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Home My WebLink About09-11-13 , � 1505611185 REV-1500 EX(02-11)(FI) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number Po eox 2aoso� INHERITANCE TAX RETURN .�+ I� �� f ( Harrisbur5,PA 17128-0601 RESIDENT[)ECEDENT � �� ENTER DECEDENT INFURMATION BELOW Social Security Number Date of Death MMDDVYYV Date of Birth Mr,noDYYYY 181-5�-3414 01192013 7,1031920 DecedenYs Last Name Suffix DecedenYs First Name M I TRESSLER MARY L (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Securiry Number THIS RETURN MUST�E FILED IN DUPLICATE WITH THE - - R�GISTER OF iNILLS FILL IN APPROPRIATE BOXES BELOW � 1. Original Return � 2. Supplemental Return � 3. Remainder Return(Date of Death Prior to 12-13-82) ❑ 4. Limited Estate ❑ 4a. Future Interest Compromise(date of ❑ 5. Federal Estate Tax Return Required death after 12-12-82) � 6. Decedent Died Testate � 7. Decedent Maintained a Living Trust � 8. l'otal Number of Safe Deposit Boxes (Attach Copy of Will) (Aftach Copy of Trust.) ❑ 9. Litigation Proceec!s Received ❑ 10. Spousal Poverty Credit(Date of Death ❑ 11. Electioii to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number LOWELL R . GATES 717-731-9600 . 9 REGISTER OFWILLS;U$EwONLY . C C'1 . ' a'.7 . ..,. —,� . , .�... i�;;J '.. . ,�_ , . . .. f�'l - First Line of Address -.� - : � 1013 MUMMA ROAD _ � - ' " Second Line of Address � r , _ ` SUITE 100 -- �;,, City or Post Office State ZIP Code DATE FILED ��, ,. LEMOYNE PA 17043 � �orrespondent'se-mailaddress: L • R • GATESaGATESLAWFIRM • COM Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,correct and comp te. ion of preparer other than the persona!representative is based on all ir,formation of which preparer has any knowledge. SIGNAIUR PE N R E LING RETURN � DATE 9- 9•�a/3 ADDRES 869 MOORE ' S MOUNTAIN ROAD LEWISBERRY, PA 17339 SIG URE 0 ER r�iC-R�MAN REPRESENTATIVE ��/�/3 ADDRESS 1013 MUMMA ROAD, SUITE 100 LEMOYNE, PA 17043 PLEASE USE ORIGINA�. FORM ONLY Side 1 �l �, 1505611185 oMasa�s.000 1505611185 � � Estate of Mary L. Tressler 181-50-3414 Executors (Page 1) Name Donald A. Tressler Address 869 Moore's Mountain Road Lewisberry, PA 17339- Tax ID - - � 1505611285 REV-1500 EX(FI) DecedenYs Social Security Number 131-50-3414 �ecedent'sName: TRESSLER MARY L RECAPITULATION 1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . � � .�0 2. Stocks and Bonds(Schedule B). . . . . . . . . . . . . . . . . . . . . . . . . 2, Q, Q� 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C), , , , , 3. 0 •0� 4. Mortgages and Notes Receivable(Schedule D) , , , , , , , , , , , , , , , , , q, 0 • �0 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E) , , , , , 3, ],,5 8 5 • 0� 6. Jointly Owned Property(Schedule F) � Separate Billing Requested , , , , g, 3 i 927• 72 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) � Separate Billing R�quested . . . . 7. 0•0 0 8. Total Gross Assets(total Lines 1 through 7) , , , , , , , , „ , , , , , , , , , $ 5,512 - �2 9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . g. 4,3 8? • �� 10. Debts of Decedent, Mortgage Liabilities,and L�ens(Schedule I) , , , , , , , . . 10. 18 9,3 61 - 81 11. Total Deductions(total Lines 9 and 10), , , , , , , , , , , , , , , , , , , , , ��, ],9 3,7 4 8 • 81 12. Net Value of Estate(Line 8 minus line 11) . . . . . . . . . . . . . . . . . . . �z (18 8,2 3 6 • �9) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J), , , , , , , , , , , , , , , , �g. � • 0� 14. Net Value Subject to Tax(Line 12 minus Line 13) , , , , , , , , , , , , , , , �q, (],8 8,2 3 6-�9) TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Ser:.9116 (a)(1.2)X.OU � • �� 15. � • �� 16. Amount of Line 14 t xable atlinealrateX.04� � • �0 16. � • �� 17. Amount of Line 14 ta�able at sibling rate X.1?. 0 , 0 a �� • �� 18. Amount of Line 14 taxable at collateral rate X.15 r� , Q� �g �• 0� 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. � • �� 20. FILL IN THE BOX!F YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑ $Id2 Z � 1505611285 1505611285 J OM4648 3.000 REV-1500 EX(FI) Page 3 File Number Decedent's Com lete Address: DECEDENTS NAME TRESS ER MARY L BTREET ADDRESS R CITY STATE ZIP CARLISLE PA 17013- Tax Payments and Credits: 1. Tax Due(Page 2, Line 19) (1) � • �� 2. Credits/Payments A. Prior Payments 0• �� B. Discount Q• �� Total Credits(A+B) (2) � • �� 3. I nterest cs> D • 00 4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. Fill in box on Page 2, Line 20 to request a refund. (4) � • 0� 5. If Line 1 + Line 3 is greater than Line 2,enter the Jifference.This is the TAX DUE. (5) � • �� Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Ye,c No a. retain the use or income of the property transferred . . . . . . . . . . . . . . . . . . . . . . . . ❑ � b. retain the right to designate who shall use the property transferred or its income . . . . . . . . . . ❑ ❑X c. retain a reversionary interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑�1 � d. receive the promise for life of either payments,benefits or care? . . . . . . . . . . . . . . . . . . LJ � 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ � 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? . ❑ � 4. Did decedent own an individual retirement account,annuity, or other non-probate property,which contains a beneficiary designa!�on? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ � 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, ?994, and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent(72 P.S.�9116(a)(1.1)(i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116 (a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are 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 tc or for the use of a natural parent, an adoptive parent or a stepparent of I:he child is Q percent[72 P.S.g9116(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 decedenYs siblings is 12 percent [72 P.S.$5116(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 ur adoption. OM4671 2.000 REV-1502EX+�,2_,2, SCF�lEDULE ,A� � � pennsylvania DEPPRTMENTOF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF: Fl�e NuMSeR: Mary L. Tressler All real properly owned solely or as a tenant in common must be reported at fair market�alue.Fair market value is denned as the price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled t�buy or sell,b�h having reasonable knaMedge of the relevant facts. Real property that is jointlyowned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of tha deed showing decedenYs interest if owned 3s tenant in common. VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. None TOTAL (Also enter on Line 1,Recapitulation.) $ 0.00 2wasas z.000 If more space is needed,use additional sheets of paper of the same size. REV-1503 EX+(&12) � � pennsylvania SCHEDULE B DEPARTMENT OF REVENUE INHERffANCETAX RETURN STOCKS 8� BONDS RESIDENT DECEDENT ESTATE OF FILE NUMBER Mary L. Tressler All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. None TOTAL (Also entEr on Line 2,Recapitulation) � 0.00 zwasss z.000 If more space is needed,insert additional sheets of the same size REV-1504EX+(9_�Z) SCHEDULE C � pennsylvania CLOSELY-HELD CORPORATION, DEPAR1Tv1ENT OF REVENUE INHERITANCE TAX RETURN PARTNERSHIP OR �si�M�ECE�Errr SOLE-PROPRIETORSHIP ESTATE OF FILE NUMBER Mary L. Tressler _ Schedule C-1 or C-2(including all supporting