HomeMy WebLinkAbout02-0381Register of Wills of Cumberland County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Estate of I. Louise G. Williamson
also known as Louise G. Williamson
, Deceased
John E. S. Williamson
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
No.
Social Security No. 184- 20 - 1374
(COMPLETE 'A' or 'B' BELOW:)
r----[ A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the execut
the Decedent, dated and codicil(s) dated
named in the last Will of
State relevant circumstances, e.g., renunciation, death of executor, etc.
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents
offered for probate; was not the victim of a killing and was never adjudicated incompetent:
B. Grant of Letters of Administration
(c.t.a.; d.b.n.c.ta; pendente lite; durante absentia; durante minoritate)
Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and
heirs:
Name Relationship
John E. S. Williamson ISDn
Joan W. Feese iDau~hter
(COMPLEIEINALLCASES:) Attachadditionalsheetsifnecessary.
Residence
5 Helen Ave., Mechanicsbur5 PA 17055
1817 Clayton Ave.,L.ynchbur~ VA 24503
Decedent was domiciled at death in Cumberland
County, Pennsylvania with his/her last family
or principal residence at 940 Walnut Bottom Road,
Decedent, then 96 years of age, died 10/10/2001
Boroush of Carlisle, Carlisle, PA 17013
(liststreet, number, and municipality)
at Manor Care Health Center, Carlisle, PA
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property
(If not domiciled in PA) Personal property in Pennsylvania
(If not domiciled in PA) Personal property in County
Value of real estate in Pennsylvania
(Location)
1,250.00
situated as follows:
Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of
letters in the appropriate form to the undersigned:
Signature
Typedorprintednameandresidence
John E. S. Williamson
5 Helen Avenue, Mechanicsbur~, PA 17055
Prepared by the Pennsylvania Bar Association
Copyright (c) 1996 form software only CPSystems, Inc. Form RW-1 (1991)
Oath of Personal Representative
Commonwealth of Pennsylvania
County of Cumberland
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true
and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of
the Decedent, Petitioner(s) will well and truly administer the estate according to law.
Sworn to or affirmed and subscribed
E. S. Williamson
before me this ~ 2'Lhday of
APRIL , 2002
MJ~Y C LEWIS 16or the-- ~--'-' "Regi~
No. ,21- OA-
Estate of I. Louise G. Williamson
Social Security No: 184-20-1374 Date of Death:
AND NOW, APRII, 12
10/10/2001
Deceased
, ..,~,~,.._, ~n consideration
of the Petition on the reverse side hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters E~ Testamentary ~'] Of Administration
(c.t.a.; d.b.n.c.t.a.; pendente lite; durante absentia; durante minoritate)
are hereby granted to
3ohn E. S. Williamson
in the above estate and that the instrument(s) dated
described in the Petition be admitted to probate and filed of record as the last Will of Decedent.
FEES
Letters ........... $ 25.00 L'~--/,/Z~ ~. c;~.~ ,).~,. ~.~'~ ._.~/.~,
MARY ~ LEWIS Register of Wills
Short Certificate(s) ..... $ 6.00
Renunciation ........ $ 5.
Affidavits ( ) .... $
Extra Pages ( ) ....
Codicil ........... $
JCP Fee .......... $
Inventory .......... $
Other ........... $
Attorney: James D. Bo~ar, Esquire
I.D. No: PA 19475
Address: One West Main Street
Shiremanstown, PA 17011
Telephone: 717/737-8761
TOTAL ......... $
Prepared by the Pennsylvania Bar Assoclatio~ ' (~o~y~ight (c) 1996 form software only CPSystems, Inc.
Form RW-1 (1991)
RENUNCIATION
.2.
In Re Estate of
I. Louise G. Williamson
deceased.
To the Register of Wills of
The undersigned J o a n W.
Cumberland
Feese, adult daughter
County, Pennsylvania.
of
the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters
of Administration
John E. S. Williamson
be issued to
WITNESS my hand this day of /~/~-~'c, 2 0 0 2
~ / / (Signature)
doa.rl W. Feese
1817 Clayton Avenue
Lynchburg, VA 24503
(Address)
(Signature)
(Address)
(Signature)
(Address)
21-02-381
CERTIFICATION OF NOTICE UNDER RULE 5.6 (a)
Name of Decedent: I. Louise G. Williamson
Date of Death: October 10, 2001
Will No. 21-02-0381
To the Register:
Admin. No.
