HomeMy WebLinkAbout07-06-15 J 1505619134
E%(n41<IIFp
REV-1500 OFFIGIAL USE ONLY
BureauoflntlivitlualTaxes CauntyCotle Year FileNumber
Posoxzeasa7 INHERI7ANCETAXRETURN n - /�
H � t PA1]12&0601 RESIDENTDECEDENT �� I � L'7�l
ENTER DECEDENT INFORMATION BEIOW
Social Securiry Number Date of Death MMooVYVY Date of Bihh MM��VVYY
2 1 2 0 9 2 0 1 4 0 1 1 8 1 9 5 2
oeceaenfs Lasl Name Suffix Deceaent's First Name M�
C H A M B E R L I N A U D R E Y L
(If Applicable)En[er Surviving Spouse's Into�maHon Below
Spouse's Last Name Suffix Spouse's First Name MI
THIS RETURN MUST BE FILED IN DIIPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
Q 1.Original Re�um � 2.Supplemental ReWm � 3.Remaintler ReNm(Oate of tleath
Prior�012-1382)
� d.FgricWNre Exemption � 5.Fu[ure Interest Compmmise(date of � 6.Federel Eslate Taz Retum Requiretl
(dahofdeaNwora%er]42071) dealhaflerl&12-82)
� �.Oecedent Died Testate ❑ 8.Decedent Maintainetl a Living Tms� � 9.Tolal Number of Safe Deposil Boxes
(Atlarhmpyofwill.) (Atlachwpyo(WsQ
� iQ Litigation Proceeds Receivetl � 11. Non-Probate Transferee ReWm � 12.�efe�raVElection of Spousal Tmsls
(Schetlule F and G Hssets only)
❑ 13.Business Assels ❑ 14.Spouse is Sole eeneficiary
(No Wst involvetl)
CORRESPON�ENT�THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE RNO GONFIDENTIAL TAX INFORMATION SHOULU BE DIRECTEO T0:
Name �aylime Telephone Number
J O E L R . Z U L L I N G E R 7 1 7 2 6 4 6 0 2 9
First Line otAtltlress
1 4 N O R T H M A I N S T R E E T
Secontl Line of Adtlress
S U I T E 2 0 0
CityorPostINfice State ZIPCode
C H A M 6 E R S B U R G P A 1 7 2 0 1
corresPonaenrse-ma�i aaeress: i�ullinoer(a�zullinoer-davis com
� RE615TEft OF WILLS USE ONLY�
i ROATEFILEUIMMDDYYYYY I .
�IZT�J �, �� �
� � m
� ` ,n �
� o
L. .. oA�Ei1LF.p�STA<.TP' �� 3l
�7
. r m m I
, � A O
O �
PLEASE USE ORIGINAL FORM ONLV �� ' '� ;� � '� T �
,. . _..� 3 � -n
Sitle 1 _ w � m
-� r
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII � � S N �
L 1505619139 1505619134 J �
� 1505619239
REV4500 EX(Fl) DecedenPs Social5ecurity Num�er
o�ee�rseame: AUDREY L CHAMBERLIN
RECAPITIILATION
1. Real Es�ale(ScheGule A) . .. . . . .. .. ..... .. .. .. .. .. ... .. .. .. ... .. .. . . �� '
2. 5rorks antl Bontls(Schedule B) . .. . .. .. .. . . . . . . . .. .. .. . .. .. .. . .. . 2. •
3. Closety Heltl Coryora[ion,Partnership or Sole-Pmpne�orship(Schetlule C) .. .. . 3. '
d. Mortgages and Notes Receivable(Schetlule 0) ... . .... .. .. .. . .. .. .. .. . .. 4. •
5. Cas�,Bank Deposits antl Miscellaneous Personal Propedy(SCIieEule E�. .. .. .. 5. , � , 7 9 , 8 3
6. Joinlly Ownetl Pmperty(Schetlule F) ❑ Separate Billing Requesled . .. .. . . 6. •
�. Inleo-Vivos Trans(ers&Miscellaneous N n-Probate Property
(ScheOule G) � Separa�e Billing Requested . ._. .. . �. •
8. Toql Gross Assets(total Lines 1 thmugh�) .. ... . . . .. .. .. ..... .. ... e. � 0 1 7 9 , 8 3
9. Funeral Expenses and Atlministrative Cos�s(Schedule H) .. .. . .. .. .. .. . . . .. 9� � 7 � 2' . 5 �
10. Debis o�Deceden�,Mortgage Liabilities,and Liens(Schetlule I) .. .. . .... .... 10. � 6 3 6 Z 9 . 9 6
ii. ro�ioea�cno�s(mcaiu�essandio) . ._ .. .... .. .. _ _._. .. .. .. . ._ i�. 1 6 5 3 3 2 . 4 6
12. Net Value ot ESGte(Line 8 minus Line 11) . .. .. .. ....... .. .. ... .. .. ... �2_ - � 5 5 � S 2 . 6 3
13. Chan�ableantlGovemmentalBequests/Sec9113Tmsis(orwhich
an election to tax has mt been matle(Schedule J) .. .. .. .. .. . . . .. .. . .. _ �3_ •
ia. Netvaiue sunjectto 7a:(une i2 minus�ine is� . . .. . .. .. .. .. . .. _ _ �a. - 1 5 5 1 5 2 . 6 3
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amounl of Line 141axable
at Ihe spousal Wx rate.or
iransfers untler Sx.9116
(a)(12)X.0 _ � . � � 15. � . � �
i6. Amount of Line 14 taxable
at lineal rate X �� 0 • � � �6. � • � �
i7. Amountof�ineiataxable 0 . 0 0 n. 0 . 0 0
afsibling ra�e X.�2
18. Amount of Line 14 taxable O . O Q
atwllateralrateX.15 � • 0 � �g.
19. TAX DUE .. . ... . . . .. . 19. 0 • � �
. . .. .. .. .. ... .. .. ..... .. .. .. .. .. .. . .. . ....
