HomeMy WebLinkAbout06-11-13 1 1505610140
J REV-1500 EX (01�10'
OFFICIAL USE ONLY
Department of Revenue
Bu reau of Individual Taxes County Code Year File Number
Bu
Po Box 260601 INHERITANCE TAX RETURN 2 1 1 3 0 2 2 8
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
0 2 0 4 2 0 1 3 0 3 1 5 1 9 2 9
Decedent's Last Name Suffix Decedent's First Name MI
F A G E N L E 0 N C I A F
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
❑X 1.Original Return 2.Supplemental Return 3.Remainder Return(date of death
prior to 12-13-82)
4. Limited Estate 4a. Future Interest Compromise(date of 5.Federal Estate Tax Return Required
death after 12-12-82)
❑X 6.Decedent Died Testate ❑ 7. Decedent Maintained a Living Trust 8.Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received 10. Spousal Poverty Credit(date of death 11. Election to tax under.-Sec.9113(A)
'between 12-31-91 and 1-1-95) (Alt'doh Sch.O) :;a
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFDRM1 ANON SHOULD BE ggECFED TO:
Name Daytime'pephone Nurtiii--iii
W I L L I A M A D U N C A N 7 1 ?' 9—' 7 7 0
RECaISTg OF WILLSyl1SE§ALYn
First line of address `—` r
r-. h'T
1 I R V I N E R 0 W
csa �
Second line of address
City or Post Office State ZIP Code DATE FILED .
C A R L I S L E P A 1 7 0 1 3
Correspondent's e-mail address: billaduncanhartmanlaw•com
Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
R is true,correct and complete.Declaration of preparer other than the personal representative is based on all information or which preparer has any knowledge.
Il N OF PERSON RESPONSIBLE FOR LING RETURN DATE
ADDRESS
620 GREASON ROAD CARLISLE PA 17015
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610140 1505610140 J
1505610240
REV-1500 EX
Decedent's Social Security Number
Decedenfs Name: LEONCIA F . FAGEN
RECAPITULATION
1. Real Estate(Schedule A) . .. . .. .. . .. . . . . . . . .. . .. .. . .. . . . . . .. . . . ... . . 1.
2. Stocks and Bonds(Schedule B) . . . .. . . . . . .. ... . . . .. .. . .. .. . . . .. .. .. .. 2.
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) . .. .. 3.
4. Mortgages and Notes Receivable(Schedule D) . .. . .. . . . . . . . .. . . . . .. . . . . . 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). .. .. .. 5. 7 8 4 1 • 5 2
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . .. 6.
7. Inter-Vivos Transfers&Miscellaneous Nl��-1Probate Property
(Schedule G) U Separate Billing Requested .. .. .. . 7.
8. Total Gross Assets(total Lines 1 through 7) . . . ... .. . .. .. . .. . . . .. .. .. .. 8. 7 8 4 1 • 5 2
9. Funeral Expenses and Administrative Costs(Schedule H) . . . . . .. .. .. . .. .. .. 9. 1 5 8 4 . 6 7
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) . .. . . . . . .. . . . 10. 2 2 7 3 7 . 9 8
11. Total Deductions(total Lines 9 and 10) . . . .. . . . . . . .. . . . . . . . . . . . . . . . . . . 11. 2 4 3 2 2 . 6 5
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . .. . .. .. .. . . . .. . . . .. 12. - 1 6 4 8 1 . 1 3
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) . . . . .. . . . .. . . . . . .. . . .. 13.
14. Net Value Subject to Tax(Line 12 minus Line 13) .. . . . . . . .. .. . . . . . .. .. . 14. - 1 6 4 8 1 . 1 -3
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X.0 _ 0 . o a 15. 0 . 0 0
16. Amount of Line 14 taxable
at lineal rate X.0_ 0 . 0 0 16, 0 . 0 0
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 0 0 17. 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 0 0 18. 0 . 0 0
19. TAX DUE . . .. . . . . ... . .. . .. . . . . . .. .. .. . .. . . . . . . . . . . ... . .. . . . .. . . 19. 0 . 0 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Side 2
1505610240 1505610240
REV-1500 EX Page 3 Fire Number
Decedent's Complete Address: 21 13 0228
DECEDENTS NAME
LEONCIA F. FAGEN
STREET ADDRESS
620 GREASON ROAD
CITY STATE ZIP
CARLISLE PA 1?015
Tax Payments and Credits:
I. Tax Due,(Page 2,Une t9). - - (1) 0.00
2. CreditsrPayments
A.Prior Payments
B.Discount
Total Credits(A+B) (2) 11 -00
3. Interest
(3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT.
