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10-25-13
BURFAU OF INDIVI�W� TAXES Pennsylvania lnheritance Tax � pennsylvania PO BOX 28a6o1 DEPARTMENTOf REVENUE NARRISBURG PA 17128-0601 Information Notice aEV-isu ex no�ex¢c �eena And Taxpayer Response FILE NO.21 ACN 13146302 DATE 09-02-2013 Type of Account Estate of DONALD D BENSON Savings SSN Checking Date of Death 06-15-2013 Trust BARRY D BENSON County CUMBERLAND Certificate 46410 SUE DR LEXINGTON PARK MD 20653-4342 PNC BANK NA provided the department with the information below indicating that at the death of the above-named decedent you were a 'oint owner or beneficiary of the account identffied. Rertat PaymeM and Forma to: A�ount No.SS610110� Date Eshblished OB-1rr2009 REGISTEfl OF WILLS Account Balance $4,40427 � COl1RTHUUSE S�UkRE Percent Taxable X 16.667 ����-E PA 17013 Amount Subject to Tau $734.06 Ta�c Rate X 0.045 NOTE': If tax Potential Tax Due $33.03 payments are made within three months of the decedenYS date of death,deduct a 5 percent discount on the tax With 5%Discount(Tax x 0.95) $(see NOTE') due. Any inheritance tax due wiil become delinquent nine months after the date of death. PART �p 1 : Pkase check the appropriete boxes below. 1 r.; A �No tax is due. I am the spouse of the deceased or I am the paren f dece�t as � 21 years oid or younger aY date of death. � � � �� P�oceed to Step 2 on 2verse. Do not check any other boxe��d�rega�the�o�t shown above as PotenHal Tax Due. � p r N _1 p g �The information is The above information is corcect, no deductions are being taken, ?�id�y�nt�iTl�be�t� correct. with my response. • 7c p c� Proceed to Step 2 on reverse. Do not check any other boxe� o o � ""� � p C T7 ".: — � �The tax rate is incorrect. � 4.5°/, I am a lineal beneficiary(parent,child, grandch��)of the�'gceasedm (Select correct tax rate at right, and complete Part � �pq, I am a sibling of the deceased. "�' � y � 3 on reverse.) � 15% All other relationships (including none). p �Changes or deductions The information above is incortect and/or debts and deductions were paid. listed. Complete Part 2 and part 3 as appropriate on the back o/this lorm. E �Asset will be reported on The above-identified asset has been or will be reported and tax paid with[he PA Inheritance Tax inheritance ta�c form Return filed by the estate representative. REV-1500. Proceed to Step 2 on reverse. Do not check any other boxes. Please sign and date the back of the form when finished. � .�a�,.t� 3 �1 G 8��..� �.�a�+�:�_ f.��,} C�� ,7' «� � q �?1.�..8� ��.. �����-�°''-, "'u"�.,.� .�„��,�..� �1 ���(�.a� �.-�7-���� 'tII C���.,-.�.� ��. t�m���a.. � � ��.5� .3'I4 ` '�.o i 3 . `f 13 (.P�.:��.`}�..�.��A `��`�e, .��p�„aa- .