HomeMy WebLinkAbout12-03-13 � �5�561�143
REV-�500 Ex�oz_,,, :��
PA De artment of Revenue y OFFICIAL USE ONLY
p penns Ivania County Code ve� File Number
Bureau of Individual Taxes DEPAitTMEMOFREVEHUE
Po Box.zaoso� lNHERfTANCE TAX RETURN /�
Harrisburg,PA 17128-0601 RESIDENT DECEDENT 21 f ✓ �
ENTER DECEDENT INFORMATiON BELOW
Sociat Security IVumber Date of Death Date of Birth
184 26 5721 06 02 2�12 43 25 1935
Decedent's Last Name Suffix DecedenYs First Name MI
WETZEL MARY E
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1. Origi�al Return � 2. Supplemental Return � 3. Remainder Return{Date of Death
Ptior to 12-13-82)
� 4. Limited Estate � 4a. Future Inierest Compromise � 5. Federai Estate Tax Retum Required
(date ot dea[h afler 12-12-82)
a 6 Decedent Died Testate � Decedent Maintained a Living Trust � 8. Total Number of Safe Deposit Boxes
(At!ach Copy oi Will) ❑ (Attach Copy of Trust}
� 9. Litigation Proceeds Received � ��• b�tween P2-31�1 antl�TDags�f Death � ��,Election to tax under Sec.9113(A)
(Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
JAMES D HUGHES ESQ �7.7 24g=:63�3a�
c `,' m rr�
�G��TER OF��lLL�'��NLY
rn �� c� ...� �
� � �,,. r- r��,i t����
First Line of Address !� =x'- �'� W ��� �-�
: Ln ..a
„ � � c;:7
3 5 4 ALEXANAE� S PRING RC? , ,�. '., -r� -r-, -R a
,- y �_ - ---� '
Second Line af Address , , r,-: '" `= c>
- rv - r��
- i.__ �
_ � - : DAT � LED 'n
City or Post Office State ZIP Code
C�iRLISLE PA 17015
CorrespondenYs e-mail address: Jhughes a�SattmannhugheS.COR7
Under penalties o(pery'ury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is irue,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNAT PERSON RESPO I G RETURN DATE
Joiene Gregor / ' - ��.
ADDRE
13U6 ' �nso C lisle PA '17013
SIG URE OF PR RE NE HAN REPRESENTATIVE DATE
� James D. Hughes Esq.
�
DDRESS ;
354 Alexande,r°"Spring Road, Suite 9, Carlisle, PA
✓
���` Side 1
�, y5�56�Cf7,43 1,5D56�,D143 J
PA Inheritance Tax Return
Signature of Additional Fiduciaries
ESTATE OF FILE NUMBER
Wetzel, Mary E. 21
Under penalties of pery"ury,I declare that f have examined this return,including accompanying schedules and statements,and to the best of
my knowiedge 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.
Signature#2
Name Kimberty etzel
Address1 5a Media Rd.
Address2
Clty,StBt�,ZIp Carlisle PA 17013
Date �j�����
� Z50�61�243
REV-1500 EX
Decedent's Social Security Number
Decedant'sName: We�Zg�, Mary E. 184 26 5721
RECAPITULATION
1. Real Estate{Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2.
3. Closely Held Corporatiort, Partnership or Sole-Proprietorship(Schedute C)......... 3.
4. Mortgages&Notes Receivabie{Schedule D)........................................................ 4.
5. Cash, Bank Deposits 8�Miscellaneous Personal Property(Schedule E}............... 5. 9, ��� • 1�
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers 8 Miscellaneous t�n;Probate Property
(Schedule G) U Separate Billing Requested............ 7,
g. Total Gross Assets(total Lines 1 through 7)........................................................ g. 9���$2 .15
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. � , 8�1 .1�
10. Debts of Decedenf,Mortgage Liabilities and Liens(Schedule I)............................ 10. 4�,�-38 . 6�
11. Total DeducEions(total Lines 9 and 10)................................................................ 11. '��r ��9• 72
12. Net Value of EstaEe(Line 8 minus Line i 1).......................................................... 12. -32 ,S S�7 . 57
13, Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Scf►edule J)............................................... 13.
14. Net Value Subject to Tax{Line 12 minus Line 13)............................................... 14. "'32 ��17 .57
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
{a)(1.2)X.00 0 . 0 a 15. 0 . ��
16. Amount of Line 14 taxable Q . ��
at lineal rate X .045 � . �� 16,
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. Q •dQ
18. Amount of Line 14 taxabfe
at collateral rate X.15 Cf . 0 0 18. 0 .0 0
19. TAX DUE.............�---.......... ...................... 19- O . �}�
...............................................................
20. FiLL 1N THE OVAL IF YOU ARE REQIlESTING A REFUND OF AN OV�RPAYMENT. �
Side 2
� 15�56��243 ],5056ZD243 � .
REV-1500 EX Page 3 Fi1e Number 21
Decedent's Complete Address:
DECEDENT'S NAME
Wetzei,Mary E.
STREET ADDRESS
Forest Park Health Cente�
700 Watnut Bottom Rd.
CITY STATE ZIP
C�rlisie PA 17013
Tax Payments and Credits:
7. Tax Due(Page 2,Line 19) (1) O.OQ
2. Credits/Payments
A. Prior Payments
B. Discount p,{jQ
Total Credits{A +B) (2) O.flO
3, Interest (3)
4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2,Line 20 to request a refund
5_ If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (6) Q.(,�0
Make Check Payable to: REGISTER OF WILLS, AGENT.
-:-.r::�-�--:.:�r� �.=.�`'�(�',�`,,�;w..�,�.-: a �c:� �-,� �' �,: �°�� ��,,-'� __..�. m-�.,.
. ����-�..a�''��"'�U'lis--`�'`�_ _..,,:.,,�'?���'�="���,__-��-`....`-��'•��y��`�'-;�Id�'..su'!•'.��k���.?cuL��'�,.:'�:-� ..._.—�..�?��''��'�.x..�:
�.....^.�--'='c'--�.",'==�-�,=„ � ..r�r=.-:• _u �'='- s �.
PLEASE ANSWER THE FOLLOWING QUESTtONS BY PLACING AN "X" 1N THE APPROPRIATE BLOCKS
i. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred:............................................................................... ❑ x
b. retain the right to designaEe who shall use the propeRy transferred or Its income:.................................. ❑
c. retain a reversionary interest;or............................................................................................................... ❑ x
d. receive the promise for life of either payments,benefits or care?............................................................ ❑ �
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receivingadequate consideration?...................................................:............................................... ❑ Q
.................
3. Did decedent own an"in trust for" or payable upon death bank account or security at h+s or her death?....... ❑ Qx
4. bid decedent own an individual retirement account,annuify,or other non-probate property which
Contains a beneficiary designation?.................................................................:................................................ ❑ ❑X
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
�� _ _ .
r�_.. _�___= _ :�a- _. .. _��
Mo?.=.s=ry?�'T�3`"_.'.T_-'+�°'��°.'T� .. �_�'c.''�:! . ..__=���a,. .5�'s��=r3� ,.. . ,..,� 1=�._+Sia.'a°.•M_�,.�F,..,� . � , o::�c�a�,ir,"�n;�`tc„a' ........,....��—...'�'-��'�asti �-��:,-.�i
For dates of death on or after July 1, 1994 and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving
spouse is 3 percent[72 P.S.§9116(a}{i,1)(i)j.
For dafes of death on or after January 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii}]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of
assets and filing a tax return are still appficable even if the surviving spouse is the onfy beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a naturai parent,an
adoptive parent,or a stepparent of the child is 0 percent[72 P.S.§9196(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)(i}j.
. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent j72 P.S.§9116(a){1.3)]. A
sibling is defined under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. �
Rev-1508EX+(��-10) g�HEDULE E
pennsyivania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCETAXRETURN PERSONAL PROPERTY
RESIDENT D£CEDENT
ESTATE OF FILE NUMBER
Wetzel, Ma E. ��
Indude the proceeds of litigation and the date ihe proceeds were received by the estate.
All property jointly-owned with the right of survivorship mus!be disclosed on sehedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DFJ�TH
1 Argus -Refund check 573.10
2 CenturyLink-Refund check 53.53
3 Forest Park Heaith Center-Refund check 8,401.00
4 Medco-Refund check 414.52
TOTAL(Also enter on Line 5, Recapitulationy 9,442.15
(tf more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev.11-10)
REV-1511 EX+(�0-09)
pennsylvania SCHEDULE H
DEPARTMENTOfREVEkUE FUNERAL EXPENSES AND
INHEi21TANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDEN7
ESTATE OF FILE NUMBER
Wetzel, Mary E 2�
DecedenYs slebts must be reported on Sahedule I.
fTEM DES�RIPTION AMOUNT
M
q, FUNERAL EXPENSES:
B, ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personai RepresenEative(s)
Jolene Gregor Kimberly Wetzef
SEreet Address 1306 Dickinson Dr.