20. FILL IN THE OVAL IF VOU ARE REpUESTING A REFUND OF AN OVERPAVMENT ❑
❑Mer penaNes of perlury.I aetlam I have eramineG Nis reWm,IntluCing acwmpan�ng sc�edules antl s�a�ements,antl�o V�e Oes�M my knoxletlge anG Deliet,
i�is W rortect an0 wmple[e.DeGa2tion ot preparer oNerNan IM1e person responsiele�a flling Ne reW m Is EauO on all inMma4on of wfiicM1 prepare��as
any k e0ge.
51 UR PE 0 ESPONSIBLEFORFlLINGRETORN OA
�0 E55
22 rick Avenue Shi ensbur PA 17 57
SIG EOFPREP RERO R ER50 PONSIBLEFORFILINGTHERETURN D TE
�
ADDR
14 orth Main Street e 200 Chambersbur PA 17201
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Side2
L 1505619239 1505619234 �
REV-0500 EX (Fl) Page 3 Flle Num�e�
DecedenYs Complete Address: wiii not probated
DECEDENPSNAME
AUDREV L CHAMBERLW _
STREETADDRESS �
121 Walnut Bottom Road .
CITV - .. � �� � STATE ZIP
Shippensbur PA � I17257
Tax Payments and Credits:
1- Tax�ue(Page2,Line19) (1) Q00
Z CretlitslPayments
A.Pnor Paymen�s
B.Discount __
(SeeinsWctions.) TolalCredi�s(A�B) (2) 0.00
3. Interesl
(3)
4. If Line 2 is grea�er�han Line 1.Line 3,enter ihe difference.This is the OVERPAYMENT.
Fill in oval on Page P,Line 20 to requesl a reNntl. (4) 0.00
5. If Line 1 .Line 3 is grea�er�han Line 2,enter Ihe diflerence.This is ihe TAX DUE. (5) 0.00
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. �iddeceden�makeaVansferand'. Yes No
a. relain�heuseorinmmeN�heMOPertyVansfened ...._._....._.._........_...._.........................._._... ❑ ❑
b. re�ain�henght�odesignalewhoshallusethepropetlYtransfertedori�sincome ......................._.__ x
u retainareversionaryinleres� ........... . _.._......._ ............ . ..... . . __. ❑ �
tl. receivethepmmiseforlifeofeitherpaymenis,henMtlsorcare� ................ .. ... .. ..... ..._. ❑ ❑X
2 Ii tleath o¢urred afler Dec.12,1982,tlitl tlecedent iransfer prope�y wilhin one year of OeMh
wi�houlreceivingadequa�econsideralion? ......................._............................_................................ ❑ ❑X
3. Oitl decedent own an'in tms�fol'or payableupon-0ealh bank accoun�or securiry a�his or her death? ......... ❑ ❑X
4. Diddecetlentavnanindividualre�irementaaounl,annuityoro�hernon-pmbaleD�oOeM�which
cnntainsaben�ciarydesi9nabon7........ ................. .._.._._.... _....._ ..._...... ❑ ❑X
IF THE ANSWERTO ANY OF THE ABOVE�UESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE R AS PART OF THE REfURN.
For tlates of tleath on or atter July 1,1994,and betore Jan. 1,1995,ihe tvc 2[e imposetl on the net value o�transfers to or tor me use of ihe surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)J.
For dates of death on or aker Jan.1,1995,ihe tax ra�e imposea on the net value of Gansfers to or for the use of the suniving spouse is 0 percent
[72 P.S.§9116(a)(1,1)(ii)�.The staWte does not exempt a transferto a surviving spouse tmm tau,and ihe staMory requiremems for Oisclosure of assets and
filing a tax return are s611 applicable even if the surviving spouse is ihe only beneficiary,
For dates of deaN on or after July 1,2000:
• The tax rate imposed on the net value of Vansfers 6om a deceased child 21 years of age or younger at death to or for Me use of a naWral parent,an
adoptive parent or a step�parent of ihe child is 0 percent p2 P.S.§9116(a�(1.2)].
• Tne tax rate imposetl on tl�e net value of tansfers ro or for ihe use a�me tlecedenTs lineal beneficianes is 4.5 percent,ezcept as noted in�72 P.S.49116(a)(1�].
• The tax rale imposed on ihe net value of transiers to orfor tl�e use of the decedenfs siblings is 12 percent p2 P.S.§9116(a)(1.3)].A sibling is defned,
under Sec�ion 9102,as an individual who has a�leas�one parent in common with ihe deceden�,whe�her by blood or adopfion.
REV-0508 EXr(40-02)
pennsylvania SCHEDULE E
oernam�er�rorAevervue CASH� BANK DEPOSITS 8 MISC.
INHERIiANCE TA%RETUFN
REsioEHroEr.�oErvr PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
AUDREY L CHAMBERLIN will not pmba[ed
InGutle the pmceetls of litigation anE the Eate the proceetls were receiveC by the estate.
All property jointly owned wiM right of survivorship must be tlisclosetl on Schetlule F.
ITEM VA W E AT DATE
NUMBER DESCRIPTION OF DFATH
t Refuntl, Shippensburg Health Care Center 8,572.83
2. Refund, Shippensburg Heaith Care Center 7,578.50
3. Received from M8T Bank Overtlraft Settlement 28.50
TOTAL(AlsoenleronLineS,Recaptulation) S 10179.83
It more space is neetleQ use adtldional sheek of paper of�he same size.
REK15H EX•(0&13)
pennsylvania SCHEDULE H
oEvaarxeHrovRevENUE FUNERALEXPENSESAND
iunewraxcEr�aEruax ADMINISTRATIVE COSTS
REsioErvroECEOErvr
ESTATE OF FILE NUMBER
AU�REY L CHAMBERLIN will not probated
DecedenYs AeOls must be repotled on Schedule 1.
ITEM
NUMBER DESCRIPTION AMOUNT
A PUNERALEXPENSES'
1. Fogelsanger-Bricker Funeal Home, balance of funeral expenses 300.00
2. Parklawns Memorial Gardens, burial expenses 487.50
6. ADMINISTRATIVECOSTS:
1. PersonalRepresentativeCommissions:
rvame(s)o�Personai kev�ntative(s)
Streelatltlress
Ciry Stl�e ZIP
YeaQs)Gommissian Paid:
p n�romey Fees: Joel R.Zullinger 900.00
3, Family Exemption'.p�dereGenYs a0025s is natNe same as daimanYs,at�ach e�pla�atlon.)