Fill in oval on Page 2,Line 26 to request a refund. (4) 0-00
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE, (5) 0. 00
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ......................................................................
b. retain the right to designate who shall use the property transferred or its Income; ............................... ID
c. retain a reversionary interest;or ........----.............................................................................. ❑
d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ IR
2. If death occurred after December 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ❑ IN]
3. Did decedent own an`in trust for'or payable-upon-death bank amount or security at his or her death? ......... ❑
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation?.—............--...........—...............—.............-................-.......... ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994,and before Jan. 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent[72 P.S.§9116(a)(1.1)(I)].
For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are stilt applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(9)(1,2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedents lineal beneficiaries is 4.5 percent,except as noted in
72 P.S.§9116(1.2)[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedents siblings is 12 percent[72 P.S.§9116(x)(1.3)].A sibling is defined,under
Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption.
REV-1508 EX.(8-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE
RESIDENT RETURN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
LEONCIA F . FAGEN 21 13 0228
Induce the proceeds of fdlgatbn and the date the proceeds were mceNed by th estate.
All property Joirdt -owned wMh dgM of survWorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION
OF DEATH
1. CORNERSTONE BANK ACCOUNT # 25664 51802 .01
[SEE DOD LETTER ATTACHED]
2 . HIGHMARK REFUND 92 . 00
3. CLAREMONT HOME REFUND 1,947 . 51
TOTAL(Also enter online 5,Recapitulation) $ 71841- 52
(If more space is needed,insert additional sheets of the some sue)
REV-1511 EX-(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
RESIDENT DE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
LEONCIA F. FAGEN 21 13 0228
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. HOFFMAN ROTH FUNERAL HOME 209. 48
2 • FUNERAL LUNCHEON 280. 57
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s) CONSOLACION HUSLER 473.06
Sheet Address 620 GREASON ROAD
city CARLISLE State PA Zip 17015
Years)Commission Paid: 2013
2. AbomeyFees: DUNCAN & HARTMAN, PC 473. 06
3. Family Exemption:(II decedents address is not the same as claimants,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. PmbateFees: REGISTER OF WILLS - 133. 50
5 Accountant Fees:
6. Tax Return Preparer Fees:
7. REGISTER OF WILLS — FILING FEE 15.00
TOTAL(Also enter on Line 9,Recapitulation) f 1,584 -16?
If more space Is needed,use addrdDnal sheets or paper of the same size.
REV-1512 EX.(12-08)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
TDECEDENT �E TAX RETURN
RESIDE NT D MORTGAGE LIABILITIES 8, LIENS
RESIDE
ESTATE OF
FILE NUMBER
LEONCIA F. FAGEN 21 13 0228
Report debts Incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses,
ITEM
NUMBER DESCRIPTION VALUE AT DATE
F DEATH
t. PA DEPARTMENT OF PUBLIC WELFARE OF
CSEE ATTACHED]
TOTAL(Also enter on Line 10,Recapitulation) $ 22,737 - 98
If more space is needed,insert adoillonat Sheets of the same size.
REV-1513 EX.(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
LEONCIA F . FAGEN 21 13 0228
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
1 TAXABLE DISTRIBUTIONS lindudeoul- In Idistributbreandtransfers under
Sec.91 16(a (1.2).)
1. CONSOLACION HUSLER Lineal
620 GREASON ROAD 1/3 SHARE
CARLISLE, PA 17015
2 . ABRAM N . LEHMAN Lineal
39224 ANCHOR BAY, UNIT C 1/3 SHARE
MURIETTA , CA 92563
3 - CURTIS G . LEHMAN, PMB 168 Lineal
P -0. BOX 439060 1/3 SHARE
SAN YSIDRO, CA 92143
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
11. NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART it-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed,use additional sheets of paper of the same size.
LAST WILL
TESTAMENT
I, LEONCIA F. FAGAN, of 620 Greason Road, Carlisle, West Pennsboro, Cumberland
County, Pennsylvania,being of sound and disposing mind,memory and understanding,do hereby
make,publish and declare this as and for my Last Will and Testament,hereby revoking any and all
other wills and codicils heretofore made by me.
FIRST. I direct that all my just debts and funeral expenses be paid from my estate as
soon after my death as practically and conveniently may be done.
SECOND. I direct that my remains be interred within my family s burial plot in accord
with my expressed wishes.
