HomeMy WebLinkAbout07-15-15 J �pennsytvanta 15 D 5 61410 5
DFMRMFMOFPEVENIIE ��03-14)(FI)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
INHERITANCE TAX RETURN ;-_��; -^ � - ------ -'
PO BOX 280601 ; i),�
Harrisburg, PA 17128-06oi RESIDENT DECEDENT � �; � y�9
ENTER DECEDENT INFORMATION BELOW �
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
---- -- --- - - -- - - — -�
° 02232015 07031921
_ --------- _ -_. _.---- � ___ _ --_— ----- - ___� _ __ _--- _...._..�
DecedenYs Last Name Suffix Decedent's First Narne MI
-- ---- ---- ---....- -- __ __._ .. . ._...
_ . - -- _
Batdorf Kathryn � g ;
---- --- --- --------------- ; �_ —._. --- ___ _--- . .__. _I _ ;
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Narr,e MI
_..� -- --—� _ ... -_ ._..._ . --, _. _.-. _ .._�
C ....._....-- --- . -. -- ----- . ._ ._... _ . ----_ .__� `.�___. _— _ --- __.___._ . __._ _._� .___.;
THIS RETURN MUST BE FILED IN DUPLICATE WITN THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Original Retum p 2.Supplemental Return p 3. Remainder Return(date of death
priorto 12-13-82)
p 4.Agriculture Exemption(date of � 5.Future Interest Compromise(date of p 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death afler 12-12-82)
p 7. Decedent Died Testate p 8.Decedent Maintained a Living Trust _____ 9. Total Number of Safe Deposit Boxes
(Attach copy of will.) (Attach copy of trust.)
p 10.Litigation Proceeds Received p 11.Non-Probate Transferee Return p 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
O 13. Business Assets O 14.Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
James W. Stock i (717) 938 6328 �
_...---- -_...---------_----------------- -----...----...—._ __.I --— _._.. ____.. _.._--- �
First Line of Address
'417 Old Stage Road
�.---- -------------------------------------------------
_ _..___..
Second Line of Address
------ ------_----------------------...-----...-- --------......---....__.
City or Post Office State ZIP Code
_._ _. __ __ ___ _._._.. -- -
__ _._..
Lewisberry ; PA 17339 �
CorrespondenYs email address: jStoCk417@COmCaSt.net ___ � o
C � � �
REGISTER �NN S USE OL11,LX �
���REGISTER OF WILLS USE OMLY�� � � G"7 � C'�'7
.�'- ►"' -1
�-�� �MU ��4�:� F.— f"�►
. (-•� � i;�
� � �t' � £ � ) .�.
�,.n.,�.>,�. „d..�,..,.�.,,...,,�,,,KK,...,..,�..�a 7 �-.. �.'.) 'Z' �1
z -r
"`> ..7 � y�
DAT,�FII;��STAMP F"'� `—
_.`j r...
=> n � f�
1 '�1
PLEASE USE ORIGINAL FORM ONLY
Side 1
� ���������������������'����l1���4��1�D����������������I���� 15 0 5 6141 D 5 J
e
�
� ��
�
1
� 1505614205
REV-1500 EX(FI)
DecedenYs Social Security Number
�ecedent's Name: Kathryn S. BatdOrf
RECAPITULATION
,_..-----__..._ -------------__..--------_:
;
1. Real Estate(Schedule A). ............. ............................... 1. ; 0.00 ;
,..__._...__.s._____.____._�,�_��.__
2. Stocks and Bonds(Schedule B) ........ ............................... 2. ! 0.00 ;
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. �� 0.00 ;
4. MoR a es and Notes Receivable Schedule D 4. � 0.00 �
9 9 ( )... .............. ......... .
�.__.._..________.._ _
�
5. Cash,Bank Deposits and Misceilaneous Personal Property(Schedule E)....... 5. � 0.00 ;
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. ! 4,000.90 :
i___.._.__....-------_..__._.....----____..__...------------ ;
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property � 1,877,001.92 '
(Schedule G) O Separate Billing Requested........ 7. ;
�__._.___ _;
8. Total Gross Assets(tota�Lines 1 through 7)... ......................... . 8., 1,881,002.82
9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. ' 14,314.00 ;
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............... 10.�mm�� 1,794.67 i
�.._._.__ _�____ �
11. Total Deductions(total Lines 9 and 10)...... ........................... 11.� 16,108.67 ;
�__._.__.
i �
12. Net Value of Estate(Line 8 minus Line 11) .............................. 12. ; 1,864,894.15 ;
I__.�._.__,. _.._._____.