� `�m 5� s� �� I - �.o i� ': �-I b cQ�,-� ► ' �.,,�. ��, � .a�, � 300.uc cJ" ' 1— �..41� ,; � 17 �-�� " �,.�.SP 'P..?.� .��, � �15:t1{ ��- I °�013 ,: `t l g c�R;�.t�, ���� C�, ��u, �'�. .c��.. � 1 l .6; C��t�. ?) �' � ' �,01� .'`�'�0 C����„ �Z.a.��.�u�.i, ��,�,,,�, Car„�a'�'i.�..`,��.. ,��, � I �n�� s�cnt 5�-�� - a�s 3 . `�z ! c4�--C��, `1���., ..�,�., ��c., .,,�,�.. $ 5�0. o0 5�-�8- �o I 3 _���' �t.-`��,,�. �''�' . Can�.�L,�k..C�pa�.%.�.�'f�Q,.o,�p.�,a�. � �I$8 ��3 7—ra.- ao��. �ta� �'°�,��.. � �'�,�,;,�. �.���,.�,.a��z .�� ��a.3i� .t� l 7 -a5 —ao�� �a9 c�.-�,�. 9�., �'� �- 'iR.(�G- G,�,...�,,�'�dl,.�a�. $ �oo,5a 10-3 - �013_�-3 3 c��.-��"!�;��,�, ��. '�.��.. .� �S�Q.. �„az, $ l`��3.6 3 7 - 17- a o i� : �'',�.. c,i�:�'s.�..�'- � C�,.�..,,��t�,,,�i�..� 7- I�- �.o i 3 .�t'�7 c.�,-��, �"�.�¢Q, � & �.�.-C�,.�.9� .�,� � I 3 5�. s s (�P��.a s+�«x? `�—a 3 —��#3 . 1 �y-(� 73�- �3.�a� ��. �7.� a��'a,�„�..� .��.. ��.. .� B � '�53. `}b � -0�.3 "�0l,3..00653�,93 �.j�7c,�,�'�..j�, o��,�,� c.Qc�l.o�P.NC �a*�= 1{— G�.�,�, c.��..-r�.��_C��..��..���..a-,�.�" :�'n�.,�- .1�.�.�. �'a�A,,'.�.. (��l !�_ •�1�h59.�s3 ._7��t s-ao 1� c;�„ `�.��.�y�,.. �.� ,�,,.����,� � a�t�. Y�`t- ,�,+�� �c,:�.. 1� C�w.�- �'.��.., �i�,a�s- � �` �� $�' . 3� 711�.. 4.. '�}o,pa,. c1�,� c� �.. .�., r:�,„��.,8�„�, � 6� � •a '�o.�., � � c1o�.�.. f�„,ua. 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':.r..' . .. _ . u.,. . ... . . . . i.�i� rk.t:t. y4% Y �tqr� ta�i? ���.�; �„"ti: t� � ' �.I'� ' k�,; S{,;1 ,u I'. . . . �';,:�: https://www.cct.pncbank.com/IMGPRINT.html 9/13/2013 _ _ � �, � ✓Tnek Your Expenaa._ � � . � . � � 4 2 6 . � ❑w�ar�„rei � n�non 'o n+ern�vo�mi � . p . q eu�res, � o�rone�man o seui�g, � � . . :. . _ . :;�f7 3� � � � � b CheAtlee ❑Footl� ���❑Tazes. - a cwn�� ❑n�. ❑uns�, e.� . . �. �a Uepe'Mam cere.�Uiwrence� ❑aner . ppp•p� � . >:.;kai � 1 -"':,va `�d��� � ,<.v . . . ��jl:t.;�'�._.arex� t �.t �%,:'� . � 3 `� .i � �-::,�l 1 '�,A �,�� - _._...�. --°-°'--'°,s�t+�NC4,> . . t � Q. . . . . . . . . .. . ....� . . . . .. . � DEPOBR . . � �TAX DEDUCTIBLE ITEM � i � : .. .G`'-� . � FOR•0. t��'"7 ` .K ' j Gs.`^f�� � '. � �-�fi• : '"# � -h.�.,5�;.�. � .; • � M°'"° �� • . '..�Vf�2 . _ � . Forenhenced secu" . ,l �:� iJ.: . . ... �� � rily your ewount numb9r will not be prinfed on thb copy � � NOT NEGOTIABLE � . . � . . . . - . .. � . ,_� �,_ � i . ., ... . .. ._.. , . . i . . � . .. . . . . . . i ��„�kr�.�...._ 4 2 7 o,w�� o� o�m� �yq .vN Q� o��o� � na,.rxw ❑�woa ❑r.�e � �.�. �.. � � �:C� C. � ❑CbNYg � ❑Flane ❑utllCee � �J " ' � ' O,�P�USnCaroOlnwtanoe OOtlnr � . �� 'rono b�� •y . �� �J_ .� ' . AYOUMT �.�'� �:.,'. j j ° . , ._k,_._ "f � _��'-_. �--� - _ . . S�LYICE .