THIRD. I authorize my personal representative to expend funds from my estate, in such
amounts as my personal representative shall consider necessary and desirable for the purchase,
erection and inscription of a suitable marker for my grave.
FOURTH. I give, devise and bequeath all of my estate of whatever nature,be it real,
personal or nixed, and wherever situate unto my children,ABRAM N. LEHMAN, CURTIS G.
LEHMAN and CONSOLACION HUSLER, in equal shares,per stirpes.
FIFTH. I direct that any and all Inheritance,Estate and Transfer taxes imposed upon my
estate passing under my will or otherwise,shall be paid out of the principal of my residuary
estate.
SIXTH I hereby nominate,constitute and appoint my daughter,CONSOLACION
HUSLER,as Executrix of this my Last Will and Testament. I hereby relieve my Executrix from
the necessity of posting security in connection with her duties,as such, in any jurisdiction in
which she may be called upon to act insofar as I am able by law to.do so. In addition to the
powers conferred by law, I authorize my Executrix, in her absolute discretion,to retain in the
form received,and to sell either at public or private sale any real or personal property owned by
me at the time of my death.
IN WITNESS WHEREOF,I have hereunto set my hand and se o this, Last Will and
Testament,consisting of one typewritten page this t day of
L
2010. j
LEONCIA F. FAGAN
Signed,sealed published and declared by the above named Testatrix LEONCIA F. FAGAN as
and for her Last Will and Testament, in the presence of us, who,at her request,in her sight and
Presence and in the sight and presence of each other, have hereunto subscribed our names as
witnesses.
L
COMMONi WALTHOFPEIYIVSYLV.9NIA
COUN770FCUMBEM4ND ' SS
I;LEONCIA F. FAGAN;Testatrix whose name is signed to the attached or foregoing
instrument,having been duly qualified according to law,do hereby acknowledge thatI signed
and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my
free and voluntary'act for the purposes therein expressed.
LEONCIA F. FAGAN
Swom or affirmed to and
acknowledged'before me, by q
LEONCIA F. FAGAN this 7 day
Of J✓VY ,2010.
Notary Public
CO MONWEALT OF PENNSYLVANIA
NOTARIAL SEAL
JOAN D.ADAMS.Notary Pub6e
Carlisle Ooro.,CuffftdWd Count
My Commission Expires March 7,2011
COMMONWEALTH o f PE NNS n Vi!NI 4
.SS.
COUNTY OFCUMBERLA"
we, �N jLUAM A ,,p 1SOA ^J and 9A114q j,, M iAA4tit_eJ.5-r
the witnesses whose names are signed to the attached or foregoing instrument, being duly
qualified accordinito law,do depose and say that we were present and saw LEONCIA F.
FAGAN sign and execute the instrument as her Last Will;that she signed willingly and that'she
executed as her free and voluntary act for the purposes therein expressed; that each of us in the
hearing and sighf of the Testatrix signed the will as witnesses;and that to the best of our
knowledge,the Testatrix was at that time eighteen(1 g)' or more years of age,of sound mind and
under no constraint or undue influence.
A AA
Swom or affirmed to and
subscribed before m bye N
,tJNG•q
V�1 E wr A /X-
this 1 4f*14 day of i f V ;20I0.
Notary Public
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL'
JOAN D.ADAMS,Notary Public
cane Sm'.Ctxnbe WW Couatl
Covnliss w March 7,2011
FROM ONEFCLJ FAX W. :7172498208 Mar. 04 2013 03:5" P2
CORNERSTONE
r e d e r a I C r p d I I U n i o n P.O.Box 1 181,5 Eastgate Drive,Carlisle,PA 17015
Telephone (717)249-1661 FAX (717) 249-8208
Member founded— Service based www.cornerstonefcu.coop
March 4,2013
William A. Duncan, Esquire
One Irvine Row
Carlisle,PA 17013
Re: Estate of Leonia F. Fagen
Date of Death: 02/04/2013
Social Security No: xxx xx 8824
William,
Sec as follows requested information:
Type of account—Saving and Checking
Account Number—25664
Name and/or designation—Leoncia F. Fagen
Single Account
Principal Balance as of 2/4/2013 -$5,801.13
Interest accrued from 2/1/-13 thru 2/25/13 - .88
1 am hopeful that this will help.
Sincerely,
K2 y Kciser
Financial Service Representative
Comerstone Federal Credit Union
MEMBER SAVINGS ACCOUNTS FEDERALLY INSURED TO $250,000 BY THE NATIONAL CREDIT UNION ADMINISTRATION
219 North Hmov
Cabe,PernworY
717.2
toll tree 1.866.4;
tax 717.2.
