HomeMy WebLinkAbout05-26-15 �e enns Ivania 1505618403
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REV-1500 OFFlCIAL USE ONLV
Bureau of Intlivitlual Taxes counryCOGe vear Flk Number
Poe0x28osoi INHERITANCETAXRETURN 21 14 0387
Narrisburo. PA 1�128-osoi RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Searity Number Da�e of Dealh MMD�YrvY Oata o(Bitlh MmooVVYY
04 1E 2014 ❑3 13 1969
Decetlenfs Las�Name SuKx Decetlenfs First Name MI
HARPER JIIDSON p
�It Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS 9ELOW
Ot OriginalRetum � 2. SupplamenlelReWm � 3. Remain42�REWrt1(tla�eoftlee�h
p�io��0 12-13-82)
� d, AgnwlWral ExempOon(dale of � 5. FUW�e Interes�Compromise(Oa�e of � 6. FeGe�al Es�a�e Tax Relurn Require�
OealhOnorafler]-0-20�2) deathaflert2-12-82)
� Z DeceOen��letl Testa�e � 8. DeceCen[Maintalnetl a Living Tms� e. Tolal NumEer of Safe Deposi�Boxes
(A�tachcoPYolwilp (A��aclicoPYot(msq
� 10. Li�iga�ionPmceetl4ReC¢IV¢tl � 1tNOn-ProbdteTrans(ereeReWm � 4. Oef¢rtdVEl¢c�ionolSOouShcTfus�s
(SCM1edule F antl O Assels Only)
� ll Business Assets � 14. Spouse is Sola Benefciary
(No Vust Involvetl7
COFRESPONUENT�iH15 SECiION MUST BE COMPLETEO.ALL CORRESPoNOENCE AND CONFIOENTNL TAX MFOFMqTION SHOIILD BE OIRECTEO T0:
Name Oaytime Telephone Number
KATIE J MA%WELL (717) 243 3341
Fint Lina of AtlOress
10 EAST HIGH STREET
Second Line ol Atltlresa
Cityo�PoslOHice SWIe ZIPCode
CARLISLE PA 17a13 �
, _ n
GorrespondenPsemailatltlress: kmaxwell(rDmartsonlaw.com '� �—� `�
. _.; -�' -. ��
NEGISTER OP WRC$USE ONLY ��
� �I
REGISiEROFWILLSUSEONLT �� V� �
DHTE FILE�MMODYYVY �� �
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F' ' '
�AT�.FILEOSTAMP� ` �'�
Side 1
L III�I�III��I�IIIIIIIIIIIIIIIIIIIIIIIIII3II�I�IIIIIIIIIIIIIII y505618403 J \
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J Lsoss1e411
REV-0SOOEX
DecetlenPs Social Secunty Number
oe�ee�r:rvame� Harper, Judson P.
RECAPITULATION
1. RealEs�ate(SchetluleA).._ __._.. __..... .....__ 1.
2. Stocks antl Bonds(Schedule B) ........... ____. ............ 2.
3. Closey Heltl Corporation, Pahnershlp o�Sole-Pmprietorship(Schedule C)......... 3. 18.�0� •�0
4. MortgagesantlNotesReceivable(SchetluleD).............................___________. 4.
5. Cash, Bank Deposits and Miscellaneous Pereonal Pmperty(Schedule E)..._..... 5. 39 5 • 50
6. Jointty Ownetl Propetly(Schetlule F) �_��, Separate Billing Reques�ed___...... 6.
]. Inter-Vivos Trensfers&Mlscellaneous Non-Pmbate Property
(SchetluleG) J Sepa�a�eBillingRequestetl_____.. 1.
8. Tofal Gross Assets(�otal Lines 1 ihmugh]). 8. 19 .395 • 50
9. FuneralExpensesantlAtlminisirativeCosis(Sc�eduleH)._.__._.....................__ 9. 4 .533 • 50
10. Debts of Decedent,Mortgage Liabilities antl Liens(Schedule I)._.._.._.._............. 10. 96�14 6 •�1
11. ToqlDetluctions(totalLines9and10)...._.. ....._.. ____.. >>_ 100,679 •51
12. NetValueofEsfate(GneBminusLinell)._ _.._._ ...._..... 12. -82.284 • 01
73. Charitable antl Governmental Beques�s/Sec 9113 Tmsis lor whic�
an eledion to tax has not been matle(Sc�edule J).__..._._.____._......_.............. 13.
14. NetValueSubjecttoTaz(Linel2minusLinel3�........._.................______.._._ �p. -82.284 • 01
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES ��
15. AmountofLinel4taxable
at Ihe spousal tax rate,or
�rensfers untler Sec.9116
(a)(12)%.00 16_ ❑ .00
16. Amoun�ot Line 14 taxable
at lineal�a�e % .045 0 •0 0 16. ❑ . 0 0
il. Amoun�of Line 14 taxable
a�sibling rate X.12 ❑•0 0 1]. ❑. 0 0
18. AmountofLlnetAtaxable
atcollateralrate X.15 �-00 18. ❑ .��
19. TA%OUE.. .__.... ..__.... .____ ________. 19. 0 . 00
20. FILL IN THE OVAL IF YOU ARE REQUESTING H REFUND OF AN OVERPAVMENT �
Untle�penalties of perlury,I�eGare I�ave eramine0��is re�um,indutling acmmpanying scM1edules anG SW�ements,an0�o t�e bes�ot my knowletlge ane�ellel..
it Is Ime,wrrect an0 complele.Declara�ion ot prepare�oPe��han Ne person responSiLle for Oling��e reNm I5 basetl on all Intormalion ol whicM1 preparer pas
any knowieEga.
SIG TURE OF PERSON RESPO E FOR FI G RETURN garry C. Harper �ATE
_, /�„ �_�� 05�3� 8O1�
ADDRE55 - ��
6375 Saucon Valle Drive, Fa etteville, PA 17222
sic nrfl URE OF P� anR rnER aEaaESENrnrnE Katie J. Maxwell �5�T�6 a��-�
Ad RES� /
10 East ' Street, Carlisle, PA 17013
I I��III II��I�IIII��I�I�III��IIII II��I I'lll IIIII II'II I�II I��I Side 2
L 150561B411 1505618411 �
PA Inheritance Tax Return
Signature of Additional Fiduciaries
ESTATE OF FILE NUMBER
Harper, Jutlson P. 21-14-0387
UnOer penalties of perjury.I declare that I have examinetl this reWm,including accompanying schetlules antl stalemenis,antl to ihe best o�
my knowleEge antl belie[il is�rue,co�rect antl wmple�e.Declaration of preparer other Ihan ihe personal representative Is basetl on all
in/ormation of which preparer has any knowletlge.
Signature#2 . � � � ��
Name Sally Ann aroer
Add12551 6315 Saucon Vallev Dr.
Address2
CI[y, SW(2�ZIP Fa etteville PA 71222
Date �'s a� ���
REV-1500 EX Page 3 File N�mber 27-'14-0387
Decedent's Comple[e Address:
DECEDENT'S NAME
Harper, Jutlson P.
STREETADDRESS ���
152 Timber Lane
cirv srnre � I,zip
Shippensbur9 PA ' 17257
7ax Payments and Credits:
L Tax Due(Peqe 2,Llne 1B) (�) 0.00
2. Cretlits/Paymenls
A. PriorPaymen�s
B. Discoun[ 0.00
Total Cretlits(A +e) QI 0.00
3. Interest (3)
4. If Line 2 is greaterihan Line 1 t Line 3,enter Ihe tliflerence. This Is�he OVERPAVMENL �q)
Check boz on Page 2,Line 20 to request a reNntl -- -
5. If Line 1 +Line 3 is greater Ihan Line 2,en�erthe difference This is ihe TAX DUE. (5) p.pQ
Make Check Payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. DiE decetlent make a transfer antl: Yes No
a. re[ainiheuseorincomeo�thepropertytransferretl; __..... .....__ ._....._ '��i Ix�
b. retain�herighttotlesignatewhoshallusethepmpertyVansferredori�sincome;.........__.__.__.__.._ � �Iz�
c. retain a reversionaryin[erest:or__ _.._._ ._.._.. .._......... ....... i � ` �
—r �' L
d. receive�hepromiseforlifeofeitherpaymen�s,benefi[sorcare4..... .,_.._. . u LI
2. I�tleath occurred after Dec. 12, 1962, tlitl deceden� Iransfer pmperty w�h n one year of tleaU withou�
r
receivingatlequateconsidetation?...._... .._._.. ........_ ____ �.x,
3. Ditl tlecetlent own an"in tmst for' or payable upon tlea[h�ank acrqunt or security a[his or her death9_.._. ❑ _]
4. Ditl tlecetlen�own an intlimtlual re[iremen�accoun� annuity or other noo-probale propetly whmh
containsabenefciarydesgnation2...._. ........ .__.... ..... __..._ `.�'� ��
IF THE ANSWER TO ANV OF THE ABOVE qUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PFRT OF THE RETURN.
For detes of tlealh on or after July 1, 1994 anG before Jan. 1.1995,�he�ax ra[e imposetl on�he net value o�Nans�ers�o or tor tAe use of Ihe surviving spause
Is 3 percent�]2 P.S.§9116(a)(1.1)(i)�.
Por dates of death on or e%er Januery 1,7995,Ihe lax rale impmetl on the net velue of trensfers lo or kr the use oi the suniving spouse is 0 Dercent
p2P.5.49116(a)(1.1)(li)�. Thestatuteticesnotexemp�at2nsfertoasurviv.ngspouselromtax,antlthestaWroryreQuiremeniskrtlisciosureolasselsand
filing a tav relum are slill applicable even if Ihe surviving spouse is lhe only beneficiary.
For tlates o!Eeath on or aXer July 7,2�00�.
• The tax rote impmed on ihe net value of tramfen hom e deceesed child 21 yearo of age or younqer at tleath ro or for the use of a naNrol Oarenl,an
adoptive parent,or a step-parent ot the chiltl is o percent[]2 PS.49116(a)(L2)�.
• The lax rote imposetl on ihe ne�value o�iransfers to or for Ue use ot ihe decedenfs I�ineal beneficianes is d.5 percen�,excepl as noted in�12 P.S.§9116(a)(ip.
. The tax 21e imposed on Ihe net value of trenekrs to or(or the use of ihe decedenfs siblings is 12 parcenl�]2 P.3.§9116(a)(1.3)]. A sbling is defioed,
untler Sedion 9104,as an individual who has al leas[one parent in wmmon wifi the decetlent,whether by blootl or adoptian.
