HomeMy WebLinkAbout03-11-14 BUREAU OF INDIVIDUAL TAXES Penns Ivania lnheritance Tax � � ennS Lvania
PO BOX 280601 Y P Y
HARRISBURG PA 17128-0601 IIlfOC171atI011 NOtIC@ DEPARTMENT OF REVENUE
REV-1543 EX Doc EC (OB-12)
And Taxpayer Response ��`_�i�1
FILE NO.21 '— (�'
ACN 14103966
DATE 01-23-2014
Type of Account
Estate of KARL D JACOBS Savings
SSN 187-22-3564 X Checking
Date 2013 Trust
MARK P JACOBS County CUMBERLAND Certificate
1605 PRIMROSE LN �
DAUPHIN PA 17018-9594
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PsECU provided the department with the information below indicating that at the death of the
above-named decedent you were a joint owner or beneficiary of the account identified.
Account No.187223564
Remit Payment and Forms to:
Date Established 08-17-1993 REGISTER OF WILLS
Account Balance $1,333.16 '1 COURTHOUSE S�UARE
Percent Taxable X 50 CARLISLE PA 17013
Amount Subject to Tax $666.58
Tax Rate X 0.045
Potential Tax Due $30.00 NOTE`: If tax 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 will become delinquent nine months
after the date of death.
PART Step 1 : Please check the appropriate boxes below.
1
A �No tax is due. I am the spouse of the deceased or I am the parent of a decedent who was
21 years old or younger at date of death.
Proceed fo Step 2 on reverse. Do not check any other boxes and disregard the amount
shown above as Potential Tax Due.
g �The information is The above information is correct, no decluctions are being taken,and payment will be sent
correct. with my response.
Proceed to Step 2 on reverse. Do not check any other boxes.
C �The tax rate is incorrect. � 4.5% I am a lineal beneficiary(parent,child,grandchild,etc.)of the deceased.
(Select correct tax rate at
right, and complete Part � 12% I am a sibling of the deceased.
3 on reverse.)
� 15% All other relationships(including none).
p Changes or deductions The information above is incorrect and/or debts and deductions were paid.
listed. Complete Part 2 and part 3 as appropriate on the back of this form.
E �Asset will be reported on The above-identified asset has l�een or will be reported and tax paid with the PA Inheritance Tax
inheritance tax 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. /�
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10/29/2013 #3355 Milton Hershey MC not covered by Humana#18782873#18843569 $125.87
10/29/2013 #3356 Holy Spirit Hospital $350.00
11/24/2013 #3357 State Employees Retirement(overpayment) $85.42
11/24/2013 #3358 Health Network Labs(Humana) $25,g3
12/31/2013 #3361 Health Network Labs(Humana) $8.03
1/25/2014 #1175 Health Network Labs(Humana) $8.10
1/25/2014 #1176 VA(final bill?) $258.80
$862.15
Guarantor: JACOBS KARL D
22 GAIL RD
CAMP HILL, PA 17011-0000
Patient : JACOBS KARL D
Visit # : 18782873
-----------------------------------------
--------------------------------
____Date___- � _Svc Code � Descri tion Units Debits � Credits �
--------------- P � I
---------------------------------------
I03/07/13 I 9835040 � MEDICARE�ADVANTAGELADI _1 �$ • 00 _
------------------------------ I I 23 . 22 +
-------------------------
-------------------------
* - Not posted � Balance : � 54 . 78 �
--------------------------
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Statement on: 10/29/13 at 11 :36 AM
Guarantor: JACOBS KARL D -
22 GAIL RD
CAMP HILL, PA 17011-0000
Patient: JACOBS KARL D
� Visit ##: 18843569
�---Date----�-Svc Code � --------Description-----Units----D----------------------
---------------------------------- � � ebits � Credits �
-----------------------------
03/06/13 1805302 OP VISIT, EST PT, LEV 1
08/05/13 � 9835040 I MEDICARE ADVANTAGE ADI _1 90 . 00
-- -- -- ---------------------------- ----- ---- I I 18 . 91- �
---- -- -----
----------------------
- Not posted � Balance: ( 71. 09 �
--------------------------
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DATE: Q MEDICAL RECORD
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REMARKS:
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� � nt : JACOBS KARL D
�•• • . - j "� h i �� #: 18782873
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---------------------------
•• ` � • � Debits � Credits (
,. . • -. .
