HomeMy WebLinkAbout11-14-14 (3) REV-1500 EX(02-11) R 1505610143
OFFICIAL USE ONLY
PA Department of Revenue Pennsylvania County Code Year File Number
Bureau of Individual Taxes OEVARTMEW OF REVENUE
Po Box.280601 INHERITANCE TAX RETURN 21 14 0665
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
06 09 2014 10 24 1919
Decedent's Last Name Suffix Decedent's First Name MI
HOLLENBAUGH GAYLE 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 DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
0 1. Original Return 2. Supplemental Return 3. Remainder Return(Date of Death
Prior to 12-13-82)
El 4. Limited Estate 4a.Future Interest Compromise 5. Federal Estate Tax Return Required
(date of death after 12-12.82)
X❑ 8 Decedent Died Testate Den hent Maiont T�esi a Living Trust Q 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) Copy i )
9. Litigation Proceeds Received 10.spousal PovertCredit(Date of Death 11.Election to tax under Sec.9113(A)
between 12-31- land T-1-95) (Attach Schedule 0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
ROGER B IRWIN ESQ 717 249 6333 '
r113
REGISTER OF WILLS USEOJdLY n
I'•l � � C � i
First Line of AddressIrT
--- t3
354 ALEXANDER SPRING RO U) =n C-
o Ca
Second Line of Address c.: C', p "T1 1
r-% C
D.4TE-FILED rn
City or Post Office State ZIP Code , Ncn
C>
CARLISLE PA 17015
Correspondent's e-mail address: rogerbirwin(a)_salzmannhughes.com
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.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RET N DATE
C Roger C. Hollenbaugh Il // 1 y
ADDRESS
525 Springfield Road, Shippensburg, PA 17257
SIGNATURE_O1F_O=HER OTHER THAN REP SENTATIVE DATE
r Roger B. Irwin Esq.
ADDRESS
354 Alexan r Spring Road, Suite 1, Carlisle, PA
Side 1
1505610143 1505610143 J
PA Inheritance Tax Return
Signature of Additional Fiduciaries
ESTATE OF FILE NUMBER
Hollenbaugh, Gayle M. 21-14-0665
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.
Signature#2
Name Shirley J.Schel
Address1 3480 Enola Road
Address2
City, State,Zip Carlisle,PA 17013
Date
1505610243
REV-1500 EX
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1. 400,000 . 00
2. Stocks and Bonds(Schedule B)..........................................I.........................I........ 2. 1 ,547 . 42
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages&Notes Receivable(Schedule D)........................................................ 4.
6. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 5,225. 43
6. Jointly Owned Property(Schedule F) 1-1 Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous Nm-Probate Property
(Schedule G) H Separate Billing Requested............ 7.
8, Total Gross Assets(total Lines I through 7)........................................................ 8. 406,772 . 85
9. Funeral Expenses and Administrative Costs(Schedule H)................................ 9. 28,126. 64
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 87 ,401. 73
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 115,528 . 37
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 291,244 . 48
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. 291,244 . 48
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(11.2)X.00 15, 0 . 00
16. Amount of Line 14 taxable
at lineal rate X .045 291f244 . 48 16. 13,106 . 00
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 00 17. 0 . 00
18. Amount of Line 14 taxable
at collateral rate X.15 0 . 00 18. 0 . 00
19. TAX DUE................................................................................................................ 19. 13,106. 00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. El
Side 2
1505610243 1505610243
REV-1500 EX Page 3 File Number 21-14-0665
Decedent's Complete Address:
DECEDENT'S NAME
Hollenbaugh, Gayle M.
STREET ADDRESS
3480 Enola Road
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 13,106.00
2. Credits/Payments
A. Prior Payments 10,700.00
B. Discount 563.16
Total Credits(A +B) (2) 11,263.16
3. Interest (3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on 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) 1,842.84
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;............................................................................... ❑ F
b. retain the right to designate who shall use the property transferred or its income;.................................. ❑ ❑x
c. retain a reversionary interest;or..............................................................................................................
1:1 lxl
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?.................................................................................................................... x
3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... ❑ ❑x
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 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 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-1542 EX+(01-10)
SCHEDULE A
pennsylvania REAL ESTATE
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hollenbau h, Gayle M. 21-14-0665
All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property would be
exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on schedule F.