Rae-0SOC EX��09-03�
SCHEDULE C
pennsylvania CLOSELY-HELD CORPORATION,
oEraarmeruroraevsrv�c PQRTNERSHIPOR
INHERILpHCE T!U RETORN
ResioeHroeceoeNr SOLE-PROPRIETORSHIP
ESTATE OF FILE NUMBER
Harper Jutlson P. 21-14-0387
acnaaoie e-i w o-a�mu�em�g eu eopoon�ng Inmrmeuoo�mus ee mmrnea mreern ucaeynem�omoreuomvannersnio���ares�a me a«aoem.oinennn�
a sol -pmpna�ors�q.Sea mslmcliom br IM1e suppwl�ng m�ormallon�o�e su0mirtetl lor colewopr�elors�lps.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OFDEATH
1 Ship Shipping,LLC -Solely owned by Decedent;actual sale value,see attachetl Asset 18,000.00
Purchase Agreement
TOTAL(Also enter on Line 3, Recapitulation) 18,000.00
Qt more svace Is neeaeE,aaoitlonal pa9es of Ine same size7
Copyright(c)2012 form software only T�e Lackner Gmup, Ina Fortn PA-0500 Schetlule C(Rev. 0942)
R..�isee ex.�oe�iz�
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
oevaarmeurornever�ue pERSONAL PROPERTY
INHERITPNCETA%ftETIIRN
PESIOENT�ECE�ENT
ESTATE OF FILE NUMBER
Harper, Judson P. 21-14-0387
m�iwa ma vro«ea:m mieatio�a�a rtre ame�na cr«�a:w.re,�:��aa ev m:a.i.ia.
ai a,aa.m i��ouy.o.,�aa.nm m.nqn�oi..rmo�.n�p m.:�e.a�.�m..a a�.�n.am.v.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEnTH
1 Unknownpayee-ReimbursementofinsurancecliampreviouslypaidtoShipShipping 395.50
Customer-check matle payable to Estate
TOTAL(Also enter on Line 5. Recapitulation) 395.50
pt more space Is neetleq atltlitional va9es of ine same size)
Copynght(c)2012 form sottware onty The Lackner Gmup.Inc Form PA-0500 Schetlule E(Rev.OB-12)
R`�""„'.,��," SCHEDULE H
pennsylvania
oeaaa*mem�oFaevervue FUNERAL EXPENSES AND
1NXER1AN0ETA"R`T�p" pDMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Harper Judson P 21-14-0387
DecetlenYs tlebts must be reparted on Schedule I.
ITEM DESCRIPTION AMOUNT
q, FIINERALEXPENSES:
8. ADMINISTRATIVE CO5T5:
1. PersonalRepresenlative'sCommissions
Name of Personal Represen�a�ive(s)
Barry C. Harper
Streetnaaress 6375 Saucon Valley Drive
ciry Fayetleville Sta�e PA zio 17222
Year(s)Commission Paid 2015 900.00
See continuation schedule(s)attached
p, Atlomey'sFees 2,500DU
See continuation schedule�s)attached
3, Famity Exemptiom Q(tlecetlenCs address is nol the same as claimanCs,attach explanation)
Claimant
StreetAtltlress
Ciry S�a�e _ Zio
Relatianshlo of Claiman[to�ecedent
4. Pmbate Fees 133.50
See continuation schedule�s) attached
5. AccoumanCs Fees
6. Tax Relum PreOarer's Fees
Z OtherAtlminis[rativeCosts 7,000.00
See continuation schedule�s) attached
TOTAL(Also en[er on line 9,Recapitulation) 4,533.50
Copyrig��(c)2013�ortn software only The Lackner Gmup,Ina Form PA-050a Schetlule H(Rev. OB-13)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Harper Judson P. 21-14-0387
ITEM
NUMBER DESCRIPTION nMOUNT
P�rsonal Reoresentative Gommissione
1 BarryC. Harper85allyAnnHarper-Atlministrators'commission 900.00
H-B7 900.00
Attorney Fees
2 Martson Law Offices-(Estimatad attorneys'fees) 2,500.00
H-62 2,500.00
Pmhate Fees
3 Cumberlantl County Register of Wills -Probata fee 133.50
H-64 133.50
Other Adminis[rative Costs
4 Ship Shipping, LLC-Jamie Butleskey-fee to transfer business accounts to new owner 1,000.00
H-B7 1,000.00
Copyrighl(c)2002(orm soflware only The Lackner Gmup,Ina Fortn PA4500 Schedule H(Rev.6-98)
Fev-15II E%��@-03�
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
oeou+.ME�+rorAE�eNue MORTGAGE LIABILITIES AND LIENS
NMERITANCE iM RETORN
RESI�ENiOFCE�ENT
ESTATE OF FILE NUMBER
Harper Judson P 21-14-0387
a.pon ao�.m��naa i+y ma e.�.o.m pnor�o aeam im��.m:mea�ov.�a a me mia or e.aq m�wams�nreime��ea m.m�.i..pe�.a..
REM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Chambersburg Hospifal -See attachetl claim 96,146.01
TOTAL(Also enter on Line 10, Recapitulation) 96,146.07
Qf more space is neetletl,atlaitional pages of IM1e same size)
Copyright(c)2012 form sottware only T�e Lackner Group, Inn Form PA-1500 Schetlule I(Rev. 1&12)
aev-+su u.lotno�
pennsylvania SCHEDULE J
oevnarmEHroFaeveNUE
���ER�,A��E.�AE.�aN BENEFICIARIES
aEs oeH.oeceoEr+.
ESTATE OF FILE NUMBER
Har er,Judson P. 21-14-0387
NAMEANDADDRESSOF RELATIONSHIPTO SHAREOFESTATEAMOUNTOFESTATE
NUMBER pER50NfS1RECEIVINGPROPERTV DECEDENT (yyortls) ($$$)
1 TAXABLEDISTRIBUTIONS [inclutleouVightspousal
disVibutions,and trans(ers
untle�Sec 9116 a 12
TOtal
Enter tlollar amounis br tlisiribu�ions s�awn above on lines 15 ihmu h 18 on Rev 1500 wve�sheet as a m riate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UN�ER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT THKEN
B.CHPRITABLE NN�GOVERNMENTAL DISTRiBUT�ONS
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON IINE 13 OF REV4500 COVER SHEET
Copyright(c)2070 form sakware onty The Lackner Group, Inn Fortn PA4500 Schedule J(Rev.0140)
ASSET PURCHASE AGREEMENT
TffiS ASSET PURCHASE AGREEMEN'T, is made as of this �"1` day of May, 2014,
by aud between BARRY C. HARPER and SALLY ANN HARPER, Co-Administrators of the
Estate of Judson P. Harper, Sole Member of SHIP SHIPPING, LLC, a Pennsylvania ]imited
liability company, being the sole owner of the business known as SHIP SHIPPING, with its
principal place of business being located at Suite I, 204-212 East King Street, also known as 208
East King Sireet, Shippensbwg, Pennsylvania, (hereinafter refened to as "Seller"); and PACK
SHIP & PRINT ETC. LLC, a Pennsylvania limited liability company, whose address is 1432
Hearthside Drive, Chambecsbarg, Pennsylvania 17202(hereinafter referted to as"Buyer").
WITNESSETH:
WHEREAS, Seller curzentty operates a shipping freight and parcel busi�ess known as
SHIP SHIPPING, located at Suite I, 204-212 East King Street, also known as 208 East King
Street,Shippensburg, Pennsylvania, (the`Business"); and
WHEREAS, Seller is desirous of selling to Buyer certain assets which Seller utilizes in
the operation of the Business; and Buyer is desirous of purchasing the same from the Seller upon
on the tem�s and conditions hereinafter set forth.
NOW TAEREFORE, in consideration of the muNa] covenants contained herein, in
reliance upon the representations ar�d wazranties contained herein, and subject to the conditions
contained herein, the parties hereto agree as follows:
Page I of I1
1. SALE OF ASSETS: Seller agees to sell and deliver to Buyer, and Buyer agrees
to purchase and take from Seller, alI of Seller's inventory, fumishings, leasehold improvements,
fixtures supplies, goodwili, customer lists and other rights owned by Seller for use in the
operation of the aforementioned Business currently operated by Seller at Suite I, 204-212 East
King Street, also known as 208 East King Street, Shippensburg, Cumbedand County,
Pennsylvania, including but no[ ]imited to the items specifically described on Exhibit "A", which
is attached hereto aod incolporated by [his reference (including all cash and accounts receivable
relating to said business of Seller existing as of the Closing Date) (herein collectively called
"Assefs"). Excep[as otherwise disclosed herein, Seller shall transfer all right, title and intecest in
the Assets to Buyer, &ee and clear of all iiens, encumbrances, securiry interests, resMctions and
claims of any nature whatsoever except those which aze created herein and those which have
bee�disclosed to buyer in this Asset Purchase Agreetnent.
2. ASSIJMPTION OF LIABILITIES: At Closing, as defined below, Buyer shall
assume aoy liabilities of Seller in connecfion to the operation of the Business incurzed on or after
May 20,2014, and indemnify and hold Seller harmless from the same.
3. CLOSING DATE: All of the transactions mntemplated herein shall be
consumma[ed at the respective time and place as the parties hereto may mutually agree upon on
or before May 3Q 2014, unless othenvise extended in writing by agreement of the parties hereto
(herein calleei "Closing Date" or"Closing").
4. PURCHASE PRICE: Buyer shall pay to Seller for the Assets the sum of
Eighteen Thousand and 00/100 Dollazs ($18,000.00) (herein called "Purchase Price"). The
parties agree that the Purchase Pnce shall be allocated solely to the tangible assets. A deposit in
the amount of Five Thousand and 00/100 Dollars ($5,000.00) (he�einafter called"DeposiP') shall
be paid directly to Seller i� cash, certified funds or attomey escrow check at the time of
execution of this Agreecnent and shall be applied towazds the mta] Purchase Price at Closing.
Buyer shall be entitled to a futl refund of the Deposit should Closing not be consummated
through no fautt of Buyer. Should Buyer fail to perfoim its obligations under tlils Agreement,
Selfer sha11 be entitled to retain the Deposit as liquidated damages and this Agreement s6a11 be
Page 2 of I1
terminated. The balance of Thirteen Thousand and 00/!00 Dollars ($13,000.00) shall be paid
direcdy to Seller in cash, certified funds or a[tomey escrow check at Closing.
