The URL can be used to link to this page

Home My WebLink About02-11-14 1�0561�143 JEx�oi-�o> � OFFICIAL USE ONLY REV��oO County Code Year File Number PA Depa�tment of Revenue pennsylvania Bureau of Individual Taxes pEVARTMENT OF REVENUE 0 6 5 8 Po aox.2soso� INHERITANCE TAX RETURN 21 13 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATtON BELOW Date of Birth Social Security Number Date of Death 180 05 27 2013 05 17 1927 Decedent's Last Name Suffix Decedent's First Name MI RvTx I MILLER � (If Applicable)Enter Surviving Spouse's information Below MI Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW �emental Return � 3. Remainder Retum(date of death � 1. Original Return � 2. Supp prior to 12-13-82) � 4a.Future tnterest Compromise � 5. Federal Estate Tax Return Required � 4. Limited Estate (date of death after 12-12-82) s pecedent Oied Testate � �- Aetach Copy�of Tr�ust)a Living Trust 8. Total Number of Safe Deposit Boxes � � � (p,�tach Copy of Will) , ��-be�brveenl2 31�31 nd�t?-�1ag5)f death ❑ ��qttach Sch.p�nder Sec.9113(A) � 9. Litigation Proceeds Received � -THIS SECTION MUST BE COMPLETED.ALL CORRESPO CE AND CONFIDENTIAL TAX INFORMAho e Numbe BE DIRECTED TO: CORRESPONDENT Daytime Tetep Name 717 432 9666 JAN M WILEY � �=-'� REGIST � lLLS�OI� .:;,; '"�, �"'"� �. .:. � 3�' r" }..,,. *�t C� ' First line of address �` �' � ti � � � €t� �7 �4 C� 3 N BALT IMORE S T �' ,� � -�, � � � � � � � � Second line of address ��r�� _ r � �,..,,a � �,.„r "� pATE FiLED � � City or Post Office State ZIP Code N' � .�,,�' DILLSBURG PA 17019 anmwiley@comcast.net Correspondent's e-mail address: 1 e and be�ief, Under penatties of perjury,t declare that.on of exaarer o than the pe sonala pr senta Ive fs baed on a nforma on�o wh'ch pre�rerfhas akn�y kno�wled9e• it is true,correct and comptete.Declarab p ep DATE SIGNATURE OF PERSON RESPONSI F FILI G RETU t Judith E Smith ADDRESS errace Drive New Cumberland PA 170?0 DATE SI ATU OF PR�PARER OTHER TH EPRE NTATIVE �.., . Jan M Wiley ADD ESS 3 , altimore St.,Dillsbur , PA Side 1 150561D143 ...,� � � 1505610143 � REV-1151 EX+110-06� SCH��LE H FUNERAL EXPENSES & COMM HR R�ID N�T D CEDEN7RNAN�A ADMINISTRATIV� COSTS ES FILE NUMBER ESTATE OF 21-13-0658 Miller,Ruth 1 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMB R q. FUNERAL EXPENSES: g, ADMINfSTRATIVE COSTS: �. Personal Representative's Commissions Name of Personal Representative(s) Judith E Smith Street Address 514 Terrace Drive �;ry New Cumberland State P� z�o 17070 10,000.00 Year(sl Commission�aid 10,000.00 2_ Attornev's Fees The Wiley Group, PC 3, Family Exemption: (if decedenYs address is not the same as claimanYs,attach explanation) 3,500.00 Claimant Street Address City State Z�p Relationshin of Ciaimant to Decedent 4. Probate Fees 5. Accountant's Fees g, Tax Retum Preparer's Fees 1,661.44 7, Other Administrative Costs See continuation schedule(s)attached TOTAL(Also enter on line 9,Recapitulation) 25,161.44 FoRn PA-1500 Schedule H(Rev.10-06) Copyright(c)2009 form software only The Lackner Group,Inc. scHEr�u�E w FUNERAL EXPENSES AND ADMINISTRATIVE COSTS +�ontinued FILE NUMBER ESTATE OF 21-13-0658 Miller,Ruth I AMOUNT ITEM DESCRtPTION NUMBER C�thp�o��inistrative Costs 210.78 1 Advertising-The Sentinel 1,35T.46 2 Settiement Charges 93.20 3 The Dilisburg Banner H_B7 1,661.44 Form PA-1500 Schedule H(Rev.6-98) Copyright(c)2002 form software only The Lackner Group,Inc. R - _ - - Rev-1512 EX+(12-08) SCHEISULE 1 DEBTS OF DECEDENT, MORTGA�E LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANGE TAX RETURN RESIQENT DECEDENT ESTATE OF FILE NUMBER Miiter, Ruth I 21-13-0658 Report debts incurred•by th�decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. VALUE AT DATE ITEM DESCRIPTiON OF DEATH NUMBER 1 Brett Lechthaler(appraisal for real estate) 275.00 26.91 2 Camp Hill Emergency Physicians " 31,007.70 3 Department of Welfare Ciass 3 Claim 4 Department of Welfare Class 5 Claim 156,286.43 1,340.00 5 Lawn Maintenance 730.00 6 Liberly Mutuai(home insurance) 260.00 7 Met-Ed 43.02 8 Mobilex 481.00 9 United Heaith 230.00 10 York Waste TOTAL(Also enter on Line 10,Recapitulation) 190,680.06 (tf more space is needed,additional pages of the same size) Copyright(c)2009 form software only The Lackner Group,Inc. Forrn PA-1500 Schedule I(Rev.12-08) __ _ _ � REV-1513 EX+(11-08) , SCHE�IULE J COMMNHERITAN E TFq P�RNETURN��A BENEFICIARIES REStDEN�DECEOENT FILE NUMBER ESTATE OF Miller, Ruth I 21-13-0658 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NAME AND ADDRESS OF DECEDENT �N►ords) ($$$� NUMBER PERSONf S)RECEIVING PROPERTY po Not ist Tru ee TAXABLE DISTRiBUTiONS [include outright spousal I� distributions,and transfers under Sec.9116 a 1.2 Judith E Smith Daughter 514 Terrace Drive New Cumberland,PA 17070 Total Enter doilar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro riate. NON-TAXABLE DISTRIBUTIONS: II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART il-ENTER T�TAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE Schedule J Rev. 11-08) Copyright(c)2009 form software only The Lackner Group,inc. Form PA-1580 � ,r, BE-00793'01'004053-MO-13165-11017-AFJ 219 UnitedHealthcare` � A UnitedHeahh Group Company �� UnitedHealthcare insurance Company v1� --- RAILROAD CUST4MER SERVICE CTR. �' PO BOX 30304 �� SALT LAKE GITY, UT 84130-030Q Have more questions about your cfaim? ,--- Visit www.myuhc.com for a(I your claim and benefit informatian � i June 14, 2013 165MEOBSB10t72005-OQi 64-C�i RUTH MILLER Member/Patient Information = C/O JUDY SMfTH Member: CHARLES MiLLER -- 514 TERRACE DR Member ID: A800Q44692 -- NEW CUMBERLAND PA 17070-1562 Patient: RUTH MILLER Relationship: SP Group Name: RAILROAC� EMPLOYEES Group#: 0023111 Explanation of Benefits Statement This is not a biit. Do not pay.This is to notify you that we processed your claim. Claims Summary Detailed claim informatian is located on the following page(s}. Dollar Amount Description Amount Billed $481.00 This is the tota! amount that your provider biiled for the services that were provided to you. Plan Discounts $0.00 Your plan negotiates discounts with providers to save you money. This amount may also include services that you are not responsible to pay. Your Plan Paid $0.00 This is the portion of the amount billed that was paid by your plan. Total amount you owe the provider(s) The portion of the Amount Bilted you owe the provider(s). This amount does not reflect any $481.00 payment you may have already made at the time you received care. This amount may include your deductible, co-pay, coinsurance and/or non covered charges. This amount does not inctude any payments made to the subscriber*. If a payment was made directly to the subscriber, you/the subscriber is responsibfe for paying the physician,facility or other health care professionai. * When coordination of benefits applies, this amount will include payments made to the subscriber. �T�-EOB Page 1 of 3 Use this EOB statement as a reference or retain as needed dl[1f17595(Y1�,F,3 ____ _ _ - - _ _ _ �b5ME0E3SB1002005-00764-U2 C � O � O C ca "� 0 U M �� M � � � O �� .- cB � N M �� O �, C � O � � �� N � O � C cG L (� � •� � � � � � � �s C- U � r 0 � N � L . � � O � � ` = � ap .� � � p � t, � � .