---------------------------
$ $ I 78 . 00 ( 23 .22- I
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�'� a"� '�---� `_' � � ---------------------------
� `� '��� � --p � Balance: � 54 . 78 �
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RECEIVED BY �l A�4'�f► � • • • •�
FM51(6/09)
PATIENT COPY
July 15, 2013
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Holy Spirit Hospital
017 SH5 2883 0726816711
Karl Jacobs Attention: Patient Financial Services
For: Jacobs, Karl D Telephone: (717)763-2138
22 Gale Rd
Camp Hill, PA 1 701 1-261 9 Pay Online:www.hsh.org
��i���i���II�����hli�illi��i�hl��liil��I��u���n��ilhl��ih�I Account# aaos2os�o
Date of Service: 12-17-12
PAST DUE AMOUNT: $350.00
VCiGI f\QII JQNVU.7. ..... ._ ._._._._.... . . . . ......__._.__ . .__ .. .. .._. ....
You have failed to resolve your financial obligation to Holy Spirit Hospital. Your overdue balance remains unpaid, despite
our previous attempt to collsct it from you. This is a serious matter and we expect payment.
Computer Credit, Inc. is a debt collector and a member of ACA International,the Association of Credit and Collection
Professionals. Unless you dispute the validity of the amount owed, you must satisfy your debt of$350.00.
This is an attempt to collect a debt and any information obtained will be used for that purpose. Your cooperation is
anticipated.
C`��
C.Jordan
Director of Operations Holy Spirif Health System provides financial counseling assistance to all patients
who may have d�culty meeting their financial responsibility_Please cal/the creditor
at the number above fo contact one of their financial counselors.
� �,�,j Reference Number
For more information � www.informationcci.com �•��� 7268 i671 5515
+�.
Return this portion with your payment
•' � , •� , � •
aece!vnr �
❑� ❑� ❑� ❑� GUARANTOR Karl Jacobs _ ,.
CARD NUMBER EXP DATE PATIENT Jacobs,Ki1fI D
ACCOUNT# 44082097 Q__
SECURITY CODE AMOUNT AMOUNT DUE $3�JO.00
SIGNATURE You may make check payab/e to5
PRINT CARDHOLDER'S NAME
ILLING AD s Holy Spirit Hospital
BILLING ZIP CODE
P.O. Box 822183
Philadelphia, PA 19182-2183
Computer Credit, inc. � :=m, �.e,
CCI KEY: 0726816711 i�ll�l��ll�lhli�i��ii������l�ull�4�l��l�i�i�hhlili��ill��l��
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TELEPHONE:(717)783-9065 .
FAX:(717}783-9599
TOLLFREE: 1-800-633-5461 �
www.sers.state.pa.us
November 14,2013 •
Estate of Karl Jacobs � Invoice#29256 _
. C/O Mazia Jacobs p . ; � �,�,c�� �
22 Gale Rd � �'`• • _
Camp Hill PA 17011 �^�``�;�' �'���
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RE: Karl Jacobs C�: �. �•z c.-�� �r,', ;�-C��'9 C�'�
SS#: ��.X-XX-3564 _--� ---- --- -- -- - __ _ ---- -
Dear Ms.Jacobs:
We have been informed of the death of Karl7acobs,a retired member of this System. We wish to
extend our condolences to you at this time. _
Since Mr.Jacobs died 10/22/13 and the October check was not returned to our office,this account
has been overpaid in the amount of$85.42 for the period from 10/23l13—10/34/13. It will
therefore be necessary for our office to be reimbursed for$85.42 to liquidate this overpayment
The reimbursement should be made payable to The State Employees'Retirement System,and
maiied with the enclosed copy of this letter to the address shown above.
