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Home My WebLink About05-29-15 1505610140 REV-1500 EX 101-10' PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Number PO BOX 280601 2 1 1 4 0 1 0 3 2 Harrisburg,PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 0 9 2 0 2 0 1 4 0 9 1 3 1 9 4 8 Decedent's Last Name Suffix Decedent's First Name MI F A H N E S T 0 C K J A M E S R (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW Q 1.Original Return ❑ 2.Supplemental Return ❑ 3.Remainder Return(date of death prior to 12-13-62) ❑ 4.Limited Estate ❑ 4a.Future Interest Compromise(date of ❑ 5.Federal Estate Tax Return Required death after 12-12-82) ❑ 6.Decedent Died Testate ❑ 7.Decedent Maintained a Living Trust ._ 8.Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) ❑ 9.Litigation Proceeds Received ❑ 10.Spousal Poverty Credit(date of death ❑ 11.Election to tax under Sec.9113(A) between 12-31-91 and 1-1-95) (Attach Sch.O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number D 0 U C L A S G M I L L E R 7 1 7 2 4 9 2 3 5 3 REGISTER 05 WILLS USE ON.L C cin 70 First line of address -� I R W I N & M c K N I G H T P - .0 Second line of address ; ''r C-0 6 0 W E S T P 0 M F R E T S T R E E T City or Post Office State ZIP Code DATE FILED C A R L I S L E P A 1 7 0 1 3 _ t, M Cfl Cn ed Correspondent's e-mail address: Under penalties of perjury,I declare that 1 have examined this return,Including accompanying schedules and statements,and to the best or my knowledge and belief, It is true,coof preparer other than the personal representative Is based on all Information of which preparer has any knowledge. ect and complete.D laretio SIGMA O S FOR FILING RETURN DAT �. RESS DRED HEIGHTS ROAD ELDRED NY 12732 SIGN AT OFPPARE TM TH EPRESENTATIVE AT ADDR S 60 WE S POMFRET STREET CARLISLE PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610140 1505610140 1505610240 REV-1500 EX Decedent's Social Security Number Decedent's Name: JAMES R. FAHNESTOCK RECAPITULATION 1. Real Estate(Schedule A) .. ...... .... .. .... .. . . . . .... .. .. . . ....... . . 1. 1 7 5 0 0 0 . 0 0 2. Stocks and Bonds(Schedule B) .. ... .... . . .... .. .. .. . .. .. . .... . ...... 2• ' 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ... .. 3. 4. Mortgages and Notes Receivable(Schedule D) .. . .. .... . . . .. . . ... . ... . . . 4. 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E). . . ... . 5. 2 6 5 6 1 . 1 6 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested .... .. . 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) ❑ Separate Billing Requested .. . . .. . 7. 8. Total Gross Assets(total Lines 1 through 7) ... . . ........ ... .... . . ..... 8. 2 0 1 5 6 1 . 1 6 9. Funeral Expenses and Administrative Costs Schedule H 9. 4 0 5 2 5 . 8 2 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) .. .... . . . . . .. 10. 1 5 8 1 3 2 . 4 8 11. Total Deductions(total Lines 9 and 10) .. .. . .. . .. ...... .. ....... ...... 11. 1 9 8 6 5 8 . 3 0 12. Net Value of Estate(Line 8 minus Line 11) ... . . ....... . ... . . . . .. ... . . . 12. 2 9 0 2 . 8 6 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) .. . . . .. . .. . . .... .... .. 13. 14. Net Value Subject to Tax(Line 12 minus Line 13) .. . . . . . . .. . . ....... . .. 14. 2 9 0 2 . 8 6 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.0 _ 0 . 0 0 15. 0 . 0 0 16. Amount of Line 14 taxable at lineal rate X.045 2 9 0 2 . 8 6 16. 1 3 0 . 6 3 17. Amount of Line 14 taxable at sibling rate X.12 0 . 0 0 17. 0 . 0 0 18. Amount of Line 14 taxable at collateral rate X.15 0 . 0 0 18. 0 . 0 0 19. TAX DUE . .... .. . ... .... ... ... . .. . ...... . . .... . . . . . . . . . .. .. . .. . 19. 1 3 0 • 6 3 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑ Side 2 L 1505610240 1505610240 Decedent's Complete Address: 21 14 01032 DECEDENT'S NAME JAMES R. FAHNESTOCK STREET ADDRESS 9 WATSON DRIVE CITY STATE ZIP CARLISLE PA 117015 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 130.63 2. Credits/Payments A.Prior Payments B.Discount Total Credits(A+B) (2) 0.00 3. Interest (3) 4. If Line 2 is greater than Line 1+Line 3,enter the difference.This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00 5. If Line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 130.63 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; ...................................................................... ❑ FX TI retain the right to designate who shall use the property transferred or its income; ............................... 131 El c. retain a reversionary interest;or ................................................................................................ El0 d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ 2. If death occurred after December 12,1982,did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................... ❑ 0 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ......... ❑ ❑X 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation?.................................................................................................. ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994,and before Jan.1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in 72 P.S.§9116(1.2)[72 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined,under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. pennsylvania SCHEDULE A DEPARTMENT OF REVENUE REAL ESTATE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: JAMES R. FAHNESTOCK 21 14 01032 All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common, VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. 9 WATSON DRIVE, CARLISLE, PENNSYLVANIA 175,000.00 SETTLEMENT SHEET ATTACHED TOTAL(Also enter on Line 1,Recapitulation.) $ 175 000.00 If more space is needed,use additional sheets of paper of the same size. pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: JAMES R. FAHNESTOCK 21 14 01032 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. METRO BANK-CHECKING ACCOUNT#2843923083 21,222.16 2. PERSONAL PROPERTY-APPRAISAL ATTACHED 5,339.00 TOTAL(Also enter on Line 5,Recapitulation) $ 26 561.16 If more space is needed,use additional sheets of paper of the same size. pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER JAMES R. FAHNESTOCK 21 14 01032 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. RASMUSSEN FUNERAL HOME 3,907.75 2. FUNERAL LUNCHEON 256.24 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) JAMES R. FAHNESTOCK, JR. 9,000.00 Street Address 6 ELDRED HEIGHTS RD. City ELDRED State NY ZIP 12732 Years)Commission Paid: 2. Attorney Fees: IRWIN &McKNIGHT, P.C. 9,800.00 3, Family Exemption:(If decedents address is not the same as claimant's,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: REGISTER OF WILLS 350.50 5 Accountant Fees: 6. Tax Return Preparer Fees: PATRICIA A. ROSENDALE, CPA 375.00 FINAL FIDUCIARY TAX RETURN 7, CLOSING COSTS FROM SALE OF REAL ESTATE 13,663.20 8. REGISTER OF WILLS-FILING FEE 15.00 9. CUMBERLAND LAW JOURNAL-ESTATE NOTICE 75.00 10. THE SENTINEL-ESTATE NOTICE 203.90 11. U-HAUL MOVING&STORAGE OF CARLISLE-MOVING EXPENSES 297.46 12. FUEL FOR U-HAUL 62.00 13. INSURANCE BOND-PROBATE 128.00 14. FOOD FOR CLEANING OUT REAL ESTATE 84.78 15. CLEANING SUPPLIES FOR CLEANING OUT REAL ESTATE 86.23 16. SUPER 8 CARLISLE-TRAVEL EXPENSE 69.07 17. RENTAL CAR 150.00 18. WATER HEATER PARTS 34.20 TOTAL(Also enter on Line 9,Recapitulation) $ 40 525.82 If more space is needed,use additional sheets of paper of the same size. Continuation of REV-1500 Inheritance Tax Return Resident Decedent JAMES R. FAHNESTOCK 21 14 01032 Decedent's Name Page 1 File Number Schedule H -Funeral Expenses&Administrative Costs-B7. ITEM NUMBER DESCRIPTION AMOUNT 19. OVERNIGHT MAIL 19.99 20. BIG RED BOX &THE DUMPSTER -TRASH REMOVAL 495.00 21. HARRISBURG PROPERTY PRESERVATION -WELL TESTING 420.00 22. PECK'S SEPTIC SERVICE- PUMP SEPTIC 195.00 23. PECK'S SEPTIC SERVICE-SURCHARGE FOR ADDITIONAL GALLONS 32.50 24. RADON VENT INSTALLATION 745.00 25. ROY D. GOTTSHALL-APPRAISAL ON PERSONAL PROPERTY 60.00 SUBTOTAL SCHEDULE H-B7 1,967.49 REV-1512 EX+(12-12) pennsylvania SCHEDULE DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES&LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER JAMES R. FAHNESTOCK 21 14 01032 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. BANK OF AMERICA-MORTGAGE PAYMENTS 6,113.87 2. SOUTHAMPTON TOWNSHIP-WATER/SEWER 93.48 3. SWENSON FUELS, INC. -PROPANE 11.66 4. PP&L- ELECTRIC 352.77 5. BON SECOURS MEDICAL GROUP-MEDICAL 164.26 6. BON SECOURS CHARITY HEALTH SYSTEM-MEDICAL 1,216.00 7. RENAL CONSULTANTS, PC-MEDICAL 269.26 8. DBA GOOD SAMARITAN EMERGENCY PHYSICIANS-MEDICAL 50.60 9. PORT JERVIS VOLUNTEER AMBULANCE CORPS, INC. -AMBULANCE 89.87 10. ROCKLAND INFECTIOUS DISEASE, LLP-MEDICAL 169.31 11. NEW AMSTERDAM MED ASSOC. -MEDICAL 377.60 12. ROCKLAND MOBILE CARE, INC. -MEDICAL 202.91 13. EMSTAR NY-AMBULANCE 75.24 14, TRISTATE EMERGENCY PHYSICIANS PLLC-MEDICAL 36.02 15. HOSPITAL ATTENDING PHSICIANS-MEDICAL 180.20 TOTAL(Also enter on Line 10,Recapitulation) $ 158 132.48 If more space is needed,insert additional sheets of the same size. continuation of REV-1500 Inheritance Tax Return Resident Decedent JAMES R. FAHNESTOCK 21 14 01032 Decedent's Name Page 2 File Number Schedule'I-Debts of Decedent,Mortgage Liabilities,&Liens ITEM NUMBER DESCRIPTION AMOUNT 16. BANK OF AMERICA HOME LOAN SERVICING-PAYOFF OF FIRST MORTGAGE 147,033.43 SETTLEMENT SHEET ATTACHED 17. WAYNE WOODLANDS MANOR-NURSING 11696.00 SUBTOTAL SCHEDULE I 148,729.43 . GRAND TOTAL SCHEDULE I $ 158,132.48 pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: JAMES R. FAHNESTOCK 21 14 01032 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec.9116(a)(1.2).] 