HomeMy WebLinkAbout06-26-15 JLsoselolas
REV-1500"`�",�°�`
OFFICIAL lISE ONLY
PA DepartmenfofRevenue P?!!nsylvania
Bureau oftntlividualTaxes '� �� Cwnry Cotle Year Ftle Numbe:
aosoxasoeov �NHERITANCETAXRETURN f
H � b PA 7 e- s RESIDENT DECEDENT a � �J O � yC�
ENTER DEGEDENT INFORMATION BELOW
Social Securiry Number Dale of Death MJ}pOWYY Dale of Bitlh MM�OYYYY
04/OS/2015 04/i6/1924
Decedenfs Lasl Name SuRx Deceden�§firsl Name MI
Balint John
Qf Applicable)Enter Surviving Spouse's Iniormation Below
Spouse's Las�Name SuRx Spouse's First Name MI
SGouse s Social Securiry Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1. Original RaWrn O �-Supplemen�al Relurn O 3- Remaintlar ReWm(�ale o10ea�b
Prior to 12-13-82)
O 4 Limitetl Es�ale O 4a PoWre Interest Compmmise(tlate ul O 5. FeJerol Es�a�e Tax ReNm Required
deetn afler 1242A2)
� fi. Decetlent Oied Tes�a�e O ].UeceOent Maintainetl a LWing Trust _ 8. Total Number of Sate Oepostl Boxes
(A�Nch Copy of Wllp (AttacM1 Copy o(TrusL)
O 9-Gligation P�oceatls Receivetl O 10-Spousal Povatly Cre�l�(Dale of�ealh O 11. Elecfion�o Tax untler Sea 8113(AJ
Betwaen 12-31E1 antl 1-b95) (Altach Sc�etlule O)
GORRESPONDENT- THIS SECiION MUST BE COMPLEiE�.ALL WRRESPONDENCE ANO CONFl�ENTIAI TA%INFORMATION SHOUL�BE DIRECTE�i0'.
Name �aytime Telephone Nvmber
Andrew C. Sheely, Esquire 717-697-7050
REGISTER OF WILLS USE QNIY
� n�
1 C�
Flrst Line o�Atltlress � - -�
127 South Market Street - ` `',
rv �
Second Line ofAtldress � �"� -� �
PO. Box 95 � ..o �. -�
DATEFILEO -�� -��
Ciry or Pos�ORice S�a�e ZIP Cotle �
r� �7
Mechanicsburg PA 17055 . ., ,�
' ` �
�
co.resaonaenrs e-mau aaaressr antlrewcsheety@verizon.net
Untler penallies or peri��Y.�aeclare Nat I M1ave eeaminea enls reW rry Inclutling acwmpanying scneaules ana statemenls,ane to ibe�est of my knowletlge ana eeliel.
II is Ima,cortecl entl aomplete.Declaratlon o!preparer oNer�nan Na personel repiosenlallva Is basatl on ell mfom�ellon of wM1¢M1 preperer M1es any knowleQge.
SIGN RE OF PERSON RESFON LE FOR FlLI G RETURN �ATE JS
.�,��..A�r ����� L �
ADDRE55
Richard A. Balint, Ex., 35 Bayberry Drive, Mechanicsburg, PA 17050
SIGN RE OF PREPARER�y E THg�EPRESENTATNE �ATE
/'.fiL� � (1 .X �r�3�7tJI.�
nooaess �
Andrew C. Sheely, Esquire, 1 South Market Street, P.O. Box 95, Mechanicsburg, PA 17055
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610105 1505610105 J /�
1�
� 1505610205
REV-1500 Ex(FI)
Decetlenfs Social Secunry Number
oe�eaemsName. JohnBalint
RECAPITULATION
1. RealEstate (Schedule A). .. . .. . .... .. . . . . . ... . . . . . . . . .. . . ... . .. . . . . . . 1.
2. 5[ocks and 6onds(Sc�edule B) . . . .... .. . . .. . ... . . . . . . . . ... .. . . . .. . . .. 2.
3. Cbsey Held CorGoration, Patlnership or5ole-Proprielorship(Schetlule C) . . . . . 3.
4. Mortgages and Notes Receivable(Schedule�). . .. . .. . .. . . . . . . .. . . . . . . . . . 4.
5. CasM1, Bank�eyosits antl Miscellaneous Personal Property(Schedule E).. . .. . . 5. $4,33074
6. Jointty Owned Property(Schedule F) O Separate Billing Requested ... .. . . 6. �
1. In[er-Vivos Transfers 8 Miscellaneous Non-Probate Property
(Scnetlule G) O Seperate Buling Requested. ._. . .. ]. 26,595.05
8. Total Gross Assets(total Lines 1 ihmugh 1). .... ... . .. . . ... ... . ... . ... . . 8. $76,92$.79
9. Wneral ExVenses antlAtlminisVative Cos�s(Schetlule H). .. . .. .. ... . .. . . ... 9. $,551.39
10. Oeb�s o!Deceden�, Mortgaqe Liabilities and Liens(SchetlWe p. . .... . . . . .. . .. 1p. 7,777.47
i�. ro�ai oeauctlore�mtai lines s ane 50). . .. . . .. . . .. . .. . . .. . ... . . ... . .. . . it � 11,328.86
12 Net Value ot Estate��ine e minus Line i�) . . . . . . . . .. . .. . . . . . ... . .. . . . .. . 12. 65,596.93
13. Charitable antl Govemmsntal Bequesls/Sec 9113 Trusts lor which
an elec�ion ro tax has not been matle(Schetlule J) . . . .. . . ... . . . . ... . ... . . . 13.
14. Net Value Subjact fo Tax(Line 12 minus Line 13) ... . ... . .. . . . . . ... . ... . . 14. 65,596.J$
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABIE RATES
15. Amount of Llna 14 taxable
atme spousaltax rate.or
trznsfers under Sec.9118
(a)(L2)X 0_ 15.
i6. Amount o(Line 14 taxable
atlinealrale X_045 65,596.93 ig 2,951_86
1]. Amoun�of Line 141axable
al sibling rate X.12 ��,
18_ Amount of Llne 14�axebla
a�mllateral rate X.15 �g_
19. TAX DUE . . . .. . .. . .. . . .... . .. . .. . . .. . . . . .. . . .. . .. 19. 2�951.8$
20. FILI IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Side 2
L 1505610205 1505610205 �
REV-0500 EX�Fl) Pa9e 3 File Numbet �/ / L"�� o/J��
Decedent's Complete Address: ✓ �
DECEDENTSNAME
John Balin�
..._.__ _ ...... .
. _.______.. . . . .. .
s`aeeraooaess ..__. . ._
1 LongstlortWay ___._
.____ . .. . ..
CITV ..... . STHTE.. .... .'�, ZIP
Carlisle '� PA 17015
Tax Payments and Credits:
1. Tax Due(Page 2,Line 18) (1) 2,951_86
2 CrpAi�slPayments
A.PnorPaymenls . ...2,80428
B. Discount �4��58
. .- -.. ........ .. — TotalCreaits�A+e) (2) 2,951.86
3. Interest
(3) _
a If Line 2 Is grealer lhan One 1 *Llne 3,enter�ha diRerence. This Is the OVERPAYMENT.