�. � . . � . � � o�oart . . �TN(�,DEDUCTIBLEfTEM. - . � � w�'o . � m,,,,, '1►'►'!�Y'�/i�51�ti'._`_� ' i —T � :Pw enhanced sewriryyour�count number wAI na ba printed on ihis capy. . P10T NEGOTIABLE i. . . . . . . : � . , . � r --• ---- ---- — ___-- ------ - ���. ^�:. + . " ✓t�rackYWrEYpant�r... � - .. 4Z0 . r 'DAUto!frevel �EOUatlon '�QMedkaWanlal : . . ��9 BWnew ❑ErneRNnmeM O SeNnpe' — . �� . . . �, PehemNS ❑woa �❑reme ! :- �+..�- :.� �, ' . , . 0 aolhino ❑Hune ❑uu5oea �- . .. '.�; . �- �. � O�apaMayntC�ere.�l ❑Otl�er raYo , II . ,�' +�iLY�:.��5.•'',.J '��'?- f. -, '�` REM � �C�j��/" . ' `` �.... , ��YOUM 'W.Y Y :. �e � � . . - eAl,w¢c . �,vS;. _ . ,.,. i.... _ ���:� � Ivl__-r. rt3� ' �:.�.�' � . . . `�,\ � oErosir�� � � � . ��.TAXDEDUCT19LEITEM .'�`_ � . � FORro . .. � I� . I �,,� � � ��'i7r. �. +�"''�,�"t��� _ . For enherroed securtty your accauntnumber will�not paprpiteA on thk copy.?'�- NOT NEOOTIABLE �--^-�-�--�--------'---� . . . _-- -.—_ . . . , . . . . , . � . . . j {/�� , 429 � � �.,1(V \ � . � ✓TnckYOUrEx�...: . � � t U7�Ct�r) � ❑nmdr� ❑Eanna, . ❑M.arauoern.i . -�euein.es ❑emerb�nnsm �8+N�ps ' �L�\� ❑� �❑Hair . ❑Ultlitles . ;. �,. : . ' I �I� : �❑DePentlxM CeK O Imurence ❑OMBf . ., F011'0 i � i 1 i.-;� . . . .. � - . . a-rttr I . . . . '-. • . , -Ai�OUxi ,r . , a ___ __..___._.,,,�. �, . _ . �.; - ,. �� 1 . � . �TA%�DEDUCTIBLE fiEM � . . . � . . Fwro ' . - j �#Aenm�`�+�,',t.�clCA;�i'u!K� .�� . � - � i . For enhenced sacuriry your accourrt number win not be prirtzd on thie copy� .NOT NEGOT�ABIE . ___ , n,� _ - .._,_ _ , . .. • � � ✓Tnek Yom Expanaes�... . . . . . _ � �G J .. . ❑FW�d(2val '� �❑:EdiWtlm ❑Medw9UDw�lei . . :� ❑Huai�ss ❑Entertainmem O SaNn9% QQ . �� . . . ❑CMri6es . ❑Foad ❑Taxes . .. ( .� : i. . .�/;1 �-. . l,� � ... .❑CbN7nG� � � ❑�lbme ❑Uillitiea � r���eeL ...��9 DapeMerrtCare O Ireurence ❑Oihet � fOR'O �I .. ' � _:`f � , � . . . . rrw q t � , . . . � . ... exouxr � . ,�I: , . : . � ii -" , , � � B411NCE . . _ � �. �. 'j D -A. � � r . -...........�...._._.+...�.��.4.. ._.,..ro...--.d_. '. .�j. : . � � . ..,�� DEPOSG � . . • . � �TAX DEDl/CTIBLE ITEM + �- ay,!.Y:.' � ��. FpR o '°ti � i n��t,� .f ' � i� I i � '�t•,1�1: i,`r�,t��r1f.,D .. '� I Memo � � I,. . . . For enhanced secuiity your accoun[number wi11 rwt tie pdnted on thie r,opy � . NOT�NEG0TIABLE . . �I i� � � � . . . - . � � � � � . . , . . . . . . . . � . � i � . -.. _ __ _' .. — . . . ,'.l i ' - 424 � _ . .✓TmckYaur:Exp�nsss... . . �� ❑Auw[Travel � ❑Etlumtlan. �❑MearaUDemel � . . . .. . � . i � � ❑Bu4reu � ❑EmerEefnmam.O3syNge. . ;,, i .� . � i � . ❑CMridee � ➢FOa1�. ..�❑Tezee. � . � �� �i Lt}I�� * -�>' `t,;;; i . . ❑ClaNinB .� ❑Homs � ❑.Ulxllas. . . 'I � . � ❑Dape�tlant Cere O Ineureixe ❑tltlrer . � .. ron u � y� � � ` � . . i � � 1� � ( � .