HomeMy WebLinkAbout06-18-13 � 1505610105
REV-1580�`t°�.">'�`>
FA DCpartm£nt 8f Reve(!ue R�+Y��a r1FFICIAL USE ONLY
,a�•,..���� CqunryCode Year PileNumber
Bureau otIndividuatTaxes �NHERITANCE TAX RETURN
PQ SOX 28o6oi �
Harrisbum,PA i'73�8-o6oi RESIDENT DEGEDENT ' �� (Z � ���
ENTER DECEQEMTINFORMATI4N 8E104V
Socia�Security Number Date of Death MM6DYYYY Date of Birth MMDDYYri
_ _ _ p9t20/2012 _ 0810911925
DecedenYS last Name ..... ._. . . _.. . ... . ... Sutfix.... Decederrt's First Name .._.. .. PAI
RITTER _ _ _. _ _ . JR _ RUSSELL _ _ _ A_
(If Applicable)Enter Surviving Spouse's Information 8elow .... .. . �.... . ....... ..... .. . .. .... ......
Spouse's Last Name Suifix Spouse's First Name MI
.... . .. . .._.. .. .... .. ... .. . ... ..... ....._ ._._. . ..,,.... ._..._ ,., ......
. . ._. _,, ... .... _. _.... ..._. ._... ._.... .__._ _.._.. .... ._ ...._.�
Spouse's Sodal Securiry Number
THIS RETURN MUST BE FILED IN DUPLICATE WRH THE
_ REGISTER C}F WtE.�S
FILL IN APPROPRIATE OVALS BELOW
� 1.Origina�Retum O 2.Suppfemental ReMUm O 3. Remainder Retum(Date of Deaih
Priorta 12-13-82)
p 4.Limited Eatate Ci 4a.Future IMerest Compromise(date of p 5. Federal Eslate Taz Return Required
death after 12-12-82)
t� 6.DeoedeN Died Testate O 7,Decedent Maintained a Living Trusl � 8. Total Number of Safe Deposit Boxes
{Ariech Copy of Nlip) {Attaeh Copy of Trust)
O 9. LiHgatlon Proceeds Received CI 10.Spousal Pqverty Credit(Date ot Death O 11. Eledion to Tax un Sec.911�)
8etween 12-31-9i and 1-9-95} (AQch Sctreduie �p �
CORRESPONDENT- THIS SECT�ON MUBT BE COMPLETED.ALL CORRESPONDENCE ANO CONFIDENTIAL TAX INFORMA�1 ULO BE�CT6?$
Name Deytime�n�Nu
ROGER R RITTER _ '{703}� � �'' � �_
... . .. .. _.. _ . ...s.�;4_ pa � ra .. �.
_ ,_. ,. ._ .. .._ . . ... � WKt�}iSE L ...
c� � a � '�n
� —
First Line of Address � � �' r �
18670 HRRMONY CIiURCii RD _ _ __ _ b ...{ „�a �' "��
Second lme of Address __.. ...... ..._ ._,_. .._.... .._...,
I Cfty or PosC Qftice . ... _._, �� State ZIP Code DATE FILED I
_...
( LEESBURG VA 20175
i
� Corresponderrt's e-maii addreas:(Ti'IkG2�r"101.COtTi
UrMer panallies of pe 1 declare hat I have examinetl this reWm,iricluding eccompanying schedulea end stetements,and to Ihe best of my knowledgs aMl6elief,
it is tnie,O�mEd a 8 parer other than the pera4�a1 represantative Is�ased on aiI information of whiCh prepNrer hae any k�owledge.
SIGNATURE OF P RSO RES ON 19 E F i RETURN �ATE
�r���za1s
Aooaess
18870 HRRMCSNY HURCH RD., LEESBURG,VA 20175
SIGNATURE pF PREPARER QTNER 7HAN REPRESENTATIVE DATE
AODF2ESS
PLEA86 tISE ORI(#illA�.FWtM ONLY
Side i
� 15Q561D1ti5 15056101D5 �
J 150561�205
Z � - rZ - � tq7
REV•1500 EX(FI)
DecedenYS Social Security Number
oececenc's w�ne: RUSSE�L A RITfER, JR I _ _
RECAPITULATION
_.__......... ..._.... .
t. steai Estate{Schaeu�e A). ............................................ t. ' 210,OOd.44
2. Stocks and Bands(Schedule B) .. . . .. . ... ... . . . . .. .. . ... ... . .. . .. .. . .. 2. �'..... 0.00 ��'.
3. Closaiy Hetd Corpora#ion�PaMersYdp or Sole-Pr�rieFastiip{Schedule C) ..... 3. �.��: O.OQ ��.
4. Mortgages and Notes Recelvable(Sahedule O) .. . ... ... . .. . .. ... ... . ... .. 4. ; 0.00 ��.
5. Caah,Bank 6epvsits arxl Misceltaneous PersanaE Praper#y(Schaduie E}....... 5. ��: 1�,496.58 ���.
6. Joindy Owned Property(Schedule P) O Separate Billing Requested . .. . ... 6. �'�. 0.00 ���..
7. Inter-Vivos Transfers&Misceltaneous Non-Pmbate Property ����� -����� ������ �������
(Scheduie G} O Ssparake Biliing Requested.. ....,. 7. 43,533.7$
,. .. ... ....._ ..
8. Total Groas Assets(rotal Lines 1 through 7).. .. ... . .. . ... ... .. . .. . ... . .. 8. �, 2$8,030.37 �.
S. Funeral Ea�{rertses arxf Actministrafive Costs(Schedule H}.... ............... 9. �' 27,427.43 ���
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I). . .. . .. . ... .. . . 10. �', 2,573.41 '��..
1L Total Deductlorrs i#otal lines 3 and 10)................................. �1. '.. 30,04d.$4 •..
12. Net Value of Estate(Line 8 minus Line 1t) ..... . ......... . .. ...... ... ... 12. ...' 236,Q29.53
__�_.._ ..._._..._ ,....___ . ... ___...
13. Charitabie and Cmverttmentai Bequestst5ec 9113 Trusts fflr which
an eiection to t2x has not been made(Scheduie J} ........................ 13. �'���,. 0.00 '�.
14. Net Value SubJect W Tauc(Lina 12 minus Line 19) ....... ......... ........ tA. '�, 238,Q29.53 �,
TA7t CAI.CUtATIQN-8fE INSTRUCTIONS FOR APPt.iCABLE RATES
15. Ampunt of Line 14 taxable
at the spousal tax rate,or
transtersunderSec.9116 ._._. ..._. . ..... ._... ....... _.-.. ._...
i (a){t.2}X.o_.._ 4.d0 , t5. 0.{}d ;
_.,.,,_,w �w. ..� _ . _�,, __.._... _._ ...�.w. ..._w.
16. AmouM of Llne 14 taxable � "'°'°" �
' at lineal rate X A 45 236,029.53 ', �g, 10,621.33 ''
_ , . .... _...._� .....,_.._.... .. . ......._..,
�7. Amount of Line 14 tacable ..
ffi sibling rate X.12 : �.� '�� 37. " 4.0{} �'...
. .�....,_.. .,.,,..... ...,_..,.. . ,. _..... . . ........._,... . . .,......_. , . �..,,,....,_��,.
18. Amount of Line 14 taxable ' '�
at collateral rate X.15 �.0� ��'.. �g 0.00 .
., . ,._. ,._,___._. .,,__.._.__.
as. Ta�c oue ..... .................. .................. .. . ..... ........ ts.I 10,821.33 '
_ _ _ _ _ .
2Q. FIU.IN THE OYAI IF YOU ARE REtNJE373HG A REFUNC}OF AN OYERPAYMENT p
$ide 2
� 1505610205 15�5610205 �
�����i
REV-1540 EX(FI} Page 3 Flie Number � ! .. ��_- f 1 � 7
� II
Decedent's Complete Address:
pECEDENT'S NAME
RUSSELI.A RITTER JR
- _. _ ___. . ...__... - _...
..STREETADDRESS .-....-- . __._._ _.. ___...._ __...._.....__
1001 GOPPERCREEK DRNE
-....__ .. . _... — ._. ._......._ _._...__.. . __ __... .. ___ _...--- ------..__..,.__
.
CITY STA'i'E ZIP
MEGHANICSBURG PA 17050
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 10,821.33
2. CreditstPayrtrents
A,Pnoc Payments 0.00
____...___.__.____._—.._.�__-�.___.
e.Discount O.dO
� Totai Credits(A+6) {2� Q.04
3. Interest
(3) 0.04
4, if Line 2 is greatsr ihan Line 1+Line 3,enterihe difference. This is the OVERPAYMENT.
Fili ln oval an Page 2,tiire 20 to raquest a retu�d. (4} p.Op
5. 1f I.irae 1 +Lir�3 is greater ih2�Line 2.enter the difle�enc2.Th'rs is d�TAX DUE. (5} 10,621.33
Make check payable to: REGISTER OF WILLS, AGEN7.
(�t`'�}:�i 3tti�N.jii��..u��,: ."�µ . . . . : ��.. . ._ . .� �' ,.-� �: ..�i�iifW3.'6.d'...� . S3tfi+,t... � hN4SI'�+4b�'�bu75&RtPo`. .. �i`�&49,�: _ .. .��$��11 ��fl�`:
PIEASE ANSWER THE FOLLOWING QUESTIONS BY PIACIN6 AN "X°IN THE APPROPRIATE 9LOCKS
1. Did�e�t make a#ransfer ar�d: Yes No
a. refain the use or income of the properry hansferred.......................................................................................... ❑ �
b. retain the right to designate who sha1l use fhe properry transfertad m its income ............................................ ❑ �
a. rebin a reversionary interest.........._........................._.......................................................................,............... ❑ �
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ �
2. if deaih occurred aft�Dec.12,1982,did decedent hansfer property wittiin one year of death
withaut receiving adequata consideration?.........................................................................................................._.. ❑ �
3. 6id decedent own an m trusi fnr"or payable-upon-death bank accpunt or security at his or her deeth?.............. ❑ �
4. Did dec�ent own an individual retirement acxouot,annuit}+m olher no�rprobate property,which
confains a beneficiary designatlon? ........................................................................................................................ � ❑
I�'THE ANSWER 70 ANY OF THE ABOVE QUESTIUNS IS YE5,YOU MUST COMPLETE SCHBDULE G AND FILE IT AS PART OF THE RfiTURN.
� � , �,„ ��`��. E� �, . �1�l3 . .,"�R�k����'u�
IFor dates of death a4�after July 1,1994,and before Jan.1,1995,the tax rate imposed on the net value of fiansfers to or for the use af the surviving s�use
is 3 percent[72 P.S.§9116(a)(1,1)(i)].
For dates of death on or atter Jao. t, 1995, the tax reie imposed on #re net value of Vansfers to or for the use qf the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.7){ii)j.The statute dces not exempt a transier to a surviving spoose from tax,and the statutory requiremetrts foe disdosure of assets atrd
filing a#ax retum are stili applicabie even if the surviving spouse is the only beneficiary.
Far dates of death on or atter Juiy f,20D0:
. The tax rete imposed on the net value of transfers from a deceased child 2t years of age or ydunger af death to ot tor the use of e natural parent, an
adoptive parent or a steppare�t of khe chiid is 0 peroent[72 P.S.§9118(a)(1.2jj.
• The tax rate imposed on the net value af hansf�s to or for Ute use of the decedeM's Iineai beneficiaries is 4.5 percerrt,eucept as noted in[72 P.S.§9116(aj(1}].
. The ta�t rate imposed on ihe net veiue of transfers to or fa the use of ihe decedenCs sib(ings is 12 percent(72 P.S. §9116(a){1.3}].A sibiing is detined,
under Section 91 q2,as an individual who has at least one parent in oommon with the decedent,whether by blood or adoption.
