The URL can be used to link to this page

Home My WebLink About09-02-14 � 1505610105 REV-1500EX(oZ-ii)(FI) j!j' �'�� OFFICIAL USE ONLY PA Department of Revenue pennsylvania Bureau of Individual Taxes OEY�xb�EUtOl�fYENVF Counry Code Year File Number INHERITANCE TAX RETURN PO BOX z8o6o1 . Harrisburq,PA i�iz8-o6o1 RESIDENT DECEDENT '�_ ; I �-I �� ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDOYYYY ' ' ' 12/26/2013 ' 09/13/1913 Decedent's Last Name Su�x DecedenYs First Name MI _ _ _ _ _ ... _ _ Deiss ' Bessie M _ _ _ _ _ _ _ (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 UUPLICATE WITH THE __ __ . REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW G� 1.Original Return p 2. Supplemental Return p 3. Remainder Return(Date of Death Prior to 12-13-82) O 4. Limited Estate p 4a. Future interest Compromise(date of p 5. Federal Estate Tax Return Required death after 12-12-82) m 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust � 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule 0) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number __._ _ __ _. _ _ ___ _ _.. __ __ .. . .. _ _ William C. Dissinger ' (717) 957-3474 N _ _ __....__ _ _ _ . _e� _a.� REGIS'IEI�F WILLS U�E ON �" � � rn� � First Line ofAddress rT1 = C'3 � � _ . . _ _. �7 ,y, t'-- "'� 400 South State Road _ _ _ _ r— ;� n� � n� . � �. � �,., _ _ _ _ _ _ _ ,� � �:,� � Second Line of Address _.. _.. _. _ _ _ _ __..... - _ _ � c� � e-, c> -<-, 3 � �::�> �'=. City or Post Office State ZIP Code � B E FILEDW � ' _ __ _ _ _ __ r;.;� p Marysville . . PA 17053 ' p � 'T� CorrespondenYs e-mail address: Under penalties of pery'ury,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 pre arer other than the personal representative is based on all information of which preparer has any know�edge. GNATURE OF P�RSO ESPONSIBLE F R F LING RETURN DATE (.�.� � � ' �� DRESS ' 4224 Elmerton Avenue, Harrisburg, PA 17109 SIGNATURE F PREPA R R THAN REPRESENTATIVE DATE (� � r�/`j,_) -- 7 QC Vl � ADDRESS 400 South tate Road, Marysvill , A 17053 PLEASE USE ORIGINAL FORM ONI.Y Side 1 � 1505610105 1505610105 � � 1505610205 REV-1500 EX(FI) DecedenYs Social Security Number DecedenYs Name: ' RECAPITULATION _ _ __ 1. Real Estate(Schedule A). ....... .......... .................. ... ...... 1. ', 0.00 ', 2. Stocks and Bonds(Schedule B) ... ...... ......... ... ... ....... ... ..... 2. ' 0.00 ' 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. ' 9,878.00 6. Jointly Owned Property(Schedule F) O Separate Billing Requested .... ... 6. ' 0.00 ' 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separete Billing Requested....... . 7. 0.00 ' 8. Total Gross Assets total Lines 1 throu h 7 8. ! 9,878.00 ' � 9 )............................. 9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. ' 2,781.90 ', 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)..... ... ....... 10. , 260,447.21 ' 11. Total Deductions(total Lines 9 and 10).. ...... ......................... 1L ', 263,229.11 12. Net Value of Estate(Line 8 minus Line 11) .................... .......... 12. -253,351.11 13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) ... .... ...... ......... .. 13. 0.00 14. Net Value Sub'ect to Tax Line 12 minus Line 13 14. ' -253,351.11 1 � ) .. ... ... .......... ...... TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 0.00 . _ (a)(1.2)X.0 0 15. ', 0.00 ' 16. Amount of Line 14 taxable . . at lineal rate X.0 0 0.00 �g, , 0.00 '' 17. Amount of Line 14 taxable . 0.00 ' 17. . . 0.00 ' at sibling rate X.12 18. Amount of Line 14 taxable at collateral rate X.15 0.00 ' �g , 0.00 19. TAX DUE .. ...... ...... ....... ... ......... ... ............. ... ..... 19. 1 0.00 ', 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 � 1505610205 150561�205 � REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: 21-1 4-0570 DECEDENT'S NAME Bessie Mable Deiss STREETADDRESS 801 North Hanover Street CITY STATE Z�p Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. CreditslPayments A.Prior Payments 0.00 B.Discount 0.00 3. Interest Total Credits(A+B) (2) 0.00 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (3) 0.00 Fill in oval 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) 0.00 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.........................................................................:. ............... ❑ � b. retain the right to designate who shail use the property transferred or its income ............................................ � � c. retain a reversionary interest .............................................................................................................................. ❑ � d. receive the promise for life of either payments,benefits or care?,,,,,,,,,,,,,,,,,,,,,,,,, ............................................. ❑ � 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 payabie-upon-death bank account or security at his or her death7.............. ❑ � 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)(i)]. 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)J.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}J, . The tax rate imposed on the net value of transfers to or for the use of the decedenYs 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 decedenYs 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-i508 EX+(o8-iz) � pennsylvania SCHEDULE E DEPARTMENTOFREVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Bessie Mable Deiss 21-14-0570 Include the proceeds of litigation and the date the proceeds were received by the estate. Ali property jointty owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1. PNC Account#4227271671 1,018.81 2, PNC Account#4228562171 5,954.20 3, Parthemore Funeral Home Refund 1,742.99 4, U.S.Treasury Income Tax Refund 1,162.00 5, Church of God Home Personal Care account 0.00 TOTAL(Also enter on Line 5, Recapitulation) $ 9,878.00 If more space is needed,use additional sheets of paper of the same size, _ . �ev-isii ex+ {os-is� � pennsylvania SCHEDULE H DEPARTMENTOFREVENUE FUNERAL EXPENSES AND INHERITANCETAXRETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Bessie Mable Deiss 21-14-0570 DecedenYs debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES, 1' Parthemore Funeral Home 259.00 B, ADMINISTRATIVE COSTS: l. Personal Representative Commissions: 1,000.00 Name(s)of Personal Representative(s) .18►'112S MOSS______ ___ street Address 4224 Elmerton Avenue city Harrisburg state PA ZIP 17109 Year(s)Commission Paid: 1,000.00 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation.) 