RZI1 AL,HOME & CREMATORY, INC. �""�W*N ff0v
into®twfinarr
Connie.Husler May 8, 2013
820 Greason Rd.
Carlisle;PA 17015
Statement of Funeral Expenses for: .Leoncia F. Fagan
_ . Date of Death:February 4, 2013
PACKAGE: Account Id: 18794-038
Immediate Cremation, Memorial Service at Funeral Home
OPTION 3-Cternatlon
$ 2.490.00
MERCHANDISE: Sub Total: $ 2ASO.o0
Um:Mother Of Pearl-gall Jar-Inlaid Rose
S' 330.00
TOTAL. :UN ERA{,HOMECHARGRg; Sub Total: $ 330.00
CASH ADVANCES: i 2,820.00
7 Certified Death.Certificates at$8.00 each
Newspaper Notice-Sentinel $ 42.00
Add'I CCs $ 182.48
Clergy $ 30.00
Flowers $ 150.00
COronees Fee $ 108.00
i 30.00
Sub Total: $ 520.48
ToW Funeral Expense;..' _" 3,340:48.
Payments Made: TOW P8Ymw tt Made: i 4,131.00
F LIC Demount Discount PrON/Cont Mac 5,2013
Check 194293 Mar 5,2013 132.83
2,998.17
Accrued Late Fees: i 2.27
t3alancs: i �1
SERVING OUR COMMUNITY SINCE 1907
��nnras��
pennsytvania
DEPARTMENT OF PUBLIC WELFARE
March 9, 2013
DUNCAN &HARTMAN P C
WILLIAM A DUNCAN ESQUIRE
ONE IRVINE ROW
CARLISLE PA 17013
Re: Leoncia Fagen
CIS #: 820318319
SSN: ###-##-8824
Date of Death: 02/04/2013
Dear Attorney Duncan:
Please be advised that the Department of Public Welfare maintains a claim in the
amount of,$22,737.98 against the above-mentioned estate. This claim is for restitution of
medical assistance granted on behalf of the decedent for which the Probate Estate is now
responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective
August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the
Department's itemized statement of claim.
A portion of this medical expense, namely 322.737.98 was incurred during, the last
six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of
the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the
claim, namely LM is to be entered as a priority Class 5.1 claim against the estate.
Please acknowledge receipt of this letter and advise whether the Commonwealth's
claim is admitted and when payment may be expected. If the estate accounting is
complete, please provide a copy. If the estate contains real estate, please provide
copies of the deed, the latest tax assessment, and a current appraisal, if available.
Sincerely;,
Elizabeth M. Wilson
TPL Program Investigator
717-214-1868
717-772-6553 FAX
Enclosure
cc: Consolacion Husler
620 Greason Rd
Carlisle PA 17015
Bureau of Program Integrity I Division of Third Party Uabliity I Recovery Section
PO Box 8486 1 Harrisburg,Pennsylvania 17105-8486
• COMMOPGiMEVmw BUR OF RORAMGR
DIVISION OF THIRD PARTY LIABILITY
RECOVERY SECTION
PO BOX 8488
NARRMAIURG,PA 1710584M
March 4,2013
STATEMENT OF CLAIM SUMMARY
Estate of FAGEN,LEONCIA
f't',c�t1,•-r�rr: 820 318 319
NE111 4 ?+nr •
INPATIENT
.00 .00
OUTPATIENT 26.08
.00 26.08
LONG TERM CARE 22,697.43
DRUG '00 22.697.13
14.47 .00 14.47
22,737.98 •� -
22,737.98
K. , � PENnsrcynNUU�
w
L i
a....'� 2✓ 4Tit1'.'AhtS.�:�.