information)must be attached for each closely-held corporationlpartnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER VALUE AT DATE NuMBER DESCRIPl10N OF DEATH �� None TOTAL(Also enter on line 3,Recapitulation) 3 0.00 zwass�Z.000 (If more space is needed,insert additional sheets of the same size) REV-1507 EX+(698) SCHEDULE D COMMOMNEALTH OF PENNSYLVAFJIA MC�RTGAGES 8� NO�ES INHERITANCETAX RETURN RESIDENT DECEDEM' RECEIVABLE ESTATE OF FILE NUMBER � L. Tressler All property jointly�owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH None TOTAL(Also enter on line 4,Recapitulaticn) $ 0.00 3wasAC 1.000 (If more space is needed,insert additional sheets of same size) REV-1508 EX+(0&12) � � � � pennsylvania S�HEDUL� E DEPPR1NiENTOF REVENUE CASH, BANK DEPOSlTS 8� MISC. . RESioErr�roEC�oeNTTURN PERSONAL PROP�RTY ESTATE OF: FILE NUMBER: Mary L. Tressler Include the proceeds of litigation and the date the prcc:eeds were received by the estate. A!I ro ert 'ointl owned with ri ht of survivorship must be discic�sed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH �. Metro Bank checking account number 538080797 1,041.88 2 Highmark (health insurance refund) 543.12 TOTA�(Also enter on line 5,Recapitulation) a 1,585.00 zwasAO z.000 If more space is needed,use additional sheets of paper of the same size. REV-1509 DC+(01-10) pennsylvania SCHEDULE F DEPARTMENTOFREVENUE INHERITANCE TAX RETURN JOINTLY-OWNED PROPERN � RESIDENT DECEDENT � ESTATE OF: FILE NUMBER: Mary L. Tressler If an asset became jointly owned within one year of the decedenYs date af death,k mi�st be reported on Schedule G. SURVNING JOINTTBJANT(S)NANE(S) ADDRESS RaATIONSHIPTO DEC�ETfI' A Tressler, Donald A 869 Moore's Mountain Road, Lewisberry, PA 17339 Son JOINTLY OWNED PROPERTY: �rea [IATE DESCWPTION OF PROPff2TY %OF DATE OF DEATH � �� FOR JOINT MADE INCLl1DE NRAE OF FINANCIAL INSTITUTION AND BANK ACCWNT NUhEER OR SIMIAR ��QF�ATM ��TS VALUE OF M.,�VB� TENPNT Ja� IDENTIFYING NIIFBER.ATTACM OEED FOR JqNTLY MEL�RFAL ESTRTE. VALI�OF ASSET INT�EST DEC�B�IT�S IM�EST 1 A 8/30/2000 M&T Bank checking account number 950556694 7,855.43 50.0001 3,927.72 TOTAL (Also enter on Line 6, Recapitulation) S 3,927.72 swaso.e z.000 If more space is needed,use additional sheets of paper of the same size. REV-1510EX+(OS-09) SCHEDULE G pennsylvania DEPARTMENTOFREVENUE INTER-VIVOS TRANSFERS AND �NHERITANCETAX RETURN MISC. NON-PROBATE PROPERTY RESIDEM DECEDENT ESTATE OF FILE NUMBER Mary L. Tressler This schedule must be completed and filed if the answer to any of questions 1 through 4 on pagP three�f the REV-1500 is yes. DESCRIP110N OF PROPERTY ITEM If�LIAETFEPI4MEOFTFE7RP,NSFEREE,THEIRRELA710N5HIPTODECEDEMAND DATEOFDEATH %OFDECD'S EXCIUSION TAXABLE NUMBE �DNiEOFT2PJ5FFAATfPGHACAWOF7HEDEEDFORREALESTATE. VALUEOFASSET INTEREST IFAPPIJCABLE VALUE �• None TOTAL(Also enter on line 7,Recapitulation)$ 0.00 If more space is needed,use additional sheets of paper of the same size. 9W46AF 2.000 � � REV-1511 EX+��p.pg) SCHEDULE H pennsylvania DEPARIMENTOF REVENUE FUfVERAL EXPENSES AND INHERITANCETAXRETURN ADMINISTRATIVE COSTS � � RESIDENTDECEDENT ESTATE OF FILE NUMBER Mary L. Tressler DecedenYs debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: �. Beaver Urich Funeral Home (balanre of funeral expense) 87.00 Total from continuation schedules . . . . . . . . . 500.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions Name(s)of Personal Representative(s) Street Address__ City State ZIP Year(s)Commission Paid: 2. Attorney Fees: 3 800.00 3. Family Exemption:(If decedenYs address is nof the same as claimanYs,eriach e�lanation.) ' Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 5. Accountant Fees: fi. Tax Return Preparer Fees: 7. None TOTAI(Also enter on Line 9,Recapitulation) $ 4 387.00 swas,ac z.000 If more space is needed, use additional sheets of paper of the same size. Estate of: Mary L. Tressler Schedule H Part 1 (Page 2) Item No. Description Amount 2 Hoss's Steak & Seafood (funeral luncheon) 500.00 Total (Carry forward to main schedule) 500.00 REV-1512EX+�,z_,Z, . � SCHEDULE I pennsylvania DEPPRIMEM'OF REVENUE DEBTS OF DECEDENT, INHERITANCETAXRETURN MORTGAGE LIABILITIE�& LIENS � RESIDENT DECEDENT ESTATE OF FILE NUMBER Marv L. Tressler 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 �� Forest Park Health Center (nursing home bill) 1,176. 95 2 Pennsylvania Department of Public We'lfare (claim against estate) 188,184.86 TOTAL(Also enter on Li�7e 10,Recapitulation) $ 189 361.81 zwasa.H z.000 If more space is needed, insert additional sheets of the same size. REV-1513EX+{01-14) SCHEDU�E J pennsylvania DEPARTMENTOF REVENUE BENEFICIARIES INNERITAhK;ETAX RETURtJ RESIDEM DECEDENT ESTATE OF: FI�E 1dUMBEF2: Ma L. Tressler RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER M1WtviE AND AC�RESS 4F PERSON{S}REGEMNG PROPERTY Do No#l.ist Trustee{s} QF ESTATE � TAXABLE DISTRIBUTIONS[Indude outnght spousal distnbutions and transfers under Sec.9116{a}{1.2}.] �. Donna L. Johnson 8 guimper Caurt Apt. 3A Pikesville, I�? 21208 Granddaughter 0.00 2 Eric A. Tressler 1422 State Road Dunaannan, PA 17020 Grandson 0.00 3 Niaole S. Raynes 5343 Beagle Road Ela.zabethtown, PA 17022 Granddaughter 0.00 4 Naney L. Thomas 98 Grimes Drive Martinsburg, WV 25AQ1 Daughtex� 0.00 EN7ER DdtLAR AMOUN�fS FOR DISTRIBUTii7NS SHOWN ABdVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SNEET,A5 APPRpPRIATE. 1) NOPI�TAXABLE DISTRIBUTIONS A.SPOUSAI DISTRI6UT1dtJS UNC7ER SECTION 5113 FtJR WNIGH AN E�EGTION TO T,4X!$NOT TAKEN: 1 B.CHARITABLE AND GOVERNMENTAL DISTRIBUTtON5: 1. TOTAL OF PART II-ENTER 70TAL NON-TAXABLE DISTRIBUTIONS ON UNE 13 OF REV-1500 COVER SHEET. S 0.0 0 if mare space is needed,use additionai sheets of paper of the same size. � 9W4&AI2.00Q Estate of: Mary L. Tressler Schedule J Part 1 �Page 2) Item No. Description Relaticn Amount 5 Donald A. Tressler 869 Moore's Mountain Road Lewisberry, PA 17339 Son 0.00 DEATH CE�IZTIFICATE H105.805 REV(9/11) LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 ,,,,��"��-�--.. This is to certify that the information here given is ��"P�ZH Of pF° correctl co ied from an ori inai Certificate of Death ��`°�1o`L`�� = Ny`r�; duly filed w th me as Local Regisuar. The original :o_ -- °; yi certificate will be forwarded to the State Vital �� ' n� Records Office for permanent filing. . L'k �_ *�� a, ^� 'T r-y4�. P 1918571 � ` � � `=�l�,,p ��`� � , r� (. �� 99lMENT�E;��'� , � Certification Number � """��"""' �� Local Re strar Date Issued ryoennM u� mmuaiw�urx a vnnanv�xu.ov,�Exr or Nryun�•vrtuncta�os "°"":"'"` CERTIPICATE OP DEATH Po.,,�,,,. 1.D�abrR'f I�I N�me(NnC MNE4�Ixy SuIRa 2 Sa L Sotl4 Twa/M MuMet �.Dab OaN(MWDN/'M(k�Mo) �y��7� Fina]e 81-So-3414 19, Z013 ' s..�w�++�cemnwm�t sumwir«. scwwri cueeawm�Md�vl+�Mtsotl►mw�l �+.��aw�amcou�nnl bwMls D�rs Maos MMUte � 1POV1�3� 1� 71.lktl�YSlCanM) L79C[E Ly ey.11wMww134maIaal/�caimtrN ee.ptldwrelsbwtmarlumla-�MWellptpal xwdDm�RUYeIn�TOrmNnt PA 700 Walm�t Bottos ltl Ore+.acdemwaam sra td.�.dws Icei.nri Q�er]md r.a,w�Rkeoael �aeoe.Kx.rwu�w+sa Cerlisle Boro �y�y,,,. 4flwY1�fatnT 30.MnkdSYMrt7lmedDeM OM�rtW WWO+�etl iLSurvNYt�>LIYIMINMI�.dw�unrMlort0lYRIMrrYR) ❑w. m ra o u� a o�ae.a a ww.wrnea 0 u�wn u.ixhsrY wme IR'�c Mtla�,uu.sulfhl u Mo1hls wme nnrm wu wrrMK(Fhn,Mka.,l� �..TOt61�i'4i�AdOYD� .71117.d tQLDB�1 14.Inbmora't/Yme 1N.M�tlwnhmtoD�adnR 1�c.WanrM'sWAYMAd6wt(SartuiAlWmCw.OlY�ibb. 