0.00 Claimant Street Address City State ZIP Relationship of C�aimant to Decedent 4. Probate Fees: 158.50 5. Accountant Fees: 0.00 6. Tax Return Preparer Fees: 150.00 �• Reimbursement for postage 23.20 a. Cumberland Law Joumal 75.00 9. Sentinel 116.20 TOTAL(Also enter on Line 9, Recapitulation) $ 2,781.90 If more space is needed,use additional sheets of paper of the same size. �ev-isiz ex+�iz-i2� � pennsylvania SCHEDULE I DEPARTMENTOFREVENUE DEBTS OF DECEDENT, iNHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Bessie Mable Deiss 21-14-0570 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• Pennsylvania Department of Public Welfare 260,234.29 2. 'Church of God Home(12122/13-Lab Serv) 2�2 92 TOTAL(Also enter on Line 10, Recapitulation) $ 260,447.21 If more space is needed,insert additionai sheets of the same size. REV-1513 EX+(O1-10) ';a .�: � ; pennsylvania SCHEDULE � . DEPARTMENT OF REVENUE � �� INHERITANCETAXRETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OP: FILE NUMBER: Bessie Mable Deiss 21-14-0570 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(5)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec.9116(a)(1,2),] 1. James W.Moss,Sr.,4224 Elmerton Ave.,Harrisburg,PA 17109 Son-in-Law 15% 2. James W.Moss,Jr., 1808 Brandt Ave.,New Cumberland,PA 17070 Grandson 15% 3. John Moss,916 Harvestview N,Mount Joy,PA 17552 Grandson 15% 4. Gregory Moss,4224 Elmerton Ave., Harrisburg,PA 17109 Grandson 15% 5. Stephanie Astle,333 Harrington Road,Rising Sun,MD 21911 Granddaughter 15% 6. Rebekah Moss,4224 Elmerton Ave.,Harrisburg,PA 17109 Granddaughter 15% 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: 1. Dover Alliance Church,228 East 3rd St.,Dover,OH 44662 10% TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size, . - - •• .. ,.� � � i • i�� n� iirv univi� YIL !VJ VVJ(, N0, 111"1 r� � . . . ., , , , , . , �� July 8,2014 Mary A Etter Dissinger, Esq. Dissinger and Dissinger 28 North 32 Street Camp Hill, PA 17011 RE: Name: Bessie M Deiss � SSN: 297-42-1776 ' DOD: 12-26-2013 Dear i1�Is. Dissinger: �z�rzsponse to your request for Date of Death (DOD)balas�ces for the customer noted above, our records show the following: Checking Account Account#422�'271671 Established: 07-01-1992 BESSIE M DEISS � DOD balance: $ 1,013.81 + 0.00 accrucd interest Interest p�id O l-01-2013 thru 12-26-2013 � 0.09 YTD SAYlUo$ACCOU112 A,ccount#422356217] Established: 06-30-1992 � BESSIE M DEISS DOD balance; � 5,9�4.20+ 0.10 accrued interest Interest paid O l-�l-2013 thru �2-26-20 t 3 $ 5.75 YTD � Please note that this office�rovides date of death balances for depos.it accouats(ZRAs, CDs,Checking and � Savings), '�Ve do not process any financial transactiops or provide statements. If you need assistance with i any of these items,please ca11 1-888-PNC-BANK(1-838•762-2265)or stop by your local�NC 9ank branch j office. � Since�ely, j �National Financia] Services Center , � PNC$ank,N.A. I Member FDIC ; 1 I I � Page 1 of 2 ; ' . _. , , , „ .,, , , ,,� �,,,,,, ,�� ,�. �� . , , �uo. ILIL r, Z . , . . � . This message is intended for the arse of the irtdividual or entity to tivhich it is addressed and may c•ontain information thnt is privrleged, confidential and exempt from disclosure urrder applicable luw. If the reaa'er of this message is not the intended recipient or the employee or agent responsible for delivering this message to the intended rectpient,you are hereby notifred that any c�issemination, distribution or copying of this commirnications is strictly prohibited. If you have received this communtcation in error,please notify me immediately by reply or by telephone at 800-762-177.i and immedrately destroy this fc�ced docacment, � ; i � i i � i i I � • ; � j . I i � Page 2 of 2 ; i _ _ _ _ . HP LaserJet 3055 Fax Call Report Dissinger & Dissinger CH 717-975-3924 Ju1-8-2014 1:33PM Job Date Time Type Identification Duration Pages Result 8304 7/ 8/2014 1:33:04PM Receive 4127050057 0:26 2 OK ,Jul. 8. 2014 1:44PN, fRC BAHK 412-JOS-POS). ko.7111 P. I 4��- PNC July 8,2014 Mary A Etter Dissinger,Esq. Dissin¢er and Dissinger 28 North 32 Street Camp Hill,PA 1901 I RE: Neme:Bessie M Deiss SSN: 297•42-1776 DOD: 12•26-2013 Dcar Ms.Dissingor: )n rasponse to your request for Dnte of DeaN(DOD)balances for the customer noted ebove,our records show the Coliowing: Chcckiog Account Account k 4227271671 Established: 07•O1-1992 BESSIE M DEISS DOD balancr. S 1,019.81:0.00 accrued inkrat intercst paid Ol-Ot•2013 ttw 12-26-2013 S 0.09 YTD Savinga Aecount Account k 42235621�I Establi shed: 06•30-1992 BESSlE M DEISS DOD balence: S 5,954.20+0.10 accrued interest Interest paid Ol•01•2013 thru 12-26•2013 S 5.75 YTD Please note thet Uis office provides dae of dnih belances for deposit eccoums(DWs,CDs,Checking md Seviogs).We do not proeeae any llnanciallraneecNone or proride atatements.If you need sssistance wilh any of Nese iums,pleese cell I-888-pNC-BANK(1•Sg8.7624Z65)or stop by your locel PNC Benk brunch oKa. Sincerely, Nationa!Financial Services Center PNC Bank,N.A. Member FDIC Page 1 of2 , , 1 l , <�� ,/ � , � � �� 'r�d��r� �f �� r^,�.�_ ��r`` ,'}'a, fi � PARTHEMORE Funeral Home & Cremation Services, Inc. Mr James W.Moss,Sr. 2/6/2014 4224 Elmerton Avenue Harrisburg,PA 17109 For the Services of Bessie Mable Deiss 1303 Bridge Street P.O.Box 431 New Cumberland,PA 17070 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 PI-1; (717)774-7721 is an itemized statement of the services,facilities,automotive equipment and merchandise that you se;ec::,d FX: (717)774-5546 when making the funeral arrangements. �n�ww.partN�emore.com — Terms Due Date Account# Net 30 3/8/2014 6761.1 Description Amount 0.00 Pink Marbleite Urn 259.00 Gilbert W.Parthemore Founder Total Services and Merchandise 259.00 Gilbert J.Parthemore `>upervisor Stephen K.Parthemore President,Cf=SP Bruce R.Parthemore Pre-Need Coardinator,CPC Pi�ofessional Memberships , . , � • . �.. , . . ; � , � Pennsylvania Funeral ' Directors Associalion ' �� .�� , � �� Order��,� ', :� Goldcn Rulc '! I •rotal $2s9.00 � PaymentslCredits $o.00 � EB Balance Due $259.00 _,� ; � �� ._....�_ I .��\ � � f // • G � �� °�r��c�r� �a� �� .� , � � -.� � ,,;�� , r--- �3��- ��r PARTHEMORE Funeral Home & Cremation Services, Inc. January 27, 2014 1303 Bridge Street P.O. Box 431 Mr.James W. Moss, Sr. New Cumberland,PA 17070 4224 Elmerton Avenue I'I-i:(717) 774-7721 Harrisburg, PA 17109 1=X:(717)774-5546 www.parthemore.com Dear Mr. Moss; r s�'" '' _ � - .. The following items were either not funded or not guaranteed in the pre- arrangements for Bessie Mable Deiss: Actual Cost As�`unded Gilbert W.Parthemore Certified Death Certificates 48.00 48.00 f ounde.r Coroner Authorization Fee 30.00 30.00 Gilbert J.Parthemore Clergy Honorarium 150.00 32.00 Si.ipervisor Stephen K.Parthemore Subtotals: $ 228.00 $ 110.00 I'r�esid�nt,CFSP Difference Due for non-funded: $ 118.00 Bruce R.Parthemore Pre-Need Coordinator,CPC Less Interest Earned: ($ 1,860.99) Total Refund Due: $ 1,742.99 Professional Memberships: . Pl'ease call if you have any questions. Thank you. � � . .