Page 1 of 4
G
March 4,2013
STATEMENT OF CLAIM
FAGEN,IEONCUA
1 820 318 319
CUMBERLAND CO COMMRS
1000 CLAREMONT RO
CARLISLE PA 17013
� /j/y�, �/y� , �a'(`C�t ,�,"'A„S,di�.',sa s' n ss�/y,�3((�}�.n/y�'�r"�"��'t.{py��'�'.�r 'y ::"s ' .fn � f a +'r '`�`aY.,'s� '��; +ri''� j�'r•�'(v}?��{'�'�[y(�"p(�(`
�SF .''�U..±Yi.�Y+.+�' Y• _ [4�. S.ec V'V�f'+aY�Tk�",�4.9'J'1 ', � nY.in ..��i'IS�,. n5{. .rjt."F�Y�I�1 lM"Z,tiY�
OW12112 08131112 01114/13 68130094096770001 661300 W 96770001 4,119.20 2,833.2
DIAGNOSIS I ; 29420 DEMENTIA UNS W10 BEHAV DISTURBANCE
DIAGNOSIS 2: 73300 OSTEOPOROSIS NOS
PROC CODE: 000000
OW01112 - 09130112 01114113 66130094096780001 65130094096780001 6,178.80 4,892.84
DIAGNOSIS 1 : 29420 DEMENTIA UNS W/O BEHAV DISTURBANCE
DIAGNOSIS 2: 73300 "OSTEOPOROSIS NOS
PROC CODE: 000000
10/01112 - 10131112 01/28/13 56130246084420001 56130245084420001 6,384.76 6,098.76
DIAGNOSIS 1 : 29420 DEMENTIA UNS W/0 BEHAV DISTURBANCE
DIAGNOSIS 2: 73300 OSTEOPOROSIS NOS
PROC CODE: 000000
11101112 - 11130/12 01128113 55130245086490001 66130245086490001 6,178.80 4,892.80
DIAGNOSIS 1 : 2989 PSYCHOSIS NOS
DIAGNOSIS 2: 29420 DEMENTIA UNS WIO BEHAV DISTURBANCE
PROC CODE: 000000
12!01/12 - 12/31/12 01/20013 55130245088650001 651302450 88660001 3,601.31 2,236.32
DIAGNOSIS 1 : 2989 PSYCHOSIS NOS
DIAGNOSIS 2: 29420 DEMENTIA UNS W/O BEHAV DISTURBANCE
PROC CODE : 000000
01111/13 - 01131/13 02/25113 20130324234090001 20130324234090001 4,060.64 2,744.66
DIAGNOSIS 1 : 2989 PSYCHOSIS NOS
DIAGNOSIS 2: 29420 DEMENTIA UNS W/O SEHAV DISTURBANCE
PROC CODE: 000000
PROYID,R:SUB;TOTAL CUMBERLAND CO COMMRS 30,413.41 22,697.43
03 100007309 0009
r
Page 2 Of 4
4 If y .5.h cvi;.4 g
March 4,2013
STATEMENT OF CLAIM
FAGEN,LEONCIA
14Md
1 920 318 319
�
ALERT PHARMACY SERVICES INC
219 N BALTIMORE AVE
MOUNT HOLLY SPRING PA 17065
.,� : - ska � cz��, , - �x A. F a �rx,•'.X sir'� �"a'+><`' T3�-a+ ,. p. .. . ,.,,
0812112 - 08112/12 11/26112 25123046384060001 25123045384060001 26.98 3.01
DIAGNOSIS 1 : 0
NOC CODE: 00591024001 LORAZEPAM 0.6 MG TABLET - ATARACTICS-TRANQUILLZE'RS
08125112 - 0812612 1112&12 26123046390800001 26123045390800001 8.68 2.57
DIAGNOSIS 1 : 0
HOC CODE: 00904606860 MI-ACID GAS 80 MG TAB CHEW - MISCELLANEOUS
99!24112 - 09/24112 1112611225i23046388T89001 26123046388780001 8.68 2.57
DIAGNOSIS 1 : 0
NOC CODE: 00904506860 MFACID GAS 80 MG TAB CHEW - MISCELLANEOUS
10124112 - 10124/12 11126112 25123045388629001 26123045388620001 8.68 2.57
DIAGNOSIS 1 : 0
NDC CODE: 00904506860 MI-ACID GAS 80 MG TAB CHEW - MISCELLANEOUS
11/05/12 - 11106/12 1217112 25123256539190001 25123255539190001 8.68 .57
DIAGNOSIS 1 : 0
NDC CODE: 00904606860 MI-ACID GAS 80 MG TAB CHEW - MISCELLANEOUS
1112312 - 11/23/12 12131/12 25123385470160001 25123385470160001 8.68 2.57
DIAGNOSIS 1 : 0
NDC CODE: 00904606860 MI-ACID GAS 80 MG TAB CHEW - MISCELLANEOUS
1210912 - 12/09/12 01121113 25123615492520001 2512361 W 2620001 8.68 .57
DIAGNOSIS 1 : 0
NDC CODE! 00904506860 MI-ACID GAS 80 MG TAB CHEW - MISCELLANEOUS
PROVIDER SUB TOTAL ALERT PHARMACY SERVICES INC 78.96 14.47 'I
24 100738646 0006
Page 3 of 4
K•'iyi'.•:
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