5. CONDITION OF ASSETS AND RISK OF LOSS: Buyer asserts that it has
had the opportu�ity to inspect the Assets prior ro time of exewting this Asse[ Purchase
Agreement and acknowledges tha[ the Assets aze in a condition acceptab(e to Buyer. Seller does
not wa�rant [he condition of the Assets and the Assets are sold "AS IS", with no upress or
implied warrantres thereon, including warranties ojmerchantability or fitness jor a particu/¢r
purpose, other than the manufacturers' warrauties existing on such assets as of the date of
Closing hereunder. Seller shail maintain the Assets in their present condition and state of repair
between the date of this Agreement and the Closing Date, ordinary wear and tear alone excepted.
Seller shall beaz all risk of damage to or loss of the Assets until the Closing Date. ARer the
Closing Date, Buyer shall bear all risk of damage to or toss of the Assets.
6. ORDERLY TRANSFER OF BUSINESS: Buyer shall being operating the
business on May 20, 2014. Sefler agrees to cooperate wi[h Buyer in ef£ectuating an orderly
transfer to Buyer of the business and any other matter associated with the Assets and the business
which had previously been conducted by Seller, incWding, but not limited to, transfer of the
FedEx, UPS, DHL, and postal accounts, and payment of any outstanding debt owed to said
carriers. Seller shali use its best efforts to preserve the goodwill of suppliers, customers and �
others having business relations with said Business. The parties here[o agree that Jamie Budesky
shall assist Seller in transfemng Ihe business accounts to Buyet and each party agrees to
compensate Mc Budesky in the amomt of One Thousaud and 00/]00 Dollars ($1,000.00)
Dollars on or before Closing.
7. TAXES PAID: Seller shall comply with all provisions of the Pennsylvania Fiscal
Code, as amended, in connection with its sale of the Assets to Buyer. Seller hereby covenants
and agees to pay any and all ta�ces due on a federat, state or local level as a result of this
transaction and that any and alf such taxes shall be solely the responsibility of the Sellec Seller
also ceriifies that, to the best of its knowledge, all taxes which may result in any lien against the
Assets, including any and all unemployment tarzes, have been paid or will be paid from the
Page 3 of 1 I
proceeds of this sale. In the cvent that any such taxes remain outstanding, the Seller shall
promptly pay the same to the appropriate taxing authority and hereby agrees to indemnify and
hold hazmless the Buyer from any and all claims,judgments and liens as a result IhereoE This
warranty and representation shall survive the Closing for a period not to exceed one(1)year after
the Closing Date.
S. SELLER'S COVENANTS,REPRESENTATIONS AND WARRANTIES:
Seller hereby covenants, represents and waaants to Buyer that to the best of Seller's
knowledge, information and belie£
a. Seller is the sole owner of[he Assets with full right and lawful authority to
sell and deliver the same to Buyer hereunder, and the sale and delivery of the Assets to
Buyer hereunder will not violate the rig}tts or interests of any person or entity,
b. There is no litiga[ion pending or threatened against Seller [hat would in
any way affect Seller's ability to transfer all right, title and interest to the Assets to Buyer
as described above;
a Seller has not entered into any other agreement regardi�g the sale or
transfer of any of the Assets which is slill in effect;
d. The sa(e and delivery of the Assets to Buyer hereunder is not prohibited by
aciy agreement, law, govemmental regttlatioq judgnent or court order binding upon
Seller,
e. Seller is not involved as a debtor in any proceedings under any federal or
state bank�uptcy or insolvency laws;
f. Seller warrants that all of the financia] infonnation and other
documentation in possession of Seller which aze being hansfecred to Buyer aze true and
w�rect and tha[ any and all financial infonnation provided to Buyer in connection with
this transaction is true and corcect and accurately reflect the services performed by the
Se](er with respect to the business perfoRned by Seller.
- Page 4 of(I
AII of the covenants, representations and wananties of Seller set forth in this
Ageement shal] be deemed to have been made again by Seller at Closing and shall survive
Closing for a period of one (1)year.
9• BUYER'S COVENANTS, REPRESENTATIONS AND WARRpNTIES: ,
Buyer hereby covenan[s, represents and wazrants to Seller that Buyet has the
fmancial resources to purchase the Assets and is a Pewsylvania limited liability company duly
organized under the laws of the Commonwealth of Pennsylvania.
10. CONDITIONS PRECEDENT TO CLOSA'G-BUYER: Buyer's obligation to
purchase and take the Assets from Seller and to comply with any other obligations imposed upon
Buyer undes this Agreement are conditioned and contingent upon the occurtc�nce of each of the
following events or existence of each of the following circumstances:
a. Seller complying with all the other temis and conditions of this Ageement
which are to be perfomted or observed by it on or before the Closing Date;
b. Buyer being able to assume a]I rigltts and responsibilities &om Seller
under the ]eese agreement for the rea] property at Suite I, 204-212 East King Street, also
known as 208 East King Street, Shippensburg,Pennsylvania, or altematively,to enter into
a new leue agreement witlt the owner of said property, which lease agreement releases
Seller from any furttier responsibility to the owner of said proper[y after the Closing date;
ar�d
c. Buyer being able to obtai� accounts wi[h the appropriate shipping
companies currently servicing the business.
11. CONDITION PRECEDENT TO CLOSING- SELLER: Sellei's obligation to
sell and deliver the Assets to Buyer and to comply with any other obligations imposed upon
Seller �nder this Ageement is conditioned and contingent upon Buyer's compliance with all the
terms and conditions of this Agreement which are to be perfonned or observed by Buya on or
before the Closing Date.
Page 5 of!1
12. CLOSING DOCOMENTS:
a. Seller shall duly execute and deliver to Buyer the following documents
and instrumen[s at Closing:
1. A Bill of Sale in form acceptable to Buyer and Seller, which
exhibit is incorporated herein by tltis reference, said document duly executed by
Seller, hansferring good and mazketable title to the Assets to Buyer,a[id
2. Such other dowments and instruments as are reasonably requested
by Buyer in connection herewith.
b. Buyer shafl duly execute or cause to have executed and deliver ro Seller
the following documents and instruments at Closing:
l. Proof of cocporate reAstery with the Commonwealth of
Pennsylvania;
2. Minutes or Consent oF Boazd of Directors of Buyer authorizing all
acfions contemplated unda the Sales Agreements,if applicable;
3. All other doctvnents required under the Sales Agreements; and
4. Such other docutnents and insfiunents as are reasonably requested
by Seller in connection herewith.
13. OTHER DOCUMENTS: Seller and Buyer shall also deliver to each other,both
before and after Closing, such other documents and instruments as may be reasonabiy required
for the proper wcLsutmnation of the transactions contemplated in [his Agreemeni and for the
proper fulfillmen[of[he covenants, represrntations and wazranties contained in this Agreerttent.
14. INDEMNIFICATION AND SETOFF: Each party agees to indemnify and
hold hazmless the otha party for and from any and all ]iability or loss the other party may suffer
(including but not limited to court wsts and reasonable attomey's fees) on account of a paz[y's
breach of any tertn, covenant, warranty or representafion set forth herein or in any of the
documents and instruments executed or delivered in connection herewith. All the terms,
covenants, wazranfies and representations set forth herein shall survive Closing and the execution
Page 6 of 11
and/or delivcry of any dowments and/or instruments before, at or after Closing for a period of
one (1)year.
� I5. NOTICES: Any notice to be given hereunder shall be given in writing and
delivered pezsonally or by registered or certified mail, reNm receipt requested, postage prepaid,
to the respective parties at the foltowing locarions:
Seller: BarryC.Hazper
6375 Saucon Valley D[ive
Fayetteville, PA 17222
Copy to : Katie J. Maxwell
MaRson Law Office
Ten East High Skeet
Cazlisle,PA 17013
Buyer: Kevin Cohick
1432 Hearthside Drive
Chambersbwg,PA 17202
Copy ro : L. Rebecca Ables, Esquire
Salzmann Hughes, P.C.
79 St. Paul Drive
Chambersburg,PA 17201
16. NO BROKER'S COMMISSION: Neither pazty hereto shall be liable For aciy
broker's wmmission in connection with the transactions hereunder, and each par[y acknowledges
and represents to the o[her party that it has not had any dealings, negotiations or consulta[ions
with any broker conceming the transactions hereunder for which compensarion is due.
t7. CONFIDENTIALII'Y: All parties hereto agree that all of the trnns and
conditions of this Agreement shall remain confidential and shall only be relayed to the parties
hereto or their duly appoin[ed representadves to the extent that such teans and conditions are not
considered public kuowledge or a part of the public domain.
� 18. NO OBLIGATIONS ASSUMED: it is hereby expressly acknowledged and
ageed by the parties hereto that Buyer is not, and will not be, assuming any liabilities, debts,
Page 7 of I1
contracts or obligations wha[soever of Seller, coiporately or individually, under the terzns of this
Ageement or through the hansactions resulting therehom other than as provided for herein.
19. LEGAL REPRESENTATION: The parties herero acknowleclge that the
scrivener of this Agreement represents Buyer, and Seller further acknowledges that it has had
ample opportunity to review this Ageement with its attomey. -
20. SEVERABILII'P: Any provision of this Agreement which is imalid or
unenforcea6le in any jurisdiction or mder any circumstance shall be ineffective to [he extent of
such invalidity or unenforceability only without invalidating or rendering unenforceable the
remauting provisions hereof iu such jurisdicdon or under such circumstances, and any such
inva(idity or unenforceability shall not invalidate or render unenfomeable such provision in any
otherjurisdiction or under any other circumstances.
21. COOPERATION: Subject to the temis and conditions hereof, each of the
parties hereto shall use its best efforts to take, or cause to be taken, such ac6on, to execute and
deliver,or cause to be executed and delivered, such additional documents and instruments and to
do, or cause to be done, all things necessary, proper or advisable under the provisions of this
Ageement and under applicable law ro consummate and make effective the transactions and
undertakings contemplated by this Agreement and to vest in Buyer all right, title and interest in
and to the Assets or Inventory, whether at or after the Closing.
22. BULK SALES LAW COMPLI.4NCE: The parties hereto expressly waive
compliance with the provisions of the Pennsylvania Bulk Sales Law, and the Seller shall
indemuify and hold[he Buyer hazmless from and against any and all liabilities imposed upon the
Buyer resulfing from such non-compliance, other than with respect to the Liabilifles assumed by
the Buyer pursuant ro this Agreement.