- . • � � � Pennsylvania Funeral ' Directors Association \I 1! \I IS li R , � � Ordcr of�r2�e � Golden Rule �EB —T- ----w--,.._..�_� �_.....,� RECEIPT FOR PAYMENT LISA M. GRAYSON, ESQ. Receipt Date : 6/12/2014 Cumberland County - Register Of Wills Receipt Time : 15 : 10 : 38 One Courthouse Square R�ceipt No. : 1078280 Carlisle, PA 17613 DEISS BESSIE MABLE Estate File No. : 2014-00570 - Paid By Remarks : JAMES W MOSS SR CJ - ------------- -- - ---- --- Receipt Distribution ------ -----------_______ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 45 . 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 40 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN - --------------- Check## 3495 $158 . 50 Total Received. . . . . . . . . $158 . 50 � ,+� pennsylvania ��II� DEPARTMENT OF PUBLLC WELFARE July 7, 2014 DISSINGER AND DISSINGER MARY A ETTER DISSINGER ESQUIRE 400 SOUTH STATE ST MARRYSVILLE PA 17053 Re: Bessie Deiss CIS #: 610202408 SSN: ###-##-1776 Date of Death: 12/26/2013 ESTATE RECOVERY STATEMENT OF CLAIM Dear Ms. Dissinger: 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�f2 0.234.29 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 $24.979.00, 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, Est'ates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $23'S,255.29, is to be entered as a priority Clas� 5.1 claim against the estate. You shoul� refer to Section 3392 for a more complete explanation of the priority rules. If a lawsuit'is filed for injuries sustained by the decedent prior to death, then the Department may a'Iso 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 � Div(slon of Thlyd Party Liability � Recovery Section PO Box 8486 � Harrlsburg, Pennsylvania 17105-84f36 ! �►� pennsylvania �� :. DEPARTMENT OF PUBLIC WEIFARE Your Responsibility to Provide Information to t:he Department Please acknowledge receipt of this letter and advise whether the Department's claim is admitted and when payment may be expected. When the est:ate accounting is complete, please provide a copy. . The Department audits all estate recovery claims and therefore we require documentation to substantiate all deductions from the gross estate. The regulations governing how the Department computes its estate recovery claim are found in 55 Pa. Code Chapter 258. These regulations are readily available on the Internet, in addition to being carried in most local law libraries. In order to document computation of the amount due the Department, the following items should be submitted to the address below: 1. For real estate: a. Copy of the deed b. Copy of the latest tax assessment c. Copy of a current appraisal, if available 2. Copy of the funeral bill 3. Copy of the statement of the burial account if one exi<.�ted 4. Copy of the statement of the personal care account balance at date of death, if the decedent was in a nursing home 5. Copies of original and updated life insurance policy foi-ms naming beneficiaries 6. Copies of any and all stocks and bonds 7. Copies of bank statements showing balances on the date of death 8. Copies of signature cards or other proof of when accounts were made joint 9. A list of any gifts or other transfers for less than fair market value made by the decedent (personally or under a power of attorney) Your Responsibilities to the Departrnent Under State law, executors or administrators may be personally liable to pay the Department's estate recovery claim if they transfer estate property without the Department's claim being paid. Persons who receive that property without paying valuable and adequate consideration to the estate may also be personally liable. The responsibilities of the primary next of kin/administrator/executor, is to advise the Department of any assets in the estate and to ensure that the remaining money, after all funeral and administrative costs are deducted, is sent to the Department. Accordingly, you must ensure the Department's claim is satisfied before making distribution of assets to heirs. Bureau of Program Integrlty � Divislon of Thfrd Party Llability � Recovery Sectlon PO Box 8486 � Harrisburg, Pennsylvanla 17105-84£36 �� pennsylvania �. OEPARTMENT OF PUBIYC WELFARE Insolvent Estates and the Fiduciary Responsibility to Creditors If there are not enough estate assets to pay the claims of ali creditors in full, then the executor or administrator has a duty to act in the best interest of creditors when administering the estate. If you must spend the estate's money to administer it, you must act prudently and make purchases as if the money were coming out of your own pocket. The Department's approval is required if you expect the legal fees to exceed more than the areater of 6% of the estate assets or $1,000. Contingent fees for estate administration will generally not be approved. If you do not obtain approval, the D�partment may consider the excessive fees to be a transfer for less than valuable and adequate consideration. Sincerely, ��ra�c.c,..�'��r....r�.k.K-�C.�t,... �3 ]essica L. Frederick TPL Program Investig��tor 717-772-6238 717-772-6553 FAX Enclosure Bureau of Program Integrity � Division of Third Party Liability � Recovery Section PO Box 8486 � Harrisburg, Pennsylvania 17105-8486 COMMONWEALTH OF PENNSYLVANIA ` BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARIY LIABILITY RECOVERY SECTION PO BOX 8486 HARRISBURG,PA 17105-8486 July 1,2014 STATEMENT OF CLAIM SUMMARY NAME Estate of DEISS,BESSIE ID 610 202 408 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIENT 100.00 579.80 679.80 LONG TERM CARE 24,879.00 234,623.02 259,502.02 DRUG .00 52.47 52.47 REIMBURSEMENT TO DPW 24,979.00 235,255.29 260,234.29 COMMONWEALTH OF PENNSYCVANIA DEPARTMENT OF PUBLIC WELFARE EIN- 23-6003113 ' Page 1 of 24 � COMMONWEALTH OF PENNSYLVANIA ( DEPARTMENT OF PUBLIC WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE ID 610 202 408 PHILHAVEN HOSPITAL 283 S BUTLER RD MOUNT GRETNA PA 17064 DATE OF SERVICE PAYMENT DATE ' ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 02/16/09 - 02/16/09 04/20/09 27090916227800001 27090916227800001 80.00 11.50 DIAGNOSIS 1 : 2989 PSYCHOSIS NOS PROC CODE: 99302 EVALUATION AND MANAGEMENT OF A NEW OR ES PROVIDER SUB TOTAL PHILHAVEN HOSPITAL 80.00 11.50 01 100772000 0016 �', Page 2 of 24 �- COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBIIC WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE ID 610 202 408 CARLISLE REGIONAL MEDICAL CENTER 246 PARKER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 01/07/09 - 01/07/09 03/23/09 20090653528890001 20090653528890001 81.90 9.36 DIAGNOSIS 1 : 30000 ANXIETY STATE NOS DIAGNOSIS 