Claimant
Str�tAtlaress
City Sh�e ZIP
Relalionship of Claimant�o DeceOent
4. pmea�eFees�. fling inheri[ance tax return 15.00
5 AcwuManiFees:
6. TaxReNmPreparerFees:
7.
TOTAL�AIsoenleronLine9,RecaDiNlalion) S 7702.50
If more space s neeGeO,use a00Nonal sheels ol paperotNe same size.
REV.t St 2 E%�(�2-12)
pennsylvania SCHEDULE I
oEwam�exroraevenue DEBTSOFDECEDENT�
inr�ew.nNCErnxREruaH MORTGAGE LIABILITIES&LIENS
REsioErvTOECEOErvr
ESTATE OF FILE NUMBER
AUDREY L. CHAMBERLIN will no[probated
Report debts Incurtetl by ihe tltte0ent priorto OeaN tha�remainetl unpaitl alMe date ol death,including unreimbursed medical ezpenses.
ITEM VALUEAT DATE
NUMBER DESCRIPTION OF DFATH
1. Joel R. Zullinger, unpaid attorney fee for services rendered prior to death 223.00
2. Pennsylvania Department of Public Welfare, claim for reimbursemen[of inedical 163,406.96
assistance to decedent, with copy attached
TOTAL(Also enter on Line 10,Recaptulation) E �63 629.96
If more space is needed,insert addRional sheets of ihe same size.
aEv.isa ex.ioi-�o�
pennsylvania SCHEDULE J
°E'�'a"'""'o`a`���E BENEFICIARIES
INHERITANCEiMREiURN
RESI�ENiOECEDENi
ESTATE OF: FILE NUMBER:
AUDREY L CHAMBERLIN will not mbated
RELATIONSHIPTODECEDENT AMOl1NTOR5HARE
NUMBER NAMEAN�AO�RESSOFPERSON�S)RECEIVINGPROPERTY DONotListTmstee�s) OFESTATE
i TA%ABLE�ISTRIBUTIONS �IncWdeoutrghispousaltlsNbutionsandVansfersuntler
Sec.91161a)li 211
1. Shawn Chamberlin, decedenf s son who is homeless with no Lineal
permanent mailing address residue of estate
EMER DOLLAR AMOUNTS FOR DISTRIeUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV4500 COVER SHEET,AS APPROPRIATE.
]�, NON-TAXABLE OISTRIBUTIONS:
A,SPOUSAL�ISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOi TAKEN:
1.
B.CHARITABLE AN�GOVERNMENTAL DISTRIBUTIONS:
1.
TOTALOFPARTII-ENTERTOTALNON-TAXABLEDISTRIBUTIONSONLME130FREV-050000VERSHEEL S
If more space Is needed,use additional shee�s o�paper of�he same size.
� pennsylvania
�EPARiNENT OF PV9LIC WELFA0.E
February 28, 2015
ZULLINGER-DAVIS P C
JOEL R ZULLINGER
14NMAINST
STE 200
CHAMBERSBURG PA 17201
Re: Audrey Chamberlin
CIS #: 800133442
SSN: ###-##-5072
Date of Death: 12/09/2014
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Mr. Zullinger:
Under State and Federal law, the Department of Public Welfare (the Department) is
required to recover medical assistance (MA) reimbursement from the probate estates of
deceased individuals who were over age 55 when such assistance was received. 42 U.S.C.
§1396p(b)(1). 62 P.S. § 1412. This letter sets forth the amount of the Department's claim
against the estate of the above referenced individual and explains the obligations of
executors, administrators, and persons receiving estate property.
Although the amount in the estate may be considerably less than that which
is owed to the Department, our claim is against the estate, no one else.
Statement of Claim Amount
The Department maintains a claim in the amount of 5163.406.96 against the
above-mentioned estate. This claim is for repayment of MA granted on behalf of the
decedent. Enclosed is the Department's itemized statement of claim.
A portion of this medical expense, namely 516,888.13, was incurred during the last
siz months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of
the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the
claim, namely 5746.518.83, is to be entered as a priority Class 5.1 claim against the
estate. You should refer to Section 3392 for a more complete explanation of the priority
rules.
If a lawsuit is filed for injuries sustained by the decedent prior to death, then the
Department may also have a lien against the personal injury action. A statement of claim
for that injury-related lien must be requested separatety.
. . . . . .. ... . . . . . . .. . _._... ... ._. ... . ... . . . .. ... . .._..
sureau of vmqram Integrity I Dlvision of Thira Party Llabili[y I aecovery SecUon
PO eox ea86 I Nar�lsburg, Pennsylvania ll1�5-Ba86
.
�� pennsytvania
�EVAPiMENi OF PV9LIC WELFpqE
Your Responsibility to Provide Information to the Department
Please acknowledge receipt of this letter and advise whether the Department's claim
is admitted and when payment may be expected. When the estate accounting is complete,
please provide a copy.
The Department audits all estate recovery claims and therefore we require
documentation to substantiate all deductions from the gross estate. The regulations
governing how the Department computes its estate recovery claim are found in 55 Pa. Code
Chapter 258. These regulations are readily available on the Internet, in addition to being
carried in most local law libraries.
In order to accurately compute the amount due the Department, the following items
should be submitted to the address below:
1. For real estate:
a. Copy of the deed
b. Copy of the latest tax assessment
c. Copy of a current appraisal, if available
2. Copy of the funeral bill
3. Copy of the statement of the burial account if one existed
4. Copy of the statement of the personal care acmunt balance at date of death, if the
decedent was in a nursing home
5. Copies of original and updated life insurance policy forms naming beneficiaries
6. Copies of any and all stocks and bonds
7. Copies of bank statements showing balances on the date of death
S. Copies of signature cards or other proof of when accounts were made joint
9. A list of any giks or other transfers for less than fair market value made by the
decedent (personally or under a power of attorney)
Your Responsibilities to the Department
Under State law, executors or administrators may be personally liable to pay the
DepartmenYs estate recovery claim if they transfer estate property withou[ the
DepartmenYs claim being paid. Persons who receive that property without paying valuable
and adequate consideration to the estate may also be personally liable. 7he responsibilities
of the primary next of kin/administrator/executor, is to advise the Department of any assets
in the estate and to ensure that the remaining money, after all funeral and administrative
costs are deducted, is sent to the Department. Accordingly, you must ensure the
Department's claim is satisfied before making distribution of assets to heirs.
eureau of Fmgram Integrity I Division of Thlra VaM LlaCllity I aemvery Sec6on
GO Box 648fi I Harrisburg,PennsyNania ll105-8a66
!� pennsylvania
OEFAPTMENT OF FVBLIC WELFPPE
Insolvent Estates and the Fiduciary Responsibility to Creditors
If there are not enough estate assets to pay the claims of all creditors in full, then
the executor or administrator has a duty to act in the best interest of creditors when
administerinq the estate. If you must spend the estate's money to administer it, you must
act prudently and make purchases as if the money were coming out of your own pocket.