I certify that notice of estate administration required by
Rule 5.6(a) of the Orphans' Court Rules was served on or mailed
to the following beneficiaries of the above-captioned estate on
April 18, 2002:
Name
Address
Joan W. Feese
John E. S. Williamson
1817 Clayton Avenue
Lynchburg, VA 24503
5 Helen Avenue
Mechanicsburg, PA 17055
Notice has now been given to all persons entitled thereto under
Rule 5.6(a) except:
None
Date: April 18, 2002
Capacity:
James D. Bogar, Esquire
One West Main Street
Shiremanstown, PA 17011
(717) 737-8761
Personal Representative
X Counsel for Personal
Representative
REV-1500 EX + (6-00)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
FILE NUMBER
21-02-0381
COUNTY CODE YEAR NUMBER
SOCIAL SECURITY NUMBER
184-20-1374
D / DECEDENT'S NAME (LAST, FIRST, ANi MIDDLE iNITIAL)
E Williamson I Louise C.
C '
E DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR)
D 10/10/2001 08/18/1905
E (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
N
T
THIS RETURN MUST BE FILED IN DUPLICATE W1TH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
C A P B 4. Limited Estate Future Interest Compromise (date of death after 1;)-17-82)
HpRL ·
E P ~ O 6. Decedent Died Testate · Decedent Maintained a Living Trust
cr~AC
~r ;~ T K (Attach copy of Will) (Attach copy of Trust)
"-- E S 9. Litigation Proceeds Received ['---] 10. Spousal Poverty Credit
(date of death between 12-31-91 and 1-1-95)
NAM E
James D. Bogar
FI RM NAM E (If Applicable)
Esquire
C
O
R
R
E
S
R
E
C
A
P
I
T
U
L
A
T
I
O
N
C
O
M
T
I
O
N
(date of death
3. Remainder Return prior to 1Z- 13-8Z)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
11. Election to tax under Sec. 9113(A)
(Attach Sch O)
TELEPHONE NUMBER
717,/73 7- 8761
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or (3)
Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
J---] Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13.
14.
COMPLETE MAILING ADDRESS
One West Main Street
Shiremanstown, PA 17011
None
None
2,044.07
None
None
1,048.50
67,875.01
Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
Net Value Subject to Tax (Line 12 minus Line 13)
OFFICIAL USE ONLY
(8) 2,044.07
(11) 68,923.51
(12) (66,879.44)
(13)
(14) (66,879.44)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116(a)(1.2) X .0 0
16. Amount of Line 14 taxable at lineal rate (66,879.44) X .0 45
17. Amount of Line 14 taxable at sibling rate X .12
18. Amount of Line 14 taxable at collateral rate X .15
19. Tax Due
(15) 0.00
(16) 0.00
(17) O. 00
(18) 0.00
(19) 0. O0
Copyright (c) 2000 form software only The Lackner Group, inc. Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
940 Walnut Bottom Road
CITY
Carlisle
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
Z. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
STATE
PA
(1)
Total Credits ( A + B + C
ZIP
17013
0.00
3. Interest/Penalty if applicable 0.00
D. Interest
E. Penalty
Total Interest/Penalty ( D + E ) (3) 0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to reClUeSt a refund (4) O. 00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00
A. Enter the interest on the tax due. (5A) 0. O0
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (SB) 0.00
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;
b. retain the right to designate who shall use the property transferred or its income; ...........
c. retain a reversionary interest; or ....................................
d. receive the promise for life of either payments, benefits or care? ...................
Z. If death occurred after December 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 designation? ................................
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN,
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 complete. Declaration of preparer other than the personal representative is based on all Information of which preparer has any knowledge.
SI~GNA~'U pE~,S~.~. R~F..,~,O~..~~LiNGRETURN 5 Helen Avenue
John E.S. Williamson DATE
-- ~Gah-dF,-xi-s-F~[~;:-~ ;--F~-- i¥6~-s- .................... 07/09/2002
SIG~A~ZREOF~I~E.P/~EROmERTHANREPRESENTATIVE./ ' . James D. Boga= Esquire DArE
/ / z,,, /Jf[...,,~C:)//~/~_, One West Main Street 07/0~, .....
t._ ---S- ................................................. / =/zuuz
........ ~' 'J~!iii~ii~!i hiremanstown, PA 17011
surv,v,.g spouse is 3%'ff~'~: S~'9116 (a) (1.1) (i)]. rs to or for the use of the
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%
[7P 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.
}=or dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one 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% [72 P.S. 9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5°/°, except as noted in 72 P.S. 9116(1.2)
[?Z 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 lP°/o [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.
Copyright (c) 2:000 form software only The Lackner Group, Inc. Form R[~V-]500 I:X (Rev. 6-00)
REV-1508 EX + {1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
Louise G. Williamson SS~/ 184-20-1374 10/10/2001 21-02-0381
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on Schedule F.
