HomeMy WebLinkAbout05-13-14 ESTATE OF i 'IN THE COURT OF COMMON PLEAS .
DOROTHY J:WARD CUMBERLAND COUNTY;PENNSYLVANIA
ORPHANS' COURT DIVISION
NO. t -14-04(oK
PETITION UNDER SECTION 3102 OF THE PROBATE,
ESTATES AND FIDUCIARIES CODE FOR
- -- -- - SEE`TTLEMENT-OF SMALL ESTATE -- - -
TO THE HONORABLE JUDGES OF SAID COURT:
Sherry Jean Ward, your Petitioner, files this Petition for Settlement of a Small Estate
under the provisions-of Section 3102 of the Probate;Estates and Fiduciaries Code and in support
thereof avers that:`
(1) Your Petitioner, Sherry Ward is a competent adult residing at 909 Boulevard,
Westfield,NJ 07090, and is the daughter of the above decedent.
(2) Dorothy J. Ward died-on February 25, 2014, at.the,age of 87 years, but,prior
thereto lived.and was domiciled at I Longsdorf,Way, Carlisle, Cumberland
County, Pennsylvania. A copy of decedent's Death Certificate is attached hereto
as Exhibit"A."
(3) Dorothy J. Ward died with a Will. No Letters have been issued.
(4) Dorothy J. Ward had no probate estate when she died other than the following:
Metro Bank account with a balance of$7,922.66 as of February 25, 2014, and a
Wells Fargo Irrevocable Burial Reserve account with an approximate balance of
$7,561.02. Copies of Metro Bank and Wells Fargo statements are attached hereto
as Exhibit"B > 2. o R
CD ,_.
5 The sole heirs and relationship to the decedent are as follows: r�03_V
O cn
P c
Sherry Jean Ward,Daughter Mallory Ann Ward, Daughter"ov,tj: Cj
Jamie Ward,Daughter Gretchen Ward, Daughter npL; CS
.. ,i^5
(6) No person or persons are entitled to the,family exemption.
io
(7) Decedent did not own any real estate, and had no other personal property of any
value.
rte.'
Metro Bank
METRO 3801 Patton Street
Harrisburg PA 17111-1418
BANK ymero3bank.com
>02627 3972088 001 092140 '
DOROTHY JWARD
113 E WOODLAND DR
MECHANICSBURG PA 17055
We're here 7 days a week,24 hours a day at 1-888.937-0004-
50 PLUS CHECKING 2840249953
,Statemenf"Balan2e,asof81128114 �' 'k& fig S-, 'ire '�1"+'y. -' "v'�`F` !'%.� +¢f� ""n'}'"a `-'� '57'6896815
rT4 aP,�tl y 6 i > j 'c• YA r�Y4,tE'< a �,!Lk�'t ` '< t4 �^>+, ,y
FI Ci 1' r 5� 'i`X .y Her `z `i' ''4 'r�'9� $17 90600
`°+"+?iPlusO 2' Daposlteand Ot er�Creditsy - �, , + 2 ,,,xg,. �c
rf {{.• tM§^i t j - rvtp?� a-Sdt
fY't^.W�4 10,0� " $nt " �}' -'y'Y N�,''"Yj'3 k 1$11 894.92y -
�.LOSS +fix 9 ,Chocks end Othete.r+ Debits ,,,Syty 1-"` !' q,•
� fistx�a }v' li�l ' W; cf�W��v',c• t.�i tit �� ky1 } ��,, ' wti.'�!xl'u3'k�J>dcer ��; 41'x.,ir'�f'9,,.,• t!