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V ��YMit�Y•Te1MhqlOfnMbpWlCal�GMtl100aY�tllw tlrtaltlds�Ydm�m�T#�Rd 07nrowb7�CatlFM•TOtMlatdmr�dw,drtl�a eetMtlnwYa.mepYQ.ndeueto»raiselslmam�mrr�ub0. � ❑MeNUIOSinLierRaaw•Onth n �IaeNn�tlpisd/alm NmyepNOn.drtli tlrtNw4tr.aWWo�.uk0uerot�ewrelsl+Mm�mwwud• rse.a..eroren.r a«ron.r ud..w�e..�/��J/O�E se'�.na co'' io�J J�:"'/v� eST�',/�'�*+rr; �f�r.c�f/sc'o.�' �+i a 3 � . a.wm,r u l�"�-6�5 � �� 0866781 Nwsw N.,..,�..,T»w. .«,,.,,.,,., LAST WILL AND TESTAMENT LAST WILL AND TESTAMENT OF MARY LOUISE TRESSLER I, MARY LOUISE TRESSLER, now of 869 Moore' s Mountain Road, Lewisberry, Yark County, Pennsylvania 17339 , do publish and declare this to be my Last Will and Testament, hereby revoking aZl other prior wills and codicils made by me. FIRST: Family Baekc�round and Appointmen� of Executar. tA} Famil�t ar�d Backqround Information. I am married to LESTER E. TRESSLER. I have not been previously married. The children of our marriage are NANCY L. TIiOMAS and DONALD A. TRESSLER. Throughout this Will, LESTER E. TRESSLER will be referred to as "my husband�� or ��my spouse" and NANCY L. THOMAS and DONALD A, TRESSLER, {and any children born tc� or legally adopted hereafter) will be referred to as "my children. �� The word "issue" will include any children as well as my ather descendants . (B} Appair�tment af Executor. I appaint as my Executor and �uccessor E�ecutor (all hereinafter referred to as Executor or Executor{s) under this Will, the following named persons or corporations to serve without bond and withou� being required to accc�unt to any Court: FaGecutor: My son, DONALD A. TRESSLER. Successor Executor: My daughter-in-law, ELAINE N. TRESSLER. {C) inter Vivos Trust. The inter vivos trust agreemen�. referred to �.his Will is en�,itled "THE TRESSLER FAMILY TRUST, " dated June �, 1995, bY and between LESTER E. TRESSLER and MARY LOUISE TRESSLER, as Settlors, and MARY LOUISE TRESSLER and DONALD A. TRESSLER, as Trustees, as now in effect or as ma� hereafter be amended. SECQND: Funeral and Last Illness E�enses; Taxes. {A} Ex�enses of Fune=al azzd Last Zllness. I direct my Executor to pay my funeral expenses and the expenses 4f my las illness from my estate. In addition, my Executor may notify ,_-��-��— C. LAST WZLL AND TE�TAMENT OF MARY LOUISE TRESSLER PAGE 2 Trustee of the Tru�t described in Paragraph FIRST (C) of any such expenses and my Exacutor may accept reimbursement from such Trustee. (B) Taxes. I direct my Executor ta pay any and aIl estate, inheritance, succession, legac�r, tran�fer and ather death taxes or duties, by whatever name cal�ed, including any and aIl interes� and penal�ies thereon, imposed under the laws of any �urisdiction by reason of my death upon gr wiGh respect �.o any and all property included in my gross estate for the purpose of such taxes, whether such property passes under or autside of this Wil1. Without any apportianment otherwise required by law and without being prorated or apportianed among c�r charged against the respective devises, legatees, beneficiaries, transferees, or other recipients of any such property t�r charged against any property passing ar which may have passed to any of them, I direct that any taxes so paid shall be charged against my residuary estate. My Executor sha11 not be entitled ta reimbursement fc+r any portion of any such taxes from any �uch person. The faregoing provisions of this Article SECC}N� sha11 not apply to such portion or porti.ons of said taxes, interest and penalties which may be required to be paid, or are actually paid or reimbursed, by t�he Trus�ee of the Trust described in Paragraph FIRST (C) , above. THTRD: Tanqible Persanal PropertY. Except �or those items excluded below and those items enumerated in the Letter of Instruction, I bequeath all my tangible personal property, inc3uding but not limited �o clothing, jewelry, heirlooms, furniture, household furnishings, personal ef�ects, motor vehicles, and aZl ather similar articles, which I own, and the insurance therean, �.a my children, NANCY L. THOMA3 and DQNALD A. TRESSLER, per stirpes, to be divided among them as they may select in as nearly equal shares as is practical. If there is any disagreement as to distribution, I direct my Executor to make such distribution. The decision o�' my Executar shall be final and binding. Any items no� selected or any i�.ems which my Executor considers unsuitable for my children may be distributed or sdld in �he sole discretion of my Executor and, if sold, the net proceeds therefrom shall be added to the residue c�f my estate. Any such article a3located ta a minor may, as my Executor deems advisable, either be delivered to �.he minor or to any person to safegruard on behalf of the minor. Notwithstanding any other provisions in this Article I , �,��' C LAST T�VILL AND TESTAMENT OF MARY LOUI3E TRESSLER PAGE 3 I may leave a separate, dated and unsigned Letter of Instruction, which I shall place with my Will, containing directions as to the ultimate disposition of certain of the property bequeathed under this Article THIRD, and such Letter of Instruction shall determine the distribution of such items. FOURTH: Residuary Estate. (A) I direct that any debt owed to me at the time of my death by my daughter, NANCY L. THOMAS, be forgiven in its entirety. (B) I devise and bequeath all of the rest, residue and remainder of my estate, real, personal and mixed, of whatever nature and wherever situated to which I am legally or equitably entitled, to the then-acting Trustee (s) of the Trust described in Paragraph FIRST (C) of this Will, to be held, administered and distributed pursuant to the terms thereof, as the same may be amended from time to time. By this devise and bequest of my residuary estate I hereby exercise all Powers of Appointment I possess at the time of my death except any power of appointment which I possess under the Trust described in Paragraph FIR5T (C) of this Will. FIFTH: Powers of Executor. In addition to the powers and duties as may have been granted elsewhere in this Will, but subject to any limitations stated elsewhere in this will, the Executor shall have and exercise exclusive management and control of the Estate and shall be vested with the following specific powers and discretion, in addition to the powers as may be generally conferred from time to time upon the Executor by law: (A) In the management, care and disposition of the Estate, the Executor shall have the power to do all things and to execute such instruments, deeds, or other documents as may be deemed necessary or proper, including the following powers, all of which may be exercised without order of or report to any Court: (1) To sell, exchange or otherwise dispose of any property at any time held or acquired hereunder, at public or private sale, for cash or on terms, without advertisement, including the right to lease for any term notwithstanding the period of the Estate, and to grant options, including any option for a period beyond the duration of the Estate. �� LAST WILL AND TEBTAMENT OF • MARY LOUI3E TRESSLER PAGE 4 (2) To invest all monies in such stocks, bonds, securities, mortgages, notes, choses in action, real estate or improvements thereon, and any other property as the Executor may deem best, without regard to any law now or hereafter enforced