Fill in oval an Page 2,Line YO to request a refund. (4)
5. il Line 1 +Line 3 is greater than Line 2.enter Ihe dlHe�ence-This is�he TAX�UE. (5)
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. �ia decedent ma<e a Iransfer an0: Yes No
a. re�ainlheuseorincomeoflhepmpertytransferred ......._ _._.._ ._.._.. ............ ❑ �
b. relain ihe ngM to Oesignate who shall use the pmpeny Iransferred or its income ..._._.._................._.....__. ❑ �
c. re�ainareversionaryinterest ._._._ _._._ ...__. _..__. _......._. ❑ �
d. receivethepmmiseforlifeofeitherpaymems,benefilsorcare� ........... ..._........ ._._.. ❑ �
2. If death occurred atler Dec.12,19ffi,did decedenl iransfer property wi�hin one year ot dea�h
withoutreceivingadeQualeconside2tion?.. _......... ........... ............ _._.... ❑ �
3. Diddeceaen�ownan'inlmstfor"o�payable-uporvdeathbankaccoun�orsecuntya�hisorhereeath?_...__.._ ❑ �
4. Dld dece0en�ow�an Indlvidual relirement accoun�,annuity or other non�robate propetly,whmh
contains a benefkiary designation� _....._ ........... _......... .........._. .._..... ❑ �
If THE ANSWER TO ANY Of THE ABOVE QUESTIONS IS YES,YOU MUST COMPLEfE SCHEDULE G AND FILE ITAS PART OF THE RETURN.
For da�es of tleath on or a(ter July 1,1994,and before Jaa 1, 1995,the tax rate Imposed on the net vaWe of iransfars to or(or ihe use o��he surviving spouse
is 3 percenl[72 P.S.§9116(a)(1.1)li)].
Fo� da[es oi deeth on or afler Jan. 1, 1995, the taz rate imposed on Ihe net value of transfers to or for the use of ihe surviving spouse is 0 percen;
[72 P.5-§911fi(a)(1 1)(ii)].The s�aWte does not exempi a transfer lo a surviving spouse fmm tax,and ihe statutory requirements for dlsclosure of assets and
fling a ax return are still applicable even if Ihe surviving spouse is Ihe only benefciary.
Por tla�es of dealh on or afler July 1,2000�.
• The tax rate imposed on the net value of iransfers irom a deceased child 21 years of age or younger at death to or for ihe uae of a naNral parenL an
adopMe parent or a stepparent of�he child is 0 percent[72 P.S.§9116(a�(11��.
• The�axra�elmposetlon�hene�valueoftransierstoorfortheuseoflhedecedentsllnealbeneficiariesis4.5percent,axceptasnotedln�72P.S§9116(a)(1)].
. The�ax rate imposetl on ihe net valua of Vansfers�o or for the use of the decedenfs siblings is 12 percen� [72 PS. §911fi�a)(1.3��.A sibling is defned,
under Section 9102,as an individual who has at least one parent in common with Ihe deceden�,whether 6y blaod or adoption.
RFR�508 E%�(11-10) I �
��� ' pennsylvarria SCNEDULE E
oEP<w�ME.* F wE�Ex�. CASH� BANK DEPOSITS & MISC.
in�aR<naT�aET�a^ PERSONALPROPERTY
zes�aemr oEcmevr
ESTATE OF: FILE NUMBER:
John Balint 21-15-0442
intlutle the pro[eeds of IitigaGon antl the aake t�e praeeds were received by[he estate. �.
All property Jointly ow�re0 with ri9M o(survivorehip murt be EiscloseA on Schedule F.
ifEM VA W E AT DATE
NUMBER DESCRIPTION OF DFAiH _
� � Member'sisfSaNngAccount#163142-00-principal$1974,accruetlinterest$0.00 �19i4
2 � Member'sistCDAccount#163142-01 -pnncipal$15,616.04,acemedinterest$1$8 5�5,617.92
3 Member515tCheckingAxoun�#163142-11.Pnncipal$1,000.55,accruetlin�erest$0.03, 1,000.58
4 MembersistCDAccountki63142-46. Pnncipal$33,687.55.accruedinterest$4.95 33,69250
I
TOTAL(Also en[er on Line 5, Recapitulation) ; 50,33074
If more space is netVee,use additiona!sheets af paper oF[he same siu.
st
1�1�
MEMBERSI"
FppF&11 WmR UMOS
REGULAR SAVINGS ACCOUNT: �63142-00
ACCount Number/Suffu( 1 o/t a/1996
Date Account Established $19 74
Principai Balance at Date ot Death g0.00
Accrued Interest to Date of Death $'9 74
Total Pnncipal and ACCrued Interest Richard A Balint
Name of Beneficianes Karen D Aven
INVESTMENT SAVINGS ACCOUNT: 1631yp-05
Account Number/Suffx 03l24/1997
Date Acwunt Established $0.00
Principal Balance at Date of Death g0.00
Aarued Interest to Date of DeaN g0.00
ToWI Principal and Accrued Interest Richard A Balint
Name of Benefciaries Karen D Aven
CHECKING ACCOUNT: 163142-1'1
Account Number/Suffix pq/03/2012
Da[e Account Establishetl g1,000.55
Principal Balance at Date of Death $Q 03
Accrued Interestto Date of Death g�,000.58
Total Pnncipal and Accrued Interest Richard A 8alint
Name of Beneficiaries Karen D Aven
CERTIFICATE OF DEPOSR: �63142�1 '163142-46
AccountNumber/Suffix 07/3�/2014 09/'I6/2013
Date Account EsWblished $75,616.04 $33,687.55
Pnncipal Balance at Date of Death $� 88 $4.95
AccrueC Interest to Date of Death $�5 6��92 $33.692.50
Total Principal and Accrued Interest None Rlchard A Ballnt
Name of Beneficianes Karen D Aven
. VISA CREDIT CARD ACCOUNT q672090000728592
Account Number 11/14/2009
Date Account Esiablished $0.00
Balance at Date of Death None
Joint Caftlholtler
MEMBERS 15T FEDERAL CREDIT UNION
ssa L Klugh
Lending Insurence Support Specialist
June 2, 2015
Estate of:JOHN BALINT
Date of Death:04I0512015
Sociai Security Number: 139-183527
�060 Louise Drive • P.O.Bos 40 • b4echanicsbuxg,Penns7lvania 17055 • (800) 283-2328 • www.memberslsvoxg
uEv- 51 :08�09'
SCHEDULEG
�. pennsylvania i
� oEpqq.„E„.oFa��E�+ue I INTER-VIVOS TRANSPERS AND
mnea*�cer�nena� MISC. NON-PROBATE PROPERTY
FILE NUMBER
ESTA7E OF p1-15-0442
John Balint —
This scheAule mus[be romplefed and Flledlfine answerro any 6questlons 1 :hrou9h 4 on page three ofMe NEV-600�yes. _
DESCRIPTION Of PROVERTY DNTE OF�EATH °/aOF DECD'S E%CWSION TAXAB:c
�iEM waweTMnuneoraam�wseaee'��auunansnivrooReoe+rovo VPLUEOf0.55ET INTERESL �rawuue�� VFWE
NUMBEA �rto�Ronwwuea. vrranccerarm[oeeowaxeuenn�.
Tr3nsfer to sen?Riche�d A Balinl 35 Bayberry Dnve,Mechanicsburg,PA pg 59506 100 3,OOOAO 26 595�7b
17050,Apnl4, 2015.