((( 3tf.*�'Plua -.�,5 IrrterestPaid , + n' , a, row , ,S1"82•
�rs�`?i. c,,,l, .-s ! ? t��{, f+➢..r, s
MA 7,:it 2. +,,... i sa:SW 1'
.Sia[eme�ntrBala, n4e.as oi'0221-4w :'YcTt�Z 'h3�l.:z. ' > AL
9Q8
Transactions By Date
— -Date rl aead tion - Debit Credit Balance
E K '� 'k"�; r kti .�r:rMi; � '✓ wa•s-.r
kN:u. m1:6..=urivr . 1'z'.LI.iY ..WitYJe':E§�u�u-s'u•'.c:. 'v�
02103114 SSA TREAS 310 XXSOC SEC - $1,818.00 $9,469.81
DOROTHY WARD
0�3/p61171N'���*,.,US''TREAS)7127�390�1()SVA�BEgEPs aka;}r, '"+A .. ; ryu (R;r, Y�$101890,00 � ,�E��55987
.���+„.i' �d'v&+DO-ROTHY„.'�JEAN WARD�11�����, c � ��lf. rA i. s Y� • �v S-i'��''.
5N-4�p L CROSS NEPA PAY N �C ��� �5� �3i� ��79 3A
DOROTHY WARD
O/;fi4�GFiEiil(#f18D": `,.�.'fl�°li''�. �i� $840 2IR°�Ei tt''7. , MYiMi;S&WHM��'9...=�1([8'�dIA -
02110/14 WTH 20 NOBLE BLVD BLDG $40.00 - $19,108.0+
RF#009205 02109 151918 CARLISLE,PA
Elm
k pOS KOHLS 033f ...- TA
y 19149'0111
[�iI`�;�e�Y{�,('� f7F#1�9� ID2� 4 .128 MEICSBUR 'P�AwA"v"S' ° ''',retry!. + '�^e«+��� ' '".!• ai•-:�`}�e;";h{',!
G2ueYSj t}SL �f'.}:Amxu--m..v
02/18/14 VISA BOSCOVS 12 $192.58 818,856.43
RF#009470 02114 141000 CAMP HILL,PA
2118tIVFA§BbSL`(3VS+2 4 #il��`F w1yt$1�01321T xa �7A '' k
-j3,2' RF#01910`'nOy14�09 ��G„AMP,�HILL FA, a ^±�/`h•�' u xi ' ; , � '} `"�� " 1 [
02/19114 CHECK 111178 $9,732.56 $9,022.66
02128114 INTEREST PAYMENT $1.62 $7,924.28
Check Transactions
Number Date Amount Number Date Amount Number Date Amount
:n.'!E'`�! 01(29' 7-77�';4F •;' 178 02/19 $9 732.56 1 80 „ H;f02�(10,;•��?$185.Q0 �'+,u�
Items denoted with an"E”are electronic entries and will not have a check image. Items denoted with an"'"Indicate processed checks out of sequence.
Interest Summary
o e-5 4a�,r�•Aa rs�2..�1 tl i3, -s' .�,]y'4 10:15
nBBgling InteresE ltBtetiF �!n S� �V"' '''*ez., ° ''i'x -i{IF�( tiv $ ; F .�f "zu °R'.r`^'+1'S- . } 1'pi
Sf ` f"rs5�:4 � �. A N
Ni3mber of Days.in this pal;Periodr 1`'r�a s
`�IiteiestEairt�tlithisStatemenlP eriod '"'d'i '''t' '}+';, xk "F'$ ' �'r'`-:, " '� � � 18162,:
Y+. l ♦ �t ! 'Y�}
,.�fnt,resiP au reu io nai Eamaa t��s`�m ���,� .vR � �t,'`� ���..�i°���.��d��;'_�
IOSc Bt a.b�..un'4_lvaW..WUCLa..��[a.;' ...v
28 Cycle Pagel of more M i.nm
Wells Fargo° Preferred Rate Savings
Account number:1010120130195 ■ April 14,2012-May 14,2012 ■ Page 1 of 3
DCRPIIDTRW 001186 Questions?