� 1 � �`��. ,•,t p� t 1 J t:_(}_.i: g �„�.'�i .�1wuNT .. � � IyW� '. � �� j- I .:q �,r . i �a`._f t �._kc-r... 1. '., r �.i�t,� � �. f i;�1 .� . . .. . .� k. . .r .�i � ... �� � p,1 oeaosir� ¢° t� `�. . � �_ : � � � ��TAXDEDUCTIBLEITEM �� �. �a'D j;. : ('� � c ,.� � � � L`�'7`i;�'(�S 3 ::� � � nvemo �'�' �� �` d�� �'. . . e i j�� For enhenced eecudty your xmunt number wi lnoi tie priMeC on this copy ��`� � NOT NEGOTIABLE . I . . . . .� . �. .� . � . - � ��+<i � �. . � I 1 _. �...: . ,--_� . ....._' ' _' . . ` .. . .- .� .. . . . . . ' . - '_J j 423 ; � . � rrreck.rourexpsn.sa_... . . ; � � ❑MilMravel ❑Eduatlat ❑MedeaVDenlal � . ' . ' i i � �&ulmm �q EMarteinmsnt O SnWngs . � ' i o c�re�. o r�a o T.x�. _ :: ;r:;i r ,�4 ' .. ❑CbtlYO9 � . ❑11me � �❑UeStim�� � � e�� . � . . ❑Depatle�Cere Dlmurerce ➢qhM � FORT � ' I i �tQ�.� �i—[UiA1��� � � � � �ro� � � � � � . r . . :.. -�_.._....:ew�xc€ . . . �� , .�-�-'x+1 _ . �� � - . oEVOar I i� � �TA%DEDUCTiBLEITEM �Q3 1y[.lt � � FM'o . � " �'i . � � � � . ,..5,..=' r � ,.i:��� � I �� . ���'.Y��� � ! . i � � PorenhancedaecuriryyouraccountnumherwillnMhe.pdntedonthiscopy . �. . NOT NEGOTABLE � :{ .. I � . . . . . . . .. .. . . . . . . . . . . � �.___ _.__._ .. ._ . ...... . . . . . . . MONAHAN FUNERAL HOME, INC. Robert J. Monaf1an Supervisor � � Robert). Monahary Jr. William P. Monahan Thomas M. Monahan Kevin M.Neideier � Ite�nized Ftmeral Expenses for ponald Benson - Date of Death Jutte 15, 2013 Cre�nation wi.th Graveside Services $2g00,00 Floral Wreath 159.00 Other Floral Arrangements 69.00 Gettysburg Times 125.00 Sioux City, SD Newspaper 127,5p Certified copies of Death Certificate 6 copies @ 6.� 36.00 Total Expenses $3316.50 Received check fran fami.ly July 10, 2013 1000.00 Balance on account $2316.50 received check from Hanover Hall on 8-21-2013 (852.87) Balance as of September 30, 2013 �� $1463.63 Thank You, �.-... ss--�-- ?��`�i3 Thomas M. Monahan � ���3`��� `t `� i / .,.��'' �' p+ }t�.' 125 Carlisle Street • Gettysburg,Pennsylvania 17325 • 717-334-2414 monahanfuneral►�ome�cnmcast,net �,�:SH �138UF2SEiiAflENTS WE NAVEADVANCED CASN FOR THE fOLLOWING: e��RY ctu�RCEs FLQWERS WrParh ]�q_� 26.50 CLERC3YMAtd NEWSPAPERNOTICES S-��.�ya rrff rtwR 125_(X} Sioux City, SD 127.50 CERTIFIED COPIES OF DEATH fi cop�-as @ �j.00 36.0() MISGELLANEOUS TdTAL CASH ADVANCED B} ��fi•50 CREDITS Received gaymeat 3u3y 17, 2d13 yppp.pp Check # 3042 from HanovF� Hall A52_s7 'fOT�4L C) 1463_�3 4.+ii�� ���ALBYq��di'�S���R 1NE FlAYEABVr1N'�.ED CASH FdF?THE FOL!OV�t6G: CEMETERY CHARGE8 -- ----- F60WERS �'�,.