I
TOTAL(Also enter on Line 7, kerzOiNla[ion) ; 26,595D5
If more space is neeGed,use additlonal sheetr of oaper of the same size.
Nft'-'SC F%+ f19-05)
a="�' pennsyNania
SCHEDULE H
oePaA+ne«*orae�F��e FUNERALEXPENSESAND
�H�Ea�r��E.�,a�a� ADMINISTRATIVE COSTS ,
aesioENr oe[Eoervr
FILE NUMBER
ESTATE OF
John Balint
21-15-0442
DecedenYs Eebfs must be reporte0 on Schedule[.
7EM DESCAIPT[ON AMOUNi _
VLh18ER
z FUNERALEXPENSES: 5225.56
�� StardustMemonals
z. Cremation Society of Pennsylvania.Inc. 5295.61
$50A0
s. Diakon chaplain
a. Hunganan Reformee Church 525.00
5. Cumbedand Crossings Memorial Wncheon $633.88
s. Funeralluncheonsuppliesandfood 51%4A3
g. ADMIMSTRATIVE COSiS:
i, P:rsonal Representa[ive Commissions: $0.00
Name(s�of Personal Reoresentative(s) Richard A. Balint _ _
s�reecnda.ess.358aYbe�Drive . __ . _.__ __ ---- --� --
�, Mechamcsburg ..stare PA .z�e��050
N__ —_ _._ ___.
Year(z)Commission Paitl'. __ --- ---- -----'-
.. I $1.260.00
atmrneyFees: ��(�—eW C• c5/Jf'�fy� E'S�l��✓��
Family ExemF�om(I�deceGenf's a0dress a not Me same as daimanPs,attach explanaPion.)
Claimanc___ . — -�— �
5treetAdaress, ____ . - �-�--'—
_ --_ _
Clty. _. __ _� _ _ __. . 5[ate_._ZIP_ __—_"_
Aela[ionshipo(ClaimantmDecedent__ _ _____- ..._____—.—- — —
$245 50
4. Pmbate�ees:
5. Pccountan[feesa
5. Tax Retum heoarer fen'.
. Postage,ovemightmailingcosfs 41�4�
i 600.00
e. Reserves lo condude Estale atlminisVatioq final accountings
TOTAL(Also enter on Line 9, Recapitulation) ;
3,551 39
� If more s0are Is needed, use addltional sneets of paper oF Ihe same size.
�
«.�����,��° 2EMATION SOCIETY OF PENNSYLVANIA, IN(
� ^«��°� Jonurown Road.Harxisbuag PA V ID9•L800-]20-ffi21• Fu]ll-541-9943•Shawn 6 CarpcS Supervis�
MeMnt I�: �191016"R �e x: BGii
phone Order
MNXX�X�S121
NAS1ERff� Entrv Ikthod: I�1
iotal' ' �'�
��is 18:41'.B4 150435 Mo
Imp. &� ��' �
prorvd: O�lice Batd�: �116
�W2 fak: NA1CH 0
c..,�� �� Apr 6, 2015
m�«rw
iuv[ a xice oan.
Mrs . Karen Aven �
25 Watson Drive � � ' -
Carlisle, PA 17015
John Balint - DeceaseC �� �
SPECIAL CHARGES
X Direct Crematfon 51 ,795. 00
Nationwide Guarantee Program
Worldwide Travel Protectlon
TOTAL SPECIAL CHARGES . 51 , 795 . 00
PROFESSSONAL SERVICES
X ServSces of Funeral Directox & Staff Included
Other Praparation of the Hody
Facilitles & Staff for Memorial Service
Staff & Equipment for Memorial Service �
Wltnessing the Cremation
Prlvate Famlly Viewing/Wltnessing Crematlon
Packaging And ForwardSng Cremated Remalns
Personal Delivery of Cremated Remalns
Scattering of Cremated Remalns
Medical Documents/Courier Fee
TOTAL PROFESSIONAL SERVICES S0 . 00
AUTOMOTIVE EQUIPNENT
X Removal Vehlcle - - � included
Lead Car/Clergy Car
Family Car - .
Service Vehicle
TOTAL AUTOMOTIVE EQUIPMENT � 50 .00
� �
MERCHANDISE
Register Book
X Prayer Cards 100 @5100.00 6e Tax $6.00 5106 . 00
Thank You Cards
Remembrance Package
Cremation Container
X Famiiy is providing g55 . 00
X Keepsake Urn B1575X
Veterans Flag Case
Grave/Memorial Marker
TOTAL MERCHANDISE $161 .00
CASH ADVANC£D ITEMS
Grave Opening .
Cemetery Equipment .
Newspapers
Newspaper .
Vault Service Charge
Clergy . - . .. .
Church/Organist/Soloist � : �
Flowers Included
X Crematory Charge $30.00
X Cumberland County Coroner Fee
X e Certtfied Copies of Death Certiflcate 546 .00
TOTAL CASH ADVANCED ITEMS � $78 . 00
SUMMAAY OF CHARGES 1 ,795 .00
Speclal Charges S
Professional Services 50.00
AutomotSve Equipsent 50 .00
Merchandise 5161 .00
Cash Advanced Items 578 .00
SUB TOTAL $2 �034.00
CREDITS -51 ,000 .00
AMOUNT PREPAID Date Dec 31 , 1998 $239 .00 � �
TOTAL
AMOUNT PAID Date Apr 9 , 2015 -SZ50.00 �
BALANCE DUE
THIS STATEMENT MAY NOT REFLECT ALL NEWSPAPER EHARGES
�.{-+�p ' ' Order Date: 4/6/2015
�l.Gii'dL�t Order Number#: SDM-42'710
memorlals
Stardust Memorials �
807 Airport Access Rd
Suite 100
Traverse City, MI 49686
BILLING ADDRESS SHIPPiNG ADDRESS
richard balint richazd balint
�5 bayberry drive 35 bayberry drive
mechanicsburg PA 17050 - United States mechanicsburg PA 17050 - United States
717-691-6758
rabali�tl@yahoo com
Shipping Met6od: FedEx Ground (1.00Ibs.) Total Items: 4
Item ID Descrip6ons and Op6ons Q�'
MAO-]02K Going Home Keepsake Brass Um ��� �
Keepsake Pouch: Included [Free] a (,
i
� �� �
Chaplainey Services at Diakon Lutheran Socia/Minisbies
Chaplaincy Services at Diakon are an integral part of the interdisciplinary team, providing spiritual suppori
and care to our residents. Through visits, worship services, Bible studies, Holy Communioq bedside prayer,.
counseling, etc., the Chaplaincy team lives out Diakon's mission to love our neighbors through acts of
service. �%
� J�:
GIV/n0 OpPOI'd1n/f1PS � �p , �
9 ���
Diakon Continuing Eduwtion Fund for Chaplaincy
Yourgik to the Diakon Continuing Education Fund for Chaplaincy will support the continuing education of
our chaplains.
Other purpose that you may wish to support Please specify on this fortn (below�.
------------------- - - -------------------
. .i .e - . . . .
� .`* c... .j�: .
Order Receipt
m�ecatering
CUMBERLAND CROSSING _ _ _ _
ror 20508 - DIAKON - _.____-- -------
-..-- .—-- This document is for infortnational PurP°s�ony.K�not a final invoice.