Attach a copy of the settlement sheet if the property has been sold
Include a copy of the deed showing decedent's interest if owned as tenant in common.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Land situate at Enola Road, Carlisle,Cumberland County, PA-at proceeds of sate-See HUD 150,000.00
1 attached
2 Real Estate situate at 3480 Enola Road, Carlisle, Cumberland County,PA-at proceeds of 250,000.00
sale-See HUD 1 aftached
TOTAL(Also enter on Line 1,Recapitulation) 400,000.00
(if more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule A(Rev.01-10)
Rev-1503 EX+(6-98)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hollenbaugh, Gayle M. 21-14-0665
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 28 MetLife 55.265 1,547.42
TOTAL(Also enter on Line 2, Recapitulation) 1,547.42
(If more space is needed,additional pages of the same size)
Copyright(c)2002 form software only The Lackner Group,Inc. Form PA-1500 Schedule B(Rev.6-98)
Rev-1508 EX+(11-10)
SCHEDULE E
pennsyivania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hollenbau h, Gayle M. 21-14-0665
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
NUMBER DESCRIPTION OF DEATH
1 Cash on hand 66.00
2 MetLife-dividend check dated 6/5/2014 9.80
3 Thornwald Home, Resident Account No. 1293 50.00
4 Wells Fargo College Checking Account No.7546814612 589.17
5 Wells Fargo Crown Classic Banking Account No.1014144392889 2,346.10
Accrued interest on Item 5 through date of death 0.01
6 Wells Fargo Value Checking Account No.9958289713 843.35
7 1991 Mercury Topaz-adeemed 0.00
8 Ford Pick-up Truck-adeemed 0.00
9 Household Goods at appraisal 1,321.00
TOTAL(Also enter on Line 5, Recapitulation) 5,225.43
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule E(Rev. 11-10)
REV-1511 EX+(10-09) SCHEDULE H
pennsylvania
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX
RESIDENTDECEDENTTURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Hollenbaugh, Gayle M. 21-14-0665
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A. FUNERAL EXPENSES:
See continuation schedule(s)attached 2,441.36
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State ZiD
Year(s)Commission Paid
2. Attorney's Fees Salzmann Hughes, P.C. 15,950.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation) 3,500.00
Claimant Shirley J. Schell
Street Address 3480 Enola Road
City Carlisle State PA ZiD 17013
RelationshiD of Claimant to Decedent Daughter
4. Probate Fees 508.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 5,726.78
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) 28,126.64
Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Hollenbaugh, Gayle M. 21-14-0665
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Eby Granite Works-grave marker 1,279.00
2 Hoffman Roth Funeral Home&Crematory,Inc.-balance due for funeral services 547.33
3 Roger C. Hollenbaugh -reimbursement for payment of funeral expenses 615.03
H-A 2,441.36
Other Administrative Costs
4 Kamela Cornman -notary fees paid to sell real estate in order to administer the estate 22.50
5 Kamela Cornman -notary fees paid to sell real estate in order to administer the estate 22.50
6 Recorder of Deeds-1%realty transfer tax paid to sell real estate in order to administer the 2,500.00
estate
7 Recorder of Deeds-1%realty transfer tax paid to sell real estate in order to administer the 1,500.00
estate
8 Roy D.Gottshall-appraisal of personal property 70.00
9 S.W. Barrett Real Estate&Appraisal Services -appraisal of real estate located at 3480 Enola 500.00
Rd.,Carlisle, PA
10 S.W. Barrett Real Estate&Appraisal Services-appraisal of real estate located at Enola Rd., 325.00
Carlisle, PA-acreage
11 Salzmann Hughes, P.C.-reimbursement for payment to Cumberland Law Journal for legal 75.00
advertising
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Hollenbaugh, Gayle M. 21-14-0665
ITEM
NUMBER DESCRIPTION AMOUNT
12 Salzmann Hughes, P.C.-closing costs and final fees for income tax preparation,postage 500.00
and miscellaneous contingencies in order to administer the estate
13 The Sentinel-Legal advertising 211.78
H-137 5,726.78
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1512 EX+(12.08)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hollenbaugh, Gayle M. 21-14-0665
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 Department of Public Welfare-Class 5.1 claim against the estate. 56,930.01
2 Pennsylvania Department of Public Welfare-Class 3 claim pursuant to Section 3392 of the 28,746.98
Decedents, Estates,and Fiduciaries Code,20 Pa. C.S.A.3392(3)
3 Thornwald Home-balance due on account 1,724.74
TOTAL(Also enter on Line 10,Recapitulation) 87,401.73
(If more space is needed,additional pages of the same size)
Copyright(c)2008 form software only The Lackner Group,Inc. Form PA-1500 Schedule I(Rev. 12-08)
REV-1513 EX+(01.10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hollenbaugh, Gayle M. 21-14-0665
NAME AND ADDRESS OF RELATIONSHIP TOSHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (Words) ($$$)
0 Not List Trustee(s)
I� TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
1 Shirley J.Schell Daughter 62.5% 182,027.80
P.O. Box 223
3480 Enola Rd.
Carlisle, PA 17013
2 Roger C. Hollenbaugh Son 37.5% 109,216.68
525 Springfield Rd.
Shippensburg, PA 17257
Total 291,244.48
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01-10)
U'j 17 PM ` 21
L 15
ORP
LAST WILL AND TESTAMENJAISER41D CO., PA
OF
GAYLE M. HOLLENBAUGH
1, Gayle M. Hollenbaugh, of Lower Frankford Township, Cumberland County,
Commonwealth of Pennsylvania,being of sound mind, memory and understanding, do
make publish and declare this to be my Last Will and Testament,hereby revoking any
and all Wills and Codicils by me at any time heretofore made.
