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HomeMy WebLinkAbout08-02-13 :� � 15D5610143 REV-'1�00 Ex���-�,, �,� OFFICIAL USE ONLY PA Department af Revenue pennsylvania County Code Year File Number Bureau of Individual Taxes �o�TMENTOFREVE1�pJE PO BOX.280601 INHERITANCE TAX RETURN �l 12 O t�7 94 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEQENT lNF4RMATION BELOW Social Security Number Date of Death Date of Birth Q5 02 2t}I2 1� 15 193� Decedent's l.ast Name Su�x Dececlent's First Name Mt C�VIES JOYCE F (If Applicable}Enter Surviving Spouss's Information Belaw Spouse`s Las#Name Suffix Spouse's First Name MI Spause's Social Security Number THIa RETURN MUST BE FILED tN DUPUCATE WITH THE RECISTER OF W1LLS FtLL!N APPR�PRlATE CIVALS BELOW � 1. flriginal Ratum � 2. Supplemental Retum � 3. Remainder fte#urn(Date of Death Prior to 12-13-82) � 4. Limited Estate � q�,Future In#erest Comprornisa � 5. Federai Estate Tax Re#urn Required (date of death after 12-12-82) g. decedent Died fiestate � L7eceder�t Maint 'ned a Living 7rust � 8. Total Number af Safe De osit Boxes � (Attach Copy af Will) ❑ (Attach Gopy of�rust) P � 9. Litiga#ion Praceeds Received a ��•b�t�ween 1Z 31���dit(Da95�f Death � 1�,Eleotion ta tax under Sec.9113(A) T {Attach Schedule O} CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIA4 TAX INFORMATION SHOULD BE DlREC7ED TQ: Name Daytime Teiephone Number BRUCE J WARS HAWSKY ?17 �3 8 65.�`t� �_, � ,_... RE,��',S�R OF Wtt�S U9�►C}�.Y �::� � � � � � � First tine of Address � y, �~-- ��,� ��t 2 32 0 NCIRTH SECt?ND STF�EE � � � � � ,� � V � Second�ine of Acldress � � � � � °� c:'� � -`� ��", �, C�- },_, . c� _ +��y"��.j �� � M " � --�►ATE�'I �� t� Ci#y or Post Office State ZIP Code � � HARR.I SBURG FA Car�spandent's e-matl address: bjW�GC1aWpC.001'ri Under penaltie pe' declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true comp te.Deelara' re other than the personal representative is based on alf ir�formation of which preparer has any knowlecige. Si TURE OF RSO ESPONS� FO 1 ETURN D �'lJ At1dr@W W. Nt7►t'fleet L�� �'' DRE 20 Deer Run Dr.� Etters� PA 17319 : 31GNATUR OF PREPAR OT ER T N REF ESE AT E p T� e .Warshawsky A .k 2320 North Second Street, Harrisbur� , Pc� A Side 1 � 150561D7,43 15D5b1D143 ,� � 1505610243 REV-1500 EX RECAPITULATION 1. Real Estate(Schedule A)....................................................................................... 1. 2. Stocks and Bonds(Schedule B)............................................................................. 2. 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3. 4. Mortgages&Notes Receivable(Schedule D)........................................................ 4. 5. Cash,Bank Deposits 8�Miscellaneous Personal Property(Schedule E)............... 5. 13 8,0 2 5 . 