23. FINANCIAL STATEMENTS; TAX RETURNS; CURRENT REVENUE.
The financial books, records and accounts of Seller have in the past been and are kept in
accordance with current federal and state tax codes for small businesses and appfied on a
consistent basis. Seller has operated and filed i[s income tax returns for fiscal years ending in
2010, 2011, and 2013, on a cash basis of accounting using[he income tax method of accounting,
Page 8 of I I
the same having been prepared in accordance with wrtent federal and state tax codes for small
business and applied on a consistent basis and fairly pcesent the financial condition of Seller as oF
such dates and the results of its operations for the pedods then ended. Seller's Federal and state
income tax retums filed for the aforesaid fiscal years aze true, correct and complete in all material
respects.
24. ASSIGNMENT. This Agreement shall not be assignable by the Seller without the
prior written consent of Buyer. The Buyer shall have the right at any time prior to Closing [o
assign this Ageement to its nominee without obtaining the Seller's consent pmvided however
that any such assignment shall only be effective if it is usigaed to an entity w(uch is owned at
least fiftyone percent (5t%) by the Buyer. In all other cases, this A$�eement shall not be
assignable by Buyer without the prior written consent of Seller. To the extent assignable, [his
Ageement shall be binding upon, and inure to the benefit of the Buyer and its successors and
assigas and the Seller and its successois and assigns.
25. MISCELLANEOUS: This Ag'eement shall be construed uoder and govemed by
the laws of the Commonwealth of Pennsylvania. This Agreement constitutes the entire
agreement between [he parties with respect to the sale and transfer of the Assets and Inventory,
and there aze no agreements, wnditions or undecsfandings, either oral or written, behveen Seller
and Buyer relating to these matters other than those which are contained in this A�eement. For
the pulposes of intetpreting this Ageement, [he masculine shall include the feminine and neuter,
and vice versa, and the singulaz shall include the plural, and vice versa, unless wnirary intent
appears. The subject headings of the paragraptis of tkils Agreement are included for ihe purpose
of convenience only and shall in no way affect the meaning or wnstrucrion of any tem� or
provision hereo£ The above WfIEREAS clauses and the attached E�chibits aze integal and
substantive parts of this A�eement and aze hereby incorporated herein by reference. This
pgreement shall inure to the benefit of and shall be binding upon each of the parties hereto and
their respective heirs, exewtors, adminishators, successors and assigns. This Ap{eement may be
altered or amended only by a written agreement signed by both Seller and Buyer. This
Page 9 of 11
Agreement may be executed in one or more counterpar[s, each of which shall be deemed an
original,but all of which together shall constitute one and the same Agreement.
IN WITNESS WHEREOF, and intending to be legally bound, the parties hereto
foirnatly execute this Agreement of Sale as of the day and year first above written.
WITNESS: PACK SHIP & PRINT ETC. LLC
(�l�] By: � � W�F\.lf� (SEAI.)
Kevin Cohick, Me ber
THE ESTATE OF JUDSON P. HARPER FOR
SHIP SHIPPING,LLC
��d�Jl�-G.p By: / . � SEAL)
Barry C. Hazp , Co-Adminishgt r
F'----- 7V"C \ JfLJC� B � VLGV�i (SEAL)
Sally arper, Co-Adminis ator
Page l0 of 11
EXHIBIT "A"
ASSETS
All Assets used in Ship Shipping as of the date of Closing, including,but not limited to, the
following items:
1. One (1) Desktop PC,EMachines EL1360G;
2. One (I) Desktop PC,Dell Inspimn D06M;
3. One (1) Laptop PC, Samsung;
4. Fow(4) Computer Monitors,Acer v173 DJB;
5. Two (2) Credit Card Swipe Readers, Magtek;
6. Two (2) Wireless Keyboards,Microsoft 800;
7. Two (2) Wireless Mice,Microsoft 1000;
8. One(1) Letter Scale,Dymo 40149;
9. One(1) Label Printer, Zebra GK420d;
]0.One(l) Label Printer, Dymo LabelWriter 450 Twin Turbo;
11.One(1) Receipt Printer,Citizen CTS310A;
12.Two (2) Cash DrawedRegister, Wasp Technologies WCD-5000 POS;
13. One (1) Receipt Printer,Citizen TZ30M01;
14.One (1) LCD Monitor, AOC 931SWL;
15.One (1) Television, Sony Bravia KDLf32BX300;
16. One (1) Copy Machine,Konica Minolta BIZHUBC550;
17.One (I) Fas Machine, Brother MFC-9970CDW;
18.One(1) Refrigerator, Emerson CR520B;
19.One(1) Document Shredder,Royal HG12X;
20. One(1) Digtal Camera,Nikon Coolpix 2570;
21.Two (2) Scales, Mettler Toledo A154399;
22. One(I)Microwave, Emerson MW7300W;
23. One(1) Passport Photo Printer, Epson Picturemate Personal Photo Lab; and
24.'I�vo(2) USB 10 Ports,Plugable USB 2.0 ]0 Port Hub.
Page l l of l l
'Chambersburg. DETAILED
� ,xo,p��y
�so e wamme�o�s� BILL
cnamoe,.e�,v.en vzm
]1J p8)-)t69
PATiENt NPME
HARPER,JUDSON P
YqTIENi NVM9EX POMIT/SEflVICEOPiE pqGE
H00051732675 04/12/14
HARPER,JUDSON P �
eiu oare oiscHaAce onre
752 TIMBERLANE LANE 05/14/14 04/18/14
SHIPPENSBUHG PA 17257 rorA�c�nRces PCCOUNTBALANCE
Continued
ixsunnrvcecow>ANr
IOENTIFICATION�PoIICY NVMBFP
MA APP 7ENDING �BILLI ZZ4�3���4
SUMMIT CARE 100% Z24�3���4
� •�• • •
CHPPGECODEi6ATCM SEflVICEORE •
OESCPIMION QTY NMOUNT
26000074 06/11/14 EP ADMIN OF VACCINE: TETANUS/flEDUCED 1 72.00
57002804 04/17/t4 ADACELVACCINE .SML >=7Vq5OLD; 7 104.33
57000087 04/17/14 AMIDATE 20MG/10ML INJ; ETOMIDATE 20 7 pq,g5
57002377 04/'I 1/14 QUELICIN 200MG/10M�INJ; 1 6.50
57000989 04/17/iq MANNITOL 25% 50ML INJ;MANNITOL 25% 2 7,gp
72.5 GM/50 ML VIAL
54000014 04/i t/14 VENTILATON MGMT-FIpST DAV 'I 1595.00
18901366 04/it/14 DETECTOp EASV CAP END CO2 7 28.00
18901040 04/11/14 qESUSCITATOR, DISPOSABLE 1 28.00
53670450 04/71/14 CT HEAD WO 1 1888.00
53672125 04/71/14 CT SPINE CERV WO 1 2028.00
53071012 04/11/t4 flAD CXEST 1 VIEW PONTABLE 7 331.00
50800048 04/11/14 ALCOHOL �MEDICAL] 7 21L00
50800259 04/11/14 PqOTHXOMe1NTIME t 50.00
50800293 04/'1!7? PARTIAL TXF.OMBIN TI�AE � gq,p0
50800003 04/11/74 COMPMETABPANEL 1 t94.00
26000047 04/11/'I4 ERVENIWNCTUflE-ROUTINECOLL 7 19.00
50800246 04/it/14 CBC AUTOMATED W/AUTO DIFF 'I 80.00
50800504 04/'11/14 BLOODGASES 1 230.00
54000021 04/11I74 ApTEqIAL BLOOD GASES COLLECT 1 88.00
26100226 04/11/14 7GCRITICAL CAHE 1 564.00
26000516 04/77/74 EF IV PUSH INITIAL DRUG 1 95.00
26000517 04/17/74 ER IV PUSH EA ADD'L OIFF DRUG 1 95.00
18910526 04/'17/14 KIT OfiAL HVGIENE SUCTIN 24HN 1 55.00
'18910430 04/ti114 pESTflAINTLIMBHOLDEfl � 1 20.50
78900156 04/11/14 OXISENSOXADU�TDISPOSABLE 1 27.00
18910448 04/77/14 STOCKING TED KNEE MED 1 12.50
18901183 04/it/'14 PpOVIDERPUMPSETPCA 1 31.35
14288-28 SET GEMSTAN MICROBORE 7 2].00
18910579 04/11/14 DRESSING BIATAIN ADH FOAM 1 1620
18910113 04/77/74 HEATING PAD REPLACEMENT 1 18.50
t8910526 04/17/74 KIT OflAL HYGIENE SUCTIN 24Hq 1 55.00
18900544 04/17/14 THAVPICCDRESSING � 7g,pp
26000005 04l12/14 EN IEVEL 5 1 2333.00
54000050 04/12/74 INTUBATION 1 303.00
18000700 04/12/14 OR BASE FEE-MAJON 1 2375.00
PPTIENTNFME pp}IENTNVM9EP POMIT/SEPVICEDATE OISCMAPGEOATE 61LL�RTE OTPICXANGES 9yp�Ai�`oyE'
HARPE UDSON P H00051732875 04/12/74 4/18114 05/14/1 �ondnutd b o ll
VOVX iN5VP4NCE BENEi1�5 NAVE fiEEN p551GNE�i0 iHE HOSPITAL PN�WE XPV E FlLE�INSOPPNCE CLAIMS iO TNE COMiqNIE51NDILATEO. PqVMENTS W C W�ING
INSUPANCE WILL BE$MOWN ON VOVfl PCCOl1NT ONLV W NEN flKENE�. IF YOU XAVE pUESilONS ABOVT YOUP B0.1,PLEPSE CFLL iHE BUSINE55 OFFlCE AT I]19136Y)169.
�BL151NE55 MOVP$AqF B 00 PM i0 6'.00 PM MpNpAY�XPQU6X FPIDAYJ EMPLQVEfl I.O.NO.13-00859)0.
GLEASE BE AWAflE THAT MPNV pHY51UAN5 VqqQICING Fi THE CXAM9EPSBOflG ROSPRAL BILL$EPPqpiELY FOP THFq$EFVICES. IF VOU 11ECENE 4 SEPAflATE BILL,YOV
SHOOL�CONSIDEfl IT t0 BE FOfl YOVF PHYSICIAN'S PPOfE5510NPL SFflVICES PELATEO TO iHE HOSPIiACS iECHNICNL SEFVICES. ANV W ESTIONS PEW PDING THESE
91LLING5 MAY 9f�IPEREO TO TNE CHAMBEPSBOPG HOSGITACS BUSINE55OFFICE.
ummit_
� r,.,s.�..W,.