ITEM
NUMBER
HCR Manor Care - Refund
DESCRIPTION
PNC Bank, N.A. Checking Account No. 5140237758, date of death
balance $1,994.00, accrued interest $0.07
TOTAL (Also enter on line 5, Recapitulation)
VALUE AT DATE
OF DEATH
50.00
1,994.07
2,044.07
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc. Form REV- 1508 EX {Rev. 1-97)
APR'30-2002 15:07 PNCBANK 412 968 3458 P.01/01
PNCBAN(
April 30, 2002
James D Bogar
Attorney at Law
One West Main St
,qhiremanstown, Pa 17011
/scp
Estate ofLouise G Williamson(Deceased)
SSN:lg4-20-1374
DOD; 10-10-2001
Dear Mr Bogar:
In response to your request for Date of Death balances for the customer noted above, our
records show the following:
Checking Account
Account #514023775 8 Established 06-0 I-1978
LOUISE G WILLIAMSON
DOD balance: $1,994.00 + $0.07acemed interest
Please note that this office only provides date of death balances for deposit accounts
(IRAs, CDs, Checking and Savings accounts). We do not process any financial
transactions or provide statements. If you need assistance with any of these items, please
call 1-888-PNC-BANK (1-888-762-2265) or stop by your local PNC Bank branch office.
Sincerely,
Er/ca L Schtegel
PNC Decedent Reporting
Firstside Center
500 First Ave, 4t~ FI CIF
Pittsburgh PA 15219-3128
1-800-762-1775
Member FDIC
TnTAI P_R1
REV-1511 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
I. Louise G. Williamson
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
SS# 184-20-1374 10/10/2001
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A. FUNERAL EXPENSES:
Bo
DESCRIPTION
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s) / EIN Number of Personal Representative(s)
Street Address
City
State Zip
Year(s) Commission Paid:
Attorney's Fees James D. Bogar Esquire
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
Probate Fees
Accountant's Fees
Tax Return Preparer's Fees
Register of Wills
Filing fee for PA Inheritance Tax Return
(If more space is needed, insert additional sheets of the same size)
FILE NUMBER
21-02-0381
997.50
41.00
10.00
Other Administrative Costs
Register of Wills
AMOUNT
TOTAL (Also enter on line 9, Recapitulation)
$ 1,048.50
Copyright (c) 1996 form software only CPSystems, Inc. Form REV-1511 EX (Rev. 1-97)
REV- 151Z EX + {1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
I. Louise G. Williamson
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, AND LIENS
SS# 184~20-1374 10/10/2001
Include unreimbursed medical expenses.
ITEM
NUMBER
FILE NUMBER
21-02-0381
for restitution of
DESCRIPTION
PA Depa~Lment of Public Welfare - Claim
medical assistance per attached letter
TOTAL (Also enter on line 10, Recapitulation) $
AMOUNT
(if more space is needed, insert additional sheets of the same size)
67,875.01
67,875.01
Copyright (c) 1996 form software only CPSystems, Inc.
Form REV-1512 EX (Rev. 1-97)
JAMES D BOGAR ESQUIRE
ONE WEST MAIN ST
SHIREMANSTOWN PA 17011
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-8486
February 12, 2002
Re: LOUISE WILLIAMSON
CIS #: 820146374
SSN: 184-20-1374
Date of Death: 10/10/2001
Dear Attorney Bogar:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $67,875.01 against the above-mentioned estate. This
claim is for restitution of medical assistance granted on behalf of the
decedent for which the Probate Estate is now responsible to reimburse the
Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as
amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's
itemized statement of claim.
A portion of this medical expense, namely $19,605.04, 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 $48,269.97, is
to be entered as a priority Class 6 claim against the estate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth,s claim is admitted and when payment may be expected. If the
estate accounting is complete, please provide a copy. If the estate contains
real estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available.
