HomeMy WebLinkAbout07-22-14 (2) REV-1500 Ex(02A1) 1505610143
PA Department of Revenue �7 OFFICIAL USE ONLY
p Pennsylvania County Code Year Fie Number
Bureau of Individual Taxes neenannseror ntveNUS
PO BOX.280601 INHERITANCE TAX RETURN 21 08 00205
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
01 17 2008 12 17 1938
Decedent's Last Name Suffix Decedent's First Name MI
BARNER LEROY B
(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. Original Return ❑ 2. Supplemental Return ❑ 3, Remainder Return(Date of Death
Prior to 12-13-82)
❑ 4. Limited Estate ❑ 41.Rome Interest Garrprem'se 0 5_ Federal Estate Tax Return Required
(date or death after 1242-82)
® g Decedent Died Testate ❑ 7, Decedent maintained a living Trust 8. Total Number of Safe Deposit Boxes
(Abacn Copy of wily (Attach Copy of Trust)
❑ 9. Litigation Proceeds Received ❑ 1o.Spousal Poverty Credit(Date of Death ❑ 11,Election to tax under Sec.9113(A)
between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAR INFORMATION SHOULD RE DIRECTED TO:
Name Daytime Telephone Number
't E 717 432 2089
REGISTER OF WILLS USE ONLY
First Line of Address �Om r— Y1
FR C ,_J
S N BALTIMORE STREET �Dr
F
Second Line of Address
�C�3`• � =t T
City or Post Office ED
State ZIP Code
DILLSSURG PA 17019 e)O
o�
Correspondent's e-mail address: /'=u^ °u-^ .r/✓^R- 4+v�cLi.. . C-a^^
Under penalties of perjury.I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge 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.
E OF PF,R,1 ONSIBLE FOR FILING RETURN DATE /
/C/ p l t Brian P. Barner
ADDRESS
627 Park Avenue, New Cumberland, PA 17070
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE r rc,, N3c,,1 Y DATE J/
Gf
ADDRESS
Stone, Duncan &Linsenbach
8 N. Baltimore Street, Dillsburg, PA 17019
Side 1
1505610143 1505610143 J
J 1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: BARNER, LEROY B
RECAPITULATION
1. Real Estate(Schedule A).......................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C).......... 3.
4. Mortgages&Notes Receivable(Schedule D).......................................................... 4.
5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)................ 5. 121 , 050 . 31
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested............. 7.
8, Total Gross Assets(total Lines 1 through 7).......................................................... 8. 121 , 0 5 0 . 3 1
9. Funeral Expenses and Administrative Costs(Schedule H)..................................... 9. 3 0 , 72 8 . 05
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................. 10. 3 0 , 92 1 . 71
11. Total Deductions(total Lines 9 and 10).................................................................. 11. 61 , 649 . 76
12 Net Value of Estate(Line 8 minus Line 11) 12. 5 9 , 4 0 0 . 5 5
.............................................................
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J)................................................. 13.
14. Net Value Subject to Tax(Line 12 minus Line 13)................................................. 14. 59 , 400 . 55
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 15.
16. Amount of Line 14 taxable 16. 2 , 673 . 0 2
at lineal rate X .045 59 , 400 . 55
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 18.
19, TAX DUE..................... ........................................................................................ 19. 2 , 673 . 02
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑
Side 2
L 1505610243 1505610243 J
REV-1500 EX Page 3 File Number 21 - 08 - 00205
Decedent's Complete Address:
DECEDENT'S NAME
Barrier, Leroy B
STREET ADDRESS
.1.100 Grandon Way
CITY STATE ZIP
Mechanicsburg PA 17050
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 2,673.02
2. Credits/Payments
A. Prior Payments
B. Discount
Total Credits(A +B) (2) 0.00
3. Interest
(3) 0.00
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box an 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. (5) 2,673.02
Make Check Payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;................................................................. x
b. retain the right to designate who shall use the property transferred or its income;...................
c. retain a reversionary interest;or.................................................................................................................. x
d. receive the promise for life of either payments,benefits or care?.............................................................. x
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?....................................................................................................................... ❑ n
3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?......... ❑
4. Did decedent own an individual retirement account,annuity,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.
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)(1.1)(1)).
For dates 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 rettum are still applicable even if the surviving spouse Is the only 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 natural parent,an
adoptive parent,or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
•The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in
[72 P.S.§9116(a)(1)].
•The tax rate Imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 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, ether y bloo�or adoption.
pennsylvania SCHEDULE E
DEPARTMENT OF
TAX TAX RETURRN N CASH, BANK DEPOSITS AND MISC.
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF Barner, Leroy B FILE NUMBER 21 -08 -00205
Include the proceeds of litigation and the date the proceeds were received by the estate.All property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE OF
NUMBER DESCRIPTION
DEATH
1 Integrity bank checking account No. 2291800562 (redemption of savings bonds) 61,608.22
2 Prudential Financial Insurance Policy#M48374738 4,791.44
3 Baltimore Life Insurance account No. 03322399 180.00
4 Merrill Edge account No. 5HP-47E79 54,286.99
5 PSECU savings account 10.39
6 PSECU checking account 173,27
TOTAL(Also enter on Line 5, Recapitulation) 121,050.31
REV-1511 EX.nI)F09)
2__ pennsylvania SCHEDULE
!.0 DEPARTMENT OF REVENUE RJNERALBITIMESAND
INHERITANCE TAX
ED RETURN DMINI�^�
RESIDENT DECEDENT FMJIY11 YIJ 1 fV1
FILE NUMBER
ESTATE OF Banner, Leroy B 21 - 08- 00205
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT
A. 1 Cocklin Funeral Home 8,793.05
2 Baughman Memorial Works, Inc. 1,986.20
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zip
Year(s)Commission Paid
2. Attorney's Fees Schrack and Linsenbach and SDL 9,378.80
3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
a. Probate Fees Register of Wills 88.00
Receipt and Release for each grandchild-filing fee 20.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1 postage, notary fees 12.00
TOTAL(Also enter on line 9, Recapitulation) 30,728.05
G�Sch' eeed{�Jdpee HHp
COMMONWEALTH OF PENNSYLVANIA rW�QI •..eJ,r
INHERITANCE TAX RETURN AckninistMw Costs lUed
RESIDENT DECEDENT
ESTATE OF Banner, Leroy B FILE NUMBER
21 -08-00205
2 Administrative Reserve 1,250.00
3 Executor Fee 7,200.00
4 Income tax reserve 2,000.00
Page 2 of Schedule H
t pennsyllvanEaE SCHEDULE I
DEPARTMENT OF INHERITANCE TAX RETURN DEBTS OF DECEDENT, MORTGAGE
RESIDENT DECEDENT LIABILITIES & LIENS
ESTATE OF Barner, Leroy B FILE NUMBER 21 - 08 - 00205
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
1 Jones Accounting (fiduciary tax return) 75.00
2 U.S. Treasury(Federal Taxes) 26,542.00
3 PharMerica 74.90
4 West Shore Golden Living Center 1,047.08
5 Moffitt Heart and Vascular Group 220.00
6 Internists of Central PA 101.63
7 Spirit Physician Services 56.68
8 NeighborCare-York 149.93
9 Quantum Imaging 189.40
10 James R. Harty, M.D. 132.66
11 East Pennsboro Ambulance 90.00
12 NCO Financial Systems (Camp Hill Emergency Physicians) 381.00
13 CCS, Inc. (West Shore Emergency Medical) 77.02
14 West Shore EMS (12/17/2007) 111.89
15 West Shore EMS (9/13/2007) 134.17
16 South Central EMS 75.00
TOTAL(Also enter on Line 10, Recapitulation) 30,921.71
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
COMMONWEALTH OF PENNSYLVANIA - LIABILITIES & LIENS
INHERITANCE TM RETURN
RESIDENT DECEDENT continued
ESTATE OF Barner, Leroy B FILE NUMBER 21 - 08 -00205
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
17 West Shore EMS (5/24/2006) 592.55
18 West Shore EMS (8/4/2007) 835.80
19 Cardiology Diagnostics, LLC 35.00
Page 2 of Schedule I
REV-1513 EX.(01-10)
{- pennsyhval SCHEDULE J DEPARTMENT INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Barner, Leroy B
21 - 08 - 00205
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not List Trustee(s)
I, TAXABLE DISTRIBUTIONS[include outrightspousal
distributions,and transfers
under Sec.9116(a)(1.2)) -
1 Brian P. Barner Son one fourth
627 Park Avenue
New Cumberland, PA 17070
2 Robert A. Barner Son one fourth
3 Lori A. Grassmeyer Daughter one fourth
171 Hoffman Road
Gettysburg, PA
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
II NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
REV-1513 EX.(01-10)
Pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES continued
RESI DENT DECEDENT
ESTATE OF FILE NUMBER
Banner, Leroy B
21 -08 -00205
NAME AND ADDRESS OF PERSON RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER RECEIVING PROPERTY (S) DECEDENT (Words) ($$$)
Do Not Llst Trustees)
I, TAXABLE DISTRIBUTIONS[include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
4 Kristy L. Banner Grandchild one eighth
13 Calvin Street
Wilkes-Barre, PA 18705
5 Paul Barker Grandchild one eighth
Page 2 of Schedule J
REV-06}9 EX+(U4i2)
Pennsylvania SCHEDULED
DEPARTMENT Or REVENUE ELEC'110NUNDERSEC.9113(A)
INHERITANCE TAX RETURN
RESIDENT DECEDENT (Jf Sn-DISTRIB now)
ESTATE OF FILE NUMBER
_
Banner , Leroy B 21 -08- 00205
PART A- DEFERRING STATEMENT
- - - ---- --- ---- --- ---- -- -For all trust assets reportable for Pennsylvania inheritance tax purposes for which a deferral of tax is being elected under
Section 9113(a),the personal representative responsible for filing the return and the trustee(s)of the trust in question hereby
acknowledge the department's Statement of Policy set forth at 61 Pa.Code§94.3 concerning any potential termination of the
trust under 20 Pa.C.S. §7710.1 that occurs after the return was filed.Specifically,the signatories recognize each individual's
assumption of liability for inheritance tax consequences that result from any termination of the trust under 20 Pa.C.S. §77101
that occurs after a return has been filed.
Signature of Person Responsible for Filing Return Signature(s)of Trustee(s)
PART B- ELECTION TO TAX AMOUNTS
Complete this section only if making the election to tax available under Section 9113(a)of the Inheritance &
Estate Tax Act.
If the election applies to more than one trust or similar arrangement,a separate form must be filed for each trust. This election
applies to the Trust(marital,residual A,B,bypass,unified credit,etc.).
Enter the description and value of all interests for which the Section 9113(A)election to tax is made.
DESCRIPTION VALUE
Total ._. 0.00
(if more space is needed, insert additional sheets of the same size)
REGISTER OF WILLS CERTIFICATE OF
CUMBERLAND COUNTY GRANT OF LETTERS
PENNSYLVANIA
No. 2008- 00205 PA No. 21- 08- 0205
Estate Of: LER6YBBARNER
(First Riddle,Lest)
Late Of: HAMPDEN TOWNSHIP
CUMBERLAND COUNTY
0 Deceased
Social Security No:
WHEREAS, on the 26th day of February 2008 an instrument dated
July 11th 2002 was admitted to probate as the last will of
LEROY B BARNER
(First,Middle,fast)
late of HAMPDEN TOWNSHIP, CUMBERLAND County,
who died on the 17th day of January 2008 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, GLENDA FARNER STRASBAUGH , Register of Wills in and
for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby
certify that I have this day granted Letters TESTAMENTARYto:
BRIAN P BARNER
who has duly qualified as EXECUTOR(RIX)
and has agreed to administer the estate according to law, all of which
fully appears of record in my office at CUMBERLAND COUNTY COURT HOUSE,
CARLISLE, PENNSYLVANIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed" thae seal
of my office on the 26th day of February 2008.
'egfster o qiiS
**NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST)
C:Myfiles/Brian/Wills/Barner,Leroy
tt� Vitt an� 'P Mam t
OF
LEROY B. BARNER
BE IT REMEMBERED, that I, LEROY B. BARNER, presently of Dillsburg, York
County,Pennsylvania,being of sound mind,memory and understanding,do make,publish and declare
this as and for my Last Will and Testament, hereby revoking and making null and void any and all
Wills and Testaments and writings in the nature thereof by me at any time heretofore made.
ITEM 1: I direct that my hereinafter named Executor pay all my just debts, my funeral
expenses, and the expenses of the administration of my estate. With this direction, I authorize and
empower my Executor to expend for my funeral expenses and interment such amounts as he may
consider necessary and proper,without regard to any limit that may be prescribed by a court of law.
ITEM 2: I direct my Executor to pay all inheritance, estate, succession, and legacy taxes
of whatsoever nature and kind, to which my estate, or the transfer of any property passing hereunder
or otherwise passing by reason of my demise, may be subject, and to charge such taxes against my
residuary estate. It is my intention that none of the aforesaid taxes, either federal or state, on any
property required to be included in my gross estate, under the provisions of any state or federal law
now in force or hereafter enacted, shall be prorated among the persons interested in my estate to
whom such property is or may be transferred or to whom any benefit accrues.
ITEM 3: I direct my Executor to carry on any business owned or controlled by me at my
death for whatever period of time he shall think proper, and he shall have the power to do any and
all things he deems necessary or appropriate, including the power to incorporate the business, the
power to borrow and to pledge assets contained in my estate as security for such borrowing, and the
power to close out, liquidate, or sell the business at such time and upon such terms as to him shall
seem best.
ITEM 4: I give and bequeath to my sons, BRIAN P. BARNER, and BRUCE L.
BARNER, each a 50%interest in my business entitled "Leroy B.Barrier, Inc." If either son fails to
V survive me, the survivor shall receive 100%. This specific bequest shall be taken and considered as
Y } part of the share of such beneficiary of my estate under this Will, and shall be accounted for against
his allotted share. For purposing of valuing this bequest,the book value of the business shall be used,
but its value is not to be less than zero(0), such value to be certified by the accountant employed at
the time or one chosen by the executor.
ITEM 5: I give and bequeath to each of my grandchildren, a $500.00 savings bond,
to be purchased with the funds from my estate.
ITEM 6: All the rest, residue and remainder of my estate, of whatsoever nature and
wheresoever situate, whether it be real, personal or mixed, including property over which I have a
power of appointment, I give, devise and bequeath to my four (4) children, BRIAN P. BARNER,
BRUCE L.BARKER, ROBERT A.BARNER, and LORI A.BARNER(GRASSMEYER), in
equal shares, per stirpes.
ITEM 7: I nominate, constitute and appoint my son, BRIAN P. BARNER, to serve as
Executor of this my Last Will and Testament. In the event my son, Brian P. Barrier, should
predecease me, fail to qualify, cease to act, or renounce probate, I appoint my son, Bruce L. Barrier
as alternate Executor of this my Last Will and Testament.
ITEM 8: I direct that my Executor be compensated for services rendered at a cormnission
deemed to be appropriate under the circumstances.
2
ITEM 9: I direct that my hereinbefore named Executor, shall not be required to give bond
for the faithful performance of his duties in this or any jurisdiction.
1N WITNESS WHEREOV'+havc"lie'reunto set my hand and seat this day of
2002.
LCROY B. BARNER
The preceding instrument c ritten.pages,was on the day
consisting this and three(3)typew
and date thereof signed� sealed, published, and declared by the Testator herein named, as and for his
Last Will and Testament, in the presence of us, who, at his request, in his presence and in the
presence ofeach other, have subscribed our'names as witnesses hereto.
OF.
OF.
3
Jun-04-2008 06:33am From-PA FISH & BOAT COIAM +7177057901 T-925 P.013/022 F-980
..-
SUITE 211
CAMP HILL, PA 17011 19
Phone#: (800) 367-0512 Federal Tax ID: 23-2463002 WEST SHORE
EMI?rWrNLY MLUI(:AL tiI(RV�C:14.i
PATIENT NAME: LEROY BARNER PATIENT NUMBER: 51147 MDIP
CALL NUMBER: 3064680A B
INSURANCE: MEDICARE B 165325861A DATE OF CALL: 05/24/2006
CAPITAL BLUE CROSS PFP16532586100 TIME OF CALL:
3064680A CALLER=FROM; LOYALTON OF CREEKVIEW
TO: HOLY SPIRIT HOSPITAL
LEROY BARNER
1100 GRANDON WAY REASON(S) SENILE DEMENTIA
MECHANICSBURG,PA 1705D FOR
TRANSPORT
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
PARAMEDIC INTERCEPT A0999 1.0 588.11 588.11
EKG ELECTRODES A0396 1-0 4.44 4.44
i
a
Total Charges 592.55
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT–INVOICE DUE UPON RECEIPT —s $592.55
RETURNED CHECK FEE–$31.00
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT 592.55
BARNER,LEROY 3064680A AMOUNT DUE
PATIENT NAME: 51147 CALL NUMBER 07/1 B/2006 AMOUNTS
PATIENT NUMBER: BILLING DATE: ENCLOSED
THIS ACCOUNT IS NOW 40 DAYS PAST OUEII Please send your
payment now. PROTECT YOUR CREDIT! yam. VISA
AND
MASTER CARD
A
WEST SHORE EMS -ALS 205 GRANDVIEW AVE CAMP HILL, PA 171)ly IED
Jun-04-2008 06:32&m From-PA FISH & BOAT COMM +7177057901 T-925 P.012/022 F-9110
vvrw I artumc rNla -IAL.0
205 GRANDVIEW AVE
SUITE 211
CAMP HILL, PA 17011
Phone#: (800) 367-0512 Federal Tax ID: 23-2463002 SST SHORE
E\IHRGENO'MEDICAL,S1RVIC65
PATIENT NAME: LEROY GARNER PATIENT NUMBER: 51147 MDEN
CALL NUMBER: 3089366A C
INSURANCE: MEDICARE B 165325861A DATE OF CALL: 08/04/2007
CAPITAL BLUE CROSS PFP16532586100 TIME OF CALL:
CALLER:
3089366A FROM: LOYALTON OF CREEKVIEW
TO: HARRISBURG HOSPITAL
LEROY GARNER
C/O BRIAN BARNER ALTERED LEVEL
REASON(S) OF CONSCIOU
627 PARK AVE FOR ALTERED�MENTALSTATUS
NEW CUMBERLAND,PA 17070 TRANSPORT r�
A , INVOICE �✓
DESCRIPTION OF CHARGE ' �4 OUANTITY UNIT PRICE AMOUNT
PARAMEDIC INTERCEPT A0999 1.0 797.87 797.87
EKG ELECTRODES(4PK) A0396 1.0 f 4.94 4.94
GLUCOSE BLOOD A0394 1.0 6.74 6.74
SALINE LOCK A0394 1.0 26.25 26.25
t
r{
>/
Total Charges 835.60
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
Total Credits 0.00
PLEASE PAY THIS AMOUNT-INVOICE DUE UPON RECEIPT --► $835.80
RETURNED CHECK FEE -$31.00
DETACH ALONG PERFORMATiON AND RETURN STUB WITH PAYMENT 835.80
BARNER,LER OY B 3089366A AMOUNT DUE
PATIENT NAME: CALL NUMBER AMOUNTS
PATIENT NUMBER: 51147 BILLING DATE: 10/18/2007 ENCLOSED
This account is now PAST I)UEII Payment must be received
WITHIN 10 DAYS. Collection process will begin. v� VISA a
- AND
MASTER CARE)
WES- f SHORE EMS -ALS 205 GRANDVIEW AVE CAMP HILL, PA 1AffEPTEE)
Jun-04-2009 06:34am From-PA FISH & BOAT COMM +7177057901 T-915 P.021/022 F-980
CARDIOLOGY DIAGNOSTIC, LLC I °`°""""`"°" "°'"'""'"" ""
725 Maple Rd 1110112007 BARLE003 1
-Middletown PA 17057
ADDRESS SERVICE REQUESTED
Make Checks Payable and Send To:
°FOR ALL BILLING QUESTIONS PLEASE CALL 1-800-290-2528. CARDIOLOGY DIAGNOSTIC, LLC
725 Maple Rd
Middletown PA 17057
LEROYBARNER
PO BOX 353
DILLSBURG, PA 17019 Amount Enclosed $ Check#
ncd `"'THIS BILL WAS PREPARED BY ACCUMED BIt LING.
please cut on dotted line and return top portion with payment
Balance Forward From Previous Statement 0.00
Patient: LEROY BARNER Case Descrip: ER/NO INS GIVEN/08-04-07 10/4/2007
Amount Paid By
Dates Procedure Procedure Description Charge Guarantor Adjustments Remainder
08/04/07 93010 EKG INTERPRETATION & 35.00 . 0.00 O.CID 35.00
PLEASE CALL OUR OFFICE WITH YOUR INSURANCE INFORMATION
G
��1Da�ey �I
� a'N 70�dbsf•=1gec,c�
All charges are billed to the appropriate Insurance carrier before you are billed. This balance
is now the patient's responsibility. Payment is due within 15 days from the statement date. Amount Due
We Thank You for paying your account promptyl
CARDIOLOGY DIAGNOSTIC, LLC 35.00
Jun-04-2008 06:32am From-PA FISH & BOAT COMM +7177057901 T-925 P.010/022 F-980
205 I SA DVI W AVE- k3L'
205 GRANDVIEW A `S
SUITE 211 #Eff SHOM
CAMP HILL, PA 17011 SL'MLRf GNr.Y97HDICALSLRVICCS
Phone #: (800) 367-0512 Federal Tax ID: 23.2463002
PATIENT NAME: PATIENT NUMBER:
LEROY BARNER CALL NUMBER: 51147 WCS
INSURANCE: DATE OF CALL: 168054W B
MEDICARE S 165325861A TIME OF CALL: 12/17/2007
CAPITAL BLUE CROSS PFP16532586100 CALLER: 06:00 PM
FROM: HOLY SPIRIT HOSPITAL
168054W TO: HOLY SPIRIT HOSPITAL
LOYALTONsbF CREEKVIEW
LEROY BARNER REASONS) .'r
C/O BRIAN GARNER FOR CONTUSIONS
627 PARK AVE TRANSPORT ,f
.J
NEW CUMBERLAND, PA 17070
INVOICE
DESCRIPTION OF CHARGE QUANTITY UNIT PRICE AMOUNT
r
Stretcher One Way Transport A0999 1.0 91.49 91.49
Transport Van Mileage A0999 6.0 3.40 20.40
d
f
Total Charges 111.89
DESCRIPTION OF PAYMENT RECEIPT - PAYMENT DATE AMOUNT
k Total Credits 0.00
PLEASE PAY THIS AMOUNT-INVOICE DUE UPON RECEIPT
RETURNED CHECK FEE-$31.00
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT
AMOUNT DUE
PATIENT NAME: CALL NUMBER AMOUNTS 111.89
PATIENT NUMBER:BARNER,LEROY B BILLING DATE: 168054W ENCLOSED
51147 01/31/2008 1
VISA
This account is now PAST DUE..11 Payment must be received AND
WITHIN 10 DAYS. Collection process will begin. MASTER CARD
ACCEPTED
WEST SHORE EMS- BLS 205 GRANDVIEW AVE CAMP HILL, PA 17011
Jun-04-2008 08:32am From-PA FISH a BOAT COMM +7177057901 T-925 P.011/022 F-980
WEST SHORE EMS - 131-5
205 GRANDVIEW AVE
SUITE 211
CAMP HILL, PA 17011
Phone#: (800) 367-0512 Federal Tax ID: 23-2463002 WE T ��0
errlr-.rnrnc'Y Mu_ulcAl Su.vlccs
PATIENT NAME: LEROY BARNER PATIENT NUMBER: 51147 WCS
CALL NUMBER: 164216W W1
INSURANCE: MEDICARE B 165325861A DATE OF CALL: 0911312007
CAPITAL BLUE CROSS PFP16532586100 TIME OF CALL: 10:55 PM
CALLER: HOLY SPIRIT HOSPITAL
164218W FROM: HOLY SPIRIT HOSPITAL
TO: LOYALTON OF CREEKVIEW
LEROY BARNER
C/O BRIAN BARNER REASON($) Unresponsive Patient
627 PARK AVE FOR
NEW CUMBERLAND, PA 17070 TRANSPORT
INVOICE
' DESCRIPTION OF'CHARGE"— QUANTITY UNITPRICE— — AMOUNT
STRETCHER One Way Transport A0999 1.0 103.57 103.57
Transport Van Mileage A0999 9.0 3.40 30.60
Total Charges 134.17
DESCRIPTION OF PAYMENT RECEIPT PAYMENT DATE AMOUNT
0 —
Total Credits 0.00
PLEASE PAY THIS AMOUNT-INVOICE DUE UPON RECEIPT �-► .F , ':_$1347.17
RETURNED CHECK FEE-$31.00
DETACH ALONG PERFORMATION AND RETURN STUB WITH PAYMENT 134.17
GARNER LEROY B 164218W AMOUNT DUE
PATIENT NAME: , CALL NUMBER AMOUNTS
PATIENT NUMBER: 51147 BILLING DATE: 10111/2007 ENCLOSED
THIS ACCOUNT IS PAST DUE! Send your payment now or contact AND
our office to make payment arrangements. vw III VISA
MAAsTER CARD
WEST SHORE EMS-BLS 205 GRANDVIEW AVE CAMP HILL, PA 1AfffPTED
Jun-04-2006 06:33am From-PA FISH & BOAT COMM +7177057901 T-925 P.014/022 F-990
�- �� aferneaf= :
Date: 12/0.3L20177= --
=—'Soil-�i G"entral EIVfS, Inc
8065 Allentown Blvd Acct#:
Harrisburg, PA 17112
(717) 6.71-4020
Tax# 237096198
13111 to:
Leroy Barner
P.O. Box 353
Dilisburg, PA 17019-
Patient: Bamer, Leroy "
control# Date Invoice Amount Paid Amount Balance
-P0739288. - - -08/1V2007-= — - . . — - -75:00- - 0.00 75.00
iy
RNAL NOTICE
�j
Comments: Thank you for using South Central Emergency Medical Services.
Payment is due 30 days from the date of invoice. Please remit payment to:
South Central EMS at 8065 Allentown Blvd., Harrisburg, PA 17112. To
ensure that your account is credited properly, be sure to include your invoice
number on your check. Please Pay 75.00
Jun-04-2008 0611 am From-PA FISH & BOAT COMM +7177057901 T-025 P.003 F-980
30 N.Chestnut Street
Dillsburg,PA 17019
(717)432-5312
January 21,2008
Mr.Brian P. Hamer
627 Park Ave.
New Cumberland, PA 17070-
The Funeral Service for Mr.LeRoy B.Barner
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES,FACILITIES,AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE TT-TAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS,
(A)OUR SERVICE:
13ASIC SERVICES OF FUNERAL DIRECTOR&STAFF . . . . . . . . . . , $3495.00
FUNERAL HOME SERVICE CHARGES . . . . . . . . . . . . $3495.00
SELECTED MERCHANDISE:
Oxford Poplar_ _ . . . . . . . . . . . . . . . . . _ . $1950.00
Graveliner , _ $715.00
THE COST OF OUR SERVICES,EQUIPMENT,AND MERCHANDISE
THAT YOU HAVE SELECTED . . . . . . . . . . . . . . . 86160.00
Cash Advances
Flowers. . . . . . . . . . . . . . . . . . . . . . . . . . . $193.98
Certified Copies of the Death Certificate . . . . . . . . . . . . . . . . . $72.00
Clcrgy Honorarium , , , , , , , , _ . . . . . . . . . . . . . $100.00
Cemetery Property . . . . . . . _ . . . . . . . . . . $750.00
Cemetery Opening . . . . . . . . . . . . . . . . . . . . . . . $750.00
Newspaper Obituaries-Harrisburg . . . . . . . . . . . . . . . . . . $266.32
-York . . . . . . . . . . . . . . . . . . . $170.55
CemeteryEquiptmcn; . . . . . . . . . . . . . . . . . . . . . . $140-00
Organist. . . . . . . . . . . . . . . . . . . . . . . . . . . $75.00
Grave Marker Foundation . . . . . . . . . . . . . . . . . . . . . 8115.20
TOTAL CASH ADVANCES AND SPECIAL CHARGES . . . . . . . . $2633.05
Total
Total Cost . . . . . . . . . . . . . . . $8793.05
SUB-TOTAL 88793.05
INITIAL PAYMENT/DISCOUNT/CREDITS 0.00
,TOTAL AMOUNT DUE 88793.05
The unpaid balance over 0 days is subjected to a 0.50%service charge per month-6.0000%per annum.
L
Mr.LeRoy B.Barner O
Page 1
Jun-04-2008 08:31am Fray-PA FISH & $OAT COW +7177087901 T-928 P.007/022 F-988
DEPT 99
WILMINGTON DE 19850
111111Itllt
11111 IN 1111111111111111111111111 IN 507 Pnidentiai Road,Horsham,PA 19044
9005974549
OFFICE HOURS:
Calls to or from this company uiay be monitored 8AM--9PM MON THRU THURSDAY
or recorded for quably assurma:- 8AM-IPM FRIDAY
8AM•12PM SATURDAY
Max 22,2008
8W2TSI 755 CREDITOR: CAMP HILL EMERGENCY PHYSICIAN
LEROY GARNER ACCOUNT#1: 31237902 0122217
1100 6RANDON WAY PRINCIPAL:S 381.00
MECHANICSRUR6 PA 17050-9191 INTEREST'$0.00
INTEREST RATE:
COLLECTION CHARGES: $0.00
COSTS:$0.00
OTHER CHARGES:$0-00
TOTAL BALANCE: $381.00
The named creditor has placed this account with our office for collection, It is important that yon forward payment in full.
If you choose not to respond to this notification, we will assign your account to a collector with instructions to collect this
balance.
Send payment in full to the address below.
Returned checks may be subject to the maximum fees allowed by your state.
You may also make payment by visiting us online at www.ncofinaneiaLeom. Your unique registration code is
C8UZT519-9BP60V6-
Ilnless you notify this office within 30 days after receiving this notice that y}ou dispute the validity,of the debt or ant'portion
thereof, this office will assume this debt is valid. If you notify this ofti-a in writing within 30 days from recaivmg this
notice,this office will obtain verification of the debt or obtain a copy of a,judgement and mail you a copy of such judgement
or verification. If you request this office in writing within 30 days after receiving this notice, this co&y will provide you
with the name and address of the original creditor, if different from the current creditor.
This is an artempt to collect a debt. Any information obtained will be used for that purpose. This is a
communication from a debt collector.
PLEASE RETURN THIS PORTION WITH YOUR PAYMENT(MAKE SURE ADDRESS SHOWS THROUGH WINDOW)
Account# Total Balance
8U2T51 $381.00 _
LEROYBARNER
Payment Amount
Credit Card Number
tVISA amt MasherCaM only}
Make Payment To:
NCO FINANCIAL SYSTEMS
PO BOX 15740
WILMINGTON DE 19850-5740 NCO81
766
01.990080:?T5I300U0flOD1U0DDDDDDDDD3&1D07
Jun-04-2606 06;32am From-PA FISH & BOAT COW +7177067961 T-626 P.0061022 F-960
Consolidated Collection Service, Inc.
P.O. Box 60550 Harrisburg, PA 17106
(717) 652-8601 J (800) 521-7559
STATEMENT
#EWNBZNZ
#790161/8#
LEROY B BARNER 790161 - 790161
627 PARK AVE
NEW CUMBBRLAN PA 17070-1725 ":"? ViOFIfzT1AfGOS
I
L, IIL�JIL ,L„ill„ „�Ri��d„LIJd,,,IJE�rI���lil __
i
_T.. - --------- _' DETACH HERE AND RETURN TOP PORTION WITH YOUR PAYMENT'
PO Box 60550 Consolidated Collection Service, Inc.
Haniaburg, PA 17106
(800)521-7559 /
�
1 ***Z_-FINAL NOTICT
\/)
4 Creditor Account # Aint -Owed-
WEST-SHORE EMERGENCY MED 162841W-»- 77.02
DEAR LEROY B BANNER
Your delinquent account in the amount of $77 . 02
owed to the above named creditor has been referred to
CCS, Inc. to make a decision concerning your willingness
to pay this legal obligation.
we have a responsibility to our client and will
take whatever steps needed to protect their interest, but
_.in the process we. want to- be fair with-you. -
It is important that you call 717-652-8601
immediately so that we can come to an amicable solution
to this problem.
C Failure on your part to call within ten days will
result as a refusal to pay this legal debt and we may
recommend to our client to proceed with any and all legal
action against you to obtain the money owed.
1 THIS IS AN ATTEMPT TO COLLECT A DEBT. ANY INFORMATION
OBTAINED WILL BE USED FOR THAT PURPOSE.
Jun-04-2008 06:33am From-PA FISH & BOAT COW +7177057901 T-925 P.017/022 F-900
NEIGH80RCpRE-YORK
3419 conlc0R0 RD_ PAGE: 1 of 1
YORK PA 17402
ACCOUNT NO: 1039.58
Im RETURN SERVICE REQUESTED 30005-U847 INVOICE NO: STATEMENT
DX NO: OPEDX
010, INVOICE DATE: 03/31/08
FACILITY: 1039 LOYALTON OF CREEKVIEW
PHONE: 717-600-8762 PATIENT NO: 58
PATIENT NAME: GARNER, LEROY
AMOUNT DUE: 149.93
TAX: 0.00
Ir,II1111 111111 1115 111111 1I t III IIIII III I'll 6IIIIII III III III I
BARNER, LEROY
C/O BRIAN BARNER DUE DATE: ff 44/30/ 8
627 PARK AVENUE 1i
NEWCUMBERLAND, PA 17070-1725 DU :L49 .93
30905•UB47'TC70AE2M7000035
2C70AF28E:1.1
KEEP TOPPORTION FOR YOUR RECORDS-RETURN BOTTOMSTUS WITH PAYMENT �III�A�I���IIIIIB��III�I�III�IIIIIQ II��iIINI�III�HI
PATIENT FACfl_ITY
GARNER, LEROY 1039 LOYALTON OF CREEKVIEW
ACCOUNT NUMBER
..
1039.58 03131/08
DATE RX N0_ TRANS DESCRIPTION PHYSICIAN NDC NO- OUANT AMOUNT TYPE
Messages
For Billing Inqulrlee please call 1.89&585.8709 Monday through FINANCE CHARGES are calculated at a MONTHLY PERIODIC RATE OF
Friday 9:00am to 4:30pm Thank You 1.50%(ANNUAL RATE OF 18.00%)based upon an unpaid balance
outstanding 30 days or morc.
TOTAL PAYMENTS C DITS AMOPR VIO S-1BA NCE CHARGES FINANCE CHARE UNT"DUF
149.93 0.00 0.00 149.93 0.00 ref "149.93 -
10 INSURE PROPER CREDR, DETACH AND RETURN THIS PORTION IN THE ENCLOSED ENVELOPE. 3ogos-uaA7•TC70AE2M7000O35 6207348
Ploaso Check It above address is incorrect and indicate change on reverse side. IF PAVING BY MASTERCARD.DISCOVER,VISA OR AMERICAN EXPRESS,FILL OUT BELOW,
CHECK CARD USING FOR PAYMENT
ACCOUNT NO: 1039.58
MASTERCARD MODISCOVER =RA AMERICAN EXPRESS
INVOICE NO: STATEMENT CARD NUMBER SIGNATURE CODE
DX NO:' OPEDX
INVOICE DATE: 03/31/08 SIGNATURE EXP.DATE
FACILITY: 1039 LOYALTON OF CREEKVIEW
PATIENT NO: 58
PATIENT NAME: EARNER, LEROY MAKE CHECK PAYABLE&REMIT TO:
AMOUNT DUE: 149,93
111111.Illrlrlrllrrrlrlrrlllrrrllllrllllrrrrlllrl,rrrrllrlllrl
NEIGHBORCARE-YORK
AMOUNT ENCLOSED $ P.O. BOX 740391
CINCINNATI, OH 45274-0391
0000001039a 5800STATEMENT3B004PEDX20000149931
Jun-04-2908 06:33aN From-PA FISH & BOAT COMM +7177057901 T-925 ?_918/922 F-980
QUANTUM IMAGING & THERAPEUTIC ASSOCIATES Ism MAWMRCARD 6ijillId WsA
PO BOX 62165 CARD NUMBER AMOUNT'
BALTIMORE, MD 21264 y , Axy.DATE"
FORWARDING SERVICE REQUESTED
STATEMENT DATE PAY THIS AMOUNT ACCT.#
189,40 $7167-QQIT2
RESPONSIBLE PARTY _ SHOW pMODNT
LEROY WARNER INVOICE: 751521 PAIDHERE $
MAKE CHECKS PAYABLE TO:
LEROY BARKER QUANTUM IMAGING & THERAPEUTIC ASSOCIATES
1100 GRANDON WAY PO BOX 52165
MECHANICSBURG, PA 17050-9191 BALTIMORE, ND 21264
Lr111111di11111111,11114111111 uIIIJI1,1111111111111111111,1
FOR ONLINE ACCESS TO YOUR ACCOUNT VISIT US AT: Mips:lhrww.ezmedinfo.com//quantum
0 Please check bm if above addross Is Incorracl or Insurance information PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMEN1
has chUngdd,and Indicate change(s)on reverse sido.
.. 198URANCE a .PA1o'RY u. 7: +, r, YAU .r -YOU:..
`,gDATE,M ;:^iOPT MOD"{, 42P' .'.- :SERVICE . .Nh .`.Loc :;�'COMRANY; AMOUNT .iNB a„ ^�IDIU$i' _rPARa..
CHARG 5 FOR PATIE EROY EARNER (87167-00l r2)
12-0706 70450-26 158 CT HEAD/BRAIN W/O DYE HOLY SPI MEDICARE 196.00 a.60 189.4
12/18/07 FILED P IMARY TO MEDICARE ART B (M 002)
08/02/07 Medicare Pay ent 8.60
01/12/08 GUARANT R RESPONSIBILITY D 7E (Char eID: 198 62)
08/02/07 Pat ent Write-off 89.x0
08/02/07 Bat kince Carr ction Deb t 99.40
08/02/07 Dal ince Carr co on Deb t 98.00
08/02/07 Pat ant Writ -off 99.00
08/02/07 Bat Lnce Correction Deb t 98.00
08/02/07 Pat ant Write-off 98.00
ADDIT ONAL INFDRMArIOI CONCERNING YOUR ACCOUN
PLEASE CO AC US IF YOU CANNOT PAY T IS BILL. THANK YO .
REFERRING RO IOER 158 IS ALAN TEPLIS - UPIN: E411S8
ADDITIONAL STATEMEYT IESSAGE
TOTALS: 8.60 0.00 0.00 ,__ 189.1
gR000UNf'#is . II .eM,'} 9i<7.IJ fl11 PAY.TH+S'f/�'II�O�N�I",l' ri il;:
01-13-2008 LEROY BARNER 87167-00I72 1 189.40.�
'I�'�;:",rJP0.YNFJI75RN,ENkDAFIER 11119RTg1EIDNT NijEWA.F APPEARAN;XBUA ME[t:6TATc7hNT.PPYm20TLIlELPON REdBPriiiNAMNYAA �i,i;;jl,� --
DAYS 0-3D 31-BD 8t-9D 97 -720 Over 120
MAKE CHECK PAYABLE TO:
ACCOUNTAGING 1 199.401 0. 0-001 0.00 0, QUANTUM IMAGING 8 THERAPEUTIC ASSOC,
FOR ONLINE ACCESS TO YOUR ACCOUNT VISIT US AT: https://www.ezmedii7fo.com//quantum
INVOICE#: 7SI921 POP BILLING OUESTIONS CALL 1-866-264-4629.
Batance reflects current Patient responsibility only and does not inClUde charae6 Dendino with VAflr insHrahro r-2mor A
Jun-04-2009 06:33am From-PA FISH S BOAT COW +7177057901 T-925 P116/022 F-990
MAKE CHECK PAYABLE TO PROVIDER
7
JAMES R HARTY MD ❑ PLEASE CHECK
1P,0. BOY 168 HERE E YOU HAVE MKOICAL BILLING SERVICES, ANC.
HUMMELSTOWN, PA 170360168 PmIS#30;
L J INSURANCE& Z75 CUMnERLAND PARKWAY
COMPLETE BACKSIDE MECHANIC911URQ,PA 17055
PARTY NAME OF THIS FORM 17171697.1955 -lb\x(717)697-3195
RESPONSIBLE
LEROY B DARNER b _i� . nnA
PO 1'"X 353
C/0 BRIAN BARNER 00000062300
DILLSBURG, PA 1'7010 Cl PLEASE CHANGE ,
ADDRESSIF
INCORRECT
DETACH THIS STUB AND RETURN WITH PAYMENT
PATIENT NAME
LEROY fi RARNE.' :'l1UE
DIAGNOSIS Y PATIENT INSURANCE
CODE % DATE CPT DESCRIPTION
CHARGES&COEDITS PENDING
332.0 ( 01/12,t0Ei 99"jo6 NCIRSING FAIT:/NEW PAS'/LEV III 150.CK)
02/21/08 CONTRACTUAL ADJUSTMENT —17 ,34
02.,'21,,'08 TRR)92Fa R 0'11'—MLi?,I,GAR—l7 —132 . 66
IN 13'2. 66
TRANSr'ER OUT—INSURANCE — 13; .66
J_•.;"�1;c:)� APPLIED TO DEDUCTIBLE: 132.6(',
i
V
CURRENT OVER 30 DAYS OVER SO DAYS OVER SO DAYS OVER IPO DAYS imn a+uwmwc�
IICCONM gni.nNCE u rLNUMG
's r f �" ^7 1 [ �o " _ 4 ., �i tin
FOR ASSISTANCE CALL:(717}697-1955
Jun-04-2008 06:32am From-PA FISH a BOAT COMM +7177057901 T-925 P.009/012 F-980
East Pennsboro Ambulance Service,Inc. Statement
Post Office Box 47
Enola,PA 17025 DATE
(717) 732-5552 FAX(717)728-9501 3/19/2008
Federal Tax Number 23-2464545
BILL TO
Bama,lcroy
C/O Brian Bamer
PO Box 353
Dillsburg,PA 17019
AMOUNT DUE AMOUNT ENC.
590.00
DATE DESCRIPTION AMOUNT BALANCE
N,01114/2008 •INV 46"I-I)iie 01114/2008.OA&Amaunt$90.00. - 90.00 - 90.00
1--•��- _,. --S1RI WAY-Non Mcmbcr$81.00
---Snatcher Mr7eage,6 Q 51.50=9.00
U\V
CURRENT 1-30 DAYS 31-60 DAYS 61-90 DAYS OVER 90 DAYS AMOUNT DUE
0.00 0.00 0.00 90.00 0.00 $90.00
PLEASE REMIT YOUR PAYMENT TODAY! APPROPRIATE COLLECTION ACTION WBL BE TAKEN ON ACCOUNTS OVER 120
DAYS OLD.THANK YOU.
Jun-01-2008 06:36am From-PA FISH A BOAT COW +71TT05T901 T-925 FA22/022 F-980
PAa
S RIT PHYSICIAN SERVICES LEROY BARNER 7 of 1
5 GRANDVIEW AVE STE 210 627 PARK AVENUE
AMP HILL PA 17011 NEW CUMBERLAND PA 17070-1725 i ST IENT
-"—' U44T'STATEMENT
ACCOUNT# 100487 y DATE: 02IB/08
IF ANY MS PLEASECONTACr SPIRIT PHYSICIAN SERVICES 717-9724490 FED TAX ID#251768971
u^ rr r'ZNq Of
wOA?e; p p7�f ESCPTIOYI IIAS , fiARGE
•'.3 �' > �d�i' n � . k,�a ����wl f1.. r� 1 r./LR�I{aST.�E� �ALA�.,�"r�' 'i
»> PATIENT: LERDY jr B GARNER 1D0487
PERFORMED BY: LORI NALLONER DO DD
PLACE OF SVC: 11
PERFORMED AT: DI
02/07/07 99213 250.00 EP LEVEL 3 65.00
02113/07 MCARE ERA PMT 0.00
02/13/07 MCARE ERA CONTRlADJ 8,32-
- -
PERFORMED BY: KATHERINE GALLAGHER MO NO
PERFORMED AT: DI
22106107 99n3 250,00 EP LEVEL 3 65.00
01124/06 MCARE ERA PMT 45.34-
01/24/06 MCARE ERA CONTRIABJ 8.32-
* 02/18(06 BLUE CROSS PAYMENT 11.34- 0.00
BALANCE: LEROY B BOER 956.68
If INDICATES NEW FINANCIAL ACTIVITY SINCE LAST BILL.
WE HAVE NOT RECEIVED YOUR PAYMENT. THEREFOREs WE HAVE NO CHOICE.
WE WILL BE TURNING THIS BALANCE OVER TO OUR COLLECTION AGENCY
AND NAVE BEAN PROCEEDDAES TO DISCHARGE YOU AND YOUR FAMILY
FROM OUR FAMILY HEALTH SYSTEM.
IIMTHESE SERVICES HERE PROVIDED BY SPIRIT PHYSICIAN Ism
mwSER10ES AND ARE SEPARATE FROM ANY HOSPITAL FEES.IeeNs
*BBOILEASE CALL 717-972-449D KITH ANY gUESTIONS *m
09MCMXERNIM THESE CHARGES. ICE
"' ,;„��:�( axr xr:atE;es'E o'EYdc7t;ixa NtrunN=&aL�a a'gxrray aP'sYSrE xs wr,�' aus PAYMExf - ---
STATEMENT DATE: GUARANTOR RESPONSIBILITY'- MINIMUM PAYMEN
S12 03/22108 $ 56.68
SPIRIT PHYSICIAN SERVICES
203 GRANDVIEW AVE(DQ i
CLAMP HILL PA 17011
61I IIIII1111111 1 Neill 1111,Ilil1 1111i1...iI pill Ills[fillip mill 000131156?
MNN SPIRIT PHYSICIAN SERVICES LEROY BARNER
to., 205 GRANDVIEW AVE STE 210 627 PARK AVENUE
CAMP HILL PA 17011 NEW CUMBERLAND PA 17070-1725
OFFICE USE ONLY cNECKONE FOR CREDIT CARD PAYMENT,PLEASE"LL IN INFORMATION DETDW
too4
11111111 - '
-VISA CARD NUMBER FXP DATE .tea
rAAIQ'
HC. 12$0 _ CARDHOLDER NAME(PRINT)
CREDIT CARD SIGNATURE SPIRIT PHYSICIAN SERVICES
❑CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
MIN ml now
____-:CLBSIFTO�DATE?+••`••4.'�;
y•
.;:'ACCOUNN�G NUldBER':i'L?
i • • • ' '.=TOtAL'ACCOUM.'BAL'aJ,CE!:y
• �� - e;DUE EROM.PATIENY;.'.•;-�;?
' ne5PON51BLE
n+ 11e1��k 9�` of �u' �a��„� •1,��
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\ 1? 7L}a 1 la- e Y a y 'i�1f�;S .- • o
44 Q[r Jl, .r• rV- •7! -`%AMOUNT ENCL.9E0
1 •r -
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Jun-04-2008 06:33am From-PA FISH & BOAT COW +7177057901 T-925 P.015/022 F-980
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CUSTOMER: LEROY B,DARNER FACILITY: GOLDEN LIVING WEST SHORE 1123 PEARL-1711dPT
DATE: 05/21108 ACCOUNT: 5702.14.31333 ERocR7oN.MA 0x301
PAGE: 1 of 1
PRIMARY FAVOR: INSURANCE POLICY#: EPEB00032961 EFFECTTVEDATES: '.01/12/08-01117108
PREVIOUS PAYMENTS NEW BALANCE $7490
BALANCE: $74'90 RECEIVED: CREDITS: CHARGES: DUE:
DATE RXNUMBER DESCRIPTION QTY BILLED DUE FROM INSURANCE CH
ARGL-S/
AMT INSURANCE ADJUST CREDITS
Balance Forward: 74 .90
Amount Due: 74.90
BTLLING QUESTIONS: MEDICATION QUESTIONS: PAYMENT ADDRESS:
08:30 AM-05:00 PM 09:00 AM-04:00 PM P.O.BOX 6413
PRONE: 866-251-5966 PHONE; 800-994-6337 CAROL STREAM,IL 60197-6413
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BROCKTON,MA 02301 CHECKCARD O FDA PAYMENT
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CUSTOMER NAME: LEROY B,BARNER DUeoATE PAY THISAMOUNT,s A=.x
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L1 information has changed,and indlcela changes)on reverse side.
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BRIAN BARNER PHARMERICA
PO BOX 353 P.O. BOX 6413
DILLSBURG, PA 17014-0353 CAROL STREAM, IL 60197-6413
5702140301030303000074903
PH;OOAANS22 31711410AA-TDJOP05R1.003001 2DJ0PVZJ0:1.1
Jun-04-2008 06:31am From-PA FISH 1 BOAT COMJA +7177057901 T-925 P.005 F-960
GOLDEN L,IVINGCENTER — WEST SHORE
4 NORTHEAST BILLING OFFICE — #0285 ,BARNER 285 41059 0001
1500 ARDMORE BLVD. #101
PITTSBURGH PA *15221 4466 ATPMLj TE OLT DxfL AMOUNT DVE
YOU CAN NOLG USE YOUR CREDIT CARD TO PAY 02/0 zI15/De ,..�1047.08
THE BALANCE. QUICK, EASY AND CONVENIENT! g Irnnnn CRCurd N.nmcotCOfldh
CARDHOLDER
i1CNAfVRE: Addrra.:
Qlcaer mu!x ctxdcx mm.ey order poyuhie tu:
005320 GOLDEN LIVINGCENTER — WEST SHORE
BRIAN EARNER 4 NORTHEAST BILLING OFFICE - #0285
HO BOX 353 1500 ARDMORE BLVD. #101
DILLSBURG PA 17019 PITTSBURGH PA 15221 4466
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NAME ACCOUNT RR $TATFMFNT,DATL
BARNER. LEROY 285 41059 0001 02/01/08
84.1–mcL FWD CUR CIiARGFS CRL•I)TTS/PAYMfNTS PAST DUfi AMOUNT DUE
0.00 1047 .08 0 .00 0.40 1047 .08
)21At—l-./PERIOD COVERED DT:SCRIPTION T1"/D1Y-q AMOUNT
BALANCE FORWARD
011408- 011708 PT B CO—INS ST THERAP 4 6168
011408 011408 PT B CO=INS ST EVAL C 1 1846
0112PS 0;1638 ROOM CHARGE 5 96694
r = 1 =
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MESV lWE PAYMENT WILL RE CONSR)ERED DNLFNOUENT n'NOT RNCEIVED RY TOP t-51I L PAYMENTS
RECENEO ATTIM Tlni um I MAY NOT RIC RIUrt�tiCTFD ON I'l11S tiTMI(MIfNT-
Jbu can nom,use. 6Ysa,Mastercard or Discover to pav your balance, Payment due by she 151h of each month
For 8dfinr Inqu;rix PknEc cal): (866) 325-5606
Jun-04-2005 05:34am From-PA FISH & BOAT COW +7177057901 T-925 P.020/022 F-950
MOFFITT HEART & VASCULAR GROUP 3 03/28/08 1360
1000 NORTH FRONT STREET PLEASE PAY THIS AMOUNT
WORMLEYSBURG, PA 17043
220.oD*
Address Service Requested _MC _VISA Disc Security
Card# i Code _
Sign Exp
39366
ESTATE OF LEROY B BARNER MOFFITT HEART & VASCULAR GROUP
PO BOX 353 1000 NORTH FRONT STREET
DILLSBURG PA 17019-0353 WORMLEYSBURG, PA 17043
RETURN .- PORTION
6AESSAGES EXPLINCO V BELOW
*** ANYUE"2IONS REGARDING YOUR BZLLt EA�E CALL (717) 731-8315 rtrtt
rtrtnYrtrtANY* UR t4tFtkdettt3ntttARDI*sY9rrY$d:rtdertieatL icic �ede9eAttrkici iticie ktttYokat•tirttic:Yrtrt�e�turtaYttirir��4ntir#rtic
08/05/07 1 2 F HOSPITAL CONSULT INITIAL 99253 780.2 140.00 140.00
08/07/07 1 2 F HOSPITAL SUBSEQUENT CARE 99232 414.02 80.00 80.00
F-Your ins did not pay us so it has become your responsibility to pay us.
RATE LIST PAW AL16 NT • - t • - 60 • •s • - r -
00/00/00 1 0.00 70.00, 0.00 80.00 140.00 - 0.00 0. 0 0.00 220.00
1:Ay MOFFITT HEART & VASCULAR GROUP r "" • t
HecK 1000 NORTH FRONT STREET
4EaA TO: WORMLEYSBURG, PA 17043 220 t
r;. =... :00 .
PAT# 1—LEROY B EARNER PRV# 2—GUTIERREZ, FELL$ 2QI FA Ph:(717)-731-83 `
Acct#: 1360
Darr.---O312'8/O9
Page I of 1