'=ham6ex��g_ DETAILED
vao e wa:n�re�o�s� BILL ,
C�amUe�sOurB.PA ���01
1)361J169
NT NAME
HARPER,JUDSON P
vnriErurxumeeR noMir�senvicEonrE vncE
H00051732675 04/12/14 2
HARPER,JUDSONP ea�onre oiscNnncsonrs
152 TIMBERLANE LANE OS114/14 04/16I74
SHIPPENSBURG PA 17257 ro,n�cNnnces qCC0UNT8ALAHCE
Continued
INSUflANCE COMPPNV I�ENtIFICATIONPOIICV NVMBEP
MA APP PENDING IBILLI YY4737��q
SUMMIT CARE 100% ZZq�3���y
' � •�• • �
CMAFGECODE/BpTCM • $EPViCE�RE •OESCPIFIION �TV AMOUNT
78000101 04/12/14 OHMINUTECHARGE-MAJON 198 70388.00
t8800002 04/12/14 ON/SDSPREP 1 608.00
16900081 04/12/14 Ofl DHP MAYO 89801 NC;MAVO STAND 7 3,Z5
78900217 04/12/74 DURAPREP SPoNGE DISP; DURA PHEP 8630 2 32.40
18900297 04/12/14 WRAP COBAN 4X5 1 9.00
18900937 04/12/14 JACKSON PNATT DNAIN 1 16.20
78910178 04/12/14 DNESSING %EPOFONM 5X9;%EROFOflM 5"X9" 1 4.00
18920370 04/12/14 Ofl SPONG 1/4 X 1/4 COD/KEND; SPONGE 1 33.50
18920475 04/12/14 FOHCEPS BIPOL CORD 12 FT; DISPOSABLE 3 48.80
1 B920677 04/t2/74 CLIP GUN NEURO CG8801 OMNI; CLIP GUN 5 555.00
18921168 04/'12/14 CLIP RANEY flEFILL CM8902 OMNI 1 88.00
18921228 04/72/14 TflAV CRANIOTOMV; CBANIOTOMV TRAV 2 614.00
18921812 04/12/14 SPONGE COUNTER BAGS 25-500;SPONGE 7 3.75
18921829 04/12/14 NEU MIDAS REX AM-8 7 198.00
" 18927887 04;7?;t4 9LD SURGICAL CLIPPEfl 4406 BAXT; BLADE 2 25.00
18927839 04/'12/14 DRAIN BARD WOUND 70740 GNENADE t 18.20
18922850 04/12/74 GELFOAM SRE 700; GELFOAM SIZE 100 3 738.20
'18923t82 04/'12/74 STAPLER PRO%IMATE SKIN PXW35; 3 61.50
18925052 04/12114 FRAZIEfl SUCTION 12 FH; FRAZIEH 1 8.65
t8925368 04/72/14 SCflEW LOW PIiOFILE SELF TAP 4MM 78 11850.30
18927733 04/12/14 14MH30 BURfl LEGEND MATCHHEAD; 1 270.83
t8927871 04/12/14 BURN LEGENO TAPENED 8CMX2.3MM: 1 188.30
18930152 04/12/14 427.522 CRANIAL PLATE 5 3899.30
57003725 04A2/14 XVLOCAINEI% EPI50MLVIAULIDOCAINE t 9.20
57000988 04/12/14 MEFOXIN 1GM/2ML INJ; cef0%ITIN 7,000 7 12.00
57003067 04/12/14 RECOTHHOM 200001U 20ML VIAL; THROMBIN 1 607.00
57000087 04/12/14 ANCEF/KEFZOL 1G/3ML INJ;cefAZOLIN 2 7.80
1,000 MG/3 ML VIAL
57007492 04/12/74 SOD CHLOfl BACTENIAL 30ML INJ; 7 3.80
570009BB 04/12/74 MEFOXIN iGM/2ML INJ; cefOXITIN t,000 1 12.00
57003125 04/12/t4 XVLOCAINE 1% EPI50ML VIAL' LIDOCAINE -1 -920
57000087 04/12/74 ANCEFIKEFZOL 1G/3MLINJ; cefAZOLIN 7 3.80
1,000 MG/3 ML VIAL
57007732 04/'12/14 VERSED SOMG/10ML INJ; MIDA20LAM 50 2 49.70
57001730 04/12/14 VENSED 2MG/2ML INJ; MIDAZOLAM 2 2 7.60
57000133 04/12/14 ATIVAN 2MG/ML INJ; LORAZEVAM 2 MG/ML t 3.80
vanervruaMc ennErvrrvuMeex qomir;scnvice onre oiscHancconre au�oa.e orn�cnnACEs e9Q;�E6D4e'
NARPE UDSON P H00057732675 04/12/14 4/18/14 OS/14/1 �O^��^� �
VOVfl INSVPRNCE BENEFIT$HAVE BEEN ASSIGNEO TO iNE HOSGITPL qN0 Wf XAVE FlLEO INSVPPNCE LLAIMS TO TNE COMPANIES INOICATEO. PAVMENT5INC W�ING
INSVflANCE W ILL BE$HO W N ON YOLfl ACCOONT ON V W HEN XECENE�. IF Y00 XAVE pVE5T10N5 qBOVT VOOP BILL�PLE/.SE CPLL TNE 6USW E55 OfFICE Ai�]t]�$BZ]189.
IBUSWE55 HOVP$PflE 8:00 PM TO 8 00 FM MONORV TMPOIIGX FPIOAV.)EMPLOYEq I D.N0.$S�6fi59J0.
PLEASE BE AWAPE THPT M<NV PHVSICIANS PPACTIPNG AT TXE CXAMBEPSBVPG XOSiITpL BILL SEPFPPiELY FOP THflq$EFVICES. IF VOV flECF VE A SEYqpqTE BILL Y00
SMOULO LONSIOEfl Ii T0 9E FOP YOUfl PMV5ICIPNS PXOFE5510NAL SEPVICES PELATE�TO TNE XOSPITACS iECMNILPL SEPVICES. PNV pVE5TI0N$PEGAPOING TMESF
BILLINGS MPV BE DIqERE�T0 THE CNPM9EflSBl1PG HOS%TAV 5 BUSW E$$OFFlCE.
umm�iL
� .r..a.�W,
'=ham6enburg_ DETAILED
'��� BILI
J60 E W as�inplon 5� .
C�am�ersWrB.PA >>�01
J]6T1169
Pn➢ENT NPME
HARPER,JUDSON P
A➢ENTNIIMBEP pOMiiSEflVICEOATE ppGE
H00051732675 04/12/14 g
HAHPER,JUDSONP eiuon*e oiscnnqceonre
152 TIMBERLANELANE 05I14/14 04/18/14
SHIPPENSBUflG PA 17257 ro.>ic�nxaes nceourvrea�nHce
ContinuM
INSVPANCE COMPANV I�EN➢FICPTIONIPOLICY NIIMBEP
MA APP PENDING (BILLI Zpq�3���q
SUMMIT CARE 100% ZZy�3���4
. � � . �. ,�. �
CHAfl6EL0�NBRCH SEPVICEOATE • •OESCPIFTION �TY PMOUNT
57000133 04/12/14 ATIVAN 2MG/ML INJ;LOFiA2EPAM 2 MGIML 'I 3.60
57001752 04/72/74 VITAMIN B-1 200MG/2ML INJ;THIAMINE 1 27,7p
200 MG/2 ML VIAL
57000733 04/72/14 ATIVAN 2MG/ML INJ; LOPA2EPAM 2 MG/ML 1 3.80
57000244 04/12/14 CAflDIZEM 25MG/5ML INJ; DIlT1AZEM 25 7 g,Zp
57002768 04/12/74 CARDIZEM100MG/700MLINJ; DILTIA2EM 7 y7,7p
100 MG/100 ML ADOVANTAGE
57000839 04/12/74 KCL 20MEU/700ML MINIBAG; POTASSIUM 1 '19.00
57001539 04/12/t4 SUBLIMAZE 100MCG/2ML INJ; FENTANYL 1 3.80
700 MCG/2 ML INJ.SOLN
57001115 04/'12/74 NEO-SVNEPHflINE 10MG/ML INJ; 2 24.00
57002533 04/12/14 MAGSULFATE/DSW7% 1G/100MLBAG; 1 g,2p
57000133 04/12/14 ATIVAN 2MG/ML INJ; LORAZEPAM 2 MG/ML 4 75.20
57000087 04/12/14 ANCEF/KEFZOI iG/3ML INJ; cefAZOLIN 1 3.80
1.000 MG/3 ML VIAL
57002533 04/12/74 MAG SULFATE/DSWt% 1G/'IOOML BAG; 1 9.20
57002893 04/12/14 ATIVAN 20MG710ML VIAL; LORAZEPAM 20 10 148.00
57002533 04/'12l14 MAG SULFATE/D5W7% 1G/'IOOML BAG; 1 9.20
57002893 04/12/14 ATIVAN 20MG/70ML VIAL LORAZEPAM 20 10 748.00
57003104 04/'12/14 OFIHMEV 7000MG/100ML IV; 1 40.50
57002334 04/t2/14 PqOTONIX 40MG INJ; PANTOPFAZOLE 1 12.00
� 57000878 04/12/14 LANO%IN .5MG/2Ml INJ: DIGOXIN 0.5 1 8.50
57007115 04/12/14 NEO-SVNEPHRINE 10MG/ML INJ; 8 98.00
t 5050018 04/12/74 qOOM &BOARD CHITICAL CANE; ROOM 1 3378.00
1123/CCU
50700011 04/72/74 BIOODTVPEABO 1 49.00
50700072 04/12/14 BLOOD TVPE, RH�D� 1 79.00
50700005 04/12A4 AB SCPEEN RBC 1 69.00
50900010 04112/14 VENIPUNCTURE -CHHOSP 7 ig,pp
50800504 04/12/74 BLOOD GASES 1 230.00
50801206 04/12/14 DRUG SCflEEN 11 PANEL 1 'I60.00
50800100 04/t2114 CXEATINEKINASE,TOTAL 1 t30.00
50B00107 04/12/14 CREATINE KINASE, MB FRACTION 1 257.00
50800230 04/12/14 TAOPONIN, QUANTITATIVE 1 198.00
50801185 04/12/14 NATqIUREfIC PEPTIDE 1 393.00
50600172 04/72/14 MAGNESIUM 1 108.00
PF9ENiNAME PqTIENTNUMBEfl qpMR/SEPNCE �ATE �ISCN4PGE�ATE BILLOATE OTpICNqqGES B'AL(�NQ�UI�E'
HARPE UDSON P H0o051732675 04I12/�4 4/78/74 OS/14/1 �oittinued 6�4o O
VOUF INSVPqNCE BENEFIT$HPVE BEEN ASSIGNEO TO TXE MOSPITAL ANO WE HPVE FRE�IN W flANCE CLFIMS TO THE COMPAMES INDICFTEp. YqYMENT5INCLVOMG
INSUF>NLE WILL BE$HOWN ON YOVP ACCOVNi ONLV WXEN flECENEO. IF VOV XAVE OIIf5TI0N5 ABOUT YOVP 91LL,PLEPSE CPLL TME BUSME55 QFFlCE RT IJt]1009-01 B9.