0 0 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers 8�Miscellaneous�n;Probate Property : (Schedule G) U Separate Billing Requested............ 7, g. Total Gross Assets(total Lines 1 through 7)........................................................ g. 138 ,025. 00 ' 9. Funeral Expenses and Administrative Costs(Schedule H).................................... s. 6,2 93 . 5 0 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 1, 67 9. 8 6 11. Total Deductions(total Lines 9 and 10)................................................................ ��. 7 , 97 3 . 3 6 12. Net Value of Estate(Line 8 minus Line 11).......................................................... �2. 13 0 ,0 51 . 6 4 �3. Charitable and Govemmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J)............................................... 13. 14. Net Value Subject to Tax(Line 12 minus Line 13)............................................... 14. 13 0,0 51 . 64 TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.00 15. 0 . 0 0 16. Amount of Line 14 taxable 13 0 ,0 51 . 64 �s. 5,8 52 . 32 at lineal rate X .045 17. Amount of Line 14 taxable at sibling rate X.12 0 . 0 0 17. 0 . 0 0 18. Amount of Line 14 taxable at collateral rate X.15 0 . 0 0 18. 0 . 0 0 19. TAX DUE.................................................................. 19. 5,852 . 32 .............................................. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. aX Side 2 � 150561D243 1505610243 J REV-1500 EX Page 3 File Number 21-12-00790 Decedent's Complete Address: DECEDENT'S NAME Ovies,Joyce F.R. STREET ADDRESS 3055 S.Sporting Hill Rd. CITY STATE ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 5,852.32 2. Credits/Payments A. Prior Payments 6,000.00 B. Discount 292.62 Total Credits(A +g) (2) 6,292.62 3. Interest (3) 4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) 440.30 Check box on Page 2,Line 20 to request a refund 5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) Make Check Pa able to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No ! a. retain the use or income of the property transferred:............................................................................... ❑ ❑x .= b. retain the right to designate who shall use the property transferred or its income:.................................. � � ic. retain a reversionary interest;or............................................................................................................... 0 d. receive the promise for life of either payments,benefits or care?............................................................ ❑ ❑x ; 2. If death occurred afte� Dec. 12, 1982, did decedent transfer property within one year of death without ; receiving adequate consideration?.................................................................................................................... ❑ ❑x ; 3. Did decedent own an"in trust for' or payable upon death bank account or security at his or her death?....... ❑ ❑x ; 4. Did decedent own an individual retirement account annuity or other non-probate property which ❑ , � , ; contains a beneficiary designation?.................................................................................................................. ❑x IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. � � � For dates of death on or after July 1, 1994 and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving � spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. ; ° For dates of death on or after January 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of ; assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: : • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent,or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. . The tax rate imposed on the net value of transfers to or for the use of the decedenYs lineal beneficiaries is 4.5 percent,except as noted in [72 P.S.§9116(a)(1)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)]. A sibling is defined under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. Rev-1508 EX+(��.�0) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENN8YLVANIA INNERITANCE TIVC RETURN RE810ENT DECEDENT ESTATE OF FILE NUMBER Ovies,Jo ce F.R. 21-12-00790 Include the proceeda of litigation and the date the proceeds were received by the estate. All property jointly-owned with the�ight oi survivonhip must be disclossd on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Cash 138,025.00 TOTAL(Also enter on Line 5, Recapitulation) 138.025.00 (If more space is needed,additional pages of the same size) Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule E(Rev. 11-10) REV-1151 EX+(10-09) SCHEDULE H COMIN � ANIA FUNERAL EXPENSES AND ����o��� ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Ovies,Jo ce F.R. 21-12-00790 Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT q, FUNERAL EXPENSES: See continuation schedule(s)attached 3,140.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zio Year(s)Commission Paid 2. Attornev's Fees Cunningham &Chernicoff, P.C. 2,500.00 3. Family Exemption: (If decedenYs address is not the same as claimant's,attach explanation) Claimant Street Address City State Zio Relationshio of Claimant to Decedent 4. Probate Fees 328.50 5. AccountanYs Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 325.00 See continuation schedule(s)attached TOTAL(Also enter o�line 9,Recapitulation) 6,293.50 Copyright(c)2009 form software onfy The Lackner Group,Inc. Form PA-1500 Schedule H(Rev. 10-09) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Ovies,Joyce F.R. 21-12-00790 ITEM NUMBER DESCRIPTION AMOUNT Funeral ExRg,p�g,� 1 Musselman Funeral Home 3.140.00 H-A 3,140.00 Other Administrative