13. Charitable and Governmental Bequests/Sec.9113 Trusts for which �
an election to tax has not been made(Schedule J) .............. .......... 13. � 0.00 I
14. Net Value Subject to Tax(Line 12 minus Line 13) ...... .................. 14. � 1,864,894.15 ;
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116 - - -___-- -_._ _._ .--- ._.----.__._-_. __ _ __._._. ____
0.00 �5 .__..__.______�_____ _ 0.00
(a)(12)X.0_ ;
16. Amount of Line 14 taxable !
at lineal rate X.0 45 1,864,894.15 �6.; 83,920.24 ;
17. Amount of Line 14 taxable � �� �� �
at sibling rate X.12 �.�� 17. ; � �.�� '
18. Amount of Line 14 taxable � �
at collateral rate X.15 �.�� �$ : �.�� '
=---.....-----..._.....____...---------.....-----.....--._...._..� �.._.___ _ '
19. TAX DUE......................................................... 19.', 83,920.24 ;
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Under penalties of perjury,I declare I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the person responsibie for filing the return is based on all information of which preparer has
any knowledge.
SI RE OF PFS$�f)�N/RES N R FILING RETURN DATE /�
3! YGo
ADDR
417 Old Stage Road, Lewisberry, PA 17339
SIGNATURE F PREPARE OT ER TH PERS N RESP SIBLE FOR FILING THE RETURN � DATE �
� 3'O
ADDRES
Hartman &Scheuchenzuber, CPAs 4823 E. Trindle Rd Ste 200, Mechanicsburg, PA 17050 717-761-4000
i iiiiii iiiii iiiii i�i��iii�i�iiiii i�ii iiiii iiiii iiii iiii Side 2 �
� 5 42 5 15D5614205
�.�� or.i7..n„ri�. n
�
' REV-1500 EX (FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Kathry S. Batdorf ___
STREET ADDRESS
417 Old Stage Road ____
CITY ' STATE � ZIP
Lewisberry PA � 17339
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 83,920.24
2. CreditslPayments
A.Prior Payments 79,405.15
B.Discount 4,179.22 '
(See instructions.) Total Credits(A+B) (2) 83,584.37
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)
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 335.87
Make check payable to: REGISTER OF WILLS, AGENT.
�� �.. ..� u _ .�:. �:._ _, ���..��...;���.�� : .��.� . v��� ����"� ��:' ���;..���
�
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" I�1 THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred.......................................................................................... ❑ �
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ �
c. retain a reversionary interest.............................................................................................................................. ❑ �
d. receive the promise for life of either payments,benefits or care?...................................................................... � �
2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. � ❑
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. � ❑
4. Oid decedent own an individual retirement account,annuity or other non-probate property,which
containsa 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.
,.. ,�� .�, �.e. �� � -� � '' ���§ :��,. .�_ ��:�;���: _k ����
3,�.' &�A' . z� x .,x . .� , t4t lc'cs.
For dates of death on or after July 1,1994,and before Jan.1,1995,the tax rate imposed on the net value of iransfers 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,antl the statutory requirements for disclosure of assets antl
filing a tax retum 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 naturai parent, an
adoptive parent or a step-parent 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 decedenYs lineal beneficiaries is 4.�percent,except as noted in[72 P.S.§9116(a)(1)].
. The tax rate imposed on the net value of transfers to or for the use of the decedenYs siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined,
under Section 9102,as an individuai who has at least one parent in common with the decedent,whether by blood or adoption.
.
� REV-1509 EX+(02-15)
� pennsylvania SCHEDULE F
, DEPARTMENTOFREVENUE �OINTLY-OWNED PROPERTY
INHERITANCE TAX RERIRN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Kathryn S.Batdorf 2115-0449
If an asset became jointly owned within one year of the decedent's date of death,it must be reported on Schedule G.