�I'III�II��I'II'��I"I'��'I�Ilrllull�tlr�trl�rll�'�IIIIIIII'�'I'
DOROTHY WARD Avdifoble by phone24 hours a day,7 days a week:
6oh*t IRREVOCABLE BURIAL RESERVE 1-800-TO-WELLS (1-800-869-3557)
236-WRIGHT-AVE —TT-Y;-1-800.877-4833 ----
KINGSTON PA 18704-4612 - Enespanol., 11-877-727-2932 -- --
a 1-800-28B-2288(6 om to 7pm PT,M-R
Online:wellsfargo.com
Write: Wells Fargo Bank,N.A.1345)
P.O.Box 6995
Portland,OR 97228-6995 0
0
M
9
O
1
a
F
You and Wells Fargo
Thank you for being a Wells Fargo customer.We appreciate your business and understand thai you are entrusting us with your banking
needs.Let us assist you In finding the right accounts and services to help you reach your financial goals.Please visit us online at z
wellsfargo.com,call us at the number at the top of your statement,or visit any Wells Fargo store-we'd love to hear from youl z
z
Activity summary Attount number: 1010120130195 z
Beginning balance on 4/14 $7,560.69 DOROTHY WARD zz
Deposits/Additions 0.33 IRREVOCABLE BURIAL RESERVE z
Withdrawals/Subtractions -0.00 Pennsylvania account terms and conditions apply z
0
Ending bafanceun 5114 $7,561.02 For Direct Deposit and Automatic Payments use o
Routing Number(RTN):031000503 S
A
N
O
O
A
u•
ro
Interest summary
0
Interest paid this statement $0.33 m
AOerage coiletted balance $7,560.69
N
Annual percentage yield earned 0.05%
interest earned this statement period $0.33
Interest paid this year $158
pennsylvania
OEPA RTM E NT OF PUBLIC WELFARE
April 21, 2014
APR 2 4 2.014
IRWIN & MCKNIGHT PC RKVi1,&MrKNIC,U
MATTHEW A MCKNIGHT ESQUIRE LKIN0F F11 Cr,
W POMFRET PROFESSIONAL BLDG
60 W POMFRET ST
CARLISLE PA 17013-3222
Re: Dorothy Ward
CIS #: 720347798
SSN: ###-##-0716
Date of Death: 02/25/2014
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Attorney McKnight:
Under State and Federal law, the,Department of Public Welfare (the Department) is
required to recover medical assistance (MA) reimbursement from the probate estates of
deceased individuals who were over age 55 when such assistance was received. 42 U.S.C.
§1396p(b)(1). 62 P.S. § 1412. 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 $13,413.20 against the
above-mentioned estate. This claim is for repayment of MA granted on behalf of the
decedent. Enclosed is the Department's itemized statement of claim.
A portion of this medical expense, namely $13,413.20, was incurred during the last
six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of
the Decedents, Estates, and Fiduciaries Code,,20,Pa. C.S.A:3392(3). The balance of the
claim, namely .00, is to be entered as a.priority.Cl'ass 5.1 claim against the estate. You
Should refer:to'Section 3392 for a more.completIe 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 I Division of Third Party Liability I Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
STATEMENT OF ACCOUNT
69908 SNOWDRIFT DRI T PRUSSIA
69908 SNOWDRIFT
ALLENTOWN,PA 181010
6 PAGE: 1 of 1
ACCOUNT NO: 9009-42
RETURN SERVICE REQUESTED 34285 INVOICE NO: STATEMENT
DX NO: KOPDX
INVOICE DATE: 02/28/14
+48772 0101 Phone: 877-670-8323 FACILITY: 9009 CUMBERLAND CROSSING
PATIENT NO: 42
You may also view/pay your bills at: PATIENT NAME: WARD, DOROTHY
https://myomniview,omnicare.com AMOUNT DUE: 68.00
d l niJn 16 d 16116 Idd rbr r In d it r TAX: 0.00
I I III u 1 II I I dl I l u h nh
DOROTHY WARD
GRETCHEN CARVELLA DUE DATE: 03/2512014
113 WOODLAND DRIVE
MECHANICSBURG, PA 17055-3373 AMOUNT DUE: 66 .00
34286-TOK09RKl TO07538
40KO9210E:1.1
KEEP TOP PORTION FOR YOUR RECORDS-RETURN BOTTOM STUB WITH PAYMENT CHIMBMgC INDIIIP10rQIII0GIIR
WARD, DOROTHY 9009 CUMBERLAND CROSSING
ACCOUNT NUMBER INVOICE DATE
900942 02/28/14
DATE RX NO. TRANS - DESCRIPTION PHYSICIAN NDC NO. . OUANT AMOUNT TYPE
Messages
Finance Charges may be assessed at a MONTHLY PERIOD RATE OF
1.50%(ANNUAL RATE OF 18.00%)based upon an unpaid balance
outstanding 30 days or more.