ITEM 1: 1 direct that all expenses of my last illness and funeral expenses,
including my grave marker, shall be paid from my residuary estate as soon as practicable
after my decease, as part of the expense of the administration of my Estate.
ITEM II: I direct that all taxes which may be levied upon property passed
under this Will and outside this Will shall be paid as an expense of the administration of
my Estate.
ITEM III: I hereby give my Ford Pick Up truck to my son, Roger C.
Hollenbaugh.
ITEM IV: I hereby give my iggi Mercury Topaz, or any other vehicle that I
might own at my death,to my daughter Shirley J. Schell,Of 5o6 Rock Hollow Road,
Elliottsburg, Pennsylvania 17024.
ITEM V: I hereby give, devise and bequeath a tract of land situate in Lower
Fran1dord Township, Cumberland County, 'Containing approximately 25 acres, having a
house and garage attached thereto, as described in Deed Book"O",Volume 24, Page
970, recorded on April 21, 1972, including the contents of each,to my da'ughte`r, Shirley
J. Schell, providing she survives me by thirty(3o) days. Should Shirley desire to.sell
this tract of land at any time after she inherits it, she shall give Roger C. Hollenbaugh of
226 Travis Lane, Davenport, Florida 33837 the first opportunity to purchase the
property after an appraisal is obtained. The purchase price shall be the appraised value
of said property.
ITEM VI: In the event that my daughter, Shirley J. Schell,does not survive me
by thirty (3o) days, I give, devise and bequeath the property described in ITEM V, unto
my son, Roger C. Hollenbaugh.
ITEM VII: I hereby give, devise and bequeath a tract of land situate in Lower
Frankford Township, Cumberland County, containing approximately 28 acres,with no
buildings attached thereto as described in Deed Book"T",Volume 28, Page 483,
recorded December 29, 1978, unto my son, Roger C. Hollenbaugh, provided he survive
me by thirty (3o) days. Should Roger desire to sell this tract of land at any time after he
inherits it, he shall give Shirley J. Schell the first opportunity to purchase the property
after an appraisal is obtained. The purchase price shall be the appraised value of said
property.
ITEM VIII: In the event that my son, Roger C. Hollenbaugh, does not survive
me by thirty(3o) days, I give, devise and bequeath all of the property described in ITEM
VII, unto my daughter, Shirley J. Schell.
ITEM IX: I hereby give, devise and bequeath all the rest, residue and
remainder of my Estate, real, personal and/or mixed, of whatsoever nature and
wherever situate,to my son, Roger C. Hollenbaugh and my daughter, Shirley J. Schell,
in equal shares.
ITEM X: I hereby authorize and empower my Co-Executors, or the survivor
of them, to sell all the real property and any or all of the personal property of which I
shall die seized or possessed,to which I am entitled at my death, in the sole discretion of
said Co-Executors or the survivor of them, at private or public sale, without an Order of
Court, at such time or times and upon such terms as my Co-Executors, or the survivor of
them, deem proper for the best interests of my Estate, thereby converting the same into
cash; to execute, acknowledge and deliver all proper writings, deeds of conveyance and
transfers thereof.
ITEM XI: I hereby nominate,constitute and appoint my son, Roger C.
Hollenbaugh, and my daughter, Shirley J. Schell, as Co-Executors,or the survivor or
them as Executor, of this, my Last Will and Testament.
ITEM XII: I direct that my Co-Executors, or the survivor of them, hereinabove
appointed, shall not be required to enter security in any jurisdiction in which they may
act.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this
12 day of IA -E- 2004.
(SEAL)
Gayle1M. Hollenbaugh
The preceding instrument, consisting of this and three other typewritten pages,
identified by the signature of the Testatrix, Gayle M. Hollenbaugh, was on the day and
date thereof signed, published and declared by Gayle M. Hollenbaugh, the Testatrix
therein named, as and for her Last Will, in the presence of us,who at her request, in her
presence and in the presence of each other, have subscribed our names as witnesses
herein.
of
of
COMMONWEALTH OF PENNSYLVANIA
ss
COUNTY OF bL�t.. .-�f -
W Gayle M. Hollenbaugh, Vt a Y,c�V4 L )o 1 I b'O�.Ilo -\V and
am, \— W 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 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 and in the presence of each other signed the
Will as witnesses and that to the best of our knowledge, the Testatrix was at that time 18
years of age or older, of sound mind and under no constraint or undue influence.
Gayle Hollenbaugh V
Witness
i ess
Subscribed sworn to and acknowledged before me by Gayle M. Hollenbr uCFh the
Testatrix, and subscribed and sworn to before me by
witnesses,this Q I "day of
) 2004.
Notary Public
-UALSS
Previous editionsz'^¢b$ole"- form HUD-1(3186)ref Handbook 4305.2
A. Settlement Statement U.S.Department of Housing and Urban Development
1. 0 FHA 2. OFmHA 3. QConv.Unins. 6.File Number F7Lan Number 8.lvSortgage Insurance Case Number
❑ 0 2014-199
This tams is furnishotl to give you a statement of actual settlement costs,Amounts paid to and by the settlement agent are shown.