� T �� V �-- .L2 C � ,C � ` O 'J c� � - CA� -C � '� ��s C C � � � C �� O � � � � •� . .._. � � �� C � � . � � � � � �N V � O � � > � U Q. O EO, p .� ,.... � U '� > (B � � � cv L � Q '� 2 0 � _ � �= a� o � o '� U -p ;._. d � U � N "" ` C :►-� 0 O .Q C �� C c/� .-. t • >+ � f"_ � Q� � � .Q � � � � C � � L � •� � c�-'n O � �U C � � � � � � t� � �? O y /'1 l � y-" L �� > L �+ � � f.i.� Q '�' � � '�S � C� Q" oU L �..Q�-� o Q- �` V � �tr,,� ,� Q O -C V? i�-1 � � � >+ t4 ,� � � � E E C � E `a � � E a c � v � > +± � `� � � o ° `�° ��? o >, � +, tn � � a' � 0� a � � � � v� . a� � � W � ;n � �> � co O •� ca -C •- Vf L — = Z � a� �� .v� � � � � � � o ° � v�i E � °' _ � U U �tn +� v '� cn ca � � � � � � '� . E � � � o � � .� � � L � f6 U tn � Q v� 3 �' a� E � ca � v � � o, L •� � C C �. � � � •(� � C � N C � � p o � � � U cB T � � � > > � y-- � � O � � O �_ O � � � � �� C U� c� �' � c � � O N � L,E '�, � � o �W M � V � p c � �► m C� � � � � L- � �� / s �W Gp M � C d N .�Q _ i F- 'p � �� C � O 'p � � � cp �o .L N Q -o � c c � O � �t— �'-a' ° � v, °' -v ° � � � O �(=}MVo � � ai �,� � � � Q �a m g L c a Z � c v� •— O ,� c�C�MYo��O � � �' � � N � � � Z � w N 7 �, O� p v��J ai o � } E c°� � � c `+'= a�i � . � �$ �_Jm J C N � � m T � � G� �� 8 ._ CQOQt O � � � O ,� � ,� L7 n. �' _ August 17•, 2013 T�the Estate of Ruth Miller; 130 Gienwood Rd. Dillsburg, PA. 17019 C/O Jud1�Smith Er.ecutor&The V►liley Group,Jan Wi!ey, Esquire This a statement of bi[ling for services for the maintenance of cutting and trimming of lawn weekiy from March to luly of 2013 and cieanup from fallen tree. 19 times @ $60.00 flat rate$1,140.00 Removal and cleanup of fallen tree in side of yard. $200.00 Total for services provided is $1340.00. Please pay upon receipt to Gerald Speck, 176 Glenwood Rd. Dillsburg, PA. 17019 Respectfully, -�.�".�— � Cc:Fi�e Judy Smith 1an Wiley :*oA2377* �: ' _ ' . :`��t-�r Ntu�c.r�..cROUr j �.��X SZ�o�.: . - =� ��.-. I:iber . ' 5072 : . " � pHOENIX AZ 8 �� . 1V�Iutual� .. .:: , -. , - INSURANCE .''. Please do not send payn�ents tn the address above . : � Thank you� VIIe appreciate your business. - CHARLES E MILLER . . Rt3TH`I MILLFR S.l'4 Z'ERRAGE`DR � CUMBERLAND PA 17070-1562 ' � � :NE�N;. . - . TH!S !S YQ�R !-�C}�nE lRSURAN�E BILL As of August 7, 2013 �U��1 fa�lu INSURANCE INFORMATION auestions Regarding Policy Number: H32-281-221239-fi0 Your Policy or Btil? Januar 7, 2o13-January 7, 2014 Policy Period: y SERVICING OFFICE giU Frequency: Monthfy PO BOX 52102 Property Insured: 13Q GLENWOOD RD PHOENIX AZ 85�72 DILLSBURG. PA 17019-9748 1-602-229-4400 Want to Pay Online? 'Lc Sign up at LibertyMutua{.com/im-service B i LL I N G D ETA � Need to Report a C{aim? `$382sC30,; 1-800-2CLAIMS(1-800-225-2467) Prev'tou�_Pol�cy Balan.ce Payment Activity -$200.00 Payments Received 54.� InstaHment Charge � ., :. : .$�$soo , . : ; _ _::. Policy Baiance: _ 08/27/13 ` $64 67': Current Arnvunt Due.By _ �;"� j�;:l`ili4��. fL i`�f�s�'•l��:', �� -�� Etiminate instailment charges by signing up for electronic funds transfer i�: payments. Simply sign the ,.� authorization and return the stu � be�ovv with your payment. :� i: . � � � � - 1 t�/ •.`� . , ' � / - ` •�, . ' f.,' . j �J _ . � . , f . t � . . ... _�. � . . �.- . ..� .: � .-, ._:.. �;t • ,. _ . . -- ° i{t 3` �� f,t n..�,�a .�T,��.z .�a�ea c... .� r�F-.. .. . .e . +�'Y . ._ ••' � r.e•��5�U�e. ..G%4 . �'_. ._r. ' �� :� ;e_:. � �< .-.'.�%5 e �1. � .v .:s �+e��Sa. �>sYA�^..c �fF t••?: s � �� .t� � j ` '�1��'�' �: � r ,� �-y v�'- eTa . 5,��5q }a{L,}� • "�,"^�_- ��a f,� ,.�j?n,#� � ��t 4�T'��-,fs i i.-, �� S — -t:: .-s ... '_' __ ' . 1 srr 4:.f"5�sa� A`re .l�e'_... � .�.� . 4'�� .—� -- '� �_ � .�� — �� v_- �._.� _r. �i e- � • ��" _ r�Me�v��'� *002400* LIBERTY MUTUAL GROUP PO BOX 52102 . PHOENIX AZ 85072-2102 •'` Llbe �� Mutual� Pleuse do not send puyments to the address above �(�$U R Q N C E Thanfc you! CHARLES E MILLER Vlle appreciate your business: ' RUTH I MILLER , 514 TERRACE DR NEW CUMBERLAND PA 17070-1562 ; f _ �:>:• ,.� ..�., �. . - �: THIS IS YOUR HOM� IIVSU��lvCE �ILL As of June 7, 2013 INSURANCE INFORMATION �UE�TlOt�S Policy Number: H32-281-221239-60 Questions Regarding Policy Period: January 7, 2013-January 7, 2014 Your Poiicy or Bill? Btll Frequency: Monthiy SERVICING OFFICE Property Insured: 130 GLENWOOD RD PO BOX 52102 PHOENIX AZ 85072-2102 DiLLSBURG, PA 17019-9748 1-800-869-4009 BlLLING DETAiLS wa�t to PaY o�i��? Sign up at LibertyMutual.com/lm-service ,: , Need to Re ort a Ctaim. . P Prerr+oUS Pohcy �a��t�ce ; ;: ; . $��: 1-800-2CLAIMS(1-800-225-2467) . . .. ,..... .. ..... Payment Activity � _ _. 'Paymen�s Hece�ved -580.00 , _ :: _::,. _ _ _ _ , __:. instaitrnent Charge $4-� Pt�l�c�:�#aia�� `x f�;.�t Y�78�Q-: .: � .:::<::�...�..��:.tri� . . ... .,.. _. _.... < .... ..<... . -.:.:>.::.. .....:. .....�. ....: . . _.:. . .. .. ... ....� ... f: G� ��x Am�n��t�� 6�2'�lt� _ ��:8�: :.. � � <.... ......... . .. .......<..<x_r„� a:..:... �..... ,.w.:..,.,_,.::.._... _ Mx H..>.:...._..,... ',..... , : ; � SAVE TIME � MONEY . Eliminate installment charges by signing up for electronic funds transfer payments. Simply sign the authorization and return the stub below with your payment. �. �Zc t� �tr.e s �{Z�� ;� �- .f.¢�_" ��.�y�"~1�-- �F.F7--•-��-: �� :€ sr'��,� !E•s=`' `fE�_t_F6..,. � :?��cf�i�c: �F`� i FiFs .•�'F�Q��.�'.�s �'`'"i��'rrFF��•,Fi.. ��M"�e.}� Fr��°t�.t�. l`it�� :.e��E'�� r t �' �. t"�.> ... �f e ^ e c f , i.� �[ k "s r. ;.�s � � t� �a � ez• � �_. rse �. _. rmm� e^ c.�': .-.- �' --. � _._ � � c�- r:, ..-_ a-:- r.- c.e �'_' r_'� ,� s-_: .,._ _.-. _._ er- ,..-_ �- �:: � �: _�. r-_ r� � ._._�rx. r;: e: :� e�: �- . � *006710* . . ;. _ LII3ERTY MUTUAL GROUP � PO BUX 52102 � `�� PHOENIX AZ 85072-2IO2 • . Liber ^ �y Mutual� Please do n�t send payments to the address above t N S U R A N C E Your Bili is Past Due. We have not received your CHARLES E MILLER payment as of 07/08/2013. RUTH;I MILLER 514 TERRACE DR P{ease send in you►payment to NEW CUMBERLAND PA 17070-1562 avoid possibte interruption to your coverage. ��`�',� TN;� !S `lQ!iR !-!��.�lE !�lS�JR�4N�E f�l�! As of July 8, 2013 INSURANCE INFORMATION C�UESTIa�!S Policy Number: H32-281-221239-60 Questions Regarding Policy Period: January 7, 2013 - January 7, 2014 Your Policy or Bill? Bill Frequency: Monthly SERVICING OFFICE PO BOX 52102 Property lnsured: 130 GLENWOOD RD PHOENIX AZ 85072-2102 D{LLSBURG, PA 17019-9748 1-800-869-4009 Want to Pay Ontine? BILLING DETAILS Sign up at Li�rtyMutuat.com/lm-service Need to Report a Claim? 5378:�0 Previ4us Palicy Balance 1-800-2CLAIMS(1-800-225-24671 Payment Activity Payments Received 50.00 Installment Charge 54.00 P�+Itcy Balanre > . . . . . . . . , ... S3$Z 00. . P�st:Due:Amoun� ': : , _ ... ,:.. . :. ::. . _.: .. .. : . . . . .. .. _ � S78 80 Current Amount Due $78-$� Tota! Amount Due By Juty 28,.2013 �157 60 • SAVE TtME & MONEY .:; .: ,.: . _ .. ; , � . .._ ._ . ,_, _.. Eliminete instaliment cherges by paying your balance in full. �:. �-��. c,�-��€�� F��'��I� `�'��` �f�i��'�`.� ��°'��E�`,�� t�`,��4? ��`�'�`�'��_ ��:E€�� n�� °�"�� €�� RQ�4.ti�E�. .. . ... . . ......... .. .... ..... -- - -r. �.a � 4r ca c>� cc c� n� cm �e: a� ax ca e� a� asa o ...•,�• .. • •.