� . Order Status'Finalized
Event Information $eN. 9
Event Name- John Ba��nt Mamorial 40
Department DIAKON-CUMBERIl�ND CROSSING
Event Time: OM2512015 N:00 AM� Order ID�.407184
Setup Time: 10:d5 AM �
Clean-Up Time�. 2:00 PM
contacT RichardBalint•(717)71zb0826041
Event Location: Davis Dinin9 Room
Event Description: Memorial serrice and lunch buffet Chairs up�nt. TaWas In bacK. 2 eas�ls- Card Yable(s).
salad w/dressings(���ude honey mustard). Coftce. iced tea,water,set up by the Ume
Additional Notes. Menu: Bread���en bresst, mashed p°m�s'�'���a k'GOm'bfO�Oli,rolls,tosse
��,ice smhs. After ser�ce set up buHet while 9uests 9
II
�tem$ � Quanfity ..— Price To1alPrice �( ;f �� �k
Name -- � E74.95 _ �`�.� � ,` /.3
Mamorial5ervice __-----'—'""— ���
__ —-- /'
L
Item 7ota��. $598.00
Other $0.00
SubTotal: $598.00
Tax: 535.68
� ToYal�. � 5633.88
Optional �items ry✓� ��� ��� �db� ���.
Serve on China 1 '
Se1FService ���z �y� `�riF �S�
VJait Staff Semce
Tabiec�oths � /
Cloth Napkins i1 �/ �.
Rolled SiNerv+are ( �^Gw N°""_"
podium J
(Ge�rerated on WetlnesdaY.�75.2015) �ees eggs,milk wt�aC 4�nuls.hee nWs.soY.fisn.shHlFsh and
�yp{ypMrgprotluar-inourbodPmau�o^ Wa�rg,eslsmaY�+eafuotlalle�gyorunsiONry.
p�ge be a•mre tt¢twE M12Mk a�M G�� -rufeau Your nsk o'foodbome
oU�er P��NaI aller9-^s. Nk imBa`/w W ask aboutMe��uds w as mest�.s��,sM1ellRsh a e994^'aY�
Nc6ce�.Beadvisedl�`a[���'9raw«uMert�� pa9z ;
illnecus.
Seno Pavment To RQ(�Q�p L
EtlibleArtangemerrts-9!7 ., - ..—
3401 Hartrdale Dr �'�i ReceiPt# �I. 50947048839 ��.
Camp HiII,PA 17011 . . ._
717-736G240 � 272286
'�.. Customer ID I
� �I Receipt DaM �,, 04l1312015 .
', Delivery ..', 04/25l2075�
3�,i!-o . ReciplenOU�clmp . , --�
CumCedand Crossing �'i. Balance � 0.00 ��
Karen Aven � —
25 Watson Drive t Longstlort Way
Carlisle, PA 170'15 Cadisle, PA 170�5 �^^�° PA�� �
� � Pnce ' Discourrt Tota
Protluc[ 0 O(
1 Delicious Fruit Design8 Dipped Strawberries... (2192) 0 0� 0.00
-1 Delicious Fruit Design�-�r9e (1079)
79.W � 12.00 67AC
o.00 io oc
-i Dipped Strawberries: Semisweet C�ocolate (Hal... 70.00 . .. � . . .. .
-1 Chocolate Dipped Bananas: 8 Pieces
72.00 .... .. 0.00 12A(
0.00 0.00 0.0(
-1 VneYa� 89A(
Sub Total 5.0(
Discount 13.94
- — - "" Delivery Chart�es OA(
Sales Tax
�Order Total � . 97'9�
PaymeM(Master CardS121) 97.9'.
Balance O.ot
���
msw s.i.ei..�.ty t.w�m�
6560 CPRLISLE PIKE
MECXPNICSBURG. Pf+ 1T055
STore Televhone: (177) 796-6555
Pharnacy TelmhorK: (717) T96-0199
S}ore i6005 OV25/15 08:16ae
BAI(E SNOP
CUST�M OROER CK 39.93 F
GROCEFY
WELC&GRPPE W/CP 3."!9 F
TP% 0.00
��+� BF+LPNCE 38.22
. ..�...x.x..xxfi.e.e�..+xk+a. -
Payment*Tvpe: VISP W �'
Card�. �x���*+�i.x�6868 .. .
Pav.mt Mt: 538.22 ..
BFLRNCE: f . . .
PUTHb 665251 09/25Q S OS'.16an
xrrrr�r�rr�a.r.���a+a�x�x�.�.�x+tx.x.x
VISP 38.22
CHPNGE OAO
09/25/75 08.16an 6005 9 34 3313
Cus}omer 4+���+e00B1
RF.CEIPT FOR PAYMENT
L�iSA M. GRAYSON, ESQ. Receipt Date : 4�21�%O15
Cumberland Countyq - Register Of Wills Receipt No��� 13��&�-9"
�arli�lethPA e170i3re
BP.LINT JOHN
� F,state File No. : 2015-00442
2aid By Remarks : RICHAAD BALINT
DB1
_ ___ _ _ __ __ _ __ __
..------ ReceipL Distribution --- - - -�-- � - - " --- -
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 90 . 00 CUMBERLAND COUNTY GENERAL FLr<
WILL 15 . 00 CUMBERLAND COUIeTY GF.NERAL F�'�
JCS FEE 35 . 50 BUREAU OF RECEIPTS & CtiTR 6i.
SHORT CEBTIFICA'1'E 25 . 00 CUMBERLAND COiN'SY GENERAL FU�
AUTOMATION FE� `� , ��7 CUMBERLAND COUVTY GENERhL rtiti
=NVFNTORY 15 . 00 CUMBERLAND COUNTY GENERAL F`.':'1
1NH TAX RETURV 15 . 00 CUMBERLAND COUNTY GENERAL� PUZ
___ -
�necx# 3121 $200 . 50
Totai Rece�ved. . . . . . . . . $200 . 50
«.. � . �,z-oal �
�� + pennsylvania SCHEDULE I
oFPaA=ME�*o�aE�F��E DEBTSOFDECEDENT,
���Fa,�>��E��*a�a� MORTGAGE LIABILITIES & LIENS
RESIDfM DKEDEN
ESTATE OF FILE NUMBER
John Balint 27-15-0442
Report debb i�rcumed bY the Oecedent prior to Aeaih that remaineE unpaid at Me date at death,iMluding unreimbursed medial expenses.
ITEM VALUE AT�I+TE
NLMtltA DESCRIPTIOIJ OF DEHTN _
�- Cadisle Regional Mediral Cen�er final bills for tlecetlenfs hospital care 5130A0
2. DiakonLutheran5ocialServices-finalbillsfordecdenYsresidentialcare 54.330J5
3. Milton S.Hershey Mediral Center Physicians Group $6z.z4
a. Milton S. Hershey Mediwl Center Physicians Gmup $2,090.46
5. PinnacleHealih-finalbiils 5160.00
6. MaslandAssaiates,final medical bill $80.00
7. Dartyl Guistwi[e,D0,final professional services 5136.37
8. Omnicare of King of Pmssia-final pharmacy bill �514 67
9. Pinnacle Healih Hospital-final medial bill $95D0
10. HospitalistSofCenlralPA-finalbills $68�3t
11. MembersisfFeaeralCreditUnion-finalcreditcardbill 54049
12. VohraPostAatecarePhysicians-5nalbills g49�18
i
TOTAL(Also enter on Line 10, Rxapitulation) $ �'���47
If more soace Is needed,-insert addi8onal shee6 of tne same slze.