Costs 2 Law Office Costs 100.00 3 Legal Advertisement 225.00 H-B7 325.00 Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-98) Rev-1512 EX+(12-08) SCHEDULE 1 DEBTS OF DECEDENT, COMMONWEALTMOFPENNSYLVANIA MORTGAGE LIABILITIES AND LIENS INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Ovies,Jo ce F.R. 21-12-00790 Report debts incurred by 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 Apria Healthcare 11.23 2 Camp Mill Emergency Physicians 16.96 3 Country Care of Newport 677.12 4 Country Meadows 184.74 5 Diamond Pharmacy 789.81 TOTAL(Also enter on Line 10, Recapitulation) 1,679.86 (If more space is needed,additional pages of the same size) Copyright(c)2008 form software only The Lackner Group,Inc. Form PA-1500 Schedule I(Rev. 12-08) REV-1513 EX+(01-10) SCHEDULE J COMM���,����,�A""� BENEFICIARIES ESTATE OF FILE NUMBER Ovies,Jo ce F.R. 21-12-00790 `' NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE ' NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT (VUords) ($$$) I TAXABLE DISTRIBUTIONS [include outright spousal ' distributions,and transfers under Sec.9116 a 1.2 Bonnie Koch Daughter Half 37 South Porter St. Marietta, PA 17547 Andrew Norfleet Son Half 20 Deer Run Drive Etters,PA 17319 Total Enter dollar amounts for dist�ibutions shown above on lines 15 th�ou h 18 on Rev 1500 cover sheet as a ro riate. NON-TAXABLE DISTRIBUTIONS: II• A.SPOUSAL DISTRiBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01-10) Aug 02 13 09:33a Norfleet and Lafferty 717-7375077 p.10 . r � •� .i: n. ':L -------- - � � ---��- � ---------------- � ---- -.._.. ___._. .;�. Y�::...•, l�''' f���T�..... .... �. .�� ...�....�...� � •.. '-..�.�= �..�"r'� .� �,. }. �. •��. ,�f �{ .. .. . .. `%� '' '' ' ' . � �� � . � .1•r.l .f�.: . ' . . �..' . .j.�.. ��� -���•" •1i14 - ' '�.'. • �e.4'. ''/••y�>a•'�� 't.;.F. . . . :'L:•.�+(.•— .:1;:'�����Y.1 h..�'.. �s+ �� �'f::�:l�+'• .. .. ` � ' . � °�� :,��= 145 ,:'� r�-�� - �:.��.:';::3.. =,:.t cK eo�z. _ :'���� ST�RE 1'�[JA Di1FL1CA7E CNECiGS!N Y17UR CHE 0 0 n►x�oEflucTia�rra ' -' :,.. 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IVOT NEG�071ABLE . • :.' � Fvr added secur:ty,Y�►rame and account number dc nol aFpear on this coPY- . � o�� v � i C � 1500 Paxton Street JOU R NAL Harrisburg,PA 17104 8�2��2��2 M U LT I M E D I A T' �»�236-4300 F. 717-236-6803 ORDER#: 85009 www.journaimultimedia.com TERMS: Net 30 Days -------------- iruvoicE To ------------ Cunningham &Chernico ------°--- ADVERTISER ff, P.C. Cunningham &Chernicoff P C Accounts Payable P. O. Box 60457 ' Harrisburg, PA 17106 INVOICING:Advertiser DESCRIPTION OF CHARGES COST — CREDIT — BALANCE PUBLICATION: CLASSIFIED/CENTRAL PENN BUS.JRNL COVER DATE: 8/17/2012 THEME: CLASSIFIED AD/CENTRAL PENN BUSINESS JOUR RATE CARD: DESCRIPTION OF AD: _ . ____ _ _ _-- -- -- ---- — ---- _ __ __ _ _ -- — --- egal listing; Estate of Joyce F.R.Ovies REP(S): MARK SUNDAY SIZE: LEGAL LISTING, PAGE: 150.00 COLOR: B&W 0.00 SPACE SUB-TOTAL: 150.00 ' BALANCE DUE: 1 .00 � ^ v► � f S b� �A {�s ; '�:✓� 1�:.