C.Note: Items marked'(p.o.a.)'were pmd outside the closing:they are shown here for information purposes and are not included in the totalsTitle , TRIeExpress Settlement System
WARNING:It is a crime to knowingly make false statements to the United States on this or an other similar form.Penalties upon
D.NAME OF BORROWER: Wayne R.Haltetnan and Eunice E.Halteman
E.NAME OF SELLER: The Estate of Gayle M.Hollenbaugll
F.NAME OF LENDER: Anabaptist Financial
ADDJIL-S& 1245 ] Route 15.New CQlunibia,PA 17856
G.PROPERTY ADDRESS: 3480 Enola Road,land on Enola Road,Carlisle,PA 17015
if.SETTLEMENT AGENT: PA Real Estate Settlement Services,LLC,Telephone: 717-249-6333 Fax: 717-249-7334
PLACE OF SM'LEMENI, 354 Alexander Spring Road lisle 17015
1-SLITLEMENI DATE 10/09/2014
J.SUMMARY OF B RROWER'S TRANSACTION: K.SUMMARY OF SELLER'S TRANSACTION:
101, Contra�Lsates_arice, 400 000.00 400 000.00
102 Ppr-naf PrnnP,j, 402 Perso Al Property
Clement charoes to bn 6 970.50 Anq
104, d
105, 4 fin
Uslm aid by seller n advance Adi VR rinadvnncp
JOT untvtaxe 10 09 14 to 12 31 14 86.40 10 09 14 12 31 14 86.40
108, School taxes 10 09 19 to 06/30/15 1 345.99 10 09 19 to 06 30 15 1,345.4
109 County Taxes 10/09/1410 12/31/14 5.32 409, County Taxes 10/09/14 to 12/31/14 5.32
1 10School T.ges 10/09/14 to 06 30 15 88.63 din R,hnnl T,iXes 10 09 14 to 06 30 15 88.63
ill 1 411
112, 412
408 496.34 420, G AMOUNT DUE TO aaLER 401 525.84
200, AMOUNTS PAID BY OR ON BEHALF OF BOREoWER 500, REDUC IONS IN AMOUNT D I I PR
35 000.00 35 000.00
380 000.00 4,045.
4 dIl{51n3- Existino loan(s)taken sublect to
qnj 504 PAyoff of First Mr-inn—I
205 rn5
207 50Z
208 908
209 rinh
211- x3ase^ III
212St;,hoDUaXes 512, School taxes
213, 511
214 1114
215, 515,
216, 516 1
217 517
218 518-
219, 519
20 TQTAL PAID BYIFOR BORROWER 415 000.00 39 045.00
101 Gra-nataunt due from borrower(line 1201 40$ 496.34 401 525.84
302 Les s amounts aid yjjgf tWrow r(in 415 000.00 39 045.00
303, CASH TO BORROWER 6,503.66 6Q3, CASH To SELLER362 480.84
SUBSTITUTE FORM 1099 SELLER STATEMENT:The information contained herein Is important tax information and Is being furnished to the Internal Revenue Service.If you are required to file a return,
a negligence penalty or other sanction will be imposed on you if this item is required to be reported and the IRS determines that it has not been reported.The Contract Sales Price described on
line 401 above constitutes the Gross Proceeds of this transaction-
You are required by law to provide the settlement agent(Fed.Tax ID No: )with your correct taxpayer Identification number.If you do not provide your correct taxpayer identification
number,you maybe 5udjec1 to civil or criminal penalties imposed by law.Under pena ties o perjury,I cenify that the number shown On this statement is my correct taxpayer identification number.
TIN: -_ i SELLER(S)SIGNATURE(S):
SELLER(S)NEW MAILING ADDRESS:_
SELLER(S)PHONE NUMBERS: (H) (W)
* Sales price for 3480 Enola Road $250,000.00
* Sales price for land on Enola Road $150,000.00
Previous editions are obsolete form HUD-1(3186)ref Handbook 4305.2
U.S.D6PAPI'MENTOF HOUSING AND URBAN DEVELOPMENT File Number:2014-199 PAGE 2
SETTLEMENT STATEMENT TilleExnress Settlement System inted 1010812014 at 11 06 KSQ
L. SETT EMENT CHARGES PAID FROM PAID FROM
700. TOIAL SALE,91BEOKER'S COMMISSION based on price 400 000.00 = BORROWER'S SELLER'S
Division of conn 1SSjon lifine 700)as foil w�- FUNDS AT FUNDS AT
201, S in SETTLEMENT SETTLEMENT
id at Settlement
800, ITEMS PAYABLE IN CONNECTION WITH LOAN
801, Loan Oricinatim Fee %
802, Loan Discount %
803Appraisal Fee
805, Lender's Inspection Fee
806, Mortgage April cation Fee
807- Assumption Fee
808. Document Preearalion to Anabaptist Financial LR 650.00
809Wire Transfer Fee In Anabaptist Financial LR 20.00
810,
811
900, ITEMS REQUIRED BY LENDER TO BE PAID IN ADVANCE
901, Interest From to ic)S Iday
902, Mortgage Insurance Premium for to
903 Hazard Innurance Prpmium for to
909
1000,RESERVES DEPOSITED WITH LENDER FOR
1001, Hazard Insurance Mo.0 S /Mo
1002 Mortnacte Insurance mo.9D$ /nno
1003, City Property Tax Mo,0 9; tmo
1004, County Property Tax Mo,0 /Mi,
1009 Aacrectate,Analysis Adiustment 0.00 0.00
1100,TITLE CHARGES
1101Settlement or closing fee —
1102 Abstract nr I tip search
1103, Title exa inAtion
1104 Overnight Mail to Salzmann Hughes, P.C. 20.50
1105 Wire Fee to PA Real Estate 12.00
1106 Notary Fees to Kamela Cornman 29.00 45.00
1107 Attorney's fees
(includes above items c,
1108Title Insurance
(includes above itern No,
1109 Lender's Coverage S 380 000.00
1110 Owner's Coveraoe$ 400 000.00
1111, Attorney Certificate to Salzmann Hughes, P.C. 2 040.00
11112
1113
1200,GOVERNMENT RECORDING AND TRANSFER CHARGES
1901 Fees Deed$ 99.00 100.00 199.00
1202 CtylCountytax/stamps 4 000.00 4,000.00
1203, State Taxlzi—ps 4 000.00 4,000.00
1204,
1205,
1300.ADDITIONAL SETTLEMENT CHARGES
1301 Surypy
1302, Pest Insciect on
1400.TOTAL SETTLEMENT CHARGES (enter on lines 103,Section J and 502 Secti,n K) 6,970.501 4,045.00
HUD CERTIFICATION OF BUYER AND SELLER
I have carefully reviewed the HUD-1 Settlement Statement andto the best of my knowledge and belief.it is a true and accurate statement of all receipts and disbursements made on my account or by me
in this transaction.I further certify that I have received a copy of the HUD-1 Selllement Statement. -.., _
y
Wayne R.LHall % EulmteE.Halteman
T Estate o M.H Ilenba
WARNING:IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE The HUD-1 Settlement Statement which I have prepared is a true and accurate account of this transaction.
UNITED STATES ON THIS OR ANY SIMILAR FORM.PENALTIES UPON CONVICTION I have caused or will cause the funds to be sbursed in accordance with this statement.
CAN INCLUDE A FINE AND IMPRISONMENT.FOR DETAILS SEE TITLE 18: 'u
U.S.CODE SECTION 1001 AND SECTION 1010. ���
By: .
MetLife Inc., MET Historical Quote - (NYSE)MET, MetLife Inc. Stock Price - BigChart... Page I of 1
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,r -� ..e._ ..... 0 .. ..� Enter Symbol: met Enter Date: 6109114
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Mon,Jun 09,2014
Closing Piice 54.66 P41 Tlt)4 4+56
Open 54.68
High: 55.21 Ill't 52
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SAVINGS STATEMENT
Thornwald Home Statement Number 1 Page 1
442 Walnut Bottom Road Date From 01/01/14
Carlisle, PA 17013 Date Thru 06/30/14
Gayle M. Hallenbaugh
Admission Date 06/23/11
Shirley J. Schell Resident ID Number 1293
191 Golfview Drive
Auburndale, FL 33823
Date/ Reference/ Fund Transaction Description Balance Deposits Disburse- Balance
Check ` Check No. Type Code Payee Brought ments
Date Forward
50.00 50.00
06/27/14 7688 MA wd close RF account 50.00 .00
TOTALS 50.00 00 50.00 A0•
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Account number:75468146120June 7.20}4-July 8. 2Ol40Page lu[4
DCDPIIDTY7 001160 -------- lectionS7
IIII 1 11111111111 1 111111$111111 1111111111111111 IIh 1111111 1111111
SHIRLEY J SCHELL 1-800-TO-WELLS (1-800-869-3557)
191 GOLF VIEW DR Enespaijok 1-877-727-2932
AUBURNDALE FL 33823-5613 1-800-288-2288(6 am to 7pm PT,M-F)
Online: wellsfargo.com
Write: Wells Fargo Bank,N.A.(345)
P.O.Box 6995
Portland,OR 97228-6995 0
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Find out how you could enter for mchance towin$a5o'000
Tell umyour story byentering our What Makes A Home Contest.For complete rules and entry information,contact a Home Mortgage
Consultant at 1'866'582'1253o/visit the contest website at wellsfargo.com/homecontest.Eligible entries must include a
cornpleted loan application for the purchase of residential real estate unless you reside in AZ,CO,IA,MN,NJ,MD,ND,TN.
ActivMtysummmmary Account number: 7546814612
Beginning balance nnm/ $s»p.`r aAYLExxHuLLEmSeUaH
Deposits/Additions 90.00 oxm�Fv�scHs��
CUSTODIAN opaxYLE MwuuENa~UGH
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Account number:1014144392889 ■ May 16,2014-June 16,2014 ■ Page 1 of 4 »
EOOCKTDTT5 013281
Questions?