2: 0 PROC CODE: 80048 BASIC METABOLIC PANEL 07/10/09 - 07/10/09 09/14/09 27092373523930001 27092373523930001 20,182.84 197.00 DIAGNOSIS 1 : 57450 CALCULUS OF BILE DUCT WIT DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: X0597 MONITORING AND OBSERVATION ASCISPU 02/16/10 - 02/16/10 05/17/10 27101173525970001 27101173525970001 236.59 40.91 DIAGNOSIS 1 : 2859 ANEMIA NOS DIAGNOSIS 2: 2689 VITAMIN D DEFICIENCY NOS PROC CODE: 82306 VITAMIN D 25 HYDROXY 02/16/10 - 02116/10 05117/10 27101173525970002 27101173525970002 118.34 13.00 DIAGNOSIS 1 : 2859 ANEMIA NOS DIAGNOSIS 2: 2689 VITAMIN D DEFICIENCY NOS PROC CODE: 82607 CYANOCOBALAMIN(VITAMIN B-12); 02I16/10 - 02116/10 05l17/10 27101173525970003 27101173525970003 77.38 12.00 DIAGNOSIS 1 : 2859 ANEMIA NOS DIAGNOSIS 2: 2689 VITAMIN D DEFICIENCY NOS PROC CODE: 82746 ASSAY OF FOLIC ACID SERUM 04/05/11 - 04/05/11 O6/06l11 27111383533420002 27111383533420002 96.48 9.36 DIAGNOSIS 1 : 78060 FEVER UNSPECIFIED DIAGNOSIS 2: 7862 COUGH PROC CODE: 80048 BASIC METABOLIC PANEL 04/05/11 - 04/05111 06/06111 27111383533420003 27111383533420003 75.63 6.00 DIAGNOSIS 1 : 78060 FEVER UNSPECIFIED DIAGNOSIS 2: 7862 COUGH PROC CODE: 85025 BLOOD COUNT;HEMOGRAM AND PLATELET COUNT 04/05/11 - 04/05111 06/06/11 27111383533420004 27111383533420004 541.98 14.00 DIAGNOSIS 1 : 78060 FEVER UNSPECIFIED DIAGNOSIS 2: 7862 ' COUGH PI�OC CODE: 87040 ', CULTURE,BACTERIAL,DEFINITIVE; BLOOD(i Page 3 of 24 _ _ _ � COMMONWEALTH OFPENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE ID 610 202 408 CARLISLE REGIONAL MEDICAL CENTER 246 PARKER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 05/17111 - 05117111 07/25/11 27111873532810002 27111873532810002 34.38 3.10 DIAGNOSIS 1 : 7993 DEBILITY NOS DIAGNOSIS 2: 0 PROC CODE: 81003 URINALYSIS AUTO W/O SCOPE 02/23/12 - 02/23112 07/23/12 27121803521410002 27121803521410002 118.87 9.36 DIAGNOSIS 1 : 4439 PERIPH VASCULAR DIS NOS DIAGNOSIS 2: 0 PROC CODE: 80048 BASIC METABOLIC PANEL 03/22/12 - 03122/12 07/23/12 27121803521330002 27121803521330002 118.87 9.36 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 0 PROC CODE: 80048 BASIC METABOLIC PANEL 04/26112 - 04126/12 07/23/12 27121803521270002 27121803521270002 118.87 9.36 DIAGNOSIS 1 : 4019 HYPERTENS�ON NOS DIAGNOSIS 2: 0 PROC CODE: 80048 BASIC METABOLIC PANEL 06/21I12 .- 06/21/12 08/06112 27121923530270002 27121923530270002 129.57 9.36 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 0 PROC CODE: 80048 BASIC METABOLIC PANEL 07/19/12 - 07/19/12 OS/27/12 27122163528210001 27122163528210001 129.57 9.36 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 0 PROC CODE: 80048 BASIC METABOLIC PANEL 07/26/12 - 07/26112 09/17112 27122403527860002 27122403527860002 129.57 1.30 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 0 ' PROC CODE: 80048 BASIC METABOLIC PANEL PROVIDER SUB TOTAL CARLISLE REGIONAL MEDICAL CENTER 22,190.84 352.83 01 100775085 0008 ' Page 4 of 24 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE 7D 610 202 408 CHURCH OF GOD HOME INC 801 N HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN ' USUAL CHARGES AMOUNTAPPROVED 03/12/08 - 03/31/08 03/30/09 90090634030180001 90090634030180001 3,555.00 1,509.37 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 04/01l08 - 04/30/08 03/30/09 90090634030170001 90090634030170001 5,164.80 3,119.17 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 05/01/08 - 05/31/08 12/01/08 27083114024040001 27083114024040001 5,336.96 3,336.33 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 06/01/08 - O6/30l08 12/01/08 27083114024090001 27083114024090001 5,164.80 3,164.17 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 07/01/08 - 07/31/08 03/02/09 55090564102890001 55090564102890001 5,373.85 3,393.37 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 08/01/08 - 08/31/08 03/02/09 55090564102900001 55090564102900001 5,373.85 3,393.37 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 4019 ' HYPERTENSION NOS PROC CODE: 000000 09/01I08 - 09130I08 03/02/09 55090564102910001 55090564102910001 5,200.50 3,219.37 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 10/01/08 - 10131108 03l23/09 55090764101090001 55090764101090001 5,373.85 3,681.36 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 , Page 5 of 24 _ _ _ _ _. __ _ _ _ _ _ ICOMMONINEALTH OF PENNSYLVANIA , DEPARTMENT OF PUBLIC WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE ID 610 202 408 CHURCH OF GOD HOME INC 801 N HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAC CHARGES AMOUNT APPROVED 11/01/08 - 11/30/08 03/23/09 55090764101170001 55090764101170001 5,164.80 3,498.07 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 000000 12/01/08 - 12/31/08 03/23/09 55090764101560001 55090764101560001 5,336.96 3,681.36 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 000000 01/01/09 - 01/31/09 O6/08/09 69091424022120001 69091424022120001 5,336.96 3,519.49 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 000000 02/01/09 - 02l28/09 O6/08/09 69091424022160001 69091424022160001 4,820.48 2,986,33 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 000000 03l01/09 - 03/31/09 06/08/i09 69091424022200001 69091424022200001 5,509.32 3,519.49 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 000000 04/01/09 - 04/30/09 06/08l09 27091424022480001 27091424022480001 4,211.80 2,222.p7 DIAGNOSIS 1 ; 7197 D�FFICULTY IN WALKING DIAGNOSIS 2: 0 I PROC CODE: 000000 I 05/01/09 - 05131/09 06/15/b9 20091524149570001 200915241 49570001 300.80 300.85 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 I PROC CODE: 000000 I 07/01/09 - 07/31/09 11/08/1�0 55103064087790001 55103064087790001 5,595.81 3,508.02 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 I PROC CODE: 000000 I I Page 6 of 24 COMMONWEALTH OF FENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE '1D 610 202 408 CHURCH OF GOD HOME INC 801 N HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAC CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 08/01/09 - 08/31/09 11/08/10 55103064088190001 55103064088190001 5,595.81 3,508.02 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 09/01/09 - 09/30/09 11/08/10 55103064088620001 55103064088620001 5,415.30 3,332.50 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 10/01/09 - 10131/09 11/15/10 55103144085420001 55103144085420001 5,595.81 3,795.36 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 11/01/09 - 11/30/09 11/15/10 55103144085780001 55103144085780001 5,415.30 3,608.80 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 . 12/01/09 - 12/31/09 11/15/10 55103144086240001 55103144086240001 5,595.81 3,795.36 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 01/01/10 - 01131/10 11/29/10 55103274086990001 55103274086990001 5,595.81 3,795.36 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 02/01110 - 02128110 11129I10 55103274087800001 55103274087800001 5,054.28 3,258.70 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 03/01I10 - 03/31/10 11/29/10 55103274088200001 55103274088200001 5,595.81 3,818.38 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 ' Page 7 of 24 � COMMONWEALTH>OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE ID` 610 202 408 CHURCH OF GOD HOME INC 801 N HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 04/01/10 - 04130110 12/13/10 55103414099160001 55103414099160001 5,415.30 4,018.52 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 05/01/10 - 05/31/10 12/13/10 55103414099500001 55103414099500001 5,595.81 4,217.97 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 06101/10 - 06/30/10 12/13/10 55103414099950001 55103414099950001 5,415.30 4,018.52 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 07/01/10 - 07/31/10 10/17/11 55112844061490001 55112844061490001 5,595.81 4,569.30 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 08l01/10 - 08/31/10 10/17/11 55112844062000001 55112844062000001 5,595.81 4,569.30 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 09/01/10 - 09/30I10 10/17111 55112844062690001 55112844062690001 5,415.30 4,371.42 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 10101110 - 10131110 10124111 55112924053510001 55112924053510001 5,983.50 4,722.12 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 11/01110 - 11I30110 10l24111 55112924054060001 55112924054060001 5,983.50 4,722.12 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 ' Page 8 of 24 COM(VIONWEALTH OF PENNSYLVANIA. DEPARTMENT OF PUBLIC WELFARE July 1,2014 STATEMENT OF CLAIM 'NAME DEISS,BESSIE ID 610 202 408 CHURCH OF GOD HOME INC 801 N HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 12/01/10 - 12/31/10 10/24/11 55112924U54670001 55112924054670001 6,182.95 4,931.69 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 01/01111 - 01/31/11 10/31/11 55112994053590001 55112994053590001 6,182.95 4,524.04 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 02/01/11 - 02/28/11 10/31/11 55112994054500001 55112994054500001 5,584.60 3,946.88 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 03/01/11 - 03/31/11 05/14/12 69121114021130001 69121114021130001 6,182.95 4,439.74 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 04/01/11 - 04/30/11 05/14/12 69121114021410001 69121114021410001 5,983.50 4,331.22 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 05/01/11 - 05/31/11 05/14/12 69121114021630001 69121114021630001 6,182.95 4,530.52 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 06/01/11 - 06I30/11 05/14/12 69121114021760001 69121114021760001 5,983.50 4,331.17 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 07/01111 - 07/31/11 06118112 69121464021410001 69121464021410001 6,182.95 4,356.66 DIAGNOSIS 1 : 2979 , PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 , Page 9 of 24 COMMONWEALTH OF'PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE 1D 610 202 408 CHURCH OF GOD HOME INC 801 N HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGiNAL CRN ADJUSTED GRN USUAL CHARGES AMOUNT APPROVED 08/01111 - 08131111 05/07/12 55121244260080001 55121244260080001 6,182.95 4,356.57 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 09/01/11 - 09/30/11 05/07/12 55121244260620001 55121244260620001 5,983.50 4,162.83 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 10/01/11 - 10/31/11 06/18/12 55121644589050001 55121644589050001 2,857.31 1,215.15 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 01l01112 - 01l31112 07116/12 55121944220350001 55121944220350001 6,179.85 4,234.84 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 02/01/12 - 02129/12 07/16/12 55121944220360001 5512194422.0360001 5,781.15 3,855.10 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 03/01112 - 03/31/12 07/16112 55121944219710001 55121944219710001 6,179.85 4,168.54 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 04/01/12 - 04130112 05/28112 20121224268670001 20121224268670001 5,980.50 4,254.37 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 05/01112 - 05131/12 06125/12 20121534334600001 20121534334600001 6,170.86 4,453.43 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 Page 10 of 24 ' i COMMONWEALTH OF PENNSYLVANIA � DEPARIMENT OF Pl1BLIG WECFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE ID 610 202 408 CHURCH OF GOD HOME INC 801 N HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 06/01/12 - 06/30/12 07/23112 20121844206730001 20121844206730001 5,971.80 4,254.37 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 07/01/12 - 07/31/12 01/14/13 55130094304510001 55130094304510001 6,170.86 4,484.43 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 08/01/12 - 08/31/12 01/14/13 55130094306140001 55130094306140001 6,170.86 4,484.63 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 09/01112 - 09l30/12 01114/13 55130094305620001 55130094305620001 5,971.80 4,284.57 DIAGNOSIS 1 : 2979 PARANOID STATE NOS � DIAGNOSIS 2: 0 PROC CODE: 000000 10/01/12 - 10/31/12 01/28/13 55130245382690001 55130245382690001 6,170.86 4,571.74 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 11/01/12 - 11/30/12 01/28/13 55130245383270001 55130245383270001 5,971.80 4,368.87 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 12/01/12 - 12/31/12 01/28/13 55130245383910001 55130245383910001 6,170.86 4,571.74 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 01/01l13 - 01/31113 02125/13 20130324258650001 20130324258650001 5,939.60 4,222.37 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 ', Page 11 of 24 COMMONWEALTH OF PENNSYLVANIA , DEPARTMENT OF PUBLIC WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE ID 610 202 408 CHURCH OF GOD HOME INC 801 N HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 02/01/13 - 02/28113 03/25/13 20130604312260001 20130604312260001 5,364.80 3,614.57 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 03/01/13 - 03/31/13 04/22113 20130914238850001 20130914238850001 5,939.60 4,189.37 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 04/01/13 - 04/30/13 06/24/13 27131514024200001 27131514024200001 5,971.80 4,368.57 DIAGNOSIS 1 : 2979 PARANOID STATE NOS DIAGNOSIS 2: 0 PROC CODE: 000000 05/01113 - 05/31/13 07/15/13 20131694020590001 20131694020590001 8,370.00 4,572.53 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 4293 CARDIOMEGALY PROC CODE: 000000 06/01/13 - 06/30/13 08/12/13 20131994020550001 20131994020550001 8,100.00 4,368.57 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 4293 CARDIOMEGALY PROC CODE: 000000 07/01/13 - 07/31/13 01/13/14 55140074274420001 55140074274420001 8,370.00 4,432.41 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 4293 