- � r+T � LLS. CSi @SR !F.R L s4 P4� F� � f�t'.. !.1" t> � ' ....... . 1 a �� • � Q � 1 � e X°S" " S 06/05/13 43.02 3605926ihs � The Highlands FOR PORTABLE X-RAY .•ti 930 Ridgebrook Road SERVICES PROVlDED AT: GOLDEN LIVING-WEST SHORE ��.ti Sparks, Maryland 21152 PRIMARY INSURANCE: PALMETTO GBA RR PA � SECONDARY INSURANCE: UHC MEDICA PRIMARY CL6837 ss o�o� RETURN SERVICE REQUESTED *x�x******************�********��***:�**x � ►� � 317 01 RUTH MILLER MOBlLEX USA JUDY SMITH PO BOX 17452 514 TERRACE DR BALTIMORE, MD 21297-1452 NEW CUMBERLAND, PA 17070-1562 ��I��i��i��l��t��fl�l�'lll�llf't�ll"��'��'ll�llt'Il��{�� i„��i�i�iii��ilill��lnllh�li.ii,i,�,ii`.�i�iii�ili��lf�l��i� AMOUNT OF PAYMENT: For Cred;t Card Payments See Reverse Side Please detach here,and encIose this portion cuith your prompt payment.Thank you! 000noo These charges are billed direct(y to the patient because a copay, deductibfe is due or your ciaim was denied by your insurance company. It is the patient's responsibility to provide current insurance information(see reverse side). ., . . . • . . � 02/16/12 73130 HAND MIN 3 VIEWS 40.00 -24.63 -9.21 .00 6.16 COINSURANCE AMOUN COINSURANCE AMOUN 02/16/12 Q0092 SET UP FEE X RAY 27.00 -16.46 -6.42 .00 4.12 COlNSURANCE AMOUN COINSURANCE AMOUN 02/16/12 R0070 TRANSPORT X RAY 1 275.00 -130.96 -111.30 .00 32.74 COINSURANCE AMOUN COINSURANCE AMOUN TOTAL 342.00 -172.05 -126.93 .00 43.02 PATIENT NAME: RUTH MILLER AMOUNT DUE: $43.02 MAIL PAYMENT TO: Please call 800-786-8015 option 2 between hours of 8:00 AM and 4:30 PM EST. Mobilex USA THIS BILL IS FOR PORTABLE XRAY SERVICES P.O. Box 17452 Baltimore, MD 21297-1452 DATES OF SERVICE: 02/16/12-03/20/12 10°t5 ��1��'�� 1138-MXRSTM-1714732-1433157820-P;7465057-2-317;33354724-1;1 . � � ' i . 1 � � 1 � e .�'�°S" 07/19l13 43.02 3605926ihs � The Highlands FOR PORTABLE X-RAY �... 930 Ridgebrook Road SERVICES PROVIDED AT: GOLDEN LIVING-WEST SHORE � Sparks, Maryland 21'152 PRIMARY INSURANCE: PALMETTO GBA RR PA s RETURN�SERVICE REQUESTED SECONDARY INSURANCE: UHC MEDICA PRIMARY CL6837 55010i �*�***�**�**********��*�***�*****�******* a �► 2397 01 RUTH MILLER MOBILEX USA JUDY SMITH PO BOX 17452 514 TERRACE DR BALTIM�RE, MD 21297-1452 NEW CUMBERLAND, PA 17070-1562 �{�11��1��111�1�1111��1'��I1�1�'�I'I�I'ill��ll�{i�ll��il��1 ii�lilil�Il��i�11�1��llliiih�i��i��ill��lilli� AMOUNT OF PAYMENT: For Credit Card Paymsnts See Reverse Side Plectse detach here,and enclose�his portion with your prompt payment.Thank you! o00000 � These charges are billed directly to the patient because a copay, deductible is due or your claim was denied by your insurance company. It is the patient's responsibifity to prov�de curreni insurance information(see reverse side}. ., . . 02/16/12 73130 HAND MIN 3 VIEWS 40.00 -24.63 -9.21 .00 6.16 COINSURANCE AMOUN COINSURANCE AMOUN 02/16/12 Q0092 SET UP FEE X RAY 27.00 -16.46 -6.42 .00 4.12 COiNSURANCE AMOUN COINSURANCE AMOUN 02116/12 R0070 TRANSPORT X RAY 1 275.�0 -130.96 -111.30 .00 32.74 CO{NSURANCE AMOUN COINSURANCE AMOUN TOTAL 342.00 -172.05 -126.93 .00 43.02 PATIENT NAME: RUTH MILLER AMOUNT DUE: $43.02 - MAIL PAYMENT TO: Please cal{800-786-8015 option 2 between hours of 8:00 AM and 4:30 PM EST. Mobilex USA THIS BILL IS FOR PORTABLE XRAY SERVICES p,p. Box 17452 Baltimore, MD 21297-1452 DATES OF SERVICE: 02/16/12-03/20/12 10°'S ��'��U 1138-MXRSTM-1769383-1466911202-P;7625397-1-2397;33487037-1; 1 The Sentinel THE WILEY GROUP AD NUMBER PAGE I�O. www.cumbertink.cam 3N.BALTIMORESTREET 422242 1 of4 /�� B �x�� DtLLSBURG,PA 17019 BILL DATE SALESPERSON t� FGf�Y� 717-432-9666 07/05/13 wolfc t.hR;P::;f S'�fi.''"__.;61:F.�. F[�i�'i'i�:sf��y . . START DATE STOP DATE 06/20/13 0T104113 AD NUMBER � AD DESCRlPTION CLASS L1JES 422242 EXECUTOR NOTtCE ESTATE OF RUTH i. 10 PUBLIC NOTICES 38 "2 cois Publication Insertions Rate Net Amount Gross Amount 3 THE SENTINEL-LEGAL 3 LGl $201.78 TOTAL AD CHARGE $201.78 3 MOBILE S{TE MOB2 $2.00 3 PROOF OF PUBUCATION 01 PRF $7.00 Purchase Order Est.Ruth Miller PAY THIS AMOUNT $210.78 $252.94* *AFTER 07/30/13 THE SENTINEL Thank you for advertising with The Sentinel! Dead{ine for c!o LEE NEWSPAPERS in-cotumn lega{ads is 4:00 p.m.two business days prior to PO BOX 540 date of insertion. For questions,call(717)240-7130. WATERLOO IA 50704-0540 Retum thfs portfon wlU�yourpayment Legal THE SENTiNEL ❑ Check# []Credit Card Ad Number 422242 c!o LE�NEWSPAPERS ❑ � ❑ � ❑ � � Billing Date 07/05/18 PO BOX 540 WATERLOO tA 50704-0540 Acct#: Amount Due $ 210.78 E�.Date:� � , Name on credit card $ Signature P�ease make checks payab�e ta THE SENTINEL �t 000,a3 THE SENTINEL '4�c THE WILEY GROUP c/o LEE NEWSPAPERS 3 N.BALTIMORE STREET PO BOX 742548 DILLSBURG,PA 17019 CINCINNATI OH 45274-2548 ��n{r��{��i��i��r��n��n�� 2154D200DD0��422242DDOODOOOOOOO�OD25294�0000210787 PR04F OF PUBLICATIUN State of Pennsylvania,County of Cumberland lackie Cox, Director of Sales, of The Sentinel,of the County and State aforesaid,being duly sworn, deposes and says that THE SENTINEL,a newspaper of general circulation in the Borough of CarIisle,County and State aforesaid,was established Deeember 13�, 1881, since which date THE SENTINEL has been regularly issued in said County,and that the printed notice or pubiication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following day(s): lune 20,27,1uI�r 4,2013 COPY OF NOTICE OF PUBLICATION ExECUTOR r,or�cE Affiant further deposes that hejshe is not Estate of RUTH I.MILLER,late of Dillsburg,Curnberlanii County,PA, interested in the subject matter of the deceased.Letters of Testamentary on said estate having been granted to me u�de�s�9�ed: aforesaid notice or advertisement,and that All p�rsons indebted thereto are requested to make immediate payment and all alleOdt1011S 1Tl�l2�Oreg011lg State171eI1�aS those having claims or demands against the same wi11 p�esent them without b delay for settlement to the undersigned,residing at: t0 t]I7Le,place and character of publication Judith E:•Smith {�e. 514 Ter.race Drive New:Cumbe.rland,PA 17070 - � Attorney for the Estate: Jan M<Wiley,Esquire The Wiley Group,P.G 3'North Baltimore Street � ' � Diltsburg,PA 170t9 � Sworn to and subscribed before me this �'1 }F � N tary Public My commission expires: COMMONWEAL't1°I 0�P�NNSYLVANTA Nprsrfal Ssal Bethany M.Holtry,Notary PublfC Cartisle Boro,Cumberland County My Commission Expires Sept 26,2015 MEMBER,PENNSYLVANIA ASSOCIATION OF NOTARTES . .. Bargain Sheet & Dillsburg Banner '�vO'�� i�F� `�� 31 S. Baltimore Street �" =��"�t Dilisburg PA 17019 -:�.�,.; -- � �� 432-3456 DATE INVOICE NO. ' >:.Y�i ws. . 