The Department's approval is required if you expect the legal fees to exceed more than the
areater of 6% of the estate assets or $1,000. Contingent fees for estate administration will
generally not be approved. If you do not obtain approval, the Department may consider the
excessive fees to be a transfer for less than valuable and adequate consideration.
Sincerely,
!1�� `Y'lL�C/�$Q
Tina M. Wise
TPL Program Investigator
717-214-1204
717-772-6553 FAX
Enclosure
eureau of vm9ram Integrity I Divislon of rhird Party Llabllity I Remvery Settion
v0 8oa Ba86 I Hamsburg, Fennsylvanla ll105-8a86
COMMONW[ALTH OF PENNSVLVPXIq
�UREAV OFPROGRPMIME4FIiV
OIVISION OFTHIR�PARTV LIABILIry
RECOVERV SEf.T10N
POBOXBCtl6
HARRISBVRG.PA 1>iP5dCP6
February 11,2015
STATEMENT OF CLAIM SUMMARV
NAME EsGte o( CHAMBERLIN,AUOREY
ID 8001334/2
MEDICAL CLASS 3 CIASS 5.1 TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 16,666.85 146,035.20 162,]02.05
�RUG ]I128 483.fi3 �p0.91
REIMBURSEMENTTODPW 16,888.11 166,518.83 i61,d06.96
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN- 23E003113
Page 1 of 14
-_ _ _ -- -
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 11,2015
STATEMENT OF CLAIM
NAME CHAMBERLIN,AUDREY
ID BUU 13�4q2
SHIPPENSBURG HEALTN GARE CTR
121 WALNUT BOTTOM RD
SHIPPENSBURG PA 1'/l5]
DATEOFSERVICE PAYMENTOATE ORIGINALCRN ADJUSTEDCRN USUALCHARGES AMOUNTAPPROVE�
O6/11/10 - 06130H0 01/14/11 55110394108320001 5511�396106320001 3,91Y.d0 �,83Y.60
[11AGN0515 1 : 32]23
OBSTRUCTIVE SLEEP AVNEA(AOULT)(PEDIATRIC)
PROC CODE: 000000
09/01/10 - p]/31H0 10H]Ht SSH38q4]8l530001 5511Y8M]8C5�0001 5,803.60 5,52621
OIAGNOSISi '. �29]]
OBSTRUCTIVE SLEEP APNEA(ADULT)(PEDIATRIC)
PROC CODE: 000000
UBI01H0 - 08/37/10 10/19H1 551128443805YU001 SSH2844384520001 6,06422 5,]]B.66
DIAGNOSIS 1 : 31]23
OBSTRUCTIVE SLEEV APNEA(ADULT)(PEDIATRIC)
PROC CODE�. 000000
09/01/10 - 09/30H0 10/1]/11 5511ZBC6384510U01 SSH1&H]8�510001 5,868.60 5,589.32
DIAGNOSIS 1 : ]2123
OBSTRUGTIVE SLEEP AVNEA(AOULn(PEDIATRIC)
PROC CODE: 000000
70I01110 - 10/31/10 10/fd/N 55112921259980001 55H29]025)980001 5,914.d9 5,823.61
DIAGNOSIS 1 : 32113
OBSTRUCTIVE SLEEP APNEA(ADULT)(PEDIATRIC)
PROC GODE: 000000
11/01/10 - 11/30/70 70/24111 551129]42519'l0001 5511I93625]970001 5,]23.70 5,632.82
DIAGNOSIS 7 : 31]23
OBSTRUCTIVE SLEEP APNEA(ADULT)(PEDIATRIC)
PROC CODE�. 000000
1Y/07/70 - 1977H0 70/26/11 55fl392C25B150001 SSH292<258750001 5,97C.49 5,823.61
DIAGNOSIS 1 : 32123
OBSTRUCTIVE SLEEP APNEA(ADULT)(PEDIATRIC)
PROCCODE' 000000
Page 2 of 14
__ -
__ _ - -- -
COMMONWEALTH OF PENNSYLVANIA ..