� � Are you or someone yoe knew without health Insurance9
�� AffoMable heallh insu2nce op�ons are now available!
„F oREQ�NAL
Q . . � . 0 • • ' • —
PBfient NBme John Balint a Online at www.carlislermacom
Axount Number 9598394 (available 24/7)
Date of Service March 04, 2015
Eme en Room Services � BY Phone-888561-2271
ServiceType r9 �Y
Insurance Name Humana Gold Choice Repla
Nartie of Insured John Balint �By d�ecK-return section below with check
Policy Number H30555940
Amount Due From You $65.00
� � . . � . . Q • . . . � . .
Arirount�due Trom you-is-$65.1)O��as�of 04/12/2015 tor � The charges list��belax do fwt reflect the discount tha
Emergency RoomServices performed on March 04, you and your insurance company received.
2015. Pharmacy 139.1'.
TotalGharges . � . .. � �� $9,o22.90 � Supplies as.a�
Discounts/AdjustmerttsGiven � � -$7,984.82 MRt� 5,293.5:
Lati 274.Si
InsurancePaY����Received . -$973.08 Emerge�qRoom 3,268.4
AmouMYouPaid $C.00 TOTALCHARGES $9•a22.9�
�� ;5
���;- r2fi
Amount Due Feom You $65.00 �'���'v
a
s
' �l , � �. � ��� 326&HMASIMT-2fi38680.1918C6]13&P: 1202]99}t-0129:35952346-1', 1
\J
� As oIM1s tlMe�Ycur accouM remains unWid:.Plsase pay�e-tiahnce in full by the di
tlaEe�or eoMact�us immeAiatey at ttre pho�re num6ershown and aak for a finaneial
eou�ebr.Our hours are between 8.00 am and 9:00 pm��C3T�Mon.through Thurs. an
between 8:00 am and 7:00 pm C3T on FAAay.ti you lrere already paid this balance,
A Are �rou or someone you know without he2lth �nwrance� �
���,,� �� ARordable heatth insurence opfions ere now available!
�Ci��.
eoicni <e.u.:n
Q � �, � Q • • • • _...
PatientName JohnBalint aOnlineatwww.carrsierm�.�om
AccountNumber 9598394 (available24/7)
Date of Service March 04, 2015 �
ServiceType EmergencyRaomServices BYPhone-886-861-2271
Insurance Name Humana Gold Choice Repla
Name of Insured John Balint �By check-retum section below with check
Policy Number H30555940
Amoun[Due From You $65.00
� • . . • . . O • . . . � . .
Amountdue from you.is-$65�:OO�asof�03f22/ZU75 for The�charge5listed tielow do not reflect the discount tha�
Emergency Room Services pertormed on March 04, you and your insurance company received.
2015. Pharmacy 139.1<
TOYaI Clfarges . . $9,022.90 Supplies 46.SE
Discounts/AtljustmentsGiven � $7,984.82 MR� 5,293.5:
InsurencePaymeotsReceived -5973.08 �� 274.BE
ArtrountYou Paid. � $D.00 Emergency Room 3,268A�
TOTAL CHARGES 59,022.91
Amount Due From You 565.00 �� �J �
���
S
� � . •' �• �A 3269-HMASTMT-260�351490223]89&P: 118]SO114-tt9]:35849658-1:1
� T}1841�C�y0U/O('b@�2C�IfIQ W�{2CI�Ity f0f�/OUf�1l8MfIC8,B 1122f�5.W0 LNb'Z y011�
experience witM1 us mat�your expecfatio�.Your insunnce�s)haslhave paid their
potdon.The balance ia m>w your�reaponaitiilily.PYease remit�the balance in fWl by th
w,.e.ae)e .
STATEMENT Page: 1 ot i
� DIAKON i
wrHennnSocu�MiN�s'ruiEs 559789 12827CCNC 04/302015
Cumbedand Crossings Retlrement Community
1 longsdort Way
Cadisle, PA 17015-7623
Facility#(717)245-9941 5l232075 $0.00
Business Office#(717) 240�040
Richard Balint �
35 Bayberry Drive Balint,�ohn
Mechanicsburg, PA 17050
Please make check payable to Diakon Lutheran Social Ministries
John Balint
-- � - CumbeAaM Crossin9s RetiremerrtCammorrity 04/302�15
Richard Balinl " �'�
_ ��.
-. . _m ._ ...
'�� ..�� :RESIO NT- ESPONSIB IiY �- gq.255.75
3/3'12015 Balance Forv2N � : .: .pp Und -4.330.75
k/16/2015 PaymerR Receivad Ck#3111 �00 Und 75.0
W/02l2015 /02/2015 Maintenance Serrice Char9e
TOTAL$ALAi�7CE�tiE so.00
g7'p7E�AENT OF PHY9�GIAN SERYICES
pqOE
JOHN BALIM � � 2
TATE HERSHEY 7 LANGSDORF WAY RM 42 — srwreunrr
CARLISLE PA 170'IS7623 opre: pq�08l15
> �.Milton S. Hershey �sTa,n,E�
�Medical Center accou�rr tt �zsss.m o,�,E: onosna
� FED TAX ID# �765703
iFnxr Warro�s.a�a�sewMincr: MSHMC PATIENT FlNANCIAL SERVICES , _. . _ ... ..... .
.... ... , ,�
.,_ .,.� -.-. s^_ �, , -
' . . �__ ,' . �..�. . . -, . .. _- . -_ �..- �.:
�<i>i P0.TIFNf: JOIN BLLIM 1Pfi6541 -
22344134
o�oai�s ro asio6ns
pERF01RED BY: JOIN P RELLEIE0. f� DMSIa OF lE��
pLILE OF SVC: ItppTIENf 513.�
■ 03IOM1/35 99222 6�5.2 �� AY�� 93.0.i-
■ p4/0.Y15 . �pI�� � � 379.29-
■ osro�nz ao.ba
■ 04/03/15 BiLItLE AFfER 216�
pERFLIlEU BY: [RISlIINd M SILI@16A PR O1VlSIa �F z�
s 03/06/15 99Y38 lLL5.Y ICSP DIY D0.Y LESS 30 1�! 49.29-
a 64/03/15 IEDICpNE AW PdY .. . 151.15-
■ 04/C3/15 IEDICNIE ADV IOJ 21.56
t 04/03/15 � BdLANCE RFTER INS�
B1LYiE: JOIH BAL47f 562.24 .. _ ._ . . .
■ INDICdTE3 !81 Fllld�IAl iCTMTY S1NCE LIdT BILL. ... .. �
OI11E0. dIRR6E5 9ILlED i0 W10. II� CQPdNi. 103.00
(d A NlliF3Y i0 Wl PATIBIIS. P511 lEDICAL EV�A IQLL
�"pBWI' 71E�NaMf� �IIbUlYCE LDifNYFPAID>xPLEf� �
C�7fACT i1B1 DINECTLY. "
lIQS ST/iHB7f LS FUR N�SICIAN SERVICES QLLY. II1 ONOER 70
a IlEEP YWt ACNN� CIWlR@if. Q�l P�LICY IS iD OPPLY YdFI PdYllBlf
� TO ifE MDFST MSTMODS BRLNiE. YW MfY 1L50 PECEIVE A
� $TAT@@7f F9R IOSPTTAL FEFS. THIfK YW PoR IbIN6 P�I .