+�th __�� �,�.4`p� other flowers 69.00 CLERGYMAN _ �� NEW$PAPERNOTICES C.?ttV. �rg_�'j�,� 125.00 Sioux Gity 127.5Q CER"FIFiEd COPtES OF QEATH 6 copie�, @ 6.00 36.EK} M�CELCANEOUS TOTAL CASH ADVANCED B) 516.50 CREDITB � Qieck gayment Ju y iQ, 2413 1004.00 � TOTA� C} 2325.50 �' ���L`'`�(�'y',1:s�,.� i��c.�� G���'�'"..�- � I `' C�... 33 � �J�#t��3`�3�`� (,r����� � i - � PRONAHAN FUNERAL YiO1ME, IrIC. t25 CARLISLE STREET GETTYSBURG, PENNSYLVANIA 17325 27 EAST MAIN STREET � �yeO�yMa,,,�,,,, FAIRFIELD, PENNSYLYANIA 17320 Superviwr � RECEIPT °� October 03,_ 2Q13 " DATE -- _ _ _ _. Cheryl Dunlap RECENED FROM Donald Benson Flmeral Expenses AMOUNT S 1,463.63 B�N� $ -0- paid in full SIGNAT'URE CVS � Pharmacy BENSON, ANITA 967 HERS RIDGE RD Private and Confidential GETTYSBURG,Pa,i�sss Intended for Addressee Only 1 0/03/1 3 Dear Patient: Enclosed is your Patient Prescription record,as recently requested from CVS/Pharmacy. If you have questions about this record,please go to www.CVS.comlprivacy for further information or contact the Privacy Office at 1.800.287.2414. Private antl Confidential Intended for Atldressee only . . _ � . PEAN$-9Li�/ANI.4 CVS PH7fRIq'ACY,L.L.C. q 01927 Page t of t ... PATIENT PRESCRIPTION RECORD 01/0 7 7201 3 THRU 04/30/2073 Date: 70/03l2073 Time:2:08:21 PM PHARMACYNAME: C:921 =p1921 110DRESS: 1275 YORK ROAD,SUITE 8 � CRY,ST,ZIP: GETTYSBURG.PA,�77325 PATENT KEV: 3744377374 hl FPHONE: (000)000-0000 PA7IENT NAME: BENSON,qNfTp BIRTHDATE: 05/10/7933 A��� 987 HERS HIDGE RD ��� F ��.�•LP:� GETTVS&/RG.PA.77325 REUTIONSHIP: Card Holtler ��'� �% RR NDC OSiU6DESCRipT(ON PRESCpIBEqNpME ::f� M^,:?gEq ry�y�gEp DATE OUANT PATIENT - -? -'?4337 000 889820.�22'�" Fl�� �P PD AMT ��'.LOL25F"GTABLET BOYD,JqMES Oi/07/2013 90.00 9.70 "��' . 6 000 6E8'e2^ Ec�- �Si,^L2i.,•3Tqgl,E7 GqpyEpig(.ryEq� 04lOS/2013 2.00 1.86 ..921 -_� OOQ @a?^4 . _= q-��HC.�^ @t"�',aTABLET GARyEFlIq(.NEpL 04/OS/2013 2.00 2.50 1921 0 ._ � ... - rc..^ '.e�,.xET^!`?{�t i}n,rGCAPSULE KRA7Z.LE0 =7821 080 �E. " __ F,�..��pF• R, 03/17/2073 90.00 13.38 ?7921 080�2�' " =_ "' ' �� .C'��� ���•N�- 04/05/2013 2.00 1.75 FC_?��ACfJ'.F.•STaBLET GAF;y6Nq(,ryEq� 04/05/2073 2.00 10.79 =7497 0984Ea� ' ' 3�J'Q!HYR.7XIPSE712MCGTABLET Bpyp,JqMES 01l07/2013 90.00 24.24 =�7927 07995EG � �� __�y,p,. t'E7FJp•f.MHCL590hiGTABLET KRATZ,LEO 03l14l2013 90.00 70.36 =5921 0803859 Cv0 c'c5Z27.28t0 t.7ETFORMINHGLSpOMGTABLEi :'921 0796212 000 00378031893 PIOGLITAZpNEHCL45MG7ABLET �q���'N� 04/05/2013 2.p0 �,5g .'.921 0803855 000 003�803t893 PIOGLffAZONEHCL45MGTAeIET �Y����' 02/25/2013 90.00 35.00 71487 OB82011 000 65862005289 SIMVASTATN20.MGTABLET __ �RVERICK,NELL 04/05/2013 2.00 70.35 0792T'-0'8p3853 000� 65862005299 SIMVASTAT1N20MOTABLE7 � �� ��'��� ' - �� ' --02f0-1.12093.