�iqiuM��rmAii.�iS�Yf�v,�.+�i.f,1�rt�"�i9��'.�P.`'�Ni�c4�.YAr�i'��r-N��tidiiaF��;�i.,1i.�d7+NYh�A�- '- .�..M.Y�d.d. _ .- . . . . _.... .-_._,�...��- r'�����ND � �J . _ 2 ,�� l.. . I �,����� CUM6ERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717)249-3188 Fax:(717)249-2883 August 17, 2012 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. --_- -- , -_-- _-- __ __ _ _ _ --- - _ _ _ -- -- .__ _ __ _ _ TO: Bruce J. Warshawsky, Esquire RE: Joyce F.R. Ovies Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. � Advertisement inserted on the fol(owing dates: August 3, August 10, and August 17, 2012 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 0 .00 Total Amount Due $ 75.00 Payment received by u,,�,.u�',I.�", i.➢Si:�:kEZ3A!4'�6�'���='�9^,!��!'13".«�t�s.�:>';?' . .,.,.__..._t;rif$;,:�,�-'+��F'r���'e�3"�.�"�i°±.$:"�r,�i'3�'$':'.���»".�...x�.:'#'- .... ,�.L. a.°�,`�"'.:.-�,"�:i=�u.....�`.:i"�"mS-.,�'.'K�"."::�+.�'° ,�.a=.�`.c��a�a Kf�'"c�..�,'°�#�wa�.aaaviY.dar�t...._+fiwd.�u7f..e�w.y"vz'� Aug 0213 09:33a Norfleet and Lafferty 717-7375077 p.11 �j�� STA�'E!UlENT t3F ACCOUNT T»� COt�lTINUING CARE RX•NEWPORT 69908 SNOWDRIFT ROAO ALLENTOWN,PA 18106 PAGE: 1 of 1 .. ACCOUNT NO: 9029-15 RETURN SERVECE REQUESTED (NVO�CE N�: STATEMENT � 39758 DX NO: KQPQX w INVO�CE DATE: 09130�12 : �o3s�e o�oi FACELITY; 9029 COUNTRY MEADOWS OF WES PHONE: 877-G70-6323 PATlENT NO: 15 You may aiso view/pay your bifis at: PATIENT NAME: �VIES,J�YCE https:llmyomniview.omnicare.com AMOUNT DUE: 677.12 TAX: 0.00 : �iln��lrt�i�l�ll�l���l���ill'����I��I�I�I�II�I�UI�'I�'��1i����� JOYCE OVIES C�O ANDREUV NORFLEET dUE DATE: -0/2��'2012 20 OEER RUN DRIVE ETTERS, PA 17319-9155 aMOUnrr ouE: �7 7.12 397 5 8*'i1VW09V$V QO�OA16 3 M4U9X3ZB:1,'! KEEP�OP PORTtON F4R 1faUR RECOROS-REi'URN ��'6"�'�lA�STUB WITH PAYMENT I:NI�IE�I�II�IN���I�IIN��rI�IIIIIIIIII •. , OV1ES, JOYCE 9029 COUNTRY MEAD�INS OF WES� SHORE • � �, 9029-15 09130I12 DATE RK �10. TRAfJS DESCRIPTIOi� PHYSICIAN hIDC N0. QUANT AMOUNT TYPE � ��^� '.`4`"1 �'tk�S� ^Z:. � •'i. �i' ��"T i?yi'^'" S41• � v�:� rt��tt;.L;j�d-j �4 p;. �.' '.+f:�a�•'a�N�fd�F�,��� �.' ti i$ � �i',. �; �,:,. , `'=a;�; ;r;.,�''(;.�k:�...�a;'':.�;`�'.?i'��",f"�°5 � �--: � ':N �a�;e;.',��+4��sX��i;�,-':?Y'�+�Lr. ,•';,+.. �5A,� �.:�''�" . •s .. ,T'� s� � ��J;'F4.'��i�'l�%%� �� � Y J{�2�u��P��.��. � ���j: (! <.y i .�.b:• '!;[s(•!: : � ' a ' ryw'i�:'*�$� V� �,.... '.�;�r:'�f�'�'.�a�'.� . .:.���?�'; '� �.... .�e.r.:?t'iT.:,t�4Hw':siw.t��.: -'�•rf.'li:��;/,i�:�..i ,�.rr,,, ...� .. r... l'„u ,�r::.: .•. ��:•;.�,;�:-q3'r�r,� '�f 'ti;2 ..?4:'�A� ,���hY��,�. z '''Y,:�":�:'..,':� E<;�s 3 7ri ,''`�•±.,.�,ity���''• �'c�r"�t• Jr',1t.k�i"S'�T�4''�!'•�,G�:�.'��. ''�`, .. ..�Y a'. .. :}F'rq�:l'.�+. t ' ,,,�. r�h' �1 � '� •`•�� =�,x 3�l�t �a'•` i} ����^, Yt� '����• • f+. �'�•a� 4� f �i,C �. k' !!;:Y,;, �li c � ��:. '�• . "�� .'T�� r�y;! *}�M �,N. y�G" ...w 1•'}•' �11�838�5 FINANCE CHARGES are calculated ata t�ONTHLY PERIODIC RATE Or 1.50�0{Al�fNUAL RATE CF 18.009'0}basec upon an unpaid balance outstanding 30 days or rnore. PREVIOUS BAIJ�NCE CHARGES FYNANCE CHARGE TaTAL CNARGES PAYMENTS & CREDITS AMOUIJT DUE 677.12 0.00 0.00 b77.12 0.00 677.12 � 39768`TM409V811Q000416 70 INSUR�PRCIPER CREDIT,Z�I�TRCH AND RETUR�I THIS PORTION INTHE ENCLOSED ENYELOPE. �5023aC ❑Please CheCk'rf above addresS is inc�rrect and indicate changE on f9vers�side. tF PAYING BY NASTERCARD,RISCOVER,VtSA OR AAIERICAI�E1cPRESS,RLL OUT BELqW. GH=C'rG CARD USING FdR PAYMENT ACCOUNT N0: 9029-15 p ^ fo'■� N,�R . INVO�CE NO: STATEMENT � MASTcRCA�D � -D`JISCOVEF l.._l,�y_,�q ' wjr"5 OERIC.1lV EXFAESS DX NO: KOPDX cnR�reur�eER INVOICE DaTE: osl3ar�2 FAC{LITY: 9029 C(}UNTRY MEADOWS OF YVEST SHORE SIGNATURE EXP.DAT= PATI ENT NO: 15 PATI ENT NAM E: OVIES,JOYCE •► � : : - . AMOUNT DUE: 6n.�2 ���i�����i��i��������I�Ili��liii�ilC��il�I��I�i�ii�iiiilll���i��� C�NTINUING CARE RX-NEWP�RT AMOUNT ENCLOSED $ PO BOX 740391 ; ClNCINNATI, OH 45274-a391 �O��OD9029-1500STATEMENT3DDOKOPDX90[3�0677122 Aug 0213 09:31 a Norfleet and Lafferty 717-7375077 p.3 � � :;,.,�. � � -- — -- — _____ ____ ��;=_, ��. ; _:...�..,,.._._...r.. _ _ _ _._.. _ . _ .. __ _ .._.......Y.. � - - � - _._..__.._..._........ _ ._ . .. _ _ .. . ..... . . .. -----:.: . -=— -- -.-. - ..�-. : � . . . _....._..... ._ . .._._ _ ... ._ _ . .. , _ .__ ..... . ..._. �� _ -- - �.....�.. , ,: .. . ... . . - -� . .. - .. .,��. ;;- t';. ��, .; Y . . .,•�:' ;' _ . •�,.. . . � +; � �;:, . - '�; -�ti: .. .;� . . . ,;�^ �,..,:,:�;},.. '. . ,,:-� �s'a'. 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A. .,��I; . ` '•� �'. r�� �,r,: t��': \ + %�� �'i� _ � . . .,1.:� r::'��?�� � . . /' ' `�;,G ' - :., �5 .�'�' �� �/� � ���� .'r�.'j ,, �, .t, i� . . � � � � �r�'� , %� a � - - �_�^" ;S�-, , ., ��� ::'��� •'P. . � f � .(; • . �� /: .p��.,.. . '.,. • j � y '.[�., ��' , ' . }.�:'::�',•'+•;y`�: • �Y::°'..il: � �, �r Y .J ,�. ,:�I . , n ry�:.fA t: G � g • r � • ' - 1� .f; '' !'Gf/ • ��� a�� . �, :...•' r{T��,,'�* �� '� - � : �*b��, c�:, } � " �. NOT NEGQTIABLE ' '•'""' '� r na�r►e and aC�unt number do�ot appear on ihls copy. �:��j C' r, �r�, �O?�9d 6�11(l��� ( .y. � '. • . ����J29?'�'F' +!r.; 1 . '. � ;� a . t' ' � � �� '� ' � �r� y • . . ;' S y� };t, ._ ... _................�._:�[:'..�k �{.�.-c Aug 0213 09:34a Norfleet and Lafferty 717-7375077 p.12 Diamond Pharmacy �1 � � �� 645 Kolter Drive Indiana, PA 15701 (8a0)882-6337 phone II'�����I"��II'�)�I� (724)349-1111 toli-free 47846 Statement Date: 05l21l12 OVIES,JOYCE 8alanoe Due: $789.87 C/O ANDREW N�RFLEET 2� DEER RUN DR1VE Arr�ount Enclosec� ETTERS,PA 17319 :. . � - �• •- � All accounts with outstanding balances will be assess�ed at the ra#e of 1.5°�per month(1$%annual). Staternerrt Dat,e: p5i2'I/12 Diamc�nd Pharmacy Customer Mumber: 47846 645 Kolter Drive FacUity ID- CMll�S4 Indiana,PA 1570t Customer•Group: P152 (8�0)882-6337 phane -- --- --- �Z - - --. Balance Forward $5d4.58 ments Check Date Check Number 4 ARtount . . � � : . I New Act�vity Date Rx Mo Drug Name Ctty Price lns.�ay Amt. Pat Pay Amt. Invoice-INQ0027025 av�s,JOYCE 03104�12 1��72204 RX•KCL 109�a(20MEQ/15M1.j LiQ -473 {$8.47� Sa.00 (,59.47) 03I04J12 103722�4 RX-KCL 10°Yo(20MEQ/15ML}L1Q 473 55.27 $3.89 Copsy $1.38 03/�6112 �03722U4 RX•KCL 10%(20MEQM5ML;LIQ -�173 ($9.47) $d.00 (39.47} 03/1W12 10372204 • RX-KCL 10%(20MEQI15ML}LIQ 473 58.67 �6.73 co�ay $1.94 03126l12 10372204 RX-KCL 10°Yo(20MEQH5ML)LIa 4T3 $a.67 38.7'3 copay �►3.94 03t281't2 10372244 RX-KCL t0%(20MEQ/15ML)UQ -473 ($1�.0'1) �0.00 - (514.01) ' OA/03J12 90620 O7C-HYDROCORT CRE 1°i6 28 $i.25 �0.00 S1.25 04/U4I12 10346975 RX-FLUTICASONE SPR 501UICG 1fi $21.15 �8.27 copay �i2.86 04105�l12 84312 RX-DALIRESP TAB SCOMCG 30 5178.13 �;4214 copay $35.99 04JQa112 10372186 RX-PANTOPRAZaLE TAB 40MC 60 $8.16 $6.53 copay S1.63 04105J12 10372187 C)TC-DOCUSATE Ci4l CAP 244MG 30 $1.25 $0.00 $1.25 0414al�12 10372211 RX•NAh1ENDA 'fA8 10MG 60 $213.56 �1�0.52 copa� $43.04 04l05��12 10372215 RX-DONEP�ZIL 7A9 10MG 30 $9.62 $0.00 copay . $9.62. 04/45112 10372217 RX-PLAVIX TAB 75MG 30 $199.52 5159,27 copay t40.25 04MSJ12 10372221 RX-ti11RTAT��IPINE TAB 15hAG 3b �5.2d $1.61 copay S3.63 Q4/05/12 1�372230 RX-SIMVASTATIN TAS 20A9G 30 $5.24 $2.09 copay 53.15 04106112 8Q180 RX-IPRATROPIUAN SOL ALBU7ER 94 $10.86 �8.97 copay 33.89 04106/12 1 d372244 RX-KCL't096(2�ME{�/15ML)UQ 473 $d.86 58.92 copay $1.94 04107112 89�40 RX-ESCITALOPRAM 20MG TABLET 34 594.29 S74.51 copay 519.78 04115/12 80 i80 RX-IPRAZROPIllM/SOE.AIBUTER 90 310.86 $6.97 COpAy 53.89 � 04115/12 $4248 OTC-BALMEX CRE 11.39's 113 $3.78 $0.04 S3.78 04l18l12 10372204 RX-KCL 1096(ZOMEQI15Ml)UQ a73 5�.33 $7.39 copay S1.94 OA/24l12 8019fl RX-IPRATROPIUM/S�L ALBUTER 90 S1�.86 $8.03 copay 52.83 a4/24f�2 104405 RX-LQRazepam TAB 0.5MG 60 59.24 52.27 copay 36.87 04/24f12 104408 RX-TRANSDERM-SC DIS 1.5MG 10 S 136.65 g119.52 capay $28.13 04/24112 ifl346385 RX-i4DVAIR D1SKU AER 250150 60 S24D.71 $192.27 Copay $48.44 04/2Gf12 104724 f3X-�42tTIifiOMYCIN TAB 2GaMG 6 56.�6 33.77 copoy ;i.48 ` 041Z5112 1037217� RX-LEVOTHYROXIN TAB SOMCG 3a $5,24 S3.60 copay �1.64 , cananued on next page Page 9 Payment Due Upon Receipt. Please pay Balance Due. 'Co pay using your MasterCard or Ysa, please call {800)SB2-6337.PharmacY Nours:Ma�dav-Fridav 9 a.m.•5 v.m.&Saturcav 9 a.m.-2 o.m. Aug 02 13 09:32a Norfleet and Lafferty 717-7375077 p.8 � ��: � _- �,. -- ____.