PREVIOUS BALANCE CHARGES FINANCE CHARGE TOTAL CHARGES PAYMENTS & CREDITS AMOUNT DUE
68.00 0.00 0.00 68.00 0.00 68.00
34285-TOK09RKlTO07538
TO INSURE PROPER CREDIT,DETACH AND RETURN THIS PORTION IN THE ENCLOSED ENVELOPE. 550mc
0 Please check II above address Is Incorrect and IndIcale Change on reverse side. IF PAYING BY MASTERCARD,DISCOVER,NSA OR AMERICAN EXPRESS,FILL OUT BELOW.
CHECK CARD USING FOR PAYMENT
ACCOUNT NO: 9009-42 G]❑ ow❑ „s<� ❑ = ❑
INVOICE NO: STATEMENT MASTERCARD DISCOVER VISA AMERICAN EXPRESS
� UM MASTERCAfl DISCOVER
GARO N BER
DX NO: KOPDX
INVOICE DATE: 02/26/14
FACILITY: 9009 CUMBERLAND CROSSING SIGNATURE EXP DATE
PATIENT NO: 42
PATIENT NAME: WARD,DOROTHY MAKE CHECK PAYABLE& REMIT TO:
AMOUNT DUE: 68.00
IIItnllrltllllulll'IIIIIIi IIIIIIII'NI'll'I'PIIIIIIIIII611r1r
OMNICARE KING OF PRUSSIA
AMOUNT ENCLOSED $ P.O. BOX 740391
CINCINNATI, OH 45274-0391 _
0000009009-4270STATEMENT3000KOPDX90000068008
STATEMENT Page: 1 of 1
D I A KO N Invoice# Account# Date
LUTHERAN SOCIAL MINISTRIES 344659 63OCCNC 02/28/2014
Cumberland Crossings Retirement Community
1 Longsdorf Way
Carlisle, PA 17015-7623 Due Date Amount Due Amount Paid
Facility#(717)245-9941
Business Office#(717)240-6040 3/23/2014 $54.00
Gretchen Carvella Resident Name
113-Woodland-Drive —. — -ward,Dorothy.J -
Mechanicsburg, PA 17055
._...... ... ... .... .. . . ... ...... . ' ........ ...._ .
Please make cHeck payable to Diakon Lutheian Social Ministries
Dorothy J Ward Cumberland Crossings Retirement Community 0212812014' '
Gretchen Carvella
Date Description Units i Net Balance
From rou Cha es Credits
01/31/2014 Balance Forward $9,732.56
2/18/2014 Payment Received Ck#178 .00 -9,732.56
1/01/2014 01/31/2014 Resident Liability(Jan) .00 29.0
2/01/2014 02/28/2014 Resident Liability(Feb) .00 -503.5
2/10/2014 02/24/2014 Resident Liability(Feb) .00 503.5
2/24/2014, 02/24/2014 Phone-Basic Service Phone Basic Service 1.00 Month 23.5
2/24/2014 02/24/2014 Sales Tax Sales Tax 1.00 Each 1.4
TOTAL BALANCE DUE $54.00
PLEASE RETURN TOP PORTION WITH YOUR PAYMENT,RETAIN BOTTOM PORTION FOR YOUR RECORDS
• Y�SA ® ® SEE REVERSE SIDE
FOR DETAILS
TP Orthopedic Institute 03/11/2014 04/01/2014
01P 1 of Pennsylvania
3399Trindle Road • NEW
Camp Hill,PA 17011
For Billing Questions please call(717) 761-5530 option 3 316944
Monday-Friday(8:00 to 4:30)
• • • •
N ADDRESS SERVICE REQUESTED 1 1 ORTHOPEDIC INSTITUTE OF PENNSYLVANIA
11111i'1111'1'1'1111111'IIIgn1111rIr11111111111rIr11111111"I' 3399TRINDLE RD FL 1
N DOROTHY WARD CAMP HILL PA 17011-4407
1 LONGSDORF WAY r IIInLIL IuulJll 16 r l r u n IJI . l d l l
-CARLISLE --Aaa-0a5-7-623-
❑ Please check box it above address is incorrect or insurance IMPUR111 Mi PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
information has changed,and indicate change(s)on reverse side.
- Page__1-of 1 ..
Date Description
01/15/14 X-RAY SPINE LUMBOSACRAL A 95.00
03/05/14 MEDICARE Payment 27.28
03/05114 Contract Adjust Adj . -60.20
03/05/14 Contract Adjust Adj . -0.56 6.96
\ F
l
Messages:
.•
Please Pay T Amount
Above charges are for care provided to: • - •' 04/01/2014_
For Billing Questions call(717)761-5530 option 3 Date Last Paid 00/00/00
Monday through Friday(8:00 to 4:30) DOROTHY J WARD
'Payment must be received by Payment Due Date See back of statement for FREQUENTLY Amount Last Paid $0.00
ASKED BILLING QUESTIONS&ANSWERS 316944
and information on our Injury Clinic. Account Number
420 Wyoming Avenue,Kingston, PA 18704
Richard W. Snowdon Funeral Director/Supervisor
Sherry Jean Ward 3/24/2014
909 Boulevard Funeral Services for:
Westfield,NJ 07090 Dorothy J.Ward
2/25/2014
Direct Cremation $2,525.00
Our charge for this service includes: -
Professional services of Funeral Director and Staff,Transfer to funeral home,
Consultation with family or representative of deceased, Securing and recording
vital statistics, Procurring necessary authorizations,obtaining&filing of death
certificate,Coordination with clergy,cemetery,crematory or other third parties,
Obtain personal family history&placement of obituary notices, Preparation&care
of deceased in manner requested,Sheltering and Identificaton prior to cremation,
Transfer to crematory by van and return of cremains to funeral home for
presentation to family, Utility vehicle to transport certificates, permits or
miscellaneous trips in Wyoming Valley,24 hour availability of personnel, Overhead,
insurance and inventory expenses.
Removal to Ewing Funeral Home in Carlisle(included in Direct Cremation) Included
Transportation from Carlisle to Kingston $360.00
Cremation Container $150.00
Urn: Maus Metal Granite Finish Solid Aluminum Urn $160.00
Urn Vault: Styrene w/Green Felt Lining(Cemetery Requirement) $95.00
Funeral Director&Staff for Cemetery Services&Supervision $375.00
(without prior use of facility)
Total Page 1 $3,665.00
Page 2
Cash Advances&Accommodations Items
Sunlight Crematory Charge $260.00
Cumberland County Coroner's Office Cremation Permit $30.00
St. Mary's Cemetery Opening Charge (Saturday) $940.00
Marker Inscription: Dorothy $260.00
1926-2014
Rev. John Hartman-Honorarium $200.00
Certified Copies of Death certificate: 5 @$6 each $30.00
10 free veteran copies ordered
Obituaries:
Times Leader $152.00
Citizen's Voice $55.00
Total Funeral Expense $5,592.00
Cumberland County Deceased Veteran's Widow's Death Benefit -$100.00
Balance Due $5,492.00
Please remit payment to:
Harold C. Snowdon Home for Funerals, Inc.
420 Wyoming Avenue
Kingston, PA 18704
Thank you for your confidence in the Snowdon Family
t
G
io n n O N – =r mA° O 8
cn
S O r X,
-
" 3 X :
CD
El 0
,°c 0 m 3 g' a y A = n 3 m o
to
II� N .Z D
30 _C 6
II > CD
N A S N O O O O
n (D N N n' O P- N I— � z O 3
A O :E a O p in j p O
a 7 N d (D A �'I1 A .� 0'
0 CD
FV 0 c m o_ ivy c o
s m p I p — � f G 3 O
it s A m 3 0 m 01 e
n N
j rt �`
SS1 N 1 O
CA ° J q
n O n S (.n O O (D
N CD 0 e F CD O N
n O N 3 N �_ CD O " n
S v W Cn Q rt N
n
m
CD
fD N N CD j w
3
N H p
(D D N
O o
((D W
c °
a o ego-
90 A
W c
t
n O 3 (Q M N
� � � tD W O
N O A
LIP
p !D = n
N leap v
V� L
`n^ x 3 x �. 3 ° N (D (D
m � m tp C _ m
W
N N O. c I CL
6 � 1 eD
3
n
CD
v �
IIO ,
� D)
CD
iv m
E7
469_ 69 Fk: (M
A 169
.O. 3
N N V PI) CA V E - N � ' (0 A'
CWeI O tOTe CWef O <O7p I�A t `A V•• p� O
v
S
"° g ` AG7 0 m m 0 m o m o ' er �i �
C. 3 c m oC m o F 3ma3o dy °c o
m C. .. C I y 2 3y Z 3 < 7 ° p � m MID a
r�T N Q N N Q ' C N 3 " N ems .� 7 so
q I -s (� "` M p N 0 (D N O er
6 TI ID o o = ° ploy o (<D _
u A O c
�_ 0 G z CD O p �" �? (D
CD
CD p m ; N a 3 �
r) N L = (/! .z p 3 N ' N
D1 e► N .� O
CL a 3 � d o a 3 � 3 0 = 3 N 3 � ° st
c c (D O_ c c N O_ y Dl O
A Nr y m (�-p Nr y m a NG (D 0 3
= NQ co O. = NQ W a - 7°r V' 3 N
o
If r
I 3 v o73 d c 2 _ o . m
m o 3 °o 0. ° m 0 CC
-2 Q ° ° CD CD CD M m a
g 3 3 ti N � C � o =.
C. (D d g at m°° °m;w CD
O c c a �O
°g
<
s I (� C 0� me a
e I Q I
CD ? N o A
CL CD 3 0
W v+ ° °
a I 0 p ,U
m � C -• °
a m s9, Nm o
v � v m ip 0m °
E; y c o
o
m m m m
° 3 ° N � N
o I n O De m N
._. z
u
r H
w � v -1 oa 34 S- = c D
r-- ^ mom 3m °nom � � m � 0 ° m Q I v
VJ N O. N e CD p O. O W • '4 O n N n n m
Q (D � vo p �• o o ' m D = sN °- acao n � O a
p � mm v CD �'. S� CD 00 v mOf) < CD o, �, p�j o
w, 3 n N O- CD l! N O <0 N (D O O N = 4
m 3 m s < m N 3 v o g < y
0) =3 � ,< (/1 ut N O N O. ^ O O - O (D 0 = 0 a O C
C1 0m p (D No � � c0CDW< a mn i o
C X � ° 20. gym = ° om
t7 0 � - fD �'
I 6 O N (? O ° N p (nD �0 (D O N ( DI O N
CD
M. r
CL E; 3oCL
O ° o p
(D O O � N O N
O �.
i x m T m 3 < o �. d = 3
� 3 � CD 3 m < o v m ' - � D' m(D 0 o fD
(D -
m ° m a � �
S2. c 3 ° <
N N ai S(o O' 0 O S O 0 o'
C T 0 FO. � N w (p O. 0 = RCD O 0
(D 0 O O `G 3 `a O. NO 0 f
I T N c v 3 a 0 0
i ^ EF 65 o ' m m
v
? m CD
N
�LJ
O
N
N
O
A ;
O N
C A S J • th D. N
co w
S p M O 0 i
y fat 7 7
LA
d'
rr rt H ,
C
,
r,
-I g r , 'v < O
z rrnpO n a N "
} A R
y ,p cn n n 2 tA r�
t D n D G1 m o
_ > O Z
O p
m m P m
Emn _Fn
D �
N
,
r+ •
N ;
V .
N
r
d
o '
N ;
N ,
A '
ID 7 O
CL
j 3
O z
7
m .� 0 n N
p iii z m o
2 D. p z S p
A m
m m
v N F
b
r'9
is
t
:
N
N
V
Lq ;
N
,a
ACCOUnt Activity - 3127114, 12:33 PM
CHASE !i
CHASEo
CREDIT CARD ( 4740)
Trans Date Past Date Type Description Amount
_i 03/24/2014 03125/2014 Sale EAST MOUNTAIN INN $102.56
WILKES-BARRE,PA 187020000 US
Online,Mail,or Telephone transaction
https:/tcards.chase,comicclAccount/Activity/437015921 Page 1 of 1
From: East Mountain Inn&Suites erniG?ioasnnourtainnln.com t¢
Subject: Folio -
Date: March 27,2014 at 12:22 PM
To: ajaarvot<�verixon.net
Best Western PLUS East Mountain Inn & Suites Mar27.20itt
&V Wildflower Dr.at Route f 15 12:24 pm
F4G> Wilkes Barre.PA 1K702
Telephone,070tK22 11111 Fax 07018224073
Each Best WesternO branded hotel is ind eaemde My owned and ope,ale d
S.11=.AN WARD 111179 .
�An)R"utr'aKi - R«en NunyMc
W,mI1c;3.Af.!7tM R-ar_S"All
N% acthW:V14 741T
,Arrival Daaw'Saluda}-%rcb'_d.2014 -
Drpanure Dstr Sunday.Shn�1t 3t.3UiJ
&icmher 9:
InformaWOn, (RESER6rATIGNlsamoiloor st"r)n
Date Deparirneni - Reference V..cF ,< IRs..I Debit I credo
0'Y2212014 Room Postings atn Pasted 610 597.317
03/222014 Sales;ax uto Posted 610 S`.,5+:
- 032212014 occupancy Tax um Posted 610 &I G2
03:23`2014 VISA H£CKED-GUNM7E 1610 102 56
I agree that rby liability toy all charges is not waived Balance: SO 0
Signature..___ _.._.,......_._._._,....,...__.._�__ .�.._._
Account Activity 3127/14, 12:33 PM
CHASE !i
CH�,ASE O
/
�e e om.
////// CREDIT CARD(...4740)
Trans Date Post Date TVOe Description Amoun t
I� 03/2212014 03124/2014 Sale GROTTO $188.34
HARVEYS LAKE,:%186180000 US
In-person transaction
t-,RC;TT0
t !AR`✓EYS ! .4K L.
570-639-- 1264
***RESTAURANT***
<53 EMILY H
-------------------------------------
ic1 492/1 Chk 1177 Gst 1_
Mal-22'14 06:07PM
- -------------------------------------
2 GLS PINOT NOIR @ 6.25 12.50 .
1 GLS MERLOT 6.25
GLS REISLING @ 7.99 15.98
2 BLUE MOON 23oz @ 5.50 11.00
I YNG LAGER 16oz 2.75
I CLUB SODA 2,19
2 K A PIZZA @ 3.95 7.90
2 rx BACUN @ 0.99 1.98
1 A MEATHEAD 6.99
1 A PIZZA 5.99
rx ANCHOVIE 0.99
rx MUSH 0.99
rx BLACK OLIVE 0.99
1 A MARGA 6,99
1 A BIANCO 6.99
1 REG PIZZA 9.99
1/2 BLACK OLIVE 1.25
4 TOSS SALAD @ 3,99 15.96 '
1 CHIX PHILLY 7.95
0 RINGS $ 1.79
2 LING CLAM SCE @ 9.99 19.98 1
Food 98.92
Bar .48
Tax
Total 153 3 j
https: �I^n no ` dfc Page 1 of 1
G �; y
t
i
,�
co � 1
0
1�°
r W
am ,'Cj l
a p
6� No�
�31fP1P o o
��
�'
i p
� d
v`,
� a U1 M
i,.
:,�` �� � �
.-�
U � d
a
1 0 `z +-
V Z � d —��,
_ � 3 `L
'1, � � � v
H
i
��
� ,,.F °�
°Cs?�M ct
2 �
M
Y�l':Q�^
`- �
�'cy ¢
U �
o c.) or.y i
�� ••Q �i F„F,y w �t� i
.3 Ewa
�o� i
����
� � `i
„a,5, � v t
.6 �+ ',
�+ �
w
�'.. ''