CARDIOMEGALY PROC CODE: 000000 08/01/13 - 08131/13 01/13/14 55140074274830001 55140074274830001 8,370.00 4,432.41 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 4293 CARDIOMEGALY PROC CODE: 000000 09/01113 - 09I30/13 01113/14 55140074275270001 55140074275270001 8,100.00 4,232.87 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 4293 CARDIOMEGALY PROC CODE: 000000 Page 12 of 24 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIG WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE ID 610 202 408 CHURCH OF GOD HOME INC 801 N HANOVER ST CARLISLE PA 17013 DATE OF SERVICE ' PAYMEN7'DATE ORIGINAL CRN ADJUSTED GRN USUAL CHARGES AMOUNTAPPROVED 10/01/13 - 10131/13 01120I14 55140154578410001 55140154578410001 8,370.00 4,389.22 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 4293 CARDIOMEGALY PROC CODE: 000000 11/01/13 - 11/30/13 01/20114 55140154578830001 55140154578830001 8,100.00 4,191.17 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 4293 CARDIOMEGALY PROC CODE: 000000 12/01/13 - 12/26/13 02103114 55140154579610001 55140154579610001 6,750.00 3,200.92 DIAGNOSIS 1 : 4019 HYPERTENSION NOS DIAGNOSIS 2: 4293 CARDIOMEGALY PROC CODE: 000000 PROVIDER SUB TOTAL CHURCH OF GOD HOME INC 389,811.76 259,502.02 03 000747604 0001 Page 13 of 24 �- COMMONWEALTH OF PENNSYLVANIA ( DEPARTMENT OF PUBLIC WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE JD 610 202 408 CONTINUING CARE RX 28 S 2ND ST NEWPORT PA 17074 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 11/01/08 - 11/01I08 01119/09 25083595330040001 25083595330040001 21.87 5.40 DIAGNOSIS 1 : 0 NDC CODE: 63304077205 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 12/01/08 - 12/01/08 01/19/09 25083595329470001 25083595329470001 21.87 5.40 DIAGNOSIS 1 : 0 NDC CODE: 63304077205 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 12/31/08 - 12/31/08 02/02/09 25090085449990001 25090085449990001 21.87 5.25 DIAGNOSIS 1 : 0 NDC CODE: 63304077205 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 01/30/09 - 01/30/09 03/09/09 25090405501230001 25090405501230001 12.94 4.62 DIAGNOSIS 1 : 0 NDC CODE: 63304077205 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 12/23/09 - 12123/09 01/18/10 25093575540670001 25093575540670001 21.87 5.05 DIAGNOSIS 1 : 0 NDC CODE: 00228205750 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILiZERS 02/15/10 - 02/15/10 03/15/10 25100465672430001 25100465672430001 8.18 7.43 DIAGNOSIS 1 : 0 NDC CODE: 00536199553 SELENIUM SULFIDE 1%SHAMPOO - ALL OTHER DERMATOLOGICALS 10I07I10 - 10/07/10 11/01/10 25102805588610001 25102805588610001 8.18 6.60 DIAGNOSIS 1 : 0 NDC CODE: 00536199553 SELENIUM SULFIDE 1%SHAMPOO - ALL OTHER DERMATOLOGICALS Page 14 of 24 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PWBLIC WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE ID 610 202 408 CONTINUING CARE RX 28 S 2ND ST NEWPORT PA 17074 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 04/06/11 - 04/06111 05/02111 25110965597770001 25110965597770001 8.18 6.60 DIAGNOSIS 1 : 0 NDC CODE: 00536199553 SELENIUM SULFIDE 1%SHAMPOO - ALL OTHER DERMATOLOGICALS PROVIDER SUB TOTAL CONTINUING CARE RX 124.96 46.35 24 100731447 0011 Page 15 of 24 � COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WE�FARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE iD 610 202 408 ALERT PHARMACY SERVICES INC 219 N BALTIMORE AVE MOUNT HOLLY SPRING PA 17065 DATE OF SERVICE 'PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 12/06/12 - 12/06112 01/21/13 25123615520490001 25123615520490001 3.06 3.06 DIAGNOSIS 1 : 0 NDC CODE: 00713026831 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 05/30/13 - 05/30113 06/24/13 25131505409040001 25131505409040001 3.06 3.06 DIAGNOSIS 1 : 0 NDC CODE: 00713026831 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS PROVIDER SUB TOTAL ALERT PHARMACY SERVICES INC 6.12 6.12 24 100738546 0005 ' Page 16 of 24 ' COMMONWEALTH OF PENNSYLVANIA � 'DEPARTMENT OF PIJBLIC WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE ID 610 202 408 WALNUT BOTTOM RADIOLOGY 850 WALNUT BOTTOM RD CARLISLE PA 17013 DATE OF SERVICE. PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 02/19/13 - 02119/13 04/22113 20130926664380001 20130926664380001 60.00 18.00 DIAGNOSIS 1 : 81304 FX UPPER ULNA NECINOS-CL PROC CODE: 73080 RADIOLOGIC EXAMINATION,ELBOW;COMPLETE, PROVIDER SUB TOTAL WALNUT BOTfOM RADIOLOGY 60.00 18.00 31 001063490 0001 Page 17 of 24 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF'PUBLIC WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE ID 610 202 408 CARLISLE DIGESTiVE DIS ASSOC 241 ALEXANDER SPRING RD CARLISLE PA 17015 DATE OF SERVICE PAYMENT DATE ORIGINAL GRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 07/10/09 - 07/10/09 08/24/09 27092196171960002 27092196171960002 1,592.00 27.65 DIAGNOSIS 1 : 57451 CHOLEDOCHLITH NOS W OBST PROC CODE: 43264 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATO PROVIDER SUB TOTAL CARLISLE DIGESTIVE DIS ASSOC 1,592.00 27.65 31 001190607 0003 ', Page 18 of 24 � COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE i July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE 1D 610 202 408 BLUE MOUNTAIN ANESTHESIA ASSOCIATES 361 ALEXANDER SPRING RD CARLISLE PA 17015 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN' ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 07/10/09 - 07/10/09 09/14/09 27092396129540001 27092396129540001 825.00 12.19 DIAGNOSIS 1 : 57450 CALCULUS OF BILE DUCT WIT PROC CODE: 00740 ANESTH UPPER GI VISUALIZE 10/14/11 - 10/14/11 02/13/12 27120246199380001 27120246199380001 1,440.00 17.75 DIAGNOSIS 1 : 8208 FX NECK OF FEMUR NOS-CL PROC CODE: 01210 ANESTH HIP JOINT SURGERY PROVIDER SUB TOTAL BLUE MOUNTAIN ANESTHESIA ASSOCIATES 2,265.00 29.94 31 001390303 0012 Page 19 of 24 GOMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE ID 610 202 408 QUANTUM IMAGING&THERAPEUTIC ASSO( 629D LOWTHER RD LEWISBERRY PA 17339 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN �USUAL CHARGES AMOUNTAPPROVED 10114/11 - 10/14111 11/28/11 20113156135080001 20113156135080001 238.00 7.57 DIAGNOSIS 1 : 7231 CERVICALGIA PROC CODE: 72125 COMPUTERIZED AXIAL TOMOGRAPHY,CERVICAL 10/14/11 - 10/14111 11/28/11 20113156135080002 20113156135080002 198.00 3.74 DIAGNOSIS 1 : 7840 HEADACHE PROC CODE: 70450 COMPUTERIZED AXIAL TOMOGRAPHY,HEAD OR B 10/14/11 - 10/14/11 11/28/11 20113156135140003 20113156135140003 36.00 .04 DIAGNOSIS 1 : 95911 OTHER INJURY OF CHEST WALL PROC CODE: 71010 CHEST X-RAY 1 VIEW FRONTAL 10/15/11 - 10115/11 11/28/11 20113156135200001 20113156135200001 36.00 .04 DIAGNOSIS 1 : 4280 CHF UNSPECIFIED PROC CODE: 71010 CHEST X-RAY 1 VIEW FRONTAL PROVIDER SUB TOTAL QUANTUM IMAGING&THERAPEUTIC ASSOC . 508.00 11.39 31 OOT617239 0085 , Page 20 of 24 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFAF2E July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE ID 610 202 408 THREE SPRINGS FAMILY PRACTICE 303 N BALTIMORE AVE MOUNT HOLLY SPRING PA 17065 _ DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 03/03/09 - 03/03/09 04/13/09 20090846388440001 20090846388440001 40.00 4.37 DIAGNOSIS 1 : 29020 SENILE DELUSION PROC CODE: 99307 NURSING FAC CARE SUBSEQ 07/O8/09 - 07/O8/09 08/31/09 20092266268950001 20092266268950001 40.00 4.37 DIAGNOSIS 1 : 4019 HYPERTENSION NOS PROC CODE: 99307 NURSING FAC CARE SUBSEQ 08/19/09 - 08119/09 10/12/09 20092666304120001 20092666304120001 40.00 4.37 DIAGNOSIS 1 : 4019 HYPERTENSION NOS PROC CODE: 99307 NURSING FAC CARE SUBSEQ 09/01/09 - 09/01/09 10/19/09 20092736230390001 20092736230390001 40.00 4.37 DIAGNOSIS 1 : 70219 OTHER SEBORRHEIC KERATOSI PROC CODE: 99307 NURSING FAC CARE SUBSEQ 09/30/09 - 09l30/09 11/16/09 20093016340840001 20093016340840001 40.00 4.37 DIAGNOSIS 1 : 4019 HYPERTENSION NOS PROC CODE: 99307 NURSING FAC CARE SUBSEQ 12I22/09 - 12/22/09 02/01/10 20100146354790001 20100146354790001 40.00 4.37 DIAGNOSIS 1 : 29020 SENILE DELUSION PROC CODE: 99307 NURSING FAC CARE SUBSEQ 04/14/10 - 04114/10 05/31/10 20101326142030001 20101326142030001 45.00 3.54 DIAGNOSIS 1 : 29020 SENILE DELUSION PROC CODE: 99307 NURSING FAC CARE SUBSEQ 06/05/13 - 06/05113 07/22/13 20131856515340001 20131856515340001 45.00 20.00 DIAGNOSIS 1 : 29020 SENILE DELUSION PROC CODE: 99307 NURSING FAC CARE SUBSEQ Page 21 of 24 � COMMONWEALTH OF PENNSYIVANiA DEPARTMEN'f OF PUBLIC WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE ID 610 202 408 THREE SPRINGS FAMILY PRACTICE 303 N BALTIMORE AVE MOUNT HOLLY SPRING PA 17065 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED GRN USUAL CHARGES 'AMOUNTAPPROVED 07/03113 - 07/03/13 08/12/13 20132056334060001 20132056334060001 75.00 20.00 DIAGNOSIS 1 : 29020 SENILE DELUSION PROC CODE: 99308 NURSING FAC CARE SUBSEQ 08/14/13 - 08/14/13 09/23/13 20132476291890001 20132476291890001 90.00 20.00 DIAGNOSIS 1 : 29020 SENILE DELUSION PROC CODE: 99309 NURSING FAC CARE SUBSEQ 09119113 - 09/19/13 10128/13 20132826217250001 20132826217250001 80.00 20.00 DIAGNOSIS 1 : 29020 SENILE DELUSION PROC CODE: 99308 NURSING FAC CARE SUBSEQ 11/05/13 - 11/05/13 12123113 20133386167700001 20133386167700001 95.00 20.00 DIAGNOSIS 1 ; 29020 SENILE DELUSION PROC CODE: 99309 NURSING FAC CARE SUBSEQ 12/16l13 - 12116113 01/27/14 20140096233460001 20140096233460001 60.00 20.00 DIAGNOSIS 1 : 29020 SENILE DELUSION PROC CODE: 9930T NURSING FAC CARE SUBSEQ PROVIDER SUB TOTAL THREE SPRINGS FAMILY PRACTiCE 730.00 149.76 31 100736327 0006 , Page 22 of 24 COMMONINEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE ]D 610 202 408 VOHRA HEALTH SERVICES PA 3601 SW 160TH AVE STE 250 MIRAMAR FL 33027 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 01/31/13 - 01/31/13 04/01113 20130776353230001 20130776353230001 157.26 30.45 DIAGNOSIS 1 : 70707 PRESSURE ULCER HEEL PROC CODE: 11042 DEBRIDEMENT;SKIN,AND SUBCUTANEOUS TISS 02/14/13 - 02/14/13 04/01/13 20130776353380001 20130776353380001 157.26 30.45 DIAGNOSIS 1 : 70707 PRESSURE ULCER HEEL PROC CODE: 11042 DEBRIDEMENT;SKIN,AND SUBCUTANEOUS TISS PROVIDER SUB TOTAL VOHRA HEALTH SERVICES PA 314.52 60.90 31 102300288 0001 , Page 23 of 24 ' COMMONWEALTH OF PENNSYLVANIA DEPARTMENTOF PUB61C WELFARE July 1,2014 STATEMENT OF CLAIM NAME DEISS,BESSIE ID 610 202 408 CARLISLE MEDICAL GROUP LLC 1600 CLOISTER DR LANCASTER PA 17601 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 10/14/11 - 10/14/11 05/07/12 27121096150130001 27121096150130001 3,164.00 17.83 DIAGNOSIS 1 : 73314 PATHOLOGIC FRACTURE OF NE PROC CODE: 27125 PARTIAL HIP REPLACEMENT,PROSTHESIS(EG, PROVIDER SUB TOTAL CARLISLE MEDICAL GROUP LLC 3,164.00 17.83 31 102326749 0001 Page 24 of 24 432 D� SP�'Wo�f c SE A�E R g1� p p P &p\SS\NGE p7123�� S�p71231�4 GER 6E� FtT OA ��SN 32N�spp��1 5��091�� 'WES o15 2a Mp N��.�-ao 20 * 2 c �� P g15'2$ c�ASSo,��ES � , �-i11.ei� �11. 1U PUB�-1C N Gross A�ount �,y�� m nt ee(1;nk• � N Av�B NetAMou �W��i W`,m � ,v pESCR�P?��N'(ARY N Rate $�p62� ��/a��c'�� P� �tEg't AM ��s ��- $�p62� ��p��vFN`'@��G v� � ��.��RS \nsert � NO.��G 3 ��.00 c�RU� $3 Q� ��pFtF NU�BER Mpg2 P�32�g1 PUa��ati0� E� ��GP� E S�N��PRGE 3TN p,OGN pN �p'!P� P�g�\�P�(1 3PROg�OS?� 3M �1�62� *PF.�� O�N� PP��N�S PM. E� � ,�t��a e.rnGO��on ,�NE SENN�WgP e�tis Se Se the o�E� 0 m e U �� 5� Anw �ess�e�e�ss ts�red��ebocked�uPockbog�.40��• pOBOR�'�Q1r o� hase o<aer �St �o�or9e��umb rS a\p yme ure��ax at 319 2 or Pur� ��tecpr�se G�ea��ca a��ea�t�o�to a se° \` �ead\��?oC e �n9 se ouP t�re • s'P �� a\ a\S�°�ta�n be�O�t send<he� �th The Seus�ness d�p��3p' �e9 be, Em YoU ma`J a\so ad�e��5,�p0 P•m•tv��Ga�\l��2 Pd Num k y°u{�ca\ads�s�• uesbo�s, our Payment eait GaCd gt\��r90a �hCO umn 1e9 e,��or.F°C a oR�o�With Y ��r t \r' da�e pf ln Return Ghe K# �� O P�`OUr o . ov� A�� o � Er�� m E�- S PpOt#'• EXp patg� �H�S�NN�Sp PpER E 05�� o��gd��a�d E�. C�o�� X 5a� 5��p. �ame H�S�Nt�N �P��R��p\P S�9na�ut�hecks payab\e�0' � gEN��NE�p ApEFtS s emaKe �N� NEWS P�ea cl o�-OX T 41548 �y2�4: � O � ► C�;,1,1`i 11��ii�� 00�162 `�`1� &p1SS1NGER ` `NG�R �R��,� op00000c�oal3� �`,��,p1 P pN\�SPP1.�� opy"�2y9't�0��0 � c 215�o20�ppo . I 'Y 1ZElySentinel DISSINGER&DISSINGER AD NUMBER PAGE NO. www.cumberlink.com 28N.32NDSTREET 432197 1of1 CAMP HILL,PA 17011 �� 717-975-2840 BILL DATE SALESPERSON �,�_�__.,__--_ cnQtistr st.��vv�NSauec: PraevcouN�v 07/23/14 wolfc START DATE STOP DATE 07/09/14 07/23/14 AD NUMBER AD DESCRIPTION CLASS LINES 432197 NOTICE LETTERS TESTAMENTARY HAVE B 10 PUBLIC NOTICES 20 * 2 cols Publication Insertions Rate Net Amount Gross Amount 3 THE SENTINEL-LEGAL 3 LGL $106.20 TOTAL AD CHARGE $106.20 3 PROOF OF PUBLICATION 01 PRF $7.00 3 MOBILE SITE M082 $3.00 PurchaseOrder Est.BessieDeiss PAY THIS AMOUNT $116.20 $139.44* *AFTER 08/17/14 Lee Enterprises no longer accepts credit card payments sent via e-mail. Emails containing credit card numbers will be blocked. Please use the coupon below to send credit card payment to our lockbox. THE SENTINEL You may also send the coupon to a secure fax at 319-291-4014. c/o LEE NEWSPAPERS Thank you for advertising with The Sentinel! Deadline for PO BOX 540 in-column legal ads is 4:00 p.m. two business days prior to �NATERLOO IA 50704-0540 date of insertion. For questions, call (717)240-7130. Return this port/on with your payment Legal THE SENTINEL ❑ Check# �Credit Card Ad Number 432197 C/o LEE NEWSPAPERS ❑ � ❑ v�� ❑ � ❑ ""'�"' Billing Date 07/23/14 PO BOX 540 WATERLOO IA 50704-0540 Acct#: Amount Due $ 116.20 Exp.Date:m m Amount � Name on credit card Et1C�OS@C� Signature Piease make checks payable to: THE SENTINEL ��}� 000�sz THE SENTINEL I� DISSINGER& DISSINGER c/o LEE NEWSPAPERS 28 N.32ND STREET PO BOX 742548 CAMP HILL, PA 17011 CINCINNATI OH 45274-2548 �i�i��n i��i��n��i��i��i��)n��i�� 2154020000000432197000000000000()001394400000116206 . - PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Patrick Doane,Production Director, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle,County and State aforesaid, was established December 13th,1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of Tuly 9, 2014 and Tuly 16,2014 and luly 23,2014. COPY OF NOTICE OF PUBLICATION ------___.---- -- Letters Testamentary have been granted on the Estate of BESSIE MABLE D�I33 Eo Jer� s W.Moss,Sr„Mary A;Etter Dissin,ger,Esquire,Rissinger � �[5issinger,4�0 South�St�te�Roed,Mery'sVille,Pennsyivarif,�17a53,";'' �,�-s�z-saza,Attom�vg. Affiant further deposes that he/she is not All persor�$�HVmg clai�is agalnst the estate are requested to present them in �terested in the sub'ect matter of the writi��a d el�persor�s fnde4te�io the-estate to,rclake paym8nt tb ft in'�are � °ft"'e�,�°�"�ya"°��a°�e. ° �, aforesaid notice or advertisement, and that �- �_ . �� .a�. . �_ � all allegations in the foregoing statement as to time, place and character of publication are true. - - • o– .'�-_�� . . Sworn to and subscribed before me this � c �� - _ , ��..�, �� . � . –�-�— Notary P�lic My commission expires: COMNfl��V�'�Al.1"hl t3i'p�NNSYI.VANIA �N�laMal Seal Bethany M.Hqftry,Motary Rublic Carlisle Boro,Cumberlancl County My Commission Expir�s 5ept.26,2015 MEMIiER,PENNSYLYANIA A5SUCIA'ffON OF NOTARIES � � �, �� °G �� ti'� '- ", � ��ssoc��°� CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREEY CARLISLE, PA 17013 Tele: (717)249-3188 Fax:(717)249-2663 July 18, 2014 Cumberland Law Journal is published every Friday by �the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Mary A. Etter Dissinger, Esquire RE: Bessie M. Deiss Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: July 4, July 11, and July 18, 2014 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Reque:;t $ 0.00 Payment received $ 75.00 Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director � '►.' , PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVANIA : . ss. COUNTY OF CUMBERLAND . Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical publisheci in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, viz: Julv 4, July 11, and Jul 18 2014 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. e �.�-- ..--- Lisa Marie Coy ie, Editor SWORN TO AND SUBSCRIBED before me this 18 day of July, 2014 --- Notary Deiss,Bessie Mable, dec'd. Late of Carlisle Borough. Executor:James W, Moss, Sr. Attorneys: Mary A. Etter Diss- inger, Esquire, Dissinger&Diss- inger, 400 South State Road, COMMONWI:ALTH OF PENNSYlVAN1A Marysville, PA 17053, (717) 957- +„ � NOTARIAO L�S—EAL_ 3474. ' OEBURAH A COLLINS � Motary Public � CARLISIE BORO.,CUMBERLANO CNTY My Commisslon Expires Apr 28,2018 t.,.....v��,�..� ♦ REGISTER OF WILLS CERTIFICATE OF CUMBERLAND COUNTY GRANT OF LETTERS PENNSYLVANIA �� ; No. 2014- 00570 PA No. 21- 14- 0570 Es ta te Of: BESSIE MABLE DEISS �� . (First,Middle,Lastl � La te Of: CARLISLE BOROUGH CUMBERLAND COUNTY Deceased Social Securi ty No: 297-42-1776 WHEREAS, on the 12th day of June 2014 an instrument dated June lst 2007 was admitted to probate as the last will of BESSIE MABLE DEISS (First,Middle,Lastl late of CARL/SLEBOROUGH, CUMBERLAND County, who died on the 26th day of December 2013 and WHEREAS, a true copy of the will as proJbated is annexed hereto. THEREFORE, I, L/SA M. GRAYSON, ESQ. , Register of Wills in and for CUMBERLAND County, in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to: JAMES W MOSS SR who has duly qualified as EXECUTOR(R/X) and has agreed to administer the estate according to law, all of which fully appears of record in my office at CUMBERLAND COUNTY COURT HDUSE, CARLISLE, PENNSYL VANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my offi ce on the 12th da y of June 2014. , , _ Regi er of lls �_._ r pu **NOTE** ALL NAMES ABOVE APPEAR (FIRST, MIDDLE, LAST) LAST WILL AND TESTAMENT OF BESSIE MABEL DEISS I, Bessie Mabel Deiss, residing at the Church of God Home in Carlisle, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils heretofore made by me. , � ITEM I . I direct that all my debts and funeral ex�enses, � including my cemetery lot and grave marker and all expenses of my last illness, shall be paid from my residuary estate as soon as �� practicable after my death as part of the expense of the � �, administration of my estate. 1 ITEM II . I make the following specific bequests : � � 1 . 10� of my net estate sha11 go to Dover Alliance Church, Dover, Ohio. � ITEM III . I devise and bequeath all of the rest, residue .and remainder of my estate of every nature and wherever situate equally among James W. Moss, Sr. , James W. Moss, Jr. , John L. Moss, Gregory A. Moss, Stephanie R. Astle and Rebekah L. Moss, or the survivor or survivors of them. ITEM IV. I direct that any and all :Lnheritance, Estate and Transfer taxes imposed upon my estate passing under my Will� or otherwise, shall be paid out of the principal of my residual estate. ITEM V. I appoint James W. Moss, Sr. Executor of this my Last Will and Testament . In the event of his renunciation, death, resignation or inability to act for any reason whatsoever, I appoint Rebekah L. Moss, Executrix of this my Last Will and Testament . I relieve my Executor/Executrix from the necessity of posting security in connection with his/her duties as such in any jurisdiction in which he/she may be called upon to act . IN WITNESS WHEREOF, I have hereunto set my hand to this my Last Will and Testament, which consists of � pages, to each of which I have a f f ixed my s i gna ture thi s � day o f �U�"1� two , thousand seven (2007) . _.� • Bessie Mab / � � . COMMONWEALTH OF PENNSYLVANIA . . s s . . ROqA1�VN��11�A� COUNTY OF �UYYI�Oe�"1 �. Notary ruDlfc (x.{'1. CARliS�E Udlt01l6H.CUMSERtAN�COUMY My Commiaslon Explrea Oct 24, 20�Q We, Bessie Mabel Deiss, and �1J��1�'1GL i-- • �T�Yt� � , and �r�� ' �a-r�- , the testatrix and the witnesses respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her Last Will and that she had signed willingly, and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the Will as witness and that to the best of their knowledge the testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. � c � \ �--,'�''',�t✓� y�.. �� ^�J�`� Bessie Mabel Deiss, Testatrix � _.�� itness ,,_��,� �.-T`� ; - �znn�;� ��-c��-�....:.;_.._.,_ Witness Subscribed and sworn to and acknowledged before me by Bessie Mabel Deiss, Testatrix and subscribe�l and sworn to and acknowledged f ore me by � ir'6 • ��'1/a.r , and � �� , witnesses this 1 day of 1P� , 2007 . � �%G�-, �'—� tary Public ,