Sincerely,
Edna L. Guido
Claims Investigation Agent
717-772-6614
717-705-8150 FAX
Enclosure
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION - CASUALTY UNIT
PO BOX 8486
HARRISBURG PA 17105-8486
February 12, 2002
STATEMENT OF CLAIM SUMMARY
Estate of WILLIAMSON, LOUISE
820 146 374
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 18,128.26 45,784.03 63,912.29
DRUG 1,476.78 2,486.94 3,962.72
REIMBURSEMENT TO DPW 19,605.04 48,269.97 67,875.01
DEPARTMENT OF PUBLIC WELFARE
EIN- 23-6003113
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC wELFARE
Februa~j 12, 2002
STATEMENT OF CLAIM
NEIGHBORCARE-ALLENTOWN J
NAME CHANGED FROM
VITALINK PHARMACY SERVICES
TO ABOVE ON 2/4 PA 11111
07/13100 07113~00 08114~00 020192039801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000 37.55 6.10
07/20/00 - 07120/00 08/28100 021387893301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE '
000000000000 16.95 12.21
07/21/00 - 07/21100 08/28/00 021387893401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE:
000000000000
126.92 113.50
07~24~00 07/24/00 08/28/00 021387893501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE ·
000000000000 62.08 55.14
07/26/00 - 07125100 08128/00 021387893601
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE ·
000000000000 63.70
56.60
08/10/00 - 08110/00 09/18/00 023489106301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE:
000000000000 37.65
6.10
08/17/00 - 08117/00 09118100 023885297601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 15.00
12.21
08118100 - 08118100 09118/00 023885297701
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE '
000000000000
117.27 113.50
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLlc WELFARE
February 12, 2002
STATEMENT OF CLAIM
WILLIAMSON, LOUISE
820 146 374
NEIGHBORCARE-ALLENTOWN
NAME CHANGED FROM
VITALINK PHARMACY SERVICES
TO ABOVE ON 2J4 PA 11111
08/21100 - 08121100 09118100 023885498001 000000000000 58.48 56.60
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE ·
08121100 - 08121/00 09118100 023885297801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000
56.97 55.14
09~07~00 - 09~07~00 10109100 025985735101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE '
000000000000
34.16 6.10
09114/00 - 09/14/00 10123/00 027086879001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE ·
000000000000
15.00 12.21
09115/00 - 09/15/00 10123/00 027086879101
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE:
000000000000
117.27 113.50
09118100 - 09/18100 10/23100 027086879201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE '
000000000000
56.97 56.97
09/25/00 - 09/25100 10130100 027790442501
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000
58.48 56.60
10105/00 - 10/05/00 11106100 028489711001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
34.16 6.10
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 12, 2002
STATEMENT OF CLAIM
NEIGHBORCARE-ALLENTOWN
NAME CHANGED FROM
VITALINK PHARMACY SERVICES
TO ABOVE ON 2/4 PA 11111
10112/00 - 10112/00 11113/00 029090276701
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE:
000000000000 15.00
12,21
10113100 - 10/13100 11120100 029790079101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000 117.27
113.50
10116/00 - 10/16100 11/20100 029790079201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000 61.54
59.56
10/23/00 - 10/23100 11/27/00 030488100401
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
58.48
56.60
10123/00 - 10123100 11/27/00 030488301401
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
47.16
12.50
11/02/00 - 11102/00 0~/14/01 110789515401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE ·
000000000000 34.16
6.10
11/09100 - 11/09100 05114/01 110789515201
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000 15.00 12.21
11110100 - 11110100 05114/01 110789515301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE:
000000000000 117.27 113.50
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 12, 2002
STATEMENT OF CLAIM
I.AME I W' ,AMSO...OU,SE
ID I 820 146 374
NEIGHBORCARE-ALLENTOWN
NAME CHANGED FROM
VITALINK PHARMACY SERVICES
TO ABOVE ON 2/4 PA 11111
11/13100 - 11113100 05/14/01 110789515101 000000000000
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE:
61.54 59.56
11116/00 - 11/16100 12/25/00 033389682701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
58.48 52.60
11122/00 - 11/22/00 12/25/00 033686509901
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE:
000000000000
6.54 6.33
11/27/00 - 11/27/00 12/25/00 033686510001
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000
8.96 8.67
11/30/00 - 11/30/00 01/08101 034997897701
DIAGNOSIS I ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE:
000000000000
34.16 6.10
11/30/00 - 11/30/00 01108101 034998372801
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE ·
000000000000
36.30 8.05
11/30/00 11130/00 01108101 034998372701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000
6.54 6.33
12/05/00 - 12/05/00 01108/01 034998372901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
20.21 6.02
COMMONWEALTH OF PENNSYLVANIA
February 12, 2002
STATEMENT OF CLAIM
I~EJ WlLLIAMSON, LOUISE
620146 374
i,
NEIGHBORCARE-ALLENTOWN ]
NAME CHANGED FROM
VITALINK PHARMACY SERVICES
TO ABOVE ON 2/4 PA 11111
DATE OF SE.viCE I PAYMENT °ATE
12/07/00 - 12/07100 01/08101 034997897801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE ·
ADJUSTED CRN ;
000000000000 16.16
15.64
12/05/00 - 12/08/00 01/08101 034998373001
DIAGNOSIS I ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE:
000000000000
43.30
43.30
12/08100 - 12/08/00 01/08101 034997897901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000
117.27
113.50
12/11/00 - 12/11/00 01/08/01 034997898001
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE ·
000000000000
61.54
59.56
12/15/00 - 12/15/00 01/29101 100389426701
DIAGNOSIS I ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
6.67
6.33
12/22/00 - 12/22/00 01/29101 100388948901
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE '
000000000000
59.73
56.60
12/28/00 - 12/25/00 01/29/01 100388949001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000
34.89
6.68
01/04/01 - 01104/01 02/05/01 100891587701
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
16.49
15.64
J
Februar7 12, 2002
STATEMENT OF CLAIM
I'NAME I W'L"AMSO., ,OUlSE I
ID I 820 146 374
NEIGHBORCARE-ALLENTOWN
NAME CHANGED FROM
VITALINK PHARMACY SERVICES
TO ABOVE ON 2/4 PA 11111
DATE OF SERVICE I pAYMENT ORIGINAL
01105/01 - 01/05/01 02/05/01 101385233501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
119.79
113.50
01105/01 - 01/05/01 02/05/01 101385233401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
43.30
43.30
01/16101 - 01115/01 02/1g/01 102491919301
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
59.73
56.60
01/25/01 - 01/25/01 02/25/01 103297124201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE '
000000000000
34.89
6.68
02/01101 - 02/01/01 03105/01 103787003001
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000
16.49
15.64
02/02/01 - 02/02/01 03/05/01 103787003201
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE:
000000000000
123.48
113.50
02/02/01 - 02/02/01 03/05/01 103787003101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000
43.30
43.30
02/15/01 - 02/15/01 03119101 105292059401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
16.49
11.64
coMMoNwEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 12, 2002
STATEMENT OF CLAIM
820 146 374
NEIGHBORCARE-ALLENTOWN
NAME CHANGED FROM
VITALINK PHARMACY SERVICES
TO ABOVE ON 2/4 PA 11111
DATE OF SERVICE pAyMENT DATE ORiGi RN ADJUSTED CRN USUAL CHARGES AMOuN~i
02/22/01 - 02/22/01 03/26101 105990505501 000000000000 59.73 56.60
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
02/22/01 02/22/01 03126101 105990505401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE -
000000000000 34.89 6.68
02/23/01 - 02/23101 03/26101 105990687501
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
8.95 8.49
02/26101 - 02/26/01 04102/01 106588024801
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE:
000000000000
6.67 6,33
03/02/01 - 03102/01 04/02/01 106889472401
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000
123.48 117.00
03102/01 - 03102/01 04102/01 106889472301
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
43.30 43.30
03/03/01 03/03101 04102/01 106889721801
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
8.95 8.49
03115101 - 03115101 04/16101 107987623901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
16.49 15,54
COMMONWEALTH OF PENNSYLVANIA
February 12, 2002
STATEMENT OF CLAIM
NEIGHBORCARE-ALLENTOWN I
NAME CHANGED FROM I
VITALINK PHARMACY SERVICES ~
TO ABOVE ON 2/4 PA 11111 I
ADJuSTEDCR" oU.T P.ov D
03122/01 - 02/22/01 04/23101 108588949301 000000000000 34.89 6.68
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
03130101 03130/01 04/30101 109392406801
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE ·
000000000000 59.73 56.60
03/30/01 03130101 04130101 109392406701
DIAGNOSIS I ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE:
000000000000 123.48 117.00
03130/01 - 03/30/01 04/30/01 109392406601
DIAGNOSIS I · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000 43.30 43.30
04/02/01 - 04/02/01 04/30/01 109689054101
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE '
000000000000 6.67 6.33
04/12/01 - 04/12/01 05/14/01 110789515001
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE '
000000000000 16.90 15.64
04/14/01 04/14/01 05/14/01 110889020101
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE:
000000000000 34.32 2.68
04/19101 04/19101 05/21101 111488889501
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE '
000000000000 7.59 6.33
DEPARTMENT OF PUBLIC WELFARE
February 12, 2002
STATEMENT OF CLAIM
I 820 146 374
i,
NEIGHBORCARE-ALLENTOWN J
NAME CHANGED FROM I
VITALINK PHARMACY SERVICES J
TO ABOVE ON 2/4 PA 11111 I
04/27101 - 04/27101 05/28101 112594374201 000000000000 57.86
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
56.60
04127/01 - 04127/01 05/25/01 112187342701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE:
000000000000
118.25
117.00
04/27/01 - 04/27/01 05/28/01 112187342601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE '
000000000000
42.29
42.29
05/10101 - 05110/01 06/11101 113588127101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE:
000000000000
16.90
15.64
05/12/01 - 05/12/01 06/11/01 113689781601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE:
000000000000
34.32
6.68
05/24/01 05124101 05/25101 115287639901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
42.29
42.29
05/25/01 05125101 06125/01 115287640001
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE:
000000000000
118.25
117.00
05/30101 05/30101 07/02/01 115588649101
DIAGNOSIS I ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
57.86
56.60
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
Februa~/12, 2002
STATEMENT OF CLAIM
I W"',A,.,SO.. LOU,S
ID I 820 146 374
NEIGHBORCARE.ALLENTOWN
NAME CHANGED FROM J
VITALINK PHARMACY SERVICES J
TO ABOVE ON 2/4 PA 11111
06/07101 - 06107101 07109101 116688187501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE:
000000000000
16.90 15.64
06109101 - 06/09/01 07/09/01 116688187601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000
34.32 6.68
06/21/01 - 06/21101 07/23/01 118087379701
DIAGNOSIS I : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE ·
000000000000
44.11 44.11
06/22/01 - 06/22/01 07/23101 118087379801
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE '
000000000000
118.26 117.00
06/23/01 - 06123/01 07/23101 118087379901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE:
000000000000
57.86 52.60
07105/01 07/05/01 08/06/01 119195872601
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
16.90 15.64
07/07/01 07/07/01 08113101 119889496101
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE '
000000000000
34.32 6.68
07/19/01 - 07119/01 08120/01 120488380501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
44.11 44.11
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 12, 2002
STATEMENT OF CLAIM
ID I 820 146 374
NEIGHBORCARE-ALLENTOWN
NAME CHANGED FROM
VITALINK PHARMACY SERVICES
TO ABOVE ON 2/4 PA 11111
07/20101 - 07/20/01 08127101 121287114601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE:
000000000000
118.25 117.00
07126101 07126101 08127/01 121287114701
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE -
000000000000
57.86 56.60
08/02/01 - 08102/01 09103/01 121989083301
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000
16.90 15.64
08104/01 - 08104101 09/03/01 122089307801
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE:
000000000000
34.32 6.68
08116101 - 08116101 09/17/01 123491707201
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000
44.11 44.11
08/17/01 - 08117/01 09117/01 123491707301
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE '
000000000000
118.25 117.00
08/18/01 08118101 09/17/01 123491707401
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
57.86 52.60
09/14101 - 09114/01 10115101 126487652101
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE:
000000000000
44.11 44.11
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIc wELFARE
February 12, 2002
STATEMENT OF CLAIM
/ NAME I WILLIAMSON' LOUISE
ID 820 146 374
NEIGHBORCARE-ALLENTOWN
NAME CHANGED FROM
VITALINK PHARMACY SERVICES
TO ABOVE ON 2/4 PA 11111
09114101 - 09/14/01 10115101 126487652001 000000000000
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
118.25 117.00
09120101 - 09120101 10122/01 127186058801
DIAGNOSIS 1 ' PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE:
000000000000
57.86 56.60
09126101 09126/01 10/29/01 127489463801
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000
7.59
6.33
09127101 - 09127101 10/29/01 127489343601
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE '
000000000000
16.90 15.64
09129101 - 09/29/01 10/29/01 127887441101
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ·
PROCEDURE:
000000000000
34.32 6.68
10105101 10/05/01 11/12/01 128896127801
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE ·
000000000000
19.25 16.65
10105/01 - 10105/01 11/12/01 128896127701
DIAGNOSIS 1 · PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 '
PROCEDURE:
000000000000
27.17 16.60
NEIGHBORCARE-ALLENTOWN
19 1702840
4,677.76
3,962.72
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
Februanj 12, 2002
STATEMENT OF CLAIM
.*ME J W'LL,AMSO.. LOU,SE
MANORCARE HLTH SVCS CARLISLE
ATTN MICHAEL MCCAFFERTY
2555 KINGSTON RD STE 200
YORK PA 17402
09/02/99 - 09130199 11115/99 931588566201
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
ADJUSTED CRN 0SUAL C~FR ~UNT APPROVED
000000000000 2,206.88 2,206.88
10101/99 - 10131/99
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
1111~99 931588566301
000000000000
2,561.14 2,561.14
11/01/99 - 11130/99
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
12/13/99 934493850601
000000000000
2,457.38 2,457.38
12/01/99 - 12/31/99
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
01/24/00 002096476901
000000000000
2,574.16 2,574.16
02/01100 - 02/29100
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
05/22/00 014087488101
0069945592O1