�osu s�ur wx rwr rxrsxaw s�rtvicEs.
------ _
�ruu �ssrsrrxe rs evu�� m vanars ieo cwer n�raao
ro vax r�a �onu en�s.iF vou x� au�srxQs x�s�nous wua
BILL CpLL �D-YYr2619 OR 717331-5069� 00. VtSI� 16 AT
TIE ACROEIQC SI�PMtf BL06.. 9D ICPE DR1VE, R001 21�i. IOAS
ARE !Q! 6k1-0RI> MS t MEU 6AMi:3dRi> TNaS 5 fRI 6pM�30PM.
r,.....,.e.�.,em curcrt auv aoDPE55 OR�NSURANCE CORRECt10N50N BACK
PE vNSTnrE H�ttsH� 1 st Statemen`
p,���S`.���y' Pa e 1 of 2
�Med�al Centec
� °OBox��' This bill re resenis the oRion remainin afler �our
rnm��n misxaazai P P 9 Y'
insurance company has processetl your claim. Please
sentl your payment tor the full amount tlue. If you have
any questions wnceming how your insurance company
. processed your Gaim, olease ca�l them.
JOHN BALINT .
CARLISLE PA 17015 623 �
N � �r�Ili9i���•,Pldd�hw�lhtlh°•i�I�I�Ihd�r�dPllldr
Patient Name BALMT JOHN ,�f payme�rt of your metliral b�l is a mncem,we may be atile ro assist
SbfeR�enlDate 04/09f15 you. PennStateHe�sheyMetlinlCeriEe�provitlesfinandal
03/04(15-03/OB/15 assistan«based onlnc6rrie,—�am7y'size antl asse5 fa1 mecically
Service Date(s) ���ry services. Please mmad our office to daass what
Type of Service INPATIENT optbnsyou may De elgib�e foc �
AccountNumber 22344134 =Mpliwuonsmnbeobtair�edonourwabsiteal
sGt h M or by mntacOrg our oRce.
New-Charges�Atlj � $0�0 u Patiem Finandal Services Is wmenieirty iocetetl on the
New Payments/Atlj $0.00 �mpus MMe Penn State Hershey Metlical Center,Acatlemic
2,090 46 Support Building,90 Hope Drive,2nd floor,Suite 2t ob.
Account Balance $ .Pharmaq Dm9 assislance pregrams are also avaBable.
Amount Pending Insurence $0.00 �
AmouniYouOwe 520904E �
_ _
For billing questions or insuwnce chanse>- DA7E DESCRIPTION � AMOUN7"
pyry preguntas acenx de su faetura o contamos con �
rcpresencantaquehablanEspanolpereasirtirle. 03I12H5 ^BALANCEFORWARD" 9010A5�
Phone. (71�)531S069or(8007?542619 03A2H5 MEDICAREADVANTAGEAOJ -2037902
InPersoo:90HopeDnveHershey,PASuite2t06 04l01J15 MEDICAREAOVANTAGEADJ -10.33a
AvailableAoura:Monday8a-Sp 06N2/15 MEDICAREA�VANTAGEPPYMEN ' 4]8020�
E TuesOay-Wetlnesda��Sa-5�.30p j5 =
Thursday-Friday8aA30p � ]�[, ���5 ME�ICARESWUESTREDUCTIO -9Z56�
WritfeoCormpondmce: ,y/� T�TA� 209�46 �
Prnn Sta4 Milron S.Hershty Medicel Center gC�" _
PotlrntFinencialServicesDeparvnmt �/�j' � _
PO B�854,MC A410
Hashq.PA 17033-0854
STATEMENT
To discass paymeut,call: The amomt shuwu below represenis your
Ctis[omer Service financial obligation to:
�� PINIVACLEH�L�TH BsBY�Z�i294 PinnacteHealrhxospitals
•
PO Box 2353
Flatnsburg,FA 17105-2353 RP^^'�'^�a^�Available For all otLer inquiries�.
Mon-Thu 8:OOAN1-6:OOPM
Fd8:00AM-S:OOPM (717)221d294
MESSAGE:
Thank you Coc choosing Pivnade Healt6 Hospitals.Tne balmce ov yoar account is due.If you nced assisfmmce m have insurance cecerage,Please
call our cus[omer service deputm�t.lf 7ou med m make arzang�ents for paymrnt,we have represrniatives availeble to asvst you.
Finsncia7 sssistmce is aveilable Sor thc wivs�ue3 and mdenasurefl n'ho apply avd qualiN.For more infom�atioq please call or sec ovr website ai
niamclehealih omlbillvav.
. Ywmayo[sopayonlineathtt '/2!1 ni Ih Iffiorn
II
HOSPI7AL SHRViCE DATE PAI7EN7'NAME . ACCOUNT NU?�ffiER
07/IOA4
F�I,EN Bu.LNT 1401144
FOR YOUR HOSPITAL SERVICES:
5imvast 20Mg Tb 4 0.65 . � �
Meihim lOMg Tb � .� .,
Prothrombin iime 5 Z5.� � �.-� � . ��4j � 1�
�aca� o.00ssso: ea q ze.00 � 3�
Mrsa screen ,y�
ck S 31.00 � �T'
Magnesium g 31.00 �
Ck
<bc & nu2o oifferential q qj,00
ckmb g q7.00
ckmb g 55.00
Ba'iC Metdb011C Pdfl21
continuetl on the Reverse Side
836498.]5
I Original Bi1leG amounY: - 4-923314
TOYaI Insuranw vaid: 4-2]200.51
ITOYaI Adjustments: 40.00
vaiient vayments: 465.00
vatient nes0onsibil5ry:
I865.00
__ ________________' —_—_—_
—__—_—
_ _-- _-- _- -- -
P[£.45EDFTnCFI,LWAEiL.2\?JATI(l\"WI]}IY'OURPAI'YffiM J OTS
V'�W,�, a 11W01.PINPAF-136
KgY�M:
DARRriGUISCWi'CE.DO
(777)609-2639
56 ASH'CON S7REE7'
CAALISLE,PA /70156914
V
\�� � (
�' c �� 3���
� �� 11261 O4/17/75 7 HU
John Balint
t LongsdorfVlay
Room 42
CARLISLE,PA 170I5 - �
cPra 105.00 � 26-7
03/04l15 99309 NursingHomeEst.Patientlevel3
pG I
PatienC Balin4]ohn -ll261
ServicingProvider.DartylKGuistwlreDO 6� �6 �� ��
04/06/2015 Humana Claims Cen[u
DARRri G[IISTWITE,W (71'1�09-2639
56 ASH7YIN S7REET
CARGSLE,PA VOISb9i4
JohnBalint I1261 �OS/13/75 1 NU
1 Longstlorf Way
Room 42
CARLISLE,PA 17075
CPT4 �. 4).�
03/02/IS 99306 NursingHomeNewPatie'rtLevel3 DG 1 185.00
Patiem:Balin47ohn - 11261
Servicing Provider.Danyl K Guistwite DO
04/28/20I5 HumanaClaims Crnter ll2.47 2335
03�09�15 �99308 NursingHomeEscPatimiLevei2 DG 1 SO.W � 2�-
Patirnt:Balin;7ohn -1 I261
� Servicing Provider.Darryl K Guistwite DO ��
Oi/04/2015 Humena Claims Cenier 46.09 13.76
03/151/5 99308 NursiogHomeEst.PadrntLevel2 DG 1 80.00 20�
J
Paeent:BalinSJoM -llffil G J��
Servicing Arovider:Darryl K Guishrite DO / ,J3�U6
OS/042015HumanaClaimsCente� 46.09 7376 /�j�� /
03/16/15 99308 N�usingHama Ert.Patiefrt Level2 DC � 80.00 ` /✓ 20
Parient Baiin4 John -11261
Servicing Provider Dartyl K Guislwite DO
OS/OS/Z015 Humena Claims Crnter 46.09 13.76
;09.