IBUSINE55 HOVIiS AflE B 00 AM LO B:00 PM MON�AV TNPOUGH FPIpAVJ EMPLOVEfl ID.N0.$3�0<659J0.
PLEASE BE AW LPF THAT MANV GMVSCIANS PPACiICING FT TXE CXAMBEPSBOPG HOSPITAL BILL SEPAPATELV FOfl THFfl$EPVICES. IF VOO PECF VE A SEPAPATE BILL VOV
$HOIILD CONSIDEfl IT TO BE GOP YQOfl PMYSICIAN'S YPOFESSIONRL SEflVILES PELATE�t0 TXE XOSPRRL'S TECHNICAL$EPVICES. ANY�V ESi10N5 flEGAF0ING TMESE
BILLINGS MAV 9F DIPfCTED T0 TNE CNAMBEP58VFG HOSYRACS BOS W E55 OFFlCE.
ummxt-
� ,..Wd,m.,.�"
'=hambe�y�_ DETAILED
�eoewasm�g,o�si BILL .
C�amEersOwg,Gq q]01 �
)1J 38]J189
CPTENT NPME
HARPER,JUDSON P
PATIENTNVMBEfl pOMIflSEPNCEOPiE ppGE
H00051732675 04/12/14 4
HARPER,JUDSON P eaionre oiscNaAcsoare
752 TIMBEHLANE LANE 05/14I74 04/18/14
SHIPPENSBURG PA 17257 .orn�cHancss ACCOUNTBALANCE
ConNnued
INSVFf�NCE COMppNV i�ENTIFlCRTIONiPOLICV NVM9EF
MA APP PENDING IBILLI 224137774
SUMMIT CANE 700% 224737774
. •• •�• • •
CXPPGECO�E/BALCM SEflVICE�AiE OESCPIWION OTY AMOUM
50900010 04/12/14 VENIPUNCTUFE -CH HOSP 1 19.00
50800001 04/'12/14 BASICMETABOLPANEL 7 iZ7,pp
50800259 04/'12/14 PNOTHNOMBIN TIME 1 50.00
50800283 04/12/14 PAHTIAL THflOMBIN TIME 1 64.00
50801187 04/72/74 F.D.P. D-DIMER�UANT 1 150.00
50800254 04112/74 FIBRINOGEN QUANT 1 178.00
50800100 04112/14 CREATINE KINASE, TOTAL 1 130.00
50800230 04/12/t4 THOPONIN, QUANTITATIVE 1 198.00
50900010 04/12/14 VENIPUNCTUflE-CHHOSP 7 19.00
50800246 04/'12/74 CBC AUTOMATED W/AUTO DIFF 1 80.00
50800101 04/'12/14 CREATINE KINASE, MB FRACTION 1 257.00
50800408 04/12/74 UPINALVSIS WRH MICPO 7 65.00
50300016 04/i2/14 CULTURE,URINE 7 53.00
53071012 04/12/14 NAD CHEST 1 VIEW VOHTAB�E 1 331.00
58000023 04l18174 ELECTpOCARDIOGRAM �ECGI CH 1 253.00
58100007 04/12/14 PGECG NEAD CH 1 87.00
'16830075 04/'12/14 400.833 SCNEW SLF DRILLING;SVNTMES 1 B '1778.00
t8930582 00/12/14 427.521 PLATE LP BOX 4H 10%78; 7 335.00
421.527 PLATE LP BO%4H 10X76; 1 335.00
1900000t 04/12114 ANESTHESIA SUPPLIES 1 ST HOUfl 1 757.00
19000002 04/12114 ANESTHESIA SUPPL EA ADD 1/2 HR 5 365.00
50700045 04I72I74 IMMED SPIN CROSSMATCH 2 286.00
54000075 04/13/74 VENTILATOH MGMT-SU9SEQUENT DAV � 1 1271.00
54000090 04113/14 CAPNOGflAPHY 1 88.00
18910802 04I73/14 9395108�POWER PICC SOLO CATH 1 389.00
12500002 04113/14 PICC IINE INSENTION >5 VRS OLD 7 t668.00
56000090 04/13/14 CAPNOGIIAPHV 7 68.00
57002788 04/t3/14 CAPDI2EM t00MG/100ML INJ; DILTIA2EM 1 21.10
100 MG/100 ML ADDVANTAGE
57002362 04/13/14 SUBLIMAZE 2500MCG/SOML INJ; FENTANYL 1 t2.00
2.500 MCG/50 ML VIAL
57000517 04/13/14 DIPflIVAN 1000MG/t00ML VIAL; PqOPOFOL 1 40.00
'I,OOO MG/100 ML VIAI �
57001539 04/13/74 SUBLIMAZE 700MCG/2ML INJ; FENTANYL 1 3.80
100 MCG/2 ML INJ.SOLN
57002766 04/13114 CAHDIZEM t00MG/100ML INJ; OILTIAZEM 1 27JO
PqTIENT NAME PqTIENT NOMBEH qOMR/$EPNCE OAiE �15CXAXGE OPTE 91LL�ATE pTAt CXAPGF$ �� H E 0 E
HARPE UDSONP H00057732875 04/72/14 4/78/14 05/74/7 �ondnued 9�1�46.51
VOVfl INSUXANCf 9ENEFliS XAVE BEEN ASSIGNED TO TXE MOSPITAL ANO WE HAVE FlLE�INSl1PRNCE CLAIMS TO THE COMPAWES IN01[REO. PAVMENTS INCLII�ING
INSVPPNCE W ILL Bf SXO WN ON VOVP ALLOLIM ONLY W HEN PECENEO. IF YOU MAVE�LIESLIONS P90UT YOUX BILL PLEASE GLL THE fiV51NE55 OFFlCE PT IJI JI 061-J189.
IBUSiNE55 XOVflS AflE B'00 FM TO 6�D0 PM MONOAV THPOVGH FPIOAYJ EMPLOYEP I.O.NO.]3 O<85910.
PLEPSE BE AWAPE THAT MANV PMYSICIPNS PPACTICIN6 PT THE CMRM9EP59UPG HOSPITSL BILL$EPpPqiFLV PoP LMFP SEPVICES. IF YOU XECENE P SEP4FATE BILL�v00
SMOULO CONSIOEP IiTO BE FOX VOUP PNYSICIAN'S GPOFESSIONAL$EflVICES PELATE�TO LNE NOSYRALS TECXNIGL SEPV ICES. ANV QUESiIpNS PEGAfl01NG THESE
91LLING$MAV BE�IPfQE�TO TME CHAMBEflSBUPG NOSPIT4C5 BUSME55 OFFICE.
�ummit_
- "'u:
Cham6ers6urg. DETAILED
'� .��'= BILL
]fi0 E Was�lrpmn S[ '
Chamben0ur9.PA Rd01
J26]J189
PAiiENT NPME
HAFlPER.JUDSON P
P➢ENT NUMBEP IiiSEPVICE�PiE pqGE
H00051732675 p�M04/12/74
HARPER,JUOSON P eiuon*e oiscnnxveoare
152 TIMBERLANELANE 05/14/14 04/78/14
SHIPPENSBURG PA 17257 rorn�crnnccs PCCOVNTBALANCE
Condnued
INSVXNNLF COMPANV I�ENTFlUTION/POLiCV NUMBEP
MA APP PENDING �BILLI Zpq�3���q
SUMMIT CAflE 100% Zyq�3���q
�. .�• � �
CHPflGECODEiOATCX ♦$EPVICE�ATE •pESCPIMION aTY PMOVNT
'100 MG/100 ML ADDVANTAGE
5700t752 04/73/'14 VRAMIN B-1 200MG/2ML INJ;TMIAMINE 1 2'1,ip
200 MG/2 ML VIAL
57002334 04/73/14 PFOTONIX 40MG INJ; PANTOPRAZOLE 1 12.00
57007775 04/13/14 NEO-SVNEPHRINE 10MG/MLINJ; 8 98.00
57000577 04/13/14 DIPNIVAN 1000MG/100ML VIAL; PNOPOFOL 1 40.00
1,000 MG/100 ML VIAL
57002768 04/73/74 CARDREM 100MG/700ML INJ: DILTIAZEM 1 21.10
100 MGI700 ML ADDVANTAGE
57003104 04/13/14 OFIPMEV 1000MG/100ML IV; 1 40.50
57003043 04/73/14 ROCEPHIN iGM/70ML INJ; cafTRIA%one 1 14.60
1,000 MGl4 ML VIAL
57002382 04/73/74 SVBLIMAZE 2500MCG/50ML INJ; FENTANVL 1 72.00
2.500 MCG/50 ML VIAL �
57002334 04/13/14 PROTONIX 40MG INJ; PANTOPRAZOLE 7 12.00
67002768 04li3/14 CARDIZEM700MG;iJOMLiNJ: DILTIA2EM 7 21.10
100 MGI100 ML ADDVANTAGE
570005t7 04/t3/74 DIPflIVAN 1000MG/100M1 VIAL; PPOPOFOL 1 40.00
7,000 MG/700 ML VIAL
57003704 04/t3/14 OFIRMEV t000MG1100ML IV; 1 40.50
15050016 04/13/74 ROOM & BOARD CflITICAL CARE; NOOM 1 3378.00
1123ICCU
50800001 04/73/14 BASIC METABOL PANEL 1 121.00
50800772 04/13/16 MAGNESIUM ' 1 108.00
50900010 04/13/14 VENIPUNCTURE -CH HOSP 1 19.00
50800248 04/13l14 CBC AUTOMATED W/AUTO OIFF 1 80.00
50800504 04/13/14 BLOOD GASES 1 230.00
50300003 04/73/74 CULTUHE, BLOOD 1 175.00
50300003 04/13/14 CULTURE, BLOOD 1 175.00
536]0450 04/73/14 CT HEAD WO 7 7888.00
54000090 04/14/74 CAVNOGRAPHV 1 88.00
54000075 04/74/14 VENTILATORMGMT-SUBSEQUENTDAV 1 7271.00
54000090 04/14/14 CAPNOGRAPHV . 7 68.00
54000090 04/14/74 CAPNOGRAPHV 1 68.00
57000517 04/14/14 DIPFIVAN 1000MG/t00M1 VIAL; PNOPOFOL 1 40.00
1,000 MGI700 ML VIAL
57001752 04/14/14 VITAMIN B-7 200MG/2ML INJ; THIAMiNE 7 21.10
>nnEurNaMc vanenrrvuMeea noMirisEAvicE onre oiscHAr+ccoare eaionrE orn�cHAaces e9tp���4e'
HARPE UDSON P H0005n32875 a4/72/t4 4/�e/'l4 0517411 �O^�^O� d �
VOUfl INSVPANLE BENFFRS MAVE 9EEN ASSIGNEO TO TNE XOSGITqL qN�W E XRVE FlLE�INSOflANCE CLAIMS TO THE COMPANIR INOICATED. PAYMENTS INC W OING
INSIIPANCE W ILL 6E SHO W N ON VOUP ACCOUM ONLV W MEN NELflVEO. IF VOU HAVE pVE5T10N5 ABOVT VOVX BILL,PtEASE CALL iHE BUSINE55 OFFlCE AT Ol)I IBI�II89.