�. DEPARTMENT OF PUBLIC WELFARE
February ii,3015
STATEMENT OF CLAIM
NAME CHAMBERLIN,AUDREV
I� 600133662
SMIPPENSBURG HEALTH CARE CTR
1]i WALNUT BOTTOM RD
SHIPPENSBIIRG PA 1]25]
DATEOFSERVICE PAYMENTDATE ORIGINALCRN ADJUSTEDCRN USUALCHARGES AMOUNTAPPftOVE�
01/OtA1 - 01120/11 10/31H1 551129942518W001 SSH2994251850001 3,449.34 I,59536
DIqGN05151 : ;2]23
OBSTRUCTIVE SLEEP APNEA(ADULT)(PEDIATRIC)
PROC CODE: OOOOOU
06/01H1 - O6/30H1 fl/0)H1 55173051Y21620001 551130592]16Y0001 5,]48.90 6,849.8I
DIAGNOSIS 1 : 32]23
OBSTRUCTIVE SLEEP APNEA(ADULT)(PEDIATRIC)
PftOC CODE: 000000
W/01111 � 09I31H1 OS/WR2 55121244]Od;80U01 5511124NOG360001 5,9�0.53 /,88�.63
DIAGNOSIS 1 : SP23
OBSTRUCTIVE SLEEP APNEA�ADULn(PEDIATRIC)
PROC CODE: 000000
0&�i111 - 08/31/11 05IW/12 55121Z4q9U51]0001 551Y1244]05190001 5,9l0.53 �,883.63
�IAGNOSIS 1 : 3Y)23
OBSTRUCTIVE SLEEP APNEA(qDIILT)(PEDIATRIC)
PROCCODE' 000000
09I01/17 - 09/30111 OS/O1/17 5512124/]05960001 55121]M]059fi0001 5,]48.90 4,]00.12
DIAGNOSIS 1 : ]2)]3
OBSTRUCTIVE$LEEP APNEA(ADULT)(PEDIATRIC)
PROCCODE' 000000
10/07/11 - 1U/]iH1 O6H8R2 551Y1654508/80001 551Y1654508460001 5,82028 q,)pg_gq
DIAGNOSIS 1 : 31723
OBSTRUCTIVE SLEEP APNEA(ADULT)(PEDIATRIC)
PROC COOE: 000000
77I01R1 - 11I30H7 O6H811P 55121659509Y90001 551I1654509290001 5,636.40 �,551.O1
DIAGNO515 7 : 3PI3
OBSTRUCTIVE SLEEP APNEA(ADULT)(PEDIATRIC)
PROC CODE �. U00000
Page 3 of 14
_ _ __ _ _ __. _
�I COMMONWEALTHOFPENNSYLVANIA � �
DEPARTMENT OF PUBLIC W ELFARE
Febmary 11,2015
STATEMENT OF CLAIM
NAME CHAMBERLIN,AUDREY
ID 800133442
SHIPPENSBURG HEALTH GARE CTR
721 WALNUT BOTfOM RD
SHIPPENSBURG PA i]25l
DATEOFSERVICE PAYMENTDATE ORIGINAICRN A0.IUSTEDCftN USUALCHARGES AMOUNTAPPROVED
1I/01/11 - 1LN/11 06H8/1Y 551I1650510380001 55721fi5�510380001 5,82d.28 4,�Ig.9p
DIAGN05151 : A019
MVPERTENSION NOS
PROC CODE: 000000
01I01/12 - 01/31H3 p]/i6/1Y 55121944p4YI50001 551219G6p42250001 5,824.28 G,936.06
DIAGNOSIS 1 : 4019
MYPERTENSION NOS
PROC CODE: 000000
02I01/1Y - 03/39/12 0]H6/12 551219b6063040U01 551219440d3000001 . 5,468.52 O,Sfi4.36
DIAGNOSISI ' 4019
HVPERTENSION NOS
PROC CODE: 000000
03/01H2 - 03/31I12 0]/i6H3 5512794I063800001 55121949063870001 5,8I<.IB 6,936.08
�IAGNOSIS 1 : /019
HYPERTENSION NOS
PROC CODE '. Op00U0
OGI01/12 . OC/30H2 O5I0]H2 Y]1312]6025690001 2]131226025690001 3,638.50 1.612.92
DIAGNOSIS 1 : 4019
HYPERTENSION NOS
PROC CODE: 000000
09/01H2 - 09/30/il 01/Y&73 55110]C43]9930001 551�02N328930001 5,2]].00 3,999.62
DIAGNOSIS 1 : l019
HVPERTENSION NOS
PROC CODE�. 000000
10/01/12 - 10/31/12 OYHB/13 55730C4CO29060007 55130�6/03906U001 5,451.90 6,463AI
DIAGNOSI51 : /079
HYPER�ENSION NOS
PROC CODE: 00�000
Page 4 of 14
� � COMMONWEALTHOFPENNSVLVANIA
DEPARTMENT OF PUBLIC WELFARE . �
February H,2015
STATEMENT OF CLAIM
NAME GHAMBERLIN,AUDREY
10 800 133/42
SHIPPENSBURG HEALTH CARE CTR
121 WALNUT BOTTOM RD
SHIPPENSBURG PA 7]25'!
DATEOFSERVICE PAYMENTDATE ORIGIWILCRN ADJUSTEDCRN USUALCHARGES AMOUNTAPPROVED
11101HY - 11/30H� WHBHI 55130N4039900001 55730C440Y9900001 5,3]].00 4,292.42
DIAGNOSIS 1 : 4019
HVPERTENSION NOS
PROC CODF- OOOOOD
iypi/13 - 19�1/12 03/18H3 55130M4030840001 551304W030800U01 5,452.9U 6,463.OY
DIAGNOSIS 1 '. 4019
HYPERTENSION NOS
PROC CODE'. 000000
01I01H3 � 01/31/13 0]H7H3 69130354021890001 691303560Y1890001 5,385.89 4,196.89
OIAGN05151 : /019
HVPERTENSION NOS
PROC CODE: OU0000
05/O1H7 - 05/31H3 06HOH3 2]13156l�2]]40001 3]131564UY9]40001 5,6Y2.16 4,53346
DIAGNOSIS i �. 4019
HYPERTENSIONNOS
PROC CODE: 000004
O6I01/13 - O6/3U1t3 0]/09/13 2)1318]�030050001 21131834030050001 5,0]8.08 3,989.08
DIAGNOSIS 1 '. 4019
HYPERTENSION NOS
PROC CODE: 000000
09IO1H3 - 0]171/13 OT110/14 551l0364230W0001 55140364220000001 4,195.81 389.85
DIAGNOSIS 7 : 4019
HYPERTENSION NOS
PROC CODE: 000000
11I01H3 - 11130H3 03/1011♦ 551<0664056720001 55710H�056720001 S,d40.80 3,291.50
DIAGNOSIS 1 : 4019
HVPERTENSION NOS
PROC CODE: OD0000
Pa9e 5 of 14
_- _ _ __
� � � � COMMONWEALTHOFPENNSVLVANIA
DEPARTMENT OF PUBLIC WELFARE
February 11,2015
