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Home My WebLink About11-25-14 � 150561�143 REV-1500 EX`°2_„> � OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code vear File Number Bureau of Individuai Taxes DEPPRTMENTOFREVENUE PO BOX.280601 INHERITANCE TAX RETURN 21 �4 00242 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 03 06 2014 08 12 1925 Decedent's Last Name Suffix DecedenYs First Name MI D IMELER ABRAM S (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 FII.L IN APPROPRIATE OVALS BELOW � 1. Original Return � 2. Supplemental Return � 3. Remainder Return(Date of Death Priorto 12-13-82) � 4. Limited Estate � 4a.Future Interest Compromise � 5. Federal Estate Tax Return Required (date of death after 12-12-82) � g Decedent Died Testate � � (AttacheCo a�of T�u d a Living Trust � 8. Total Numbe�of Safe Deposit Boxes (Attach Copy of Will) PY ) � 9. Litigation Proceeds Received � 10.betweenP231 y1 a dt1(Dags�f Death � 11.Election to tax under Sec.9113(A) (Attach Schedule 0) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number ROGER M MORGENTHAL ESQ (717) 234 2401 REGIS�ER OF WILLS_�SE ONLX� � �.,. � �_ ,�i e�'� First Line of Address �'• �� :=� `�� ca � r _.. 4431 N FRONT STREET 3RD r � ``I `'�' � � J r=a _.. -- �� r E.� Second Line of Address � � � � *"g �, .. � . � �;} (,�9 ..� _:.� _'f•� bA'TE�FILED'i -"� City or Post Office State ZIP Code � � c...� �_„_ r;� HARRISBURG PA 17110 � • � �,.� � � CorrespondenYs e-mail address: rmorqenthal@sasllp.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. SIGNAT RE OF PERSON RESPONSIBLE OR FILING RETURN DATE � Susan E. DeWalt ! /`{ (y ADDRESS 370 Meadows Road Newville PA 17241 SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE Roger M. Morgenthal Esq. � ADDRES 4431 N. Front Street, 3rd Floor, Harrisburg, PA Side 1 � 1505610143 150561�143 J , , � �� , � 1505610243 REV-1500 EX DecedenYs Social Security Number Decedent'sName: D11'Tl@I@r� Abram S. RECAPITULATION 1. Real Estate(Schedule A)....................................................................................... 1. 2. Stocks and Bonds(Schedule B)............................................................................. 2. 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3. 4. Mortgages&Notes Receivable(Schedule D)........................................................ 4. 5. Cash,Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 6, 7 33 . 7� 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers&Miscellaneous�nq Probate Property (Schedule G) U Separate Billing Requested............ 7, 8. Total Gross Assets (total Lines 1 through 7)........................................................ g. 6, 7 3 3 . 7� 9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 4, 4 8� . 2 4 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 12 , 171 . 65 11. Total Deductions(total Lines 9 and 10)................................................................ ��. 16� 651 . 8 9 12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. -9� 918 . 19 13. Charitable and Governmenta�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. -9� 918 . 19 TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.00 15. 0 . �� 16. Amount of Line 14 taxable at lineal rate X .045 0 . �0 16. � . 0 0 17. Amount of Line 14 taxable at sibling rate X.12 � . �� 17. � . �� 18. Amount of Line 14 taxable at collateral rate X.15 0 . 0 0 18. � . �0 19. TAX DUE................................................................................................................ 19. 0 . 0� 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. � Side 2 � 1505610243 150567,0243 � REV-1500 EX Page 3 File Number 21-04-00242 Decedent's Complete Address: DECEDENT'S NAME Dimeler,Abram S. STREET ADDRESS 105 Fairfield Street Apartment 1 CITY STATE ZIP Newville PA 17241 Tax Payments and Credits: 1. Tax Due(Page 2, Line 19) (1) 0.00 2. Credits/Payments A. Prior Payments B. Discount 0.00 Total Credits(A +g) (2) 0.00 3. Interest (3) 4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (q) 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) 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 shall use the property transferred or its income:.................................. ❑ ❑x c. retain a reversionary interest;or............................................................................................................... ❑ ❑x d. receive the promise for life of either payments,benefits or care?............................................................ ❑ ❑x 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?.................................................................................................................... ❑ ❑x 3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... ❑ 0 4. Did decedent own an individual retirement account, annuity,or other non-probate property which contains a beneficiary designation?.................................................................................................................. ❑ 0 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 Jul 1,1994 and before Jan.1, 1995,the tax rate im osed on the net value of transfers to or ~ y p 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,Z000: • 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 decedenPs 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-1508 EX+(11-10) SCHEDULE E pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT OF REVENUE INHERITANCETAXRETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Dimeler, Abram S. 21-04-00242 Inciude the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with the right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Citizens Bank -Balance at Date of Death 1,608.93 2 2 dressers and single bed-Sales Price 125.00 3 2005 Chevrolet Malibu -Sales Price 4,000.00 4 Air Conditioner-Sales Price 25.00 5 Dinette table and 4 chairs-Sales Price 45.00 6 Jazzy Szelect Wheelchair-Sales Price 200.00 7 Miscellaneous Household Items-Sales Price 289.00 8 Radio Shack Scanner-Sales Price 45.00 9 Vizio 32"TV with stand-Sales Price 100.00 10 Comcast -Refund 40.13 11 Highmark-Premium Refund 143.40 12 PPI Electric Utilities Corp-Refund 112.24 TOTAL(Also enter on Line 5, Recapitulation) 6,733.70 (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) �� . � �_ � �..� N � � � � � �.� �� ;. ��-�� „� �,`��:�d � � �; One Citizens Drive ROP112 Riverside, RI 02915 June 23, 2014 Smigel, Anderson& Sacks, LLP Attn: Roger M. Morgenthal 4431 North Front St., 3rd Fl. Harrisburg, PA 17110-1778 , Estate of Abram S. Dimeler Date of Death: Mar 06, 2014 SSN: 198-14-5635 Dear Sir/Madam: In accardance with your request, the enclosed information sheet has been provided in the above decedent's name as of his/her date of death. The decedent also had a Line of Credit account as of the date of death. Therefore, your request for date of death information has been forwarded to our Consumer Finance Department. If you need to inquire about your request,please contact that deparhnent directly at 1-800-708-6680. In regards to your safe deposit box inquiry, according to our records, the decedent did not have a safe deposit box with our institution as of the date of death. Should you have any questions regarding the enclosed information,please call 1-877-579-2667, option 2. Sincerely, .- � w r �.��1�,�~ ' ��.�:,*��°-+=_.__.�._---_ �:1 i�;�L-, ,�-"-: Heather Medeiros Decedent Account Processing REF#: 633536 �� w�� . , � � '"� � �� "� � � � � �' " �� a x. ��«� � s� .� ��:;..�'�.�� $ .z.� Account Number 610063 8774 Account Title Abram S. Dimeler Date Opened 1/3/2002 Account Type Checking Principal Balance as of DOD $1,608.93 Interest from Last Posting to DOD $ .00 Account Balance as of DOD $1,608.93 YTD Interest to DOD $ .00 Abram I)imeler Estate Items Sold Jazzy Szelect wheelchair $200.00 Vizio 32" TV w/stand 100.00 Air Conditioner 25.00 Radio Shack Scanner 45.00 Dinette table & 4 chairs 45.00 2 dressers & single bed 125.00 Misc. household items 289.00 2005 Chevy Malibu 4000.00 4829.00 ��1t�tC:�s� ��cp� ��: ��<.:�� r��r�a, ��s:r�aa.