies af the (nheritance Tax Retum in the
above-referenced Estate along with a check in the amount of$15 for the filing fee. Wiii you
kindly file the original Tax Return and provide a time-stamped capy to my office in the enclosed
seif-addressed postage prepaid envelope.
Thank you for your assistance in this matter. Certainly do not hesitate ta contact me
shauld you have any questions.
Very truly yours,
�, �����
rk W. Allshouse
MWAIsa
Enciosures
cc: Mr. Kenneth M. Snyder, Admin.
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