�BVSINE55 MOlIPS PPE B'00 RM TO 6:0�PM MON�AV TMPOIIGM FPIOAV 1 EMPLOVEP I D.N0.3]�09859]0.
PLETSE BE PW AflE TXAT MANY PMVSICIANS PPACiICING Ai THE CNPMBEPSBOPG MOSVITAL BILL SEVPPPTELV GOX TMEIX SEPVICES. IF VOV PECEIVE<SEP>FRE BILL,VOV
SHOVL�CONSIOEPITT06E(OPYOUflPMV51CIPN'SPflOFf5514NAL5EflV2E5PELATEOTOTHEMpSPITAVStECNNICPlSEPNCES. FNVpUE5T10N5PEGAPOINGTXESE �
BILLING$MqY BE OIFEQE�TO TXE CXAMBEPSBUflG NOSPITACS BUSW E55 OFFICF.
ummit_
� ,.,....�w..
�Chambenburg. DETAILED
� _ �a���
�soewa.nms�a�s� BILL .
cnamee�:e�,a.Pe nzo�
]I>]fiJ-0169
PATENT NFME
HARPER,JUDSON P
PATENT NIIMBEfl ppMITiSEPVICE�PTE pqGE
H00051732675 04/12/14 g
HARPER,JUDSON P eiu oare oisc�nAce oare
152 TIMBENLANELANE 05114/14 04/18/14
SHIPPENSBURG PA 17257 .arn�cHances accouxren�ar�ce
ConNnued
INSVPANCE COMPPNV IpENTfICPTIQN/POLICY NVMBEP
MA APP VENDING �BILLI 224137774
SUMMIT CAflE 100% yyq�3���q
� � , �„�, �
CXAPGE COOEIBAiCN • SEPVICE�AiE OESCPIPTION �tV RMOUNT
200 MG/2 ML VIAL
57002334 04/14/74 PHOTONIX 40MG INJ: PANTOPRAZOLE 1 12.00
57003043 04/14/14 pOCEPHIN 1 GM/10ML INJ; ca/TRIAXone 1 t4.60
7,000 MG/4 ML VIAL
57003104 04/14/14 OFIRMEV 1000MG/100ML IV; 1 40.50
57000577 04/14/14 DIPflIVAN 1000MG/100ML VIAL; PflOPOFOL 1 40.00
1,000 MG/100 ML VIAL
57002334 04/74/74 PROTONIX 40MG INJ; PANTOPqAZOLE 1 12.00
53670450 04/14/14 CT HEAD WO 1 7888.00
7 5050016 04/14/14 pOOM & BOAflD CRITICAL CARE; ROOM � 1 3376.00
1123/CCU
50800001 04114/14 BASIC METABOL PANEL 1 121.00
50800172 04114114 MAGNESIUM 1 108.00
50800246 04114/14 CBC AUTOMATED W/AUTO DIFF 1 B0.00
50600163 04/74I74 LACTIC ACID 1 179.00
50800184 04/74174 OSMOLAIfTV. BLOOG 1 98.00
50800504 04/14114 BLOOD GASES 1 230.00
50800747 04/14114 METHEMOGIOBIN. QUANT 7 98.00
51600007 04/74174 L/p flED CELLS PROC FEE APC . 1 580.00
51800007 04/14I74 L/R qED CELLS PROC FEE ARC 1 580.00
50900010 04/14114 VENIPUNCTURE-CH HOSP 7 19.00
50800248 04/74174 CBC AUTOMATED W/AUTO DIFF 1 80.00
54000090 04/15/14 CAPNOGHAPHV 1 88.00
54000015 04/t5/74 VENTILATOfl MGMT-SUBSEQUENT DAV 1 1271.00
54000090 04/'15/14 CAPNOGNAPHV 1 88.00
54000090 04/15/t4 CAVNOGNAPHV 1 68.00
54000080 04/15/14 CAPNOGflAPHV 1 88.00
5]003104 04/15/14 OFIRMEV 7000MG/100ML IV; 1 40.50
57001752 04/7 5/14 VITAMIN B-7 200MG/2ML INJ;THIAMINE 1 21.10
200 MG/2 ML VIAL
57003104 04/i5114 OFIRMEVt000MG/700MLIV; 7 40.50
57002334 04/15174 PNOTONIX 40MG INJ; PANTOPRA20LE 1 72.00
57003043 04/15/14 ROCEPHIN tGM/70ML INJ; cetTRlAXona 1 14.80
'I,000 MG/4 ML VIAL
57003104 04/15/14 OFIRMEV 1000MG/100ML IV; 7 40.50
57002334 04/t 5/14 PROTONIX 40MG INJ: PANTOPflAZOLE 1 '12.00
PATIENTNPMf PqTIENTNUM6EP A�MITSEPVICE �RE DISCMPPGEOATE 91LLDATE OTPLCXAPGES 9�(�'�(o4E'
NARPE UDSON P H00057732875 04/72/14 4/18/t4 05/t4/t �0���^�� 6 a O
VOVfl W SVPANCE BENEFlT$HPVE BEEN ASSIGNEO TO TXf XOSPITPL 4N�W E XAVE FlLEO INSVNFNCE CLAIMS T0 THE COMGPW ES INpICATEO. PRVMENTS INCLVOING
INSUPANCE WILL BE$HOWN ON YOOfl PCCOVNT ONLV WXEN PECENE�. IFVOU MME QUESTION$R60UT VOUfl BILL plEASE CALI iHE fip5ME55OFFlCE Ai�Jt]13B]]I09.
IBUSINES$HOUN$AflE 9:00 AM TO B'.00 PM MONDAM iMPOUGH FPI�PVJ EMPLOYEfl I,p.N0.230G959]O.
PLEPSE BE AWANE THPT MANY PHYSIPANS YPACTICING AT THE CHAM9EPSBVPG MOS%TqL BILL SEPPPREV FOP LHHP SEPV ICES. IF YOV PECF V E P SEPAPPTE 6iLL,VOV
$M Wl�CONSIDEX IT TO BE FOP VOVfl PHYSPAN'S PflOFE5510NAL$EflV ICE$PELAiEO TO iHE XOSPITACS iEMN6AL SEPV ICES. ANV W ESilONS PEGFPOING THESE
BILLING$MPV BE DWECTE�TO THE CHPMBEfl59Ufl6 HQSPITAL'S BUS W E55 OFRCE.
ummif_
� �..Wo.�..,.
'=hamb��urg_ DETAILED
,saEwa,�,�,o�:� BILL .
LM1am�er5awg,PP 1)I01
J36JJ169
PPENiNPME
HARPER,JUDSON P
>nnerv.rvuMeEA noMirreEA�nce oare pqcE
H00051732675 04/12/14 �
HARPER,JUDSON P an�onre oiscNaqceoarE
152 TIMBERLANE LANE 05/14/14 04I78/14
SHIPPENSBURG PA 17257 rora�cnnAces pcwurvreninrvee
GonNnued
iNSUXANCE COMPPNV IOENTIFlUTION;POLICV NVMBEfl
MA APP PENDING (BILLI ZZ4�3���4
SUMMIT CARE 100% Z24�3���4
� �. .�.
CHPRGECODE/BATCM SfPVICEDATE •pESCPIPiION QTV AMOUNt
57000443 04/15/74 DECADPON/HEXADflOL 10MG/MLINJ; 1 6.50
57002818 04/15/14 KEPPRA 500MG/SML INJ: IevETINACETAM $ qZ,2p
500 MG/5 Ml VIAL
50800001 04/15/14 BASIC METABOL PANEL 7 72�.pp
50800772 04/15/14 MAGNESIUM 7 708.00
50800246 04/75/74 CBC AUTOMATED W/AUTO DIFF 7 80.00
50800183 04/15/74 LACTIC ACID 1 779.00
50800784 04/15/14 OSMOLALITV, BLOOD 7 gg,pQ
50800504 04/15114 BIOOD GASES 1 230.00
50300023 04/75/74 GRAM STAIN 1 37.00
50300071 04/75114 CULTUNE, SPUTUM 1 181.00
53071012 04/15/14 RAD CHEST i VIEW PORTABLE 1 331.00
15050078 04/15/14 ROOM & BOARD CRITICAL CARE; ROOM 1 3378.00
11231CCU
50300041 04/15/14 AENOBIC ISOLATE ADD'L METHOD 1 53.00
50300051 04/15114 SENSITIVITV;MIC 1 53.00
18900544 04/15/74 TPAV FICC DRESSING 7 7g,Zp
78910420 04/75/14 STATLOCK VICC PWS SLIDNG POST 1 1810
54000015 04/i6/14 VENTILATOR MGMT-SUBSEQUENT DAY 1 1271.00
54000090 04/16/14 CAPNOGRAPHY 1 68.00
54000090 04/'I6/14 CAPNOGRAPHV 1 88.00
54000090 04/18/14 CAPNOGRAPHV 7 5g,pp
54000090 04/i6/14 CAPNOGRAPHV 1 68.00
57000443 04/i6/14 DECADNON/HEXADflOL 10MGIML INJ; t 6.50
57000443 04/18/14 DECADRON/XE%ADflOL 70MG/MLINJ; 1 6.50
5�002334 04/i6/14 PROTONIX 40MG INJ; PANTOPRA20LE 1 12.00
570028t8 04/18/14 KEPPRA SOOMGI5ML INJ; IevETIRACETAM 1 q2,Zp
500 MG/5 ML VIAL
57001752 04/18/14 VITAMIN B-7 200MG/2ML INJ;TNIAMINE 1 27,ip
200 MG/2 ML VIAL
57003104 04/i6/74 OFIRMEV 1000MG/100ML IV; 1 40.50
57000443 04/18/14 DECADRON/HEXADROL 10MG/ML INJ; 1 8.50
57002382 04/1fi/14 SUBLIMAZE 2500MCG/50ML INJ; FENTANVL 1 12.00
2,500 MCGI50 ML VIAL
57000443 04l'I6/14 DEGADNONMEXADROL 10MG/ML INJ; 1 6.50
57002334 04/16114 PHOTONIX 40MG INJ;PANTOPIiA20LE 1 12.00
PATIENINPME pqTIENiNVMBEfl A�MR/SEflVICE �AiE �ISCHAPGEOFTF 91LL�ATE OTALCMPPGES BALPN EOqE
NARPE UDSON P H00051732875 04/t2/14 4/18/14 05/14/1 �ontinued 961�6.01
YOUP INSIIflANCE 9fNEfITS XAVE BEEN ASSIGNEO TO TXf XOSPITAL AN�W E MPVE FlLE�INSIIPANCE CLAIM$TO TXE COMPANIES INpICRiE�. PPVMENT$WCLU�ING
INSUXANCE WILL BE$XOWN ON YOUP PCCOUM ONLY WXEN flECflVE�. If VOV XAVE pVE5T10N5 PBQOi VOOfl BILL,PLEASE GLL iHE BVSINE55OPFlCE Pi V1JI 1BJJ189.