"�— STATEMENT OF ACCOUNT
OMNM.ARE OF KIN6 OF PRUSSIA
89808 SNO4WRIFf RD PAGE: 1 of 6
ALLEHTONM,PA 18108
� ACCOUNT NO: 9009.277
RETURNSERVICERE�UESTED 3a285 INVOICENO: PH7346058
ox No: Koaox
BILLING HOURS: 5:00 AM TO 6:00 PM INVOICE DATE: 06n2/75
000:3� phone: 877�70�323� FACILIN: 900acUMeERL4NOCROSSiNG
asos PATIENTNO: 2n :�
��VOu mey elso viswlpay your Wlls at: PATIENT NAME: BALINT,JOHN
https:llmyomnNiew.omnicare.com AMOUNT DUE: 5ta.e�
iqq,uqdru��i�luP�p���i��yyullhpiq�p�„ridPu, rnx: a.00
JOHN BALINT
C/OHELENBALINT oueonre: 05/07/2015 �
1 LONGSDORF WAY#42
CARLISLE, PA1701S7623 i nxourrroue 51a . 6'
�}
� 1� ���� " 31I85•TB�DASQiQ00983]
� �' 08�OBiFFG:1.6
KEEP TOP POFff10N FOPYOUR RECORDS-RENFN BOTTOM 5TUB WITN PAYMENT I�I�I���I�I.��O���
BALINT, JOHN 9009 CUMBERViN4�CR0.SSING
9009277 � 64/72/15 � . .
DRTE RIf�NU. � TRA15 y,�BESCRT�7tUM : �;. '�. AGAMT .: : PMOUNT TYPE
MeEliwEc�D"NbY.�.�� P1115 NEDICh(tE�� � .� . .: ,
03XZ4f15 784-: . �•�i4i "'T1MNK`:YtiY..Lactboz:2Q�3240&'t5ot.'. �'=363_84
_ _ . _
g �02/R/15 R8992161 REiUBI TttETNttN�OPBHFf��%'325pG iqBLEt �� ._.- GttISTYITE�.� 009m-f962'-80 � y-28 � � -0.14 OiC
02/28/i5-�R23992171REZFIRN.� MtILTiViTAMfN�TTPB-A-VIiE) TkBLET � IYIlST411�iE:. 00994-0530-H0..��. � -21 -0.1� OTC
� 02/28/TS R239927 REFdRN' �CYAMOCWi1tFMG11�Y1T Btt�100kMCGItML VIAL GU35TWITE� 63323-OWb-01 � -1 -12.49 Rz
� 03/20/15 R240608� �LNARGE CLINDNITCEN�Ntt 30dIG LAiSULE (COPAY) OTN - � GlISTVITE 005914932-01 3 11.15 RX
Co-pay�is the financ'ral respmsibility of [he � � �
coveretl�berief ic�ary/guarentor �
03/20/15 R24016781 CNRRGE TMISULOSIN�HCL O.LMG CRC.SR 24N (CW�Y),OTN - WISTYITE 00378-2500-10 34 10.20 R%
Co-pay is She finaMial respwsibitiiy of [he �
covered beneficiary/guarantor
PAessages .
Fsarice C1a�ge5 may be aaemetl ataMOMIILV PERIOD RATE OF
i.w o(nrvHuni tuiE or ie.om�)msea uw�an unwa eam�
oumlaMin9 w Eays m mae.
vxEVIdIS BALAN[E CNA0.GE5 F[NFNCE CXARGE TOTAL CNRRGES PAYNENTS 8 CREDIiS � AMWNT �UE
363.84 514.67 0.00 898.51 -3C3.84 514.6]
�lOINSURE PFiOPER CREDIT,DETAGH AND pETURN THIS PORTION INTHE ENCLOSED ENVELOPE. 36te5'TH�OASa1000983� �5�_
-i PI¢35P CM1PLk it d�VP dCGlESS IS'JICURKI d�p IMICdIP Cl18�gP On�pVB@B 310P. IF PLYINO BY AUSiEqCMR 018COVE11 VI$AOF A4EqIC�N EXPPESS.RLt O11T BFLOW
r LHECKCARDUSINGFOFGRYkEM
ACCOUNT NO: 9009277 i ���q ^qo -p �q �Op `�Eq�w�exP-_ss
�NVOICE NO: PH1346058
DXNO: KOPDX ��aoxoneeA
INVOICE DATE: 04/1D15
FACILIN: 9009CUMBERLANDCROSSING sicea.vae =xeonr
PATIENT N0: 277 �
PATIENTNAME: BALINT,JOHN �
AMOUNT DUE: 51a.67
iqi��q���t�tl��u��ldh!�hn�Ill��ihP�I�ruhndlP������
OMNICARE OF KING OF PRUSSIA.
AMOUNT ENCLOSED S_ � P.O. BOX 740391
� CINCINNATI, OH 45274-0391
0000�9009a27720PH13460580000KOPDX90000514678
0o na sxM cortespo�Mence to this address.
� ON4MSY01 J
PO Box 1022 a, PINNACLEHEALTH
Waom MI 983931022
AD�RESS SERVICE REQUESTEO HOSPII8I5
(717)221-1294
(888)467-2563
Apn19, 2015
Representatives Available:
Mon—Thu B:OOAM—B:OOPM
69257908-1000 5847410t5 Fri S:OOAM—S:DOPM
Ill,n�lldq�u�lllu�l�llri��pqp���y�ulll�ini„���i���u
John Balint
t Longsdort Way#42
Cadisle PA 170t67B23
Bill#: 2384731 _ _ _. _. . _ . . ._ - . _ .
Patient Name- John Balirrt
Date of Service: 07J11l15
Location of Service: Pinnacle Healtti Hospitals
Balance Due- $95.00
Our records indicate the balance on your acwunt is now due in full. Please pay this immediately using the
enclosed emelope.You may also pay by credit card by using the form below.
If you need to make payment amangements, please rall us as soon as possible.
Financial assistance is availa6le for the uninsuretl or undennsured who apply and qualify. For more information,
please call or see our website at www.oinnacleheatth.oro/billoav.
You may also pay online at https://bi!lpav.pinnaclehealth.or4
Sincerely, V�. �
i � b '�y
Pinnacle Health Hospkals :{. 3 y
Patient Accounts Department n���
L
SEE REVER3E SIDE FOR BILLING DETAULS AND OTHER IMPORTANT INFORMATION
nccount #: 1403SZ113— Please Pay: �L L�O Due oate: v.n � �r i �
v � To pay by cred"H or tlebit card please go to our online patient payment portal at t d comlh 'tel tscentraloa
Payment
�s����o� AmauM Ad ustments
Date o.00
BALANCE FORWARD LAST STATEMENT 138.00
04/OS/15 99238 HOSPITAL DISCNAFGE DAY MGMT 49 z9
04/23/15 INIX INSURANCE CHEIX -6].15
04/23/15 INWO INSURANCE WRITE OFF
n r � S�J
WI ��
Y� �i//y.j/3�
�-LL
A WordAbout Your Aacu(A
BALANCE DUE IS YOUR R SPONSIBILITY A SHOULD BE PAI�
IN FULL WITHIN 15 DAYS.