limiting investments of fiduciaries . (3) To retain for investment any property deposited with the Executor hereunder. (4) To vote in person or by proxy any corporate stock or other security and to agree to or take any other action in regard to any reorganization, merger, consolidation, liquidation, bankruptcy or other procedure or proceedings affecting any stock, bond, note or other security. (5) To use attorneys, real estate brokers, accountants and other agents, if such employment is deemed necessary or desirable, and to pay reasonable compensation for their services . (6) To compromise, settle or adjust any claim or demand by or against the Estate and to agree to any rescission or modification of any contract or agreement affecting the Estate. (7) To renew any indebtedness, as well as to borrow money, and to secure the same by mortgaging, pledging or conveying any property of the Estate. (8) To retain and carry on any business in which the Estate may acquire an interest, to acquire additional interest in any such business, to agree to the liquidation in kind of any corporation in which the Estate may have an interest and to carry on the business thereof, to join with other owners in adopting any form of management for any business or property in which the Estate may have an interest, to become or remain a partner, general or limited, in regard to any such business or property and to hold the stock or other securities as an investment, and to employ agents and confer on them authority to manage and operate the business, property or corporation, without liability for the acts of such agent or for any loss, liability or indebtedness of such business if the management is selecte or retained with reasonable care. �7�� LAST WILL AND TESTAMENT OF MARY LOUISE TRESSLER PAGE 5 (9) To register any stock, bond or other security in the name of a nominee, without the addition of words indicating that such security is held in a fiduciary capacity, but accurate records shall be maintained showing that such security is a Estate asset and the Executor shall be responsible for the acts of such nominee. (B) Whenever the Executor is directed to distribute any Estate assets in fee simple to a person who is then under twenty- one (21) years of age, the Executor shall be authorized to hold such property in Trust for such person until he/she becomes twenty-one (21) years of age, and in the meantime shall use such part of the income and the principal of the Estate as the Executor may deem necessary to provide for the proper support and education of such person. If such person should die before becoming twenty-one (21) years of age, the property then remaining in trust shall be distributed to the personal representative of such person� s estate. (C) In making distributions from the Estate to or for the benefit of any minor or other person under a legal disability, the Executor need not require the appointment of a guardian, but shall be authorized to pay or deliver the same to the custodian of such person, to pay or deliver the same to such person without the intervention of a guardian, to pay or deliver the same to a legal guardian of such person if one has already been appointed, or to use the same for the benefit of such person. (D) In the disbursement of the Estate and any division into separate trusts or shares, the Executor shall be authorized to make the distribution and division in money or in kind, or both, regardless of the basis for income tax purposes of any property distributed or divided in kind, and the distribution and division made and the values established by the Executor shall be binding and conclusive on all persons taking hereunder. The Executor may in making such distribution or division allot undivided interests in the same property to several trusts or shares . (E) The Executor shall have discretion to determine whether items should be charged or credited to income or principal or allocated between income and principal as the Executor may deem equitable and fair under all the circumstances, including the power to amortize or fail to amortize any part or all of any premium or discount, to treat any part or all of the profit resulting from the maturity or sale of any asset, whether �� ,� ;2 �_ LAST WILL AND TE3TAMFNT OF MARY LOUISE TRESSLER PAGE 6 purchased at a premium or at a discount, as income or principal or apportion the same between income and principal, to apportion the sales price of any asset between income and principal, to treat any dividend or other distribution of any investment as income or principal, or apportion the same between income and principal, to charge any expense against income or principal or apportion the same, and to provide or fail to provide a reasonable reserve against depreciation or obsolescence on any assets subject to depreciation or obsolescence, all as the Executor may reasonably deem equitable and just under all the circumstances. If the Executor does not exercise the above discretionary power, the cash or accrual allocation shall be in accordance with Chapter 81 of Title 20 of the Pennsylvania Consolidated Statutes, or the corresponding provisions of subsequent state law. (F) If at any time the total fair market value of the assets of any trust established or to be established hereunder is so small that the corporate Trustee� s annual fee for administering the trust would be the minimum annual fee set forth in the Trustee' s regularly published fee schedule then, in effect, the Trustee in its discretion shall be authorized to terminate such trust or to decide not to establish such trust, and in such event the property then held in or to be distributed to such trust shall be distributed to the persons who are then or would be entitled to the income of such trust. If the amount of income to be received by such persons is to be determined in the discretion of the Trustee, then the Trustee shall distribute the property among such of the persons to whom the Trustee is authorized to distribute income, and in such proportions, as the Trustee in its discretion shall determine. (G) Except as otherwise provided in this Will, when the authority and power under this Will is vested in two (2) or more Executors or Trustees, the authority and powers are to be held jointly by the Executors or Trustees, respectively. A majority of the Executors or Trustees may exercise any authority or power granted under this will or granted by law, and may act under this will. Any attempt by one such Executor or Trustee to act under this Will on other than ministerial acts shall be void. The action of one such Executor or Trustee under this Will may be validated by a subsequent ratification of the act by a majority of the Executors or Trustees . ?