REV-1502 IXt(42-12;
�pennsylvania SCHEDULE A
DEpARTMENTOfREVENUE REAI ESTA7E
IHNERITAClCE TAX RE7URN
RESIDENT�ECH}ENT
ESTA7E OF: FSLE NUMBER:
RtlSSEL�A RiTTER JR 29-12-1957
All real property owned salely or as a tanant fn cqmmon must be reported at fair market value.Fair marke[velue is defined as the price at which prnperty
woultl be exchanged between a wiliing buYer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant fatts.
Reai properSy that is jo3ndy-owned wfth HgAt of survivorship must be dtsciosed pn Schalu�e F.
Attach a copy of the settiement sheet if the property has been sold.
ITEM indudp a copy of the deed showing decedent's inkerest if owned as tenant in common. VALUE AT DATE
Nl1MBER �p�AT�
DESCRIP'fIQN
1• 1001 COPPERCREEK DR., MECHANIC88URG, PA 17050 210,000.00
_ _ : �
T07AL(Also enter on Line 1, Recapitulation.) $ 210,OOp.pO
If mwe spare is fleedad,use addifianei sheeks of paper af the same size.
f7EV-15o8 EX+(o8-iz)
�pennsylvania SCMEpYLE E
t�� OEPARTMENTOFREVENUE CASH, gANK DEPOSITS & MISC.
INHERITANCETA%RETURN PERSONAL PROPERTY
RES7DENT DECEDENT
ESTATE OF: FILE NUMBER:
RUSSELL A RITTER JR 21-12-1197
lndude the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of wrvivorehip must be disclosed on Schedule F.
ITEM
NUMBER VALUE AT DA7E
DESCRIPTION OF DEATH
1. M&T BANK, LEESBURG,VA; 9856461430;CHECKING 9,000.00
2, M&T BANK, LEESBURG,VA; 2676088291;CHECKING 668.09
3. 1998 BUICK PARK AVENUE
1,200.00
q, HOUSEHOLD CONTENTS(SOLD AT AUCTION&OTHER) 1,628.49
TOTAL(Also enter on �ine 5, Recapitulation) ; 12,496.58
If more space is needed, use additional sheets of paper of the same size.
R6'V-i510 EX+ (OB-09)
� pennsylvania SCHEDULE G
�EPAqTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
'""E0.'T""cE'"x"E`°"" MISC. NON-PROBATE PROPERTY
RESIDENT DECEOENT
ESTATE OF FILE NUMBER
RUSSELLARITTERJR 2� �2 ��9�
This schedule must be mmpleted and flled if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY
NUMBER �xcwoemeNnnEO�n�ernnxs�aee,rn�aa�unonsntaTOOeceoer�nxo DATEOFDEATN %OFDECD'S EXCLUSION TAXABLE
THE DAiE OF iRANSFER. AiTACH A[OPY OF iHE DEED FOR REAL ESTFTE. VALUE OF ASSET INTEREST (IF APPp[48LE VALUE
1 ROGANN R MATTHEWS, DAUGHTER 8/31I2012
VARIOUS CHECKS DURING 2012 17000.00 100 3,000.00 14,000.00
2 ANNUITY: TRANSAMERICA 32,533.79 ' 100 3,000.00 29,53379
BENEFICIARY: ROGER R RITTER,SON(EXECUTOR) 9/20I2012
TOTAL(Also enter on Line 7, Recapitulation) � 43,533J9
]f more space is needed,use additional sheets of paper of the same size.
RBVd511 EX+ (10-09)
� pennsylvania SCHEDULE H
DEPAFTMENTOFqEVENUE FUNERAL EXPBNSES AND
INHE0.ITANCE TPk REfURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
RUSSELL A RITTER JR 21-12-1197
DecedenPs debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A FUNERAL EXPENSES:
1' MALPEZZI FUNERAL HOME, MECHANICSBURG, PA
608J4
2 GINGRICH MEMORIALS,MECHANICSBURG,PA ENC,RAVING 165.00
3. FAMILY MEMORIAL SERVICE REFRESHMENTS&SUPPLIES 425.97
s. ADMINISTRATNE WSTS:
1. Personal Representative Cammissionr. � �����'� �� � � �
Name(s)of Personal Representative(s) �� � � � � �� � � � � �
Street Address
.___.......- .... --......_.___
City... . . ......--- ... __...._-- . .._--..__State __......ZIP .___.._---..
Year(s)Lommission Paid:
z Attorney Fees: 250.00
3� Family Exemption: (If decedent's address is not the same as claimant's,attach explana[ion.) � �
Ciaimant
Street Address
__....._.. ... .____.._.. . ......_____. ......____ _._..._ . ..---...._... ._-----.......__
City__
_........_ .._-----.... . .. ......--._ .. .......__---State ._-.-____ZIP
___.........____....__..
Reiationship of Claimant to Decedent
4• Probate Fees: 513.09
5. Accountant Fees: 0.00
6• Tax Retum Preparer Fees � � � 0.00 ���
� AUTO EXPENSE-PRIOR TO SALE 150 48
INSURANCE&PROPERTY TAX 2,016.87
REPAIRS&MAINTENANCE �� �8 21
UTILITIES 919.02
MISC EXPENSES 932.58
,TRAVEL EXPENSES•EXECUTOR 3,597.47
TOTAL(Also enter on Line 9, Recapitulation) �; 27,427.43
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+ {i2-i2)
� pennsylvania SCHEDULE I
DEPARTMENTOFREVENUE DEBTS OF DECEDENT,
'""Ea'TA"cET""RET°"" M�RTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
RUSSELL A RITTER JR 21-12-1197
Report debts incurred 6y the decedent prior to death that remained unpaid at the date of death,Including unreimbursed medical expenses.
ITEM
VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1' COMCAST
14.10
2. PP&L ELECTRIC 54.75
3. VERIZON 10177
4. HAMPDEN TOWNSHIP(SEWER,TRASH) 155.05
5. ALL MEDtCAL(UNREIMBURSED) 2,037.87
6. KOHLS CREDIT CARD 23.52
7. CAPITAL ONE CREDIT CARD 186.35
TOTAL(Also enter on Line 10, Recapitulation) � 2,573.41
lf more space is needed,insert additional sheets of the same size.
. .__ . __ . —.
HEVd513 EX+ (01�40)
pennsylvania SCHEDU�E J
OEPARTMENTOKqEYENUE
�Nnewraeice ruc a�uaN BENEFICIARIES
RESIRENT 4KEDENT
ESTATE Ofc FItE NUM$ER:
RUSSELL A RITTER JR 21-12-1197
RELATIpNSNIP TO DECEDENT AMOUNT OR SHARE
NUM6ER NAME AND ADDRESS OF PERSpN(S}RECEIVING PAOPERTY Do Not listTruaten(s} 4f ESTATE
I TAXABLf DISTRIBUTIONS I���ude outright spousal distributions and transfers under
Sec.9116{a}(1.2}.]
i. ROGANN R MATTHEW5;1701 Taxville Rd,Apt 10A,York,PA 17408 RAUGHTER 1/3share .
2. RAWN R RITTER;7t56 Cou�ty Rd 422,Grandview,TX 76056 SON 1t3shara
3. ROGER R RITTER;18674 Narmony ChurCh Rd,Leesburg,VA 20175 SON fi/3share
ENTEft ODWIR AMQUN75 fQR DISTRtBUTI0N5 SNOWH ABOVE 6N LINES t5 THROUGH 1$4F REY-1506 COVER SHEET,AS APPROPRIpTE.
I� NON•TAXABLE DI5TRIBUTIQNS
A. SPOUSAL 6tSTRIBUTtONS UNDER SECTION 97.13 fOR WHiCH AN ELECTS6N TO TAX IS N6T TAKEN:
L . . . .. . . . . . . .. . .. - - � .
B. CHARITABLE AND GOYERNMENTAI DI5TRIBU7ION5:
1. . . . . . . . . . . . . .. . . , . .
TpTAL OF PART II - ENTER TOTAL NONdAXABLE pISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. #
If mare space is needed,use additionai sheets of paper af the same sfze.
. . Mark Hxwnen Reel EeWe
RsaideMialApprN Re(mrt �ru �aotCoppercrae�c
7ne pupm�awe�mpanBn piwpe C�e r�ent�Wh eaeMHe opniuntl�w MbawYue ame�aP�^PaN.9�me NieiqM uce mneepaefoe�,
�aer }'�KN ' . @
1 0 Harm urcAti � VA 20175
e1 Reaita'•t�ad�tbnai iM
uae Felr ue
t Y D11ve hen PA 17 7
m �emm A&Dain6 D Rtlter Cw
1 DsBd 80ok 27Z Ps 6:151
�'" PrtNS t i&lOB�-W2 16rzYar2{}t3 R.ET&ms42 .00
�l„� Neme Rebrence See A88eaeo15 Parcel 6 cerawitett 0113.02
ak eYeartraMaoldew hrAeurr me aremwa
P�Wr . ore Nora wltliin tl16 3 an�e s Raeo
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VNo.i id In e oi M receM es te•F rua 28 11 7
� dMhq;pMlanuq�warnYmneelkNvedmeameapprewY WA
Umn Rwol Ve1�n su6k �edY� Pn GE OnsUNI 78%
' 761F 9696 11 Q! WP &iWt %
itma �3mAis O.arBimre t Law N Muti�s�m 1%
pNpMMnod BwMMp A ad m 76 %
976 P�ea. Y 10 46
NeqidwtnMDaotpnn a nei Ilc I I el em m
la cHasr k� havsaimllaramenities. acdvi a+re�a or
x in me aoe.Np uMavprable feclo were which xauld m I .
tAUi�cabYOre(MU�nOr,�Ppatmrtiee0cwconeutlare) A e0
ppmsine � tt�.dt 1 r vmw A
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tde do
blrttipM6t9MhaetweMMwpedWnRM'a9impo�ed(anP�P�eedP�O�eroMtlNa�)tlieO�MUee4 Yes No tlNo.Ee9luWe. Bd
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ntte In m a �ro �v �er eG�+xee
a�Ihi slfe. e weli ers mon in 1Fds
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vnuY mYlorwe6 B11dc umlfl 1
oet. uit eawnera 472 t �matsumm i� Wootl
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Yaer0uK7$78 � � �
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cammnsanmeYnprcwmera M em a afav I hem and m efiar�ce.
P
vaW In tN ael la to Ma etbn the lowin items:
l'he iee6eriw of fihe w�i �c7.
vAii be t�d.
in i II cl
n h I I
r�.suawa �a� ...,sr..am � �x.a�. oawam wa arr.r.�e. �
Ip'�^7 anw wpw imwlmrolw�
«c�m�m..ev"�..imp�.
, . ����
ResideMialApprela�Re�port A.ru iancoppxcrewc
cawn ra.i nn�e : xas
�ao+co�x craek ornre �i�o�,ae way aaxi cn�ror�onVg saa i.�„R��
PA 1 O60 pA 17050 PA 1T050 F� PA 17071
n Nes 7.0.5 mi 1 mi
3 790 74
lic .R 108.98 108 .t tl
eM 8 Recor�&MlS em Reoards&
R & MlS t
V 6AQHISTAIENT3 �IMION .� OE4CRN+f10N .� DESCPoPTION .�
SYeawsHnp FHA FHA FHA
N Known Seller st -3125 Aesisf
MsYettime 1 14Y20i2 t7116t201E i3
rt�m+ rben Subu n
Fee Slm F m Fee Slm le Fee m e
SMe .at ,2 +6 Ob0 26 ac +6 000 . 0
vbx A A Aw Av
2 2 2
m Avere A Aver e v
36+/-V 4i YeeB 43 Y 0 V 0
Conrokn Oood ootl Avera +75000
Moracreae rai oie. rw aem rmi eo. ras
FromCant 7 3 2.6 7 3 2.5 7 3 7 3 2.
w� . 1 7 .R 1 8 -4 800 1 742 .R 0 1 840 ,
eremenecwtrod Full Baeenent Full 9esement Full Beeemerit Full BaeemeM
eaiw e Uefl Rm 3 UnBn Uefl
A A
Olf FA CA HP CA 0 Oit F 0 A CA
T T Mr e T T for
M Q Oare +2 fI00 2 C Stl E Gar �6a �2
F.oc Por Pa P t +4 Cat Por P +4�OQ Cw Por Cav +
t i19 1 tfl
c6 None W Fence •t Ch LiMe Fence -500 N
None None N
. s 2 X. E 20 3T5 + 3 304
+�u�sre�tar t�u+�4. O.tx t�n�. 1P.7w rinag. 't.5se
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SALE OF HOUSEHOLD GOODS:
Terry VonNeida Auctions 778,49
(copy of deposit slip attached)
Sale of stairlift 850.00
(copy of Craigslist ad and
Deposit slip attached)
TOTAL 1628.49
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� , � Terry Von Nieda Sales
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ACORN STAIFtLIFT- Like NEW-REDUCED!! -$S50 (Mechanicsburg,PA) '
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s[eps. 14'p�at longest point Fairly eacy to install.Must pickup in Mechanicsburg area � �
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• iPs NOT ok ro<onmct lhis posler with eervitts or olher coinmercial inroasts ��
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TL�?N�A��� July 14, 2009-July 14,201p
o LIFE INiURARCE COMPANY
Annuity Products and Sen�ces
ATTN: Customer Care Group
4333 Edgewood Road NE
Cedar Rapids,IA 52499
RUSSELL A RITTER
100� CdPPER CREEK dR
MEGHANIICSBURG PA 17050
Aartnitanz:RU55E(.L A RITT�cR
Owner.�RUSSELL A RITfER
,_.. _ _ IssnGDau: -duly 74,20Q9
Typed Niin-Qiialified
CerkiRcate Nnm6er:02C8T167536
this Period Since Inception
B.si.�i.r PoNey v�ll.e to.00 fo.00
Total premium payments 36,0�.00 36,�.06
Premium enhancement crediu 75.00 75.00
Tota3 withdrau�is/deducdons 0.06 0.00
7otal interest aedited 9p2.25 902.25
�w�r,�e�of�/�al�na xao.s'nss saa.�n.as
vabw<r ot x�t�/� va�as�et i/��f2ora
Cash wrtender value $0:00 $30,OOO.pO
tvfinimum required casfi value $26,543.00
Pkase refa to tke Dxfinieiarzs and Disctmura Section Jer furtka inJarmattan.
� LtC'1'CSL . . . . .,... . . ..... ....... . .
�$LC�i D011B?Ve�'Ui �.
Current Annual Ef fec€eve Tnterest Rate: 2.75%for policy year 2
Efiectire Date Trwsacdon Amonnt
7/14/2009 Premium Payment 830,000.00
7J14J2009 Premium Erthancement $75.00
'Mw�meNu Lfe Im�uce CompaoY
M����,��.7�raup Page I of 2
OQ2-0Ol•1-00966-4-0
� 'I'ltAN5AMERICA CAPITAL BCJILDETi
]ixly 14, 2009-Juiv 14,2010
Certi&cntc Nnmber:02C8T167536
qwner:RUSSELL A RITfER
This Paiod Year to Due
5urrender charges $0.00 $q,00
Surrender charge $1,951.57
Pleau refrr to thc Def3n{tians msd Disdawra Sution for Junhcr in formatian.
Now you can make W�� ryyyw,�r jp��,�qp
transactions on yaur
paliryan-Hnevtathe �� customercare@aeganusa.cam
websitc.
24-6sY�INta�ctlYa Voita Raspe�se Bystam � � ' � (800)553-5957
��'��� Manday-Thursday 7:Ot}am-5:30 pm(C7}
Friday 7:00 em-4:3o pm (Ci)
uuto.ar serria�t P�w.e Nn.i�be.. (aoo) sss-s9s7
Addrau Annuity Produc[s and Services
ATTN: Customer Care Group
4333 Edgewaod Road NE
Cedar Rapids,IA 52499
Please rrritw this wttemmt emrfutiy and iepmt any discrepmuia w us in.uwiting within 3S7 days frmn rectigt of
tke statemmt on which the aror accurred. Aering your review,mnke certuin that qIi transattions yau btiitvc h¢vc
occurred ara rcJlcctrd on the stmemrnt.
Your annuity does not cantain an E<cess Interrst/Market Value Ad,�ustmme �
� � Vilr!lMM�qqt. . .. ' . . - �.
Tntal�virhdmwaic/ri•AUrn""=_j'h�5um oJ rrqutsttd Qartial wtthdrawak und any applicabie chargu shown in th<
"BrncJits¢Charga Duail"section. , .
P„�7,.,�,rti^,Ka,h,P_Theaceumu7attar.Jpoticyva2ueasofthsstatemcn[mddate. S7asamountCadNsttdbY'�'+Y
Mher appticab2t po2ity clmga,brnef if gumantus,or nanfarfrllutt requiremtnts punuant w the tmns of ywi
policy)is mailable as a death brnefit ar ta Qrovide a paid up annuity 6rneJit.
�'��h�,**•+*�P*�a==P-The amount which woutd be gayabk upan surrada�rsuimt to tAt tmns af yaur po-2tcy.
assuming surrrnder ac<urred os of ctu datt s7�own.
�a;n;,.�,,,.�rw�,+.rd neh,n,tnr_77ie mintmum requirrd nanJorfeiture mnwnt,or othn cqsh value Jlomguarantee
ac of the seattmrnt end ddte. This amaunt is used tn detmnine your cnsk:urrmder vclue. �
Bassflfs tE d�a�DataH
So„�Pr�t..�h�ra�_Suzrmder charges incurred duc to partiat wtthdmwais during t7u smtcmcrtt pnied.
t++,�..�d���hn.e._Surrendcr charge i f a Juil sunendn were gacnsrd an the seaf�rmrn�rnd datc.
Page 2 af 2
� �TR�vsAM��tcA A�;���at�so��:
4333 Edgewood Road NE
� LIFB INSLIRANGE COMPANY CedarRagide,IA52k99
October 3, 2Q12
ROGER R F2IT"PER
18670 HARMONY CHURCH RD
LEESBURG VA 20175
RES Axtauity l�smber{�} paCHT167536
Dear Claimant:
We have received notification of the death of Russell Ritter. We
extend aur sincere condalences to you for yaur loss. The inEormation
in this letter is being grovided to aesist you in submitting death
claim paperwork. Our records reflect the following information
regarding this annuity:
Annuitant: Russell A Ritter
Owner: Russell A Ritter
Claimant: Roger Ft Ritter 100�
Annuity value: $32, 39'1 .62 as of 09-20-2d12
Annuity type: Non-Qualified
Ta� Iai`oxmatioa
This letter includes general tax information that shauld not be relied
upon for persanal ta�c planning. Transamerica Life Znsuzance Company
does nat give legal, tax, or accounting advice. You may want ta
consul.t ypur atCorney, tax advisor, or accountant with questions
regarding the direct tax consequences when selectzng an option.
C�iea+�ra2 Snfosmatioa
� The financial professional of record will remain on this annuity
' unless we are notifieci af a change in writing.
Please be advised automatic operatians such as Systematic Payouts and
Automatic Faymerzts have besn stopped.
en AEKiOFt cattparty
�
Please svl�mit the £ollowiag dacUmeat� v.y7oa selnctioyn a� aa
optioas
• An ori�iaal eert3fie8 death certificate for Russell Ritter
indicating the manner of death
• The original annuity contract (excluding the Cpntinue Option}
• The campleted Annuity Claimant's Statement
The fallovviaQ optioal�} islare availabl� ta the claimaat:
Lump Sum 8a1+�ent
The cleath proceeds value will Iae distributed to you in a lump sum
payment .
The t�able amount of any distributian will be reported on a Tax Form
2099--i2 in January of the fallowing year.
Sattiemaat ODLiaa
The proceeds af this annuity golicy will be distrihuted in periodic
payments over a minimum of five years calculated on a minimum valus of
$5, 000 . 00. The following restrictions or raquirements may also apply,
depenfling on the settlement option chosen and as described in the
contract provisions :
• The period may not exceed your life e�ectancy;
• The payments must begin within one year of the clate of the death;
• A minirnum number af annuity policy gayments may be required; and
• An annuitization request form must be completeti ancl submittecl ta
us.
The ta�cable amount of any distributions will be reparted on a T�x Farm
1099-R in January of the year following the distribution.
Please contact us for information regarding annuity products available
to you.
DelaY the Lvuo�► Sum 8aymeat ux► to 5 years follarrirn� trhe Zlate of danth
You are responsible for requesting we flistribute any remaining
proceeds prior to December 318t of the fifth year following the death.
The taxable amount oP any clistri2aution will be reported on a 2'ax Form
1493-R in Januazy of the follawing year.
Ccatinue ae Dic�a-Qualified Stretch
This aptian requires you to begin taking annual minimum partial
withdrawals calculatecl basad on your iife expectancy. This optian and
first withdrawal must be made within one year from the deceased's date
af death and must continue until all proceeds have laeen distrikauted.
You cannat make any premium additions to the annuity policy or
discontinue your payment stream. If the withdxawals are changed, we
may flistribute any remaining praceeds as a lump sum.
If you select this opkion, a completed 3ystematic Payout Option farm
will be required prior to comple�ing this claim. Yau may contact us
in order to obtain this form.
If you have questions, please contact your financial prafessiozxal ar
call us at 1-800-553-5957 Monday through Thursday between 7cQ4 a.m.
and 5 :36 p.m. and Friday between 7 : 00 a.m. and 4:3� p.m. Central time.
We appreciate yaur business .
Sincerely,
Administrative ServiCes
Claims
Ss
Enclosure (s) : Non-Spouse Annuity Claimants 9tatement
Return Envelope
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RUSSE LL RF7TER , �
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Thank y��u for your prnmpt pgymer�t.
You are e�roiiad in the Cotitcaet Auto P0y P1o�ta111.The ���� „'i`�r4, �'�''�s;i.��"°�" °"�"'����3�a;h�l �e
amount d+ie+,�ich wNl be deduc6ed from yaur t�nk acoount or a'" �f � :' ° ' r='��, �"� ��"°�`� �`� �
will be ap�d�d tb y�wr crodk caM mey indude t�atges � � , , �, . �.; <
incurred o r cred�s ieaubd aRer the sfatement prepared d9te. ? �"� ` , � , �
D�a�s afi any ct�arges or credifs posGed arter the sfe�artient �
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�t7CY1C175�. n��u�r��m� 09547 i97301-01-7
Auto Pay 10�07/12
�sss suzv sr�r To#ai Amocmt Dua 570.51
tEBANON PA 170q6�831'1
AV p7 018578 737329 89 A"5D6T �6tN1�EI'ICIOf6d f
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i0U1 �APPER CREEK OR
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COFICAST CABI.E
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09547 1973�3 C13 7 b Ot77�51
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COII�AST
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ATTN: LEBANOli SUPPORT 38RVICEB �
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AUSSSLL RZTTER 1749T 0740-29-55-3DG
1001 COPPBR CREER DR
?�CSA1fICSBt1RG, PA 17050-1953
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PAYMENTSUMMARY
cNECKwa. 4809743868
accounrM4: 09547-1973q101 CNECKDATE: 1Of19/12
Dear RUSSSLL HITTER,
Tfie attaoLed check represents a refuud £or macount number 44547-1973Q101 in the asaunt a£
Ssb.41.
If you are a Caseaet ZP'ZNITY custa�er and have questions regardiag your refund oheck, pou
caa mite us at the address abave, call Coacast'e toll free custo�aer service auaber at
1-886-CpllCAST (1-888-266-2276), ar chat xith us at vwnr.aoecast.caxfohat. 8ur
representativea are availahle to assist yon 24 hours a day, 7 daps a treek.
If �rau aro a Caacaet Spotlight client or ageacy, pleaee contact youx lacal Spotlight
affiaa.
OETACHANp RETMN THk5 SFATEAdENT
THE ATTACHED CH�K IS IN PAYMBdT OF ITE'MS DESCRIBEDPB04E.
I � ff ti6T CORRECT,RLEASE NOT�FY US PROMPTLY.NO REC6PT QESIRED.
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�;�` (1-Sfk}�342-5775) 55225-371b3
wi,..a,�e uuw,.. � M-F:Sam ta Spm
Your Electric Usage Proflte 811iing Summary (BwInQ deral�a on badc)
Servke ta: Balance as of Sep 21,2012 SQ.att
RUS5ELL A R1T1'ER Charges:
SOdi C4PPER CREEK DR Total Pennsyfvanfa 6as&Electrlc Charges 533.55
MECNANtC58UR�,PA 1705Q ;�1 pp�EIEV.3rIc UtIIIUES Charges $21.20
Meter.67741436
Your next meter reading is on or about qrt 19,2012. Total Chatges $54.75
'rhis section he�ps you undetstand Your year-tayear
eiectric use 6y maMfi. Meter readings are acWal uniess p,�a�gaa�r��Q 554.�5
otherwlse nated.
■pi1 ��12 PPL Eledric UtllkiAS'price tp compar.e for your rate is 7.907 cer�ts per kWh
effective 9J1j2012 to 11/30/2012. For a qst of wpplier offers,vistt
se papowerswritch.wm or www.ocasteta.{�.us.
d5
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� z7 • wFthpaperlessb�1�t�,you canr.eceivcand.paq=your
PPL ElECtric UUIIUes 6ills oc+llr�e.Thr�Process is free,
� � qulck;convenipM and secure.To learn more or sign up,
� visit pPkkctric.com.
9 ?
� . Information 8bout appfianc0 ener�y use and Ups on �
� c n� n n+ � � a s o t� n saving energy are avalla6le through yU�e En�rgy 14brary �
on our W�b 5�te,ppkkctrtc.com.
�"^S • Before digg�ng around your home br propBrtY,Y�
should alwgys call the state's One Cal1 natlflcatlon
system to IocatE any underground utllity!lnes. You can
do this by simpiy dia�ing 811,which wlll connect you to
Sep 2biE 30 343 . il lOF �e One Caii-system. Be safe and wIi 811 befi�re ybu
dig.
SEp 2d11 32 b00 19 68F �
PaYment Methods =
Sep 19 Actuai 72071 qnllne at: �By t�one:1-80G3�2-57T5 �
Aug 20 Achial 71728 � �'p���com or call BIUMatrlx(service fee ap�les) -
at 1-8CD•672-2433�PaY using Visa, �
38 Days kWh Biited 343 MasterCBrd;Dlscover or debk catd. _
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Oct 2d11-SeP 2d12 i0103 g,q2 2 NOrth 9th Street CcKtomEr SBrvices = �
CPC-GENN3 827 Hausman Road =
Oct 2014-Sep 2021 3947 � 829 AlleMOwn,PA iS1U1-2175 Alleirtcsvm,RA 38184-4392 �
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ca��-ee�a-s�a7zssmereure ra�'re�me
neet ncrixa,aeMCes at a great wwe-tmm N�ne,
Inlamef aM 1Y,to morey sa�Mp puqlas,yd�mst��
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QuesUom+�boutyou�bW Or»rMIC!?
Ykw yMrl�ills In dBqilBt w9tliWl.COm or C�t-808-VfPo7AN(t-&q-$37-4966�
6Rer yaur ten dglt numper 7tT-737-257&INa 865 q qmitqd inryqq q�er
idendficeliori code.Cuatomers with ' c�t-80D-9TA-800&i7Y.
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� � ,.:. .. � PIEASE RBMIT�PAYMENT TO:
. HAA�D�ITOWNStiIP
. 230 S.Spwting Hill Roed
Mxhaoiabug.PA 17050.3097
PHONB 7I�-909�-7J d5
ha6�dm W Aampdentownship,us�
. � acxw,hemp�hentowuship,us
Atac W EardlVisaeAq�1ldr.
NiLf)PER7'YAPDRIiSS� 1001 C�,Y��tG^"RgEK:#�k� �
RllSSELL A RIt7'BIt �
1003COPPIDt�CRE6KDR DUEDAFE ]N3�1/2012
MECHANICSBURGPA17050-1953 CN: �12071-000
� LC: IOI61060032
AMOUNTDUE f153.05
aZETUBIV TOP POBTION WITH PAYMENT Direct WithdrawW-Do Not Pay
. BW Includec aewer and/pr tryyp�p�rgq�pr p�[ope�.O��r. Payment MU bs.withdrym�(rom yppr pank accomt on 10/31/2012. Pleue 4rve
. ... .._ . . . �s�A�i'Sl€�y�'hesi��'Fti�o�jo_u—. .. ... . _ ._—_—__ . . . . .
DAT6 CONSUMPITON AMOUNT �,�I�I�
BALANCE PpRWARD 07Po12012 � I55.05 �
� PAYMBNT 07/312012 � -155.05
SSWER 70/012012
I14.25
TRASH �oro�no�z � ao.so
ADJUS'fG7EN7' . ' 6.00 �
��� 0AO
AflPRES'C � .
� ,. E�F�!'/'#eAAdR��� [�Yl�MC�lt`fltBittfffiR':
Ip�S$F1.L A:R77"!ER . •
IWICQPPE&�CRCEKDIN CN: dk2pTl-Of1U � �
hffiCtIAMICSHIALGPAI7050.t453 LC: f01610604Y3�
UUBDATE 10/3U12
� AMOU.*TT'DUH Sl55.05
GItQSS BALANCE PAYAB1,g AF7'gR 30 DAYS � �r��6dn�rd-Du Not Pay
DOttiCf W�R�IDRAWAL AVAll.ABL6 -
___ __ �J
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RECEIPT RECE►P'f iNS. PAT.
DATE PATtENT DOGTQR CF�T4 DESCRIPTlON GHARGE FHQM 1NS. FROM PAT. A0.1. BAL BAl
09/09/12 Ru69e11 Waheed 98223 INITSAL HOSPITAL CAAE �289.00 $153.60 $9l.14 . p0.U0 �38.3
99/03J72 Russe2l 57aheed i123F ACP DISCU58lDSCN MKR DOC' $O.CO 80.00 $p.00
a9114/22 Russe2l Anjum 44233 SU&9E9�NT ROSPZ2RS CARE $U8.60 $78.51 �iA.86 90.00 618.6
09l11/12 Russmll Anjum 99232 SUBSEQUENT HO5PITAL CAR.E $1Q9.00 �$5l.71 #��•61 . ;Q.40 $13.68
09/12/12 Rueaell Anjum 99232 � Sf]BSEQUENI' AOSHITU Ca[tE . ¢103.00 #5/.71 $34.61 $0.40� $18.
69113l12 Rusaell� Anjum 99232 SUBSE4vENT��HOSPITAL CAFEE �108.Op $5�.91 � $91.61� � 44��4 . $13.69
� Q9/141i2 Ru5se21 A.'t}Um 1I23F ACP DISCUS$/DSCN N�[t[i DOC' $6.00 6p.00 $0.00
09/14/12'� xuasel3 �Rnjwa 94238 t20SpYTN, DISCHARGE nAY $102�.Op �5�.70- . �31�.00 f0.00 013.60
� 09/20/12 Ruesell � � Naqra � �99223 IN2TIAL xOSPITAL CARE .$289.00� � � $2S3.S0 : $97..12 $0.00�. #3$.38� �
09/20/12 Russell � Nagxa 1123F ACP bISCUSS(DSCN MKR DOC' $Q.00� �tl.00� �0.00
l�
CURpENT 3Q-8q DAY3 80•$O pAYB 90�720 pAYS AVER 72p DAYS TOTAL ACCOUNT BALANCE
D QM PATI
$t51A3 $0.00 50.00 $0•00 $0.00 5757.03 �151.03
Thank You For Yaur Payment. For Bi�ing nuestions, Pkaee Ca1L• (717} 972-4490:
������H��N�����
HEALTHSOUTH
Rehabilitation of Mechanlaburg
aate: �a/2312osi
Address: RUSSELL RITTER
Street 1�ti1 COPPER CREEK DRIVE
Gity;State MECHANICSBURG, PA 1705Q
Patient Name: RUSSElL R�TTER
P�at;ern�kccount#: _ - _ 9,Cs5s3 __ _ _..
pates of Service: 4f 14J12-9j20J12
Previous Balence: So.oa
Patient Payments Received: 50.0o Thank You!!
Inwrance Assigned Amount: $1,is5.00
New Account Balance: ;t,u6.00 �
� insurance assigned CaPay due
�X Insurance assigned Coinsurance Due UNITEd HEAITHCARE
� Insurance assigned peductible Due
Your insurance has paid, but assigned the abave amount as your responsibility.
IThe#akance shown is due and payabie within 30 days of the date af this
notice. .Please contact me if yau are unab(e to pay in full within the 30 days.
Thank you in advance for your prompt attention in this matter, and thank you for
thoosing HEALTHSOUTH! _
HEAL7FfS0UTN Medicare Account Representative; lii) Kulic
Phone: 717-691-4961
Email: "�.kulick@healthsouth.com
For yqur�canvenience,we now accept VISA, MAS7ERCARD,AMERICAN EXPRESS,and DISCOVER
card for payment. Your bill is payable at our Rehab Hospita!or any of our Qutpatient sites.
1�5!a»caster Blvd�Mechcrnicsburg, PA I7Q55 "'717-b91-370Q�Fax 717-691-d979
PHYSICIANS OF REHABILITATIOt�, INDUSTRIAL&SPINE MEDICINE, P.C.
775 Lancaster Boulevard 4310 Londonderry Road Michael F. �upinacci, M.D. STATEMENT
P.O.Box 2028 Bloom Bldg.Suite 106 William A. Rolle,Jr.,M.D. �ST�T�'��T�T� ak�iE���
Mechanicsburg,PA 17055 Harrisburg,PA 17709 William A.Pomilla,M.D.
(717)691-3755 (717)561-4242 Lisa A. Eaton, PsyD www.prismdrs.com 141123/12 01
Biliing Dept:(777)591-4405 Tax I.D.#25-7651500 ACCOUrlf
Please retain this portlon of y},aman�lor yp�r records. NUMBER Ij152838
WNSACTIONOA7E MN:NO: POS. �.:PATIENT�� - DR. ��PFiOCEDURE � -�DESCRIP,TNIM��OF,SERYICES Dt�1D315 .�� AMOUNi
09/14/12 AL' RUSSE MF 99222 INITIAL HOSP VISIT, �EV2 7993 ��S. mm
10/0,?,/12 RUSSE MF 40 MEDICRRE DISALLOW i13. 81
10/$3/1^c RUS$E MF iiD PRYMENT—MEDICqRE gg_ gs
1@/16/1� RUSSE MF —4 UHC faPF�LD Sc^2. 24 TO CD—IN
_ __.
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PLER:3E C LL 91 4405 W TH QUESTIONS ETWEEN 8:30 AM-4 pM
TE�L US F' W A E MEET NG YOUR NEEDS www. prismdrs. com
^c2. 24 ��. 24
cun�xr a�+aoo�irs �trtoa►MS' �esooars a��s�rs r�uE
i i.i
�^a-.�•�Y s.,.-,rr�+.•• _. . . .
_.� . • �� a �� � ._ . ,.. .. • . : . . ._...,-.. . .. . .. . A.. ...• ... '
*** Please Pay upon Receipt. Idfgyou have any guestions pl,ease call the ***
�***�B*���*��tD��.-�**�#***��*�*���*��c��r�t��*��**�.�t****�t�*��c��Q*�c�r�t*�***�c***�t*�c�*�**�*�t
09/18/12 1 3 L HOSPITAL INITIAL CARE 3 99223 294.20 250.00
1QjQ9Jl2 Hedicare Paymant . 153.50
10/09/12 Accept Assign Ad� . -5$.12
14/23f12 TJNITED F€EALT Payment O.OQ 38.3$*
lN `� �
G� �
� ����
t � .
L-The 'PLEASE PAY' iacludea unpaid co-pay or co-ins. Please make papmeat.
oa'fE�tdsr R4D; ..,.aM04iMr ?,� .
OOJA01�� ��� � 0.00 38.38 0.40 Cl.00 0.00 Q.00 � Q. �� � � � �_� �� �
G�2 II.pD 38.38
Peaaaylvania Naurological Associates ,
� , +
r�i�ac 110 LoWther Street
AYA8lET0. . L884jRt$> PA i�7fl43-2012 � - - . . - . 38.38 .
P}ae(717)-774-2202
PAT� 1-RU53ELL A RFTTER PRV� 3-HECR, ALBERT W., 24) ACet�: bl$35
Date: 10/23112
Page 1 :of 1
!
_ _. ��, ..,_. ..__ �.... �..T_..
� . . • � . . . � r . .- ! . , : - :
*** PLEASE PAX UPdN RECEIPT. FOR HILLING QUESTSONS CALL 774-1366 BETWEEN lq ***
*** AM AND 4 PM AND CHOOSE BZLLING. EFFECTFVE 3J1j10 THERE WZLL BE A ***
�*xx����x�*#�zD��D���������at�*�*��*���*���***�r**#**�**�#t���t**�*xt�*�e****�c***
Insorance Charges pending to,Prv: 485.00
Ins Pay/Adj against Ins pendxng 273.55 -143.05 68.4Q
09/24J12 1 15 L HQSPITAL INITZAL CARE 2 99222 7$4.2 Sb7.00
1d101jl2 Medicare Payment . 1Q4.65
lOJOlj22 Accept Assign Ad� . -36.19 26.16*�
f �
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4
. � � �� �� ; . . . � . .
4
L-The 'PLEASE PAY' iaclndes uxspaid eo-gny or cc-ias. Piease make ,gsyaeat.
wtE tasr PntD nMOU►n" '
00/00/00 0.00 26.16 4.04 Q.QO O.OU O.QO fi8.44 ' 0«{i{� �: ` �.36
i� INTERNISTS OF CEZiTRAL PA . , ,
xecu IO$ LOWTHER S4'REET
axas��ro: I.EMOYNE. PA 17043 26.16*
Ph:C7i7)-7 23bb
PAT� 1-AtFSSELL A RITTER PRP� 15-YISWANAI'�IAIi, PRtiTBE85H, Acct�; ?f)52fl
Date: lU/2�Ji12
Page 1 af I
I
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ifi]. ,.�/��: bC.l � .
Qccount: 105670 Services Rer�rleredAt:ttOi.Y SP#R#7 HOSPl7AL
Proc '. , ayments
Date Code Descrtpiion Char9e Ad ustments 8alanc�
9/9/2012 7101Q C4tEST SINGLE VlEW pROM"AL 38:60 SJ4
10/12J2012 PMT MEOICARE Pi�,RT B-NOVITAS 6.94
�07�2/2012 CR AdjustmeM MEDiCARE PART&NOVlTAS 27.32
9t9/2012 ]8450 GT SCAtd'SRQFN Wi0'CQN'fRAST 1S8.A0 6.Q6
1QJ12l2412 PMT MEDiGARE PART 8-NOVITAS 24.25
1 0/1 212 01 2 CR Atljustment MEDICAf2E PAR7 6-NQ?1lTAS 167.69
9/9/2012 �2125 CT CERU SWNE WO GON7RAST 238 00 14.24
tpt1272012 PMt MEDICARE PART B-NOVITAS 40.86
SOl1?12012 CR Ad)'usttnerrt N1ED#CRRE PART B-NOVITAS 186.93
9/i V2012 7205Q 5PlNE CEFtVICAC.?4 VIEWS 63.Q4 3.09
10115/2q12 PMT MELI�CARE PART B-NOVITAS 12:34
1011512Gi2 CR Adjustment MED(CARE PART&NOVITAS 47.57
912QI2012 71Q1Q CHESi S1NG1:E VIEW FRQNTAL 36.00 1.T4
1 012 3/2 0 1 2 pM7 MEDfGARE FART B-NOVITAS 6.94
10/23/20�2 CR Adjustment MEDiCARE PART B-NOVITRS 27.32
_ .__�. . _ _.__ __ _ ._ __. _. _v _ .
_
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�ry� �
� ,��'
Current 3i -60 81 -90 S1 -120 OveH2O BALANCE DUE
0.00 22.54 0.00 0.00 0.00 PAY BY Due Upon Receipt
��k� For 6illing quest+ons call: {717)932-5955
i'�SA�E � �� ro r � .
; ' , y y'� � � � or. (87�932-5955
IFs ,� �i ��'� ��� � Fax: (71�932-4$58
��6., � , ,,,s � �, - Off1ce Haurs:8:00 AM-d:30 PM
Ta pay yaur b1li anline and register for e&tatemer�t
y�d� STATEMENT p�ease visit us at:www.qita.com
I I ����I�IIA������ SEE REVERSE SIDE FOR IMPOR7ANT BILUNC3 INFORMATION .____ __,
.�..rauoeu�...fiaaws�.u.�r:ro� rGtt ._ . . .. . . . . . . . . . . . .
Aecourrt: 9p5670 Services Reradere�[A#:H4LY.5�+1RIT HBSP►TAL
date �� Description Cha►9e "` ustmentez Balanea
9t9JZ042 79010 CHEST SING�E VfEiM1t FRONTAL 36:00' 1.7
10l12J2412 PMT M€ClICARE RAftT&NOYiTAS 8.94
10/12/2012 CR Atljustmerrt MEDiGARE PART B-NOVlTAS 27.32
9/8/2012 90450 CT SCAM$RAIN W/O C�NTRA3T 198.00 6.
10l12t2012 PMT MEDICARE PART B-NOV(TAS 24:25
10l9212012 CR Adjustmerit MEC?ICARE PART 6-NOVtTAS 167.69
9/9/2012 72125 CT CERY SPINiE V�U'CONTRAST 23$'.QQ: 10.2t
10/t2I2D12 PMT MSCMICARE PART B-NOViTAS 40.86
10t1212092 GR Adjustmerit MEDICARE PART B-NOVITAS 18fi.93
9l1tl2t?12 72056 SPINE QERYICAI.}d V1ENtS 63.06 3.
70f15l2�12 PMT NlEQICP,RE PART&NOVlTAS 12.34
'IO/15J2D12 CR Adjustment MEDICARE PART B-NOVITAS 47.57
8/2d/2612 �1810 CHfST SiNBLE ViEW FRONTAL 36.00* 1.74
10f23t2412 . PMT MECitCARE PRRT B-NOVITAS �� �� � � 5.94
1ql23l2412 Gft Adjustmenf MEdICARE PART B-NOVITAS 27.32
�V
Current 31 -6p 81 -9q 81 -120 Over 120 BAtANCE DUE S21.i4
21.1p 0.00 0.00 0.00 O.00! PAY BY Due Recei
'f'HIS A4eeouM7�tC��Yc1llFE RESPp1�lSa81i.1TY: For billing questions cat1: {717)532-5955
i�.E/�SE 1�1�iT�k�Ki'IN F'Ui.L'�I3R GAt.t:'QC�2'. ` or: {877j932-5955
oF�u:��an^�t+��r�rr��arrmra�x Fax: ���es2-asss
tNSURANGf-1�`t�tdS NEC�s�aF2Y. Office Hours: 8:00 AM -4:30 PM
Tha�se eharges shwm`wlttr an"'"lnatcate pendln$N�nrance: Ta paY Your bill aniine and register for eStatemer�t
STATEMEl+IT p�sg visit us at:www.qita.com
' ���,�������� SEE REVER$E SIDE FOR IMPORTANT 81LLING INFORMATION „� ,�,�
! . !' • .., � � r � �
*** Thankr you far yaur prompt payment. Please cali 717-731-8315 with any ***
�,t***�**�#���*�*�**�r�**�**�*�*��*�***x*�e**�*:t*��***�**�**:t**�**�t*�**�t******�******�
Insurance Charges pending to.Prv; 27Q.00
Ins PayJAdj against In� pending 245.17 -64.83 d.00
09JSQ{12 1 10$ HOSPITAL INITiAL CARE 2 99222 414,01 190.00
14/11f12 tiedicare Payment, 104.65
1Of11/12 Accept Assi gn Ada . -59.19
10/24(12 UNITELI HEALT Payment O.Od
11I26/12 Credit Card Payment 2b.i6 O.dO
69J1dJ12 i ias EC$0 {2D) COMPLETE, HOSPI 93306 424.1 1GQ.40
10/25J12 Hedicare Payment , SQ.54
ipli5Ji2 Acce t Asci n Ad�. -96.$2
10/24ji2 UNIT�D HEAi.� Paymemt 0.00
11J26f22 Cradit Gard Payment 12.64 0.00
04111/12 1 108 HOSPITAL SUBSEQUENT CARE 99232 414.01 90.00
10J11j12 Medicare Paymant. 54.�1
rolilfi2 Acce t n88� Ad�. -21.61
1Aj24/12 UNIT�D HEAL�Payment Q.QO
11/26j12 Credit Card Payment 13.68 4.40
49/ZO/1Z 1 $4 L H4SPITAL INiTIAL CARB 2 99222 4Id.71 190.00
10(22/12 Hedicare Paymeat �.00
1OJ25/12 liadicare Pay�ent , 88.95
1OJ25112 Accapt Aaeign Ad�. -78.81
I1/Ob/12 UNITED HEALT Payment 0.00 22.24*
L-The 'PLEASE PAY' includes uap�id co-pay or ca-ias. Please make psqment.
�re u�sr P� nx�oUrn'
11/26/12 52.48 22.24 Q.00 Q.00 O,QO 0.00 O.Od 4.80 22.24
PINlIACLEHEALTA CARDTOVASCULAR INST, INC � . •� � +
HecK 1008 N FRONT ST (itOFFITT HEART & VASC}
�eiera: �pg�,EYSBi1RG, PA 17p43-I034 �� v �.-�.�" 22.24*
Y
��� Ph; (717 1
PAT� 1-russell a ritter PRY� $4-RICE, REISH, M3't Acct�: 215115
PRV�1Q8-ISICANDAR, EMAri, D.O. Date: 11l30/12
Pags 1 of 1
i
�
- , . • # � . _ . . ; .
*** Thaak you far your prompt gayment. Please cal2 717-731-$315 with any ***
�****�*���*��*�*********�*****�t*******rt�**�********�*************�*�************�*
Iaaurance Charges ending to.Prv: 460.OQ
Ina Pay/Adj agains� Ias pend�ng 88.95 -78.81 242.24
09114(12 1 !Q8 L HOSPITAL INITIAL C,ARE 2 99222 4i4.01 190.Od
10(11/12 Hedicare Paytaent , lOk.fiS
10j11/12 Aceept Assign Ad�. -$�•l� „i
1Oj24/12 UNITED HEALT Payment O.Otf 26.16*
09Ji0JI2 l 1d8 L ECHO (2D) COHPLETE, HOSPI 93306 424.1 160.00
IOJ15ji2 Hedicaxe Payment . Sp.S4
30/15J12 Accept Assign Ad� . -96.82'
14/24f12 UNITED HEALT Paymeat 0.00 12.64*�
09/11J12 1 108 L HQSPITAL SuBSEQ[IENT CAkE 99232 414.01 90.00
10111J12 Medicare Payment, 54.7i
ld/11/12 Accept Assiga Ae3�. -21.61
10/24/I2 UNITED HEALT Payment 4.00 13.6$*��
L-The "PLEASE PAX' ineludea uapaid cp-pay or oo-ias, Please make pspmant.
GRTELASTPARJ� ��AfA�(7'.�_���:'.
00{00/OU 0.00 52.48 0,00 Q.00 0.00 O.OQ 292.24 0.9Ei 344.72
PINNACT.BHP.l�LTH GARDIQYASCULAR IPIS'F, INC , .
�H�� 10{!0 N FROHT ST (2S4FFITT ,HEART &.WASC) (
�v��T-a: WORMT.EYSBHRG, PA 17043-1034. �� 52.48*
Ph: (717)- - IUi
PAT� 1-rassell a ritter PRY�lU$-ISRADiDAR, F.2SAD, D.b. Aect�: 225115
Date: II/01J12
Page 1 of 1 '�
�_. .
CARAIONET
PO Box 101928 Dept 2491
Birmingltam,AL 35214-6428 azZS$
� � . ��
CARDlONET�
Gef fn the Heart af fhe Prabtern.
87?-831-6027
"11IIIIIIII�P11�11'I�I��i�11��i���I���Ji6IIq�'I�i��l'Or�l"
34t43-30A1 i**"AUTq"'MIXED AADC 350 �1P��fomisiion
Date: i1f3Ql?Al2
RusseilRitzer $alan¢e: $147.73
IOdI Copper Creek Dr Ciicat Aceount#: pOtOp0636247
Mechanicsburg,PA 17050-1953
Desaiption of Ireurance Fatla�rt PatieM
Date Petient Rovider Services Charges Recei Recei ���� 9algnce
12/69117 Russetl CardioNet 93229 RB^10CeECGTech �,�.� �.yQ gp,pp g3�i46.37 $147.73
Supp Up 7a 30
��� �u� ��
t�
� For Billing(j�esrions Ffease Contact Our Billing Departrnent At$7'7-837-6027 Or Send An Email To
Paaern-b'sIlingCa'�Cardionet.Com.Please Do iVot Cail Your poctor's Office As They Do Not Have
Acass To Your Cardionet Account.
PLEASE 3UPPLY INSUitANCE INFORMATION ON THE$ACK OF THIS FORM
Aecou�t Number Curtent 3Qpeya $6 Days 90 Aays 920 CYays otsi Account Belsnce
6D1D06636247 $147.73 $0.00 $O.OQ $Q.00 $Q.00 $t47.73
____.. .
�.,..�: �...»._.. _, .._......
� . •< � _ � � . • .- � + .
*** PLEASE PAY UPON RECEIPT. FOR BILLING QIIESTIONS CALL 774-1366 BETWEEN 14 ***
*** Ati AND 4 PM ANt� CHddSE $ILLING. EPFECTIVE 3JSI10 THERE i1ILL BE A ***
*** LATE F�EE ADDED TO �ALANC�E"� ��ER �� DAY� OI�D ***
****��t�*� * �**����*** *��* :t * **� ***� ** **:t*sr�x**********�tt***:t*****x***,k**�*
09j14/12 1 25 HOSPITAL INITIAL CARE 2 99222 780.2 167,dd
10/O1J12 Medicare Payment 1fl4.65
10/Ol/12 Accept Assign Adj. -36.19
SIJO8J22 Credst Card Payment 28.16 0.00
t39j15/12 1 1S L HOSPITaL SUBSEQUENT CARE 99232 780.2 97.00
24J0$!12 Hediaare Payment , 54.71
10/08J12 Ac¢ept Asaign Ad�. -28.61
1OJ22j12 UNITED HEAI.T Payment O.DO 13.68*
09/16(12 1 i5 L HoSPITAL SUBSEquENT CARE 49232 7$0.2 97.00
lOjO$J12 Medicare Payment , S4 Jl
14(48/12 Accegt Asaign Ad�. -2$.61
10/22/12 UNrTED HEALT Payment Q.00 13.68*
09/17(12 1 3 L FiQSPITAL SSfBSEQUENT CARE 99232 380.2 91.00
10/08/12 Medicara Paymerat, 54.71
lOjQ8/12 Accept Assiga Ad,� . -2$.61
10f22/12 UNTTEI} HEAI.T Pay�nent 0.00 13.88*
09j18J22 1 3 L HOSPITAL SUBSEQIIENT CARE 99232 780.2 97.00
10(0$/12 Medicare Paym�nt. 34.7i
30/08j12 Accept Assign Ad�. -28.61
14122/12 UxITED BEAI.T Paymeat 0,0t1 13.68*
09J19ji2 1 3 L HOSPITAL SUB5EQUENT CARE 49232 780.2 97.00
lOJQ8ji2 2fedicare PaymonY , 54.71
io/os/lx a�c�pt n,:�gn aa�. -zs.ti
10/22j12 UNITED HEALT Paysettt 0.00 13.d$*
L-The 'PLEASE PAY' includas unpaid ca-psy or co-ins. P2oase,make payment.
oA7e�nsr pan ;�Mair+t,
11108112 26.16 0.00 68.40 O.Od 0.00 O.dO O.r30 0.00 68.kU
INTERNfSTS OF CENTRAL PA . , ., , �
He�c7c 108 LOWTHER STAEfiT � l
arne«�ro: LEtiOYNE, PA 17043 ��� �� �Q ���" fi8.4Q*
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Ph: (717)-774-1366
PAT� 2-RUSSELL A RITTER PBV� 3-TYNDALL, JAMES A. , H.D. Acet�: 70510
PRV� 15-VISWANATHAN, PRATHEESH, Dats: 12I17J12
Page 1 of I
�������IiII�17�U�
- STATEMENT OF ACCOUNT (2)
CAMP HIIL EMERGENCY PHYSICIANS ��:��t Date: DeM:ember is,2ot2
PCY80X 19693 ACCOUNT NUMBER: HYP43331727
PIi1�ADELPHlA, PA i$101-3693 Patkn4Nerne:RUSSE�I,AR1'rteti
- Ta�c ID#:�20-A66'7340
Accowt Balarnx: 534.79
� Amount Pending
insttrat�ce: $0.00 �
�.�.�„►.�.�.ini�r�#4r#�t��.*��u�l�.��litl{�i��l��tl�l'N�1� APatienf{CurteM) SD:00
0lS2516-kILIQ0�43331727-D6 a.m�unt��Fmm
� � #81N�V.�FDH - � �Patlent(Past Due): $3479
J�OQOdtSITYP6822421# Pay This Amount: i�4:78
RUS5ELl A RiTTER
1U�1 COPPER CREE#C Df2 YOUR ACCOUN7IS PAST Clt�t PLEk$E
MEGHAMiCSBIiRG PA 17050-1953 a�Mrc PAVmEwT Prsou�rTi-r. Tr�rxc
. - Y�i. Pkase�to hMow far -
PeYmer+�insUU�ns.
Pay your bifi securely on{ine any#ime at wvwv.MyMedicaiPayments.com
Da6o x Oseorqtksn Chwgp Pdd�� Peid�' Patd � AmbuM DtioFrom PAT�NT
. . Fnd Ms. .CHAer Irm: Pafie� AdN�ed I�utafxx BAiANCE
08/0W72 t �990/2R}iYTHMBIRIPINJERPRETATION S�.
DX:78�.20R.CIAVTOWM0I.Y 9plRt�/iOSPITAL
td15/12 MEDIGARECONTRAC7UAtALIWJMICE� �� . . � 8�72. - .
tOti5H2 ME�M.AREAAYMINI' , SS. _...,__ . ._ _ ._..f1.47
_ ._ '6WWNiZ.: ._2 -BceAR7_F1EqD�CP'EVAL`SMCM!'(1VI:� � � .#ti2dtl. .. _ _ _.. .. _ _.-:_... .
�DX783.20R.CUYiONIIiOLYSPIRfft105PIT�L . � � �
. � 10H&12 Mh'DIf:ARECONTRACTUALALLOWPNCE y-i,079.�
� 1Q+131t2 FIEOICARE PAYMENT . $.133. $39. .
ltnport8nt MeSS8gs5;
Tt�TA1.$: s�,szs.m ar�:ve so.ao w.00 s�.�szos sa.ou sa+.ra
Thb�mutia#1rGasEiroUtroae+wntuMlara�pavnnnoFCwTa+ racerieG.fromea�Emeryer� �Phri�enHFMYSP�rtt.Hmpm�:TMfewiartl�k�b
p�ysicianarobipstlaapralNyfromanYho�plb�cry�ypsudM..qoMwHnat�aes�kwx#�Wumeya7sc��beiwpplei6M. TMrdare.shqWOWurecNVeaMN�framths
hespitilordhe�ChYUaamalarehv9alnumroctionwkAMUSSbiC4x��incN+ESiMitams'daMd!at�tlusebMMlk � .
"Payntettt Plans"Acs�pted
Questions abowt this stateme�7lLlame de Lunes a Vierrtes?
6aN t-SOD-365-2dTd Monday#hrough Fr�day 9:3flAM-4:OOPM.
Your automst�G syst�n access code is t�01-4383172'l, or you can send emaii to
bilfin9_questions�emcare.com.
�,3R,�T �1+�4 Plle�se detach and return 6ottom 'rtion with yonr nemirtance. +f�+Y
__ __�.__ ______—_--------�°-------__-----______
rzussEi�.a RirreR STATEi�ENT OF RCCOUNT
1401 COPPER CREEK DR Si�srrss�tt D�e: Dacembar f8,20i2
MECHANICS9URG PA 17Q50-7953 A�GOV�T(1�U(Y�B�R: �P4333�7n
YOU MAY PAY THIS BILL WITH YOUR CREDIT CARD PathM NMn�e:RUSS£lt A
PI.EASE SEE REVER5E SIDE.
PaymerN Due By: PAST WE
i Mike ChecklMoMy tkder payabie to: 1�rtauM Due: a.N.78
I Anwmtt EnCbercd: �
Ga Green-�y+online at
CAMP HI�L EMEt2GENGY PkiYSlCIAN5 �'MY����=�'�
Tne inw�a�ws Infamatlon in wr fik a rs qelow.Pkass maW anY cprpctlons
PO BOX 73893 o'w«aa��na,sa,mem�a.x�eeo�mm,�dnu,mxw�n.n,�ra�.
PHILADELPHIA, PA 19101-3693
I�EED NOVITIIS 1�£DICARE PART B
LuIIIJn���1111unnILJLdL�6Ludld�6u�11��I�LI meiszaa�a ?z5o2
,.,,�71 M7RSA UWTEDHEN_TNCARE
tI"q ,��ti�,,,. ��'��ss sncT�io E an ui sa��
� If your address has changed, check this 6ox. ��;
and campiete the reverse side of this form
❑825Y6�0a00433317270000347900�00��DQ�Q02
.. I I��III�III
- sra�atE�rr o�aecouroT (a>
CAMP HILL EMHRGENCY PHYSICIANS Sptemem Date: November ts,2ot2
PO BOX 13893 pCCQUNT NUMBER: HYP43417914 �
PHIIADELPHIA, PA 19i41-38$3 �N�ne:etts5EUAwT'rER
.Tax.10#: 20-4667340 � .
Aoca�nt Balance: $3z1.79 �
� � Arrrounl PerWing . � .
. lnsurance: SO.�Q . .
hmli���M411rt�4�i���t�l�iRhiu�lir��4rm��kP,i��.d11 +�w�a o�e�„,
P�+ienc�curre�u?: �aa7s
Q82516-Q000�43417914-1]6 nmax�tDueFran
� � �WNJFDB � PatiOnt(Past Due).50:00� �� . . _
� YP$88f1987# �Y'��� t3t.ts
RUSSELL A RI7TER
1 fl01 COPPER CREEK I}R PEEASE�MIF PAYNIENT BY'PXICMENT
MEChlAN1CSBURG PA 1705Q-1983 o�e Bv"DATE."fHANK YdU. plaaae rqhr
�WCWIpOit:bEbW��T�pB�lil�lit� � .. . .
mstnictions.� .
P$y yoar bill secwely onlina anytime at www.MyMedieaiPayrtients.com
Dqe # Dsaciiplie+n Charge PaidSY Paid6y �P�d� Airwivet OueFrom�:PAS�FiT. .
FlnY��: Other ins. PatieM� Atljuatetl I�umnca�BALANCE
09/26'12 t �sEMERGENCYEYACdtAptd({Lri5) Si.TAB. .
oxno.w oa,enrsnwHar�rsrr rasvrrra
1429(72 MEOICAREGOMFRACTVALAUOwANGE a�r,o1&
,a�»z �ac�aErAnaErrr aaaa. � � . .
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_ ...._ _..,_ . . .�... ...._ . ..,� ..__,s33. __..
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� �6XA18.QDOR.BfRMWiOLY�M7FfHQ9PtTAt -
tMy12 MEDICARECONTRACfUALALLOwANCE � 'q'/Z.gp �
7W2&72 MEDICAREPAYMI:M §.5,
ttA&t? e�A1Jf;EGIAMi�-CO.�AFKE S6: 57:41� .
lmportant Messages:
TOTALS: s,.�.� .s,�.,e �.� �.� s,.,s�� �.� s�,.�
ThiesMemeMiaforthedMctGMabrenlanNaM+P�ionMwroyoursceMly neei.�WfromanEmerpencYPoyakWnKHpy'SpidlMapWL7AehmM.tlusorivpte .
phyaicianarodYetlseWmMYhom+nY,Ip+PXa�cMrgeaoraMx. paMeio�albeefu�Mlch4'a+�aYi�oA�erospo�i0k-Tlfe�efote.MwNYY�tscaiwa0�4atrCro
FwaA�l Ot�CNC!MV�81(V C�I�N M ENIl1lGfW11 VIIMU116 vMR xwtn ewt inunae nie Ironu rm.a an mk.mbmsne
•.Payment Pla�s"Accspted
Gtuestions abouY this�atemerrt?!i.lame de Cunes a Yier�s?
Caii 1-800-385-2470 Monday thro►�qh Friday 9:30AM-4:60PM. �
Your automated sys�em aecess code is�t-4349791A,ar yau can send er�sil to
blliing_questions�emcare.tnm.
s+�o�-�asas _*� i�tease detac#and rste+m bottom parEian wkh your remil�ance. �y
RussEtz a R�rFER � � � � ^ STATEMENT OF ACCOUNT � �
ip01 COPPER CREEK OR SMtemalt DaNa: Novernb�r 18,2072
MECNANICSBUR6 PA 17050-495;i ACCOUN7 NUMBER: HYP43417514
YOU MAY PAY THIS BILL WITH YOUR CREDI7 CARD (PatlaM Name:RIISS LL A R --'1
PLEASE SEE REVERSE SIDE. ///���� pe����. ����Z
Make ChecWMoney Order payabb to: 4 / ' �DU��: �.7g
�� � MauM Enclosetl: �
� Go Grean-pay oNine at
CAMP HILL EMERGENCY PHYSICIAN�l,�.t����;"'�,MY„�;;,,�°1;�i��"�'„CO��,b,,,�,,,,,�,,,�Y�R,�,��s
P{3 BOX 13693 t ; wt+«,aav«r«�u,e�rror�ama�tamwm�awmatoua.-mamcyw.
PHILADELPHIA, PA 19101-3893
L,�IItd����dill,�����ii��0�d1��LI����il�i�L���ILJ�GI �o``�siez+"s n�+z�P�$
e��sn ur�zFOriEa.��
ar.r�+asin�eara arne
ao eox aosss sa_T uu�cm ur eaoao
[a tf yaur address h8s changed, check this box.
and complete the reverse side of this farm
0825b60000043417914�00�347900p0000000D02
74! 11(26/:2 ACCT4 2�51'S PHM (727}-737-2578 LEDGFR CAftD FAOM: 00/OOj64 T6: 71J26J12 PAGE 1
Esta[e of xussell a nitter PZNNACLEHEALTN CARDIOVASCULAR SNST, INC
1007 cOpper creek dtive lORO N FROH'i' ST {MOFF2:? HEART 5 VASCy
MECHANICS6URG� PA 17050 , WORlII�EYSBURG� PA 17093-1039
(717�-731-0101
IAST PER PD: $52:A8 11/26/12 ,
LAST BIL: 11/O1/12 CURAENT 30 60 90 120+ YTD NCHG: INSM 2 - MEDICARE PA
TTL BAL: 522.24 22.24 0.00 O.Oa 0.06 0 AO YTD PPAY: $52.48 42 + UNITED HEALTHCARE
ASZGN'D : 50.00 O.pO 0.00 O.bO 0.66 tl.00 YT6 OPAY: 5�64.02 Cov: t`NOne, !9ome}
COLL (z): 50.00 O.bO 0.00 p.00 q,00 0.00 DR M-NAME I.D. A
WGNF(W�: 50.00 0.00 0.00 tl.00 p.0� p.00 129-FRY, MINDI, 32-0321362
PERS (*}: 522,24 22.2a p.60 0.00 0.00 0.60 242-xERCHELROAiA 32-43213b2
108-ISIfANDAR, EM 32-0321362
FEE DIAG DIAG DIAG PER CXG
RECORDN £ROM/TO DATES. PATZENT CPTfRCPCB D65C SCH tl t2 y3 L D S A CLAZMf C?WRGES REC3ZPTS RALAtICE
. ..................................................................................................:..:...::::
190163A 09/10/12 (d)mssel HOSPITAL INITIAL C 94222 419,01 424.1 780.2 1 108 N N SO/11/12 $190_00
273741A 11l26/12 (d�rusael C[iE�ZT CARD(CK9%X%X2052} pBYMENT 1 106 N S2fi.16
1901fi1A 70l2dI12 {d7russel IINZTED HEALT{CK�{�G62957942} PAT'4ENT 1 208 H g0.06
196165A 101llJ12 id)russel MEDICARE(C1C9H86797595) PAYMENT 1 108 N $104.65
190166A 10/11/12 (d)russel Accept Assig ADJUST 1 108 N $-59.19 $0.00
180754A 09110J12 (d}russel £CHO iZa) COMPLETE 83306 L2d.1 424.2 A29.3 1 SOB N N 10/15/12 5160.d0
MODIFIERS: 26 bIAG M9: 414.01
273742A 11/26/12 (d)russel CREDIT CARQ(CKRXXX%2052) PAYMENT 1 14B N $12,64
19016flA ZOj29j72 {d}zvssel UtiZTED AEALT(CtC�iQGfl295t991) FAYMENT 7 Sp8 N $p.pp
190161A 10/15I12 (d)IUS9e1 MEDICAR�(CK8886808719) PAYMENT 1 Sbe N $50.54
140162A 10/15/12 (d�russel Rccept Aaeiq ADJT3ST 1 1�8 N 5-B6.B2 $0.00
2$6755A 09JiiJi2 tdyrussel H03PZTAL 3UBSEQUEN 99232 41A.01 A29.1 1 168 N N 10/11/12 $90.00
2737a3A 11/26/12 (d)russel CREDIT CARD(CXY%7IXX2052) PAYMENT 1 108 N $13.68 .
14Q156A 10124/12 (d)xussel UNITED HEALT(CKEQG02957491) PAYMENT 1 198 N $p.¢q
SS0157A 70j11J12 {d7rvssel HEDZCARE{CK#BSb?97595} PRYMII7P 1 108 N g5q.77
190158A 10/11/12 (d7russel Accept Assiq ADJUST 1 1p8 N $-21.61 $-0.00
290152A Q9I72112 {d}russel HOSPZTRL SUBSEQUFN 44242 a27.31 7 262 N N S2IO2t72 $96.�0
263886A 21/27/12 (�{)russel tlNITED HEALT(CKYQGp3059388) BAYMENT 1 2tl2 N $13.68
19Q153A 11/02/12 (d)ZUS981 MEDICAAB(CKY88687168'1) PAYMENT 1 202 N $54.71 .
, 19Q15CA 111Q2(12 (d)russel Rccepi Ass1g RDdOST 1 202 N $-27.fi1 $-4,o-p
...._-__. ......__.. _....__ .___..
190149A 09/13/12 (tlyruasel HOSPITAL 5UBSEQUEN 84232 927.31 1 202 N N 11/02/12 $90.00
283987A 11/21/12 (tlJaussel UNITED HEALT(CK4QG03059388) Pf�YMENT 1 262 N $13,66
i90150A ll102I22 (d}russel MEDZCARE{G[C#ggfi8?7&$7} ?gy�� 7 202 N SSd.71
196151A 11l62J12 td)rvssel Accept Assiq ADJV$T 1 202 N $-2i.61 5-0.00
196146A 09l14/72 (dirusssl NOSPITAL SUeSEQUEN 9923? 427.31 7 292 H N 11f02f72 546.00
269675A i1121/72 {d}rvssel UNZTED HEALT{CK#QG�3058388) FAYMEN3' 1 202 N S13.fi8
14q147A 11/02/12 (tl)russel MEDICAAE(CKk886871887) PAYMENT 1 202 N y$q,71
140148A 11(02l12 (dliussel Accept A981g PDJUST 1 202 N $-21.67 s-�.aa
190141A 69/20712 (d)rvssel NOSPITAL TNTTIAL C 84222 A1D.'il 458.9 428.0 1 129 N N 10/25J12 $190.00
DIAG %4: 424.1 .,
190142A 11145l12 {d}zussel UNZTSD HEAS,T{Cx#QG03d04aff7} YAYMENT � 7 129 N 56.00
190193A- 20125172 td7russe7 MEIISCARE(CKN8868505801 PAYMENT 1 129 N $88.95
190144A 1P/25/12 (d)russel .Accept As9ig ADNST 1 124 N $-78.81
190195A SO/22/12 {d)russel MEDICARE(CRk366709918� PAYMENT 1 129 N $p.OQ $22.Y4*
� 1!/26/]2 ACCT_e 215115 opy ��17)-�37-2578 LE�GEA CAR� FROM: 00/00/00 T0: 11/26/12 PAGE 2 �
V FEE DIAG DIAG DIAG PER CHG
:ECORDA FROM/TO� DATES PA£IENT CPT/HCPCS DESC SCH ql A2 %3 L D I A CLAIM CHARGES RECEIPTS BP.LAA*CE
.......................................................................................................................
GROSS CHARGES: 5900.00
TOTAL AbJUSTS: -321.26
� TOTAL BALA[4CE: 5578.79 556.50 22.29
ASSIGNED BALANCE: 50.00
COLLECT BALANCE: $0.002
WCOMP/NF BALANCE: SO.00w
� PERSONPS, BALANCE: g22.2q•
. VISIT COUNT: 6
iSGNATURE:
?LEASE NOTE: FOL� AT "_" MpR((S FOR STANDARD y10 WINDOW ENVELOPE.
THE ABOVE INFORMATION REfLECTS ONE ACCOUNT MEMBER ONLY, "
(d) INDICA2ES THAT PATIENT IS DECEASED.
.. _ .. _ ._ _ . . . ._ . _
Capital GardiovascularAssooiates � �`"��"'ry�'�'ORD�"'`�"'��°'"
PO 6ax 1292 ❑"�� ❑��
Camp Hill, PA 17001-1282 ffi� �_�v
M��rn�,-�s��
RETURN SERVtCE REQUESTED ���4i�`"
�����
8ifiing Phone: 7i7-724-6482 ' :��� ����
BiUing Fax: 717-724-6461 04/15l2013 $5.01 118934
O�ce Haurs: Monday-Friday 8:p0am-4:OOpm —� —�
CHARqESANOCpEDITSMADfAFfEflSTAFEMEPIT SHOWAMpUNT
OA7EWILLpPPEARONNFXTSTA7EMENT. PAIDHERE �
SNIt IINi:31YL65930 ��MAKE CtiHCKS PAYABCE/REMIT TO:�
nh'I�Iflllq��hiurl�u�.n�il�•I��lIhl��ld�t,1l�nll�I�q, ��*,�
� „y,,.. RUSSELL RITTER
�y�� 1p�1 COPpER CREEK DR Capitai Gardiavascu2ar Associates
f� MECHANICSBUR6 PA 17�50-1953 P4 84X 3292
CAMP HII� RA 17Qt31-1292
r,,,ui,,,iti�„a„�,,,u,,.u„i,n,i,,,.i,u,i,�„i,i�u„E
Pieaee thecic bm�H abqve aadress is incortect or irsumnca � PLE4SE DETACti ANO RETl3RN TCN'POFET@N NYTH
� infqm�ticn haa changad,�d indicate change(s}on reverse slde. � YOUq PAVMENT IN ENCL0.SED EN4ELOPE
-........,._.._.. _ ....- - ' .,_ . _ ,. ,_. _ ._ ., ......... � .
� - � .'tw^ti afi3° ..,�:': �'v 4f„�-".S ' . � � -
� 8'�RP1CB�, WAMS � S70d$.� � DI�WX . .' �8�. � �� � �..... . . .
I��� '� ��PT WidStSa' 8TZ7�HCE
� �`
04�24/12 RSM � 536ZW$$p � �� �. �'���P3RR � 4 C.,s+d"T tia Sfi.6$ 1.67�
iis%sa�i'� "s"��a�f�tri s3o���,a�„, ,"�, �»� �"� r � .ua " ie.se �.si'
`ff➢
- 09�3211Y $PSZ2ZB�tZ 9302.' $ rr n u4 x" �•.� `� ,« : 7 2"a".7.00 15.68 1.67
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. . . . . . . . .. .. . . . . . , . .. . ,
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8i�i6hg F�ha�e:717+� , �; � : AMOUNT DUE
, � �. ��r
S.D1
STATEMEMT
���������� SEE REYERSE SldE FOR lMPORTAPIT$Il.UNG lNFORMA710N �mi�i.0 _�,.....
_�.,.....:.._.,.... ............ . �� vuare���r � � uHRARICE � � � � AM6UN7' �
Wheelcheir Qne Way-Member AQ130 1.0 46.52 46.52
Trensport Van Mileags 50209 5.7 9.74 2�.32
��( �
V �
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J1
TaRai Charges $7.84
pE$CRtP'tiQM�OFPAYMENT REGElPT PAYMENT.DATE AMOl1NT
Totai Crodits 0.00
PLEASE PAY TWIS AMOUNfi-INYOICE DUE UPON RECEIP7 ^-► $67.$4
RETURNED CHEGK FEE-$3i.00
233369VY
� PATIENT NAME RITTER, RUS$ELL A G,0.Li.WUMBER: ���'ZQ,�2 - AMOUNT PA1D:� .
IMPORTANT MESSAGES: TH13 SERVICE IS MOT COVERED 8Y MEBICARE dR MEDiCAL
ASSISTANCE.
WE5T SHdRE EMS-BLS 20S GRANQYIEW AVE SUlTE 211 CAMP HILL, PA 97011-1708
�
Dailey Eye Associates, P.C. �a�raoervisawes�ncu�o.n�scovenoa�wcurown�,ae.ournaaw
t$57 Center Street �� o��� �a�Y�p� �+��
Camp Hill, PA 17011 �`m1e
. �— MUflillY.1L('EJOGIT
RETt1RN SERVICE REQUESTED y�"��""�"
Patie�t Naroe: RUSSELL RITTER
ForBillingQuestions: '71�-781-3011 09l06l2012 S2Z89 t7547
Office Hours: 8:00 A.M,to 5:04 P.M.
CMqfl4ESAN�CP@UfTSMAD@AFfEpSTATEMENT SHOWAMOUNT
DATEWILLAPPEApONNEXTSTATEMENP, pAIDHERE �
Shht IDH:1911p8283 ��MAKE CHECKS PAYABLE/pEMiT TO:��
,ii�li'I�i�Ili�1�la�ami�l�4�iluP�El�,��u�ld�llEl�I►�u�i, �,el.�
� ,�.,,;, ftLlSSELL RITTER
� 1�01 GOPPER CREEK 4R Dai2ey Eye AssociaCes, P.G.
MECHANICSBURG PA 17U5�-1953 1$57 CENTER ST
CAMP HI�L PA 17d11-1773
L�JH„�IIL����JL��tI„�IIL��II�.�LdLI�1tJ�L��I.�U
� IMMmAtlan I�ai cAen98d.znd chaz�ge(s!an�eraea eido-. ��� PlFASE DETACNAN[J ftENRN T�P P4flilON MRf}I
YOI1R PAYMENT�N ENCLOSED ENVELOPE
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PROVIDER:
8/27/12 CVS 62.39
9/07/12 DR. PASTUKA, DDS 86.00
TOTAL 148.39
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i:st Will .(�nd Tes��,e.,�t�,t Of
�,USSELL A. RITTER
I, AI7SSFIZ A. g�jg,$, af the CTTY of MECHANICS$URG,
COtJIV'fY of CUME{ERLAND, COMMONWFAI,TH of PF.NNSYLVANIA.,
being in good bodily heakh wd of sauad and disposiag miad and memory>aad not
using under duress,aunace,fraud,or undue influeace of any person whamscever,
mere2q calting to mind the fraiity of human iife,wd being des'saus af disposing mY
worldly goads while I have t6e scrength and capacity so to do, I do make,publish
1Tid c�1[e T�1i9 my T.ACT i. NTS CTAMRNT, I beseby nNO� c�acCl
wd avnul all my former Wills aad Testamtnu,iacluding c«licils tharexo,6y me at
azty time made,and deeIate this alane to be mp LAST WII,L APID TESTAMENT'.
AS TO SUGH ESTATE AS ST HAS PLEASED GOD TQ ENTRUST ME
WiTH IN THIS LINETIIviE, I DISPO5E OF T�IE SAME AS FOLLOWS,
VIZ:
TlEM1. I direa chaz my Execvcors hcreinafur named,IsaY and discharge ati of
ffiY lust detra,funeral and tacamontary espenscs.
�TEM2. All the resc, residue and remxiader of my eeuire estatc,whexescever
Isituate, wd whauoeva ix map consisc of> I give, devise, and bequeath, �luolutely,
and in fce, to my dprly Extoved wifq �} A D. I
1YA7 $ITSEB. In tfio event mY �
dearly beioved wife dia with me ia a simultaneous disester, or faiis to survive my
deac6 by c6ircy (30} days, then I give, devise aad bequeath my eatire escate,
wheresorver siurau,and whatsoever it ayay consist of,a6solutelp and in he,w mp
dearly 6elaved cluldrea,share aad share alike,per capita.
TTEM�, I nominate and appoiat as Execvtrix of t6is
my LAS't' iVII.L and T'ESTAMENT. Should tlte Executrix herein named,fai! to
quulify or ce�ae [o ut u F.�cecutrix, s4ma I appoiat ROGER R gj�$ u
Exee�tor ia bet stexd.
ITEAd9. I hereby dirxt that all my personal representatives, as well as thur
succeasors,ahall not be requirecl to give bond fo t13a°�f�ithfirl performaace of
����c�/',�`
:k� _���
ItUSSELL A.kTCI'ER
t�ez of a
duries im anp juriadiczion.
ITEM� I arder auct d'rr«c shac my Personal Reprnstataave(s} named hercin
use che legat servias of JAMES M.$ACH,as Attorney for my Estue.
IIEMIL I dirax that aU escatq sucassion, 1a8acY, inberitan« or other trans#er
taxes, however cksignaced t6az shatt bewme payable by reason of my death in
respect of all groperty comprisiag my gross ettau far tau gurposes,whecher or nat
�ProPen3'P��dc� ��T WII.L, shap be paid by my E,xecucor oux of
my rrsiduuy estue.
TTEM.Z� T grnnc co my personal representativa herein
named, in additian to,
but not in Iimitation af these gowers vesced by 1aw,to be axercised cvixhout prior
applicatioa to ar approval of wy ooutt, the power and authprity co retain
indefinitely aaY PmPtnp�to invat and reinvest any uuu or the proceeds dtrived
from the sate af �saets, atthough said iavescmenu may not be af the charac4a
prescabed by lnw, to sell, convey, astign,transfer and encum6er any property,to
PaY>�ttle ar campromise all ciaims,ta make distributiou or divisions in cash or in
kind, aad in general to e�ercise all powers ixi che management of anY ProI��S
hemwder which aay individual could ezercise ia che managoment of similu
property owned in his own right,wd to execute and delivex any and aIl instrumonu
wd ta do all uts which may 6e deemed necessary xnd groper.
:�
�� . ' !r� ,�'. ' �'_�/;',5� � a.rl � �
RUSSELL A.RPI"TF'.g
WfPNE r �WICNE9S,�i����.'
� J• SUSAN T.MAZ �'R �
Paga 3 0£a
gS'Rnrc�wLr�M}?.1VT'
COMM4NWEALTFT OF PENNSYLVANIA }
} ss
C4i7NTX OF C[TMBERLAND }
I, RUSSp.Li, p, RPifiBR, che TESTAfiOR, whou name is signed to che
anuchai or foregoiag instrumens,having ban duly qualified accordiag co law, do
heroby acknawledge that I sigaed aod axecuted the inscrument u my I.AST WILL;
chac T signed it rovillingly; and that I si$ncd it as my fra aad valuntuy au for the
F�Pou therain egpressed.
Sworn to or af6rmed aud acknowledged 6efaro me,by:RUSSEI.L A.RI7'TER,the
TFSTATQR chis 14�daY�'�.R�m�C>122&;�
e
�,� c�. .C�t I���„��
RUSSET.L A.RiTTER
NOTiRiALSEAL � �
ATror�i'�pa,�Cn.r�,Pw�pc ES M.BACH,A5C2LTtRE
��� NOTARY PUBLIG
EqNn��a�,}gyp Mec6anicsburg,FA178S5
My Commissiaa Fapira: 85If3199
AFFIDAVIT
COMMONVVEALTH OP PENNSYLVAIVIA )
) �
COUNTY CIF CUMBERLAND )
we, Insorr j. tvtnzz�� susntv x. �uzzz�,c��c�s�h�
namnes are sigaed to the ucached or foregoiag instrument� beinB �Y 4ualified
acearding to law,do depose and say thu we wcro present nnd saw the'IT?STATQR
sign and esecuu the instrumaat as his LAST WILi.; chau the TESTATOR signed it
willit�gly wd thu lu executed it as his free and wluntary ace for c6e purpose
thcrein espressed; that eacfi witness in cLe bearing and sight of the TESTATOR
signed the WILL u witnesses; and thaz, to the besc of our knowledge, the
TES'Y'ATOR was,u the tima,l8 or mare yeus of age,of souad miad and under no
constraint or undue infbuence.
Swom to or af6rmed aad acknowlcdged before me, by:JASON j. MAZZEI and
5USAN T.MAZ2EI,witn�sus,this 14'_°day of��y�t,292H•
r
�1� wrr�vESS T �c..
A J. SUSAN'I'.MAZZEI/; !P
NCSTARIAL8Eq1, �� '" � � "
A�'�e u,enCH,r�ryp„y� AMES M.BACH,ESQUIRE
��"�0"'��ta,ieoo NOTARYPLTBIdC
Mec6anicsburg,PA 170.45
My Commiasion Fagires: Q5/13l99
Pag<4 of a