If yon have notalready done so,we will need a certified copy or an original death certificate (
for onr file. If you cannot pennanently spare the originals,please submit them with a note to ask �
us to zeturn them. We will return the originals to you within 5 working da.ys.
Upon receipt of the reimbursement,this account will be closed. There are no further benefits to
be paid from this System. -
Should you have any questions concerni.ng this matter,please do not hesitate to contact me at the
above address or by telephone at(717)783-9065 or 1-800-633-5461,
Thank you for your coopera.tion.
Sincerely,
\��y
�, ��U�
L"mda Dolan,Admuinistrative Assistant
Harrisburg Regional Counseling Center
F.nclosure
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L A B O R A 7'O R 1 E S pNe�I�I ❑ws+a�r�o� po�eoovEn�
� 2024 LEHIGH STREET °""�""� °'°"'° "°°"`
ALLENTOWN, PA 18103 ,,,,�r,„�,�,�
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Please cor�tact your insurance company sra��tenrf on� p�v-rt�ts;�ouNr . " -ACCtwH'r�a.< `
for an expianation of your bitl. 12/23/2013 �.�0 250L130724-0
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Patient Name: KARL D JACOBS '� � � - • PAID HERE
�MAKE CHECKS PAYABLE/REMIT TO:��
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,,..; KARL JAC08S PO BOX 8500,LOCKBOX # 9581
� �'� C/0 MARIA JACOBS PHI�ADELPHIA, PA 19178-9581
V l���t 22 GALE RD
tAMP HILL PA 17�11-2619
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uiformation has cManged.and ir�ate changef�ai reverse side. YOUR PAYMENT�I ETI(�D E�IVEI.OPE
Physiciari: BRXTER DREW WEI,T.MON Diagnosis Coda: 782.3
Proceduee
Date Code Description Amount
10/27/13' 36415 :PHLEBOTdMY CHARGL� - 8.32
10/17l13 80098 BASIC NfETABOLIC PRNEI, 22.51
10�1�I13 85025 CBC WITH DIFF 23.23
10/17/13 P96d4 NURSE HM TRAVEL FLAT 1-68
10/17L13' PIMC NOT APPROVED (12/23/20T3,PIMC,1,26,00 - -5.32
10/17/13 :PIMC PAYMENT (12123/2013,PIMC,1-,26,0004171 -2_10
10/17/13 PIMC NOT P,PPROVED (12/23/2013,PIMC,1,27,00 - -10.88
10/i7/13 PIMC PAYMENT (12/Z3/2013,PIMC,1,:27,00041'71 -8.14
10/17/13 PIMC'NOT:APPR4VED {12J23/2013,PIMC,1,28,00 ' ` -12.91
10/17/13 PIMC PAYMENT (12/23/2013,PIMC,1,2$,OQ04171 -7.11
10J17/13 PTMC PAYMENT (I2/23/2013,PIMC,1,29,0004171 _ -1:18
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'"`Cre t Card payment accepted at: www.t�ealthnetworkl bs.co **
If y,our orrect ins rance information was not provided,to HNL at the time o service, it is
imp rtant that ou contact us immediately with this �nformation or you m � be held
responsible for the baisnce.