- _.g0.06--- . GAHVERICI(.NEAL 04/05/2013 2.00 2.05 �`° �' ` ,,+� ,' � ' �,,J� `-'' ," �� TOTAL M OF PREBCHIPTIONS: 7 3 TOTAL PATIENT PAID AMOUNT; . 241.46 For customers who require additional informatlon please contact the CVS privacy office at 800-287-2414. Private and Confitlential Intended for Addressee only STATEMENT Hanover Hall Reside�t: Benson,Donakl(28p5464) 287 Frederidc Sheet Location: - tatement Date: 7/1 f2013 Hanover, PA 17331-3614 dmit Date: 2/27/2013 (71�637-8937 Discha Date: 8l15/2013 ALL7RPN . 73 N7L1 APPEM OH VOUR NEXT STAT�IEIPf Cheryl Dunlap 967 Herrs Ridge Road ,�� Geriysburg,PA 17325 ENCIOSE $ Pleese make dieeks payabb to:Hanover Fia9 Nuning arM RehaE Center PIFASE DEfACH AND RETURN NrtIH YOUR PAVMEM � � Hanover Hall Reaident Benson.Donald(2805464) 287 Frederidc SVeet Locatlon: - - -----Harroorer,PA�7334•36t4------------___.._._...Statement-Date:-7/tf2093 --.__.__ _ (71 n 637-8937 Effectfve Date D�cM� Unifs Unk Amount Amount BALANCE FORWARD $3,138.7g 6l20/2013 PaymeM-#2983 ($�,3g3_p� 8/27R013 Oximetry Chedc 12 a2.50 $30.00 6/272013 Nebulizer Mec Day Rental 6 a1.43 $8.58 8272013 Sudion Machine Procedure,each 12 y1.88 $22.56 4/19/2013 N Daily -30 E1.00 (a30.00) 4/19/2013 N Daity 1 $17.00 $17,00 5/172013 N Daity 31 $1.00 (531.00) 5M7/2013NDally 1 577.00 y17.00 6/202013 N Deily 30 51.00 $30.00 5272013 Gel Sodcs, Large,Poaey,pair -1 $39.76 (i39.78) 8/12013 UHC(Jun)OeducHWe (g2pp,5p� BALANCE DUE 51,577.59 Q�'�� �a� a'3�4 0` _ . ___ _ ....nl��'� �� . _ _.._ STATEMENT SUIYp�WRY Previous Balance $3,138.7 Payments (51,383.05 CurteM Chargea ($178.14 Total AmouM Due $1,577.5 a3«.�► � �.59 o,��� ����� Y73 , ya �,.�� rll.arp-k�a..� �,-en� Pt�+-�- �� �� (��t. ��a,��3� �35J�7' _ _ STATEMENT .---_ Hanover Hell Residenr Beneon,Anita(2805492) 267 Frederick Street �ocation: A 104-A Hanover,PA 1733t-3614 tatement Da#s: 71t12023 (717)637-8937 dmit Date: M9/2073 ALL O ,M30,ipW WtLI.AtWERR ON VbUR NFXT STAlE6ENT Gheryl Duntap _ . .._ _ 967 Herts Ridge Road u,p�� � Gettysburg,PA 77325 erm�.ase � Pieaea meka chedu peyeMe M;Herwver Ha1 Nurainp arq RMab CdNx � pLFlBE UETACH ANQ REfURN 1M7H YWR VAYMENT Hanaver Haii Reslde�rt: 8enson,Anita(2805492} 267 Frederick Street �ceatlon: A 104-A Hanover,PR-9i334-369A------��_...�_ ... ----°°-SfaEement Date: �/9f1013 - --------- --- (717)637-8937 EH�iva g� D4�crfotion Units UnkAmount Amou�rt BALANCE FQRWARE} $1,356.55 6/20/2013 PeymeM-#2993 ($604.50) 9112013 Patient Liability Due Jun 1-30 2D13 $0.10 7(1124i3 Patient Li�kty Dua Jut 1-312013 $SO5.� 6/1J2013 UHC(.hm}Deduc#3die ` (�264.507 BALANCE DUE $1,292:65 ��� � � � a��y� STA7'ENIENT SUMMARY � ��.�, �p Prevksua Balance $1�356.5 4 1�'�'" Payments {§804.50 � GturentChargss 5540. 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