IBVSME55 HOVF$APE 8 OQ PM i0 8'00 GM MON�PV iHflOVGH FPIOPVJ FMPLOVEP I.O.N0.E3 OCfi59]0.
PLEASE BE AWPPE TXPT MANV PHVSILIPN$iPACTICIN6 4T iHE CHPMBEP56UPG MOSPITAL BILL$EPPqqTELY FO5 THFP$EP VICFS. IF VQU PECENE A$EPPPPiE BILL YOLI
SHOI1l0 CaN51�EP li i0 9E FOP VOIIF PXVStlPNS PPOGESSIONAL SEPVICE$PELAiED TO iHE NOSPItACS TELMNICAL SEPNCES. ANY pVE5TI0N5 flEGAP0ING THESE
61LLINGS MAY BE�IPECiEO i0 TFE CHAMBEPSBVflG MOSPITRCS BVSMESS OfFlCE.
U/Yl�/��
� mwd��.
'=ham6�rsburg_ DETAILED
� � BILL
J60 E W aSMng�on 5� '
C�emOarsburB.P� �>�O1
)t>i6Tn69
PAiIENT NPMF
HARPER.JUDSON P
YqTEM NIIMBEF li/SEflVICE DATE pqGE
HARPER,JUDSON P H00051732675 p�M04/12/1q g
BILLOFTE OISCHAqGEOqTE
152 TIMBERLANE LANE 05114/14 04I78/14
SHIPPENSBURG PA 17257 .o*a�cHaacEs ACCOUNT BALqNCE
Continued
INSUFNNCE COMPRNV IOENTFlCATION�POLICY NVMgEfl
MA APP PENDING (BILLI Z24�3���4
SUMMIT CAHE t00% Z24�3���4
�• ��• •
CNAflGECOOEiBPTCH , $EPVICE�RTE • •pESCPIPi10N �TV PMO�NT
57002818 04/18/14 KEPPRA SOOMG/5ML INJ: IevETINACETAM p qZ,pp
500 MG/5 ML VIAL
57003043 04/18/14 ROCEPHINiGM/10MLINJ; cefTRlAXone 7 iq,5p
1,000 MG/4 ML VIAL
57002382 04/18/74 SUBLIMAZE 2500MCG/50ML INJ; FENTANVL 7 12.00
2,500 MCG/50 ML VIAL
50800246 04/i6/14 CBC AUTOMATED W/AUTO DIFF 1 60.00
50800783 04/18/t4 LACTIC ACID 7 779.00
50800172 04/18/14 MAGNESIUM 7 108.00
50800184 04/18/74 OSMOLALITY, BLOOD 1 98.00
50800504 04/'I6/14 BLOOD GASES 1 230.00
53033130 04/18I'14 qAD HAND MIN 3 VIEWS LT 7 403.00
53043130 04I76/t4 HAD HAND MIN 3 VIEWS NT 1 403.00
53033000 04/78/14 FAU CLAVICLE COMP LT 7 qp�,pp
53043000 04/i6/14 RAD CLAVIGLE COMP qT 1 401.00
53077075 04/16114 RAD BONE SUHVEY COMG 1 1328.00
53870450 04/'16114 CT HEAD WO 1 1888.00
53070250 04/18114 flAD SNULL < 4 VIEWS 1 524.00
53070250 04/18/74 qAD SNULL < 4 VIEWS -1 -524.00
15050016 04/i 6/14 HOOM &BOAND CNITICAL CARE; NOOM t 3376.00
1123/CCU
54000015 04/17/14 VENTILATOR MGMT-SUBSEUUENT DAV 1 1271.00
54000090 04/17I74 CAPNOGPAPHV 1 68.00
54000090 04/17I74 CAPNOGHAPHV 1 68.00
57000443 04/17/14 DECADflON/HEXADROL 10MG/ML INJ; 7 6.50
57000443 04/17/14 DECADNON/NEXADHOL 10MG/ML INJ; 1 6.50
5]001752 04/17I74 VITAMINB-7200MG/2MLINJ;THIAMINE 1 21,'Ip
200 MG/2 ML VIAL �
57002334 04I77/14 PROTONIX40MGINJ;PANTOPRAZOLE 1 72.00
57002B78 04/77/14 KEPPNA SOOMG/5Ml INJ;IevETIRACETAM 2 q2,2p
500 MG/5 ML VIAL
5700'1034 04/'17114 MOF7HINE 2MG/ML INJ; MONPHINE 2 2 13.00
57007034 04/t7114 MORPHME 2MG/ML INJ; MONPHME 2 1 6.50
57007034 04I77/14 MONPHINE 2MG/ML INJ; MORPHINE 2 1 8.50
5700'1034 04/17/14 MORPHINE 2MG/ML INJ; MORPHINE 2 7 6.50
57007034 O4/17/74 MORPHINE 2MG/ML INJ; MORPHINE 2 7 8.50
PAPENTNPME pAiIFNTNOMBEP pOMIT/$EPVICEDAiE �ISCXAXGEpATEBILL�ATE OTALCMAP6E5 BA�pNCEDE
HARPE UDSON P H00051732875 04/12/14 q/7g/iq QS��q�� �ontfnued 96146.�1
YOVP INSVNANCE BENEFlTS XAVf BEEN q551GNE�TO TNE HOSPITAL FNO W E MFVE FILEO INSIIPANCE CLAIM$TO iXE COMPANIES IN�ICATE�. PAYMENTS INCLUOING
INSUPPNCE WILL BE SXO W N ON YOI:fl PCCOVNi ONLV WHEN PECENED. IF VOV XAVE QVESTIONS PBOUt VOUF BILL PlEPSE CPLL TXE BIISINESS OFRCE AT pl J128JJ199.
IBOSNE55 MOVPS AflE 8'.W FM TO 8:00 GM MONOAV iHPOVGX FNIOFVJ EMGLOVEX I 0.N0.33 OOB59)0.
GLEPSE BE AWPFE iHFi MANV PXVSiCIqNS PPARICING PT TXE CXAMBEPSBUFG MOSPIT4L BILL SEGAPPiELY iOF TNEIP SEPVICES. IF VOU PELfl V E P$EPAPPiE BhL VOV
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57001034 04/17/14 MORPHINE 2MG/ML INJ; MORPHINE 2 1 8.50
57001034 04/17/74 MORPHINE 2MG/ML INJ; MORPHINE 2 7 g,5p
t 5050018 04/17/14 ROOM &BOAND CflITICAL CARE; POOM 1 3376.00
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50800163 04/17/74 LACTIC ACID 7 pg.pp
50800504 04/17/14 BLOOD GASES 1 230.00
50900147 04/17/14 METHEMOGLOBIN,QUANT � 1 98.00
57002382 04/18/14 SUBLIMA2E 2500MCG/50ML INJ;FENTANVL 7 72,pp
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57000503 04/18114 DILANTIN 250MG/SML INJ; PHENVTOIN 4 26.00
250 MG/5 ML VIAL
57001034 04I78/14 MONGHINE 2MG/ML INJ; MORPHINE 2 1 8.50
57001034 04/78/14 MORPHINE 2MG/ML INJ; MORPHINE 2 1 6.50
57007034 04/18/14 MORPHINE 2MG/ML INJ; MOpPHINE 2 1 6.50
57007034 04/78/14 MORPHINE 2MG/ML INJ; MORPHINE 2 1 8.50
••• SUMMARV BV SERVICE `••
200 INTENSIVE CARE GENEHAL 8 20258.00
250 PHAflMACY GENERAL 2 604.80
270 M/S SUPPLV GENENAL 45 2577.83
272 M/5 SUPPLY STEHILE SUPPLY 2 405.20
278 M/S OTMER IMPLANTS 41 17995.80
300LABOFATOflY GENERAI 77 t085.00
301LABOflATOflY CHEMISTflY 36 5768.00
302 LABORATOflY IMMUNOIOGV 2 288.00
305 LAB HEMATOLOGV 8 554.00
306 LAB BACTEflIOLOGV/MICROBIO 7 727.00
30] LAB UROLOGV 1 65.00
3201iAUlOLOGV DIAG GENEFAL 8 3929.00
351 CAT SCAN HEAD 4 7544.00
352 CAT SCAN BODV 1 2026.00
360 OR SVCS GENERAL '198 13369.00
370 ANESTHESIA GENEflAL 6 1122.00
390 BLO00 STOR/PROC GENERAL 2 1180.00
410 HESPIRATORV SVC GENERAL 8 8327.00
450 EMERGENCV ROOM GENERAL 3 2523.00
480 PULMONARV FUNCTION GENEBAL . 15 1020.00
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787 TNEAT/OBS RM TREATMENT RM 7 1668.00
771 PNEVENTIVE CAflE VACCINE 7 72.00
981 PflOF FEES EMERGENCV NOOM 1 564.00
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