Total Now Due u. 56
Meke Chiekf HOSPITALISTS Of CENTHAL PENNSYLVANIA For Billing��Quesilons Cali
Pa�abie To: PO BOX 62722 (888) 616-8322
� BALTIMORE,MD 212642722
PAGE 1 OF 1
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JOHN BALINT
MELEN BALINT Statement Closing Date:
AccouM Number.Y#'#It k####M#k 8592 April 26.2015
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03H9/15 John M�Ichell 999W NURSING FACILfiY CNRE INtT E202.51 S11P.47 ��-� 0.00 8a�
03/19I15 John Mitdiell 4281 TECH OiHER THAN SURFC S��
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03/19/15 John MM1che�l 426fiF NO WET-0itY DRSSINGS R% $0�
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FILE NUMBER:
ESTpTE OF:
John Balinl 21-15-0442
REtA40N5HIP TO DECE�EM AMOUfJT OR SHARE
NUMBEA NAME AND A�DRE55 OF PERSON(5)RECENING PROPERiY Do Not List TruIIee(s) Oi ESTAtE
I TAXABLE DISrW6L�II0N5[Indude outrigh[spousal Gistributions antl tansfers untler
Sec.9116(a)�12)1
t. Richard A.Balinl,35 8ayberry Dnve,Mechanicsburg,PA 17050 Son 5��
2 Karen D.Aven,35 Watson Dnve,Cadisle,PA 17015 Daughter 509 0
ERTER DO�IAR AMOUNTS FOR D[STitBUT10N5 SHOWN AeOVE ON LMES IS THROWH IB OF REV-I500 COVER SHEEf,AS APPROPRIATE.
13 NON-TA%ABLE DISTRBUTIONS
A. SPOUSFI DISIItIBMONS UNDfR SECf10N 9I13 FOR WHICH PN ELECIION TO TA%IS NOT iAKEN'.
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B. CHARRABLE AND GOVERNMEIJiAL DISTRIBUTIONS:
1.
TOTAL OF PART II- ENTER TOTAI NON-TAXABLE DISTRIBUi70N5 ON LINE 13 OF REV-1500 COVER SHEEC S
If more space is needeG,use additional shee6 of Daper of the same size.
LAST WILL ANI? TESTAMENT
OF
JOHN BALINT
I, JOHN BALIlVT, of 44 Honeysuckle D.*ive, Mechanicsburg, (Silver
Spring Township), Cumberland Counry, Pennsylvania, make, publish and declare
this as and for my Last Will and Tzstament, hereby revoking all other Wffis and
Codicils heretofore made by me.
_ _ _ _ _ .
FIRST: I direct that any and all just deUts, funerel and administrarive
expenses within reason, which may be oayable by reason of my death, shall be
paid out of the principal of my estate as the sarrie can conveniendy be done.
SECOND: I give, devise and bequeath all the rest, residue and
remainder of my estate of whatever namre and wherever situate, including any
property over which I hold power of appointment aad together with any insurance
poGcies thereon, unto my wife, HEI.EN BALiNT, provided she survives me by
thirty (30) days.
THIRD: Should HELEN BALIlVT predecease me or die on or before the
thirty-first (31st) day following my death, 1 give, devise and bequeath all the rest,
residue and remainder of rny estate of whatever nature and wherever situate, including
any propzrty ovei wnicn i hold power of appoin?ment and together with any insurance
policies thereon, as follows:
(a) Fifty percent (50°io) thereef unto my daughtei, KARII� D. AVEN, of
Carfisle, Pennsylvania, ptovided that should iiAI2F.N D. AVF.N predecease me, I give
and bequeath her share unto her issue, share and share alike; and
(b) Fifry percent (50°%) thereof un2o my son, RICHARD A. BALINT, of
Mechanicsburg, Pennsylvattia, provided thar shoeld RICHARD A. BALINC
predecease me, I give�and bequeath his unto his issue, share and share alike.
FOURTH: In addition to all powers granted to them by ]aw and by other
provisions of this Will, I give the fiduciaries acting hereunder the following powers,
applicable to all property, exercisable without court approval and effecrive until actual
distribution of all property:
(A) To sell at public or private sale, or to lease, for any period of time, any
real or personal properiy and to give oprions for sales, exchanges or leases, for such
prices and upon such terzns (including credit, with or without securiry) or conditions
as are deemed proper. This includes the power to give legally sufficient instruments
_ ___
for transfer of the property and to receive the proceeds of any disposition.
(B} To partition, subdivid�, or improve real estate and to enter in:o
agreements conceming the partition, cubdivision, improvement, zoning or management
of real estate and to impose or exdnguish restrictionc on real estate.
(C) To compromise any ciavn or controversy and to abandon any
property which is of little or no value_
(D) To invest in all forrtts of property, including stocks, common trust
funds and mortgage investment funds, without restriction to investments authorized for
Pennsylvania 5duciaries, as are deemed proper, w�Yhout regard to any principle of
diversification, risk or productivih�.
(E) To exercise any opaon, right er pm�ege granted in insurance policies
i o: is cther:.�ves.r.erts.
(F) To exercise ar.y elect;on a� pcivuege given by the Federal and other fax
laws, including, but not ne:essarily being &mited co, personal income, gifr and estate or
inheritance tax laws.
(G) To make distributions te mY herein aamed beneficiaries in cash or in
kind or partly in each.
(H) To borrow money from thecnselvas or others to pay debts, taxes, or
estate or trust admuistration expenses, '.o aru�ect or imorove any property held under
I my will, and for inveshnent purposes.
�
I (I) To select a mode af paymen, un�ier any qualified retireme�t plan
(pension plan, proSt sharing plan, emp[oyee stack ownership pian, or any other rype of
qualified plao) to the eactent provided for by the piar, or the law.
FIFI'f�: I direct that any arid all inheritance, estate, transfer, succession
i
� and similar death taxec shall be paid nut of t�he principal of my residual estate.
i
� SIX1'H: I nominate and ap�oint RICFI�RD A. BALLNT, Execntor, of
�
this, my Last Will and Testamcnt. Ln the event eF*he death, resignation or ieablicy to
�; serve for any reason whatsoever o€RtC'.33,2iZ7 .�.. &ALI!�'T, I nominate and appcint
iKARFIV D. AVEli, Executr.x c:this, :r.y [.ast lS'iL aafl "I estamen:. I direct that my
I Hxecutor or Executrix, as the case ;nay be, sha!: ret be required to post security or a
� bond for the periormance of t:�e'tr J�a�3es in:�n_d �uri�diction.
i
1
� IN WITNESS WHEItEOF. i have hzreunto set my hand and seal to this,
� my Last Will and Testament, this �� day of Juiy, 2012.
� �-�✓� � u('�'vt'i (SEAL)
i . J'J SALItiT, .
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I Signed, seated, published ana declared by rhe above-named "Pestator as and for
I
ihis Last Will and Testament in our presence, �,�ho, �: his requast, in his preser,ce and in
ihe presence of each ather, have �erecc:te s�hscribed aar names as attesting wimesses.
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