2,330.71 2,330.71
03/01/00 - 03131/00
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
04117/00 010586554501
000000000000
2,536.65 2,536.65
04/01100 - 04130/00
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
10/29101 129657048301
014087435901
2,442.90 2,442.90
05101/00 - 05131/00
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
06112/00 016186509801
000000000000
2,555.56 2,555.56
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF pUBLiC wELFARE
February 12, 2002
STATEMENT OF CLAIM
I-.MEI W,'L,^MSO...OU,SE
ID I 820 146 374
MANORCARE HLTH SVCS CARLISLE
ATTN MICHAEL MCCAFFERTY
2555 KINGSTON RD STE 200
YORK PA 17402
DATE OF sERVICE ~ PAYMENT DATE ORIGiNALCRN :: ADjUsTEDCRN UsuaL CHARGES AMOUNT~PROVED
06101/00 06130/00 11119/01 129657048601 018989907401 2,442.90 2,442.90
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
07/01/00 - 07/31/00
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
08114/00 022398397001
000000000000
2,719.86 2,719.86
08/01/00 - 08/31/00
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
10/29/01 129657048701
025898994601
2,710.78 2,710.78
09/01100 - 09/30100
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
10/29/01 129657048801
028793135101
2,601.90 2,601.90
10101/00 - 10/31/00
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
10/29101 129657048901
031288921401
2,690.63 2,690.63
11/01/00 - 11/30/00
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
10~01 129657049001
034589439301
2,582.40 2,582.40
12/01/00 12/31/00
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
10/29/01 129657049101
101298607601
2,690.63 2,690.63
01/01/01 - 01/31/01
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
10129/01 129657049201
103992671401
2,668.08 2,668.08
DEPARTMENT OF puBLIC WELFARE - J
February 12, 2002
STATEMENT OF CLAIM
820 146 374
MANORCARE HLTH SVCS CARLISLE
ATrN MICHAEL MCCAFFERTY
2555 KINGSTON RD STE 200
YORK PA 174O2
0~01~1 - 0~2~01
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
0~01~1 03/31~1
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
0~01101 - 04130101
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
05/01/01 - 05/31/01
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
06/01/01 - 06/30101
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
07/01101 - 07/31~1
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
0~01~1 - 08/31/01
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
09101~1 - 09130/01
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
08127101
08127/01
11/19/01
07/16/01
08/06/01
09/17/01
10115/01
123387162201
123387162301
113186633301
129657048401
119089754801
121685596501
125489267701
128391902501
: ADJUSTED CRN USUAE C~RGES AMOUNT ~pRO~D
1O68882495O1
2,343.39 2,343.39
109688043501
2,668.08 2,668.08
000000000000
2,804.88 2,804.88
115988443601
2,890.89 2,890.89
000000000000
2,753.65 2,753.65
000000000000
3,127.19 3,127.19
000000000000
3,127.19 3,127.19
000000000000
3,004.15 3,004.15
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 12, 2002
STATEMENT OF CLAIM
820 146 374
MANORCARE HLTH SVCS CARLISLE
ATTN MICHAEL MCCAFFERTY
2555 KINGSTON RD STE 200
YORK PA 17402
10101/01 - 10109101 11112/01 131089073501
DIAGNOSIS I ·
DIAGNOSIS 2 '
PROCEDURE:
000000000000
420.31
IPROVIDER SUB TOTAL
MANORCARE HLTH SVCS CARLISLE
36 1106891
63,912.29
420.31
63,912.29
REV-~S~3 EX+(9-00) I
I SCHEDULE J I
COMMONWEALTH OF PENNSYLVANIA I BENEFICIARIES
INHERITANCE TAX RETURN
~ u M ~"~"~:~:R:EE~"~?"V A" ' ^ I BENEFICIARIES
ESTATE OF
FILE NUMBER
I. Louise G. Williamson SS~/ 184-20-1374 10 1~_~_~001 21-02-0381
NUMB NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I.
1
2
II.
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and
transfers under Sec. 9116~1.~]
Joan W. Feese
1817 Clayton Avenue
Lynchburg, VA 24503
John E.S. Wiiliamson
5 Helen Avenue
Mechanicsburg, PA 17055
Daughter
Son
0ne-half (1/2)
of rest,
residue and
remainder
0ne-half (1/2)
of rest,
residue and
remainder
ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET
(If more space is needed, insert additional sheets of the same size)
0.00
Copyright (c) Z000 form software only The Lackner Group, Inc.
Form REV-1513 EX (Rev. 9-00)
STATUS REPORT UNDER RULE 6.17
Name of Decedent:
I. Louise G. Williamson
Date of Death: October 10, 2001
Will No. 21-02-0381 Admin. No.
Pursuant to Rule 6.12 of the Supreme Court Orphans'
Court Rules, I report the following with respect to completion of
the administration of the above-captioned estate:
1. State whether administration of the estate is
Yes x No
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete:
complete:
3. If the answer to No. 1 is Yes, state the following:
a. Did the personal representative file a final
account with the Court? Yes No x
b. The separate Orphans' Court No. (if any) for
the personal representative's account is:
c. Did the personal representative state an
account informally to the parties in interest? Yes x No
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
Date: July 9, 2002
Sfgnature Bo~g
James D. ar, Esquire
Name (Please type or print)
One West Main St.