07/04/13 1 Z5503 B1LL TO Jan M. Wiley, Esquire 3 N BALTIMORE ST Dilisburg PA 17019 TERMS DUE DATE Net 30 08/03/13 {TEM DESCRIPTION QTY RATE AMOUNT 6 Legal Ruth Miller Estate ran June 20 3 9.80 29.40 6 Legal Ruth Miller Estate ran lune Z7 3 9.80 29.40 6 Legal Ruth Miller Estate ran )uly 4 3 9.80 29.40 66 Notary 5.00 5.00 Tatal $93.20 CAMP H!L!. EMERGENCY PHYSICIANS ITYP STATEMENT OF ACCOUNT PO BOX 13693 � �, ymants receHed alter this date wiB PHILADELPHIA, PA 19101-3693 Stafement Date: 11/23/13 appearonyournextstatement TAX 1D# 20-4667340 Page 1 Account Number. HYP44914661 Account Summary Pafient Name: RUTH I MILLER Account Balance: 26.91 :�a�a�ro. Amount Pending lnsurance: 0.00 082516-0000044914661-06 Amount Due from Patient(Current): 26.91 #BWNJFDB Amounf Due from Patient(Past Due): 0.00 #OOOOOOHYP7363868# Pay this amount: 26.91 RUTH I MILLER 770 POPLAR CHURCH RD CAMP HILL, PA 17011 Please refer to the coupon below tor payment instructions. Pay your bill secure{y online anytime at www.MyMedicalPayments.com �ATE # DESCRIPT/ON CNARGE PAlD BY p�t/D BY PAfD BY AMOUNT DUE FROM �'ATlENT FIRS7INS. OTHER lNS. PATIENT ADJUSTED lfIISURANCE BALANCE i4l05l13.1 12001-GW WOUND REP 0-2.5CM SCALP ETC �29� DX:873.0 MATTHEW DIRODIO.PAClHOLY SPIRIT HOSPITAL 15l04;13 MEDICARE REOUIRES PERF PROV 0.00- )5/14/13 MEDICARE CIAIM DENIED-COVERED BY HOSPICE OA�- 16/06/13 INSURANCE CLAIM DENIED-COVERAGE TERMINATED 0.00- )8/19/13 INSURANCE CLAIM DENIED-NON-COVERED SERVICE �-�� )9/07/13 MEDICARE CONTRACTUAL AILOWANCE 59�.18 19l07l13 MEDICARE Sequestration 2°�6 Cul 0.61- )9/07l13 MEDICARE PAYMENT 29.65- 0/15113 lNSURANCE CLAIM DENIED-COVERAGE TERMINATED 0.00- 7.56 )4/05/13 2 99284-25-GW EMERG INJURY EVAI 8 MGMT-LVL 4 837.00 DX:873.0 MATTHEW DiRODlO.PAGHOLY SPIRIT HOSPITAL )5/04/13 MEDtCARE RE�UIRES PERF PROV 0.00- )5l14/13 MEDICARE CLAIM DENIED-COVERED BY HQSPtCE Q.00- )6/O6/13 INSURANCE CLAIM DENIED-COVERAGE TERMINATED 0.00- )8/�9/13 INSURANFE CLAIM OENIED-NON-COVERED SERVICE �� 40.24- )9/07/13 ■ lmportant Messages: Totals CONIINUE CONTINUE CONT►NUE CONTtNUE CONTINUE CONTINUED CONTINUED ' This statement is tor the direct treatment and/a supervision of care you recently received from an Emergency Physician at Holy Spirit Hospitat. The fees tor this private physician are billed separately from any hospital charges or other professional fees for which you may atso be responsible. Therefore,should you receive a bitl Erom the hospitat or other physicians for charges in conneccion with this visit,it will not inciude the items listed on this statement. "Payment Plans"Accepted �`Question about this statement?/Llame de Lunes a Viernes?CaN 1-800-355-2470 Monday through Friday 9:30AM-4:OOPM. 3'oc:i-aut�mo�E��y�tam s�c�s�cad�is Q�Q?-4�3:456?,ar y��cac�s�na��rnail!c billing qlest�ens�em�are.corrt. •-------------------------------------------------------------------------------� PLEASE DETACH AND RETURN BOTTOM PORTION WI7H YOUR REMlTTANCE. Statement Date: 11/23/13 Payment Due By: 12/14/13 �P��OGBA w�,�zs»e �2�r Amouni Due: 26.91 PO BOX 10068 AUCaUSTA GA 30BOD Account lVumber. HYP44914661 Amounf Enclosed:�� , COM ASERACARE Patient Name: RUTH I MILLER Go Green-pay online at wosf3 www.MyMedicalPayments.com ATTN�HEALTH CLAIMS HARRISBURG PA 17 1� 7UC�IG�I�T fOI�. PMA01 DEPAR7AAENT OF PUBLIC WEI.FARE 3001948C12 ET213 The insurance in/ormation in o�file appears to the right.Please make any carec[ions and/or RUTH I M I LLER additions on the reverse side o/this form and �elum it fo us.Thank you. 770 POPLAR CHURCH RD CAMP HILL, PA 17011 YOU MAY PAY THIS BILL WITH YOUR CREDIT CARD PLEASE SEE REVERSE SIDE. Make Check/Money Order payable to: 0825160000044914661000026910000000000006 CAMP HILL EMERGENCY PHYSICIANS ITYP �If your address has changed,check this box and complete the reverse p0 BOX 13693 side of this form. PHILADELPHIA,PA 19101-3693 Page 2 � Account Number: HYP44914661 Patient Name: RUTH f MILLER Guarantor: RUTH { MILLER 770 PQPLAR CHURCH RD CAMP HILL, PA 17011 7A TE # DESCRlPTION CHARGE PAID 8Y PAID BY PqID SY AMOUNT DUE FROM DUE FROM PATfENT F1RST INS. OTHER/NS. PATIENT ADJUSTED INSURAAlCE 9l07t i 3 MEDICARE Sequestration Z°i�Cut t.55- 9/07l13 MEDICARE PAYMENT 75.86- 0l15l13 INSURANCE CLAIM QENIED-COVERAGE TERMINATED 0.00- 19.35 PIEASE CALL OUR OFFiCE WITH YOUR INSURANCE)NFORMATION. THANK YOU TOta�S �466.00 105.51- 0.00 0.00 1333.58- � 0.00 26.91 FROM: �Nvo�c E Brett lechthaler Appraisa�Solutions INVa10ENU.N{BER' . 16 S3n Juan Drive 13-Miller Mechanicsburg,PA 17055 DA7f. 7/3/2013 Telephone Number:717-697-1828 Fax Number: 717-697-0220 REFERENCE T0: Intemal Order#: lernier Case A�: Estate of Ruth Mii�er Client Fle#: c/o Wiley Group,3 N Baltimore St Dillsburg,PA 17019 Main File li on torm: 13-Miller Other File A�on form: Tefephone Number Fax Number. Federal Tax ID: Ahernate Number. E-Mait: Empbyer ID: � ��I�� & '3,,�� , ; �':' ,� , ` ,�,E : � . ..<�s.�....'P�pz ,�.rir',::,.... .. ...-.. .: ....i. .. ...�.: , , `.i .:�'.t,.. �r,..'�:, .�..:'.. 4 Lender:Estate of Ruth Miller Ctienti Estate of Ruth Miller Purchaser/Borrower.NA Propetty Address:130 Gtenwood Rd City:Dillsburg County:York Stafe:PA Zip: 17019 . Legal Description:Deed Book 46V Page 644 8 Deed Book 50W Page 142 .: .� �-��.' '��r�,: '�. '� � � a � '� ; ��"3 � .: �� . : `^, �.E__ _ ' � :� 3a: �,.� .. .�<a�; }�',y�x >?$..i _ r e:.._ �"'A.t..4 '�..��a�'�.,....axY.: Form 1004 275.00 SUBTOTAL : 275.00 - : �y� r '�,�.-�� .w,�,1 -�r, .� .�. 'S � '�.�✓ . � ��.� � -�3k .�+>t v� '� ,�,''�x""� . .� �}� � � r }�� 3� �''`r�«.� E � z } � � �.�,& -�: ��°t�z ?� . ��_��{��`� � r- � �.�;j� n�c �°�� ,g z*� h o� r^ s f�a a 3 ��, �I r, � 2+"�t �%,Y ��a ! k � �� r $�-.�, ir x �.�r-*�t..�+h L� �"s f :. ..k �" "� ..�,��''�fr.a�Y��'� r �k'� ��k. ..<�., x''�.x: -. .x....,..�.0 s..- �.. �,...�:t.,r,. .,.:,.s ......-,>.,..r..<:,.r, .,:..: .._.....,.. ,-,: fg Check!/: Date: Description: Check#: Date: Description: Check#: Date: Description: SUBTOTAL : TOTAL DUE $ 2�s.00 Fam NIV5—"WinTOTAI'appraisal sottware by a b mode,inc.—1-BOQALAMODE Appraisal Sdutions(717)&97-1626 �� .` pennsylvania OEPARTMENT OF PUBLIC WELFARE July 31, 2013 THE WILEY GROUP JAN M WILEY ESQUIRE 3 N BALTIMORE ST DILLSBURG PA 17019 Re: Ruth Miiler CIS #: 870Z55398 SSN: �##-##-3636 Date of Death: OSj27/2013 ESTATE RECOVERY STATEMENT OF CLAIM Dear Attorney Wiley: Under State and Federal law, the Department of Public Welfare (the Department) is required to recover medical assistance (MA) reimbursement from the prvbate estates of deceased individuals who were over age 55 when such assistance was received. 42 U.S.C. §1396p(b)(1). 62 P.S. § 141Z. This letter sets forth the amount of the Department's claim against the estate of the above referenced individual and explains the obligations of executors, administrators, and persons receiving estate property. Although the amount in the estate may be considerably less than that which is owed to the Department, our claim is against the estate, no one else. Statement of Claim Amount The Department maintains a claim in the amount of �187,294.13 against the above-mentioned estate. This claim is for repayment of MA granted on beha{f of the decedent. Enclosed is the Department's itemized statement of cfaim. ion of this medical ex ense namel 31 007.70 was incurred durin th� (ast A '�� , Y , 9 six months of the decedent's life; therefore, it is a Class 3 c{aim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namefy $156,286.43, is to be entered as a priority Class S.1 ctaim against the estate. You should refer to Section 3392 for a more complete explanation of the priority rules. If a lawsuit is filed for injuries sustained by the decedent prior to death, then the Department may also have a lien against the personal injury action. A statement of claim for that injury-related lien must be requested separately. Bureau of Program Integrity � Division of Third Party Liability ( Recovery