city Carlisle state PA zio 17013
Year(s)Commission Paid 2013 1,000.00
See continuation schedule(s)attached
2. Attomev's Fees Salzmann Hughes, P.C. 750A0
3_ Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State Zin
Relationshio of Claimant to Decedent
4. Probate Fees 43.50
5. Accountant's Fees
6. Tax Retum Preparer's Fees
7. Other Administrative Costs 27'62
See continuation schedute(sj attached
T07AL(Also enter on line 9, Recapitulation) 1,821.12
Copyright(c)2a09 form software only The Lackner Group, lnc. Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND A�MINtSTRATIVE C�STS
continued
ESTATE OF FILE NUMBER
Wetzet, Mary E 21
ITEM AMOUNT
NUMBER DESCRIPTION
P,-2!'SOn�j,$e�resentative Commissfons
1 Jolene Gregor-Co-Executor's fee 5d0.00
2 Kimberly Wetzel-Co-Executor's fee 500.00
H-61 1,d00.00
Other Administrative Costs
3 Cumberland County Orphan's Court Division-Fiting fee for Inheritance tax return 15.00
4 Salzmanrt Hughes,P.C.-Certified mai(ing costs reimbursement 12.62
H-B7 27.62
Copyright(c)2002 form software only The Lackner Group, fnc. Form PA-1500 Schedule H(Rev.6-98)
Rev1572 EX+(�y-OB)
SGHEDULE 1
pennsylvania DEBTS OF DECEDENT,
OEPARTMENT Of REVENUE
INHERITANCETAXRETURN MORTGAGE LIABILITIES AND LfENS
RESIDENT DECEDENT �
ESTATE OF FILE NUMBER
Wetzef, Mary E Z�
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenees.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Estate of Lonas Wetzel -Cfass Ifl creditorfuneral expenses ���•23
To be paid on a pro rata basis as a Class 3 creditor
2 Guardian LTC Pharmacy-Lien of Class III Creditor 1,514.23
prescriptions To be paid on a pro rata basis as a Class 3 creditor
3 PA Department of Public Welfare-Lien of Class III creditor 38,447.14
To be paid on a pro rata basis as a Cfass 3
TOTAL(Also enter on Line 90,Recapitulation) 40,138,60
(If more space is needed,additional pages of the same size)
Copyright(c)2008 form software only The Lackner Group, Inc. Fortn PA-1500 Schedule F(Rev. 12-08)
REV-1513 EX+(01-'f0)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN B EN EF{C IAR I E S
RESIDENT DECEOEN7
ESTATE OF FILE NUMBER
Wetzel, Ma E. 21
NAME AND ADDREBS OF RELATIONSHIP TO gHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT {Words) ($$$)
o i t T te
� � TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116 a 1.2
1 Danielle Gregor Granddaughter 25%of residue;
pq however estate
is insolvent.
2 Jolene Gregor Daughter 50%of residue;
pq however estate
is insoivent.
3 Makenzie Gregor Granddaughter 25°/a of residue;
pq however estate
is insolvent.
Total
Enter dollar amounts for distriGutions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro riate.
NON-TAXABLE DISTRIBUTIONS:
I I . A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NUT TAKEN
B.CHARITABLE AND GOVERNMENTAL DlSTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTlONS ON LINE 93 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group, Ina Form PA-1500 Schedule J(Rev.01-10)
W[LL OF
MARY E. WETZEL
I, Mary E. Wetzel of Cumberland County, Carlisle, Pennsylvania,
declare this to be my last Will and hereby revoke ali prior Wills and
Codicils.
, 1. i direct that all my just debts, funerai expenses, gravemarker
and administrative expenses shall be paid from my residuary
esta#e as soon as practicable after my death.
2. I direct that afl inheritan�e, estate, trans�er, succession and
death taxes of any kind whatsoever which may be payable
by reason of my death sha11 be paid out of my residuary
estate.
3. I direct that my entire estate be distributed as follows:
A. I direct that my entire estate go to my husband, Lonas
L. Wetzel.
B. Should rny husband predecease me, I direct that 50%
go to Jolene Groger, 25% go to Makenzie Groger,
and 25% go ta Danielle Groger.
C. Should Jolene Groger predecease me, her share
shall lapse and be divided into equa( shares between
her children.
4. I appoint Lonas L. Wetzel Executor of this my last Will. If
Lonas L. Wetzel should predecease me or cease to act in
such capacity, I appoint Kimberly Wetzel and Jolene Groger,
jointly.
5. The Executor of this Will shall have the power to distribute
my estate in kind or in cash, or partly in either.
6. I direct that no Executor acting under this Will shall be
required to enter bond in any jurisdiction.