�'I,�' � LA3T WILL AND TESTAMENT OF MARY LOUI3E TRE33LER PAGE 7 SIXTH: Rights and Liabilities of Executor. (A) No bond or other security shall be required of any Executor. (B) This instrument always shall be construed in favor of the validity of any act or omission by any Executor, and any Executor shall not be liable for any act or omission except in the case of gross negligence, bad faith or fraud. Specifically, in assessing the propriety of any investment, the overall performance of the entire Estate shall be taken into account. (C) Each Executor shall be entitled to receive reasonable compensation for services actually rendered to my estate, in an amount the Executor normally and customarily charges for performing similar services during the time which he/she performs the services . SEVENTH: 3pendthrift Provision. No beneficiary shall have the power to anticipate, encumber or transfer his or her interest in the estate in any manner other than by the valid exercise of a power of appointment. No part of the estate shall be liable for or charged with any debts, contracts, liabilities or torts of a beneficiary or subject to seizure or other process by any creditor of a beneficiary. EIGHTH: Tax Elections. (A) In determining the estate, inheritance and income tax liability relating to my Estate, the Executor� s decision as to all available tax elections shall be conclusive on all concerned. If the Executor joins with my spouse in filing income tax returns, or consenting for gift tax purposes to having gifts made by either of us during my life considered as having been made one-half by each of us, any resulting liability shall be borne by my Estate and my spouse in such proportions as they may agree. In accordance with IRC Section 2632 (a) and without regard to whether a Federal estate tax return is actually filed, my Executor shall allocate so much of the Federal Generation Skipping Transfer (GST) exemption amount as will fully exempt any generation skipping transfer which may occur under this Will. (B) The Executor may, in its discretion, determine the te as of which my gross estate shall be valued for the purpose � � LAST tiVILL AND TESTAMENT OF MARY LOUISE TRESSLER PAGE 8 determining the applicable tax payable by reason of my death. (C) The Executor may, in its discretion, decide whether all or any part of certain deductions shall be taken as income tax deductions (even though they may equal or exceed the taxable income of my estate and whether or not claimed or of benefit on my estate' s income tax return) or as estate tax deductions when a choice is available; and in the event that all or any part of such deductions are taken as income tax deductions, no adjustment of income and principal accounts in my estate shall be made as a result of such decisions. NINTH: Definitions and General Provisions. (A) Survival . Any beneficiary who dies within sixty (60) days after my death shall be considered not to have survived me. (B) Captions. The captions set forth in this Will at the beginning of the various articles hereof are for convenience of reference only and shall not be deemed to define or limit the provisions hereof or to affect in any way their construction and application. (C) Children. As used in this Will, the words ��child�� and "children" shall include persons who are legally adopted and the issue of said persons, whether born in or out of wedlock, so long as any person born out of wedlock is acknowledged in a written instrument executed by the one of their natural parents who is a descendant of mine to be the child of said descendant. The word ��issue" shall include descendants of all generations including adopted persons . A posthumous child shall be considered as living at the death of his parent. The birth to me or the adoption by me of a child or children subsequent to the execution of this Will shall not operate to revoke this Will. Except for discretionary distributions which may be made unequally among a group of persons and distributions pursuant to a valid exercise of a power of appointment, in making a distribution to the children of any person, the property to be distributed shall be divided into as many shares as there are living children of the person and deceased children of the person who left children who are then living. Each living child shall take one share and the share of each deceased child shall be divided among his then- living descendants in the same manner. (D) Code. Unless otherwise stated, all references i �i�,X.� C LAST WILL AND TESTAMFNT OF MARY LOUISE TRE5SLER PAGE 9 Will to section and chapter numbers are to those of the Internal Revenue Code of 1986, as amended, or the corresponding provisions of any subsequent federal tax laws applicable to my estate. (E) Other terms. The use of any gender includes the other genders, and the use of either the singular or the plural includes the other. (F) Powers of Appointment are Exercised. By this Will I exercise any and all Powers of Appointment which I possess at the time of my death except any power of appointment which I possess under the Trust described in Paragraph FIRST (C) , above. IN WITNESS WHEREOF, I, MARY LOUISE TRES3LER, the Testatrix, have to this my Last Will and Testament, typewritten on eleven (11) pages, including the Acknowledgment and Affidavit, set my hand and seal this !N�rday of June, 1995 . �� ; ,�� MARY OUISE TRESSLER Signed, sealed, published and declared by the above-named Testatrix, as and for her Last Will and Testament, in the presence of us, who have hereunto subscribed our names at her request, as witnesses hereto, in the presence of the said Testatrix, and in the presence of each other. Each of us further declares that he or she believes the Testatrix to be of sound mind and mem The preceding instrument consists of this and ten (10) o er consecutively numbered typewritten pages including the Ack le ent and Affidavit. " l �� t�'� � residing at � �✓��v"'�� C�.� � � 6 - rint name) �, � l. / '�� ; � -� ; 6 residing at t� l \C�� k- • D ��yi�?.,�' (print name) � �� r� /S.' � ACRNOi�ILEDGMENT AND AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA . SS: COUNTY OF �(�M ��f�a�C� • The Testatrix and the witnesses whose names are signed and subscribed to the attached or foregoing instrument, being first duly sworn and qualified according to law, do hereby acknowledge, depose and say to the undersigned authority, that the Testatrix signed and executed the instrument as her Last Will in the presence of the witnesses; that she signed it willingly or willingly directed another to sign it for her; that she executed it as her free and voluntary act for the purposes therein expressed; that each of the witnesses were present and saw the Testatrix sign and execute the instrument as her Last Will; that each subscribing witness in the hearing and sight of the Testatrix signed the will as witnesses; and that to the best of their knowledge the Testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. e atrix , Witness G�,�� l� � Witness Sworn to or affirmed, subscribed to, and acknowled ed, before me b�the above-named Testatrix and witnesses, this y h day of _ /�,�,�t�. , 19 9 5. , � � otary Pu ic My Commission Expires : ."��+111Gi;` .-'�I . Swacty L.�`!ac�,i�ci�.n'FubCC Fem',-��' i�,.r,.JU;'':�r�C:�i,�� r:�,��,�:,;,;:��.....:��i;��':oti.. s. ��s� {�1�'IBi i ia2i;F'"vtltl�j'I�e'd�i�%ya+'Y:.',a�Ji 1 Of�VJ�'.�;;�> PA REV-1500 SCHEDULE E CASH, BANK I�EPOSITS � MISCELLANE�U� PE�SONAL PROPE�TY .