SURVIVING)OINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A.James W. Stock 417 Old Stage Road Son _
Lewisberry, PA 17339
B. - _
C. _
JOINTLY OWNED PROPERTY:
�rrER on� DESCRIPTION OF PROPERTY �o OF DATE OF DEATH
ITEM FOR]OINT MADE INCLUDE NAME OF FINANCIAL INSTIfUTiON AND&4NK ACCOUM NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF
NUMBER lENANT JOINT IDENTIFYING NUMBER.ATTACH DEED FOR)OINTLY HELD REAL ESTATE. VPIUE OF ASSEf INTEREST DECEDENT'S INTEREST
.... .. ....... . ........ ...._ ...... ... ..... .. . . ._.... . ....... . ..:..
1. A. PNC Bank Checking Account 8,001.79 50% 4,000.90
TOTAL(Also enter on Line 6, Recapitulation) $, 4,000.90
If more space is needed,use additional sheets of paper of the same size.
���m�ir,i n�rrr� �
REV-151Q EX+ (02-15)
� � pennsylvania SCHEDULE G
DEPARTMENTOFREVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF PILE NUMBER
Kathryn S. Batdorf 2115-0449
This schedule must be compteted and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
DESCRIPTION OF PROPERTY
ITEM INCLUDETHENAMEOFTHETRANSFEREE,fHEIRRELATIONSHIPTODKEDENTAND DATE OF DEATH %Of DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1• 'Cash-transferred to James W.Stock,417 Old Stage Rd,Lewisberry, PA 10,OOO.GO 100 3,000.00 ' 7,000.00
'Transferred on 01/0212015
2 United States Treasury-2014 Individual Income Tax Refund 319.00 100 319.00
3 Edward Jones Individual Retirement Account 30,408.25 ` 100 30,408.25
4 Edward Jones Investment Account-Payable-upon-death ' 1,720,840.80 100 1,720,840.80
5 Edward Jones Investment Account-Payable-upon-death 118,433.87 100 118,433.87
TOTAL(Also enter on Line 7, Recapitulation) $ < 1,877,001.92
If more space is needed,use additional sheets of paper of the same size.
.�_���rr..n�ri�� ,
� REV-1511 EX+(02-15)
� pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCETAXRENRN ADMINISTRATIVE COSTS
RESIDENT DECEDENT �
ESTATE OF FILE NUMBER
Kathryn S. Batdorf 2115-0449
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERALEXPENSES:
1' Hoover Funeral Homes&Crematory,Inc. 13,564.00`:
B, ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address _..____
City__ State _ZIP
Year(s)Commission Paid:
2. Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation,)
Claimant _--_
Street Address _..._____
City State______ZIP
Relationship of Claimant to Decedent .___
4. Probate Fees:
5. Accountant Fees:
6. Tax Retum Preparer Fees: 750.00
7.
TOTAL(Also enter on Line 9,Recapitulation) $ 14,314.00
If more space is needed,use additional sheets of paper of the same size.
.�, ,,, u rn
� REV-1512 EX+(02-15)
� pennsylvania SCHEDULE I
_ DEPARTMENTOFREVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RENRN MORTGAGE LIABILITIES &LIENS
RESTDENT DECEDENT
ESTATE OF FILE NUMBER
Kathryn S. Batdorf 2115-0449
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,inciuding unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1• Fox Rehabilitation Services- 0511212014 Rehabilitation Services-remaining balance 21.65
2. 'Family Home Medical-Wheelchair-01/26/2015 74.59
3. 'Synergy Home Care of Mid PA-Home Care-0211612015&0211712015 96.00
4. 'Synergy Home Care of Mid PA-Home Care-02/0212015 through 02I08I2015 336.00
5. Alert Pharmacy Services,Inc.-Medicines-02111/2015 through 0211712015 13.02
6.' Holtgate Podiatry,PLLC-Medical Services-02/0412015 31.08
7. Diana M.Reed&Associates-2014 Individual Income Tax Preparation 535.00
8.: 'PA Dept of Revenue-2014 Individual Income Tax Balance Due 646.00
9. ',Physicians Mobile X-Ray,Inc.-Medical Services-02116/2015 41.33
TOTAL(Also enter on Line 10, