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HomeMy WebLinkAbout09-17-14 • r� J 1505610105 REV-1500 EXj02-11)(F0 OFFICIAL USE ONLY PA Department of Revenue aev'Un.. County Code Year File Number Bureau oflndtwdualTaxes INHERITANCE TAX RETURN PO BOX 290601 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Dale of Death MMDDYYYY Date of Birth MMDDYYYY 07262013 06162027 Decedent's Last Name Suffix Decedent's First Name MI RHINEHART DOROTHY L (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 BOXES BELOW © 1. Original Return Q 2. Supplemental Return (] 3. Remainder Return(Date of Death Prior to 12-13-82) Q 4. Limited Estate Q 48. Future Interest Compromise(date of Q 5. Federal Estate Tax Return Required death after 12.12-92) 0 6. Decedent Died Testate Q 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes ' (Attach Copy cl Will) (Attach Copy of Trust) Q 9. Litigation Proceeds Received Q 10. Spousal Poverty Credit(Date of Death Q 11. Election to Tax under Sec.sit 3(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number SHERRI L MILLER 717 796-1�5-51 0 REG E1 ILLS US rL Dr G C)Z First Line of Addresses N i 19 SKYLINE DRIVE �_- SecondLineofAddress CD N --n DATE FILED C City or Post Office State ZIP Code N v MECHANICSBURG PA 17050 M c M s 0 M M °W V) c> o Correspondent's e-manaddress: DUANE@SFAUSA . COM CO -T n -O p Under penalties o jury.I declare that I he"examined this return,Including accompanying schedules and statements,and to 1heT !Cl(ny,know e�tl a arWk a d complete.D bon re r Nan th personal representative Is based on all Information a whkh a or as any knowletl e SIGN T E ERSO �ES ON F •ILIN TURN 8 C') FDA E7D / -1j -rt N1 '.rt C 1 • � M 19RSKYLINE DRIVE MEC ANICSBURG PA 17050 SI TURE OF PREPARER OT THAN RE ESENTATIVE =l_/DATE T, ADDRESS - 4999 LOUSIE DRIVE SUITE 101 MECHANICSBURG. PA 17055 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610105 1505610105 1505610205 REV-1500 EX(FI) Decedents Social Security Number De denrsName: DOROTHY L RHINEHART RECAPITULATION t. Real Estate(Schedule A)........ .. .. ..... .... .... ... ....... .... .... 1. 0. 00 . 2. Stocks and Bonds(Schedule B).. .. .. .. ........ ........... . ......... 2. 0. 011 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)... 3. 0. 00 4. Mortgages and Notes Receivable(Schedule D).. .. .... ....... .. ........ 4. 0 . 00 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). .... 5. 49389.71 6. Jointly Owned Property(Schedule F) 0 Separate Billing Requested....... 6. 0. 01) 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) =]Separate_Billing Requested... ... . 7, 0. 00 8. Total Gross Assets(total Lines 1 through 7). .....:........ .. .. .... .... 8. 49389. 71 9. Funeral Expenses and Administrative Costs(Schedule H)....... ...... ... . 9. 13141. 92 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)...... .. .....10. 2937. 59 11. Total Deductions(total Lines 9 and 10).. .. ....... ....... ... ...... ... 11. 16079. 51 12. Net Value of Estate(Line 8 minus Line 11) 12. 33310. 20 . ..... ....... ..... ......... . 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) 13. 0 . 00 .. ..... .. ..... .. .. .... 14. Net Value Subject to Tax(Line 12 minus Line 13)..... ........... .. .... 14. 33310. 20 TAX CALCULATION-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 .0 0 - 15. a.'00 16. Amount of Line 14 taxable ' atlinealrateX.o 45 33310 . 20 16. 1498 . 96 17. Amount of Line 14 0. 00' taxable at sibling rate X . 12 n. 18. Amount of Line 14 taxable at collateral rate X . 15 18. 0. 00 19. TAX DUE.. ... .. .... .. .. . .. .. . .. .. .. .... ......... ... .. .. .. .. . ... . 19. 1498 . 96 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610205 1505610205 REV-1500 EX(FI) Page 3 File Number 210-18-5745 Decedent's Complete Address: DECEDENTS NAME DOROTHY L RHINEHART STREETADDRESS 19 SKYLINE DRIVE CITY STATE ZIP MECHANICSBURG PA 17050 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 1498.96 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 0.00 3. Interest (3) 4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. Fill in box on Page 2,Line 20 to request a refund. (4) 0.00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 1498.96 Make check payable to: REGISTER OF WILLS,AGENT ME PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "I IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred......................................................................................... ❑ b. retain the right to designate who shall use the property transferred or its income............................................ ❑ ❑X c. retain a reversionary interest............................................................................................................................. ❑ IR 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?............................................................................................................. ❑ 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?........................................................................................................................ ❑ 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 Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of , assets and filing a tax return are still 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,whether by blood or adoption. REV-1508 EX+(D&12) SCHEDULE E pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT OF INHERnANCE TTAXRETUNRN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Dorothy L Rhinehart Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE . NUMBER DESCRIPTION OF DEATH 1. M&T Bank 49,389.71 See Verification attached TOTAL(Also enter on line 5, Recapitulation) $ 49,389.71 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(0&13) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RESIDENT DEC DENT RETURN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Dorothy L Rhinehart Decedent's debts must be reported on Schedule I. ITEM .NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Wiedeman Faclder-Wiedeman Funeral Home,23rd&Derry Street, Harrisburg, PA 10,435.42 2. Gingricli;Memorials, grave marker 2,328.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) SbeetAddress city State ZIP Year(s)"Commission Paid: 2. Attorney Fees: 3. Family Exemption:(If decedent's address is not the same es dalmant's,attach explanation.) Claimani Street Address city State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 5. Accountant Fees: ' - 200.00 6. Tax Return Preparer Fees: 7. Cumberland County-Register of Wills, filing fees 178.50 TOTAL(Also enter on Line 9, Recapitulation) $ 13 141.92 If more space Is needed,use additional sheets of paper of the same size. REV-1512 EX-(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE INHERITANCE TAX RETURN DEBTS OF DECEDENT, RESIDENT DECEDENT MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER Dorothy L Rhinehart Report debts Incurred by the decedent prior to death that remained unpaid at the date of death,Including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Repayment of Social Security Benefit 1,408.00 2. Holy Spirit Hospital medical bill 36.00 3. West Shore EMS-ALS, medical bill 1,493.59 TOTAL(Also enter on Line 10,Recapitulation) $ 2,937.59 If more space Is needed.Insert additional sheets of the same size. REV-1513 EX-(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Dorothy Rhinehart RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS(Include outright spousal distributions and transfers under Sec.9116(a)(1.2).) 1 Sherri L. Miller, 19 Skyline Drive, Mechanicaburg, PA 17050 Granddaughter 25% 2 Shelly Shadle,8770 State Route 209,Williamstown, PA 17098 Granddaughter 25% 3 Jeff Simpson,3047 Sensei Drive, Manheim, PA 17545 Grandson 25% 4. Jerry Simpson, 502 Ridgeway Drive,Wrightsville, PA 17368 Grandson 25% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF 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: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: I 1. TOTAL OF PART 11—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If mom space Is needed,use additional sheets of paper of the same size. This instrument prepared by: STEPHEN D. CARLE of HODGES & CARLE,P.A. P. O. Box.548 3 84 10 North Avenue Zephyrhills, Fl, 33539-0548 Telephone: (813)782-7196 m 7.: C. C� Bob �Tshznt of 1, DOROTHY L. RHINEHART, of Pasco County, Florida, do make, declare, and publish this to be my will, hereby revoking all wills and codicils which I have made previously. ITEM I PERSONAL REPRESENTATIVE I nominate and appoint my daughter,CAROL L.MYERS,as personal representative of my will. If she should fail to qualify or cease to serve,I nominate and appoint my granddaughter, SHERRI MILLER, to serve. I direct that any personal representative appointed to serve under this will,whether original or successor,be permitted to qualify and serve without giving bond in this or any other jurisdiction. Any reference in this will to "personal representative" shall mean the personal representative then serving from time to time under this will, whether original or successor. No successor personal representative shall be liable for any act of any predecessor personal representative. Any use of the masculine shall include the feminine, and the singular the plural, when such meaning is appropriate. ITEM 2 PAYMENT OF DEBTS,EXPENSES. AND TAXES I direct that all debts that shall be legally owing by me, my funeral expenses and the expenses of administration of my estate be paid by my personal representative as soon as practical, except that my personal representative may pay any debt secured by real estate,whether by mortgage or by any other security instrument, or permit such real estate to pass subject to such debt. I further direct my personal representative to pay all estate, inheritance, and death taxes that shall be imposed and which shall be payable with respect to any devise, legacy, or distribution under this will or that shall be imposed by reason of my death, including such.taxes on proceeds of insurance on my life, whether or not the property, transfer, or proceeds with respect to which said taxes are levied are a Last Will and Testament of DOROTHY L RHINEHART Page 2 part of my testamentary estate at my death. Such taxes so paid by my personal representative shall be charged against and paid from my Residuary Estate. I authorize my personal representative to claim any expenses of administration of my estate as income tax deductions upon an income tax return or returns whenever the personal representative deems such action advisable to achieve an overall reduction in the income and death taxes payable by my estate. I further direct no compensating adjustments between income and principal shall be required or made as a result of such action. ITEM 3 DISPOSITION OF RESIDUARY ESTATE All the rest and residue of my estate, of every kind and character, whether the same be real;personal, or mixed, and wherever situate, shall be referred to as my "Residuary Estate." I give,devise and bequeath my Residuary Estate, subject to the charge of all death taxes, as provided in ITEM 2, to my daughter, CAROL L. MYERS, if she survives me, otherwise equally to my grandchildren who survive me. ITEM 4 SIMULTANEOUS DEATH If any beneficiary or beneficiaries under this will die with me in a common accident or disaster, or under such circumstances which make it difficult or impossible to determine which of us died first, I direct that I be deemed to have survived such beneficiary or beneficiaries and that this will be so construed. ITEM 5 MISCELLANEOUS PROVISIONS 5.1 Dealing with Personal Representative. No person dealing with the personal representative in any capacity shall be bound to inquire into the capacity to act on the part of the personal representative or into the authority for, or propriety of,any act or to see to the application or disposition of any money or other property paid, delivered, or loaned to the personal representative. 