1. JAMES R. FAHNESTOCK, JR. Lineal 967.62 6 ELDRED HEIGHTS RD. 1/3 REMAINDER ELDRED, NY 12732 2. TRISTA FAHNESTOCK Lineal 967.62 9 WATSON DRIVE 1/3 REMAINDER CARLISLE, PA 17015 3. CHRISTOPHER FAHNESTOCK Lineal 967.62 113 WHITE BIRCH RD. 1/3 REMAINDER MATAMORAS, PA 18336-2419 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II. NON-TAXABLE DISTRIBUTIONS: A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size. OMB Approval No.2502-0265 A. Settlement Statement (HUD-1) 6.Type of Loan 1FHA 2.©RHS 3.❑Conv.Unlns. 6.File Number: 7.Loan Number: 8.Mortgage Insurance Case Number. 15031 000009628 4.[]VA 5. Conv.Ins. C.Note:This form Is furnished to give you a statement of actual settlement costs.Amounts paid to and by the settlement agents are shovm Items marked "(p.o.c)"were paid outside the closing;they are shown here for Informational purposes and are not included in the totals D.Name&Address of Borrower E.Name&Address of Seller: F.Name&Address of Lender Jonathan D.Kuntz,Heidi A.Kuntz Estate of James R.Fahnstock Orrstown Banat 245 Creekview Road,Newville,PA 17241 9 Watson Ddve,Carlisle,PA 17015 2695 Philadelphia Avenue,Chambersburg,PA 17201 G.Property Location: H.Settlement Agent I.Settlement Date:02fl9/2015 9 Watson Drive 1st Advantage Settlement Services Inc. Disbursement Date:0211912015 Carlisle,PA 17015 6375 Mercury Drive,Suite 102,Mechanicsburg,PA 17050 West Pennsboro Township 7175917755 Place of Settlement: TitleExprens 6375 Mercury Drive,Suite 102,Mechanicsburg,PA 17050 Printed 0 211 9/2 01 5 at 10:02 am by AM J.Summary of Borrower's Transaction K.Summary of Seller's Transaction 100. Gross Amount Due from Borrower 400: Gross Amount Due to Seller 101. Contract sates price 175,000.00 401, Contract sales price 175,000.00 102. Personal property, 402. Personal property 103. Settlement charges to borrower(line 1400) 10,670.20 403. 104. 404, 105. 405. Adjustments for items paid by seller in advance Adjustments for items paid by seller In advance 106. City/town taxes to 406. Cityhown taxes to 107. County taxes to 407. County taxes to 108. School Traces OWlE015 to 06/30/2015 898.36 408. School Taxes 02!1912015 to 06/30/2015 898.36 109. 409. 110. 410. 111. 411, 112. 412. 120. Gross Amount Due from Borrower 186,568 56 420. Gross Amount Due to Seller 175,898.36 200. Amounts Paid by or in Behalf of Borrower 500. Reductions In Amount Due to Seiler 201. Deposit or earnest money 1,000. 0 501. Excess deposit(see instructions) 202. Principal amount of new loan(s) 178,571.00 502. Settlement charges to seller pine 1400) 13,983,87 203. Existing lou s taken subject to 503. Existing loan(s) taken subject to 2D4• 504• Payoff of first mortgage loan to Bank of America '147,033.43 Home Loan Servicing 205. Appraisal Fee Refund 25.00 505. Payoff of second mortgage loan 20& 50& 207. 507, 208, 508, 209. Sellers Assist 7,896,00 509. Sellers Assist 7,896.00 Adjustments for items unpaid by seller Adjustments for Items unpaid by seller 210. Cityllown taxes to 510. (city own taxes to 211. County taxes 0110112015 to 02/1912015 75.57 511. County taxes 01101/2015 to 0211912015 75.57 212. School Taxes to 512, School Taxes to 213. 513. 214• 514. 215. 515, 216. 516. 217. 517. 218. 518. 219. 519. 220• Total Paid byffor Borrower 187,567.57 520. Total Reduction Amount Due Seller 168,988.87 300. Cash at Settlement fromito Borrower 600. Cash at Settlement tolfrom Seller 301, Gross amount due from borrower{line 120) 186,568.56 601, Gross amount due to seller(line 420) 175,898.36 302. Less amounts paid by/for borrower(line 220) 187,567.57 602. Less reductions in amount due seller pine 520) 168,988,87 303. Cash Q From Q To Borrower 999.01 603. Cash Q To ❑ From Seller 6,909.49 a r,■svonse ,.n. «+„na, w mnym r m o,m. mtsram,ummn miam■uvvwormmwamimxr.Noaonnaew:mruacsunca;u.,mwmwenmma.ray.mm.tiemynearom.a.eaeouna.m■aesv��.,eawn:.eionimramun. u. ufnement pom:t Previous editions are obsolete Page 1 of 4 HUD-1 .Tement Charges 700. Total Real Estate Broker Fees $10,320.00 Paid From Paid From Division of commission Oine 700 as follows: Borrower's Seller's 701• $5,310.00 to Berkshire Hathaway Homesale Realty Funds at Funds at 702• $5,010.00 to Re/MaxlstAdvantage Settlement Settlement 703. Commission paid at settlement 10,320.00 704. Commission to Re/Max 1st Advantage 445.00 800. Items Payable in Connection with Loan 801. Our origination charge (Includes Origination Point 0.000%or$0.00) $870.00 (from GFE#1) 802. Your credit or charge(points)for the spedfic interest rate chosen $ (from GFE#2) 8D3. Your adjusted origination charges (from GFE A) 870.00 804. Appraisal fee to E er Appraisals,Ina $375.00 P.O.C.B (from GFE#3) 805. Credit report to CBClnnovis Inc. (from GFE 93) 38.35 806. Tax service to from GFE 43 807. Flood certification to CBCinnovis Inc. (from GFE#3) 10.00 808. Rural Guarantee Fee to Rural Development (from GFE#3) 1 3,571 A2 900. Items Required by Lender to be Paid In Advance 901. Daily Interest charges from from 02119/2015 to 03/01/2015 @$15,9000/day (from GFE#10) 159.00 902. Mortgage Ins.Premium for months to (from GFE#3) 903. Homeowner's insurance for 1 years to Donegal Mutual $356.00 P.O.C.B (f om GFE#11) 904, months to from GFE#11 1000.Reserves Deposited with Lender 1001.Initial deposit for your escrow account (from GFE#9) 1,227.43 1002.Homeowner's insurance 3 months(%$ 29.67/month $89.01 to Orrstown Bank 1003.Mortgage Insurance 2 months 0$ 73.73/month $147.46 to Orrstown Bank 1004.City Property Tax months Q$ 0.00/month $ to 1005.County Property Tax 1 months Q$ 46.911month $46.91 to Onstown Bank 1006.School Taxes 9 months iM$ 202.87/month $1,825.83 to Orrstown Bank 1007.Aggregate Adjustment $-881.78 to Orrstown Bank 1100.TiVeChatges 1101.Title services and lender's title insurance $ from GFE#4 1,705.00 1102. Settlement or dosing fee to $ 1103. Owner's title insurance-First American Title Insurance Company $ kom GFE#5 1104.Lender's title Insurance-First American Tide Insurance Company $1,570.00 1105.Lenders title policy limit$178,571,00 Lender's Policy 1106.Owners title policy Omit$175,000.00 Owners Policy 1107.Agents portion of the total tide insurance premium $1,228.25 to 1st Advantage Settlement Services Inc. 1108.Underwriters portion of the total tide insurance premium $341.75 to First American Title Insurance Company 1109. 1110.Notary to Annette Myers 10.00 1111.Tax Certification Fee to 1st Advantage Settlement 5.00 Services Inc. 1112.Wire Out Fee-Payoff to 1st Advantage Settlement 20.00 Services Inc. 1200.Government Recording and Transfer Charges 1201.Government recording charges $ (from GFE#7) 194.00 1202•Deed$79.00 Mortgage$115.00 Release$ to Cumbedandzounty Recorder 1203.Transfer taxes $ (from GFE#8) 1,750.00 1204.City/County tax/stamps Deed$1750.00 Mortgage$ to Cumberland County Recorder 1205.State Tax/stamps Deed$1,750.00 Mortgage$ to Cumberland County Recorder c 1,750.00 1206. Deed$ Mortgage$ to 1207. $ to 1300.Additional Settlement Charges 1301.Required services that you can shop for (from GFE#6) 1302.Survey to $ 1303. to 1304.2015 CTYPWP taxes held in Escrowto 1st Advantage Settlement Services Inc, 700.00 1305. Installation of Water Purifier to Culligan 1,558.20 1306. Inheritance Tax Escrow to 1st Advanta4e Settlement Services Inc. 320.67 1307. Seller Attorney Fees/POC to Irwin and McKnight Law Office $ r 10,670.201 13,983.87 *Paid outside of dosing by(B)orrower,(S)eller,(L)ender,(I)nvestor,Bro(K)er."Credit by lender shown on page 1.