IN WITNESS WHERE�F I have h�r,eunto set my hand this
�.5 d ay of :'�;;Z.�2s�.(`.��� 2010.
,
LA�\'OFFICES OF `^'
�TEPHEN J. HOGG Mary E. etzel
19 S. HAI�OVER STREET
SUITL- l0i �
CARL3SLE,PA 17013
The preceding instrument consisting of this and one other page
was on the day and date hereof signed, published and declared by
Mary E. Wetzel as and for her fast Will in the presence of us, who at
hsr req�est, in hsr presence an�+ in the �resence of each other have
subscribed our names as witnesses hereto.
�
i-
�
� ,� " ii :;
�- �..
WETNESS NESS
L.4�V OFFtCES OF
�TEPHEN J. HOGG
19 S. HAN�VER STREET'
SUITE 10]
CARLISLE, PA 1�013
ACKNOWLEDGMENT
State of Pennsylvania
ss
County of Cumberland
I, Mary E. Wetzel, the Testatrix, whose narne is signed to the
attached or foregving instrument, having been duly qualified according
to law, do hereby acknowledge that I signed and executed the
instrument as my last Will; that I signed it willingly and as my free and
voluntary act for #he purposes therein expresse�
Mary . Wetzel
Sworn to or affirmed and acknowledg�d,before me y Mary E.
Wetzel, the Testatrix, this f Sday of _%'°��1Z�L° -�. ,
2010. �`
/:}
��eFdtA���, ✓C_..- ��'�L�....
�'���•��,,��ary�,� N ,ary Pub(ic/Attorney �'
�ct3sfe�r�,�cc�n�r�sanr!Ca PA
�'i�es�s�x,+a�-:a�@s�v�a 3ss�,��� V!T
�........�_...<,�...,
State of Pennsylvania"'
ss �
County of Cumberland
We �.� (�. � L��I . eY. and h�� �� C�? ��r l. � : the
w�tnesses whose names are signed to the attached or forego�ng
instrument, being duly qualified according to law, do depose and say
that we were present and saw "the Testatrix sign a�d execute the
instrument as her last Will; tha# the Testatrix signed willingly and
executed it as her free and volunta.ry act for the purposes therein
expressed; that each subscribing witness in the hearing and sight of
the Testatrix signed the Will as a witness; and that to #he best of our
knowtiledge the Testatrix was at that time 18 or rnore years of age, of
so �ic! mind and �nder no constraint o undue influence.
�l.�- -; / ��,1� � ;.
Sworn to or affir. ed and subscribed to before me by witnesses,
this ' �day of [�t���...�--�' , 0 0.
�,
. ,� ,��-�,�
L�1V OFFICES OF ���d������ -- - J ,
TEPHEN J. HOGG �'��'J•����•��►3r���tar Public/Attorney f�
l9 S.HANOVER S"fREL-T �'��1��ao���b��dt�l C�.pl�
SUITE 10] �"��ii1•'�r:�'T��`33�N.�7��,8F4$63Yt�$5T u4��313
�.e...._...,..:..,.�.,.
CARLISLE,PA 17013 � -"""
•• pennsyLvania
►• •
DEPARTMENT �F PUBL[C WEIFARE
- October 12, 2012
SA[..ZMANN HUGHES PC
JAMES D HUGHES ESQUiRE
354 ALEXANDER SPRING ROAD
SUITE 1
CARLISLE PA 17015
Re: Mary Wetzet
CIS #: 220309385
SSN: ###-##-5721
Date of Death: d6/02/2012
Dear Attorney Hughes:
Please be advised that the Department of Pubiic Welfare maintains a claim in the
amount of �38.447si4 against the abave-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 $38�447.14, was incurred during the last
six months of the decedent's life; therefore, it is a Gass 3 claim pursuant to Section 3392 af
the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the
claim, namely .00, is to be entered as a priority Class 5.1 claim against the estate.
Please acknowledge receipt of this letter and advise whether the Commonweaith'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,
����'�f
Debra J. Kochel
Claims Investigation Agent
717-772-6616
717-772-6553 FAX
Enclosure
t3�!rea�.i .n`Program Integrity � Division of Third Party Liability � Recovery Section
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486
� COMMONVJEALTH OF PENNSYLVANIA
' BUREAU OF PROGRAM INTEGRITY
� DIVISION OF THIRD PARTY LIABlLITY
RECOVERY SECTION
PO BOX 8486
HARRI58URG,PA 17105-8486
_ October 12,2012
S7ATEMENT OF CLAIM SIiMMARY
NAME Estate of WETZEL,MARY
lD,.�'' 22Q 309 385
_, :._-.: .. .,
_,
MEDICAL: . ;. CLASS 3 CLAS5 5.1 ., ; TOTAL
INPATIENT .00 .00 .00
QUTPATIENT .00 .00 .00
LONG TERM CARE 38,442.25 .00 38,442.25
DRUG a.89 .a0 4.89
REIMBURSEMENT 70 DP1N', ,- 38,4A7.14 .00 38,447.14
`.GOMMONVVEALTH OF..PENNSYLVANIA .::
_ ._ . .::.: _ .