__. _. ��-= �;�:f•=`: ;����:: ,�:., ,: :�: ... ���. . ._ .._-_' ....�..� . _�...._.__ ��_. ....- ..� . ""__"' '���"'.._=....��_..~ ...'-�_..��� .... ._� .�.... - �7 ' �;. y�. 1:' • 4; f •��.. ,t w..i: •.� y r . •f{ . . . . �:'�' .�'�' • • :M ti . . . ._ t h�•' ' � • . . �'.'?R:. . ' . .� . . ' • .-y 4 :.f wk.' ..ti.. � . ,' ' l�,��;j'..,;.�• r''� �':�' K:�:. � ' � r. 'i3'� , f , .5���JLJ���lbM�.�rI7GVIt.7�ib�L/�' V�+r'.CiX P� •�`•'� 1 J : . ���k,���«:$... n 1�6 �'� ° TVl-]EGUC:�6Lc 1TE).1 � '�' , . ❑Ctathing �F�od C3 Transpa'tatlon . �: . . . .�. �.. :;; ❑Credit Card p UtiliiEes ❑I�or'tgage ,r� };:°'�'� � D Entertainment p Insurance ❑Otier: :�—.�U��� -�'�'���.. . . ��"� . ,;�-`- Foawar� `*"`�.. . :... .. . . .�;' �y, �.��f.'u,� �=.,�.:: . . . . : `� �(J�/f �l�'���C'�'� r►*s rreM Y � � .;�: . ' . , - - . , .� iG��� . BALANCE ,';►'"', . , ' � . � • �^'i .' `, f' . j ..r , . - •��:;'i'., . . . . . N�%�'� :'' .. . ._,:'i..:�� ...�'� "'r:'. ,'�'�✓% --''f r1 . ��DEPGS7T � +` . " � , I � , J o'n+ea --- ���,;_:�.: . . • " � Y�IVWFiD �`,•t . . ir . � z:.= i . � , ��„'�-_ �''g� ti, ;'. . �;._ ��' ,,•� ,e G�!!: � . , � ����',r ,/ ��"�'�x t ., ., .. !r I 't� � f . L.. . `J NOT ASEG�TiABLE `"`�}' ,��` � � . For added secur:T�your narne ard acCOUnt ntxnber do noi a�+peEr on Ihi�aopp- f ��y ,i-a . . , ! ^�,a_e:.•. .�. - �!+i Aug 0213 09:32a Norfleet and Lafferty 717-7375077 p.7 . ,, r�. .�. �. � T ��,�" �r;.�; �:� '�:. ;,:' ';� :{ "�: r.� . .ir.? r; •- ' i� ' . . ��, • !{'. •�. )1•t ' . � .. .�c ,y,' . . . � • •;.':. }. t . , -.. _..,n•� irr':.'. . . . . � '�� �.F. . !R i_, . : . '�.. . ' �:i...,". }.. ���..� . f:; •� .'.:',• �.y�'','�ii�v�?. S�'Yi--. �. .: ��'..t..:�. �. � .Yi .�1J. :^.�4';•�'� -.V �Yi;�1'n..l'• �;;I�;.: . u / �� "•+r�.3': ',1 . 'r��� ' ''-�'`����v'��.f ''�.�• - - •. ���•;w�. .-.-��!�".;y�. 7'. . H i i"'. . �':r�.w'p'l..i�y�� ' . .. . .. ,i.":c:;. S.=.,.•....�;��'r..- ._ .. • ,. . .� .�� �Y.}i..*�Y C'7�C/V4i7�J�fI�1..�{��Mf7GLRO 1���W�1 ir�••i/iR PV/L f�.�r" .. . • ' •' ". �.,r .�a�r�c ... -,::�-:K. _ :.��::�� --. 1�7 -�-= � �'.,�: �tBt.�C rDl1T�J�@�9l� _ •T'-�X-:.�^..�T".�.:..'�'..a:c t� ��`"• . '��. '>� � p clomt�g D Foad �Trar�scftaoon �: � 4�. ❑�.'11�t�'iSrQ ❑V1��IIBS ❑�0�2�B j,, ;:N'' ' ,, ❑Entertainmerq ❑Insurarx:e ❑ather. / �' " V:,., . Sf�� � ��. �,_• , . .��' B�LLifiCE� :�s,"�; - • - r_ FO�,'11'4RD, . . • `,. �`'! . . ' . - . I!� f 1��� �j TrIS'.TEM ��.":u ."!b' • ' .. r.. ;, t � � '�"' . .. � .r?__, g,AUWCE � :?" . . .. . '7 �'� «- ...r...� ...,�,.,. . . . , , ,: . r . : , , 1:f� � ;�j •....: ' . • - �� �._ ��: .:�..- .:./!i��� DEPCSIT ' •'',�.�. - . ' , L'� ��'• . . . . . • • : OTH£R �,�;�' _ ' • . '' enuv�ce �,. �:,r: � . e ��AFiD ''�-��'.t� r.. .�." ' a: . Ni� • 'r.� '-�� - . 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