��a ��w�co�-:� �;�.�:�e�~i::.:a is�i��;.zat��a, E>� J:�4a; ��,: �....,,,,,� �.....,....w::. �c��,"��1 �,1��"z„4;1��?:ii �i"Y�S°�r {;��_��^..�4—�'i.�Ci�,.'. „�t'� F��°k`� FG1� �d�'r�SF�,"�,��, �Fs. �"T��.--8 i�:� _�._. �1i�A1��6��1�'��"(��i��(arF�f�°��"1��'��}��y��i�'4�i�' ;R,..��.._.- : �� „_ .... �y �t �t`� � p �t, , �. ��''�i �,"Y��.a��a[T ��s't�,��'��`i�1 i� � � � � �' w�t��t��c ��1�:i 31��.� �,:.�r:��.r��:�,E� ��,�,_��`t:�� :��,�r�c��rc:; �3�'l�0"3� �a�:�c- �� r�:-�r�a,. 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PP�EtecYric Ut�tit9es Corp -,�p�`„e;,*'. sz-� s�� Two Nosth Nirsth Stree# • •,�.�, No. 799$8 A°�er�x°w"Pc�s�p� �� :y-- Void aftsr 180 days .;•.' _.. � __ __.. ._._i ``�" Uate Q6/30/ZQ14 .___. �*�'��*****�1'i 2.24 """'One Hundred Twelve ar►d 2419€3D US Doliars**** __ ___ ____ ___ . __ PAYTt?TNE flBRAM QIMELER o�tta�Rc��: 370 MEApOWS RD NEWUILLE PA 17�41 USA /jj � , � j ��-�� The Bank of New Y r ork htetlort Phifadetphia,PA Aufharized�Signature � 8A865QD0120 REV•1511 EX+(10-09) gCHEDULE H pennsylvania DEPARTMENTOFREVENUE FUNERAL EXPENSES AND R SEDENTDEC D NTTURN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Dimeler, Abram S. 21-04-00242 DecedenYs debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER q, FUNERAL EXPENSES: See continuation schedule(s) attached 1,312.74 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zin Year(s)Commission Paid 2. Attorney's Fees Smigel,Anderson 8� Sacks, LLP 2,632.50 3, Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation) Claimant Street Address City State Zio Relationship of Claimant to Decedent 4. Probate Fees 118.50 5. AccountanYs Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 416.50 See continuation schedule(s) attached TOTAL(Also enter on line 9, Recapitulation) 4,480.24 Copyright(c)2009 form software oniy The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-09) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Dimeler,Abram S. 21-04-00242 ITEM NUMBER DESCRIPTION AMOUNT Funeral Ex ep nses 1 Cocklin Funeral Home, Inc. -Funeral Services 1,312.74 H-A 1,312.74 Other Administrative Costs 2 Cumberland County Law Journal -Advertise Estate 75.00 3 PPL Electric Utilities Corp-Electric Bill 129.72 4 The Sentinel -Advertise Estate 211.78 H-67 416.50 Copyright(c)2002 form software only The Lackner Group, Inc. 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S § � � __ � _ ��1'r'��1°�� :- ��,�.`�"`i.�.� ��S'� �T?1C"3E��l#� � ��i'�w��3.�°�� ; „��,�,aaM ...� ...,,��d.� �3c�� ,�'12.74 .<':�ii. a.4n,:.a�. ._ ...,,.?!. ... ... .... ...,«.t ,d...... __-�_.. --�,m...�.. .. ..,. , <�_��y —.. e,. —... ..._ P F created with ndfFactorv trial version Vvww.adffactorv.com ��RjAND c� G J�� 'G v ti � �. r w - � �, � ��9SSOC�`�o CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tele: (717)249-3166 Fax:(717)249-2663 April 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: Roger M. Morgenthal, Esquire RE: Abram S. Dimeler 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: April 4, April 11, and April 18, 2014 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 Total Amount Due $ 0.00 Becky H. Morgenthal, Executive Director �� > r,;f ' a.. �, r _ ;� ., t;arJ. � ` 3 t t f � Z,F1u#'`��''C�$ 6«�`��?1 � � �� "�,�v �'{"-� �i �� z a �_ s, -- . :1 "�i.r "t-'a:>. � , 'T r ., <��i_ r_t1,e:: ��, ;`I.s� ��.a�;� �'�. �;;u�.�ar aa3,��. �` 7 F s.:l- ,� �.��'�,irr`k ; . . .. „ sr� . _�,_.__�___m_...._._,.,...,...�, ....�,..,-.<, ..�...<.,...�.�.« , ....,.x '�'��~ ��i� ��:�c�� '�ra�� tl�r�� arr��,. �. ��taa��f��r�t��k� .��_�..... .... _. ___. S�;�vac�iz�,_ f�,�t�r��r �� ,f �nr 3�+; �� T��,,� �;��..,."s F'i a 3.;..; r.� �,` ., � ,.x`�''�, � ,�I,�+�� 's`; t.<C�: � t `I:�w�"': :�f,E i,( Y,(,� ,:'; a;.,u;� t �' a� 3 �F �'�. A p,. >..,,,,,xu...,,,N..�.�, � -�za r ?.�,�, a:'.�a i a m�€� .,,� t '"��, ��,a t.��i;:3��.w �',� t't' ��;��: �;��'�� r°r�`�c�a�� t�� ,��r ��,._ . 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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 portion with your payment Legal THE SENTINEL ❑ Check# ❑Credit Card Ad Number 429439 c/o LEE NEWSPAPERS ❑ � ❑ v ❑ � ❑ �"'� Billing Date 04/16/14 PO BOX 540 WATERLOO IA 50704-0540 Acct#: Amount Due $ 211.78 Exp.Date:m m Amount Name on credit card EfIC�OS@C� � Signature Please make checks payable to: THE SENTINEL r,� 000iss THE SENTINEL !� ATTORNEYS SMIGEL,ANDERSON &SACKS c/o LEE NEWSPAPERS 4431 NORTH FRONT STREET PO BOX 742548 HARRISBURG, PA 17110 CINCINNATI OH 45274-2548 �i�ii��i��i�i��i��i�i��n�n��u��i��n��n�� 215402D0�0000429439000000000000000254140000021,1784 Rev-1512 EX+(�y-08) SCHEDULE 1 pennsylvania DEBTS OF DECEDENT, DEPARTMENT OFREVENUE INHERITANCETAXRETURN MORTGAGE LIABILITIES AND LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Dimeler, Abram S. 21-04-00242 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 Allegro Acceptance-Financing for Hearing Aid 3,195.00 2 Carlisle Regional Medical Center -Inpatient Services 25.00 3 Citizens Bank -Line of Credit 6,263.56 Payoff as of Date of Death 4 Department of Public Wefare -Lien 1,857.23 5 Graham Medical Clinic, P.C. -Medical Bill 75.00 6 Green Ridge Village -Balance Due 656.51 7 Millennium Pharmacy Systems, Inc. -Prescriptions 13.50 8 Pinker&Associates -Medical Bill 35.00 9 Walmart Credit Card- Balance Due 50.85 TOTAL(Also enter on Line 10, Recapitulation) 12,171.65 (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-OS) ��9 ��Q,�� ROGERM.MORGENTHAL,ESQiJIRE �"A �� P PHONE� �717)234-2401 ATTORNEYS AT LAW TOLL FREE� 1-800-822-9757 FACSIMILE(717)234-3611 EMAIL= rmorgenthal�easllp.com www.sasllp.com File No. 11532-2-SA May 5, 2014 ; . FBCS, Inc. 2200 Byberry Road, Suite 120 Hatboro, PA 19040-3738 Ite: �sseP Itecovery Solr�tion� Allegro 14cceptarcce I'oas��le.• 1754�1059 Ladies and Gentlemer: I represent the �state of Abram Dimeler, the alleged debtbr in the referenced matter, who died on March 6, 201�#. As I informed you in an earlier letter, this claimed debt is disputed in its entirety. However, whether or not the debt is disputed, it is clear that his estate will be insolvent with no funds available to pay unsecured creditors such as Allegro Acceptance after payment of the administration expenses and a Department of Public Welfare lien. I will note this as a claim against the estate, and it will be included on Schedule I of the Pennsylvania lnheritance Tax Return when it is filed. You may of course file a formal statement of claim with the Register of Wills. Thank you for your intention to this matter. Very truly yours, �;�� ,�_ � ,�,,�'�f�.-��,,�-- R ger M. Morgenthal, Esquire 4431 North Front Street 3Td Flr Harrisbur� Pennsvlvania 17110-1778 A PENNSYLVANIA LIMITED LIABILITY PARTNERSHIP FBCS 2200 BYBERRY RD STE 120 HATBORO PA 19040-3738 800-220-2018 5/1/2014 Roger Morgenthal C/O Abram Dimeler 4431 North Front St, 3rd FLR Harrisburg, PA 17110 Client: ASSET RECOVERY SOLUTIONS ' Account#: 0006532913 File #: 175481059 Dear Roger M. Morgenthal , We have placed your account on hold pending your receipt of the enclosed documentation that you have requested. � Please note your account will remain on hold until your response is received in our office informing us that the account is no longer a dispute. After reviewing the documentation kindly forward our office a letter informing us of one of the following options below: 1. You are disputing the entire balance. 2. You are disputing this account due to fraud. 3. You are disputing a certain portion of the debt, if so please provide amount. 4. You agree with the debt, if so please contact our office to speak with one of our agents. , If I can be of any further assistance please feel free to contact our office. 800-220-2018 Thank You, Correspondence Department This is an attempt to collect a debt and any information obtained will be used for that purpose. This is a communication from a debt collection company i 7 F% U Al1VJell'Sales Dacument�ystem Page l af 3 (21338#�ime�r-Page 1 of 3) �� l Ft�'tAIL IfdST14t1„AMEPlT CQt�T'RAGT $EGURtTY�GREF.NRENT AND 21336 DISGLOSURE STATEMEtdT A ftNANGiNCs PAqGRRM BY��_ o r�o: KOSbG GRED{T .K CREDITOR: "��ZB A6.LEGRO ACCEPTANC� DATE ,Januaey 2�2412 9971.BAYHILLDRlVE,SU1TE 450 SAN BitUNO,GA 94Q66-3045 SEIi.ER(Hereinafter fl-pearing Inste�uments-Cartisle reler�etl to as.seUer). qnq�� 26]P�nrose�laza Car�isle,�A'i70l3 �.lime�ee- Abram 9UY6R tHereiaaRe►rete�red to as huye►� t.ffieNen» � S� , _ BUYER(Heee'inaiter rofetred io as btuyer) lestNamo FiritNmttt l�1 ADORESS 14S�'airfiel�d Street Apt l 7EIEAWONE S� r+a�w "7i7 776-b170 iVewvilfe �A 17241 eis� ce� cnr _ sa�e z�c SALE3 AGREEMENT.�I�'BUYER'}may pay cash'for ihe'�roduct'destx+bad bebw a�1 may buy on credit. I haue.chasen to bt�y the P�roduct on crat!'R ai�d hi consfdetation ot ar+y cxedit extended'to me,I agree 3o ati3de by the tertns oE 3his Re.tail Installment' Conttecti5ecurifY A9�eement, :IMFG. ARflDEL me 4100 ite 1tEfAlL iN$TAL�..MEMT CONTRhCTI$EC�1RIlY AGREIE�IIENT: 1 agree ta make the payments set forth be[aw in ft�e�ederal Disdosure Bwc and 1 ack0owled�e:that i am granOng ANegro Ac�ceptance{'Selier"j or�s assigr�a purohase- mo1�y seaurit�r irrte.rest in the Pr�pur�hased I agree to sign any d�cuments necessary ta pe�fect this security interest and to it�e exEent provided hy law,I wawve any exemRtions refate�M tt�e'Protlud.tn this Contre�cttAgreement,the singular iridudes the pfural and if there is+nor�than t�ne Buyer,liebility hereuntler is jairn anii several: I't'EMIZ�T{C1N UF TH�AIYIOUNT FtPrANC�D OF 3 3,195.08 1.$ 3,511.95 C1MSh�PRICE 2.S '316 95 LESS'TUTN.OOWMPAYIVIEtd7' 3.$ 3,i45•00 AMQUNT�INANGER Assfgned ta Wefls�argo Bank (Form HU400-Continued fln Page 2} � '��j ��, �'?��, _ � � ��' � https,//a�ilweli:al.legroac�eptance.�omldealerslsdslfinHtJ l UO.asp?UID-POI�I90pK597&Uni... 1/312412 �tl�c��ales I�Qa.va�ez�t 5ystc� ��ge�of'3 �,�i6 Atme�es•�age s ot�) �lYttiid�.T'E6t�,�+iD CONQi'TiCANN� • "NE�Ol�.O1NMIG!S�►C+ONTIP1t�AT10N O�"f'i�PE CL�[TRaG'P QN TFIE PREVlDUS PAGES MEREOF ACL Q�VsMiCH GDN$TtYkFfEB ONE CakYRAG�. underste�d arni agree t►�C 3. RESTRiCT101+t ON SEL4INQ:k w�na[end can►urt$e11,ex�an�s,l�rx otherwiae dispose of the Product ar aM'M ny n"gnt�s to YO�e Frneuet wtq�oui Feliet's pricx w�eer�pc►mission:This int�udes P�ng ihe Pr9duCt as cdtarter�d aor altpwi�sny securiry ir►tsrest to ettach to it,sxa�alrt the s�urity,intenest�Sed U�1tti�c4nuact• 2 MAINYENANCE A1�D U$E'I;wi�-maineafn the P+vdt�t in goc�+�onQiHO�n a►W repairand I wUt'�ot us�:Produ�ct so as M'o8�se�ny tmteasot►at4e deterinrs6a►br dBpnCt�iation.. 3. D�FAULT:1 wlll bl'in defaue�dar ft�COn�&Ci;f, ;a, 6 am in delaurt in tlwpq;�OtrnB�utie a!any of my 4bGGgaeor�under tflis GsnQraOt�or b. Sell�c.or the AoMet of this Co�re,ot behcvea� faudi that d►e P�apa�t of ReY��t Ar per(armsnce by me 1s;impaured.'�This p:ovistan Ooes not ap�plYto COr�ractc e�it8red�nto in C�and I+iew Jersey:) �q, i�hnEtNEs:.M che evem af aer�dt.an�+at anyr a�e tt�►eereaflaar�seuer ma�i at se��er'g cption,exa►asn any ana a�t ripMs p�o�iaea senar byr sqJRlicable i�'inCh�fH tnd nat!'imited to: a. Oac�u'o atI bD��►s�rsd hetehy anmedie�ely due BrYd phydble; b. PraeeW�a et�or�pal�'n�i'�t of�l sUct��1 c �wai.be�esPons�te tR�e�oosis r�azy��farce pe�lotmaave.pay�oe rnor�8y aw4d under thi.s Gonwatt to SeUer b�►me,fictuding m,�one�lNo attommya#ees; d, i ahefl be liable iar ts S1t1.00 dter�p�t fbrerery cheek i prgSent;whiCh iy�henwed by ttte brsUt4tb�1 u{KN►Whkfi 1t is dra�vvn.A diShpnOt�eC chedc m�1�o�oin a 4ate pa�nor�c ch�rgr,{Y16p Ar,ovision dves not�ty w«xw�1s�tn vvyoantrrg)� �. AtGHTS AFTER DEFIIULT•A1te`lSeNer aat��'&ces the mefur�Y at tl1e'C�+traCt.�r 6�t4et Mte Gmd achedumd muurity date,whict►ever 4oCuts fitat.I ngree b pay,�nil�e Ohe1'De'fioni�t�tlete c�x�,ltPd ui7�4t1 the amauclt Ie9�N ownd:�r me st an�a�tueu�ate ai 8r�nca diat�►e.quat pD the!w P.at rete oT linanca�Che�rA�dlbw6d.Ey aPA�fe i�r.N Sell�r�11;�GBi+1�enYi�9 of vafue.de�n4d 1fn6tr�ce. dl8rpe��PM�. e iaw wl�h wadd 6z0�ed the rt�so�mun►a�rWunc of�nanoa d�atD�P��e undEx app6q�e la�n.!he exoass �nar�e d�sugg��h8►a be�ed to ifie r�of the unpa;Q emoiall of the CoMracx or re�ed to tne. $�. GEfdEHJ1�F'Ft01flS{CtNS O�7HI8 CQNTFt�►CT: A the�nT of fi�uBmGe tt�ar�e Ihed maY Ge charged�r,cotleGted und�r ihis a. Seuet and 16�tR�ad W conl0rm slfidlY t4 e11��,�,.��Ccxstm�i af�nir be►add�ed ra.aducdo�t:4�me amaunt.auowe�f under Coraraot Eufd��r linance+�►8g�9� said taws. b 1�la rrAtvw of 8d►�r de¢aun by Se11er shatl operate e�s watv�.of at�y ath8r dEfAud: c.. lh6 term8 M R!►��ontted aheU ba bitdinp upon Utia h�s,e�rs:ad�Etttona,aui�ces�ors�snd assigns of SeR�r and me. �. IF any Ota�isiWt af tNa COritt�ct l�wil bY tlot�rmin�¢�44 frivdl�nt utiortfo�'xsWe,ihe remafnder oi this�Cotwr�ct�rematn in fidl farce �a►d ei�a�t, e. This Contract is��farmahtQ by me 'rahr iA ihe vdu�y in wf�►ipw 'tha Prad�ct; f, 8uy�r(s�herebY a�to 9Ao gran4nga Dy$�r of an�dension af 'stt� �andLcx detennent ag any payener�s by and at Seiler's sofa dit+c�tl4�n. q� ii ttds;Gvrtb�ia tmtapproved antl.the Ptadu�t,Ihe subjeet ot this Cor►i�tci,h8s been debrered,Ure doUveiY shaU not be conswed to gan�tNuoe acaeP�►�oe aY the F+�uer anq 1 h@�y ovnsent to:d►e retwtt W aaid Praduct u demand ot Se➢er. h. �as6i�nn�en2 i�f this COn1�6�fst anY�h�Otn b�e9e�shaWd be�ead to a�lu��►y asst9ns o198��er`�d�4vb8 thB wrilten appravat af 9re asa�9►�et�a any approda�s�ecitdrad of Sel�r'ttarei�Dove. i. pnY�cf this.Comra�x not!n acoordqn0e wi�A 1_h8 i&w�M tlt0�iC in wtdch�hc C+on�ect w�s asxs�epY enteted in�a�halt�B @i4her tlei@l9A s�ndl�o��mat�8sd to tltB e?dQ�t 111a;:�provl9wn s1inA oomphl srrictlY w}tlt�e:►aqukemmrta of RYCh apptio�e tbtrr, AAPUG/lBLE'1.IAW REGARD11t�p.ACt:ELEHd1T1OFE OR REPA7�ilENT lneamed'Ftnance:Gt+arges ate cret�ted acaoM��g tn:t��"Actueu�aa Haiund Method`and�artUee assurt�tiaatt�payments wePe made�c o�ginalfy �dt�luled'ot,t9deQerlad,aadete►ree�+ 1�@t9Yl�E iNY�tQU3ER 0�TNtS CC1N$UMEA CREGIT�ONYfiACT 15 SUBJL`-CT TO ALL CLAIMS APi�DE�FENSES @YNiC.�!�HE pE91`d�i C�llLD ASSERT �f'fH�E DEB'fOH�SH�At.L NUT�E)CCEED�OUNTS PaU 8Y TtiE�DESTOR HER�E NOER'INiTH THE PROCEEGS HEREDF R�GOVERY HEREUI+IDER =ocrn HU1t7o•�ni{1aa+ment� �as..�r.�l/w��1.....l1..11.......�.+,n�........+�...1...��-n...+..l.�.....1�..�..J.:.iw../lS..YYYt1f1f1,+.��....,�14SPi"�. Tf1�47AT1tYLA�f8.73.�,r'�"._4YY 1A !'�A'lA�Y►11dh �1U1�7d+�i�l,�liegro�,r.c�p[a�ve-V'iew��ast��te��pp�ica�ia� Pag� 10�;1 �� u r ��s��<�p it�:a�� ►�r�w�ev ., �r��A�p�s��i�� s�,�n,�3q�,��s�e . __ � ,�,�.�.� r72a�-2aos lDisAepse► Photoe or Fsu �'11fl1Et8[ ,�„�fa�!! ,,,�cm��— L�a!Nan� F'm�Name 1niW� Os4e oP BirN► 9�oouse INams iQ¢FsIRe1d$ire�tA�a4 t ,�,,, �a„�w ',I��e EA t 4� �_„7�r•��r„?t1-- Str Addresg �CitV Sfaae Yip No of Years Tetephone � . So a18e�u�itv P1umb¢r ••��nbors l.ecensa No r SQats R�nUOv+m: � Mor9iMV PaVmonb.: 500 re� � � ��"� Pres�nt EmP�+�[ � --Posi�lo�� No otVepnB MonMl1►Inoqme �maf�ver t�ddress +�i4v S�iote 'Pelephane .�.�._. �.— �v� �� Othev laawna '1�$airast iielati?W�Ar�'i�nd INaR.Tiyinp aS1h v0u1 R�lationshi� A�ars3s cthr �te 7'�e�horte IE cv-eq�plicarn,R�ease-Qc+r�let�a�s fapow�tg(ap�NiCam ana co,appuaarrk:mubi+esiae aE tha sa,ne aadre�f .r_--.......�.. �:p�p FieSt NAt11� (rli4ia! R�19NOer;hiP f4�1Daticant �'woial So�tuitY OJ� 08te o4 Biv{ti �� 4 Present E�fover' Positio�s � Mo of Yaers 1Aonthtv Inconne �mt�love� Ci4v 6taee TeleP?wne • liC77CE TO:�PRLICd1N78; YSU Ma1►.ApFiY�sfr qr0dit 1n�nalae�lon�withaut your spo�+9!Oc any vt�ee pe�aoe►.regafdtess cf sex or mafiaf 519�.'t'ne �e�erai Equa�e�ae(t Ctppaureue�i�r l�t vevnuMvs crad�tw�s tr�om xuuximinae�eg agansr.cfe�t sp�iaants-oR tha b�is al race, qplor rai[gbn�Hid�01(1'1 Wigio.�8x nt8►ifai 81dWBr I1�0(PI'W�d9d�18"8�lpliCAl11�S tli4 CipeCllyl t0 d�@t�11bp�1:biRd1'liQ.1�1Mf1C4��: bo+aau�e�or park ot;the app��oa�►b:iYwvme deriVes i►an a�puWtc aesi�enoe pmqrdm;or bscause ffie eppltcaztt h�s,tn gooal 1aFtfi,e�eisa6 aey:rtgl�t undertl�a Consum�r C►ldit Po4ltaaon Aet.The'tederat'dgei1�1►.ihat�nfsters our�pntipliaqtae v�[Ui this au rt Eaw i��Me fede►�al'thq�r Commi�slvn,dqusi�rpoli�Dr9�cPPo�!h►►W88hi1g0on�OC Y�B�l.We do atate ind i'epresR�ihat tl�o informat�an 1i0fed on:pds ap�fica�s ic trtlo�td comP�eb.Wa authOrk�O Ya+��Y p'�A��to v�ly nryMur p'8di� �►ding and emptoynaont pa aeamed neaaessary•CompleNon of tAa aboye appiica�tioo with cd!phane aumber{s)andlor�haU adaressies)rans#tutas aonae�u'ta ao�act me/us via a�if Rar►e�d ernsU transmissku�s. _ Date �,� '".�b/�•. WiMp�s �P�� .��'�''�"' D�de - +Ali�ness &�pPl�kani 7a Be.i;ornple�Sy Store; MDSI�! me-41 d0 Re �� PriCe 35f y 93 CeSh Q/P ,P� �16•9�� Ap�roYe1� __e�� 02t066 Cisp� �� IYt�, 60 $10t� n a Pmts 75.6_A_4 �PDi.� �iPst PMt 1/92 _ A�a�aQa:�t�t�o,a�r�:oo�w FOanna�l�t1'{�orn77�w9�awvn.�+��ww.owr.wn r.w...l.8aw9.....!a..l..w�w...«�. .:....�.._ .�.....__..�..nTatv� ��a�. r+4e.vr..�an�n++r� �+.,. ri.a..�..n��,.+ ��,�� ticx�ERJI_.IEORCE\Til�1T..r•.sc}t;��cs: � �� PHo�3�.; {�7�)��a�t-_>an� I,LF' <�TTOR\E'lS<1"f,L.�lt'1' 't•UI.I,I•"RL�'�t 1-l30D-A2`2-97:K" F:1GSI}'IIL�{i 17):;.':•1-SGJ[ r�t:lll.; rrnotornthcila,u�Fip.corn )vu•ty:StlF11r;C4p: �'t:lt"�U. �l.��a:.�??-'�^'��! .�il�Y�1.?�)I? �11e��rU A�:c��t�t�ce :',��30� ?'_t?7 S�tn f3rtin�. C�1 �3=��CiC�-f 2U? I2e: .hc�E�unt;�tuml�er 713:#t302i3 d,,aciies.<znd G.entlei��ei�: I'le�se be�d��ised ii�at i r�cpce�e;nt �t�ram I)inz�.l�r, l�J:�.Fair��ld Strcet,�pt �i,�ie��ille. I?t1 l 7?�#l. �r1}.cliciir li�.s pro��id�;d u�e��i#ti uo}?ics ul''cc�rres��r�a�tiuc tl3�tt voti st�nt�ci i�ina d�tccl .lune }?and:�un�2$�'?(ll?. `;1�fr.Dimeie�•dc�es not r�cZtl �i��%iir�a�t�r ciea`IinS,�s��•itli�J�ur cc�ti�p�n}°or si�nin��nti+ e��atrac;tua! a�r�z�t�c:n�s«�itll Alic�i-c�Acc�:�tanc�ti�at�ti�uuld c,��c:�tt�;an vhliyFatiox�on ltis par�t� ��t��tatt anytl�ii��. 1 f��C>U�Zc1C�f.' S�1CI1 t�ACtitClGtltS,I t�Tc�t�la ap}�reciat� rceci��inc�,�i�n}�y, I�}'pU f{1'C c3Cfltli�as a cichti c�llector��e�:ii��to recQ��ct`�COri51lT17GT t�e�)t#}Ia�111i'clie;nt is. <�ileged to o�;'e t�rtothci-p�rt��.then y-�ur coriLspaizdcncc is in s�rious��iolation of t��la Cederal ara�! Penns�rl�rat3ia consu��cr pratecfion la��s. In:�ucli c�sc,�VC Tt;5C11r� lI1G Ilf;Ilt�q i111f1�1�G A C011l��1[Elt �writl� tt�e statc Attornev General anci/or to fi1L s�rii i�ndcr the Pe��i�s�rlvalti�Unt�ir'I'racie.l'raetic:cs �t��d Cc>nstui��t�Pr�t�cYion 11.ci. I rec�uest�nc(deZ��anei t1�at;��oti ccnsc;alt contact v�Titl� mal cliei�t. 11ny corr4sponclenec s�iouid be.di��cicd tn n1e as liis atEui�ey ancl be i;��ritt�r�i�rm. 1'ou n1�►y usc my email �rtcic�es� sllp�cn a(�s�ve En�ac�titatc tix�a�ly.corn�nunic�itiot� if�'�U�1'15�1 �0 CIC?SO. Tl�anl.��oei for ti�ot�r�niici�atid ic�o�cr�ti��i ac�d lttei�tion to tilis tn�ittcr. lf e �:tnti�r��atu•s. Go�y: A:. i�inleler ::�{�"��'�;�-��-..:�i Pt�►�r 1��I,.titor;?en�l�al,:C;s t�i�-c � �. _ �l _ �tl31 \��hh Frat�t�tin�t.3�Fir..!�larrist�ur�,R�n►��vl�•�ixi7 l:r I 1�-]_i rS �t I>I��\\S�'I.X':�tI.1 l:1AiCi'lii>i;3:�t31S,1'I'�P.13tT��1:ItSHII' ��SYC �C , c ��ir � �.�.�� a .A.��a.�� f r�� l`' ��"� '�_� �� >' �� S�ni�el,A«�iers�n c.Q: S:�;cks LL[' =��31 No��1� Front St.3`a rfr Harrisbur�;. Penn$ylva�3ia 1711t)-1778 .lul}� !i; �01'? iZ�;; Abra�t� Dinieler �lecntrnt�f 713�8Q'?8 d�)ear iVl.��, [2c��cr J��tr�rbcnlE�at. I �m ��•ritin�to you it� reccipt of}�our lctticr-rc�acding Mr..�lbram Dimetcr.. Mr. I�in�cler ent��ed int�a seeured t-etail installment i4an�jrith us far thc l�cai�ing aid l�c �urc�iased from t-lea.rin�[nstrumei�ts—Cat�lisle.This loan is financed by us for tl}e arriaunt �f��19�.Op syn�ed arid dat�:d January 2,?O i?. I laave includeci a copy nf tiie signed iaan a�cecment and atso apay�nent his�orS�, 1��i�. Dimeler's daugliier Su.�an alsc� }}��oned us in May aclvisin�tis they iifiil not'm�kc an� ��}�ii�c��t to tl�a�e�c►�:�nl ciuc to tl�c hcari��;aid i�at y��vrking can•ecil��. �t'�explained th�t tlie}� ne�cl io contact the dis�cnsei•t•�gardin�;:thcir cancerrts�ttd issucs with fE�e hearin� aid devicc tis tlicy u�ould be i(3e 4i�cs��rizo can n�ake the adjustrnents or service tfl ttie�i� nnd#ltat ttie I�an pAym�ea�ts stil! i�eed to be made an a tinYely �nan�cr. �l+e stand b}�our�icned agt�ecrnent��,�ith Mr. i7in�eler to v��hich he is fully�responsiblc ar�d c�bli�ateci to paS� I�aek fi�e lo�l�. T�ie;accouni is na�a�3 months deiinquent yr,�ith a ctirrent past due b�lancc �f$?"?7.�2. �'lc�se feel fi•e�ta contact mc for furiher qucstic�ns or cUncerns rcgardin�tl�is n�aticr. � S�i ccr y, � �1 C�r��f� C ��,�-t. '`L�., ,� � CustAmer .5enri�e Alkegra Acceptance P.�. Box 32Q7 San Bruno;GA 9AOb6 Ph�: 1.87�.33�,3458 E:-mai( :;dale�,�re�altegrt��ce�tanee�ca,r�, '!l'1`I E3ayl�ill Drive,fiui#��50,San Bruno,C;t1:940(,�6>3{l5� -� I'hane: (80t)�fs��1-f��y�� I�ax;t�(l0) (��;t�-fi��)� � O eY' d7 iV CO"C�'00 i0 ln Cfl CO O'l M N (O Lt3 t,A 00 CV r ►1� �}' 04 E�- �-- O Sl' M 1` Cp O !� C+') hl C4 tI9 +61 0f3 CV �- � O aD !`�: '�(' tf� N 'Y.�f) N O W 4S� OD f� tn irJ r C� 1� (O � N O QO CO tn M �- CA 1�, tt3 iY r- C� 00 CQ zY N C? �7 l�- p O tp c� tr7 I`� OD I` DD N ►� �- 1�- cn 1` c+i !� N L!7 N CD N CU •- tf) r �.cj +r 'x1' Q +ex C.? tf' O M '4� M 4i sM OQ (V a, a'> r- a7 tU t4t� �htnd' N'tV C] Oa0o000COtt NNOC1o000CDCUctetcyc� a> onoo �.c� co ,�, Ga .- •-� .- c� cv'� c� c� r� �t �r �c�s i�i co cc> r- r- r- r- oo eo rn m o 0 0 ,- ,- _-- cv cv r. c- r r i--r � s- r d � � � I � — � rniorvoocoornc� uscom:�n �n � cflu� ►�- cflmoacs�-ooaor� �tr� ao � rnmcflcr� cor� C c� cn �r ,� COoDCV <47d' 1�:a0t�. � COtDOD1` tnO� h-� C� �1' o0'� u'� cY? t�- �n �t' N (O �tNOM .- v'it� inl� �T; LV tMe- d' cM '�i' d' t� .-:ti0 cn �. �t` oo d' �- �[i T- tt� r � d et rn ci> i�. r tfi ai tV t0 ai tYi u� C3i Ci C tn Oi O �} � 00 � ('7hr- d? 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Patisnt Name Abram S Dirnefer � Accoun#�1urr�ber 9566�47 ;� On(in�at ��bY�r.��;s•�,s��t�e��.r.c��z C�ate af Service December{�6, 2Q13 (avaifab4e 24I7} Service Type 3npafient Services �� y phcrne-7'f7-96U-1�80 insurance Name �reedom Blu ivledi-Rep(c �lame af lnsureti Abram S C3imeler �By cheek-return section beiow with check Poficy Number FER11?9135630{�1 � ��^a�..��._ ��_x � .�;�'� ��o.< �,. ��',s � �. � .--a;y � , , , . � - . � a s , .. , � o - �� _ � , '°, . � n _.._ __.._ _ °�.m� _....___.._. Amount due from you is$25.t30 as of 04/'13/2Q14 for The charges listed below dn r�at reflect the drscount that Inpatier�t Services perfarmed an [�ecember O�i, 2013. yau and your insurance cc�mpany received, Radiolagy 1,377.57 TataE Charges $26,79293 Lab 3,$17.10 DiscQuntslAdju�tments Given -$�1,226.83 Nursing 3;832.92 Insurance Payments Received -�5,266.1� Pharrnacy 2,293.62 Amount Yau Paid -��7�.pp �V 5olutions 1,720.86 5upplies 2,731.6� Respir�tor� 2,t�08.40 Emergency F�oom 5,�46.t34 Processing fee for blaod 891.32 .�� ....M �,��t,; '��` :�; �,s C?ccupafional Therapy 7�2.12 � Therapy 'E,281.49 q Nursing 'I,Q�9.83 � TC�TAL GHARCES $26,792.93 � N � ��.� a �','�` `��°"'�� ,':'""� �;''�; ��I�.*{I1�i'�i�'�'.��ll� 3269-HMAS7M7-2117447-1674340662—P;$721110-1-442;34430$34-i;1 � � ___._�.___._�..___._.._.__..—•--,---,--_._. _____----.�_—_._��____ ._------___�___..__ ..._..._..�__.. ��,T�II Your payment has not been received on the installanent plan that yc�u agreed upon. "Chis may�Se an oversac�ht on ycsue part,bu�requires your prompt atte�#icsn.We must receive your payrr�ent wathin 15 days in order#o continus with ycsur installrnent pfan. ( ��. �� OISC VEA; ��Y' �s ta1AS7ERCAR� .�, DISG/JVER �� Va.3a �s�+� A�EX �- 1�� 361 AEexander Spring Rd. Save Time and Postage. Pay yc�ur bill C)nCine ar by Phor�e = �.Lc��;�,.�� Carlisle, PA 17016 Today. Et's Fast, �asy, and Secure. � wwvr.carl islermc.corn �PATIENT PdAME STATEMENT C3ATE - �ATE AUE_ Abram S Di1TlBler fl4/1312Q14 UPON RECEIPT� .�'��Y �r3tlE.'Ct�FIC1r"�C1G12r�«.Sf?IVIGC'$: ACGOUNT NUM�ER Ai6tOiJNT DClE AMOUN7 PAYiNG .. ��_�"' 717-96U-168Q ': 9566547 $25.Ofl , ,.. _�.�... �: . .,_ _�.._.�,�ru._ _.._ �. � , .� .,_.. . , . . ,<�. _ � �i��>�:`��:;'1� �'t'�''Ii`�a.�,.�e�?"«ai�..#,�'s�v�: .. .. r S o�zas�o,o: ABRAM S I}IMELER CARLISLE F�EGICINAL ME[�#CAL CENTER 1(?�FAIRFIELD ST APT 1 P�}Bt�X 28�442 NEW1fI�.LE, PA 17241-'124Q Atlanta, GA 3Q384-1442 �II�i��I��i��fII�I��i��t4��i,i1�E��l�tl�li��l� ��f��I��ii�l��i��1F��,il�i�,��l�l��l��ill�l�i��oi��i�ll�� QQ�C1�95665W7�1Dpt�OQ02S��ABRA�i��IP1�L�R 4 �� Citizens ��nk �� Loan Account No: 6007978552 Date: 6/26/2014 Requestor Name: Smigel, Anderson & Sacks Attention Ta: Fax: 717-234-3611 Customer Name: ABRAM S DIMELER Collateral Description: You are receiving this notification as a result of your recent request for a fax payoff confirmation. To pay your account in full, you need to remit the balance owed of$6,263.56. The amount reflected above is your outstanding loan balance of$6,263.56 inclusive of a recording fee of $0.00 and/or an early termination fee of$0.00. This amount also includes the Fax Fee of$0.00 which was disclosed to you at the time of the fax confirmation request. The payoff is valid through: 3/6/2014. The Per-diem is$1.19 per day if payment is received after the valid- through date. Payment can be made at any Citizens Bank branch or mailed to: Consumer Finance Attn:Payoff-RJW230 443 Jefferson Blvd. Warwick, RI 02886 Please check one of the following selections and sign where indicated below: ❑ By signing below, I/We request that this account be permanently closed to further advances and a discharge of mortgage be issued. ❑ By signing below, I/We acknowledge that this account is to remain open and available for future advances and that the payoff amount is requested only for the purpose of paying down the account balance. ABRAM S DIMELER PLEASE READ THE DISCLAIMER BELOW Any outstanding checks or charges that are not included in the above payoff amount are the responsibility of the customer. The customer is also responsible for the entire balance on the account regardless of the quoted payoff amount. ff this account is secured by a mortgage, the mortgage will not be released until the above conditions are met. The customer information contained in this fax is only for the use as requested or authorized by the customer whose name Is listed above. This information may not be reused for any purpose or re-disclosed to any a�liated or nonaffiliated third party unless authorized by the customer or by Citizens Bank of Pennsylvanla. If this fax has been received in error, please destroy this document immediately. �,� pennsylv�nia �� - _ `+ DEPARTMEN7 OF F'USLIC WECEARE � , April 24, 2�I4 SMIGEL ANDERSON & SACKS LLP ROGER Nl MORGENTHAL 3RD FL RIVER CHASE OFFIC� CTR 4431 N FRONT ST HARRISBURG PA 17110-1778 Re: Abram Dimeler CI$ #: 9101S200F3 SSN: ###-##-5b35 Date of Death: 03/t�6/2Di4 ESTATE RECOVERY STATEMENT OF CLAIM Dear Atty Morgenthai: Under State and Federal law, the Department of Public Welfare (the Deparkment) is required to recover medical assistance (MA) reimbursement fram the probate estates of deceased individuafs who were over age S5 when such assistance was receivecf. 42 U.S.C. §1396p{b)(1). 62 P.S. § 1�412. This letter sets forth the amount of the Department's claim against the estate af the above referertced individual and explains tt�e obligations of executors, administrators, and persons receiving estate property. AEthough #he amount in the estate may be considerabiy less than fihat which is owed to the Department, aur claim is aga�nst the estate, no one elsa. Statement of CEaim Amount The Department maintains a claim in the amount of�1,�57.23 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 oP this medicai expense, namely $1,857.23, was incurred during the last six months of khe decedent's fife; 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, nameJy .UO, is to be entered as a priority Class 5.1 claim against the estate. You shauld refer to Section 3392 for a more cornplete explanation of the priority rules. If a lawsuit is filed for injuries sustained by the decedent prior ta death, fihen 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 Prograin Integrity � Division ofTh(rd Party Llability J Recovery Section PO Box 848b � Harrisburg, Pennsylvanla 17165-8486 ` �+�',. pennsylvania ';��I�� . DEPAR7MEN7 OF PUBt1C WELFARE 1 Your Responsibility ta Provide Infarmation to the Department Please acknowledge receipt of this letter and advise whether the Departrr�ent's ciaim is admitted and when payment may be expected. When the estate accounting is complete, p3ease provide a copy. The Department audits al# estate recovery claims and therefore we require documentation to substant+ate all deductions from the gross estate. The regulations governing how the �epartment computes its estate recovery claim are found in 55 :Pa. Cade - Chapter 258. These regulations are reacl�ily availabfe on the Internet, in addition to being carried in most local law libraries. In order to document computation of the amount due the Departmenfi, 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 o€the funeral bill 3. Copy of the statement of the burial account if one existed 4. Copy af the statement of the personai care account balance at date of death, if the decedent was in a nursing home S. Copies of original and updated life �nsurance policy forms naming beneficiaries 6. Capies 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 af any gifts or other transfers for less than fair market value made by the decedent (personally or under a pawer of attorney) Y�►ar Resporasibilities to fihe Departrnent Under State law, executors or administrafiors r►�ay be personally liable to pay the Department's.estate recovery claim if they transfer estate property without the Department's claim being paid. P�rsans who receive that property withaut paying valuable and adequate consideration to the estate may also be personatly liable. The responsibilities of the primary next of kin/administrator/executor, is to advise the Department af any assefis in the estate and to ensure that the remainir►g maney, after all funera! and administrative costs are deducted, is sent to the Department. Accordingly, you must ensure the Department's claim is satisfied befare making distribution of assets to heirs. Bureau of Program Integrity � Dlvision of Thlyd Party Ltability � Recovery Sectlon PO Box 8486 � Harrisburg, Pennsylvanla 17105-8486 r ,��'�, pennsylvan�a : ';�EPARTMENT p.F PUBLI.0 WELFARE . ,. , , , Insolvent Estates and the Fiduciary Responsibility to Creditors If there are not enaugh esfiate 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 creditars when administering the esfiate. If you must spend the estate's money to administer it, you must act prudently and make purchases as if the money were coming aut of your own pocket. The Department's approval is required if you expect the legal fees to exceed more than the reate of 6�/a of the estate assets or $7,,OQ0. Contingent fees for estate admfnistration will generall� nct.be-approved. IP you do not obtain approval, the Department may conslder the excessive fees to be a .tr-�nsfer for less than valuable and adequate consideration. Sincerely, l [�'� '�� -R�ry�' Nathan L. Snyder TPL Program Invesfiigator 717-772-6266 7�.7-772-6553 FAX Enclasure Bureau of Program Integrity � �ivlsion of ThErd Party Llability � Recovery Section PO Box 8486 � Narrisburg,Pennsylvanfa 17105-8486 � � COMMONWEALTN OF PENNSY�VANIA BUREAU OF PROGRAM INTEGRITY DIVISIDN OF TNIRD PARTY LIABIL ITY RECOVERY SEC71qN PO BOX 8486 HARRISBURG,PA 17�05-&l86 April 15,2014 STATEMENT OF CLAIM SUMMARY 2'iE:';iii;;rliiiii;ti!'iiii c ......':_t::;�1:�:::::::::': '�ifiii..:i..............:.. �i;;�1�1A1111�;'i.;�;;�: Estate of DIMELER,ABRAM ;;�;i=::";�::�:;s`d;ti3' �t:;::lC�::s'i>"sii=;'r';;;;. 910 152 008 �_.:��:s:�:::,:_.., t �!liM�QIIiAL. trt' r+� � {[ � � !j� � Y� s.�i i t'�i � t: � �I � 1 r, ,,;�_._ „,.�.� �,��; ,,.',N y � ' �R : > > C!A$S�v"1 , �� TOTAE, . � ......... .{.�. .....<.�: .. .....,,. t ..,..,, .I 15..�....., 1.v1 t...?.: .. ... F INPATtENT .0� .0� .�0 OUTPA7IENT .00 .04 .00 " LONG TERM CARE 1,857.23 .00 1,857.23 dRUG .00 .00 .00 ::;�:,,�:.,. � �r;.,� `.REIIUIBURSEMENT TQ DP{N''4,;: 1,$57.23 -_-.......... :...„�::.,:..,..,,��,,,.:. .00 1,857.23 -yi t�t��sSa�' ,<<�'�t�` t a COMMQNWEALTN QF pENrySYL1/AN1A ` , "';'j '', , �" D�Pl�RTMENT O�E'UBL'iC UVELFA�tL�di� a�, ," , ,:� :f, , � ,� �t„ � � s , ��'� � _ �'" EiN 23 6003113 , r1� ` � �� _ � �.....;: s. .......:: ,.::.,..... ....._:.. _. . .:...... ,.,.i �� ..... Page 1 of 2 •• .. ............ . . ..... .,,..........,.. _......,_... ..................................... ... _ .::.,•.�,,:::::;:;, .:_:.�,�::::..:::: ..: ;.....��t•�:::::: .. , � . � , , .,.:::::. ..:........................:.......:..:: �.-........ � _ ....�..S.i..�:r.:::;:.:u?i.:........ �.�- .,........,,. _. .,.:-� .......��. ...., .., ;:•:,�ci.l::t—::^::: � � ....,. ��..�..............;..�--�::.::::�:::<.:�:.iii�:i;f :.:::r::::.:;.:r. . - ..:c:r.;:9'r:::c::: C . �:,, a � . -'c::::::..:.:::::.::.v:::mu:.:i.i, �. � .. .. : ; . N .;; f :::��,,:_::::. �:.:.:....:...::..:.:::•::r:::.�..:::::;s:::�;::;.:t::.,.......,...;..:�.:��::::..::........._....._::...:.... N EALTH.. �. ...EN YLVANA .... .....:._.....::�::...., : ..... . ::?�:;::�::==:::. .. ,..a..: .: .._�..::-::::::::.::::::::: ..�...:...::::.�::::• ,. COMMO W,.:........,...Q.;;..P. ........� .:•::::<.,.._...,...........,.,:::::.�.. .:a � ::;�.:::::::::... ..: .... .......................... ........ ....... ....:..: �_ . _ ,_:._�::::,-�::::•, :;a�:=:s�� — : ..... .....:.......::::�s:::::::..,........;....�,...,.,,..... ' - :a:::::::L::...,...; .; �� ......:.:.:.:'r.:r. .��...:,.�... -...:;..... '_,..,..,. ...., .. � .. r .. bEPARTM�NT OF FUBLIC WELFARE ' "' i . � � �..... i.:.:. ... :.. ...... ,..... ,. ....... .: ::......, ...._�, .....,.._ .... . ._...... ........ ,. .. .,.. _:�. . ._��. .......::�......�..... . . .�:. �.,.::::- ° _.... i' April 15,2014 STATEMENT OF CLA(M NAM��; DIMELER,ABRAM r:��::;�;:;;�;. %t�.:�Cia:�ii 9�0�rJZ Q{�8 SWAIM HEALTH CENTER 210 B!G SPRING RD NEWVILLE PA 17241 ...:.:........ ......_.... .............,;,.. .. .,,...,.......,,...........,..�:�::::, :�::::::.::.:;:, .......,....:_.,..... .............. ..... .:...............,...............�........ _�.. ...... _.......�....�.._......... . ........ .�. , ............. � ::..:..:...._....>.�. ;;::::;: . .... ,...L.. ....T...............L...i ...:... .............�.........�.....i....v........�..u-�:,..s.......�............� . . .....S+:c:ra..::E. ...r.....::::;e•r.:::::�4EE:ii:s..:.<�� .::. .�` ....sri..��.o.�......r::, .»..... ,..,•, .............. ,t............t.......... .�.:t......t....,.at.....�.......,. .. ...n......... ........,.... .....c. . { . ................_�.. ... .�...�.�....... _...�::u.._.......i�......,......._......,........,...........r.,.:... ......�.. . ..:.�..c...�a.�..�.. . . .......a..--- ....�... . ........!u........,,th....::--e ....................�..;....,..;;.:•.,,,5;,�:ur•r:r::..............;.:,....:...;...,;.,.:...,........,.e..:..., ..............,,...w--�...c.....t......n,;. . :�r^::,s�..e�.....�.£su.......,�ciii � t ... .aLr.. . �.:fi:. .,..s �.{,,... ....:8ii7._?��i`�^i�::ii9iir � . . t- � �DATE i0F SER�1lCE� PAYtJl�N7 DA`TE 4i =� ORiGINAI�G�tN , �1DJU�T�D CRN-. USUA�CHAF'tG�S, ANlbUNTARP�20V�0: 1 i .�f....:. ... ......�.. ........��hiR {„.. .,,,. �, .�.,:.._....... :.:r. � .� ... .!.....�{i......,. ,.....�..,i. I�.-..!. ....i r. : ..,..!........_. � !..d.. ,.°i ��.,,_:... .'.. . ..... �� ..�...� ..�?...",...' ...x: 01l08t14 - 47/31/94 04/09/14 271409940234400Q1 27140994023440001 67.88 67.89 DIAGNOSIS 1 : 586 RENAL FAILURE�105 DiAGNOSIS 2: 496 CHR AIRWAY OBSTRUCT NEC PROC CODE: 0000004 02l01I14 - 02l28/'14 04/09/14 2Tl4099a023A50001 27140994U23450001 1,425.69 1,098.34 DIAGNOSIS 1 : 586 FtENAL FAILURE NOS DIAGNOSIS 2: 496 CHRAIRWAY QBSTRUCT NEC PROC CODE: Q000000 03/09174 - 03/06/94 04/09/14 27140994023460001 2714Q994023460001 1,018.35 691.00 Uff1�i3051S 9 :"'S$S F�Ei3A�FAILCiRE NOS . -__ . . . . . . _ DlAGNQSIS 2: 496 CHR AIRWAY 0B5TRUCT NEC PI20C CODE� 0000000 _�'''��;:>:i;�;��e.s;�:i��i�sSi=i�;:i;iiS:•.'•.i;;-s=:i::�i:: t.....�,:��............t..a::�:•P?-�7' ;PROU(DER;:S;lJ.B�TG2TRLi�;'•. SWAtM HEALTH CENTER 2,51i.92 1,857.23 :i:�;":��:��-'-::?ipYt::::�-��;�:';';';i`;'�`•: 03 100749488 0012 � ,,:i:�i":-::::!:::::�.:,i':�:�::: ?'iiivljii;iiiiii7:o�li?�;Si';?,Fti:?il i��7(j!t!`i:'i��1 Page 2 of 2 (_—_._...___.�.._..'__"__._.._.�._.._......_._._.�..........�_________�......._._. "_ b• � � � 0 9 @&/ZS/14 256342 � 75.06 GRAF3AM MEQICAL CLINICs P.C, - - e > -: e s � , i�� '{�{�.3� S�R��C� � �'�" Y1Si e. NEidVILLE, PA 17242-5409 ; � «� ❑_<:, ❑�,'�` �: � � 1(�, C '.1,:8-� i l '�.i�:; �i�:ld.?E( � 1�.-� . i i '�,:in,t"s:;r 4�Lg>e�.,s�-ack �. P :.isi„ �E_. :•.n.l ',. �c'f,.4 :,'r ._... —�._..,_ .�r.Dri�".� ; t ]� Cl$7�4 t � � ��R GCtANAM MEDICAI CLINIC, F�.C. 3 • � j ESFA7E t�� A�RAh� S DINiELER 100 5QUTH HIGH STft'EET 105 F�IR�IELD 57R�ET, APT #1 �1EI�VILLE, Pt1 17241-1469 ; t�EWVILLE PA 17241 i 1 1 } t FIr3 e�t3.tcfc b3�c i;af�oae�dds�s== nca re-c ar i3 er�nce 1e��yIp! �n Pj��;�sr_c ic�z,r 3f re r'�e�rc lydli•3},arld� is d3f:er�nr dsa�i 59atc- � `�rt,arn��Eicm has chan�ned.and indicaie chan�ct_)on r.ur_rse side. �,�T; ' � '�me:nt�ddrPcs<racl sar#. in acld.c,s n��b<i..l�_ , � .... _. .. _ . .. . ..... . _ .. ... . . .::, _; _.._.. _...__. ___.. .._.... . �......... ....__ __. .......... ...... _... _..__. ...... ...._.. _.. _..._... __.. ... ��i?.Ox2�?':?f�P+��'Z?I�R��'��1'��`t_C�l�s$�"�'�€.�T'=.�RE �LEASE PAY UPC}�i RECEIRT, F(}R BILLINGS QUESTZt��US PLEASE CALL 717-?76-3114 �XT. 103 i�ppcsintment Service Descrzptiran Charge Pay�nent Adjusf ��taerat � r✓�1��! 3.� - tiVilW't ' ��LJfY3 JL/.,7�T'� H.3 V� SUB �lElRSING CARE EVAL/MAN 99308 75.00 75.@0 �6f18/14 NI�HMARK BS Payment �.0t� i i ! � i � 3 j i i � � � """_ _._... � �,.. ....._,.._. ..,-__ �.""'^�:. `.��r��ceiv�c� � Current Over30 tiver60 Over9� O�.Jer12C� Patien� ��,_00/�0.��,._._� .��0,��0.�..._u._,..�.��.�ff_..,�..___g=-��.-____ 6.00 �.66 0.00 �5.0� ,� ____.�.� ..�___�:.�. F��.��5� GRA:NA�1 MEBICC,L CLThiTC, P.C. I =r�a�c�e��e 1@0 SOIITH HIGFi 5TRE6T ,,;: '"�� I �z��r�s��xc�: �y�WVILLE, PA 1,72��.-14t39 '� Payment [3ue Rate 09125114 � 75.00 , t. _.___. ; � i Ph.{717�-77�-3114 Statemen� t3ate: 081�8l14 Acct#:250342 Fage 1 of �. � _...._� ___._._�__.__.____.��.% __._._. _.... __.� __ .__ ____.___�.__.__._ . _.� _ ___ ___ _....... ....�9EDN140G291A35S.008%14.C1.0?.;1CG6G �:��Efl# k�1k3G��fl�.i.fi�� ,,..>,� Statement Date Due Date Account Number ��_ �i� �"��`�'�� '�`� 43131J2Q14 Upon Receipt 62003GRV �t��=�y`'v'll_I_i� ��";`2�.9 • • � _ . $656.51 ?`3 i�1i`r�-£�2fl�3 AMt7UNT i'Ail3$ P�ease make checsc payan�e to G�tEEN RIDGE VILLAGE ��-arr� S �si,�e(G� Remit 1"0; cisa Sussr� C�e�.rali Presbyteriart Homes InclGreen Ridg�lSwaim 3?� N3e�duws R�aca P t�Box 41B82S !�a'�tr��r�ii� P,�, 1i2�1 8cssfon MA t12241-682$ Pfease detacii and return this portion vvith your remittance io the address above. Camrnen#s - � � .+ •� ,� * _ _ $656.51 �� Llate `� � .�� E3escription�. � � Days 1 Rate � Charg�s f Payments Balance�:��"�� '�� Units'��. .��. - � � (Crecf�t) , � `..�_. ��'�� °:� �3aiance�orward � $1,448,23 � 01/31/14 01/3i114 Ro�mlBoarrl MA pending _q -$�5.74 -$65.74 42t22/14 02l23f14 Patient Liability $327.35 (12122i14 02/28/14 ftooml8oard MA pending -7 -$197.24 -$1,380.68 t13101114 �a3l02/14 Patienf Liab€lify �327.35 Tota!6alance C�ue $656.61 i F�ClL1TY NAME RESIDENT NAME ACCt?UNT NUMBER LGREEN RIDGE VIL�AGE At�ram S t}irn�ler 62003GRV _..._. _ _..... / We accept Visa, Mastercard,Discover,and American Express. Auto-Pay is available. Millennium Pharmacy Systems,Inc. Secure online payments via www.mpsnc.com, click"ContacY',click"Pa P.O. BOX 823441 Make checks payable to Millennium Pharmacy Systems, Inc. Y Your bill". Write or include Account#on your check or bill pay slip. Philadelphia,PA 19182-3441 CONTACT INFORMATION: Millennium Phcy. Systems Mechanicsburg Offce Hours Mon Fr�9AM 5PM Fax 1=866 230 7435 Phone �-866 GO-MPSRX or 1 724-940 2490{Option#4) , � ;Email Bilhng@mpsrx com : ,....�; - - INVOICE: 02/25/2014 ABRAM DIMEI.ER ACCt#: GRVN2058 c/o Susan Dewalt MA PENDING 62003GRV DUE BY: 03/27/2014 370 Meadows Rd Newville, Pa i�2ai MAP p� Amount Due 13.50 : Amount Paid '.. .: Please Detach Here and Return Top Portion With Your Payment - --- -------- � ::- - - - - --- --- -------- ---------------- ------------------------------------ ----------------------------------------------- Invoice Date:02/25/2014,Acct#:GRVN2058, DIMELER,ABRAM,Green Ridge Village NC-PHI,A,PION,JOSEPH �atg � :Rx Number uanf Amount SalesTax _ Total T g---�C . - , Descriotion;: :' _ voe: _. , � ,... :: 02/22/2014 6910176 2.00 Aspirin Oral Tablet Chewable 81 MG $ 1.50 $ 0.00 $ 1.50 OTC 62211-0288-99 02/22/2014 6924323 4.00 HydrALAZINE HCI Oral Tablet 25 MG $ 0.50 c $ 0.00 $ 0.50 RX 50111-0327-03 02/22/2014 6924324 2.00 Amlodipine Besylate Oral Tablet 5 MG $ 0.50 c $ 0.00 $ 0.50 RX 68382-0122-05 02/22/2014 6924326 2.00 Atorvastatin Calcium Oral Tablet 10 MG $ 0.50 c $ 0.00 $ 0.50 RX 60505-2578-09 02/22/2014 6924346 6.00 Mirtazapine Oral Tablet 15 MG $ 1.50 c $ 0.00 $ 1.50 RX 00093-7206-56 02/24/2014 6922218 15.00 Atropine Sulfate Ophthalmic Solution 1% $ 8.00 c $ 0.00 $ 8.00 RX 24208-0750-06 02/25/2014 6923889 24.00 Loperamide HCI Oral Capsule 2 MG $ 1.00 C $ 0.00 $ 1.00 RX 00093-0311-05 PrevBaF as P m ' Last Payment Finance Cha YTD Fin Cha' ' th r: �( ; QI�' IVSP : IVPR. . Total ' $ 0.00 $ 0.00 $ 0.0 0 $ 0.0 0 $ 0.00 $ 12.00 $ 1.50 $ 0.00 0.00 � $ 13.50 �� RX-Prescription OTC-Over the Counter IVPR-IV Pump Rental IVSP-IV Supply c-Insurance Co-Pay �� r � � � � � � �� , � � � � � �harrr��c�� y�ste�1�� I�c. Cranberry Business Park,Building 120 100 E.Kensinger Drive, Suite#500 Cranberry Twp.,PA 16066 P: 724.940.2490 F: 866.230.7435 W.www.mpsrx.com To All of Our Valued Customers, J Milfennium Pharmacy Systems, Inc. wil( bi{I all Medicaid Pending charges directfy to the responsibie party. PLEASE IVOTF: Millennium Pharmacy Sys#erns, /nc is nc�t rzquesting paymenf af this time UNLESS resid�nL is in the SPENDOWN ca#egory. Hov+�ever, if Medicaid is not appro+�ed, or upvn Medicaid a�proval the approval dafe does nvt go back fo the original "Pending Da�e,"ful/ payment will be requested at that time. Your caaperation will be greatly appreciated in a�erting both Mi(lennium Pharmacy Systems, Inc. Billing Department, and the respective nursing faciiity of any future changes in regards to the resident's Medicaid Pending status. , A monthly invoice will be mailad to you until Miflennium Pharmacy Systems, (nc. is notified of a resident's appro�iaf, or denial, for Pennsyl�ania Me_dicaid__ ___ _ ______________ , coverage. Thank you for your cooperation. !f you have�any questions, please do not . hesitate to contact us. Millennium Pharmacy Sysiems, 1nc. Billing Deparfinent Miliennium Pharmacy Sysiems, Inc. Billing Departmeni Hours of Operatian .' Monday thru Friday: 9:00 a.m. — 5:00 p.m. Toil Free Phone Number 1-866-468-7779 0�11�IZ4 54b� � 3�.�� Pinker & Associates . � > �� . �, , , 47 Brookwood Ave � �� bl5'VER��. Carlisle, PA 17615-9126 �� ❑ "�� ❑��... : ❑ .�� ____�___. __._.. ._._....._� _.�. . CFlt'iD NUFd18E? (hUS Ht�(a{r�710N�GOE r'�� 1 -as!; r 4 uiyils n��taack �..'�i_.!L�`�� :`Car�i�Y s�ry,';21ura lii�e't '---.__. ... . .._.................. ... . . . .. . .. ...��. �SGPI.RTURE .. ......_.... .._.:... CX?O?.Tr._..._.---___�.. 09252 � Pinker & Assc�ciates SUSAN DEWALT 47 Brookwood Ave 370 h1EA[70�JS ROAI� Garlisle, PA 17615-9�.26 NEWVILLE PA 17241 P3easz fheck kaox�#�bova�ddr�s�is rnccarr;�ct nr insur;�nre F�3+>ase chec�C box if�re�it��r�billing addr�ss is�iE��rrt thari sta�e- f-.,irrf�rmatiar�ha�ctaan�ed,and irid`scafe r,��rrye(s)o�v'mve�rse side. � : � � rt�nt<�ciclr�ss and�.rrite in aeldr�Ss on bz+sk: - - - -- Fi�T'l1R'N T�CFP�C)R7`i#�N��2�'CA��+3 L:�7W��3,'�'C3fi7`1CJN - - - ��}2��-zsg� Appointment Service Description Charge Payment Adjust Patient 02J28/14 - ABRAM DZMELER - Golec, Mark S. , DPM DEBRIDE NAILS ANY METHOD 11721 110.1 60.00 35.00 0311?/14 NIGHMARK FRE Payment 8.13 63/17J14 Accept Assign Ad�. -16.71 03J17/14 Aceept.AsSign Ad7, -9.1b The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make paym�nt. _.._. �.,_...._.._.�......._.___ ��`��'��'��'.�� r, Current Over30 Over60 Over90 Over120 Patient M0,j69 �+Q 9..00 35.06 6.60 0.00 0.00 0.00 35.00 as��. � �i�ker & A��ri��es �� :� ; � �r��c��c� +�7 ��*oc��t��r� Av� . ; �i��cs� . ��r1�,s3,'e, i�� .7F�15�-J'l2fi Paymerit T�u�"CJp�n Rec�ip�C 35,00 Ph'::('�17�-2A3��23E+ Staterner►t Date: 031181'14 Acct#:5460 Page. �. af �. MEDiV 14Q31814624.0092$2.01.01.01�000 ��M �� i �� V � ��9� � �� ,.. SiVE VT:�YS�?)(.�_iVF'FTG'si'tuC. �� `� � �� .� :,.. `;;, .;; -, ..�; c a �, ,a :t T F�r. �. ,��w. a ^� � A . � �-- ._� ., . ,�... . ,. . �.., . . �. A�`.z��-M � e,�-.�. . ,,..n.... :.,. ..,, _.....�..Miyr,.,.C..�.rYfim._...`5..::3?f,.. F.'�e��s k'.#rs,_.. "S , 5 '-F 2.k� :�' ':;. � 't ti� \� '�y} , 3 � ��.��: >Sign up for online account management. ' �" �"� `��x� �-Enroll in electronic statements. ��.��,,.� � r =-�-� :,�.. «��fi��r��.�� Get access to your�r��F6CC?"'Cr�dit S�nre. �,.� �_� i• ...y,.,�a >.:1� . `%�'C • � • • �� /1 +£i` �r.:��a- ..,t:;�.l'..i, �::?.,..�r��t^'„'�r..a�.., �r>..;:Y;li.��E��:sv.�,".�'�.��er�..S`r..'::�;.�,. .2�+.�.;:..'�z..N'�:,�..:,.M .,.aix";`�S ''ww;,s.. .. _ . .,..... .._�..s,_, t *WalmarC"Credit Ca�A accounls that enroil in electronic statements may also enroll to receive a munthly NCO�Cr��ii[kore,as well as the fop two ieawn axies affecting the scote at no cosl.The information qathered(rom the credit bureau lo deteimine the fIC00 Credit Smre wili not impact ihe acrount's aedit smre.fIC00 Oedit Smres will be presented within tl�e online accoun(servicing site a�htip://www.wahnai I.com/cretliUajin. Dixover"and the Dixover acceptance mark are service marks used by GE Capital Retail Bank under license fran Discover Finan�ial Services. The"Spark'design(:;:),Walmart and Save Money.Live Better.are marks and/or registered marks of Wal-Mart Stores,Inc. Walmart� ABRAM 5 DIMELER Visit us at walmart com/credi N� Diseover• CiC�r� Account Number: 6011 3100 0002 0948 Customer Service: 1-866-611-114£ V �5ummary of Accnunt Activity.: , = Payment:information Previous Balanca ' $98.34 �Balance $75.85 -Payments $25.00 Total Minimum Payment Due $25.00 +Fees Charged $1.24 Payment Due Date 03/12/2014 +Interest Charges $�•27 Late Payment Warning: If we do not receive your minimum New Balance $��,85 payment by the date listed above,you may have to pay a IatE fee up to$35.00. Credit Limit $3,500 Minimum Payment Warning: If you make only the minimur payment each period,you will pay more in interest and it will Available Credit $3,424 take you longer to pay off your balance For example. Cash Advance/Quick Cash Limit $700 Available Cash , $699 ;If you make no ; You will pay eff And>;you will end 5catement Closing Date o2/17/2ota �additional`charges i the�halance -' up;:paying an. Days in Billing Cycle � 28 using this cartl shown on th�s' estiinated total (� �nd eacFf'�nonth ° sta#ament in : ; of � � you pay atsbut _ `� Only the minimum + 4'months $78.00 \i�� payment �� - G�'3`'� If you would like informa6on about credit counseling services,call 1-877-302-8775. _ _ �J._-i --- ------------ ___ -- —-- --_ �--- -- — -- � Cash Earned Summary ;; Cash News ' ' -- I Previous 6alance $5.68 ( ; Earning cash backwith the Walmart�Discover� i(+)Earned This Period $0.00 � �I is easy! Simply use your card everywhere �=6alance $5.68 i Discover� is accepted. Remember every � time you earn just$10,you will receive a i check in your billing statement-it's automatic. � � i I �� ' , i $� $2.5� $5.00 $�.50 $,�.