�'"'� ETRC� p /� A ' � 3801 Paxton Street 888.937.OQ04 G�/�11 y Harrisburg, PA 17111 mymetrobank.cam 4l15/13 Law Offices of Gates, Halbruner, Hatch 8� Guise, P.C. 1013 Mumma Rd. Suite 100 Lemoyne, PA 17043 RE: Estate of: Mary Louise Tressler Tax Identification Number: 181-50-3414 Date of Death: January 19, 2013 To Whom It May Concern: This letter is in reference to decedent account information you requested far the individual listed above. We are able to pravide the#ollawing: Account Type:Custodian CK Account Number: 5380$p797 Da#e Upened: 02J0112008 Owner: Mary L. Tressler Legal Custodian: Danald A. Tressler Accrued �n►�rest: * $J.C�S date of Death Balance: $ 1,041.88 *"` Please nate: The accrued interest will not be paid if the account is closed prior to the date the interest is scheduled to post. Please#eel free to cantact us at 1-888-93�-0004 if we may be of further assistance. Sincerely, _ __... �.�.___.,..w.__. �...... ..__�.�a.� .__- ...----.--� ,,,_-._ �,..- _.... ...___._ __.._ _. _�___.,. �._ �.-µ�_�..._____.. �� nifer,Jacobs Research Associate Metro Bank .� _ __.. 0 � m o o '� � bb �n. m { � f"'- �Wr � � s � p � x � � r.t. a..�, : � OO � � � �� :. " �� :, Ct � p � �' �,h� t tb �� x`' � n � '� . fij�2 t� �k":;;�. :: . r,,, �y 'C,7 ::,.. rr nu � O ,�� t�`� . #K W � �' ty'. y::;r : � � �y � � � o w �'�' z � y � ; � ` w � �. � r '� : � �' tn ,� ; l] � �:.� tn ,� �` r ;...:� � Q � <;� . .. �-+ � � Q �. � � ,e- �.n -.:� " :�.. . n., ,..� -� :•- , ,`. u't � E.�, CJ W � � �' � �. � : �. :� �,: �,. �:; � � � � � � � - z � � �� . �: � :a , s5'S � .�.� � _..'� r fi `'�! Q y � � � � � ,�« �. y� . ? � �'�y 7 w... 4.+..! � � . ry�� `.,,/:, � "...L ti �l� � Q� .� � � � PA REV-1500 SCHEDLTLE F JOINTLY (.�`'Vl�TED P1aOPERTY Q 1vI��T sank �F��.... �"�.:"^^`. S�`"C� i °r��E . '� -:^.`r.. 499 Mitchell Road,Millsboro,DE 19966 Adjustment Services ��/�� = � ;s t{ �� 0�� ///)�Phone 888-502-4349 �F aa� (302)934-2955 April 17,2013 Law Offices Of - Gates, Halbruner,Hatch & Guise, P.C. 1013 Mumma Road, Suite 100 Lemoyne,PA 17043 Re: Estate of Louise Tressler Social Securitv: 181-50-3414 Date of Death: January 19, 2013 Dear Sir or Madam: Per your inquiry on April 09,2013, please be advised that at the time of death,the above-named decedent had on deposit with this bank the following: 1. TypeofAccount CheckingAccount Account Number 950556694 Ownership(Names o� Donald A. Tressler Mary Louise Tressler Opening Date 08/30/2000 Balance on Date ofDeath $7,855.43 Accrued Interest $ .OS _..........................................._.... ......_._....._....................._.. Total $7.855.48 For any sddiHonal informstion on the above accounts,including ownership and any c6anges,closures and/or reimbursement of funds, please call tl�e Fairview at 717-938-1829. We were unable to locate any safe deposit boz for the above-mentioned decedent. This letter dces not include any sccounis in which the deceased may have been Gsbed as Power of Attorney,Custodian of Uniform Transfers, Representative Payee,or Trustee under a Written Agreement Sincerely, Valarie Mercer Adjustment Services PA R��-��00 SCHEDUI�E H FUNERAL EX�'ENS�S and ADMINI�TRATI�E CO�TS [�1V1&1-�IIK . 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Check #1063 Paid :O1/23/2013 sa�.00 Check #1063 Paid :O1/33/2013 sa�.00 --- .._'� � . . .�w . .__ _'1 ,T � MARY LOUISE TRESSLE{i e�� 10 6�f E t r ! � p? ' DONALD A TRESSI.ER s �_ r`o, 899 MOOR�S MOVMTAW ND. � ' � D LEWIS6FARY�PA 17399$/84 1�.1'g O��/; � ' � . � ,;� T � �� /J I� �// � ] J Q�. . � � - H� O v � � PAYTOYtiB l�V✓��/�h�+��FFCW�i�4.(PJ— I +' s • i+ �� 7�o�ce �; . .a3__ 3�] if ' � � ��Tl i �"A.,raP�r...�!Q t-{�–�.�.,�.�'��5',-x A-�„-"��DOLLaRS 6 i�? o'��i'� R a� .1 �� °y° � � G�M8{Tltt�nk A"�^'� 02 �g�4��s - �� g n� � � �' rr�.warr , z� 5��d�'` �iY T� a stcwo�i�l.��'eZ.II.9A'r - ' �'� �r „� N.$ '$°sL.� d � Y��'.s +:O�i302955�: 950556694��'i064 ' � � � s��g �� - •�� Check #1064 Paid :O1/25/2013 �1176.95 Check #106� Paid :O1/ZS/4013 :1176.95 "• M ,, � - >031309123< zg 13101/24 1822:54 O MARYLOUISETRE�sst..eR ,"�,—�, �� 1065 ,; �: ;,��. susQ ��oeoi000azz�ao i DONALb A TRESSLER -=�- � fl�MOORES MOVNiAIN RD. 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Check #1065 Paid :O1/25/9013 5500.00 Check #1065 Paid :O1/ZS/1013 5500.00 PA REV-1500 SCI�EDT.TLE I DE�TS OF I�E�EDENT, MORT�AGE LIABILITIES and LIENS V 1V1&1-1�IlK . � >::»AC�OUHT_s>::;':?;:«:`;»`::>`»::>::::: >`:_>::PAIG�:>::�>`:�<>;:>:::>::s; 000000950556694 2 OF 2 00002296-0008201-Paga 2 o(2•FIDS1541G7010'1281301-00002296 .� 'Y y . � r { / �^..�-�°'.�� . . *.s �� I 8 � O MARY LOUISE TRESSLER �b�os 10 6 3 �� "�� ;ao; � DONALD A TRESSLER �°,r 3 >031301896< �' g � zcBf.9 MCK3AE5 MOUNTrVN RO. � - ! 070/3 � 3� e� Metro Sarilc Hub �F�3 �� -� irwiS�NNV,Na i�ss�-�r,� nnrn � � $ 2013-01-22 0�. �� p � Sf i�q r�_ , } R� 031071992 i�� _� + � r.�vi�flie~ Y'loavr.r r� �,. � o.-ti� I $ 67•� `�d � a G 3 i 0 i 1 :t:i 2 , s � m �r;u�:�un --. �L<< ,.0 ��— ��o . � �� ;�v ' � �' Q — r-_�• c�'��s�x 't=o � �o ' .ie••� _ni�,a.nRS A t ?p��,�� q '7.a► a �,� o� Q�ci;a �r �� ,�i,�+ � � &TBank � . 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Check #1065 Paid :O1/ZS/4013 f500.00 Check #1065 Paid :O1/SS/4013 Z500.00 �# pennsylvania DEPARTMENT OF PUBLIC WEIFARE April 11, 2013 GATES HALBRUNER HATCH & GUISE P C LOWELL R GATES ESQUIRE 1013 MUMMA RD STE 100 LEMOYNE PA 17043 Re: Mary Tressler CIS #: 340240878 SSN: ###-##-3414 Date of Death: 01/19/2013 Dear Attorney Gates: Please be advised that the Department of Public Welfare maintains a claim in the amount of $188,184.86 against the above-mentioned estate. This claim is for restitution of inedical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $26,787.05, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely �161.397.81, is to be entered as a priority Class 5.1 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if availabte. Sincerely, V , ` Karen H. Peterson Claims Investigation Agent 717-772-6615 717-772-6553 FAX Enclosure Bureau of Program Integrity � Division of Third Party Liability � Recovery Section PO Box 8486 � Harrisburg,Pennsylvania 17105-8486 COMMONWEALTH OF PENNSYLVANIA BUREAU OF PROGRAM INTEGRITY � DIVISION OF THIRD PARTY LIABILITY ' RECOVERY SECTION PO BOX 6486 HARRISBURG,PA 17105-6486 April 9,2013 STATEMENT OF CLAIM SUMMARY NAME Estate of TRESSLER,MARY ID 340 240 878 MEDICAL CLASS 3 CLASS fi.3 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 26,772.44 161,239.14 188,011.58 DRUG 14.61 158.67 173.28 REIMBURSEMENT TO DPW 26,787.05 161,397.81 188,184.86 __ _ _ _ __ . _.__ ._ _ ._ _ COMMOMNEALTH flF PENNSYLVANIA DEPARTMENT OF PUBLIG WELFARE EIN- 23-6fl03113 Page 1 of 11 i____._-______.___ _-______.-.___ ______--_._.__ __-__ __ ___ i • COMMONWEALTH OF PENNSYLVANIA � � DEPARTMENT OF PUBLIC WELFARE L- -- - _ _ - -- - April 9,2013 STATEMENT OF CLAIM NAME TRESSLER, MARY iD 340 24U 878 FOREST PARK HEALTH CENTER 7Q0 WALNUT BOTTOM RD CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 12J16/09 - 12/31/09 12/13/10 55103425273950001 55103425273950001 3,383.68 3,307.36 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 0 PROC CODE: 000000 01/01/10 - 01/31/10 01N0/11 55110044269160001 55110044269160U01 6,555.88 4,600.29 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 0 PROC CODE : 000000 02J01/10 - 02/28/10 01/10/11 55110044269170001 55110044269170001 5,921.44 3,977.52 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 0 PROC CODE : 000000 03/01/10 - 03/31/10 01/10/11 55110044269180001 55110044269180001 6,555.88 4,600.29 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 0 PROC CODE: 000000 04/01/'10 - 04/30/10 02/14/11 55110394261410001 55710394261410001 6,344.40 5,053.70 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 4019 HYPERTENSION NOS PROC CODE : OUOUOU 05/01/10 - 05/31/10 02/14/11 55110394262300001 55110394262300001 6,555.88 5,261.29 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 . 