5.2 Income During Administration. During the period of administration of my estate, the personal representative shall be authorized to make distributions of the income of the estate to the same persons, and in the same proportions, as might be made if the administration were completed. 5.3 Disposition of Assets. I authorize the personal representative, without the order of any court, to sell and convey any of my real estate or personal property not specifically devised or bequeathed by me at public or private sale, without the joinder of any beneficiary, in such Last Will and Testament of DOROTHY L. RHINEHART-Pate 3 manner and upon such terms and for such prices as may seem best; and on every sale of real estate the proceeds are to be deemed and treated as forming part of my personal estate. t � Waiver of Inventory ports and Appraisal. I authorize my personal representative to administer and settle my estate without the necessity of filing an inventory or making any report or final settlement with any court to the extent permitted by law. I expressly waive appraisal of my estate in the event an appraisal shall be required by law. 5.5 Discretionary Powers. In addition to and not in limitation of all common law and statutory authority and all powers otherwise granted in this will,the personal representative shall have the following specific discretionary powers,duties and obligations: (a) Investments. To hold and retain as investments all property of every kind and description which shall at the time of my death be included in my estate. (b) Diversification. To acquire, by purchase or otherwise, and retain temporarily or permanently all kinds of realty and personalty without regard to principles of diversification. (c) Borrowing. To borrow money if the personal representative deems it advisable in the administration of my estate upon such terms and conditions as my personal representative deems advisable. (d) Leases. To enter into leases extending beyond the period of administration of this estate. Distributi on. To make distribution in cash or in kind or partly in each, even if shares be composed differently. (f) Responsibility. To exercise,in general,all powers with respect to the property included in my estate which any individual would exercise in the management of similar property owned in his own right and not be responsible for losses, if any, resulting from honest mistakes of judgment. 5.6 Distributions to Minors. Whenever my personal representative is authorized or directed to pay any money or to deliver any property to, or to use any money or property for the benefit of any minor,my personal representative shall not require the appointment of a guardian,but I authorize the personal representative in the personal representative's sole discretion to retain any part of such money or property during such minor's minority or to deliver all or any part of such money or property,without the necessity of requiring bond,to the guardian of the person or property of such minor or to the person with whom such minor may reside or to such minor. The receipt of any such person for such money or property shall discharge the personal representative irrespective of the age or other qualifications of such person. Last Will and Testament of DOROTHY L RHINEHART -Page 4 �l�ll !�j1 have signed and sealed and do publish and declare these presents as and for Will and Testament in the presence of the witnesses attesting the same this a).n,l day of August, 2000. I OR L. RHINEHA T a�llD� �9 declared,and published by the said DOROTHY L.RHINEHART,as and for testator's last will and testament, in the presence of us,the undersigned, who,at testator's request and in testator's sight and presence,and in the sight and presence of each other,have subscribed our names hereto as attesting witnesses the day and date above written. Name Address Zephyrhills, Florida e 1 _ Zephyrhills, Florida _J REGISTER OF WILLS CERTIFICATE OF CUMBERLAND COUNTY GRANT OF LETTERS PENNSYLVANIA No. 2013- 00898 PA No. 21- 13- 0898 Estate Of: DOROTHY LOUISE RHINEHART (First.Middle.[enl Late Of: SILVER SPRING TOWNSHIP CUMBERLAND COUNTY 0 Deceased Social Security No: WHEREAS, on the 16th day of August 2013 an instrument dated August 22nd 2000 was admitted to probate as the last will of DOROTHY LOUISE RHINEHART /First,Middle,lestj late of SILVER SPRING TOWNSHIP, CUMBERLAND County, who died on the 26th day of July 2013 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: SHERRI L MILLER 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 the seal of my office on the 16th day of August 2013. HegiSter of W If i ePUtV o **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) t M.&T Bank I Jndm=du9 what's imPortu_e Carlisle Pike Office H You have any questions, please call our Telephone Banking Center at 1-600-724-2440 Today's Date: Business Date: 08/16/2013 08/19/2013 Time: 02:36 PM Checking Deposit $49.389.71 ****823 4942/05 5 M. Thanks for visiting us today. We are happy to assist You! WIEDEMAN FACKLER- WIEDEMAN FUNERAL HOME, INC. FUNERAL HOME 357 South Second Street WIEDEMAN 23rd and Derry Streets Steelton, PA 17113-2524 Harrisburg, PA 17104-2726 Phone: 717.939.2344 FACKLER-WIEDEMAN Phone: 71.7.564.1434 Fax:717.939.1999 Fax: 717.56027a Dennis L Wiedeman, FD,President,Supervisor -Steelton I lames W.ToliarL FD,Supervisor-Harrisburg _ William A.Sibert,FD I Lisa M.WiedemomKrosnar,FD,Marketing Coordinator EmolL wiedemonf ftomcast.net I WebsRe:www.wiedemdnfunefolhome.com Mrs.Sherri L. Miller August 13, 2013 19 Skyline Drive Mechanicsburg, PA 17050 ' For the Funeral Services of: Dorothy L.Rhinehart CLIENT NUMBER: 2013-FW-043 PROFESSIONAL SERVICES Services of Funeral Director and Staff $ 1,895.00 Embalming $ 795.00 Hairdressing, dressing, cosmetology $ 290.00 OTHER STAFF AND RELATED FACILITIES Viewing (1 Hour) $ 250.00 . Funeral Ceremony, Rite, or Service \ $ 495.'00 . TRANSPORTATION Transfer of Remains to Funeral Ho Q$ $ 325.00 Hearse.(Casket Coach) �b�l3 $ 295.00 Service Car/Van �' Ifl'�35. $ 150.00 MERCHANDISE New Horizon - 18 Ga. Steel Protective Cas $ 2,595.00 Guardian Burial Vault $ 1,195.00 Casket Spray+ Tax $ 26500 CASH ADVANCES Opening Gfave/Crypt/Niche $ 11250.00 Cemetery Equipment . ' $ 175.00 Newspaper Notices - Local $ 262.42 Clergy Honorarium $ 150.00 Certified Copies of Death Certificate $ .48.00. . TOTAL AMOUNT DUE: $ 10,435.42 family owned and ape rated . . . we care AA P.O.Box 4,650 ACH/EDI Services Buffalo,NY 14240-9975 *** This is an Advice *** (800)724-2240 .. Date: Monday,August 05, 2013 DOROTHY L RHINEHART SHERRI L MILLER 19 SKYLINE DR SILVER SPRING TOWNSHI PA 17050 Subject: Notifca 'or. Of Death/Reclamation Case Number: 52852 Funds Deposited to Account: ******1663 Funds Deducted from Account(s): ******1663 $1,408.00 This is to advise you that on 8/5/2013 we deducted from the account(s) shown above the amount of$1408 for the SSA Direct Deposit of 8/2/2013. Due to the fact that DOROTHY L RHINEHART has passed away pridr to the issuance of the credit,the Treasury of the United States is requesting reimbursement. In accordance with Federal Regulations, any subsequent post-death benefit payments should be returned immediatly,by ACH,to the Government Disbursing Office. If the number of the'account deducted from' is different from the account into which the funds were originally deposited,the deduction is authorized under the bank's rules for right of offset because one or more of the owners on both accounts are the same. r Should you have any further questions about this charge, please call and refer to the case number above. This advice is provided to facilitate,the reconcilement of your monthly account statement. Respectfully, ACH/EDI Services M&T RECEIPT FOR PAYMENT - ------------------- ------------------- GLENDA FARNER STRASBAUGH Receipt Date : 8/16/2013 Cumberland County - Register Of Wills Receipt Time : 11: 17 : 27 One Courthouse Square Receipt No. : 1075254 Carlisle, PA 17013 RHINEHART DOROTHY LOUISE Estate File No. : 2013-00898 Paid By Remarks : SHERRI L MILLER HMW ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 90 . 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 15 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- - Check# 6685 $178 . 50 Total Received. . . . . . . . . $'178 . 50 SCHANCISSURG. PA 1705t CELL: 717-574-8365 Po I IS 252 . Patient: DOROTHY L RHINEHART — — Account: 386268. ' Services-Rendered At: HOLY SPIRIT HOSPITAL Payments Date Code Description Charge Adiustments Balance 7/26/2013 71010 CHEST SINGLE VIEW FRONTAL 36.00 36.00 Current 31 -60 61 -90 91 -120 Over 120 BALANCE DUE $36.00 36.00 0.00 0.00 0.00 0.00 PAY BY Due Upon Receipt , _ For billing questions call: (717)932-5955 r or: (877)932-5955 E _i Fax: (717)932-4856 t II!! I Office Hours: 8:00 AM- 4:30 PM ----- —�- -- - ----y------ — To pay your bill online and register for eStatement IIIII�Ilul IIIIIIIuI��I�I�III�II II�I IIII STATEMENT please visit us v✓ww.gita.com SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION 19670-274 6TUB WITH PAYMENT �4 •DESCRIPTION'OF'GHARGE` ° `trY' J' 011'AN`T1TY' v �t �2lJNIT+PRICE xAfe t,{`�w' .,- "A a ' ' 'hd E 1wt.F. a ...r f.YS :,.Q#i aie�l :ti5sw AMOIjNT�i. 'k `9'�` NSS 0.9% 1000cc Bag A0394 2.0 3.48 6.96 NSS 0.9%250cc Bag A0394 1:0 3.00 3.00 OP SITE , A0394 1.0 1.92 1.92 SALINE PREFILLED SYRINGE A0394 1.0 2.56 2.56 STYLET• 40422 1.0 7.96 7.96 SYRINGE(10CC/12CC) A0394 1.0 0.32 0.32 Total Charges 1493.59 s h1�..`�`r�''�`u,°0'ESCYi1P��I�ON Oaf?AYMEFYT� i c }`� '#}y���RECEIPT1y}< � RAYMENT DATEy��$�u `T`�" �`AMOUNT✓`I E�' lL�s�+ r.•s,�>,�3�` 'ux .5 :•'% Y�t.�'H.� ti t� �x..v S-.y�,a.t,.:ia�:s3�: :s�_-.....r�.:l,i. _::Y� ���16 . �� .,s Vie.<.:13vxk..�._��. : Denied by Insurance-HIGH MARK 09/11/2013 0.00 Denied by Medicare 08/29/2013 . 0.00 Total Credits . 0.00 M,� �, ' •wn i 'l '. PLEASE PAY THIS AMOUNT–INVOICE DUE UPON RECEIPT —► ,"J RETURNED CHECK FEE–$31.00 Mai rru $$ s "' 'FA, 'f 9'T�ik4 �+ �� 'i� '.A 5,��#�I 1f14NL� JX Url �.�}�� Y�.�S ��J` } IIt4 �tk to ! 4'3 rc < f ' 17"e";&tAaa < T i. °' ; } '�.�r '� �Y'� Kls 1PATIENT E R, NEHART+DORxOT Y k` CAt1,NUMBER z 1�31242bA� -`''AMiO UNf'Y�AID s xza "` Yt ' r. f£�f 09/12/ 013'A o " ,`� k dC yl J s'w i'A +�y� 's Sr 1 � `^+ :4,`t1at5.x_��� ? IMPORTANT MESSAGES: A claim for this invoice amount was DENIED by your insurance 5 3 `carrier. The balance is your responsibility- please remit payment to our office. 13� WEST SHORE EMS -ALS 205 GRANDVIEW"E STE 211 CAMP HILL, PA 17011-1708 it • Y -?Y,�,;��sDESCRIPT10NfOFyCHARGE�-,.rtk"ice y'j.�^�.T° r'��,a yQUANTITY k�{< q'auUNIT,PRIC£',1����•�� ,�rt' �?AM N�T,���f, v�_+i%j - ALS EMERGENCY LEVEL 2 A0999 11.0 1043.55 1043.55 20GTT TUBING A0394 1.0 14.72 14.72 ANGIOCATH(14-24) A0394 1.0 . 6.72 6.72 DOPAMINE VIAL 400MG A0394 1.0 3.92 3.92 EKG ELECTRODES(1) ( A0398 10.0 0.80 8.00 EPI 1 MG 1:10000 PFS A0394 1.0 8.16 8.16 ET TUBE HOLDER A0422 1.0 11.40 11.40 ETCO2(ADULT)FILTERLINE SET A0422 '1.0 36.00 36.00 EZ-10 26mm NEEDLE A0394 1.0 297.00 297.00 EZ-10 STABILIZER A0394 .1.0 16.00 16.00 GAUZE PADS A0382 2.0 0.20 0.40 MASTERFLO 60 GTT IV TUBING A0394 1.0 25.00 25.00 ¢av `:,5. yy t a 5r t 3 yeyx�qt_ w�•`�"G3*� DECRIP-770N OF PAYMENT�4.. w, �,, '. 1+ •REGEIPTn�w. Lrt.PAYMENT DATE �,� Xr 'AMOUIJT PLEASE PAY THIS AMOUNT- INVOICE DUE UPON RECEIPT -� ' 'Y s �Y � r' RETURNED CHECK FEE-$31.00 Colnued onNextlP gem . ais 4 r '� � +71 �t�2}•�'" sk''��"yykt °t"�fi ! i aY" "',�'YC4' t s"+ ,a, f- L fwJ K i i N� >;'Y" .-."�. H..FS, - • r .k' '", . � r'a�, ; !'r'r� r r hy*t ° ,�'+}JIB §"'.,�''f '�•1.s#` �'J`r+'� 3 � 'Lwy,�z ,e�3 '"le�'i'1 .� . � �! RH NE�I�iT OY2''OTHS"� ""�""ALiNUMBER 1.31�i2�20'Arl'�'��+` �•d'I nAMOUNTaPA1D'mt.?-r.-a ��a4�!w± -.$ �*y �? r .x. s,-l- t ] r 1 S �� _"i.h r!s.'F}'HY�YLl4ri!f n y • '' +* a '` '� �" ,'t .u� ''. �t. t. .32 i� -.,ca09J1212013..•`tL r. v � i ,,t fi � � . � �r�y�><Fx k .'�ns+ •�.',. -S_..S:LI.aE. � �YyV�.,a '� �J.u.'%ice<..i. c r _Pt ..a7`#!:�:e':F4.:.'t IMPORTANT MESSAGES: A claim for this invoice amount was DENIED by your insurance carrier.The balance is your responsibility- please remit payment to our office. WEST SHORE EMS -ALS 205 GRANDVIEW AVE STE 211 CAMP HILL, PA 17011-1708