_ . �.
` DEPARTMENT OF PUBtIC WELFARE'..> ` !'
, ....,_ ,
EIN ;:23�003fi73
Page 1 of 3
` COMMONWEALTH OF PENNSYLVANIA `' `
DEPARTMENT OF PUBLIC V1lElFARE
October 12,2092
STATEMENT OF CLAIM
' NAME` WETZEL, MARY
ID 220 309 385
FOREST PARK HEALTH CENTER
700 WALNUT BOTi�OM RD
CARLISi..E PA 17�93
. ; . , , : . , ; _ .
.. . .
DATE OF SERVICE; PAYMENT DATE„ ;. ." ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APRROVED
12/01/11 - 12l31l11 06l44/92 551213741008900U1 55121374100890001 6,537.28 6,403.36
DIAGNOSIS 1 : 08881 LYME DISEASE
DIAGNOSIS 2: 0
PROC CODE: 000000
09/01112 - 01/31112 O6/98/12 551216�ta984060001 55121644'[84Q60001 6,537.28 6,485.51
DIAGN051S 1 : 08889 LYME DISEASE
DIAGNOSIS 2: 0
PROC GODE: OOOOQO
02/01!'}2 - 02129/12 06118l12 55121644184040001 55121644184040001 6,115.52 6,067.09
DIAGNOSIS 1 : 08881 LYME DISEASE
DIAGNOSIS 2: 0
PROC CODE: OOa000
03/01/12 - 03/31/12 06/18l12 5512'164A784Q50001 55121644184050001 fi,537.28 6,485.51
DIAGNOSIS 1 : 08881 LYME DISEASE
DIAGNOSIS 2: 0
PROC CODE: 000000
04/01/12 - 04/30f12 05/28l12 20121234027870001 20421234027870001 6,290.70 6,29Q.70
DIAGNOSIS 1 : 08881 LYME DISEASE
DiAGNOSiS 2: 72887 MUSCLE WEAi(NESS{GENERALIZED)
PROC CODE: Q00000
05/01/12 - 05131l92 06/25/12 20121534303510001 2012153430351000i 6,500.39 6,500,39
DlAGNOSIS 1 : 08881 �YME DISEASE
DIAGNOSIS 2: 72887 MUSCLE WEAKNESS{GENERALIZED)
PROC CODE: d00000
O6/01/12 - 06/82/'t2 07/30N2 Z0121854028480041 20121854028480001 209.69 209.69
DIAGNOSIS 9 : 08881 LYME DISEASE
DIAGNOSIS 2: 72687 MUSCLE WEAKNESS(GENERALIZED)
PROC GODE: OOQODO
PROVIDER SUB TOTAL �OREST PARK HEALTH CENTER 38,728,14 38,442.25
03 901867397 0001
Page 2 of 3
i-- : -
;_ ' ' '. COMMONWEALTN OF,PENNSYLVANIA_ ;; ,;
� DEPARTMENT OF PUBLIC WELFARE
October 12,2012
STATEMENT OF CLAIM
NAME WETZEL,MARY
ID 220 305 385
GUARDIAN LANG 7ERM CARE PHARMACY I
123 BRUBAKER RD
BROCKYJAY PA 15824
, .. . . ,
,.., . . _
DATE OF SERVICE!;._ PAYMENT DATE .:. ORIGINAL CRN, , ` �:ADJUSTED CRN ' .USUAL CHARGES ' AMOUNT APPROVED:
04116/72 - 04116112 05/281l2 25'i21215485900001 25121275485900001 6.66 4.03
DIAGNOSIS 1 : Q
NbC CODE: 00228205750 LORAZEPAM 0.5 MG TAeLET - ATARACTICS-TRANQUILIZERS
04117/12 - 04117/12 05/28/72 2512121548745U00� 25121215487454001 25.86 .86
DIAGNOSIS 1 : 0
NDC CODE: 00228205750 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
PROVIDER SUB TOTAL GUARDIAN LONG TERM CARE PHARMACY INC 32.52 4.89
24 102290870 OD01
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