06/01/10 - 06/30/10 02/14l11 55110394263170001 55110394263170001 6,344.40 5,053.70 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 4019 HYPERTENSION NOS PROC CODE : 000000 07/01/10 - 07/31/10 10/17/11 55112854568400001 55112854568400001 6,555.88 5,273.69 DIAGNOSIS 1 : 331U ALZHEIMER'S DISEASE DIAGNOSIS 2 : 4019 HYPERTENSION NOS PROC CODE: 000000 Page 2 of 11 ',--_-___- -..__-_ ____.- ____..____._..._.--___ j < COMMONWEALTH OF PENNSYLVANlA � � DEPARTMENT OF PUBUC WELFARE April 9,2013 STATEMENT OF CLAIM NAME TRESSLER,MARY ID 340 240 878 FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM RD CARLISLE PA 17013 DATE OF SFRVICE PAYMENT DATE ORiGINAL GRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED O8/01/10 - 08/31l10 10/17/11 55112854569170001 55112854569170001 6,555.88 5,273.69 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE : 000000 09/01/10 - 09/30/10 10/17/11 55112854569950001 55112854569950001 6,344.40 5,065.70 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 10/01/10 - 10/31/10 10/24/11 55112924728260001 55112924728260001 6,555.88 5,363.28 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE : 000000 11/01/10 - 11/30/10 10/24/11 55112924729020001 55112924729020001 6,227.70 5,152.40 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 4019 HYPERTENSION NOS PROC CODE: 000000 12/U1/10 - 12/31/10 10/24/11 55112924729760001 551'12924729760001 6,435.29 5,363.28 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE : 000000 01/01/11 - 01/31/11 10/31/11 55112994713720001 55112994713720001 6,435.29 5,372.08 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 4019 HYPERTENSION NOS PROC CODE: 000000 02/01/11 - 02/28/11 14/31/11 55112994714240001 55112994714240001 5,812.52 4,739.44 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 4019 HYPERTENSION NOS PROC CODE : 000000 03J01/11 - 03/31/11 10/31/11 55112994715150001 55112994715150001 6,435.29 5,372.08 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 4019 HYPERTENSION NOS PROC CODE: 000000 Page 3 of 11 --- -- -- ---------------------- ----------- - ----- � , COMMONWEALTH OF PENNSYLVANIA � DEPARTMENT OF PUBLIC WELFARE April 9,2013 STATEMENT OF CLAIM NAME TRESSLER, MARY 1D 340 240 878 FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM RD CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 04/01/11 - 04/30/17 11/07J11 55113054627390001 55113054627390001 6,227.70 5,161.2U DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE: 000000 05/01/11 - 05/31/11 11/07/11 55113054628160001 55113054628160001 6,435.29 5,372.08 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE : OOOOOU O6/01/11 - 06/30/11 11/07/11 55113054628880001 55113054628880401 6,227.70 5,161.20 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 7812 ABNORMALITY OF GAIT PROC CODE : 000000 07/01h1 - 07/31/11 05/07/12 55121254052880001 55121254052880001 6,435.29 5,159.73 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE : 000000 08/01/11 - OS/31/11 05/07l12 55121254053030001 55121254053030001 6,435.29 5,159.73 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 09/01/11 - 09/30l11 05/07/12 55121254054440001 55121254054440001 6,227.70 4,955.70 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE : 000000 10/01/11 - 10/31/11 05/21/12 55121374098880001 55121374098880001 6,537.28 5,238.16 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 4019 HYPERTENSION NOS PROC CODE: 000000 11l01/11 - 11/30/11 05/21/12 55121374099570001 55121374099570001 6,326.40 5,031.60 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 4019 HYPERTENSION NOS PROC CODE: 000000 Page 4 of 11 ------------------ — �-_ _- ___ ----- -- -- � � COMMONWEALTH OF PENNSYLVANIA �__ _ DEPARTMENT OF PUBUC WELFARE April 9,2013 STATEMENT OF CLAIM NAME TRESSLER,MARY (D 340 240 878 FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM RD CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMQUNT APPROVED 12/01/11 - 12/31/11 05/21/12 55121374100340001 55121374100340001 6,537.28 5,238.16 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 4019 HYPERTENSION NOS PROC CODE : OOOU00 01/01/12 - 01/31/12 O6/18l12 55121644182170001 55121644182170001 6,537.28 5,342.41 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE : 000000 02/01/12 - 02/29/12 06/18/12 55121644182850001 55121644182850001 6,115.52 4,870.49 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 03/01/12 - 03/31/12 06/18/12 55121644183790001 55121644183790001 6,537.28 5,288.91 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 4019 HYPERTENSION NOS PROC CODE : 000000 04f01/12 - 04/30/12 05/28/12 20121234027830001 20121234027830001 6,290.70 5,094.10 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE : 000000 05/01/12 - 05/31/12 06/25l12 20121534303440001 20121534303440001 6,500.39 5,303.79 DIAGNOSIS 1 : 331U ALZHEIMER'S DISEASE DIAGNOSIS 2 : 4019 HYPERTENSION NOS PROC CODE: OOOU00 06101/12 - O6/30/12 07/30/12 201218540284200Q1 20121854028420001 6,290.70 5,OS4.10 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 4019 HYPERTENSION NOS PROC CODE : 000000 07/01l12 - 07/31/12 01/28/13 55130244377720001 55130244377720001 6,500.39 4,937.99 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 Page 5 of 11 r -- ------------ ---- -- � � COMMONWEAtTH OF PENNSYLVANIA � ( DEPARTMENT OF PUBUC WELfARE April 9,2013 STATEMENT OF CLAIM NAME TRESSLER,MARY ID 34U 240 878 FOREST PARK HEALTH CENTER 700 WALNUT BOTTOM RD CARLISLE PA 17013 DATE OF SERViCE PAYMENT DATE ORIGWAL CRN ADJUSTED CRN USUAL CHARGES AMaUNT APPROVED 08/01/12 - 08/31/12 01/28l13 55130244378400001 55130244378400001 6,500.39 4,937.99 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 09/01/12 - 09/30112 01/28/13 55130244379300001 55130244379300001 6,290.70 4,740.10 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 4019 HYPERTENSION NOS PROC CODE: 000000 10/01/12 - 10/31/12 02/18/13 55130444303960001 55130444303960007 6,500.39 4,937.99 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE : 000000 11/01/12 - 11/30/12 02/18/13 55130444304690001 55130444304690001 6,290.70 4,740.10 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 12/01l12 - 12/31/12 02/18/13 55130444305410001 55130444305410001 6,500.39 4,937.99 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 01/01/13 - 01/19/13 OZ/25/13 20130354051760001 20130354051760001 3,774.42 2,478.27 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 4019 HYPERTENSION NOS PROC CODE : 000000 PROVIDER SUB TOTAL FOREST PARK HEALTH CENTER 237,038.87 188,011.58 03 101867397 OOU1 Page 6 of 11 � COMMONWEALTH OF PENNSYLVANIA � DEPARTMENT OF PUBLIC WELFARE � --- ---- - --- -- -- -- - - - -- - --- - -- ---- __- - -- - - - --- -- -- - April 9,2013 STATEMENT OF CLAIM NAME TRESSLER, MARY !D 340 240 878 GUARDiAN LONG TERM CARE PHARMACY I� 123 BRUBAKER RD BROCKWAY PA 15824 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOtlNT APPROVED 12/16/09 - 12/16/09 05/24/10 25101185421960001 25101185421960001 7.20 4.90 DIAGNOSIS 1 : 0 NDC CODE: 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 01/18l10 - 01/18/10 05/24/10 25101185421990001 25101185421990001 7.20 4.94 DIAGNOSIS 1 : 0 NDC CODE: 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 02/11/10 - 02/11/10 08/09/10 25101965481760001 25101965481760001 11.83 8.37 DIAGNOSIS 1 : 0 NDC CODE: 50111099001 