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HomeMy WebLinkAbout07-11-13 �- i 150561�14� ...� REV•�5�� ex ro�-�o� FA OpwrtmsM of Rsvenus OFFlCt�1l U8E QW.Y 8ureau of individu�N Tauea CourM Code Ysr fNe Nurt�her P4 Box 2eoeot INHERITANCE TAX RETURN 2 1 1 3 0 2 1 2 _. _. . Hurbiwrg.PA 17i28i18Q4 RESIDENT DECE�NT EN7'Elt OECEDEl/7'INFORfAA71f�N 8El.OVY` 3oWl Saauity Numbsr DYte of ileaM MMDDYYYY 08te of Birfh MMDOYYYX 0 1 6 5 2 0 1 3 1 � � 5 1 9 1 7 Osc�MnCS Gut Nama SutHx DaaedanYS FirK Name MI E C K E N R 0 D E H A R R Y W (H 11pp11cabN)�nt�t Survlving Spousa's IMonnNlon BNqw Spou�s's l.ast Namt SuHbc Spouse'a FNSt Nams Mi Spoutit's Sociel SecurNy Numbar THIS RETURM MUS7 BE FlLED IN dUPL,tCATE INiTH THE REGiSTEtt OF WIILS �nu.iN,�araorw��ovN.s e�.ow � !.Or{pN�al Rstum � 2.Supplsmentai Retum � 3.Remrindsr RtNum(d�af cis� ptfor W 42-13-82) � 4.Limited Estate � qa.fuWro�l�Canpromise{dats of � 6.Pederoi Estab Tau Retum Repuked deMh attsr t2-t2�2j (� 9.o.�nc Di.e v��ata ❑ �.aaaamn u1.MUinea a u,�nQ rn,u _ s.raal Nwnber or sat.o.pwK 9oxe. (Attach Copy M WiH} (Apach Copy ot trust) � 9.LidpWion Proasds Reosivad [] �o.svcusa aow�ey crad��d�r a�aen � ti�.��ro ux under sec.e��3W bslvrosn 12-3t-94 and t-1-9b) (Att�cA SGA.Oa CORRESPWi6ENT-TiN58fCT10li MUST 8E COIIPLETED.ALL CORRESPWbENCE A)W GWFFiDENT'W.TNf INiOitWTpN 8H4UL0 BE OWECTED TG; Nama Chytkna Tskpho�w Numbet W I l L I A M A � D U N G A N 7 1 ? 2 4 9 7 7 6 0 n - aeqis �gus uae�.r � m �-' � iT� P'"r n7 e? c:_: „` �c'> Fint Nns of atldress �r _ c,..�� , � � r— i-._ 1 I R V I N E R 8 W � � ~ � sacona li�s�aadross � '-` � .� r: � �, � :'- _:,': "., . ti., � Criy u Part 011fce StaGe 2lP Cab ,v biqe Fu.EU�:� -° {....� [i} �-..i C A R l I S L E P A 1 7 0 Z 3 `" '�t c«n+vond.nrs«n.uadem«: biil�lduncanhartmanlaw.com unar w�ww.a w�Wrr.�ar�..rrr�nw.hwnh.a�u�a,m,u�a�q ac�m�M�a.a�.a�a...oa.i.rmanu.,r,u a W.waa mr wwwrup.nw awr. a x ew.oaqa ra aomp�M. . a p�pr.rwwr 7rn me PMa�ai np+wNMM b eaw m a 4�tamwwon arMYtl�prprsr nr a�wwwruya. SqNA Cf FWt RkTURN ✓A7'Ey"l7 817 &OBIN DRIVE CARLISLE PA 17013 SqNATURE OF PREPARER OTNER THAN REPRE$EMTATNE OATE PLEA9E USE OWGINAL FORM OIKY Sie�1 � 1505b1Q14D 150561�14Q � � 15U56Z0240 REV•i S00 EX �pa Sada!Securily Nutnber o.aa.�r,wm.: HARRY W. ECKENRBDE nec,u���vu� 1. RealEsqta(SchaduM A1 ........................... ... . .. . ... . .. ... t. � 2. StodcsaM BondeiSchsdub B) ........... ........................... 2. • 3. Cbeely lield Co�wratWn.Partnenhip ar Sr�PraDtbtonfiip(Sdutdub C) .. .. . 3. • i. Mortprper and NoGU Raceivabk(Scheslub Q) .................. ...... .. 4. • s. CaW+,Bank Daposds aM Mbcetlensoua Pawna�ProP�Y iSdieduk Ej....... 5. 6 9 7 9 . 8 4 8. Jointly Ownsd Proparty(SchMub t7 ❑ �a6e B�IrW ReQuastetl .... ... 8. � T. In�r-VMOS Transten 8 AMSCaNanmous/�Probats Properly (Scheouk G} t,J Separete 0111inp Requested ... .... 7. . 6. ToW Grosa Afs�b{tohl Unen!Utrouph�} ... ... ... ... . .. . . ...... ... . 8, b 9 7 9, 8 4 8. Fumuai Expeneas and AdmMistratiw Goets(Schedub H) ...... ............ 9. � U 4 0 , 7 9 40. osecs of osaw«rc,Mon�.aae�b�uaee,and G�om�ise�reaub i� . . .. .. ... .... io. 1 4 7 8 3 3 . 5 6 ��. Twi waucdaa�ta.i unes u and�o� .................. ............. ». 1 4 E 8 7 4 . 3 S �a. i+.c v�xw or�ao.t�ine e min�•une�s> ... ..... .................... �2. - 1 4 1 8 9 4 . 5 y 13. CharitrDle aiW GovatnrtwMal 8aqunWSec 8113 Tnista fw wMich an ekdbn�tax Ms rw!bs�n mWf(Schadek Jj . . ... .. . .... . .. ... . .. . 13. . 14. NK VNue Subpct W Tax lLind 12 minus Line 13) ...................... 14. � 1 4 1 8 9 4 . 5 b TAX CAi.CU4AT14M-$EE INSTRUC710N8 FOR APPLICABLE FtATE8 t S. AmouM M LG1m 7�tYribk at tta epoueal tax rats,or trYnsbrs utMiN Sac.81 f8 tax�.z>x.o � o . a Q ,s. Q. 4 C! 78. Anwunt or uns t4 tpxaob et N�rw4 rats X _ = 18. � • 0 � t 7. RtnauM af tins 14 tazabk at siD9ng rats X.12 0 . d � 17. � . Q � � ,e. ��'z.,"'�° o . a a ,a n . � o ,s. T��,� .......................... .... .. ... ... . . . . ... ....... .. ,�. a . o 0 20. flLL IN TNE OVAL iF YOU ARE REQUESTIWG A REFUMQ OF 11N OVERPAY/AENT ❑ Sidi 2 � 1585610240 150567�Q240 � REV•�504 fX Page 3 Fik Num6K Deeedent's Complete Addrsss: 21 13 �212 �CEDENTS NAi� HAftRY W• ECKENR4DE STREETADORESS 801 N� HANOVER STREET cro sTa� zw CARLISLE PA 17�13 Tax Payments and Credits. i. Tax Due(Page 2,u�,s� t�r n.E 2. Credits/F'ayments A.Prbr Payments B.pismunt TWai Credta{A+B) {2) Q.Q 3. Interest ta7 q. ii Line 2 is greatet tl�an Line 1+Line 3,enter tlie d'dYerence.7lus is ttw OVERPAYMENT. FW in avN an PNp 2,LFm 20 M nqtmtt�rNumi. (d} �-Q 5. ii tine 1.i.ine 3 is greater tl�an Line 2,enter the diHete�we.This Is tl�e TN(DUE. (5) ��0 Make check paysble to: REG(Sl'ER OF WILLS, AGENT � �,,._ , ��s��;G�,� .°,. �;�� . - . ,.. __ . PIEASE ANSWER THE Fl�f.LOWiNG QUESTtONS BY PI.ACiNG AN"X" iN THE APPROPk(ATE BLOCKS 1. Did deceda�N make a tranafer and: Yes No a. relain Ne use or k�cane of Ihe praperry hanaferred: ...................................................................... b. reqin ttie right to deaigna�who shaA uae fhe poperty Uansfened a its inoane: ............................... c. remin e rereisbnary intere�;a ................................................................................................ d. �ive tl�e pranhe fa iih d eHirer paymenis,bawfiis a care7 ....................................................... ❑ 2. tl dealh aocwmd atNr Oecen�et 12.1982�did decedent iransfer properiy wifhin one year af death wiUaut rocdvhg adequa�oonsidaretlatT ....................................................................................... � � 3. Did decedent own an'In�for'ar pa}�a6le�upon�de�h baMt 2cwutat a securiry at ttls ar tier d�M9 ......... A. nld deOBdBiN awn an Mdvbu2l r66ren�eni HOCAUM�81x�Uity Of OtlIBf f�W�{Ma112t8(1fOpB1Yy�WhiCh contains a t�flday d�an�_................................................................................................ ❑ rX1 IF YNE XM{SWER TO ANY Of THE ABOVE QUESTIONS 1$YES,YQU MUST COMPLEfE SCHEDUl.E G AMp FILE IT AS FART OF THE RETURN. � rx � Fa da6es 4t dee�on ar al6�July 1, 1984,�ut before J�.1,1995,No f�ra�imposed on the net vaiue ot h�ansfers Bo or for the uee of tl�e survivin4 sp�us 3 percent(!2 P.S.§9118(a)(t.1}(ijJ. For�of deatl�on or at0er Jan.t.1995.ihe te�c rate imposed un�e net velue d tanafas to qr for tlre uae�Cba swviving epa+se is q peroent (72 P.S.§9118{a)(1.1)(�J.The a�u6e doee aat erampt a�ansfar 6a a survivkg SP�+�Uom tax,ar�d me e�amtwy requ�emen�wr aia�osure a asee�s an f�g a tatc re�am are sal appYCa41e even if the surviving sPWSe ie ihe oniy beneficiary. Por rk�bs�dealh at a�r Juty t.2006: • The ta�c rab urpoted on tlie net walue of Mdnsfers trom e deceased child 2! years of age or pounger at deatlr�or ia the use of a naWrsi parent,an adup6ve parent a a atepperen!�tl�e chiW�Q percent[72 P.S.§8116(a}i1.2jj. • 7tie te�t rate imposed an Ne net vak�e of�s�rs to a tor Uie usa of tlte dacedent's i�ai beneficiaries is d.5 percent,e�ccePt�no0ed in 72 P.S.§8t 18(t.2)(!2 P.S.§9i16(a}(tjj. • The!e�raie impoaed an tl�e net value pf trarrsEers fa or for#�e nse of the decedenCs sibrings ia 12 percent[72 P.S.§9i 1${a�{1.3)l.A sidN+g is sleHned,und section 9ia2,as an i��auai wno nas ac bas►one parenc u�c�mma,w;m me as�dent,�ay baoa«edopto�. i REV•1508 EX�(b98) � scxEavu� E co�.r,a�u.neoFVEra�sr�Y�,. CASH, BANK DEPOSITS, &MISC. '""�"`^"`�T^""�" PERSONAL PROPERTY RESIDENT E8T�iTE 8F FN.E IIIIMlER NARRY W• ECKENR4DE 21 13 �21c� krdudsme al�bnaad6�edqems .xerecdwnlr�nseetw. Ar r� of mwtb�tdNdawdon$�is�. ITEM YAIUE AT DATE NUMBER DESGRIPfl�N OF DfATH t. PROtEEDS 4F flEMBERS FIRST TAVINGS ACtT. �t130949-U� 3,072 •0 [SEE DOD I.ETTER ATTAtNED] 2- PROCEEDS OF MEItBERT PIRST tHECKING ACtT• *13II949-11 2,338-4 iTEE DOD lE?TER ATTACHED] 3• tHURtH OF G6D HOME REFUND 1,569-4 I raiA.(Also enk�r an raie 5.Recap�latlaal t 6,979•8 4 (n mas saoe b+�eeaea,i�pan sdatlone��hesro d nr�na Nmi REV•i5ti EX�(1Q-U91 pennsylvania SCHEDULE H °£P"��°``�"'� FUNEItAL EXPEN5ES AND iN�wrar�rNCr�rua+ ApM�H�STRA7IVE COSTS a�sia��r o�cEO�+r ESTATE Of flLE FNM�R HARftY W• ECKENRObE 21 13 A212 wua.m�.a.na muu a nporad on scd.aw.i. lTEM NUAIBER DESCRIPTIt7N AMOUNT A. FUNERALEXPENSES: t. FUNERAL LUNCH - GIANT [SEE ATTAtHED] 164�? 2 . FUNERAL LUNCHE4N - [SEE ATTACNED] 29.9 B. ADMINISTRATlVE C4STS: 1. Pe�son2tl Repreeent2Uve Cartunissfuna: t�ne(aidPena�d�m�ey D4NNA i.- {14YER 3p8•9 svebqdd�eea 817 GOBIN DRIVE cay tAR�ZTIE � PA z�a 17013 Ye6t{E)Comn�On Psid: 2 Q13 2, Ammer�=eee: DIINtAN & HARTMAN, PC 34d-9' s. Femtly�:�ttaec�bnrs�saianan�esm�eas�'a,�cnez�tlOn.7 . CieimBM StaetAdtlreu CNy Sme 7.� RaleUOnelYp d CkYnpnt b Dea9dtlM 4. arocateF,a: REGISTER 4F LIILLS 133•5C 5. AcaounantFaea: $. Taac ReWm Piepe�xFexs: 7. REGISTER 4F WILLS — FIl.IN6 FEE 15•�� tO7u�tdsoenteronuire9,RecadwiaWn! i 1,04Q•79 �f mae�pece b neaMa.uoe aedlEabl aheeb a pepsr d rie aems e'as. REV•1512 fX+(72-08) pennsylvania SCHEDULE I pEPMTMENiOFREVEINlE DEBTS OF DECEDENT, ��^����T�+ MORTGAGE CIABiLiT1ES,8 LlENS RESIOEM P�EOEHT ESTATE OF FILE NUI�ER NARRY W• ECKENRBDE 21 13 C12Z2 Rpat Mtk�IneurtW by tlre dewd�nt qior to daih tlu��smei�d unpdd at fha Aabr of dalh.indudNy wa�Nn6arwd m�dkal ixpenK. ITEM YALUE AT DATE NUMBER DESCRiPTiON OF pEATH t. CNURCN 4F 64D H4flE 1,057•0 CSEE ATTACHEDI 2. PA DEPARTMEN7' 8F WEtFARE LLAIM 146,77b�5 [SEE ATTAtHMENT] TOTAIfAtaoe�ron line 18,iaecspiw�ar) i 147,833•56 n n�a.aa.oe b need.a.Fmen aaanaw�I�eeb a me smne alze. pEV-1613 EX*�01.101 i����Y�'���t$ SCHEDULE J o�v�N►o�� BENEFICiAR1E8 i�r+�nu�TNC�ura r+�rtor�o�+r ESSATE GF: fN.E 111,�1RElC HARftY W• ECK NR4DE 1 0212 F�1A7lON&hllP TO� AMQUNf t�t SFiARE NUM9ER NAIAEAND ADDRESS pF PER"aOW�RECHV�t?PNQPERiY Do Not U�Taq�w(sj QF ESTATE I. TAXA9LEC1tSTRIBt)T14IV�TlMtlue��ouYluFl�puwl��enat�a(rsuntler �1TS WN.�J. t. DONNA L• MOYER �irteal 517 GQBIN DRIVE 100i GARLIStE, PA 17D13 ENitii Di�i.iARAMdUNTS WR OISTRIBUTlfJNS SFI044N A84YE OPI LlP�S i5 TFIROUGH 180F i�V-1500 CBVER SNEET ASAPPt10PRIATE. II. A.SPOUBIVt.DIBTRIBklf`K1N8 UNOER SECTk�P14113 FOR WNICFI AN EtECTK1N TQ 7AX{S NOT TAKENt 1. 8.CFUdi1TAt�LE AHDC+OV£RNAIEMTAI[NSiR18ttTiUNS: 1, � TOTAL GF PART II-ENTER TQTAk NON-TA%A81.E OISfRIBtRiOMS OFt Ut�f3 OF f�V4500 C6VER SHEET. # N more a�e b nfleded�uee ad9qa�1 aheeM d peper d d+e same a(ae. _ � ... . ., �.. �.r..� ... .., . . �, � � �w�T , x�r�- w�.,,r�, ,.s .� � . � ,., �F:�.�sv��x,^�s u „ " : r ��, . _ .,., , �i�t��� �i�t �i��t�t,erit � , ' II�. __ __ � �?� �`• ��,�, A1�a�'�S�I+�id�M�'F��� t ��►,� � � '���`�����u�'��� : '"� ��������°� T���v��r�� ��+�r +�:� .�. oe�r vv��u��+��l�.'��7►"°� ' �. �d�re�l.t�al��,�d4�;�#fi►a�'�4�be�pd��le+�tates� �oca��?��}� �����''�''�=i a. �. ,, � 9��� ��rac,�t�m,�r�beri�at�raa�w��mg ��Kia��c�rd � ���� _.. �t f. �.���`��� �"�������� ���r�� ,F �"�`;��'.� , ��'�'���'. �' , ,:, � . , � ms�t� .�a�����"����,����'� �by �r�►�rn�b������,��►+�.+����� - ,�� ���/� +�j������`���w�?� ' :`�a�twlk�. ' �f1��1>e^ ��� . . .. � • � � � ��f�,�41l� ��ds��t��,��r�a�ti�ati�eot} , '��!�!�"� , , p��<���14!���F � ���t��r�t�'�'�l�l�� , µ�' tl'T�I���V�w��� ���i���►7",f�.�` par�1�e�u,` . ... . h .. ' . �`y—� � . _�- Y . ��,� �.��y�� •."�'—��^., � �����' {�. . J y��}�'�+��'+�4�� ,!i� �Ta �������� y .: � �'1���� y � + t��.:'3� . ' ���� { n . Yd i . �.����,�i!�: . , �� f.�- 4: �� �����.�'r�������� . . W��Y��l�:��'Q���bs�a�afd�t�ofmlr �� �ir�T"[B.� I�by^n�ey�+l���7f'N�'R.�Y�• EC�I;,��=��ia4altf�ta��'.V�#�tt?aAawreiM::�ili�ssra�nGdn�, claitk�aMiawtcr�*i����taM�e�a1�4���� �#'aG$I��dqs,�ml!appoiat mY dw�r,DOl�ffe4'L.M4'!€Blt aa Bx�oa�ruc eutt6itmy'�t Ws��''F�K: I heseb�r rr�i�anrc mg Ez�a�c�ra�a t6e �ea�ty of pos�g�i1y in a�mec�oawitb 6ar fidiet,u sucb,ia au�►}u�i�oa ia which sha any be c�lad'uproa to act ineotir as I nm aWa by law W da�a. In�tian ta t6a pa�vers . .., ...��m.. ..,.m ..va=. r.,..�ga ti.r _ ,c •. 'S � . t � .. — X. , � ��.e,.h3 r � .. � �� ' � . . . � . . F �:;. . . . . t + . +�°7 �wns��'�}i�X�1�➢Ir 111�►018�0�D�t1r L8 TQ{81111Q�18�OY'/ll iACA{\f!R{� ip�t�i0�{'pt�iif�l+�.���lVAtO 0�4�Y�a P��P�Y��'�Y� at thE ti�e ofmy dath. " P�'QiTH. I IrivR ta�e,cu'mt�r 6a�►1i�,e to tiaae milte,�wri�n m�na�andu�n ���,�'�8►v�e��dkea€P�onal.l�P�Y��P�> I+��Y �trac+a►tf��i�c�t ihaie wiaia. 9uch`a ma��un,ifrn�day s[nf!be stored ia��ri�lt tkps`W'�!: ' II"t Wi'�N�B�YR�QF>I baYe�o aat my bAnd �1 to this,n4Y Lark Wilt �od T�,�.cdtma t�rpao�rittaa P�Ya thi�o�qt�be�': 1948: r�. ��c,.��,. �T 4}��V�.�Y ' � � -e���... . si�.d, �eded�d.and�nt�a�b�!�a aba�ue►n�ad�T�I�.X w: BaCFtT�'�d'`s���L��#W�'aad T� ra�lis�r;�'w►�at his"° req�,ia�ri;�+p�`,�`and ia�the�a�[p�eocaa�"aa�,a{har,Laxe h�o a�ed ai�c�naat.�wit�:, �� �` ���as�''�" , I . w ,.,q7��r s-; � .�rrm �x 3 r.,�. r+-re� xr�.. u;-ra.-, z v^ ii< 'x9 .",5"l +t`�,� �'""�'iF ' - ::- , , " , .. ' . V�. a. ,..a_FPt' . . . . � • � . .. . . , � . . .. . . ' , . , .� . . � . � .. . - , . Ct,�4' _ft1,,Yil�,�d��OFP�YN«�FLI�AN7�! : . 5.4. 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ECKENROpE oa�.a o..n,:ouo�m�s soeai a.�wny aumar: ��s-�asseo 5000 Loaise Drive, P.O. Bns 40. 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Pp Bmc 8186(Harrkquq,PennsyNanfa 177058486 � Pennsylvania DE►ARTMENT OF ►USLIC WELpARE 717-772-6553 FAX Enclosure aureau a v.�pr,m t^ay,�r I aviswn a rniro ra ��x�9b I HaMSburg, Pennsylvan au171p5 gq�very SecUon Re: Harry Ecke�rode CIS;�: S402719?8 SSN: #���k•##-2950 Date of Death: O1tOS12Ui3 bECEDENTS ASSETS ITl�M2LTION�jL,RM �n j�d��Z,��'[jQ(�( eRESENT VILUE Proprrty/Rra! F.dsde Address 3 Ba�k Ao�ou»t(a) Aaauni No. � (Ptt�e indfcate a 3oint account by ptadr�q a "7" Account Na. # to the right W the accau�t number) Rccount No. ; Parsonai Cae's 1lceauni $ 8u�iai Acwu�#{s} Accaunt No. # Accaunt No. # iewrsnc� Palicies Palicy No. # . Beneffciary Name Policy Na. $ 8eneficiary Name Policy Na. $ 8erseficiary Name Stacksiionds # WNI tM d�ta�d�nt's rsbtr b1�probatai? { }YES ( ) NO (Probate is n�ctssary when therc are assets in the deCedenYs name only. Assets heid joindy and assets that have designated beneflcartea usuatiy do not require probate). Is s sa�all�stats p�t#tion i�in�p fliad? ( )YES ( ) NQ (R smali sstate peUtio�, a fcrm of probate, Can be filed if the estate assets are #25,800 or iess) Ii you hsw any qupqons raqardinp probat�isw, pi�s�re eu�wlt M�psl eoueuel. I ACKtiOWLED6E YMAT THE INFdtkMUlTIt►N I HAVE SUPPLIED ON THIS FORM IS SU87ECT 70 TME PENALTTES ; S!T M�ORTM IN iS VA C.S.4404(nNsRtny ta u�sworn falsMicstbn to sutl�oritiesl Name{Piease print ckarty) Signature(Piease sign in ink} Date GOM�OMNEK7M OF PENN9YLVANN BUREAU OF pROC.IWA WiEGRIh' OMSi6q L�F THU16 PFRTY CU�80.I7Y F�CBVER'!SECi16N PO80X8/88 � wuxisisw�c.ra rnaseaga March 4,2013 ' STATENIENT OF CiJdM SUMMARY y,i �� �`� ENat�of ECKENROISE.NARRY - , , �. .,�a Q/0 2T7 878 ,:� .L: e,� , ,:� �,.'yi.a� c� , +. > � " ✓: P4!� ..,.<. -xa.e+. :a.'a. . �a w, !lIpAT1ENT .00 .00 .OQ . OUTFRTIENT .00 .00 .CQ LqNG TERM CARE 32.887.8T 713,Y36.7Q 146,6W.d8 6Rt7G 98.36 134.74 473.10 T� . .;.., ,,.4.:9 ty.. p� wI�M I� a� ,t�Ma! .� +s>7W.Vli �1�Y�O.W T`�ry/IY�a9 �_ �� ; T � + � , n � . �'�&, Y,.. c �8°� Page 1 of 1.0 r�y � i';aa .�. wk�'r�.� � � • � r�Yp.� . �yqp d ._� -�- � n�fi s„��'?`;S-. `^�/!M' 'i.�':u.. March 1,2813 STATEMENT OF CtAfM , . ECKEMROOE,HARRY � ip ,` $�0 271 8T� CHURCH OF f300 tiQME ING - !01 N HAN6YER ST CARLi3LE PA 17013 LiATE GF9ER ,Y�.'�r' AFVa���Q��, .`M�xn'��!�`,�.r"µ s�, c+„ c �:�, :c' r°` z�.� _ � � �_ 10f417iQ - tOf31tt0 10/2i/11 55112824Q63W0001 lSBN2Y3A063WW01 6,ta.96 6,89Y.81 OiAGN6S151 : 7167 DIFFICUkTYltt WALKtNfi DIAGNOSIS 2: 0 PROC COOE: 000000 . tilO1H0 - 11/30f1Q tOt201i1 Sb1i292+406412G04f 66N29240641AWDi 6,8t3i.50 5,{90.it QIAGNOSlS t : 7197 DiFPiCULTY IN WALKIN6 DIAGMOSIS 2 : 0 PROC COOE: OOW00 t2Wit10 - t2l31J10 lW2M11 561128Z40b4i/OOOf 56112i3�06471G004 B.ii2.s6 b,6YY.Bi OIAG�NUSiS 1 : �ti7 WfFiCULTY iN WALK�NG DIAGNO$iS 2: 0 pROC CODE: 000000 01/41IN - Oif3ti11 1W3i177 b817RlFiW38650Ci01 6b112S8i06�660d01 8.fY2.46 8.244.03 OURGNOSIS t : T19� DIfFFCUITY IN WM.KING ouc,Hasis 2: a PROC COpE 000000 USl6i111 • OZl28IN f0i31111 56t12994064130041 5511299408�13000f b,584.60 6,f8B.16 DIAGN4SIS t : 7197 DIFFICUl.7Y Ik WALKItlt3 DIAGNOSVS 2: 0 PRLiC COOE: pU0000 63M1111 - 03/31111 ifk3111f 6611288406663G001 b61 1 29 8 40 6603 0 0 0t 8,182.95 B,G68.42 DIACrNQS15 7 : Tt97 DiFFICULTY fN WALKIM6 OIAGNO$!S 2: 0 PROC COOE: 000000 0410flfii . Oft�pN7 44l07fi1 55113p6466Z6BOd01 56113064Q4288000t 5,983.50 , 8.4Y4.70 DIAGNOSIS 1 : 7147 DiFFiCULtY IN WALi(tNG OfAGN0.SIS 2: o PROC CODE: MIGOQQ MYQtiN • 0613ihfi 77107t11 S6tt9064pti329006t fi811306Wb3290041 8,152.95 $.17$.25 DtAGNOSIS t : T19T OIFFICt/lTY IN WALKING oucaosis z o PRt?C CODE: 000000 Page 2 of 10 '+ s `� s`".^� ,'� '� - t:�' Y�K'sx � n4��(�(5� y�arq t .3 t '^fyy}� 5 ��i�� }1 w . g� •n� ;}�'. March 4,2U13 STATEFIENT QF CLAIM � NAM�� ECKENRODE,HARRY� !¢ ::���. 8�6 271 878 CHURCH Of GOD HOME INC !Ot N HANOYER ST CARLISLE VA 1T013 • ��F�Yw�a��r�'t ,'R,��rt:T..�:Ri �-�+�':°�'E�..,�� �:.n°r «N�S � 17+ OWO1H1 • ON30N1 1LU7141 56N30640W22C001 56113WFW64220001 5,l�3.60 b,'223.23 piAGNO&IS t : 7981 DIFF�CULTY IN WALKINGI DiAGN45i5 2: 0 PROG COOE: 000000 0T10111t - 07131H1 OW07772 55721TA425882U001 661212442b9630001 B,il296 5.211.87 OWGNOSIS t : 7187 WFFICUL7Y IN WALKIN6 D#RGNOSIS 2: 0 PROC COOE': OW000 OB101111 - 0&3flt1 CS1Q7f12 56121t{i26d1�4001 b81213A42BQ130p07 f,fi2.96 6,231.8T DIAGNOS�S 1 : 7187 WFFICULTY IN WA�KING owcra�os�,s 2: a PROC CODE: OOq060 OiNliift - OW30N1 061U7112 l3 51 21 74 428 0 8TOOQt b6t2i2442806i0p67 $.8W.60 5.037.83 DIAGNOSi51 : 7147 pIFFtCULTY IN WALKfNG DUIGNOSIS 2: 0 PRdC CODE: OOOOOQ iNC1t11 - iW31111 OBh8i12 5612184i66Y080001 554218M669040fW1 6.tTA.ib 3.438.08 OUCiNO$!$i : 7147 6fiFiCULTY iN WILLKING i ouc+�osis 2: o � PROC CODE: WOOpQ it/01/17 - 1113Qt2t 06ti8l12 5412t8M689810W1 561216N68881GOD1 S,fl�l.50 5,8:{8.49 DiAGNOSIS 1 : M97 DIFflCULTY IN WAIKiNG pUGN9S13 2: 0 �rsoc caoe: o00000 17/61/11 - 17/31f11 UBHNt2 5612t8f4696300001 951218+14K90300041 6,178.86 6,421.09 OUtGNO5iS t : 718i DIFF�CULTY IN WALKING DUGNQSIS 2: 0 . PROC CODE: 000000 Ot141Jt7 - Ott3t/t2 o7/i8ii2 58127ffi1421888U001 561219M218880Q0t fi,t79.$6 5,090.20 DIAGMOSlS t : 7197 W FP3CULTY iN WALKiN6 OIAGFIOSiS 2: 0 PROC CODE: OOQOGD Page 3 of i4 r: . o- ,, y � . ,t �_ H. .� ".,y�� }��L� y.x ., x. . , .: '�' �t° ! �-✓ �,. r .i ,. ;E i ����� . . � } March 4,2013 STATEd1EN7 OF CLAiM t{A� ECKENRODE,NARRY !R ,, ��� &/0 277 878 � CHURCH OR GCQ}lOME INC B61 N HANOVER ST CARLISLE PA 170l� /�.�t'-` �..y� yµ��.y .(.. s X?t�:�`~ .?�+� 'sj; 'F ,::✓.,..ti,r, .:✓ ' tiY'z.,, ::TMr. . ���MF� R' .p�� �4+lI t .�w .�i %�.Ui�*' Y,� �k.. o�a+m • oanwtz m���r�s se�s�sa�s�auuoai satrs�sriw�oom s,n�n.�s s,7�zse 61AGN0SI5 t : 71Y7 DiFFfCULTY iN WALKING piAGNOS{S 2: 0 � PROC CODE: 0lM004 03(Q1h2 - OSt3t/12 D711&12 66t21W421S780001 b6121944t4Y780W11 8.174.86 S.OTA7'0 DIAGN0.SIS t : T14T QlFF3CW.YYlN WAtKiNCr l71AGN431S 2: D i"ROC C86E: 000000! OM01H2 - Q430I11 QN2&t2 2012122426906006i 261Y1�24269060007 5.860.E0 6,173.63 AViGNO3(S t : 771Y/ DIPFiCULTY IN WALKING D�AGNOSIS 2: 0 . PROC C40E: OOOOIS6 OiS�SJ72 - Ob/31M3 ON35t72 2012153�73Ad80001 241215343.9�886q01 6,170.86 6,371.6Y DIAGNOSIS i : �497 BIFFtCUtfiY iN WALKING BUtGNOSiS 2: 8 PROC COpE: 000006 06701lY2 - 0&3WY2 8i1231'f2 2012iYN20707Q601 204218M2QTQT00�1 5.9T1.80 5,161.51 DLIGNOSSIS 1 : T197 OIfFlCUl7Y IN WALKINti . ou�c,rws�s s: a PRdC C170E: OOOOOQ C1/07N2 • OT131112 01N4ft3 86t900H4��/M88(304i d6i300913Q1b68001 8,l7d.88 6,39t.5y OUlGN9S�S 1 : T1YT DIFFICU�TY IN WALKING OIAGNOSIS 2: 4 PROC CODE: aD0006 W/01N2 • 08131N2 04H�H3 561]UQ943U507tl00� 851�Cti�3030T000i 8,17q.84 6,408.89 � DUGNO515 t : 71Yi piFFICULTY IN WAi.KING DIAGNOSIS 2: 0 PROC CODE: 000000 OQ161J12 - 09150712 Oi/1tlt9 Sb7300$130667Q001 56134Q843056TOUOt 5,47t.8Q 5.490.53 DIAGNOSIS] : 714T DIF�UtTY Ni WAtKiNG a+acNas�s z: a PROC CODE: OOOOOp Page 4 oF 14 .. � h�y .,r � � �, . .. , �., , . Y y �jy�C_y61f4��,S�`,,.y.�2° � __ . . . #k � ')ar: � u _ J!5`` ' . #,� i�° �. ANareh 4,2Qi3 STATEINEHT C1F CWM ��� : ECKENRODE,HARRY . I � &W 27t 876 ( GNURCH OF GOD HOME iNC . 8Ct N NANOVER ST CJ,R{.I9LE PA 17013 � Y^�FK V�1lIGin' PA� t � `F'.ti � • { A » �°�� 4"C nP., y.� ,Z{��:: .��Mu � �:�.h.M�:1'}' :'.'.< F Pl,r.�', � _.✓,. s ��r�o��12 - �aaan2 at�zaria sai�tus3ax�+ooa� ss+ao2�saen�000t sa�o.es a.�<r� piAGNBSiS 1 : 71Y7 pIFFICUITY IN WALKINQ � � QIAGNOSIS 2: U � PROC CODE: 006000 i1101N2 • 11/30/12 Ot/28f13 6613021638332COQ1 6fi19024Q��63S70601 5.977.8tl 6.2]0.t3 OU�GMOSlS t : J19J DiFFICULTY IN WALKING AInGN6Si3 2: D F+ROC C40E: COOq00 1Z01112 - tYt31tt2 81/28113 5613U8463i3980001 66l702�5383YBOU01 b.476.86 $.�83.78 oucNOS�s� : r�s� o+FF�cucrt a�wnucirics DIAGNOSIS 2: 0 PROC CODE: OOOOOp 01/01/19 - Q7lG6/18 COIOO/CO 0��00800000000401 948.00 132.T1 DiAGNqSIS t : ESTIM PROC C�: Wq30S CASE MIX �SU6.TpTAL' d1URCH OF tiOD FiOi�iNC t84�9l6.60 118.603.I8 . � � -� . CS WQT47804 COQ1 Page 5 of 20 < .� �.. .,. ,.,, m...... _ _r. �. .,. �., - _. � ., r :�•. March�,Z013 STATLMEMT OF CLAIY .�.GI(ENR�GE.FIARRY� . 6W 2Tt 978 CONTU�A.�ING GARE RX � � 18S2M4y1 MEWI?CrR f pA 1T074 M�: � � 4' ' iWM13l�tA - 16f1Jtf0 t3l06M$ 2i103106At0ad00M 2b1091�<.: . �� xl.8�� 6.'7.1 OtAGN0:71:5 t: 0 � . NDCC��[�i Op2�76p IqRAZEPAN�6.6YfiTABk.Ei - /�7ARAC7IC$-TAAqCEMLiZ�3� �as�r,o �. �unrno 7]M6l19 2510Si8fi4316U00Q'! 261pStl64316600� 1�.ii t.�i DIAl31WS.9lS I : 0 � � . NDC IX�G F: OOxZl�A6760 tqWA#PAM 0.61Kt TABL�T • ATARIN,'71CS-TRMN�1��� N115+10 . itri61'10 i1NS110 ]61WfY61TZ"f1UCN1 2616�796471710001. - . 2�.p SZ3 ouc,�c,s t� ; ; o NDCCC�DrS: 0022{Z06T6Q tORA2EN'Ai/0.6iKiTA8t.E7 * ATARACTiGi7RANCMiWZE�S 11H7/1U . t1H7/10 tlpllflQ 2ii9D21660t2TQQpt y�iq32!#6N17qp@1 y�#,qT 10.Y7' GY1GNdSl$i : 0 � . .. � NOC COOF,: OOUMpNT01 PANl'CRRA20LB:aCiP OR/Q Y9 TA8 - ANTFtlLCBR PRENBlQI11tTAQWf�#T1NM.PREPB 11/2W10 • �1i1W10 0110?Mt YBiQ.Mx6l6t1i0001 Y816�4�0001 Zg,BE 1,21 OIl�GNa'si;i 1 : 0 NDCCQt� : d�t60 tW3AZ�A�F�.6MKiiABLET - ATARACTICB-1'RANWJILIXEI� 4�1+W0 • 17tl�ft9 OfllTtti �iWi6i6W2Q00�H 261d31Sbi6t3�60p01 23.N 6.Oi D(/�GNQE�i� k 0 ' NOC COC�E: 00�761'If0 GOpA2EGAY 9.4 Y!i TllBtfiT • ATAW�CTICS-TRAM4L�tt�S 19/iW10 �� 1:L:1W10 Otf2iF11 76/0�f/b�lOM0001 Z6l0�{pqp�1 2�.iE i.01 ouoNOSis� : o I�iC CODE Q92�206160 LORAZEPAY O.i Mf3 TABI.ET • ATARAC71C8-TRANQUILIZERS 81ri�1Y! • M%iiti q?NMti 461101163Y4�00001 26110176iiY9Y01p7 64.Z5 7.06 a�cawosis r : o NDC COQkE: OOZ�D6T60 LORAZ@FAM 4.5 M6 TABLET - ATARACTICS-TRANpUiLi�B Page b of IO { �"��������� ;„, r,.� ,. ,s .� MarCh 4,2013 STATEMENT dF CI.ANI I�AI�r�,. ECKENROdE,HARIiY � �;'e�;� 6W 271 8T9 � CA)NTINUING CARE RX 28 S 2ND 67 NEWP4RT PA 17074 .. x � . �� � t . .:^a �, . S��f 1� o f �-3.� e�a =.'ha�a` 'a�'�e, � . n �' _ _ _ . �a. ` k.�..� dy�. „ e ..., �J �?€'�9!F�1�'�.` `?.�',��,� . .�� .�,i a�rzsn� - oansrtt ouau+� ss+vaeeseaae0000+ 2s��oesseeae0000i ea,aa r.oz 6WGNOSIS 1 : 0 NDC CODE: 04228306760 LOftAZEPAY 4.61MCi TABtET - ATAifAC71C8��TRAN4U1lt2ER8 � QMi3111 • W/'11l11 06/09/17 251110�63116Mq01 Z611iW63118G0041 64.&1 6.89 pIAGN0.51S t : 0 NDC COOE: DC2382C6760 CqRAZEP1tM O.S MCi TXBI.E F - A7ARACTIC&TNANG�UB.iZERS 087SO/i1 - DN3W11 OUZ7/i1 24111506308620001 251115063p8620001 6Y.61 6.84 DIAGN�SIS 1 : 0 . � NDC C90E: CQ32B205TSD LORA2EPAM 8.b MCf TABtET - A7ARAOTIC&TRANGUILiZ�R3 07M71'It - 07117/17 OBlOBf11 3b171996�126U0UQ1 25itt93S31250U11C1 Et.7d 5.86 DIACaNOSIS t : 0 NDC CODE: OQI7E23211i6 ICiRAZEPAM 6.6 MG T1lBLE'I' - ATARACTICS«TRANGUILIZERS � OW1W17 - 06f1W11 0910Nt1 25112225833660001 231i2228b336bOqQ1 i1.76 5.88 D1AGtJQ3lS t : 4 NOC COQE: tt8378232'48S LORAZEPAY D.6 MG TABLET • ATARAC7ICS-TRANnUIIIZERS OW1W17 - C4t4Wti 10riGfri 261t26S66S'7690601 25112586517B90001 3Y.78 b.7t ouc,�os�s� : a NDC CODE: 0037t432106 LORAZEPM10.6 MG TA6lE7 - ATARACTlCS-7RANQUILtZER$ PR�RStJB74TAL C4NflNUlt16Cr4AEfiX 8a2.st B3.t7 24 tQD7314iT 40tt Page 7 of 2Q � � .. 4 � " � aKT y' � ,�'i�Y�.�ti'. Y�. t . �t� � ��t� a 7°r;�!'.'+���'"�'�,�'d, .,t�z• - Much 4>201� STATEMENT OF CLAIM " ECIfENR4DE,HARRY � ,w Ss BW 271 978 i � ALERT PHARNACY SERVICES INC 419 N 8Al"�SNlORE AVE M6UNT HULt.Y$PRING PA 1T086 _ �p < « ,�,: ty .:. .� -%�' . �:.ro� .»•i�'� �ca,, ry , . ,��.z � :�.,�'m�.".�,1 . ��.:'r .' ?k3.� �a�a�� � �a�a�t 41187/ti satiza�a�as2tnoot za»nusztsstonw a.�t an OIAGNdSiS i : 8 � NpC Cf3DE ' OOSY10Z1010 LdRAZEPAY 0.5 YG TABLET - ATARAC71C8-7FtlUK�UIIiZERS 1110891t - ftl69/ti � 1�104J11 25NNS62639�OW1 2b113i382&7l�0001 M.4f S.7t DUlCrNUSiS 1 : 0 NCiC C6UE: 0069102�01b LORAZEPAY O.S YG TABLET - ATrtRAC71C8-TRANQ11iL►ZERS 19Y1Ztt9 - 12ri?111 01lOW12 2511»65263390001 1S113166�53.19G001 14.4t S.Ti DUIGNO5IS 1 : 0 NpC COOE: 006Y1G2401Q I.ORAZEPAI!@.6 YG TA$lET - ATARACTIC&TRANQUIti7�ER3 8116Wt2 - L1/OWfS 0]JOBIt2 1�67200Y6247B6GU01 Z612Wl9624T860001 J6.80 6.71 DIAGNOSdS 1 0 NOC COOE: 00641024006 �ORAZEp/11�t 4.6 MG 7A8tET - A7ARA+CTtCB-TRANfiUILt2ER$ . O7J06/12 - 0.31p8itZ 03M6I72 28110ST5�8fi81000t 2lh20376469810W1 i8.� 6.7i owcNOSis, : o NDC CODE'.: pOBYt024Cq6 LBRAZEYAM Q3 M6 TABLET - AT11itA4TiC3-TRANQUILIZEI28 03rON1T - OSNWi2 pY01/12 26120866387830061 28i2a6i3fi38T83000t 1i.50 &71 awc�osis� : a NOC C04E: �f02i0116 L41iA2EPAN 0.6 MGt TABLE7 - ATAFiACTIC$•TRANpULL.12ERS WqT/12 • WYCTl13 06IQ7lt2 26120W628913000t 2S1ZQ8S82SY43q001 �6.� 6.71 DLlfiN051S i � S N6C CODE : �)0�{Sb2i061 iORAZEPAM D.6 MCi TABLET • ATARACTICS-TRANQUILI2ERS ON07t12 - OSttl7112 O&M112 SSi212l642011QWt 2S12i286420t10001 �B.OB 5.71 DIkGNbSRS i : t+ tiOC CqDE: 6 0 60 7 0210 01 LORA2EPAN 0.6 YG TA81.E'1' - ATARACTICS-TRltNQtliklZERS - Page 8 of lU 7 e r r �- � r 6 � �'� . r1 AIYry� P R. Si� 'JY�'} �:P[^ L£ 44.': Jh �€ Fi f t �'��„`'�C R�1kt4N!�a' � r`biys� d€ �, �� F"'�, �'�, �tz- �� �, � AAarch 4,Nl11 STATEMENT OF CWM ��,.¢IA1�...� ECKENRODE.HARRY+i�-� - }q= "- BW 271 878 ALERT PHARMAGY SERViCES ING � 214 M BAI.TIM4RE AYE MOUNT HOLLY SPRING PA 17088 f :,� Y} � ' 4 .':t/���j.,��i,��7 'r '..:]��n �"''t'.''S i '.,f•ls ,`t% :'Ir`:. DAT��'� n�'.+.. ��#.. �*, . .�' .�Y���' Y'-'':�4'��$�Mi?f2��'£ � aarou�� • aeiovu 0Tf04H2 2S121b863298200Q1 �s+sesesszsezoow us.or ar� owcriosis� : a NDC COGE: D069102�W0! LORAZEPAM 4.5 MG TABtET • ATARACTtC&7RANCU0.IZERS . 06(itH2 • 08111142 O7l30l12 2b1218i619fi260061 25131846�Y6260001 7.62 7.t8 aucroas�s� : o NOC C04E: 009tltTl049Q ASPIR-LOW EC St M6 TABLET - NON-NARCOTIC ANM.6ESICS 07/OS/12 � 07lOBM2 07730)12 2612188b283��0061 I6121a8628374000i �6.49 �.Oi piAGNOSl31 : 0 . tJDC CODE: dC641024p6t tORAZEPJtM 0.6 MO TABIET - ATARACTIGS-TRAkCU1lIZENS OTM111Z - 07N1112 06120H2 Y612307b${1820001 261220TS64T620001 1.82 21B OIAGNOSIS 1 : 0 NQC COOE: 08904776N0 ASPIRIQW EC 91 MG TABIET - NON�t/ARCOTiC ANAL6ESIC$ 4BM6l12 - 6t10i/12 OWO�,t12 26t2219624Y600!GI)1 2StY24'A824860000t 46.08 ^6US' DIAGNOSiS t : 0 NESC CODE: 0669102+1001 LORAZEPAM 0.6 N(i TIIBLET • ATARACTICS-TRANqUILREfCB OBI1W12 - ON16112 09l2M12 2$12241557828400t 251�2436378280001 � 7,82 2.1$ afAGNU$I5 1 : 0 NOG COpE: G09WTJ0490 ASPIR-IONi EC s1 MG Td81.E'T • NON-NARG017C XNALGESlCS ... Oilp6H2 • CYNNt2 14lQtlt2 �8122486423360461 26i22496�23260001 �6.G8 4.C4 6UlGN8SiS t � 0 NDC CODE: �91024001 LORAZE{�AM 0.3 MG TABLET • ATARAC71C3-TRANQUlIIZER3 OW09/12 - 09l09tt2 10t2Y112 251228b6626i1066i 261226Bd6Y&17Q001 7.82 2.t8 oucr�os�s+ : o NOG CODE: 0090477W80 ASPiR-LOW EG 81 MG TABLET - NON-NARCQTlC AMALGESIGS Page 9 of 14 . . . : . :j,2y y� ��Y..�+Y 1 �{� � nrf Y 4ty���)'F� we �'w — _.� °( v March 4,2Q43 STATEMENT OF CWM �' ECKENRODE,HARRY� . : 640 2T1978 _.1 XLERT AHARMAGY SERVICES INC 370 N BALTIAIORE AYE NIQi1tlt}IOLCY SPNiNG PA i7886 F �..-�wr,:n d �(.hc+ °�:+3s .:i':.�' ;;3� .1 f' .K. O/.�TEO�,.��xi P�1�''�l�, "�'� a., 1pfOM12 • 1WOMtt 10l29/42 251227859i293GOdi 25122�8631 29 3150 01 �6.0! 3.49 61AGNOSIS 1 : o NOG CQpE: dDS8t0?AtWi IQRAZEPAY 8.6 M6 TABLE7 - ATAFtACTIC&TpANC1UIL12EltS tWOWt2 - ipW9112 17/79/12 2b1228bb61966UUQ! 261229686138600Ct 7.8x 2.18 DIA6N08131 : Q NDC COOE: UOYWTtWBC ASP#R-LOMt EC Si MG 7ABLET - NONa1ARCdTiC ANALGESICS tpl2iY12 - 14f24712 11tiW'12 Tb17296660�iG30001 23122Y6880AC�OOU1 18.27 2.54 CSIACiN(3SI51 : 0 ' NDC CI�: 60W1024161 LORAZEPAM 1 iN3 TABLET - ATARACTIC&TRANQUIL12ER3 it1Wi12 • it/WH2 7?/OJl72 26l2309b3244740Qt 261280Y63344Tt�tF1 �6.08 3.4Y 01AGNf351S i : D . � NOG G04E: 006910?A001 EORA2ERAM 0.6 M6 7A9LET • A7IIRACTICSTRANUUILIZERS - 11t06/1� - iti0l172 13/17/72 3872J286383760W1 24512328634376pOQi 7.82 , 2.18 DWGNOSIS t : 4 NOC CODE: 004QtT/046C ASPIR-F„OW EC 84 MG TXBLE? - NON-NARCOTIC ANALGE8I{:$ 111Q5117 - 4?1q3t12 17f31/12� ` 26123385�967�W01 261Y338639bT400U7 46.q8 3.48 DIAGNOSIS i : 0 NpC CBDE: 0069iO3�001 LORAZEPAM Q.5 M6 TABLET - ATARACTICS-TRAHQUILF2ERS 1�I4N72 - 1�MBh2 Q'1t21113 251238t56158i0001 23f2341551691W01 T.$2 � 2.18 aucHOSas i : o NDC CODE: d0l164770466 ASPIR-L8W EC 87 MG TABI.ET - NON•NARC017C ANALGE$ICS AROVWER SUB TOTAk. ALEAT PFIANAtACY S�tVICES iNC �54.16 89.$3 . 24 700T3d516 1M05 Page 10 of 14