STATEMENT OF CLAIM
NAME CHAMBERLIN,AUUREY
ID BOOt33442
SHIPPENSBURG HEALTH CFRE CTR
1]t WALNUT BOTTOM RO
SHIPPENSBURG PA iR5]
DATEOFSERVICE PAVMENTOATE ORIGINAICRN ADJUSTEDCRN USUALCHARGES AMOUNTAPPROVED
1�/01113 - 1]/31117 03/1011{ 551406C905�600U01 551406d405]W0001 5,622.16 3,/62.05
DIFGNOSIS 1 : 4019
HVPERTENSION NOS
PROC CODE: 000000
01101H4 - 01/31H4 10/13114 6914382<021960001 691028Y6021960001 5,623d6 3,281.66
DIAGNOSIS 1 : <019
HVPERTENSION NOS
PROC CODE-. 000000
OL01H4 - OL38HC 1D/13/10 69142ffid0219]0001 691Q834021W0001 4.645.'/6 ],]9�.04
DIAGNOSIS 1 : 4019
HVPERTENSION NOS
PROC CODE: 000000
03I01116 - 03/31114 10/13I10 69142824021980001 6914182/021980001 5,143.51 3,291.80
OIAGNOSISI ' <019
HVPERTENSION NOS
PROC CODE: 000000
04/01114 - 04/30I16 O5/OS/11 3]1d1]240315l0001 21111220021560001 5,205.00 3,353.28
�IAGNOSI51 : <019
HVPERTENSION NOS
PROC CODE'. OOOWU
05/01116 - 05/37H4 06/09H4 2]'1475740]6970001 2714153CO10920001 5,3]8.50 3,526.18
DIAGNOSIS 1 : 0019
MYPERTENSION NOS
PROC CODE: 000000
O6/01/14 - 06/30114 07101/14 2114'IB2403]5]U001 2]1418340]]5'/0007 5,205.00 3,353.28
DIAGNOSI51 ' <019
HYPERTENSION NOS
PROC CODE: 000000
Page 6 of 14
- - - --- �
� � �� COMMONWEALTHOFPENNSVNANIA ,
OEPFRTMENTOF PUBLIC WELPARE �
February 11,2015
STATEMENT OF CLAIM
NAME CHAMBERLIN,AUDREY
ID 800133462
SHIPPENSBURG MEALTH CARE CTR
137 WALNUT BOTTOM RD
SHIPPENSBURG PA 1]25]
DATEOFSERVICE PAVMENTDATE ORIGINALCRN ADJUS7EDCRN USUALCHARGES AMOUNTHPPROVED
W/01/14 - �]I31H4 0&11/14 551431]d0&1530U01 551021]4084530001 5,3]0.50 3,085.96
DIAGN05151 �. 4019
HVPERTENSION NOS
PROC CODE'. 000000
08101H4 - OBI31H4 09/2T/14 69142601023080001 691dY604033080001 4,931.68 3,085.)1
DIAGNO515 1 : 4019
HVPERTENSIUN NOS
PROC CODE '. U00000
09/01/14 - 09/30/14 t0106114 2l1/2]5/02�290001 21102]56U2'l290001 4,]'/8.40 2,9Z6.43
DIAGNOSIS 1 : 0019
HYPERTENSION NOS
PROC CODE: 000000
10I01H4 - 10/31/iC 11/10H� 2]143U84U37]10001 1]11308C031]10001 <,]2531 3,2<239
DIAGNOSIS 1 : 4019
HVPERTENSION NOS
PROC CODE'. OOOU00
11IOt/t0 - i113011d 11/OB116 2'l143151040960001 3714375�040940001 /,002.64 5'12.40
DIAGNOSIS 1 '. 6019
HYPERTENSION NOS
PROC CODE: 000000
12/01/1/ - 72I09/14 12HSH4 2l1<363/023110001 2]143l30023910001 5]YAO 400.68
DIAGNOSIS 7 '. 4019
HYPERTENSION NOS
PROC CODE' 000000
PftOVIDERSUBTOTAL SHIPPENSBURGHEALTHCARECTR 211,929.61 160,119.25
03 007550908 000Y
Page 7 of 14
� COMMONWEALTM OF PENNSYLVANIA
DEPARTMENT OF PUBLIC W ELFARE
February 11,2015
STATEMENT OF GLAIM
NAME CHAMBERLIN,AUDREV
ID 80013�4a1
LAUREL CARE NURSING 8 REHAB CTR
6315 CHAMBERSBURG RD
FAYETTEVILLE PA 71322
DATEOFSERVICE PAVMENTDATE ORIGINALCRN AOJUSTEOCRN USUALCHARGES AMOUNTHPPROVED
09101/OB - 09/30/OB O6115/09 690916'14U21620001 690916140Y162U001 1,201.60 2,5]2.80
DIAGNO5151 : ]2Q
LUMBAGO
DIAGN05152' ]5000
DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION,TYPE II OR UNSPECIFIED TYPE,NOT STATED AS UNCONTROLLED
PROC CODE: OU0000
PROVIDER SUB TOTAL �UREL CARE NURSING 8 REHAB CTR 1,]0].60 2,523.80
03 001805560 0001
Page B of 14
_ - __ _ ___ _ -_ __ �
COMMONWEALTH OF PENNSVLVANIA .
DEPARTMENT OF PUBLIC W ELFARE
Febmary 11,Y015
STATEMENT OF CLAIM
NAME CHAMBERLIN,AUOREV
ID 800133M2
PHARMACARE INSTITUTIONAL SERVICES
1 JAMES DAV DR
CUMBERLAND MD 21502
DATEOFSERVICE PAYMENTDATE ORIGINALGRN ADJUSTEDCRN USUALCHARGES AMOUNTAPPROVED
09119/11 - 09H9H1 10/31H1 ]5112i952663�0001 25H2]]SY66360001 1P.50 11.55
DIAGNOSIS 1 :
NDC CODE: 5199103NC9� FOLBIC TABLET - WATER SOLUBLE VITAMINS
10/07H1 � 10/01/11 1U2&11 ]511306528Y450001 25173065282450001 3026 Y264
DIAGNOSIS 1 :
NDCCODE: 5799103899 FOLBIGTABLET - WATERSOLUBLEVITAMINS
H/01/H - fl101H1 13261H 25H3365060650001 25113365660650001 2].BG 34.56
DIAGNOSIS 1 :
NDC CODE' S1991038C9 FOLBIC TABLET - WATER SOLUBLE VITAMINS
1T/01/71 - 13I01/11 01/JO/72 25120025353580001 251200]5353580001 28.65 25.7]
DIAGNOSIS 1 :
NDCCODE: 5'1991038C9FOLBIGTABLET - WATERSOLUBLEVITAMINS
O1/l0/12 - 01/30/12 0]/2]/12 25120325/08090001 25120325d084900D1 12.�0 4.86
�IAGNOSIS 1 '.