Section PO Box 8486 � Harrisburg, Pennsylvania 17105-8486 � �`` pennsylvania � DEPARTMENT OF PUBIIC WEIFARE Your Responsibility to Provide Information to the Department Please acknowledge receipt of this letter and advise whether the Department's claim is admitted and when payment may be expected. When the estate accounting is complete, please provide a copy. The Department audits all estate recovery claims and therefore we require documentation to substantiate all deductions from the gross estate. The regulations governing how the Department computes its estate recovery claim are found ir� 55 Pa. Code Chapter 258. These regulations are readily available on the Internet, in addition to being carried in most local !aw libraries. In order to document computation of the arnount due the Department, the following items should be submitted to the address below: 1. For real estate: a. Copy of the deed b. Copy of the latest tax assessment c. Copy of a current appraisal, if available 2. Copy of the funeral bill 3. Copy of the statement of the burial account if one existed � 4. Copy of the statement of the personal care account balance at date of death, if the decedent was in a nursing home 5. Copies of original and updated life insurance policy forms naming beneficiaries 6. Copies of any and all stocks and bonds 7. Copies of bank statements showing balances on the date of death 8. Copies of signature cards or other proof of when accounts were made joint 9. A Iist of any gifts or other transfers for less than fair market value made by the decedent (personally or under a power of attorney) Your Responsibilities to the Department Under State law, executors or administrators may be personafly fiable to pay the Department's estate recovery claim if they transfer estate property without the Department's claim being paid. Persons who receive that property without paying valuable and adequate consideration to the estate may also be personally liabte. The responsibilities of the primary next of kin/administrator/executor, is to advise the Department of any assets in the estate and to ensure that the remaining money, after all funer.al and administrative costs are deducted, is sent to the Department. Accordingly, you must ensure the Department's claim is satisfied before making distribution of assets to heirs. Bureau of Program Integrity � Division of Third Party Liability � Recovery Section PO Box 8486 � Harrisburg, Pennsylvania 17105-8486 � ! pennsyLvania DEPARTMENT OF PUBIIC WELFARE Insolvent Estates and the Fiduciary Responsibility to Creditors If there are not enough estate assets to pay the claims of ali creditors in fufi, then the executor or administrator has a duty to act in the best interest of creditors when administering the estate. If you must spend the estate`s money to administer it, you must act prudently and make purchases as if the money were coming out of your own pocket. The Department's approval is required if you expect the tegal fees to exceed more than the greater of 6% of the estate assets or $1,000. Contingent fees for estate administration will generally not be approved. If yau do not obtain approval, the Department may consider the excessive fees to be a transfer for less than valuable and adequate consideration. Sincerely, � �� v� Elvetta E. Knox Claims Investigation Agent 717-772-66I3 717-772-6553 FAX Enclosure Bureau of Program Integrity � Division of Third Party Liability � Recovery Section PO Box 8486 � Harrisburg, Pennsylvania 17105-8486 BUREAU OF PROGRAM tNTEGRITY DIVISION OF THIRO PAR7Y LIABiLfTY RECOVERY SECTION PO BOX 8486 HARRISBURG,PA 17105�486 June 21,2013 STATEMENT OF CLAIM SUMMARY NAME Estate of MILLER,RUTH ID 870 255 398 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT _00 .00 .00 O UTPATI E NT .00 .00 _00 l_�NG TERM CARE 31,C�07_70 156,286.43 187,294.13 DRUG .00 _00 .00 RElMBURSEMENT TO DPW 31,007.70 156,286.43 187,294.13 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBUC WELFARE E!N- 23-6003113 � Page 1 of 6 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBUC WELFARE June 21,2013 STATEMEN7 OF CLAIM NAME MILLER,RUTH ID 870 255 398 GOLDEN LtVINGCENTER-WEST SHORE 770 POPLAR CHURCH RD CAMP HILL PA 17011 DATE OF SERVtCE PAYMENT DATE ORIGINAL CRPI ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 08/22M0 - 08/31110 10/17/11 55112854480040001 55112854480040001 2,176.50 1,530.03 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 09/01110 - 09/3Qh0 10/17/11 55112854480030001 55112854480030001 6,529.50 5,869_23 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA DIAGNOSIS 2_ 2768 HYPOPOTASSEMIA PROC CODE_ 000000 10/01l10 - 10/31/10 11/21/11 55113194401770001 55113194401770001 6,747.15 6,482.37 DiAGNOSIS 1 : 29010 PRESENILE DEMENTtA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 11/01110 - 1t/30/10 11/21/11 55113194402670001 55113194402670001 6,902.40 6,252_63 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMiA PROC CODE: 000000 12/01/10 - 12/31/1a 11/21/11 55113194403810001 55113194403810001 7,132.48 6,482.37 DIAGNOSIS 1 : 29410 PRESENILE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 01/01/11 - 01/31/11 12/19/1 i 55113474400030001 55113474400030001 7,132.48 6,128.48 DIAGNOSIS 1 : 29010 PRESENILE DEMENTiA DIAGNOSIS 2: 2T68 HYPOPOTASSEMIA PROC CODE: 000000 02/01111 - 02/28i11 12/19/11 55113474400040001 55113474400040001 6,442.24 5,453.63 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 03/01111 - 03/31/11 12119h1 55113474400050001 55113474400050001 7,132.48 6,128.48 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA DlAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: �0�000 Page 2 of 6 � COMMONWEALTH OF PENNSYLVANIA � DEPARTMENT OF PUBLIC WELFARE June 21,2013 � STATEMENT OF CLAIM NAME MILLER,RUTH ID 870 255 398 GOLDEN LIVINGCENTER-WEST SHORE 770 POPLAR CHURCH RD CAMP HILL PA 17019 DATE OF SERVICE PAYMENT DATE ORiGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 04/01/11 - 04/30t11 01/16/12 55120124183910001 55120124183910001 6,902.40 5,567.83 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA DIAGNOSIS 2: 2768 NYPOPOTASSEMIA PROC CODE: 000000 05/01111 - 05/31/11 01/16/12 55120124183920001 55120124183920001 7,132.48 5,781.59 DIAGNOSfS 1 = 29010 PRESENILE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: OOQQ00 06/01/11 - 06/30/11 01/16/12 55t20124183930001 55120124183930001 6,902.40 5,567.83 DIAGNOSIS 1 : 29010 PRESENILE DEMENTlA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: OD0000 07/01/11 - 07/31h1 05/07112 55121254283690001 55121254283690001 7,132.48 5,540.41 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA DfAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 08/01111 - 08/31/11 05/07/12 55121254283980001 55121254283980001 7,132.48 5,540.41 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA DIAGNOS(S 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 09/01/11 - Q9/30/11 05/d7/12 55121254283680001 55121254283680001 6,902.40 5,334.43 DIAGNOStS 1 : 29010 PRESENILE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 10/01111 - 10/31h1 06/18/12 55121654229800001 55121654229800001 6,626.56 5,913.96 DtAGNOSIS 1 : 29010 PRESENfLE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMlA PROC CODE: 000000 11/01h1 - 11/30/11 06/18/12 55121654232010001 55121654232010001 6,412.80 5,695.93 DIAGNOSIS 1 � 29010 PRESENILE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE= 000000 Page 3 of 6 ICOMMONWEALTH OF PENNSYLVANIA I DEPARTMENT:OF PUBLIC WEL�ARE June 21,2013 STATEMENT OF CLAIM NAME MILLER,RUTH ID 870 255 398 GOLDEN LIVINGCENTER-WEST SHORE 770 POPLAR CHURCH RD CAMP HILL PA 17011 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 12/01h 1 - 12/31h 1 06/18l12 55121654233330001 55121654233330U01 6,626.56 5,913.96 DIAGNOStS 1 : 29010 PRESENILE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 01/01112 - 01/31/12 07/16N2 55121944355320001 5512'!944355320001 6,626.56 5,73'!_99 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 02/01l12 - 02129/12 07l16/12 55121944357380001 55121944357380Q01 6,199.04 5,307.67 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 03/01l12 - 03/31/12 07/16/12 5512194435883Q001 55121944358830001 6,626.56 5,T31.99 DtAGNOSIS 1 : 2901Q PRESENILE DEMENTIA DtAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 04/01112 - 04/30l12 05128/12 20121254Q65160001 20121254065160001 6,412.80 5,714.23 DIAGNOSIS 1 : 29010 PRESENILE DEMENTlA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 05/09/12 - 05/31/12 06/25/12 20121534140360001 20121534140360001 6,777.84 5,932_87 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 06/01/12 - 06/30i12 07i23/12 20121844266810Q01 20121844266810001 6,559.20 5,714.23 DIAGNOSIS 1 : 29010 PRESENILE DEMENTtA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 07t01h2 - 07/31/12 01/28/13 55130244792860001 55130244792860001 6,777.84 5,325.58 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 " Page4of6 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WEI�ARE June 21,2013 STATEMENT OF CLAIM NAME MILLER�RUTH ID 870 255 398 GOLDEN LIVINGCENTER=WEST�SHORE 770 POPLAR CHURCH RD CAMP HILL PA 17011 OATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 08/01/12 - 08/31/12 01/28/13 55130244794290001 55130244794290001 6,777.84 5,325.58 DIAGNOSIS 1 : 290'�0 PRESENILE DEMENTlA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 09/01/12 - 09l30/12 01/28/13 55130244795790001 5513024-4795790001 6,55920 5,379.68 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA D{AGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 10/01/12 - 10/31/12 02N8/13 55130444208950001 55130444208950001 6,777.84 5,6Q4.6'1 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA DIAGNOStS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 11/01/12 - 11/30/12 02M8/13 5513044421'1350001 55130444211350001 6,559.20 5,334.43 DIAGNOSIS 1 : 29010 PRESENILE DEMENTtA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 12/01/12 - 12/31/12 02/18/13 5513Q444212970001 55130444212970001 6,777.84 5,566_09 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA DIAGNOStS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 01/01/13 - 01/31/13 02/25h3 20130324231770001 20130324231770001 6,170.55 5,497.32 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 02/01113 - 02/28/13 03/25/13 20130604233810001 20130604233810001 5,767.44 4,883.55 DIAGNOSIS 1 : 29010 PRESENtLE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 03/01/13 - 03/31/13 04/22/13 20130914185480001 20130914185480001 6,385.38 5,701.32 DlAGNOSIS 1 : 2901Q PRESEN{LE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 Page S of 6 __ ___._ _ _. _ 7 _ _ _ _ _ � __. ( COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WEtFARE June 21,2013 STATEMENT OF CLAIM NAME MILLER,RUTH ID 870 255 398 GOLDEN LIVINGCENTER-WEST SHQRE 77U POPLAR CHURCH RD CAMP HILL PA 17011 DATE OF SERVICE PAYMENT DATE OR{GINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 04/01/13 - 04/30/13 05127/13 20131234055280001 20131234055280001 6,179.40 5,074.33 DIAGNOSIS 1 : 29010 PRESENILE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PROC CODE: 000000 05/01113 - 05/27/13 06/07/13 69131584022170001 69131584022170001 6,116.61 4,285.09 DIAGNOSIS 1 : 29Q10 PRESENlLE DEMENTIA DIAGNOSIS 2: 2768 HYPOPOTASSEMIA PRQC CODE: 000000 PROVIDER SUB TOTAL GOLDEN LIVINGCENTER-WEST SHORE 222,016.93 187,294.13 03 1Q1553152 0001 Page6of6 OMB NO.2502-0265 � A B. TYPE OF LOAN U.S.UEPARTMENT OF HOUSING 8 URBAN DEVELOPMENT ��fHA 2.QFmHA 3�CONV UNiNS 4�VA 5.QCONV INS 6 FILE NUMBER 7. LdAN NUMBER SETTLEMENT STATEMENT wES,zz-,z 8. MORTGAGE INS CASE NUMBER C. NOTE This form is lurnished to grve you a statement oi actual settlemen[cosa Amounts paid to and by the settlement agenf are shown. IFems ma�ked'(POCj"were pard outside the cfos�ng;they are shown he�e for mformatronaf pwposes and are nof included rn the fotals '•0 3.5E �V1'ESt72-t7 PFD/WESt2?-t2�; D. NAME AND ADDRESS OF BUYER: E. NAME AND ADDRESS OF SELLER: F NAME AND ADDRESS OF LENDER WILLIAM H V1�ESSELS ESTATE OF RUTFi I MILLER PRE-APPROVED BANK LOAN 871 RTE 15 NORTH 130 GLENWOOD ROAD DILLSBURG,FA 17019 DIILSBURG.PA 17019 G. PROPERTY LOCATION: H. SET7LEMENT AGENT 25-1619811 L SETTLEMENT DATE: 130 GLENWOOD ROAD TRt-COUNTY ABSTRACT SERVICE DICLSBURG.PA 17019 August26,2013 YORK CounN,Pennsylvania PLACE OF SETTLEMENT 3 NORTH BALTlMORE STREEl DILLSBURG.PA 17019 J.SUMMARY OF BUYER'S TRANSACTION K.SUMMARY OF SELLER'S TRANSACTION 100. GROSS AMOUNT DUEFROM BUYER: 400. GROSS AMOUNT DUE TO SELLER: 101. Contract Sales Price ! 129,OOD.00 401. Contract Sales Pnce 12g ppp pp 102. Personai Pro e 402 Personal Pro ert 103. Settlement Char s to Bu er(Line 1400) 2,a62 00 a03 104. 404 105. � 405 Ad ustments For Items Paid 8 Seller in advance Ad ustments For ltems Paid 8 Sef/er in advanee td6. Ci ffown Taxes 08t26/13 to 01/01!'I4 255 1a ap6 Cit/Town Taxes 08/26l13 to 01/01/14 ! 255 14 107. Coun Taxes to 407.Courn Taxes to 108. SCHOOL 7AX 0826/13 to 07l01l14 , 1,729.66 408 SCHOOL TAX 08l26/13 to 07101/14 1,7zg_� i 09. � 409 110. 410 � 111. 4i1 I 12. 412- 120. GROSS AMOUNT DUE FROM BUYER � '133,446.80 470 GROSS AMOUNT DUE TO SELLER � 130,984.80 i ?00. AMOUNTS PAID BY OR IM BEHALF OF BUYER: 504. REDUCTIONS IN AMOUNT DtJE TO SELLER: '01. De osil or earnest mone 5,000.00 501. Excess De sit See Inslructions ; ?02. Princi al AmounC oi New Loan s 502 Settlement Char es to Seller(Line 1400 ' 3,342.26 '03. Existin loan s taken sub�ect to I 503. Existi loan s taken sub ect to � �� i 504.Payoff of first Mortgage '05. 505.Pa off of second MoR a e '06. 506. �� 507.(De sit disb.as roceeds '08. 508. '09. 509 Ad ustments For Items Un aid B Setler Ad ustmenfs For ltems Un aid 8 Selfer '10. Ci lTown Taxes to � 510.Ci lTown Taxes to 11. Coun Taxes to i 511.Coun Taxes to � 12. SCHOOL TAX to 512.SCHOOL TAX ta , �3 513. 14. 5t4. 15. 515. �6. 516. 17. ' S17. 18. 518_ �g� 519. 20. TOTAL PAtD BY/FQR BUYER 5,000.00 520. TOTAL REDUCTION AMOUNT DUE SELLER j 3,342.26 00. CASH AT SET7LEMENT FROM/TO BUYER: 600. CASH AT SETTLEMENT TOfFROM SELLER: 01. Gross Amount Due From B r line 120 133,446.80 601. Gross Amount Due To Seller Line 420 130,984.80 02. Less Amount Paid /For B t(Line 220) ( 5,000.00 602. Less Reductions Due Seller(Line 520) ( 3,342.26 03. CASH(X FROM)( TO)BUYER 128,446.80 603. CASH(X TO)( FROM j SELLER �27,gq2_5q The undersigned hereby adc e receipt of a completed copy of pages 182 of this statemenS&any attachments referred to herein_ • 1 HAVE CAREFULLY REVIEW T E HUD-1 SETTLEMENT STATEMENT AND TO THE BEST OF MY KNOWLEDGE AND BELtEF,tT lS A TRUE AND ACCURATE STATEMEN7 OF CEIP7S AND DISBURSEMENTS MADE ON MY ACCOUNT OR BY ME IN THIS TRANSACTiON. 1 FURTHER CERTIFY THAT f HAVE RECEIVE� F THE HUD-1 SEITLEMENT STATEMENT. Buyer Seller ESTATE OF RUTH I.MILLER WI AM SSELS BY� TO THE BEST OF MY KNO DGE,THE HUD-1 SETTLEMENT STATEMENT WHICH I HAVE PREPARED IS A TRUE AND ACCURATE ACCOUNT OF THE =UNDS WHICH WER CEIVED AND HAVE BEE OR LL BE DISBURSED BY THE UNDERSIGNED AS PART OF THE SETTLEMENT OF THIS tRANSACTION. , ' .�� . � � M�, TRI-C TY A S RV ��' Settlement Agent NARNING: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATE MENTS TO THE UNITED STATES ON THIS OR ANY SIMIIAR FORM. PENALTIES UPON :ONVICTION CAN tNCLUDE A F{NE AND IMPRISONMENT. FOR DETA{LS SEE: TITLE 18 U.S.CODE SECTION 100t 8 SECTtON 1010. Page e L.SETTLEMENT CHARGES 700.T::TAL COMMISSION Based on Price $ o�p Ph1�J(ROAA PRICfROAF Jivis�on of Commissron(line 700)as Fallows '�1.$ (p 6UYEF'S �EiiER'S '02 $ to �uNOS c, FuNes a7 '03 Comm�ss�on Paid at Settlement `EriiEr�ENT seiTLEMEk' '04 TRANSRCTION FEE to 300.ITEMS PAYABLE IN CONNECTION WfTH LOAN )01 loan On inatior.Fee % t0 �OZ loan Discount °k to 303 Appraisal Fee to 164 Credrt Report �p _ i i05. Lender's Inspection Fee to 106. Mort a e tns.A Fee to -- t07.Assumption Fee to s08 s09. I10 �1 1. �00.lTEMS REflUIRED BY LENDER TO BE PAID IN ADVANCE �01.Interest From te @ 5 ldaY ( days %) �02 MIP Totlns for LifeOfLoan €or months ro �03.Hazard Insurance Premium tor 1 0 ears to �04 ( �05. 000.RESERVES DEPOSI7ED WITH LENDER 001 Hazard Insurance months $ er month 002.Mort a e insurance months � er month 003 Cit/Town Taxes months $ er month 004 Coun Taxes months $ er month 005 SCHOOL TAX months @ $ per month 006. months $ 007 er month months @ $ per month 008.AGGREGATE ESCROW ADJUSTME months $ er month 100_TITCE CHARGES 101 Settlement or Closin Fee to 102.CLOSING PROTECTION LETTER to FIRST AMERICAN TITLE INSURANCE COMPANY 103 Titie Examination to t04 Title Insurance Binder to 105.Document Pre aration to 106.Nota Fees to CASN 1fl7.Attorney's Fees �0 10.00 inGudes above item numbers: 108.Title Insurance to TRI-COUNTY ASSTRACT SERVICE/AGENT FOR 1ST AMERICA 1 045.00 includes above itern numbers5011442-0076918E 109.tender's Coverage g 110_Owners Coverage 5 129.000.00 1,045.00 111. ENDORSEMENTS 112. 113. 200.GOVERNMENT RECORDING AND TRANSFER CHARGES 201.Recording Fees: Deed $ 63.50;Mortgage $ Releases $ 63.50 202.Ci ICoun Tax/Stam s Deed 1,29�.00•Mort a e 1,290:00 203.State Tax/Stam s: Revenue Stam s f,290.00:Mo a e 1,290.00 204.2ND DEED to YORK Coun R ister of Deeds 63.50 205. 300.ADDITIONAL SETTLEMENT CHARGES 301.Surve to 302.Pest Ins ction to 303.RE-IMBURSEMENT FOR TAX CERTS to TRt-COUNTY ABSTRACT SERVICE �� 304.2013-2014 SCHOOL TAXES to CLYDE M.FLOHR,TAX COLLECTOR ID 29-000-NC-0057 �,471.54 305.2013-2014 SCHOOL TAXES to CIYDE M.FLOHR,TAX COLLECTOR ID#29-000-NC-0057A 530.72 300.TOTAL SETTLEMENT CFiARGES (Enter on Lines 103,Section J and 502,Section K 2.462_00 3.342.26 3f 59^�9 Pege 101 Rrs staumenC 7�e signetories ack^ow�etl9e�eceW��a wmp�emG coPY of page T of tlrs�rro Ia�emaK ^�\ � N� s ' �� TRI-C NTY ABSTRA T SERVICE �ertified to be a true copy. Settlement Agent - �wes,n-,z,wes,zz-,z,e� , i � ' � ► E I I � t I �!�� i�.� ��tx� t�J��.t�rrx.��t� � � OF R1�7'H I.MII..LER E B�� IT RENIEI�IBERE7). that l_ Rt�TH I. MILLF 1i_ r�l i,(1 C�lert��uoci R��a��_ f � Dill�hl,r�_l�orl.Cc,imt��_Peiu��I�:t��ia_bein�ofso�u�d mincl_r7��c�r� anii�inder�tai�di�z,�. ; d�,mak�_puhfi�h and declarf�tr,i�as and form��I.,�tSt V�JIII dllC� I�titallltlli_�1�i�I)V ECV(1�1I1�� - � � � a�;d �?�akin�� null and void any an�-�al� l�l-ills and Testament�; an� ��itin�s in tl�e natii:e thereof b.°me at a�1��time heretofore made. l7'EM l: 1 direct that all my}ust debts and funera]e�penses be paid as soon aftei- mv demise as ma�-be convenient. . ITEM 2: Al1 the rest;residue and remainder of my estate.of whatsoe��er i�ature and �vheresc�e�•er situa,e.whether it be rtal_personal or mixed.includin��propertv over��-hich 1 ha��e:a po�her�f appointment,I�i�-e,devise and bequeath u�ito my husband,CHARLES E.Ml.l_LER,absolutely.provided he survives me for a period of thirty(30j days. �TEM 3: Should my husband,-CHARLES E.MILl_ER,predecease me_faiI t� survive me for a period of thirty(30)days,or sh�uld we die simultaneouslv, I then give devise and bequeath my residuary estate as follows: A_ I give my home situate at 130 Glenwood Road:Dillsburg,Pennsylvania, consisting of approximately 2 acres,as well as all personal property therein,to my daughter NDIT�-1 E.SMITH,providing she survives me. B_ I give the sum of Five Thousand Dollars($5.000.00)to my da�ghter, NANCY K.BENDER,providing she survives me. C. 1 give the remainder of my estate,to MY LIVING GRANDCHILDREN. 'ITNESS: / �S � '1 -c.��' C�!. ��,.��SEAL) � RUTN I.MILLER % � � � �� -j.- i I ITEM 4: 1 di�-ect m��hereinafler nait�ed f:�ecut��r to pa�� a}1 inE,critance_est��te. suceession and le�a��• taxes uj��hatsoe��er ncit�fre and kind_ to ��hic4i m� e�tate or the transfer of an�°pri�p<►-1� passin�_>hereunder o�-i�ther�vise passin��b} reatie�n ul�m� demise_ .. { � ma� be subject anci t��ch,rge sucl�taxes again�t ��: residz�an�estate_it hein,�t:�v intention , - - - - that nane of the aii�resaid ta�es_ either federal or state. on anv propern required to be included i�i my�r��s�estate_under the provisic�nt of any state or federa} 1�� no��in force or hereafier enacteci.shal)be prorated amon�tl�e persons interested in n�� state to whom such property is or may be transfen-ed or to��hom any benefit accrues. ITEM 5: 1�tE��)n1J1[I71y husband,CHAK1_ES E.MILLER;as Exe�utar of this my Last Will and Testament. Should my husband predecease me_fail to gualih-,cease to act or renounce prob�te_ I then appoint n�y dau`�hter. 3UDITH E. SMI7�H, as alternate Execiitria of this m��Last �Vill and Testament. ITEM 6: I direct that my Executor.c�r his successors shall not be required to gi��e bond for the faithfiil performance of their duties in any junsdiction. IN WITNESS WHEREOF,I have hereunto set my hand and seai this c°f h day of Aug�t;?ao�. ESS: ,, � �► '— � ( �� .�tiC�c� � � ��--c�SEAL ( ) RUTH I.MILLER G�� / -2- (�(>��i1�70NWEALTH OF PF\�SYL�'ANIA . :SS ('()t;;�'TY OF YORK V4'e. RLiTN l. iV]ILLCR, JAN M. ��ILEI', ES(�UIRE and R9A�tC1 �:. 12L1�HA�'1'_the Testatrix an�the w.itnesses respectivei�_��1�oce names are si�nei;u�th� attac}�ed or foregoing instrnrue�t_ heine first duJy s��on�_ do herebv declare to ii�c un�iersigned authority that the Testatrix si�ned and executed the instniment as her 1_.aci 4��i l I and��estament and that she had signed willingl� (or willin,�ly directed a�iotller t��i�1t 4i�r her►_ and that she executed it a� her free and volwtta�-� act for the purposes therein e�pressed, and that each of the �vitnesses, in the presence and hearin�of the��estatrix. si�ned this Last Wi11 and Te:�tament as witness and that to the best of their kno��led�r tI�r Te�tatriY v��as at the time eighteen(I S)years of age or olcler,of sound mind and uf�der nu constraint or undue influence_ � �� -��- 'x <' , ��- I ,C-C,E'_::�'--- I.MILLER `—� _'�+�r � �•.� — SS /' ' C, `��.� .� WITNESS S«c,rn to and subscribed before me this �`�da of Y August;2U07. NOTARY PUBLIC MY COMMISSION EXPIRES: co+►�,r,�faR,Ea��-;G�PEiVNSYLVANIA �8!�$�,��`�) ' . +i•-�If�'� ...r��. . ,y . ` ��.YW�C C,pl1f)l�j IC E�res May 17.20pg Member,Pe��artia As��;��n�f Hotaries ��N'W a��N�'!��-;i:�PEiVNSYLVANIA � i Notaria[Sea� � t S.Dawn Giadfelter,lVotary Public �9 Boro,York Coirriy ��n��`�s�ay��s� Member.Pennsylvania Association of Notaries _Z_ N � � � � ( � \ n � � , i � � . � � � � � \ � � � � — —� , — �-- _ � �: } '" � ��, .�� * � � ��{ - — . — — _ — ,.. �. . .. ,._. , , ,e � . i , . �' �� ,� � ,� � � � -> �s „ . - e _ :_S� � c:5tr .. .. �� . . .. �. .. . p,- � s. ,.. �+„��-�b fv . ... .. z: ?z . � ,� . . . `� �.^�Y��.'a� �� : . . . ��n� �.x ��**��S%'k�w a'�,t?: $��q�., ., � _ . - - � . - § "�a" � � x 9 k',�y �� . ... . :'� ,�+- � �� . . � k��#x� � 3 � �kM1: 4 . �� { � h," ��k x ;k�`'��.� ��,; � p!�.,` +# � s.�,^K Es '� �,T. -r.'� �s � # -f y"'a� � ��.,� W;.. 'a S' _ s''� �`„a�+��'� �. ..��.�r�. . . _ �„, r"��.-�°` r � � 3`''�:�=rD�`�f-5,., .. �9 ";s .Y.�;„�a` � _ � � . , ` +� u ° _ ., J � �'� ,. � �, ..�. �' `� '�'i�v��'`� u r Y.�' '�-.,�y' rr � �` '..� . ��"» F� t_ �' �i"� �.�'�;G« '� +�.i�+�r��,.:. . � . � 4� .. .x � � i &` ' . • g .� ° , ��' #.. �k �� ,�:.��"'�y��r�Y` d . .�;,x t . 3 . �.�i�:�. � k i' I � '-*��' I 6 `'J � �r" �-` �': ' RA � ; +-�� U.� �� „� � �, , , � �: ,��. X�Y•�4a . �� : . bF �`P,g�'Y*f9" �' :. dr., ��. ,x '4 sfCf�i'4��'+�. � 'S�� F'S . �5��'" �5� � � �'£� ��` ii . r � '��,�� _ x_5 � � ' � �� M � � �� ,�� r�' ;��r' ,��'��',�� x � w� � .� �� 3-��.'°� '.,�h ri' 4�`��"�� t . . o x � _ ��s �,S :. " . :s r�� '. � ' �� a y a � �� , �� ,�,�fi� �:'�' i �,�� „ � ,� � £.�'��".'��f� �l��. � - : �a� �. �� '�.�' �t�� i � "'�' y°: . �,�ri�,°�*� �jr��"a�� : . �'� 3;� } }�� "�-�.� w' � � 0.'.h ' . � � i l �£�a�.,,'x'�L A , . i . . . .. . ��.:'"�-�Y 7'" .n :+:'.�� '"�� . c: � d . . � •� , .-r �.� . � �. ' � : ., -.� i�'. ..�. . . . . . . .. . . .....� w .. ......, ..��' . . " .. '--_", ".:�. .... ,,�:�ds'�`�n.s�¢�F �.,:..�t ,-..:- � ,... .,..... ..... ,'.. .� . . �.� ...... .... ._.. t. ... .:... ...., _. . .' .. .... .�.�� . . . . . � . . . ... ...Y. .>....... . ... .. . ., . �...._.. . . .....�..�., .. V',�,,'�'°', ��'�*+,"e+' . . .� ' _ ��a,�v .; .� � 2� . 3,��,� ..��- �, '". . � ,, :.. : . Y Y � . � 7 L } 5*�h �t � '.-i �+� ' Y r�{ m . - � . �.� 4 „� . �a ,�, 7`- �{q 'Y • h� . k a�� ... , .. .. . _ . .r � '� . � .,' , ... . .' . � . ��,� . . . . � . . �� , i> '� '. ' . .. . K.� .5 � +,".. . � . . :ZYt�✓f t ,�� ,.i... . ?: . . ��`�� .:.� * � � C, . q ' p �� 6�� '� _? �_c .. ��E £ �'��'"��,a�°��* - � ��'" �� '+�'�� ;�� , � _ . a .,:. ,r»k s, �,, � �4 ,�.� � �. �� . +'�«xr�'t�4� d ..� �-� .� �t�r-i�, �'- - . .. . . - f ��4'M'R..: '",. y�.' k t .'.� f�"T� • w^n.� >' ' ,' � � .. ��§*1:^vxa`"R�'s+" i ,�. _ �: � I i rF�I�'1 d�� i�i'C ?@� - � � L .� i+�� . f,, `�. 1 � '��`C f' j . • � � . � � b -�� „ q'�A 4�r ��, .. .. . �'s^�$`�� P 'q�'�'F�-.,� . � � �� . . . . .. . . . ... . .. . �:: . . >� . . .. . -.. . . . .. . i . . , . . , z . . . .. .. . . . . �_ ��, � � . . . . . . . . . , .. �k�� ! J �� ? . ��,.} . x �� . . {. _' . . ,. � �4. k�.:�_. �,"�a ''�� , � �'�.�+�� '� '_.�� . �`�: �°�. � ` � $ ,�� ; x`�'^��. �„ �. ,c . .` � z � ' y, � �. * �,!f�* t �'� ��.�� .'�.�'� f c^�+C��4Y� �3 4 v'.�� II .� ; �'.. '�'� '� w- �n §.�`:�' "V� `k .. - � " � ��`� � .y � . . . . . .. �{,� �t'�a�� ; , y � � a �",'�a i}�.� . - �k _ .��,�;,•x ...., . Z x,� � � ��. �� i Yk�. �.. ..��} '�, %*.r �r:.y � . . - ' �,...�.'�` �'�,';a"" x # �d s - �t �''� " ..� .. ' ,�.�y� �ii . �: , .. {� � , � . n�S .�� ,�,� . ��'� �. i ' C 1 '3 �t� J • c . �i i��S..��.. .. . .� � �e'�,�,.�-� :'sr` .: .'.,. .,.. _ b�T'�`�,.�a��'L`.��`�'tix'��,�. .. fi F`'Ya�' � s �,. �� .�y v'4t��r # �,�°-.:�.. . ,.. §.,��.��.,� �i y"��,��&v 5 �,� p > �...��'. ; . i ��,.. :=Y�':��i��e . �,.`� �.,g1 ?ac � Y A � �"�.�.sP � �� '. �� '�, � � . . 3!:RC A �� f .�}_ �`� c�� li }�� y v . _. F,.s. �a�4 � i � � �+ � �'o u '��'.�'`'�"�',r �� i - . . . . . ��.y�� y��r � �`� '�`� "''��t t � u '-��. `, ° � �� <- #�s�. �_'� }�' � .c . .y.�- .�� ii � ��+ ','�4��a�.tt.a�s r `��i-��. � . � � �u�'�m�{ h �,t� �K� �x � .{{ - �,/� piht r`. . � --. f � . FS �4rt�%- .F�..��,,��;s . . .. _ sr��`� t'� � �a T � � .� � ��' s - � �+�' �`�-, : , ��,�, :�,�,,� '� ��. g�_.: ,� _ . . €�'�. " �,: � �^�,x a �� - �� .�k� ��?. ..� y. i .�� : �{ -ar t t; �� ` � � - . . � .- '.,�.� v µ � �„' �� a� � 3 � � .�z��y �+ I�' � 4�'3v ��'�S' k � - - � . � �...�,�.. �v , I- � f �4YY � ��.. � ��p'. 4 c .., . . . . 'a 'Rd�k �� y�-P��s � � R k:� .a, "`.' .. . * ��.�� ' �t {`Y' 43f . �'� 1 +'� �.�`�:. � � . � � �''� �a � .�� +� t�' 'T � `� ,�� ,z, � � &'� ?.�: ,� �a ��r`c a Y�.,'`� '� 1 � .�� JF' � � 'i"� H . � y � � � Y�, �c�,y�r , .�V �.� �J 'F .+ r� t "+k� y , e.:�' . �� 'M ,�, �. � . �•F� 9E �. .4 �'S.: ,�'. iD ,� �;� ��q.Y �`. ��°`�`�!t . � S ; �� : a � ��y yy;� ��: � 4 t�� , y° — •�T _ �� U. ��i'4. r �x � '� � � 4 ��! -r�. ��A� .: . �h��ty:, > .�J � a 5 -: : � . �� -l��,a- `� ,��?a�' a"d'`�y�-:'. '„�i.i, � i�. . . � ,• - . � � �f S° �� IVIL ��`� M > r 5 � .;��x'� $ ��, °��4`� .g.. � �'z�?,�` t M�, �*ql - � �� " � �� ""� �"xc-�.y�;� �� ' , �f� B .��#Y ' �1' f"�`tF',', -� ,:�,5' ' � } f � �j ' �� . .i 6 ' ii. iii f i I,' ' i 'I {�� ..� x�'� � , . .. ��' �.��}�°i ��, � t�� .#y^�a�"��^e�+'�_,�. �.?'�, _ .. ^�k?_ `�'� ' t ��;.' ^t . , .:xt�'.:' '�'��T"�"� }y�'°# I'�� . . ._ . s, ._7,-. F '.�.'�- . �ti-.. , S r _ � ,= , � :� � "t��{V � rj. � ��i��i I �"�.<,�A� . +��' 'nt`�TY 3,: i�� '� � �, � � +� ... � «��, * "��'frx'.t' �,��v^ . ^`..; '1 i t e 13 � � �II '7', ��' � r � � � `< � ,�� _�� ,�. I�'�` � � �� +� I� �� .�� M �5 { � y i r;y��', � . t�'' +�7�.a��&� � ,�� . r3 �,r ad'�SS y �n*c�� i ..� y�. �J%'?�'� � � f q �� zx�� - a.' �-t' � i !�. � `.y �� x^ 4;, a ;a� � s €-�n'��= � �' �r��,� ��'� �`� �-�s��' �',�� nw "��" ., � , 1. r t� � , � ,,, ��,. ,�. i t�S �,.e �:,e v�» + �.r�.+�r s� . �,�,a;.� �a " `' .`': ,�- x�.:'� ' e :::y� �.`x`",��u.�, � a,.� °' '�-�� '�"°""+� �r��J � ..r'.� a �� ,`w�,��,'�-�'k�,#„-,r�`x^R 3'.�,��'�`�"i` p �� ;�"%��g��`i�s+�°',.,�� `,�v.��`'��,..`r*a'�-' •re x '� �x �;'„, >��- � , �� h�� -�� `�,-�. �e ��-° �"r` .^,� �� : <4�,� �,�,��: .�._ •*� _.x. ��k.�` �" � �a�, ��.. ��`�e*a.r ��,.�',4 p : . . �,: � . . �� 'R. k ' . 'G,�y. 3 � ` � ��s t . ..��.�i� �.. . , �,. �. � ,�j Y �� . r ,�. �x . � i _ , ��'�' �� ..• , sx � �+'9' � 3 �.vY�'".�} 1� .: h L.y fi �. -�� °,.��4��+,s "� 1�'��"�.��, r ;E� s �k�� ri'g"��a*�� `; ° �'� �� p��' �� a '�� :� '� � �� `?�� 2 �`�� `'�''�'? 'k �,'^'�` d' L:4 1 �. �' �,�.. ''�^a� }EF{ e'4-�. �^Y:�*�Y' � .G t: s'y 'Y .��",3�f' .,� . g . � „ ....s� ... �.�<':7 .� . .� k -�..i. � �. , . ,�z .,-_ ��: .. ,. . �+.�t�.:�,. ,a :5•°a m _ ..s _ �.. _- ..'F ��f?:r..,, ��:- _ . .T . . " � � � f''�J '.:,,;n � � � � � � � � � � � � � � � � � � n � t�" �.` m �'' � � �,, � � !—� � c�' � . %,� C3 Q� �7 � � "'� -,� -�t� � � `�,� -� -� � � �� ; • ;;�,� �,�. �„,,,, i � '"""� �,"' � � � � � C'�J ��; � � � � ; i � ; ; � O = . N � . '� � • O "' � � � O ; ,., • ,p► . ; • _;; .. �s _. , O � . �N �. . v� O � � � N..a Op • 3� �P►.... • 0 �� ` O� � �D $ �