-Credit by seller shown on page 1. Previous editions are obsolete Page 2 of 4 HUD-1 Comparison of Good Faith Estimate GF and HUM Charges Good Faith Estimate HUM Charges That Cannot Increase. HUD-11 Line Number Our origination charge # 801 870.00 870.00 Your credit or charge(points)for.the specific Interest rate chosen # 802 0.00 0.00 Your adjusted origination charges # 803 870.00 870.00 Transfer taxes # 1203 1750.00 1,750.00 Charges That in Total Cannot Increase More Than 10% Good Faith Estimate HUM Government recording charges # 1201 150.00 194.00 Appraisal fee #804 400.00 375.00 Credit report #805 62.70 38.35 Flood certification #807 10.00 10.00 Rural Guarantee Fee #808 3,571.42 3,571.42 Owner's title Insurance # 1103 0.00 0.00 Seller Attorney Fees/POC #1307 0.00 0.00 4,194.12 4,18877 $ 5.35 0 -0.1276% Charges That Can Chane Good Faith Estimate HUD-11 Initial deposit for your escrow account # 1001 2,959.68 1,227.43 Daily interest charges from #901 fl-5.9000/day 238.50 159.00 Homeowner's Insurance #903 700.00 356.00 Title services and lender's title insurance # 1101. 1,755.00 1,705.00 # Loan Terms Your initial loan amount is $178,571.00 Your loan term is 30.years Your initial interest rate is 3.2500% Your initial monthly amount owed for principal,interest,and'any mortgage $777.15 includes insurance is ❑X Principal X❑Interest ❑Mortgage Insurance Can your interest rate rise? (E No. ❑Yes,it can rise to a maximum of %. The first change will be on / / and can change again every years after 1 I . Every change date,your interest rate can increase or decrease by %.Over the life of the loan,your interest rate is guaranteed to never be lower than %or higher than %. Even if you make payments on time,can your loan balance-rise? ❑X No. ❑Yes,it can rise to a maximum of$ Even if you make payments on time,can your monthly amount owed for. ❑X No. ❑Yes,the first increase can be on / I and the monthly principal,interest,and mortgage Insurance rise7 amount owed can rise to$ The maximum it can ever rise to is$ Does your loan have a prepayment penalty? ❑X No. ❑Yes,your maximum prepayment penalty is$ Does your loan have a balloon payment? ❑X No. ❑Yes,you have a balloon payment of$ due in years on I I . Total monthly amount owed including escrow account payments ❑You do not have a monthly escrow payment for items,such as property taxes and homeowners Insurance.You must pay these items directly yourself. ❑X You have an additional monthly escrow payment of$353.18 That results in a total initial monthly amount owed of$1,130.33.This indudes principal,interest,any mortgage insurance and any Items checked below: ❑X Property taxes Q Homeowners insurance Q Flood insurance 0 RH FEE ❑ ❑ Note: If you have any questions about the Settlement Charges and Loan Terms listed on this form,please contact your lender. Previous editions are obsolete Page 3 of 4 HUD-1 Page HUD CERTIFICATION OF BUYER AND SELLER I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief,it is a true and accurate statement of all receipts and disbursements made on my account or by me in this transaction I further certify that I have received a copy of the HUD-1 Settlement Statement Jon D.Kuntz Heidi A.Kuntz e of James R, Settlement Agent The HUD-1 Settlement Statement which I have prepared is a true and accurate account of this transaction.I have caused or will cause the funds to be disbursed in accordance with this statement 624&his SETTLEMENT AGENT DATE WARNING:IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM.PENALTIES UPON CONVICTION CAN INCLUDE A FINE AND IMPRISONMENT.FOR DETAILS SEE TITLE 18:U.S.CODE SECTION 1001 AND SECTION 1010. Previous editions are obsolete Page 4 of 4 HUD-1 Name of Borrower. Name of Seller. File Number Jonathan D.Kuntz Estate of James R.Fahnstock 15031 Heidi A.Kuntz TitleExpress Prepared 02/05/2015 at 4:32 pm Note: This page is furnished to give you an itemization of the amounts shown on all rom- Lines 1101,1103 and 1104 of the Settlement Statement(HUD-1).This page orrow&s-,' <:: -8 i 6 f 1,e* s:`i accompanies but Is not a part of the settlement statement.If a discrepancy "nt.,,' Sef�.e M..hf- exists,the Information shown on the Settlement Statement(HUD-1)applies. e;,m*-e' e 11,00;TIVe Charges AmdOnts'Included: 1101. Tide services and lender's fille Insurance 1,705.00 a.Wire In Fee 15.00 b.EmaiMoc Copy Fee 50.00 G Overnight Delivery Fee-Package 25.00 d.Notary Fee 45.00 $ 135.00 1102. Settlement or dosing fee 1103. Owners title insurance 1104. Lender's title Insurance (policy) 1,295.00 $ 11570.00 a.Endorsement 900 EPL-Residential 50.00 b.Endorsement 100 No Violation) 50.00 c.Endorsement 300 Survey 50.00 d.Closing Service Letter 125.00 (Total 1103+1104) 1105.:'Lenders title poliq limit$178:571.00 1106. Ownefi 006 policy limit 4173'00100:'. . - 1107.'Agents Ooftio h of.thetotil 996 insurance premium $ 1,22825.' 1108. Uhderwdt6es-pardondfthe.totalfiflelhsurandeprem., .'.341.75--, (Total 1107'-i,1108) 1109. 1110. 1111. 1112. 'Addiiionpii Information for Line I 101 Items B" -'sillbir .--Tdfal.' offower'l;- qMwer,. 1100. -Tift-Cha riisvilth Piyii. . CW` -:- ---.--POC!ot-CredIt-: ".Uni 1101. Tide services and lender's title insurance $ a.Wire In Fee to 1st Advantage Settlement Services Inc. 15.00 15.00 b.EmaiftDoc Copy Fee to 1st Advantage Settlement Services Inc. 50.00 50.00 c.Ovemight Delivery Fee-Package to I st Advantage Settlement Services Inc. 25.00 25.00 d.Notary Fee to Annette Myers 45.00 45.00 1104. 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I • 14AII ri 19191 1 I I _I�Y•% j r y'• �g pmai `•:�V rJ s+.� J¢� ,1C+��•, .w,.: °n" aq^ r`:'"t_y�, I d-•;:,:: iq:_'�• .kS^t; „00011 "', vk 3'Y6�f''rtic.:.-.. r-u C'.'`rl-,�,. �".•`i 'tit i' �:z "I' y' :aM10 f c,:.,•} .,. �.t¢: :•r�.,b.: Y;, �'�*.Si• .. ;{�a. �,'�,y _ �if. x1 ':MU ,>aS ��c `i�.F:' _.3' r. 'Sr' ( 1t ;Y. r. ;�i.� ,r.t.:5,"yf�:,..,L,2, �.t,, ,t.., 1�'`"''%r• 9•�.,, 't;. �tt� ��2,74 :x,.:..4,li� yfr,!i�11 "iFy,r,+�z ,�' 1'v.�� t,J 'n.,rh�.�'•qi�",h�e3"i`:O'•7:!.,.�'�:'dt 3,:�ti �4 �,al t"ut ,r..: .J.._n:.::.st.�g. :�',!_.:,<,i UQ..�h;ki.,P..F,:.r`'r_�»>t... ..�:.5i...Y,....t..,•f•I�e2i.. * :-.r-t'�i '?^' .:.r_. u-.:`�:�:,<�,C�S�i`.�.T:t' ' !Y .w 1 • I I •I 1 SAM, ..aq 7 ,� :•ti, yi y�}�,i. .,'' ;,a m?S r' tsat.` r a�. ,ra> b �f • `•rd. I"e>:i''i .t.!`:srs.3 I I�x- mak', ..,�#.� 7, :;," ;,ry };��r}+S ,, m; !~3 hV. �._�?� .,a;i ��;� t:tt, �;£ �;i,!,, ,�;.,_ 'LF� �.y';�=c.,.Fia'�;ti•'�£j,%i4rr`�v,�. .,4�;1c��`?'�kt%�.�;h?;�; �:�,� �- �t,��. �. �9�X�" �!'r�.,et� J�V, 'i`?Ft .�, i�:3?-'lk!lt •S'. .t� :>:T!:. a.�-:a?\.v cr •8.• rw: 1.��> rr� t_ tir?..:.:5:..._ :i8. a... `b". 1s.f I 11. 1 1 1 METRO BANK Transactions By Date Date Description Debit Credit Balance C: 091021 POS Wal-Mart Super C $37.26 $21,948.16 RF#482090 09102 123015 CARLISLE,PA -�- , 09/09/14 CHECK#5017 $80.00 .9,866.16 ,,. .. , . _ .pf'. ., �. ,A R: lil Check Transactions Number Date Amount Number Date Amount Number. Date Amount. Items denoted with an"E"are electronic entries and will not have a check image. Items denoted with an—'indicate processed checks out,of sequence, '— Fees Summary — a Total Overdraft Fees Year to Date $0.00 t'— Total Returned Item Fees Year to Date $0.00 For your convenience,a summary of overdraft and returned item fees appears on your monthly statement. Please note that the overdraft fee summary includes non-sufficient funds fees,uncollected funds fees and unavailable funds fees. The summary does not reflect refunded or waived items credited to your account. N p O 0 0 0 0 0 0 0 0 0 M 0 v n 0 r- cm m N 7 10 r` N 0 2843923083 Page 3 of 4 92140 ROLL 07111 �� _� �s � ■" vim' / 1`� Em- 0 - �� ✓ �P-4 Rm ,.ate � ' i I / p - �%/lam /L�/.• � / / I / � .r<.�+: �_ _ _.�� :/lam✓ s / i i IS i ,aw�t vC0 6"i� wl i D 6flfB % .�D GY> D o 41 U ug appraisdi. . 0-* ]�. - 516000+ --1957300+ //,3',250.00+ 5,339- 0-* ,3390-* - �b�o(Z�ssA a6( ' RASMUSSEN HOME FURNISHINGS' 90 MAIN STREET Rasmussen Funeral Home NARRONSBURG. PA 12764 25(845) 2-3901 PO Box 155 TERMINAL a1 Merchant ID: 3994 Narrowsburg,NY 12764 Term ID: 71424601 Ref u: 0003 (845)252-3901 Sale XXXXXXXXXXXX0369 VISA Entry Method; Swiped September 27, 2014 Total: Mr. James R. Fahnestock Jr. $ 3'645'90 6 Eldred Heights Rd. Eldred,NY 12732 Inv : 000003 Rppr Code: 020111 Transaction ID: 464263676790122 Rpprvd: Online BAN: 000129 For the Funcral Expenses of Mr. Jaynes R. Fahnestock: Customer Copy Transfer and Preparation...........................................................$ 125, THANK YOU Arrangements and Supervision.................................................. 185U.V PLEASE.COME AGAIN! Use of Funeral Home.................................................................. .550.00 Schuylkill Haven Oak Casket Rental, Eggshell Int. Total Merchandise.............................................. 1195.00 Alternative Vehicle....................................................................... 250.00 Addtional Services and Merchandise........................................... 225.00 Funeral Home Charges.................................... $ 5320.00 Cash Advances Crematory................................................$ 260.00 Death Certificates 8 @ $6.00..................... 48.00 Coroners Authorization to cremate............ 20.00 Total Cash Advances..........................................$ 328.00 Complete Funeral Expenses.....................................................$ 5648.00 Payment James Fahnestock Visa................................................ 2000.00 Payment Dolores Bassney MC 9-20-2014...*............................... 3645.00 Times Herald Record Obituary.....................................................262.75 Balance........................................................................................$ 262.75 TPa4tricJ. Pson pf. miamE.,,rs 9 PROCT93 ROAL ELDRED NY 12.732 SfOfE MANAGER [it. husmv,-i 845--55 1-631 E 9 PROCTOR ROAD GRED WY 12732 1 @ 2/3.0: ORE 14ANA317-IR W. MUSTOVS, pErsj,. Dirr NP i E*. f. -6315 vm;.) 14FL. BuTrERMIL 1 @ 2/3.0: PERRY NUTTY CONE 2*1 IFIE!:Sl DIET NP I .E PERRY NUTTY CONE 2*. BP DF:'-0 3 IT Flux O.c-, - jE,L0 GEL STRAW ; ,9s' 3 PERRV NUTTY LONE 3.2') 1: DH FTG FRTY COW CF' STRING CIPESE PERRi NUTTY 1,ONE I,fI1f ON1(J'4 :300111 H6 BAR COLBY JACk 7-: 1: [:fit -,OUR 1 @ 215.K toil '.OUR i-iG BAR MUEN3TER I @ 2/5.O-) POS RNRS SE� SLT BR r TON-Ifl) BASIL W.R. RF VIE414A FRG I @ 2/S 01) VKR FUDGE STRIPE E j!Af— TOM 111) BASIL IRIO CINNA-113-4 RywH(II KI-1 H7* R3 c IS -0 FOIL (,P,I)J-EY 2% MILK 2/6.N: TA*.4 2:; LE,Y'S SFT RYE SEL C **n* BA1.14CE 3 @ 2.30 MAPTIN LONG PTO FO u14 RE CKWLEY 24t 4ILK rA:i( 0.2.; CR'64ILCY 2% 1111-K gl.3.", x1ifL* ItiAl-44cc 11 4 @ 0.0.E RF 'e-AC REFUND O'c' Debit Card - SWIPED IAS 0.9", SJBTorAl.: 3,41.49 BkANCE 19.6 C)SHBACR: :S).Oe) A.-.COUtI1 W143---R; Debit Card - SWIPED A:'PROVAL C01": 2.23560 SUBTOTAL: 1,49.62 c;-Qtl[tlCf WIRER: 31.310 CASHBACK: X1,0.00 1 ): SIJIP..-! ACCOU14T NUMBER: TOTAL AMOUNI: 311 -41 APPROVAL C6DE: 392030 0)/21/14 01:413-3m 'u,T9 3 SEOUENCE W.MBER: 3993 TERMINAL )'C:: SWIPED Del)i I TOTAL AMOUNT: $49.62 Pur,cha!lle -i- CI-111* .0 09/18/14 O.o':39rm 9130 3 T)TAL NUMBER OF IfEW. SOLD 15 CHANGE 0.C'l (0/21114 111:48air, 53 1 43 7279 TOTAL NUMBER OF i,rt-:,i,.; SOLD = 16 09/18,/14 0;:39rm 5 3 134 9100 Wa I m a re t :. Save money.Live better. t 570 ) 251 -.9549 MANAGER JOSHUA BOODBARD 777 OLD BILLOW AVE HONESDALE PA 18491 $TN 2400 OP# 00006699 TEN 16 TR# 04025 BATH TISSUE 003700066704 9.97 N PEPSI 2 LT 001200000230 F 1.40 X MOO 2LT 001200000935 F 1.40 X 154T POT STM 007249506257 22.97 X HHOIE MILK 00704721.1014 F 1.50 0 PEPSI 2 LT 001200000230 F 1.40 X COOL WHIP 004300000960 F 2.67 0 COOL WHIP 004300000960 F 2.67 0 BELL PEPPER 000000004065KI 4 AT 1 FOR 0.00 3.x02 N HH ORIGINAL 004300002922 F 3.90 N BRISK SUL 2L 001200620237 F 1.40 N PEPSI IT 2LT 001200044211 00006Q 4013KI 1.40 K 0.60 lb G 1 lb 11:10.- 0.71 R ASIA BAKER 007472942020 2.44 X PEPSI IT 2LT 001200000031 F 1.48 X 98 BLOY HARY.005100020 55 F 3.48 X JELLO PUD 004300020.x{42 F 0.94 0 JELLO PUD 004300020431 F 0.94 0 CHEESE SAUCE 003 20000210 F 1.60 0 JELLO PUB OQK300020442 F 0.94 a JELLA POP 001300020431 F 0.94 0 JELLO PUD 08 300020442 F 0.94 0 JELLO PUO 004300020442 F 0.94 0 FAMILY SIZE 004400003338 F 3.501 sOEET 00005 007209000271 F 4.90 0 S EE1 OOODS 0072030021.43 F 4.96 0 CCOOLNHIPALT 044800000956 F 0:67 0 NUGGETS 002910001452 F 5.23.0 NUGGETS 002370001152 F 5.23 0 BTR OLU OIL 0034500151.79 F 1.90 0 VELVEETA PLD 002100061161 F 6.80 0 BAR%N-FRANKS 001590418401 F 1'.98 0 OV SHARP 00787,1201403 F 4.98 6 GU C VlJK S 060538 18790 F 2.48 0 CS 840E 008160400103 F 1.98 K CS P OGLER 00 760400095 F 1.98 X BV 390118 00 074222003 F 1.98 N HOSP CRUST 0071923.0000 F 1.25 0 At T A 061300812085 F 2.70 N OV S USAGE 007874208014 F 7.00 0 V S USAGE 00187200014 F 7.08 0 O!V► SAUSAGE 047171208014-F00 7.08 0 CARD 0060004027 0.47 X EORS 0071438305 F 2.94 0 SUIT TAL 162.6 TAX 1 5.000 1 2.41 DEBIT TTEND 165.18 CHANGE DUE 0.00 EFT DEBIT PAY FROM PRIMARY 165,13 TOTAL PURCHASE ACCOUNT A seye #t#* **** 4647 S NEF 1 426300126750 TERMINALI9 H1274847PR CORE 041366 09/20/14 112:41:22 ITEMS SOLD 50 TC# 4301 5425 6214 6107 4523 1 . II{{ILII{SII{II{I{II{IIIII�II{II{IIID{1111{{III{III{IIN{VIII{IIIIIIII{{111111{III{{I Try the new Savings Catcher today! Go to walmart.coe/SaV1n9sCatchar 09/20114 12:41:24 1Chie-Way Rental(OUT)-Saturday.10/2512014 12:13 PM ContractNo.:81591705 IIIII'IIII III��III�II'Inl'IIIInIIII� ROADSIDE ASSISTANCE:mvuhaul.com or L-800-528-0355-TT 2381E Dispatched From,811067-Safe-Protection:(NO) Customer: 845-701-7015 Renting Location: Jim Fahnestock DL:xx:o=3891.NY,0918 U-Haul Moving&Storage of Carlisle- 6 ELDRED HEIGHTS RD jrif@frontiernet.net (811067) ELDRED,NY 12732 1111 Harrisburg Pike CARLISLE,PA 17013(717)249-8818 Towing Vehicle: •[agree that only the"ToWng Vehicle"listed on this contractxvill be used to tow U-Haul Equipment. Destination:BETHEL,NY Due Date/Time:10(27/2014 12:12 PM DROP OFF EQUIPMENT AT: Bethel Self Storage Park 1998 Rte 17B,BETHEL.NY (8451583-4920 Days Allowed:2 M otveu:23 . Extra Day Rate for the TT t40/60 Per Day $0.40 Per M I MI out ....., CoveragE lRental Charge, _.. ., ]Total Charge AA2381E 35251.5 $0.00 236.00 5236.00 E51628 AZ REGULAR c -IN--uwdL ON FILE Environmental Fee: $5.00 SubTotal:. 44.00. FUEL TANK CAP0 GALLONS Rental Tax: $19.28 Motor Vehicle Tax: $4,00 E 1/8 1/4 3�8 8 3�4 7/8 F Sales item(details below): 533.18 E I r 1 ! r r ( r I r Rental Deposit Paid: $0.00 20 18 18 136.10 U 516 Total Rental Charges(including Deposit): $297.46 Estimated gallons needed to r rn to atched level of 1/2 Acc uth: X)00000000000000(7602 DDebit Card Payme $297.46 Net Paid Today: $297,46 Part Cade oescriotion Item Cost uanti _ cs� MED BOX,MEDIUM,3CF L8X18X16" $1.11 20.00 ea. $22.20 55T TAPESLFSTK PPR,1-3/4"X55YD,R $3.85 1.00 ea. $3.85 40001 TAPE,POLY,ECONPCK,W/DISP,UHAUL $5.25 1.00 ea. $5.25 SubTotal- $31.30 Taxer. $1.88 Total Sales Including Tax: $33.18 https://webbest.uhauldealer.com/WBReceipts/receipt.aspx?source=printing_obj ects&save... 10/25/2014 CSI'?SIN PA 1701 3<fli 0,LF L113761MI OU V 0. PA 0;A ka53,26 A0 Mir- 0 7602 Pastvc,I d 20.0050 3,444 S 62.00 Subt-Ait 6 62,00 !ix:$ 0.00 i'ati1:1 62,00 8 62.00 IS To a .EASE CO E AGA!ll Agent Name F f'-,a-r MCtej, J 0),\ Agent Code#& State 33 — 6—7 13 Bond/Policy# N 439 44?16- o Rol 1 2014 The enclosed materials were: underwritten by: MARK typed by: checked by: The Fidelity and Surety Bond Department appreciates your business. Please read the checked items below closely. Please read carefully the items checked. on enewa"Wad: with power of attorney. After your insured has signed as Principal,he/she needs to send both to the Obligee(entity requiring the bond). • Resident Agent: if required,you will need to sign. • Acknowledgment of Principal: if required,your insured will need to have a Notary Public or County Clerk complete it. Please verify this bond appears on your system. If it does not,please contact us immediately. For renewals,a bill is being sent to the insured. If this renewal bond is not needed,please mark `cancel' and return it to us. ❑ Indemnity Agreement: Please have appropriate person(s)sign where indicated,and return the original to us within 30 days. ❑ Continuation Certificate: with power of attorney. Your insured needs to send both to the Obligee(entity requiring the bond). A bill is being sent to the insured. If the bond is no longer needed,please mark`cancel' and return the original Continuation Certificate to us. ❑ Stipulation: (endorsement)with power of attorney. After your insured has signed as Principal,he/she needs to send both to the Obligee(entity requiring the bond). ❑ When this box is marked, the Obligee(entity requiring the bond) must sign a copy of the �t ,,,,1 the stipulation and have it returned to us within 30 days. '11: Attached for $ ❑ Please collect the premium before releasing the bond,to your insured. To follow for$ a3, rm = Sq-7Z M-rI 4 rr—ffJ ❑ Fidelity Policy: This is for your insured. No countersignature is required. The extra copy of the Declarations page And Schedule page(if schedule bond)are for your files or you can give them to your client. ❑ Fidelity-Amended Dec.Page/Change Form: This is for your insured. ❑ When this box is marked, the insured must accept the amendment by signing a copy and have it returned to us within 30 days. ❑ Other: State Farm Fire and Casualty Company Fidelity and Surety Bond Unit 2702 Ireland Grove Road—2E Bloomington,Illinois 61709-0001 800-251-BOND (2663) ABS>Business Lines>Fire>Bonds-Fidelity Surety i KFC 70 North Hanover Carlisle, PA 17013 (7111j241-8161' 2014-10=25 DI�' ''SAIL w t CHANGE D.ETAIL:.: Name: JAMES R FAHNFSTQCK Card Type: : MasterCard Account: *#**********7602 S Audi Cade, 001552 Trans3404 Ad. Rsi,. 4700017T Seguenpe' C. 001552 0 AUTR AMT 20:1.47iQ-25 L! T3 : 6 36 PM CUSTOMER COPY c� DATE 23-85579000001 TIME 12/06/14 6060000000 19:13 SUPER 8 CARLISLE 100 ALEXANDER SPRG RD. CARLTSLE PA 17515 717-245-9898. TRAM PP, RUTH 159 805466 CLERK ;D ROOM R 01 414 MSTR SALT ACIETA €dNBER EXP j XXXXXXXXXXXX4639 XXXX � • TOTAL $69.07 THANK YOU CUSTOMER COPY More saving. More doing: CARLISLE PA-17 STORE MANAGER. MARC COCHR,., 717 249-1771 4149 00058 94274 10125114 06:18 PM CASHIER SELF CHECK OUT - SCOT58 014717150118 ELEMENT 4500 4- 20.98 ELEMENT 450OW/240V INCOLOY LWD FS 014717150262 ELEMENT 4500 4- 11.28 ELEMENT 450OW/240V HWD SUBTOTAL 32,26 SALES TAX 1.94 TOTAL $34.20 XXXXXXXXXXXX7602 DEBIT 34.20 AUTH CODE 332940 4149 58 94274 10/25/204 2156 RETURN POLICY DEFINITIONS. POLICY ID DAYS POLICY EXPIRES ON A 1 90 0112312015 THE HOME DEPOT RESERVES,THE RIGHT TO LIMIT / DENY RETURNS. PLEASE.SEE THE RETURN POLICY SIGN IN STORES FOR DETAILS: BUY ONLINE PICK-UP IN STORE AVAILABLE NOW ON HOMEDEPOT.COM. CONVENIENT, EASY AND MOST ORDERS READY IN LESS THAN 2 HOURSI �rwr*rrc�cx,r�rr�r�rrrtx�c��r�r�c�r��cxrr�cr�r�r��r�rrr�rrcrx ENTER FOR A CHANGE TO WIN A $5, 000 HOME DEPOT GIFT CARD 1. Share Your Opinion With Us-1 Complete the brief survey about your store visit and enter for a chance' to win at: www.hamedepot.com%opinion COMPARTA SU OPINION EN UNA BREVE ENCUESTA PARA LA OPORTUNIDAD DE GANAR. User ID : 2PX2 192986 188895 Pass�n►c�r.d 14525 188837 Entries must be entered by 1112412014. Entrants must be 18 or older. to enter. See complete rules on website. No purchase necessary. ❑gym:-�: � : �.. ...� o: Q9.. .:: If M .z: a .o.. '. CL :-Xz .. � �.• :_. �t ��::�. .�..:.• �` - �'�•:`ori �,b:_ _ ... r � d gym. CO 4 3 e _ _ FMP IN _ Pg ..ih. ;�� -�' 0' � �. .:=w ':�.?►�: '. _tom�. . i - _ v,: a d, -.� ='in', vi:' g:�❑. _ _ -_ _ �`�- �" _ :Q Q :' Page I ot' l Lois From: <no-rep1y@,e-hps.corn> Date: Thursday,October 23,2014 3-02 PM To: <jr1f@frontiernet.net> Subject: BIG RED BOX&THE DUWSTE;-Heartland Gateway Transaction Receipt BIG RED BOX & THE DUMPSTE 1721 PINEVIEW DRIVE COLUMBIA, SC 29209 803-783-6834 Please see the details of your transaction below. Date: 10/23/2014 Time: 3:02 PM Transaction Type: Recurring Billing Transaction ID: 325767854 Customer ID: 344001 Account: ************7602 Card Type: MC Entry Method: Manual Authorization Code: 000981 Result: Approved Clerk ID: D P Description: 9 Watson Drive, Carlisle, PA--Initial Delivery Subtotal: $495.00 Total Amount: $495.00 Thank you 10/23/2014 1,11u�111� v 1`.vv l i auaas.,Livu t ago 1 CA L, LOIS F TOCK 50-OW210 � 120 JAMES RFAHNESTOM JR. 6.ELDRED HEIGHTS RD, ELDRED,NY 12732 DM MY Ta '7 w $ t dt> 6 MORDBR:OF - RamTHE FIRST NATIONAL BUNK OFJEFFEMONVILLt ELbRED OFFICE Eldred NY 1273 �oAr T ` +1:02L9093421: 12 1052 gue 0120 Ol - • CL https://web3.secureintemetbank.com/IMG—IMGI 151/IMG 1151.... 2/19/2015 i Converge Page 2 of 2 PECKS SEPTIC SERVICE 68 PINE SCHOOL RD GARDNERS, PA 17324 '71.7-486-5548 PECKS SEPTIC SERVICE 0005560008018072499000 Date: 12/19/2014 02:40:42 PM CREDIT CARD SALE CARD NUMBER: *********{4639 K TRAN AMOUNT: $32.50 APPROVAL CD: 032255 RECORD #: 000 CLRK ID: 552272 CUST CODE: 0963 SALES TAX: $0.00 Thank you! Customer Copy 1. Converge. Page 2 of 2 PECKS S r,P7S-F1'RV IC on ccwllSh- 8 0 1 ;4:_:990 v �� c CRE,I)ET CAQZ"') CARD NUMBER: +"46.39 X T RAN A-IMOUNT �:l 95 0,01 APEPROVAT 254 53 RECORD CLEIRK CUNT COCH SALES TAX: I z m Mike Sheely Home Inspections 1000 Wolfe Road x" Enola, PA 17025 y (717) 732 - 6538 ------------------------------------------------------------ January 13, 2015 To: James Fahnestock, Jr. Property: 9 Watson s Drive Carlisle, PA 17015 Job Description: • A radon mitigation system will be installed at the property listed above on January 9, 2015. Total paid....$745.00 Ck. #: 119 Thank you, Mike Sheely NAHI#: 10-14277 FUC #: PA063092 DEP#: 2691 113 Forge Rd., Boiling Springs, PA M In Account With ROY D. GOTTSHALL, i Southampton Township Southampton Township 200 Airport Road ' 200 Airport Road ((( 0 t Shippensburg,PA 17257 Jab Shi ppenshurg,Pq 17257 I (717)532-7885 �' (717)532-7685 SERVICE ADDRESS SERVICE ADDRESS CUST NO OUST NO r i 9 Watson Drive 9 Watson Drive 5ST00107A 5ST001074 SETICES DICE '_.` , ;:. 't1tNp.UNTPREVIOUS BALANCE Ai00 PREVIOUSE 0.00Scheduled Service 46.74 Scheduled 46.74 Payments Received 46.74 ; I -46.74 ; i I ( RE rtYr rv. t:� i 01!01 _ 03 1 * S TO. 10101 - 12/31 n. 46.74: 12 i; KETURas TO �� 07 LO CA GAS 5L NSON FUELSo INC. L.P. In c DELIVERY DAI'E ym SWE > c TRUCK NO. :-1 3027 Cold Storage Road %10 0 DRIVER NO.1TIME KEROSENE L0 Now Bloomfield, PA 17068 BIO-HEAT (717) 582-2949 e Or Date:1.03/2014,Inv:296576 ACCt#j. 2p ,' ' /10 ....... ATFAHN payant: MESI FA--iNESTOCK Dolv Day-.:" Fill Loc.: JA! I . 7-00 Uj AcType: Hchq Defy Ty: Julian9 WATSON Dk CARL]. LE PA 17c:11 5 ��aJ Rte: C MiN <r U Tank 8: 1p 8L&St:03411112014 Nxt:05/2012014 2 z 1 Terms. 4z t -.4 GA*1_10,DAYS' i w JE 'M W1 CL c:- TerAs: Ni X30 Phoner 6-4443 3- 040 nce Due: 0 C Ed ji C3 MAO -WaY4. 0.00 6: 0.00 w 1F111 MOO a. PLEASE PAY-,FROH THIS. INVOICE LIMID PROPANE = V DISC. ART. P4.. IN 10 DAYS - :2 "M PFFCROS�ROWSCHOOL RD KNOCK ON-DOOR FOR,PAYHENT cl M Z- 0 BON SECOURS MEDICAL GROUP 'ter"6"' - 2 CROSFIELD AVE STE 318 OSA X ❑MO ERIDARD® ❑DISCOVER Attn: A/R Center CAMMAE" EV.DATE AAAWNT West Nyack, NY 10994 EgNA71piE MUST INCWDE3 DIGIT SECURITY CODE FROM RETURYON VICE REQUESTED SACK OF CARD ^sTATEMENT.bAtEt$164.26 PAYTHIS`AMId NT-.r.,' ACCQUNTNO Locatio SECOURS NEUROLOGY (845) 533-7119 11/01/14 101427421 SHOW AMOUNT PAID HERE Stmt ID#:672505676 ®MAKE CHECKS PAYABLE/REMIT TO: 107120-493 JAMES FAHNESTOCK BON SECOURS MEDICAL GROUP 9 WATSON DR 2 CROSFIELD AVE STE 318 CARLISLE PA 17015-7436 ATTN: A/R CENTER WEST NYACK NY 10994-2220 I��IIII��rI�I��III�r�l��l��l�l��lrl��l�lll��rl�l��llrl�l��l ] Please check box 9 above address is incorrect or insurance . PLEASE DETACH AND RETURN TOP PORTION WITH information has changed,and indicate change(s)on reverse side. YOUR PAYMENT IN ENCLOSED ENVELOPE -MAKE€tIE1;KS-PAYABLE TO FOR ACCOUNT QUESTIONS GALL: GSH MEDICAL CARE, P.C, (845)533-7119 PATIENT:JAMES F'AHNESTOCK DUE DATE: 11%19/14 Date. Description charges Credits ' Insurance Patient.Balance Balance 09/01/14... CRITICAL.:CARE.',.. E/M' 769..00 0.00 769.00 0•.00. . .. . Billing:.Provider: DENNIS, LYLE JAMES 09/03/14 CRITICAL CARE,. E/M., 769..00 0.00 769.00 0.00 Billing.Provider: DENNIS, LYLE JAMES 09/02/14 SBSQ HOSPITAL.;CARE/DAY 35-MINUTES 281.00. 0.00 23.40 Billing.Provider: TAYLOR, GREGORY. W. 19/14/14 INSURAt?..C8 PAYMENT .NY_MEDICARE:_ 91.72, 10/14/14 INS OR OTHER CONTRACTUAL ADJUSTMENT..-NY ME* 164.01 10/14/14 MORE SEQUESTRATION ADJ-NY MEDICARE 1.87 09/04/14 SBSQ.HOSPITAL CARE/DAY 35 MINUTES 281.00 0.00 23.40 tilling:Provider., TAYLOR, GREGORY W 10/14/14 INSURANCE PAYMENT,=NY. MEDICARE , . : 91.72 10/14/14 INS OR OTHER.CONTRACTUAL ADJUSTMENT-NY ME* 16:4.01. ,.. 10/14/14 MCRA SEQUESTRATION-ADJ-NY MEDICARE 1.87 09/05/14 CRITICAL'.CARE., E./M 769.00 0.00 50.60 pilling Provider.* TAYLOR,, GREGORY W 10/14/14 INSURANCE PAYMENT-NY MEDICARE 198.37 , 10/14/14 INS OR :OTHER CONTRACTUAL ADJUSTMENT-NY ME* 515198 09/06/14 CRITICAL.CARE, E/M :7.6.9.90 0.00 50.60 Billing Provider:. TAYLOR, GREGORY W 10/14/14 INSURANCE PAYMENT-NY MEDICARE 198.37 10/14/14 INS OR OTHER CONTRACTVAL.ADJUSTMENT=NY ME* 515.98 10/14/14 MCRE SEQUESTRATION ADJ-NY MEDICARE 4..05 _._. .:__.. 09/07/14 SBSQ:HOBPITAL CARE/DAY 25 MINUTES 195.00 0.00 16.26 Billing Provider: TAYLOR, GREGORY W 10/14/14 INSURANCE.PAYMENT-NY MEDICARE 63.72 10/14/14 INS OR OTHER CONTRACTUAL ADJUSTMENT-NY ME* 113.72 10/14/14 MCRE SEQUESTRATION ADJ-NY MEDICARE 1.30 09/09/14 EEG,COMA/SLEEP RECORD ONLY 156.00 0_ .00 ` 156.00 0.00 BillingProvider: TAYLOR, GREGORY W CURRENT 30 DAYS 60 DAYS 96 DAYS OVER 120 DAYS Insurance Current Balance Pending Due 164.26 0.00 0.00 0.00 0.00 1,694.00 164.26 Doing business as: RPMA, HVMA, RVSA, Community Medical Care,Bon CLOSING DATE: 11/01/14 Secours Medical Group, GSH Medical Care, Mahwah Medical, Metropolitan Cardiology, Rockland Heart&Vascular Assoc. ACCOUNT NUMBER: 101427421 STATEMENT �IIIIIIIIIIIIIIIIIIIIIIIIIiI�jl}IIIIIIIIIIIIIIIIIIIIIIIII) SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION 107120-493 -4337250 BQN SECOURS Charity Health System n Secours Community Hospital 0 Box 28538*Richmond,VA 23228-8538 1111111111111111111111111 Jill 1111 MER December 1, 2014 mixed aadc 604 E 000008(1949) JAMES FAHNESTOCK 9 WATSON DR THIS IS A BILL CARLISLE, PA 17015-7436 �1��1�'I'1��II1�I�111�11�1��111�11"�II�III�1�„IIII'llll�l'lll� Patient: James Fahnestock Account#: 51142420086 Balance: 1216.00 Service Date:08/30/2014 Dear James Fahnestock: We wish to inform you that your account is seriously delinquent. If we do not receive the balance in full within thirty(30)days,we will recommend that the account be referred to a professional collection agency. You will be responsible for the unpaid balance plus reasonable cost of collection, including attorney fees. Payment may be made either by phone or by mail using your credit card or checking account. If paying your balance in full is not possible,please call our Customer Service Center. They will explain our extended payment options including our financial assistance program to you. Please be advised if you do not contact customer service to establish a monthly payment plan then the balance is due and payable. We look forward to your response to this letter within the next thirty(30) days. Payments or adjustments made in the last five (5) days are not reflected in this notice. Please disregard this notice if payment has been made by you or if payment from the insurance carrier has been verified. Thank your for your assistance. This is a final notice. PLEASE RETURN LOWER PORTION WITH YOUR PAYMENT Date: December 1,2014 Make check payable to: Bon Secours Community Hospital Patient: James Fahnestock Please call our Customer Service Center or pay on-line if a credit card Account#: 51142420086 payment is needed to be applied to an account. Service Date: 08/30/2014 Pay on-line: https:/ibonsecours.parathon.com/or call our Customer Balance: 1216.00 Service Center they will be happy to process a credit card payment. Please visit us at www.bonsecours.com and take advantage of our new online billing tool "Online Account Manager" Customer Service Center Toll Free: 1-877-342-1500 Bon Secours Community Hospital 8:30 AM to 1:00 PM P.O.Bog 742791 2:00 PM to 7:00 PM M-F Atlanta,GA 30384-2791 Calls/inquiries may be monitored for quality control LT49C IF PAYING aY.MASTERCARO;DISCOVER,VISA OR AMERICAN EXPRESS,FFlLLOurSELO.W. RENAL CONSULTANTS,PC CHECK CARD USING FOR PAYMENT 13 IM rr,, 1 MEDICAL PARK DRIVE ®aSrERCARD DISCOVER ® I A AMERICAN EXPRESS POMONA,NY 1 0970-3 51 6 CARD NUMBER SIGNATURE CODE 33066 SIGNATURE - - EXP.DATE STATEMENT DATE PAY THIS AMOUNT ACCT,k Phone No.:(845)725-7930 11/6/2014 $269.26 1220.7-69525693 008085 E-Mail Address: 0101 show AMOUNT .PAGE: 1 Of 1 PAID HERE I�y�nlni�rllli�lll�lrlllll�II�I�IIIIIr�IIlrn�rll�ll�llltU�l I�i4illillliltl�ll�ll411irllt�r��llllllit�ntni�niln�i�„Ip JAMES FAHNESTOCK RENAL CONSULTANTS,PC 9 WATSON DRIVE 1 MEDICAL PARK DRIVE CARLISLE,PA 17015-7436 POMONA,NY 10970-3516 33066"T7COIGH8R004356 0 Please check box if address is incorrect or insurance STATEMENT PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT information has changed,and indicate change(s)on reverse side. ,aoosT - - Patient Patient Service. Procedure Service Amount Amount Name ID Date Provider Due. Fahn .stock, James 69525693 09/03%14 .99291 .crit.ical.dare .Ill/ Ravichandran, La $576.00 $50.60 09%25/44 'ImSyrance Payment. -.$198:37 09/25/14 Adjustment -.Contractual 4322.98 09725%14 Sequestration - reductio 44.05 Fahnestock, James 69525693.09/04/94 99291• CH.tical. Care Ill/ Ravichandran, La $576.00 '$50.60 0.9/25/14 I'nsurance.Payment. 4198.37 09125/14 Adjustment Contractual -$322:98 09/25/14 Sequestration- reductio i Fahnestock;;;lames 69525693'09/05/.14 99291. Critical Care Ill./ 'Ravi hand ta' $576.00 $50:60 09/25/14 .I ns.urance:Payfient. -$198.37 09/25/14, '• Adjustment -.Contractual . -5322.98 , '09%25/14. Sequesicat:ion -' reductio: -:$4:05 .Fahnestock, James 69525693:•09/06/.14 99291_ Critica.l Care Ill/ Ravichandran, La $576.00' . •$50:60: 09/25%14 • Insurance.Peymenf $998:37 09%25/-14 Adjustment -.Contractual . $322:98. 09%25/14 SggUdstreti.on reductio -$4.05 Fahnestock-, .James 69525693`09/07%.14 ;99291 Cr.i'fica'l Care'Ill/ ' :Ravichandran, La W6.00 .$50.60- 09/25%14: Insurance•Payment -$198.3.7' 09%25%14, Adjgstment s' Contractual -$322:98.. ; 09725/14 Sequestration - reductio =54.05 Fahnestock,..James 69525693 09/08/14 99232 Sbsq Hospital Care Reddy; Satish $155.00 596.:26 10/06/1.4 Insurance Paymerit . . =$63.72 .10/06/14 Adjustment Contractual $73.72 10/06%14 'Sequestration -. reductio -$1:30 Your account is 30 days pastdue. Please remit poikment now. CURRENT OVER 30 DAYS OVER i0 DAYS OVER SO DAYS OVER 120 DAYS $16.26 $253.00 $0..00 $0.:0 . `$'0.00 • $269.26 PATIENT IS RESPONSIBLE FOR MAKE CHECKS "PATIENT BALANCE"SHOWN. . STATEMENT DATE ACCOUNT NUMBER PAYABLE TO: 11/6/2014 12207-695.25693 RENAL CONSULTANTS; PC DBA GOOD SAMARITAN EMERGENCY PHYS.11rS Page 1 of 2 WIRU Thank you for choosing DBA GOOD Statement Date: 12/2-2/14Responsible SAMARITAN EMERGENCY PHYSICIANS for Responsible Party: JAMES FAHNE$TOCK Account Number: 55008 0039686018 your health.care needs. Due Date: Upon Receipt REQUEST FOR PAYMENT "Z Summary of Account trS:"-.'.. ,v.�_.d�Y'';tiv'l¢-::fG1<a:�.:.�l:u''f':4',�•�:;�o�s��r�y:,"-4°ri1'�r.:.af.f,ti^iC�;a"uc';?c':pr�,'':.:X-c'"t.r!'^tz..�ti.:�SF'i.g:;Hr:,a',v.5v,;rS.,.?;.-."��'3FI:,,r.S:::tc.i:;'';�,VM.,:'.:,-,>s.•YT:i:ti<;rti.;5`==:��`)y•/�.y:�_:�.e.`.p:?��3r:�,9�rc;a.a-.,.i.::="::-.w��:Y•..,,_;:-;;rfT�,+,:+`K1.,.d:j.'=�`'r.:�2?aE.=:i�:c:`.�.,'s-.4<(�7iurS��!r',-r:14�•c-!.am,,:_�4�.".Total Charges 846.00 A�� ._Jti�ia•^',:�;i,�r;'':'?`�,,v<.a>"C�.:y-::j?l.4+.t : K:ir�y.."" ,f,},�.,...uSa:x*:y_,..�z..s;.?:..�-�.T;,;,.. 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"� -\.. .v _ ,t� 511- :. :�.*..,e ?•r:_.,Fk -.>.:r,. s:, i��..{� xr <6�ti'r'... ,:u�;`-;:rX(•� t�.�, fi4Y't�+ 1 t _ :oaf, t•_..- :^> .i?ti::t-.":'i'•: .`'.>^:vyy;: ':'�'., ei�:-. -:+3r- ,a4_ - +•2 ":.(.G ,^'S,w ��k^`' .r <'�•>:. _. f::�- -. f:r. ._.c. ...,.,i:`n:"�T•.,of \ h. - i. x )'4 a .....:, : ��. .__ ..-... •--.......:,... >. ., ,......._ ;_ �- -- ....... ,.... ..,..._,..;,. ..._._. _... .._,. ... PPa B Mall —Please detach and return bottom stub with your check ay y —Include account number oh check and correspondence DBA GOOD SAMARITAN EMERGENCY PHYSICIANS 55008*0039686018 JAMES FAHNESTOCK P.O.BOX 8080'.., GRAND RAPIDS,MI 49518-0808 Temp �Arliun,L7ue # [ie �, `ArnodntPaid Temp-Return Service Requested 12/22/14 . $50.60 Upon Receipt For your protection: Do not include the credit card information in the mail. Make CHECK payable and remit to: o 10 01 GRAP`0717`0039686018`c55008 I�IIIII�II��I�I�III��llll�ll��lll��ll�l�lll��11llll11lll1'II' 000 200327 164967 94964588 JAMES FAHNESTOCK DBA GOOD SAMARITAN EMERGENCY PHYSICIANS WUI 6 ELDRED HEIGHTS RD 20,GRAND ST FL 3 ELDRED,NY 12732-5020 WARWICK,NY 10990-1035 Port Jervis Volunteer Ambulance Corps Inc PO Box 90 Danville,PA 17821-0090 (800)3 4 Patient name: FAHNESTOCK,JAMES Sr. Run Number: 14-109852 Date of call: 8/30/2014 From: 6 ELDRED HEIGHTS JAMES FAHNESTOCK Sr. To: Bon Secours Community Hospital 9 WATSON DR CARLISLE,PA 17015 Primary payer: National Government Services,Inc. Secondary payer: Patient Pay Payment Description Payer Check# Quantity Unit Price Date Amount ALS 1 Emergency 1 $900.00 $900.00 Mileage 0,1 $15.00 $1.50 Contractual Allow-Medicare National Government Services,Inc. 09/11/2014 $451.75 Contractual Allow-Medicare National Government Services,Inc. 09/11/2014 $0.41 C/A Medicare National Government Services,Inc. 10/01/2014 10:47 10/01/2014 $7.19 Payment-EFT National Government Services,Inc. 10/01/2014 10:47 10/01/2014 $351.43 Payment-EFT National Government Services,Inc. 10/01/2014 10:47 10/01/2014 $0.85 PAY THIS BILL ONLINE AT WWW.EMSBILLPAY.COM PLEASE PAY THIS AMOUNT OR CALL THE NUMBER ABOVE TO PAY BY PHONE $89.87 ........................................................................................................................... ............. ......................................................................................... ................................................................... DETACH ALONG LINE AND RETURN STUB WITH YOUR PAYMENT.THANK YOU. Patient name: FAHNESTOCK,JAMES Sr. Run Number: 14-109852 AMOUNT $ ENCLOSED: Date of call: 8/30/2014 Current date: 10/31/2014 REMIT TO: Port Jervis Volunteer Ambulance Corps Inc PO Box 90 Danville,PA 17821-0090 This is the 2nd invoice we have forwarded to you.A balance remains on your account and is now past due. Please respond today with the appropriate information or forward payment. Port Jervis Volunteer Ambulance Corps Inc PO Box 90 Danville,PA 1782�-0090 (800)369-75644 Pent name: FAHNESTOCK,JAMES Sr. Run Number: 14-109852 Date of call: 8/30/2014 From: 6 ELDRED HEIGHTS JAMES FAHNESTOCK Sr. To: Bon Secours Community Hospital 9 WATSON DR CARLISLE,PA 17015 Primary payer: National Government Services,Inc. Secondary payer: Patient Pay Payment Description Payer Check# Quantity Unit Price Date Amount ALS 1 Emergency 1 $900.00 $900.00 Mileage 0.1 $15.00 $1.50 Contractual Allow-Medicare National Government Services,Inc. 09/11/2014 $451.75 Contractual Allow-Medicare National Government Services,Inc. 09/11/2014 $0.41 C/A Medicare National Government Services,Inc. 10/01/2014 10:47 10/01/2014 $7.19 Payment-EFT National Government Services,Inc. 10/01/2014 10:47 10/01/2014 $351.43 Payment-EFT National Government Services,Inc. 10/01/2014 10:47 10/01/2014 $0.85 PAY THIS BILL ONLINE AT WWW.EMSBILLPAY.COM PLEASE PAY THIS AMOUNT OR CALL THE NUMBER ABOVE TO PAY BY PHONE $89.87 DETACH ALONG LME AND RETURN STUB WITH YOUR PAYMENT.THANK YOU. Patient name: FAHNESTOCK,JAMES Sr. Run Number: 14-109852 AMOUNT $ ENCLOSED: Date of call: 8/30/2014 Current date: 12/1/2014 REMIT TO: Port Jervis Volunteer Ambulance Corps Inc PO Box 90 Danville, PA 17821-0090 We have contacted you 3 times regarding the balance due for our services and we have not heard from you. Please contact us immediately or remit payment today. BILL DATE ACCOUNT No AMOUNTDUE 11/20/14 2117 1 $ 169.31 ROCKLAND INFE9f0US DISEASE, LLP IF PAYING BY CREDIT CARD AMOUNT'ENCLOSED 2 CROSFIELD AENUE, SUITE 102 Credit Cards Not Accepted $ WEST NYACK, NY 10994-2233 1 Forwarding Service Requested CARD NUMBER AUTHORIZATION CODE M1100 (last 3 or 4 digits on back of card in signature line) SIGNATURE EXP.DATE 26830 ROCKLAND INFECTIOUS DISEASE, LLP Eli JAMES FAHNESTOCK 2 CROSFIELD AVENUE, SUITE 102 9 WATSON DR WEST NYACK, NY 10994-2233 CARLISLE PA 17015 F] Please check box if above address is incorrect or insurance n pl Please check box if credit card billing address is different than state- information has changed,and indicate change(s)on reverse side. ment address and write in address on back . .......... . —--------------------- RETURN TOP PORTION•RETAIN LOWER PORTION Past Due Notice Patient Name Amount Due Notice Date JAMES FAHNESTOCK $169.31 11/20/14 Final Past Due Notice Unfortunately, records indicate that this balance has not been resolved. This is a final notice avoid legal actions to receive payment. Our records indicate that this bill remains unpaid with us. This bill is your responsibility and must be paid now. We needyour payment for this balance sent to us now. If there is any issue related to paying this, we need you to call us immediately. Thank you very much, in advance for resolving this outstanding past due balance on your account. Sincerely, The Staff Billing Collections Department AST PAYMENT RECEIVE6 1/00/00 0.00 ROCKLAND INFECTIOUS DISEASE, .LLP . ,,, EC, 2 CROSFIELD AVENUE, SUITE 102 • !L:To. WEST NYACK, NY 19994-2233 169.31 Ph:(877)-643-2336 Statement Date: 11/20/14 Acct#:2117 Page 1 of 3 UIMNIA1414144AA n')gQln A4 n-2 MA— CHECK CARD USING FOR PAYMENT ' NEW AMSTERDAM MED ASSOC -SP PO W � I] PO BOX 95000 CL#5280 MASTERCARD DISCOVER t VISA ILEVa AMERICAN EXPRESS PHILADELPHIA, PA 191955280 CARD NUMBER SIGNATURE CODE 16466-3X35 SIGNATURE EXP.DATE RETURN SERVICE REQUESTED STATEMENT DATE PAYTHIS AMOUNT ACCT.# �� Questions? Please.call, 201-818-1847 01/16/15 $377.60 366536-00 020277 Billing Office Hours: Monday-Friday 9am-5pm. BALANCE.DUE UPON RECEIPT. SHOW AMOUNT 17 Hours Mon-Fri 9:00AM-5,00PM PAGE: 1 Of 2 PAID HERE MAKE CHECKS PAYABLE TO: 500005A IIII'lllll9ll'I'11'lllhI111111PIIIIIII Ill'lllllllll111 1 l'I' I'PII1111 III'1111111'lll'I'I'I''11-II11'llllll"III"III'1411 JAMES FAHNESTOCK NEW AMSTERDAM MED ASSOC -SP 6 ELDRED HEIGHTS ROAD PO BOX 95000 CL#5280 ELDRED, NY 12732-5020 PHILADELPHIA, PA 19195-0001 16466-3X35*T9D0A1GZ0000024 Please check box if address is incorrect or insu.$nce PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT information has changed,and indicate change(s)on reverse.side. STATEMENT DATE DR PATIENT DESCRIPTION CHARGE PAY/ADJ BALANCE Coinsurnace 50.60 08/31/14 rsi James Crit Care Um-unstable Pt; 1st Hr 331.16 41/06/14: Plan Payment:891844726 - Empire NY Medica -198.37 11/06/14 Adj:Contractual. Allowanc - Empire.NY Medi -82.19 BILL Balance:136.081 50.60 Coinsurnace 50.60 09/01/14 rsi James Crit Care E&m-unstable Pt; 1st Hr 331.16 11./06/14 Plan Payment:891844726 : Empire NY Medica -198.37 11/06/14 Adj:ContractuaL Allowanc - Empire NY Medi 82.19 Bill. Balance:136084 50.60 . Coinsurnace 50.60 09/02/14 rsi James Crit Gare E&m-unstable Pt; 1st Hr 331.16 11/06/14 PLan Payment:891844726 -.Empire NY Medica -198.37 11./06/14 Adj:Contractual .ALLowanc - Empire.NY Medi -82:,19 BILL BaLance:136087 50.60 Coinsurnace 50:60 09/03/14L rsi James Crit Care E&m=unstable Pt; 1st.Hr 331.16 11/06/1.4 Plan PAyment:891844726 -. Empire NY Medica 198:37 11/06/14. Adj:contractuaL AtIowaric - Empire NY Medi. 82.19 BILL Balance:136090 50.60 Coinsurnace 50.60. 09/04%14 rsi James Crit Care E&m=unstable Pt; 1st Hr 331.16 1,7/06/14 Plan Payment:891844726 - Empire NY Medica 198.37 11/06/14 Adj:ContractuaL Allowanc- Empire NY Medi -82.19 ACCT: 366636-00 CURRENT 30-60 DAYS 60-90 DAYS 90-120 DAYS OVER.120 DAYS INS BALANCE 0.00 331.16 0.00 0.00 0.00 PATIENT DUE CONTINUED PATIENT BALANCE 0.00 0.00 317.60: 0.00 0.00 I I *Amounts pending with insurance are not included in the balance due. You will be billed once your insurance responds to our claim. NEW AMSTERDAM.MED ASSOC -SP PO BOX PA 1918955280 201-818-1847 16466-3X35*T9DOA10Z0000024 II�II�I� II'III II�pI I�If�IIII IIIIII�IIII�'�IIIIIIII�I�I'�I Rockland Mobile Care Inc. 540 CHESTNUT RIDGE RD CHESTNUT RIDGE,NY 10977-5646 (845)627-8615 Ext. 3198 Billed to: Customer: JAMES FAHNESTOCK JAMES FAHNESTOCK 6 ELDRED HEIGHTS RD 6 ELDRED HEIGHTS RD ELDRED,NY 12732-5020 ELDRED,NY 12732-5020 (845)000-0000 Orio;,in: Good Samaritan Hospital Destination: 255 LAFAYETTE AVE Wayne Woodlands Manor 476-1 o2 295 SOUTH ST SUFFERN,NY 10901 WAYMART,PA 18472 Re: Run Number: Date of Service: Amount Overdue: 14-13047 09/12/2014 $202.91 Dear JAMES FAHNESTOCK, Our records indicate we provided transportation for JAMES FAHNESTOCK on the above date of service,and have sent three invoices to you requesting payment.To date,we have not received your remittance. Your immediate attention is required to avoid any further collection efforts.Full payment is due no later than 01/25/2015.If you are unable to remit the full amount,you should contact our office immediately to set up a payment schedule. Please be advised that this is the final notice you will receive.if you have any questions,you should immediately contact our Collection Representative. Thank you for your cooperation. Sincerely, The Collection Department Printed on 1/15/2015 EMStar NY 386 Route 59 Suite 300 Airmont,NY 10952 (845)704-8000 Patient name: FAHNESTOCK,JAMES Run Number: 14-32462 Date of call: 8/30/2014 Time of call: 23:24 Caller: ICU STAFF From: BON SECOUR COMMUNITY HOSPITAL JAMES FAHNESTOCK To: GOOD SAMARITAN HOSPITAL-SUFFERN 9 WATSON DRIVE CARLISLE,PA 17015 Primary payer: MEDICARE DUT/PUT/ORANGE/ULS 171365795A Secondary payer: Bill Patient Payment Description Payer Check# Quantity Unit Price Date Amount ALS Non-Emergency 1 $275.83 $275.83 Mileage-Ambulance 52 $7.03 $360.39 Payment-Wire MEDICARE DUT/PUT/ORANGE/ULS 891633070 11/04/2014 $221.95 Payment-Wire MEDICARE DUT/PUT/ORANGE/ULS 891633070 11/04/2014 $339.03 PLEASE PAY THIS AMOUNT $75.24 --------------------------------------------- -------------- ------------------- ------------------------------------------------------------------------------------------- -------- DETACH ALONG LINE AND RETURN STUB WITH YOUR PAYMENT.THANK YOU. Patient name: FAHNESTOCK,JAMES Run Number: 14-32462 AMOUNT $ ENCLOSED: Current date: 1/7/2015 Due on: 01/17/2015 REMIT TO: EMStar NY 386 Route 59 Suite 300 Airmont,NY 10952 TRISTATE EMERGENCY PHYSICIANS PLLC 393w 431292 6-PA'YIQ1Wd9=6dA1mR.t-d01'tAEld00• 004828L CHECK CARD USING FOR PAYMENT STE 104 = 0 484 TEMPLE HILL ROAD GDE]MASTERCARD VISA AMERICAN EXPRESS DISCOVER NEW WINDSOR NY 12553 CARD NUMBER AMOUNT RETURN SERVICE REQUESTED SIGNATURE EXP.DATE BILL QUESTIONS: (845)565-9400 STATEMENT DATE PAY THIS AMOUNT ACCT.1t 11/24/14 36.02 6325094 r•+ cKEcK • ISHOW AMOUNT PAGE 1 OF 1 PAID HERE w A ••• TO: N JAMES FAHNESTOCK TRISTATE EMERGENCY PHYSICIANS PLLC 0 6 ELDRED HEIGHTS RD STE 104 a N ELDRED NY 12732 484 TEMPLE HILL ROAD N UNITED STATES NEW WINDSOR NY 12553 [sill 111111 lll'1'II �Illllll11111'll�'ii�l��lli'� Please check box if above address is incorrect or insurance ❑information has changed,and indicate change(s)on reverse side. PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT PAYMENTS DATE PROVIDER DESCRIPTION PATIENT' CHARGES 'BALANCE". OB%30/14 HMOUD EMERGENCY:,.DEPARTMENT VISIT-,P, A JANES 687.00 36 OZ . 10/01%14 PAYMENT INSURANCE (141:18) C,6ntractual,Wrltes,0ff 10Y0i%I4 WRITE OFF INSURANCE C2 88J 10/01114 ; ; WRITE OF.F INSURANCE (506. 92) hy MESSAGES' . 41 THIS B:ILL I$ FOR THE ER PNYSIC,IAN CHARGES AT BON SECOURS OR ST. ANTHONY. IT IS NOT THE 'HOSPITAL BILL. CURRENT 31=60 DAYS 61 90 DAYS 91. DAYB OVER 120 DAYS UNAPPLIED BALANCE DUE :_0.00 56.02,, - 0.00 0.00 0.00 .0.00 ,. 36...02 PLEASE REMIT TO: TRISTATE EMERGENCY.PHYSICIANS PLLC ACCOUNT NUMBER: 6325094 STE f 04. 484 TEMPLE HILL ROAD NEW WWOSOR NY 12553 PLEASE PAY THIS AMOUNT 36.02 BILLING QUESTIONS: (845)565-9400. HOSPITAL ATTENDING PHYSICIANS Patient Statement 484 Temple Hill Rd,Suite 104 Friday,September 26,2014 Pagel of NEW WINDoOR,NY 12553 (845)`65-9400 (800)571-7440 1781929 $180.20 Payment Type: Check Mastercard Discover -� eoc Visa Hoc PAR Account# �6AP James Fahnestock Expiration Date_/ / 9 Watson Dr. Signature Carlisle, PA 17015 Date / / Security Code Reflects transactions posted through 9/26/2014 Date Description Check p Fee Units Insurance Patient JAMES FAHNESTOCK(1781929)/KENNETH ZWEIG MD/3973766 Location: Hospital Attending Physicians Diagnosis: (410.90) Diagnosis: (518.81) Diagnosis: (584.9) 08/31/2014 Critical Care,Evaluation And Management Of The Critcally Ill Or Injured $1,015.00 1.00 $1,015.00 $0.00 Patient,Requiring The Constant Attendance Of The Physician;First 30-74 Minutes(99291) 09/10/2014 Mcare Wo Adjustment from Medicare Empire Downstate ($713.48) $0.00 09/26/2014 Mcare Wo Adjustment from Medicare Empire 891558650 ($48.50) $0.00 09/26/2014 Co253 Adjustment from Medicare Empire 891558650 ($4.05) $0.00 09/26/2014 Medicare Payment Payment from Medicare Empire 891558650 ($198.37) $0.00 09/26/2014 Transfer From Insurance 891558650 ($50.60) $50.60 Balance: $0.00 $50.60 JAMES FAHNESTOCK(1781929)/RICHARD W RONDAMNAMD/3973767 Location: Hospital Attending Physicians Diagnosis: (410.90) Diagnosis: (518.81) Diagnosis: (584.9) 09/01/2014 Subsequent Hosp Care Low Severity(9923 1) $148.00 1.00 $148.00 $0.00 09/10/2014 Mcare Wo Adjustment from Medicare Empire Downstate ($105.62) $0.00 09/M/2014 Mcare Wo Adjustment from Medicare Empire 891558650 $2.01 $0.00 09/26/2014 Co253 Adjustment from Medicare Empire 891558650 ($0.71) $0.00 09/26/2014 Medicare Payment Payment from Medicare Empire 891558650 ($34.80) $0.00 09/26/2014 Transfer From Insurance 891558650 ($8.88) $8.88 Balance: $0.00 $8,85 JAMES FAHNESTOCK(1781929)/GEORGE SAMUEL MD/3973768 Location: Hospital Attending Physicians Diagnosis: (410.90) Diagnosis: (518.81) Diagnosis: (584.9) 09/02/2014 Subsequent Hospital Care(99233) $371.00 1.00 $371.00 $0.00 09/03/2014 Subsequent Hospital Care(99233) $371.00 1.00 $371.00 $0.00 09/04/2014 Subsequent Visit(99232) $257.00 1.00 $257.00 $0.00 09/05/2014 Subsequent Visit(99232) $257.00 1.00 $257.00 $0.00 09/06/2014 Subsequent Visit(99232) $257.00 1.00 $257.00 $0.00 09/10/2014 Mcare Wo Adjustment from Medicare Empire Downstate ($1,058.32) $0.00 09/26/2014 Mcare Wo Adjustment from Medicare Empire 891558650 $23.14 $0.00 09/26/2014 Co253 Adjustment from Medicare Empire 891558650 ($7.64) $0.00 09/26/2014 Medicare Payment Payment from Medicare Empire 891558650 ($374.60) $0.00 09/26/2014 Transfer From Insurance 891558650 ($95.58) $95.58 Balance: $0.00 $95.58 JAMES FAHNESTOCK(1781929)/GEORGE SAMUELMD/3973769 Location: Hospital Attending Physicians Hospital Attending Physicians*484 Temple Hill Road STE 104*New Windsor,NY 12553-5529 Patient Statement 484 Temple Hill Rd,Suite 104 Friday,September 26,2014 Page 2 of 2 NEW WINDaOR,NY 12553 (845)55-9400 (800)571-7440 ❑ ❑ ��aM 9oc PAR James Fahnestock -s"P Date Description Check# Fee units Insurance Patient Diagnosis: (348.1) Diagnosis: (410.90) Diagnosis: (507.0) Diagnosis: (518.81) 09/07/2014 Subsequent Visit(99232) $257.00 1.00 $257.00 $0.00 09/08/2014 Subsequent Hosp Care Low Severity(9923 1) $140.00 1.00 $140.00 $0.00 09/10/2014 Mcare Wo Adjustment from Medicare Empire Downstate ($277.14) $0.00 09/26/2014 Mcare Wo Adjustment from Medicare Empire 891558650 $5.81 $0.00 09/26/2014 Medicare Payment Payment from Medicare Empire 891558650 ($98.52) $0.00 09/26/2014 Co253 Adjustment from Medicare Empire 891558650 ($2.01) $0.00 09/26/2014 Transfer From Insurance 891558650 ($25.14) $25.14 Balance: $0.00 $25.14 i ***Please fill out insurance information below or email to CustomerService@medicom-mgmt.com.Please include Patient ID(listed at top of statement)on all emails***If services are related to a accident,please provide us the name,address and claim number for your insurance. To prevent denial from your insurance,return within 5 days. IF YOU HAVE INSURANCE,COMPLETE THIS SECTION AND RETURN TO US FOR BILLING: PLEASE CHECK ONE: [—] Medicare Medicaid Health No Fault Workers Compensation FAHNESTOCK,JAMES- 1781929 Date Of Injury: Insurance Company Name: Insurance Company Address: Insurance ID Number: Group Number: Claim Number: Employer Name: Employer Address: $180.20 $0.00 $0.00 $0.00 $0.00 l $180 20 I $0.00 I $180.20 Hospital Attending Physicians*484 Temple Hill Road STE 104*New Windsor,NY 12553-5529 STATEMENT Wayne Woodlands Manor Statement Date: 10/01/2014 37 Woodlands Drives a PA 1472j8 66 W I ar . 0130 Due Date: 10/20/2014 Telephone: (570)4 Amount Enclosed$ - Amount Due: $ 1,696.00 Account#: 2734 RE: James R Fahnestock James Fahnestock 6 Eldred Heights Road Eldred, NY 12732 Please detach and return top portion with payment. MTR-1 N NO 2 09/12114-09/19/14 SEMI-PRIVATE 8 212.00 1,696.00 1,696.00 current 31-60 Days 61-90 Days Over 90 Days Amount Due 1,696.00 .00 .00 .00 We accept Visa,MasterCard,American Brprm,Discover All Accounts over 120 days will be sent to collections. Questions regarding your bill? C311 570-488-7130 x1125. Statement Date: 10/0112014 All payments are expected by the 15th of the month Thank you for allovAng us to take care of your family Due Date: 10/20/2014 James R Fahnestock-Account#: 2734 Wayne Woodlands Manor 37 Woodlands Drive Waymart, PA 18472-9366 Telephone: (570)488-7130 WCAIS - Submit Request Page 1 of 1 Home O H2(p PAMarcus McKnight,III 10 Logout Search Helpline My Matters WCAB WCOA Healthcare UEGF Profile Dashboard Submit Request +Expand WV1C)AIS Claim#: 7281338 Claimant/Employee Name: GATES,TODD Defendant/Employer Name: GRANE HEALTHCARE `r Claim Status: Med Only Date of Injury: 61312013 View Claim Summary Dispute: DSP-7281338-1 iii' Status: Waiting for Briefs View Dispute Summary Thank you for your online submission of the Continuance Request. Submitted by Marcus A McKnight,III on 5/28/2015 at 10:52 AM on Dispute DSP-7281338-1. You will be getting a copy of the Request by email for use to serve parties by mail or in person. Please click here to view and print details of the Request. Please dick the print button to print the confirmatin message for your records. Print Return to Dispute Summary Site Map I Accessibility Statement I Privacy Policy I Security Policy I Contact Us Copyright©2011 Commonwealth of Pennsylvania.All rights reserved. https://www.wcais.pa.gov/ol/AJ/REQ/SSR75522.aspx?N_wg2hquyvVHPtl@CyD 1 bkTad... 5/28/2015 WCAIS - Submit Request Page 1 of 1 Home R Help CPA pennsytvania WORKERS COMPENSATION A—MATI-I ANO INTEGRATION S—F-� Marcus McKnight,III U Logout Search Helpline My Matters WCAB WCOA Healthcare UEGF Profile Dashboard Submit Request +Expand fW'C'AIS Claim#: 7281338 Claimant/Employee Name: GATES,TODD Defendant/Employer Name: GRANE HEALTHCARE Claim Status: Med Only Date of Injury: 6/3/2013 View Claim Summary Dispute: DSP-7281338-1 } Status: Waiting for Briefs View Dispute Summary Thank you for your online submission of the Continuance Request. Submitted by Marcus A McKnight,Ill on 5/28/2015 at 10:52 AM on Dispute DSP-7281338-1. You will be getting a copy of the Request by email for use to serve parties by mail or in person. Please dick here to view and print details of the Request. Please dick the print button to print the confinnatin message for your records. Print I Return to Dispute Summary i Site Map I Accessibility Statement I Privacy Policy I Security Policy I Contact Us Copyright©2011 Commonwealth of Pennsylvania.All rights reserved. https://www.wcais.pa.gov/ol/AJ/REQ/SSR75522.aspx?N_wg2hquyvVHPtl@CyD 1 bkTad... 5/28/2015 WCAIS - Submit Request Page 1 of 1 CP 10 Home R Help " • Marcus McKnight,III E Logout Search Helpline My Matters WCAB WCOA Healthcare UEGF Profile Dashboard Submit Request +Expand W('C�AIS Claim#: 7281338 Claimant/Employee Name: GATES,TODD Defendant/Employer Name: GRANE HEALTHCARE V Claim Status: Med Only Date of Injury: 6/3/2013 View Claim Summary Dispute: DSP-7281338-1 ( Status: Waiting for Briefs View Dispute Summary Thank you for your online submission of the Continuance Request. Submitted by Marcus A McKnight,III on 5/28/2015 at 10:52 AM on Dispute DSP-7281338-1. You will be getting a copy of the Request by email for use to serve parties by mail or in person. Please click here to view and print details of the Request. Please dick the print button to print the confinnatin message for your records. Print Return to Dispute Summary Site Map I Accessibility Statement I Privacy Policy(Security Policy Contact Us Copyright©2011 Commonwealth of Pennsylvania.All rights reserved. https://www.wcais.pa.gov/ol/AJ/REQ/SSR75522.aspx?N_wg2hquyvVHPtl@CyD 1 bkTad... 5/28/2015