�0 L � PAYMENT DUE BY 5 P.M. (ET1 ON THE DUE DATE. NOTICE:We may convert your payment into an electronic debit.See reverse for details, Billing Rights and other important information. 5404 U006 BGH 1 7 17 140217 PAGE 1 af 3 6Z10 1000 A323 O1�F5404 150' REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Dimeler,Abram S. 21-04-00242 RELATIONSHIP TO NUMBER NAME AND ADDRESS OF DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE PERSON(Sl RECEIVING PROPERTY (Words) ($$$) Do Not List Tr stee s I� TAXABLE DISTRIBUTIONS [include outright spousal distributions,and transfers under Sec.9116 a 1.2 Vicki A. Colby Daughter One-Third(1/3) 174 Old York Road Share of the Dilisburg, PA 17019 Estate Susan E DeWalt Daughter One-Third(1/3) 370 Meadows Road Share of ths Newville, PA 17241 Estate David A. Dimeler Son One-Third (1/3) 214 E. Pine Avenue share of the Bensenville, IL 60106 Estate Total Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro riate. 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) LAST YVILL AND T.ESTA�IVIENT I, ABRAM S. DIMELER, of Dillsburg, York County, Pezuisylvania, being of sound r�.ind, disposing memory and full legal age, do hereby mal�e, publish and declare this to be my Last Wili and Testament, hereby revoking alI Wills and Codicils heretofore made by me. ONE. I direct my Executor or Executrix, as #he case may be, to pay a11 of my debts, fiineral and aciministrative expenses as soon as convenient after my decease. Purtharmore, I direct that all state, inheritance, successzon and other death taxes irnposed or payable by reason of my death and interest and penalties thereon with respect to a11 property composing of my gross estate for death tax purposes, whether or not such property passes under this VViII, shall be paid by the Executor or Executrix of my estate. Further, to the extent that sufficient assets exist in rny estate, a.ny and all inheritance or other estate taxes, whether to non-charifiable or charitable beneficiaries, shall be paid by my Executor or Executrix from the residuary of my estate. TWO. My Executor or Executrix may, at his �or her discretion, compromise claims, borrow money, retain property for such lengtla of'time as he or she may deem proper; lease and sell property for such prices, on such terms, at public or private sales, as he or she may deern proper; and invest estate property and income without restrictzon to legal investments unless otherwise pravided hereuzider. I authorize and empower my Executor or Executrix to sell any realty and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at pubiic or private sale or sales and to give good and sufficient deeds andlor biils of sale therefor, in fee simple, as I could do if living. My Executor or Executrix is authorized and empowered to engage in any busin.ess in which I may be engaged at my death, for such�eriod of time after rrzy death as seems expedient to said Executor or Executrix. THREE. I give, devise and bequeath a11 of my estate of whatever nature and wherever situate to my children, VICKI A. COLBY, DAVID A. DIMELER and SUSAN E. BLYMIER, in equal shares, per stizpes, which provides that tlie child or children of any deceased beneficiary shall take the share their parent would have talcen if living. FOUR. If, under any of the provisions of this Will, any principal becomes vested in a minor, my Executor or Executrix, as the case may be, including any administrator c.t.a., shall have the discretion either to pay over such principal or any part thereof to any parent of such rninor, any guardian of the person or estate af such minor, or any persan with whom such minor resides, or to retain the same as trustee of a pawer in trust for the benefit of such nninor during his or her minority. Any of the principal thus retained, and any of the income therefrom, including the whole thereof, �nay be paid to or applied for the benefit of such rzzinor from time to time in the d'zscretion of the trustee of such power. When such rninor reaches majority, the funds so held sha11 be paid over to such person, or, if he or she sha11 sooner die, to his or her legal representatives. In so holding any principal or income for any minor, the trustee of such power shall have ali the rights, powers, duties and discretions conferred or imposed upon my fiduciaries acting under this Will. I further direct that no bond shall be required from any person xeceiving a payment hereunder and receipt from such person shall be a full discharge to the trustee of such power who shall not be bound to see to the application or use of such payxnent. The trustee of such power shall be entitled to commissions at the rates and in the manner payable to a testamentary trustee. FIVE. I nominate and appoint SUSAN E. BLYMIER, to be the Executrix of this my Last Will and Testament. In the event she has predeceased me, failed to qualify or is not able or does not serve for whatever reasan, I then appoint VICKI A. COLBY, to be the substitute 2 Executrix of this my Last Wiil and Testament, whereby the said substitute personal representative shall have the same powers as are given to the original Executrix hereunder. SIX. No person(s) shall benefit hereunder unless such beneficiary shall survive me by sixty {60) days. SEVEN. No Executrix, Executor or Guardian acting hereunder shall be required to post bond or enter security in this or any other jurisdiction. EIGHT. No beneficiary may assign, anticipate or pledge his ox her znterest in any _ income or principal laeld or distributable hereunder, and no beneficiary's creditors may levy, attach or otherwise reach any such interest. IN WITNESS WHEREOF, I have hereunto set my hand and seal this�day of Apxil, Zoas. �r� ��yl l�l�z� _—tSEAL) AB M S.DIMELER Signed, sealed, published and declared by the above-named person as and for a Last Will and Testament, in our pxesence, who at said person's request, in said person's presence and in the presence o£each other have hereunto set our names as subscribing witnesses. � � 3 � 6 ACKNOWLEDGMENT AND AFFIDAVIT WE, ABRAM S. DIMEi�ER, SUSANN B. MORRISON and JENNIFER M. NEGLEY, the testatox and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authorify that the testator signed and executed the instrument as his Last Will, and that he had signed wi`.lingly, and that he executed ?t as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and heaxing of the testator, signed the Will as a witness and that to the best of their knowledge the testator was, a#that time, eighteen years of age or older, of sound mind and under no constraint or undue influence, �� l��t��? ASRA S.DIMELER � �. SUSANN B. ORRISON JEN FER M. NEG Y C�MMONWEALTH OF PENNSYLVANIA . . SS: COUNTY OF CUMBERLAND . Subscribed, sworn to and acknowledged before me by GEORGE D. BR.ANDER, the testator herein, and subscribed and sworn to before nae y SUSANN . MORRISON and JENNIFER M.NEGLEY, �vitnesses, this_l�day of ,�Yt t, 200 � �A ,�H F p SYL CO MO Nataria�s��o�ry pub�� N t Public JacQ�elina L.Drawba��C��7 Mou�'�m��"�,Exp��°�A vania Arsoo4atlon d4 NO�� Member,Pennsy� REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Dimeler,Abram S. 21-04-00242 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S1 RECEIVING PROPERTY DECEDENT (�/�/ords) ($$$) Do Not List Trustee s I� TAXABLE DISTRIBUTIONS [include outright spousal distributions,and transfers under Sec.9116 a 1.2 Vicki A. Colby Daughter One-Third(1/3) 174 Old York Road Share of the Dillsburg, PA 17019 Estate Susan E DeWalt Daughter One-Third(1/3) 370 Meadows Road Share of the Newville, PA 17241 Estate David A. Dimeler Son One-Third(1/3) 214 E. Pine Avenue share of the Bensenville, IL 60106 Estate Total Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro riate. 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)