1...'I'I"I�IIIIII1111'II���II�I'II"�Il�lrl�ll"II�IIII'���I'�III�I
GAYLE M HOLLEN BAUGH Available by phone 24 hours a day,7 days a week:
3480 ENOLA RD 1-800-TO-WELLS (1-800-869-3557)
PO BOX 223 TTY: 1-800-877-4833
CARLISLE PA 17013-0223 Enespanol: 1-877-727-2932
p 1-800-288-2288(6 am to 7 pm PT,M-F)
Online:wellsfargo.com
Write: Wells Fargo Bank,N.A.(345)
P.O.Box 6995
Portland,OR 97228-6995 r!F
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0
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company and look forward to continuing to serve you with your financial needs. convenient services with youraccount(s). Go to z
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questions or if you would like to add new services. z
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U,
Find the right borrowing options for your opportunity
Whether you need to pay for college,renovate your home,or buy a new car,we can help.Wells Fargo has the information you need to C.
better understand your credit,and the borrowing options that can help you make the most of your opportunities: N
o
-Student Loans
-Home Equity Loans or Lines of Credit
-Personal Loans or Lines of Credit
-Credit Cards
-Auto Loans
Learn more today at welisfargo.com/creditopportunities.
Account number: 1014144392889 ■ May 16,2014-June 16,2014 ■ Page 2 of 4
Activity summary Account number: 1014144392889
Beginning balance on 5/16 $2,333.70 GAYLE M HOLLENBAUGH
Deposits/Additions 1,089.74 Pennsylvania account terms and conditions apply
Witlidrawals/Subtractions - 1,077.32 For Direct Deposit use
Ending balance on 6/16 $2,346.12 Routing Number(RTN): 031000503
Overdraft Protection
This account is not currently covered by Overdraft Protection. If you would like more information regarding Overdraft Protection and eligibility requirements
please call the number listed on your statement or visit your Wells Fargo store.
Interest summary
Interest paid this statement $0.02
Average collected balance $2,406.84
Annual percentage yield earned 0.01%
Interest earned this staternent period $0.02
Interest paid this year $0.11
Transaction history
Check Deposits/ Withdrawals/ Ending daily
Date Number Description Additions Subtractions balance
6/2 US Treasury 312 Xxcw Sery 060114 Gayle M Hollenbaugh 1,089.72 3,423.42
6/4 1114 Check „ 1,077.32 2,346.10
6/16 Interest Payment 0 02 2,346.12*
Ending balance on 6/16 2,346.12
Totals $1,089.74 $1,077.32
The Ending Daily Balance does not reflect any pending withdrawals or holds on deposited funds that may have been outstanding on your account when your N
transactions posted. If you had insufficient available funds when a transaction posted,fees may have been assessed. w
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Summary of checks written(checks listed are also displayed in the preceding Transaction history)
Number Date Amount
1114 6/4 1077.32
Monthly service fee summary
For a complete list of fees and detailed account information,please see the Wells Fargo Fee and Information Schedule and Account Agreement applicable to
your account or talk to a banker.Go to wellsfargo.com/feefaq to find answers to common questions about the monthly service fee on your account.
Fee period 05/16/2014-06/16/2014 Standard monthly service fee$20.00 You paid$0.00
How to avoid the monthly service fee Minimum required This fee period F C1i.
Have any ONE of the following account requirements
Monthly automatic loan payment to a Wells Fargo mortgage 1 0 ❑
Combined balances in linked accounts,which may include $1,000.00 $0.00 ❑
- Average daily balance in time accounts and FDIC-insured retirement accounts
Combined balances in linked accounts,which may include $1,000.00 $3,890.16 Q
Average daily balances in checking and savings
Wells Fargo Values'Checking
Account number:9958289713 ■ June 3,2014-July 1,2014 0 Page 1 of . . i
QQDP11QTYU 001069
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' GAYLE M HOLLENBAUGH Available byphone 24 hours a day,7days a week:
SHIRLEY J SCHELL RP 1-800-TO-WELLS (1-800-869-3557)
3480 ENOLA RD 7-Y: 1-800-877-4833
PO BOX 223 Enespa4ol: 1-877-727-2932
CARLISLE PA 17013-0223 4�MQ 1-800-288-2288(6 am to 7 pm P7;M-F)
Online: wellsfargo.com
Write: Wells Fargo Bank,N.A.(345)
P.O.Box 6995
Portland,OR 97228-6995 0
n
0
v
0
You and Wells Fargo Account options
Thank you for being a loyal Wells Fargo customer.We value your trust in our Acheckmorkin the boxindicates youhovethese
company and look forward to continuing to serve you with your financial needs. convenient services with youraccount(s). Go to z
wellsforgo.comorcoil the number above ifyou hove z
questions or ifyou would like to add new services. z
z
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Online Bill Pay E] Auto Transfer/Payment z
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0
0
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Other Wells Fargo Benefits
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to
V
Find out how you could enter for a chance to win$250,000
Tell us your story by entering our What Makes A Home Contest.For complete rules and entry information,contact a Home Mortgage
Consultant at 1-866-582-1253 or visit the contest website at welisfargo.comihomecontest.Eligible entries must include a
completed loan application for the purchase of residential real estate unless you reside in AZ,CO,IA,MN,NJ,MD,ND,TN.