NDC CO�E '. 0059102/00 LORAZEPAM O.S MG TABLET - ATARACTICS-TRANQUILIZERS
01/31H2 - 01/31H2 OP29H7 25120345494040001 25120345190040007 27.90 ]5.29
DIAGNO515 1 :
NDC CODE: 5199103899� FOLBIG TABLET - WATER SOLUBLE VITAMINS
021f9/12 - 03139/72 03/26112 357206256fi41300a1 25120625660]300U7 25.53 z1.21
DIAGNO515 1 '.
NDC CODE: 5799103849 FOL61C TABLET - WATER SOLUBLE VITAMINS
Page 9 of 14
_- _
_-
COMMONWEALTH OF PENNSYIVANIA
�' DEPARTMENT OF PUBLIC WELFARE �
February 11,2015
STATEMENT OF CLAIM
NAME GMAMBERLIN,AUDREV
ID 8001]340]
PHARMACARE INSTITUTIONAL SERVICES
1 JAMES DAY DR
CUMBERLAND MD I1502
DATE OF SERVICE PAVMENT DATE ORIGINAL CRN ADJUSTEO CRN USUAL CHFRGES AMOUNTAPPROVED
03/31113 - 03/31/12 Od/30/12 2512W05786]40001 Y5120905]86]<0001 2].90 3529
DIAGNO515 1 :
NDCCODE: 5199103849 FOLBICTABLET � WFTERSOLOBLEVITAMINS
06/10/11 - OOHN12 OS/14/13 25121095Y]2550001 25121U952]Y550001 14.53 9.61
DIAGNOSIS 1 : �
NDC CODE' 5199103849 FOLBIC TABLET - WATER SOLUBLE VITAMINS
09H6H2 - 09H6/12 10IYY/12 25122695295310001 2512Y695Y95910001 15.31 1039
DIAGNOSIS 1 '
NDCCODE: 51991016�9FOLBICTABLET - WATERSOLUBLEVITAMINS
PROVIOER SUB TOTAL P�RMACARE INSTITUTIONAL SERVICES pyp,�6 162.55
20 100]28693 0003
Page 10 of 14
— �� COMMONWEALTHOFPENNSYLVANIA �'�
DEPAftTMENT OF PUBLIC WELFARE
February 11,3015
STATEMENT OF CLAIM
NAME CHAM6ERLIN,AU�REY
I� 8 00 13 3 411
TRINITY PHARMACY SERVICES
100 N 4TH ST
NEWPOftT PA 1]0]4
DATEOFSERVICE PAYMENTDATE ORIGINALCRN ADJUSTEDCRN USl1ALCHFRGES HMOUNTAPPROVE�
09H]/12 - 09/1]11] tOH5HY 2512Y625586]50�01 251226]5586]50001 ].96 3.N
DIAGNO515 1 :
NDC CODE'. 0090tl5908 FERROUS SULFATE 335 MG TABLET - HEMATINICS b BLOOD CELL STIMULATORS
09H]H2 - 09/19HZ 10/i5113 2512�625586800001 Y51YY625586600001 34.40 20.58
DIAGNOSIS 1 :
NDC CODE �. 5199103899 FOLBIC TABLET - WATER SOLUBLE VITAMINS
10/1]l13 - 1011]/12 11/1912 35112975311650001 25122915311650001 34.44 22.58
DIAGNO515 1 :
NDC CODE: 5199103849 FOLBIC TABLET - WATER SOLUBLE VRAMINS
11H3/12 - 11113/12 72H]H2 25123255Md930001 ]512325544M193D001 ].97 Y.69
DIAGNOSIS 1 :
NDC CODE�. 5199103869 FOLBIC TABLET - WATER SOLUBLE VITAMINS
111i6/12 - 11H6H2 1P/t011Y 25123]t53]6210001 25123]153)6]30001 3d.l6 3258
DIAGNOSIS 1 :
NDCCWE'. 51991038�9 FOLBICTABLET - WATERSOLUBLEVITAMINS
1P/i6liZ - 1P/16H3 01H4/73 Y51Z35Y5299200001 25121535299200007 34.44 72.58
DIAGNOSIS 1 �.
NDC CODE: 519910�BI9 FOLBIC TABLET - WATER SOLUBLE VITAMINS
72I37H2 - iLY]/12 01I21H7 35727635301530001 Y5123fi25301530U01 8.99 ].O]
DIAGNO515 1 '
NDC CO�E: 6130409920 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANpUILRERS
Page 11 of 14
- _ __ _- - _
COMMONWEALTHOPPENNSYNANIA ��� .
DEPARTMENT OF PUBLIC WELFARE I
February 11,PU15
STATEMENT OF CLAIM
NAME CHAMBERLIN,AUOREY
ID 800133042
TRINITY PHARMACV SERVICES
100 N 4TH ST
NEWPORT PA 110]0
DATE OF SERVICE� PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CMARGES AMOUNTAPPROVE�
U1H5HJ - 01/15/13 01/11Ill 25130155382220001 Z5130155382220001 �,9� 2,6g
DIAGNOSIS 7 :
NDCCODE '. 5199107809 FOLBICTABLET - WATERSOLUBLEVITAMINS
OSH2113 - OS/12H3 O6H0/13 ]513133525H30001 25131335251130D01 q�,�9 Zy2y
DIAGNOSIS 1 :
NDCCWE: 5199103809 FOLBICTABLET - WATERSOLUBLEVITAMINS
� O6/H/13 - O6/11R3 0)/08H3 25131625333]90001 25131fi25I33]90001 11.99 2.69
DIAGNOSIS 1 :
NDC CODE: 51991 W849� FOLBIC TABLET - WATER SOLUBLE VITAMINS
11I08/il - it/OB/13 1L02/17 251331I51�6'l00001 25113125216�OU007 67,1) 2p,5g
DIAGNOSIS 1 '.