Curnent 31-60 Days 61-8Q Da s 81-12�Da s 121-180 Da s Over 18Q Da s pmount Due- 58.10
$s.�o $a.00 $o.00 $o.aa $o.00 $o.�
HEALTH NETWORK LABORATORIES�
PO BOX 8500,LOCKBOX#9581
PHILADEtPH1A.PA 19178-9581
If yocr have provided insurance information,the Amount Due Tax ID: 23-28487T4
represents;your insurance co-pay;deductible or non-cove�ed B'�p'�O"s cau=s�o�2��70
ser��ces_ Tai rree sr»os�z�
F�s�o�aes�
Account Number:250L13d724-0
STATEMENT P�eM Name:KARL D JACOBS
������������� SEE REVERSE SIDE FOR IMPORTANT BlLLING INFORMATION 17
� Health Network �r���s��W�Ma�ow.w�f�v�uqw�m� �a�w�esww
� LABORATORIES pv� ❑w�srr�o� p��
2024 LEHIGH STREET °�•°'"`
ALLENTOWN, PA 18103 es�n�e �sin�uX�o��r
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Piease cor�tact your insurance company �TAT���'�A'�'� PaY Tw�s an�ou�,T' ' accour,T n�o.
for an explanation of yaur bill. 11/21/2013 i6.03 249L.138684A-0
- SHOW AflAOUNT�
Patient Name: KARL D JACOBS - - = PAID HERE
�■�MAKE CHECKS PAYABLE/REMIT TO:��
�""IIIIII��III"III'IIII'I'I11�11'IIIII'�III111'1'lll�f'II'IIII �'10 HEALTH NETWORK LABORATORIES
� KARI D JA�OBS PO BOX 850D,L8CKBOX # 9581
C/0 MARIA JACOBS PHILADELPHIA, PA 19178-9581
22 GALE RD
CAMP HILL PA 17�11-2619
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249L138684A0000008�30U091913 6
] Piease check box if abwe address is 4xArtect a insura�e . PLEASE OETACH AND f�iURN TOP POHTION YVtiH
infortnadaf has changed,and imficate diange(s)on reverse�de. YOUfi PAYMENi IN ENfL05ED E�NEI.OPE
Physician: sAxTER DFtEw wEL�lorr Diagnosis Code: 285:2g
Date Procedure
Code Description Amount
09/19/13 36415' PHLEBOTOMY CHARGE 8.32�
09/19/13 80048 BASIC MLTABOLIC PANEL 22.5I�'
09/19/13 85025 CBC WITH DIFF 23.23•
09/19/13 P9604 NURSE HM TRAVEL FLAT 1.44��'
09/19/13 PIMC NOT APPROVED (11/21/2013.PIMC,1,20,00 -5.32v"'
09/19/13 PIMC PAYMENT (11/21/20i3,PIMC,1,20,0003606 -2.10=''
09/19/�3 PIMC NOT APPROVED {11j21/2U13,PIMC,1,21,00 -11_25 -� • �
09/19/13 PIMC PAYMENT (11/21/2013,PIMC,1,21,D003606 -'7.�� ; `�°'
0y/19/13 PIMC NOT APPROVED (11/21/2013,PIMC,1,22,00 -12.54 �'
09119/13 PINSC PAYMENT (11/21I2013,PIMC,1,22,0003606 -7_98.--
09/19/13 PIMC PAYMENT {11/21I2013,PIMC,1,23,0003606 -1.01�-
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If your orrect in rance information was not provided to HNL at the time o service, it is
�mp rtant that ou corrtact us immediately with this information or you m y be held
responsible for the balance.
Current 31-60 Days 61-90 Da s 41-120 Da s 121-180 Days Over 98�Days AIT10URt�U8' $8.03 ��
$s.o3 $o.00 $o.00 $o.00 $o.ao $o.00
HEALTH NE7WORK LABORATORIES
PO BOX 850Q.LOCKBOX#9581
PHILADELPHIA,PA 19178-9581
If you have provided insurance information,the Amount Due Tax ID: 23-2948774
represents your insurance co-pay, deductible or non-covered ���9 q��s ca��=B�0�o2-8170
services. Toll free 877-402�d22i
Fax 610-102 76B1
Account Number:249L138684A-0
STATEMENT P��ent Name: KARL D JACOBS
��� � �� SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION 10