Activity summary Account number: 9958289713
Beginning balance on 6/3 $829.35 GAYLE M HOLLENBAUGH
Deposits/Additions 649.00 SHIRLEY)SCHELL RP
Withdrawals/Subtractions - 635.00 Pennsylvania account terms ondconditions apply
Ending balance on 711 $843.35 For Direct Deposit use
Routing Number(RTN): 031000503
ccount number:9958289713 n lune 3,2014-July 1,2014 ■ Page 2 of 4
i
rverdraft Protection
its account is not currently covered by Overdraft Protection. If you would like more information regarding Overdraft Protection and eligibility requirements
lease call the number listed on your statement or visit your Wells Fargo store.
ransaction history
Check Deposits! Withdrawals) Ending doily
Date Number Description Additions Subtractions balance
6/3 SSA Treas 310 Xxsoc Sec 060314 xxxxx8570A SSA N 1"Gd"Shirley 649.00 1,478.35
Schell for 1N 1"Be"Gayle Hol
614 107 Check 635.00 843.35
Ending balance on 711 843.36
Totals $649.00 $635.00
The Ending Daily Balance does not reflect any pending withdrawals or holds on deposited funds that may have been outstanding on your account when your
transactions posted. If you had insufficient available funds when a transaction posted,fees may have been assessed
summary of checks written(checks listed are also displayed in the preceding Transaction history)
Number Date Amount
107 6/4 635.00
utonthly service fee summary
or a complete list of fees and detailed account information,please see the Wells Fargo Fee and Information Schedule and Account Agreement applicable to
tour account or talk to a banker.Go to wellsfargo.com/€eefaq to find answers to common questions about the monthly service fee on your account.
Fee period 06/0312014-07/0112014 Standard monthly service fee$5.00 You paid$0.00
How to avoid the monthly service fee Minimum required This fee period
Have any ONE of the following account requirements
Average daily balance $1,500.00 $865.00 ❑ o
0
Qualifying direct deposit $250.00 $649.00 [/J
VC/T9 W
Other Wells Fargo Benefits
For a limited time get interest rate discounts on select new loans and lines of credit,with a qualifying relationship,during The Great
Rate Event.
welisfargo.com/greatrate
Did you know that you can review your safe deposit box information through Wells Fargo Online Banking?Sign on to online
banking and go to your account summary page.Check it out today.
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pennsylvania
DEPARTMENT OF PUBLIC. WELFARE
July 30, 2014
SALZMANN HUGHES PC
ROGER B IRWIN ESQUIRE
STE 1
354 ALEXANDER SPRING RD
CARLISLE PA 17015
Re: Gayle Hollenbaugh
CIS #: 530417003
SSN: ###-##-8570
Date of Death: 06/09/2014
ESTATE RECOVERY STATEMENT OF CLAIM
Dear
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 $85,676.99 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 $28,746.98, was incurred during the last
six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of
the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the
claim, namely $56,930.01, is to be entered as a priority Class 5.1 claim against the estate.
You should 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 also have a lien against the personal injury action. A statement of claim
for that injury-related lien must be requested separately.
Bureau of Program Integrity I Division of Third Party Liability I Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
Pennsylvania
:DEPARTMENT_OF PUBLIC WELFARE
Your Responsibility to Provide Information to the Department
Please acknowledge receipt of this letter and advise whether the Department's claim
is admitted and when payment may be expected. When the estate 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 accurately compute 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 existed
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 forms 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 Department
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 Integrity i Division of Third Party Liability I Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
''W�7
...pen,: [lama
..QEPARTMENT OF PUBLIC WELFARE
Insolvent Estates and the Fiduciary Responsibility to Creditors
If there are not enough estate assets to pay the claims of all 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
greater 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 Department may consider the
excessive fees to be a transfer for less than valuable and adequate consideration.
Sincerely,
Marianne Meckley
TPL Program Investigator
717-772-6246
717-772-6553 FAX
Enclosure
Bureau of Program Integrity Division of Third Party Liability I Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
COMMONWEALTH OF PENNSYLVANIA
BUREAU OF PROGRAM INTEGRITY
DIVISION OF THIRD PARTY LIABILITY
RECOVERY SECTION
PO BOX 8466
HARRISBURG,PA 17105-8486
July 28,2014
STATEMENT OF CLAIM SUMMARY
NAME Estate of HOLLENBAUGH,GAYLE
ID 530 417 003
MEDICAL CLASS 3 CLASS 5.1• TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 28,746.98 56,856.24 85,603.22
DRUG .00 73.77 73.77
REIMBURSEMENT,TO DPW 28,746.98 56,930.01 85,676.99
.:COMMONWEALTH OF PENNSYLVANIA.
DEPARTMENT OF PUBLIC WELFARE
EIN 23-6003113
< . r ,.
Page 1 of 5
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE .
July 28,2014
STATEMENT OF CLAIM
NAME HOLLENBAUGH,GAYLE
ID 530 417 003
THORNWALD HOME
442 WALNUT BOTTOM RD
CARLISLE PA 17013
DATE OF;SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED
11/01/12 - 11/30/12 04/22/13 20130864020440001 20130864020440001 5,882.10 3,894.27
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
12/01/12 - 12/31/12 04/22/13 20130864020430001 20130864020430001 6,078.17 4,078.80
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
01/01/13 - 01/31/13 04/22/13 20130864020420001 20130864020420001 5,851.56 4,182.65
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
02/01/13 - 02/28/13 04122/13 20130864020410001 20130864020410001 5,285.28 3,616.37
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
03/01/13 - 03/31/13 04/29/13 20130924029270001 20130924029270001 5,851.56 4,182.65
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
04/01/13 - 04/30/13 05/27/13 20131224066950001 20131224066950001 5,861.40 4,192.49
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
05/01/13 - 05/31/13 07/01/13 20131554041870001 20131554041870001 6,056.78 4,387.87
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
06/01/13 - 06/30/13 07/22/13 20131824251510001 20131824251510001 5,861.40 4,192.49
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
Page 2 of 5
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT.OF PUBLIC WELFARE
July 28,2014
STATEMENT OF CLAIM
NAME. HOLLENBAUGH,GAYLE
ID 530 417 003
THORNWALD HOME
442 WALNUT BOTTOM RD
CARLISLE PA 17013
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN . ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED
07/01/13 - 07/31/13 01/13/14 55140074903020001 55140074903020001 6,662.52 4,993.61
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
08/01/13 - 08/31/13 01/13/14 55140074903340001 55140074903340001 6,662.52 4,993.61
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
09/01/13 - 09/30/13 01/13/14 55140074903700001 55140074903700001 6,447.60 4,778.69
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
10/01/13 - 10/31/13 01/20/14 55140154059430001 55140154059430001 6,446.76 4,792.85
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
11/01/13 - 11/30/13 01/20/14 55140154059780001 55140154059780001 6,238.80 4,569.89
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
12/01/13 - 12/31/13 02/10/14 55140154060130001 55140154060130001 6,446.76 4,777.85
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
01/01/14 - 01/31/14 03/17/14 20140514023670001 20140514023670001 6,662.52 4,964.64
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
02/01/14 - 02/28/14 06/02/14 69141264021940001 69141264021940001 6,017.76 4,324.02
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
Page 3 of 5
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
July 28,2014
STATEMENT OF CLAIM
NAME HOLLENBAUGH,GAYLE
ID 530 417 003
THORNWALD HOME
442 WALNUT BOTTOM RD
CARLISLE PA 17013
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES 'AMOUNT APPROVED
03/01/14 - 03/31/14 06/02/14 69141264021960001 69141264021960001 6,662.52 4,968.78
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
04/01/14 - 04/30/14 06/02/14 69141264021990001 69141264021990001 6,447.60 4,737.96
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
05/01/14 - 05/31/14 06/30/14 20141574026570001 20141574026570001 6,646.09 4,952.35
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
06101/14 - 06/09/14 07/11/14 20141924027900001 20141924027900001 1,715.12 21.38
DIAGNOSIS 1 : 42830 UNSPECIFIED DIASTOLIC HEART FAILURE
DIAGNOSIS 2: 0
PROC CODE: 000000
PROVIDER SUB-.TOTAL,.' THORNWALD HOME 119,784.82 85,603.22
03 100755529 0006
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COMMONWEALTH OF PENNSYLVANIA- .
DEPARTMENT OF PUBLIC WELFARE
July 28,2014
STATEMENT OF CLAIM
NAME HOLLENBAUGH,GAYLE
ID'• 530 417 003
MILLENNIUM PHARMACY SYSTEMS INC
5020 RITTER RD
STE 110
MECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE` ORIGINAL CRN. ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
02/01/13 - 02/01/13 03/25/13 25130585334230001 25130585334230001 273.46 35.14
DIAGNOSIS 1 : 0
NDC CODE: 00173069500 ADVAIR 100-50 DISKUS - BRONCHIAL DILATORS
03/04/13 - 03/04/13 04/01/13 25130635257110001 25130635257110001 273.46 35.14
DIAGNOSIS 1 : 0
NDC CODE: 00173069500 ADVAIR 100-50 DISKUS - BRONCHIAL DILATORS
09/19/13 - 09/19/13 10/21/13 25132675267030001 25132675267030001 37.69 3.49
DIAGNOSIS 1 : 0
NDC CODE: 25010040515 MEPHYTON 5 MG TABLET - VITAMIN K
PROVIDER SUB TOTAL MILLENNIUM PHARMACY SYSTEMS INC 584.61 73.77
24 001887261 0008
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