VIT D2 1.25 MG(50,000 UNIT) - FAT SOLUBLE VITAMINS 02/18/10 - 02/18/10 05i24/10 25101185422010001 25101185422010001 7.20 4.90 DIAGNOSIS 1 : 0 NDC CODE: 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 04/17110 - 04/17/10 06/07/10 25101315634030001 25101315634030001 7.20 4.90 DIAGNOSIS 1 : 0 NDC CODE: 00517003125 CYANOCOBALAMIN 1,000 MCGlML - WATER SOLUBLE VITAMINS 05/10/18 - 05/10/10 06/28l10 2510153562249U001 25101535622490001 7.20 4.90 DIAGNOSIS 1 : 0 NDC CODE: 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 06/02/10 - 06/02/10 06/28/10 25101535697470001 25101535697470001 7.20 4.90 DIAGNOSIS 1 : 0 NDC CODE: 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS O6l25l10 - 06125l10 07/19/10 25101765533800001 25101765533800001 7.20 4.90 DIAGNOSIS 1 : 0 NDC CODE: 04517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS Page 7 of 11 , CflMMONWEALTH OF PENNSYLUANIA � I DEPARTMENT OF PUBUC WELFARE April 9,2013 STATEMENT OF CLAIM NAME TRESSLER, MARY ID 340 240 878 GUARDIAN LONG TERM CARE PHARMACY it 123 BRUBAKER RD BROCKWAY PA 15824 DATE OF SERVICE PAYMENT DATE ORIGtNAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVE� 07l19/10 - 07/19/10 08/16/10 25102005686960001 25102005686960001 7.20 4.90 DIAGNOSIS 1 : 0 NDC CODE: 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 08/20110 - 08/20/10 09/13l10 25102325591260001 25102325591260001 7.20 4.90 DIAGNOSIS 1 : 0 NDC CODE: 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 09/18/10 - 09/18l10 10/18/10 25102615386080001 25102615386080001 7.20 4.90 DIAGNOSIS 1 : 0 NDC CODE: 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 10l13/10 - 10/13/10 11/O8/10 25102865479340001 25102865479340001 10.07 5.23 DIAGNOSIS 1 : 0 NDC CODE: 00228205750 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 10/19/10 - 10/19/10 11/15/10 25102925479090001 25102925479090001 7.20 4.90 DIAGNOSIS 1 : 0 NDC CODE: 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMiNS 12/18/10 - 12/18/10 01/17/11 25103525336450001 25103525336450001 7.20 4.90 DIAGNOSIS 1 : 0 NDC CODE: 04517003125 CYANOCOBALAMIN 1,000 MCGlML - WATER SOLUBLE VITAMINS 01/18/11 - 01/18/11 02/14/11 25110185344180001 25110185344180001 7.20 4.90 DIAGNOSIS 1 : 0 NDC CODE: 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 01/25/11 - 01/25/11 02/21/11 2511025529043U001 25110255290430001 25.86 5.01 DIAGNOSIS 1 : 0 NDC CODE: 63304477205 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS Page 8 of 11 � _ — - -----— --- � COMMflNWEAtTH OF PENNSYlVAN1A I DEPARTMENT OF PU$L1C WEtFARE April 9,2013 STATEMENT OF CLAIM NAME TRESSLER,MARY ID 340 240 878 GUARDIAN LONG TERM CARE PHARMACY It 123 BRUBAKER RD BROCKWAY PA 15824 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 02118t11 - 02/18/11 03/14/11 25110495411680001 2511 U495411680001 7.31 4.90 DIAGNOSIS 1 : 0 NDC CODE : 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 03/18/11 - 03/18/11 04111/11 25110775571500001 25110775571500001 7.31 4.90 DIAGNOSIS 1 : 0 NDC CODE : 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 04/19/11 - 04/19/11 05/16/11 25111095264820001 25711095264820001 7.31 4.90 DIAGNOSIS 1 : 0 NDC CODE: 00517003125 CYANOCOBALAMIN 1,000 MCGlML - WATER SOLUBLE VITAMINS 05/OS/11 - 05/OS/11 OS/30/11 25111255263260001 25111255269260001 25.86 4.96 DIAGNOSIS 1 : 0 NDC CODE : 63304077205 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 06/20f11 - O6(20/1'1 07/18/11 25111715509020041 25111715509020001 7.31 4.90 DIAGNOSIS 1 : 0 NDC CODE : 00517003725 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 08/01/11 - 08/01/11 08/29/11 2511213587097U001 25112135870970001 7.31 4.90 DIAGNOSIS 1 : 0 NDC CODE: 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 08/26l11 - 08/26/11 12/26/11 25113345531230001 25113345531230001 7.20 4.90 DIAGNOS�S 1 : 0 NDC CODE: 00517003125 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 10l02/11 - 10/02/11 12/26/11 25113345531560001 25113345531560001 6.64 4.03 DIAGNOSIS 1 : 0 NDC CODE: 00591024010 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS Page 9 of 11 �--------- -- —— — ----- ------- --- ----- COMMONWEAtTH OF PENNSYLVANIA � I DEPARTMENT OF PUBLIC WELFARE April 9,2013 STATEMENT OF CLAIM NAME TRESSLER, MARY ID 340 240 878 GUARDIAN LONG TERM CARE PHARMACY IP 123 BRUBAKER RD BROCKWAY PA 15824 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 10/04/11 - 10/04l11 12/26/11 25113345531870001 25113345531870001 45.73 1.71 DIAGNOSIS 1 : 0 NDC CODE : 00228205750 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 10/18/11 - 10118/11 12/26/11 2511334553220U001 25113345532200001 7.20 4.90 DIAGNOSIS 1 : 0 NDC CODE: 00517U03125 CYANOCOBALAMIN 1,000 MCGlML - WATER SOLUBLE VITAMINS 01l24/12 - 01/24/12 02/27/12 25120325380650001 25120325380650001 7.73 5.30 DIAGNOSIS 1 : 0 NDC CODE: 63323004401 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 02/18/12 - 02(18/12 03/19/12 2512049529412Q041 25120495294120001 7.73 5.30 DIAGNOSIS 1 : 0 NDC CODE : 63323004401 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 03/19/12 - 03/19/12 04/16/12 25120795337050001 25120795337050001 7.73 5.30 DIAGNOSIS 1 : 0 NDC CODE: 63323004401 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 04/19l12 - 04/19/12 05/74/12 25121105295260001 25121105295260001 7.73 5.30 DIAGNOSIS 1 : 0 NDC CODE: 63323U04401 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 05/03/12 - 05/03/12 05/28/12 25121245358080001 25121245358080001 25.86 4.86 DIAGNOSIS 1 : 0 NDC CODE: 00228205750 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 05/18/12 - 05/18/12 06/11/12 25121395429080001 25121395429080001 7.73 5.30 DIAGNOSIS 1 : 0 NDC CODE: 63323004401 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS Page 10 of 11 ----— --- - - -- — --�__—_ — -- ------ -- -—__ � , COMMONWEALTH OF PENNSYtVANIA I DEPARTMENT OF PUBUC WELFARE I- _ _ _----___----.-- _ _ _--- -- -- ---- -- ---_ __ __ _--- -- _ --- ---- - Aprii 9,2013 STATEMENT OF CLAIM NAME TRESSLER, MARY ID 340 240 878 GUARDIAN LONG TERM CARE PHARMACY I� 123 BRUBAKER RD BROCKWAY PA 15824 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 08/20/12 - 08/20/12 09/17/12 25122335631710001 25122335631710001 8.16 3.62 DIAGNOSIS 1 : 0 NDC CODE: 63323004401 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 08/21/12 - 08/21/12 09/17/12 25122345429750001 25122345429750001 8.16 1.&2 DIAGNOSIS 1 : 0 NDC CODE: 63323004401 CYANOCOBALAMIN 1,000 MCGlML - WATER SOLUBLE VITAMINS 09/18/12 - 09/18112 10/15/12 25122625530360001 25122625530360001 8.16 3.62 DIAGNOSIS 1 : 0 NDC CODE: 63323004401 CYANOCOBALAMIN 1,000 MCG/ML - WATER SOLUBLE VITAMINS 10/18/12 - 10/18/12 11/12/12 25122925459570001 25122925459570001 11.00 5.75 DIAGNOSIS 1 : 0 NDC CODE: 00517003225 CYANOCOBALAMIN 1,0�0 MCGlML - WATER SOLUBLE VITAMINS FROVIDER SUB TOTAL GUARDIAN LONG TERM CARE PHARMACY INC 370.53 173.28 24 102290870 0001 Page 11 of 11 ��* FN� OF AT'�A��Il�'I�1�TTS *�� bl��d S� � oi � f��- O CS � ti7 � C'�i � iL7 � �'S W � � �� a � �l�l�b'H f' �•,tik�`�' .,�� C? �• �'' � W = O �- � � M �' � � r"'v � � o v 4� � . r._ �' oo - a o � r',� �' G1 _.,,t � .� _ ��.+ �, a., �CJ � ., ,._ - :.,? � 'x �Z ' — .pq `^-� V� .-�-+ _ 4 � ,.-,, Q H cn d _ y � a� a ? t�u p� - � �} � � . ,., s � ., "' w "� O t+'3 - .� � ,� ¢ , . t ";,� .� O �Z .� � � .� a :.. ' .; r,d,� � w Q W — O a. o ai - , i� � Z �� , � , ;� � �W _ 4.a � y s�., i.�.J � c—�- � � � m� _, � U � U _ ' � Q � O W J � # ` � V � � �