Shiremanstown, PA 17011
Address
~717I 737-8761
Tel. No.
Capacity:
_ Personal Representative
(MAH:rmf/AM3)
X
~Counsel for personal
representative
BUREAU OF INDIVZDUAL TAXES
ZNHERITANCE TAX DZVISION
DEPT. 280601
HARRISBURG, PA 17118-060!
COHHONNEALTH OF PENNSYLVANZA
DEPARTHENT OF REVENUE
NOTZCE OF ZNHERZTANCE TAX
APPRAZSENENT, ALLO#ANCE OR DZSALLO#ANCE
OF DEDUCTZONS AND ASSESSNENT OF TAX
JANES D BOGAR~SQ .... ~':! ~
I W HAIN ST
SHIREHANSTOWH PA 17011
DATE
ESTATE OF
DATE OF DEATH
FZLE NUNBER
COUNTY
ACN
REV-154? EX AFP (01-D2)
08-19-2002
NZLLIANSON
10-10-2001
21 01-0581
CUNBERLAND
101
Amount
LOUISE G
HAKE CHECK PAYABLE AND REHZT PAYNENT TO:
REGISTER OF NILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THZS LZNE ~ RETAZN LONER PORTZON FOR YOUR RECORDS ~
REV-1547 EX AFP (01-02) NOTZCE OF ZNHERZTANCE TAX APPRAZSEHENT, ALLONANCE OR
DZSALLONANCE OF DEDUCTZONS AND ASSESSNENT OF TAX
ESTATE OF NILLIAHSON LOUZSE GFZLE NO. 21 02-0~81 ACN 101
DATE 08-19-2002
TAX RETURN #AS: (X) ACCEPTED AS FTLED
RESERVATZON CONCERNZNG FUTURE TNTEREST - SEE REVERSE
CHANGED
APPRAZSED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Rea/ Estate (Schedule A)
2. Stocks end Bonds (Schedule B) (2)
3. CZosely Held S~ock/Partnership Znterest (Schedule C) (3)
~. Nortgeges/No~es Receivable (Schedule D) (~)..
5. Cash/Bank Deposits/Nisc. Personal Property (Schedule E) (5)
6. Jointly O~ned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
B. Total Assets
APPROVED DEDUCTIONS AND EXEHPTZONS:
9. Funeral Expenses/Adm. Costs/Nisc. Expenses (Schedule H) (9).
10. Debts/Nortgege Liabilities/Liens (Schedule 1) (10).
11. Tote1 Deductions
12. Net Value of Tax Return
2~0~.07
.00
.00 NOTE: To insure proper
.00 credit to your account,
.00 submit the upper portion
.00 of this form with your
tax payment.
.00
(8)
1,0~8.50
67,875.01
(11) _
Z, O~,q. 07
8B.923.5]
66,879.~4-
ZF PA~D AFTER DATE ZNDZCATED~ SEE REVERSE
FOR CALCULAT/ON OF ADD/TZONAL ZNTEREST.
DZ$COUNT {+~
ZNTEREST/PEN PA~D (-)
(19)= .00
AHOUNT PATD
TOTAL TAX CREDZT
BALANCE OF TAX DUE
'rNTEREST AND PEN.
TOTAL DUE
.00
.00
.00
.00
( ZF TOTAL DUE ZS LESS THAN $1, NO PAYNENT ZS RE~UZRED.
ZF TOTAL DUE ZS REFLECTED AS A "CREDZT" (CR), YOU NAY BE DUE
A REFUND. SEE REVERSE SZDE OF THZS FORN FOR ZNSTRUCTZONS.)
tAX CREDZTS:
PAYNENT
DATE
NUNBER
(12)
15. Char/table/Governmental Bequests; Non-elected 911:5 Trusts (Schedule J) (13) . O0
1~. Net Value of Estate Subject to Tax (1~) 66,879.4~-
NOTE: Zf an assessment ~as issued previousZy, lines 1~, 15 and/or 16, 17, 18 and 19 ~ill
re~lect ~igures that include the total o~ ALL returns assessed to date.
ASSESSHENT OF TAX:
15. Amoun~ of L/ne lq a~ Spousal ra~e (15) . O0 X O0 = . O0
16. Amoun~ of L/ne 1~ ~axable a~ Lineal/Class A ra~e (16). . O0 X 0~5 = . O0
17. Amoun* of Line 1~ at Sibling ra*e (17). . O0 X 12 = . O0
18. Amoun~ of Line lfi ~axable a* Collateral/Class B ra*e (18) . OO X 15 O0
19. Principal Tax Due = '