NDC CODE' S1991 W849 FOLBIC TABLET - WATER SOLUBLE VITAMINS
1P/OBH3 - 12/OBH3 01H3114 251335Y5338600001 ]51]3535338000D01 41.V 23.58
DIAGNOSIS 1 :
NDCCODE�. 51991038�9FOLBICTABLET - WATERSOWBLEVITAMINS
07I07H6 - 07/0]l14 0]/03/iC ]51�U075298820001 Y51d00]SZC882000'I 41.1] ]2.58
DIAGNOSIS 1 :
NOCCODE' S199103849 FOLBICTABLET - WATERSOLUBLEVITAMINS
OI/031i4 - 0]/0311d 0]I03/74 ]51d03953]3150007 251403453]3350001 1].58 5.15
DIAGNOSIS 1 :
NDC COOE: 4612200393 MIGONAZORB AF 2Yo POWOER - pNTIFUNGALS
Page 12 of 14
_ _ .__
-- _ _ --_
COMMONWEALTH OF PENNSVLVANIA
DEPARTMENT OF PUBLIC WELFARE I
Febrvary ii,]015
STATEMENT OF CLAIM
NAME GMAMBERLIN,AUDREY
ID 80013J 44]
TRINITY PHARMAGV SERVICES
100 N/TH ST
NEWPORT PA i]0'!4
DATE OF SERVICE PAVMENT DATE ORIGINALCRN ADJUSTED CRN lISUAL CHARGES AMOUNTAPPROVED
0]/06/14 - �1/O6/14 03/03114 251401]5245400001 251403]5145900001 39.16 ]1.21
DIAGNOSIS 1 '.
NDC CODE: 5199103849 FOLBIC TABLET - WATER SOLUBLE VITAMINS
OLO6/14 - 03/O6/14 OW31114 25140655]41090001 251406552N090001 �9.�5 p�_p�
DIAGNOSIS 1 '.
NDC CODE' S199703849� FOLBIC TABLET - WATER SOLUBLE VITAMINS
OGI03H4 - Od/03H4 O6/]B/i4 ]51409�5351810001 35140935254810001 394fi 2121
DIAGNOSIS 1 :
NDC CO�E '. 5199103849 FOLBIC TABLET - WATER SOLUBLE VITAMINS
OS/01H0 - O5/O1/1/ OSR6/14 ]5141Y15269580001 35141215269580001 39.16 21.]1
DIAGNO515 1 :
NDC CODE: 5199107809 FOLBIC TABLET - WATER SOLUBLE VITAMMS
05/29HC - OS119/1� 01/Y1H4 Y51d1]85299680001 ]5161]85299680001 3946 ]1.Y1
DIAGNO515 1 :
NDC CODE '. 51991076C9 FOLBIC TABLET - WATER SOLUBLE VITAMINS
O6/26H4 - O6/26H4 07I21H6 257�1]'l52833600U1 25161]]5282360001 39.16 7�.p�
�IAGNOSIS 1 :
NDC CODE: 5199103849 FOLBIC TABLET - WATER SOLUBLE VITAMINS
O6/30114 - O6/SO116 0]128H4 251�1855254850007 25147855256850007 g�.g� p3.aq
DIAGNO515 1 :
NDC CO�E: 001891]MO MEPHYTON 5 MG TABLET - VITAMIN K
Page 13 of 14
_ , . ____ - _ . .
��, COMMONWEqLTH OF PENNSYLVANIA
DEPAftTMENT OF PUBLIC WELFARE
..___ ... _ _. . . . _. .. ._ . .._—_ _ _. .... ..—_ _. i
Febmary 11,2015
STATEMENT OF CLAIM
NAME CHAMBERLIN,AUDREY
ID 600133A02
TRINITY PHARMACY SERVICES
1 UO N 6TH ST
NEWPORT PA 1�014
DATEOFSERVICE PAYMENTDATE ORIGINALCRN ADJUSTEDCRN USl1ALCHARGES AMOUNTAPPROVED
O]/20H4 - 09124/14 OB118/16 3514Z055313810U01 25162055012810001 39A6 Y127
DIAGNOSIS 1 :
NDCCODE: 5199103849 FOLBICTABLET - WpTER50lUBLEVITAMINS
OB/Y1H4 � 0&21H4 09/1511! 2514Y�65251]]0001 25162345251]]0007 ]9d6 21,N
�IAGNOSIS 1 :
NDC CODE' S199103849� FOLBIC TABLET - WATER SOLUBLE VITAMINS
09ABH6 - 09/18/10 09/39/1/ ]51Q615290130001 251<Y615290130U01 39.�5 p�_Z�
DIAGNO515 1 :
NDC CO�E'. 5199107809 FOLBIC TABLET - WATER SOLUBLE VITAMINS
10H6I10 - 10H6/14 1013]/id 251G3695349050001 25142895Z69050001 �9.16 ��.p�
DIAGNOSIS 1 '.
NDC CODE: 51991 W869 FOLBIC TAB�ET - WATER SOLUBIE VITAMINS
10/30/74 - 10/30114 11/1]/10 251430t53926]0001 2516304529]6)OOOt 09.45 32.06
DIAGNOSIS 1 �.
NDC CODE: 0078]i]O60 MEPHVTON 5 MG TABLET - VITAMIN K
71/O6/iC - N/O6114 11I2N14 25143N5351130001 2514311535]130001 8).90 60d3
DIAGNOSIS 1 :
NDC CO�E: 0 01 817 10 4 0 MEPHVTON 5 MG TABLET - VITAMIN K
PROVIDERSUBTOTAL TRINITYPMARMACVSERVICES 933.66 523.36
24 7024]OY07 0003
Page 14 of 14
� � � �
n � � �
o � w n N
y. � � � �
� � s
� � � � � �
r, ,r w n � A � .
o a
ro u °' °n � Z � ��.. .
am c� � O (Q
o ^
�n C .� N � � (�
�G n r C- ' � '�
o W �c m [D
w m o � N d �
°c � o � �
� y � U, G
g v � N
� � �
" N .�
1D O �
� � � �
co ..� �' �
� A c_ � o
:� �
v r N a
nxc� � o
� ,� r �� m
_ „� � �
.., �' �::. .-� o :; �
. : �. �, � -'� �i �.t �
3 T
�� �
= O Jv .
`� w r m
r o
f � T
� �
*
` ��
� �
�
. . : .:�Ef�: � _
Ci .
O
ij f V
Cd.� ,
�
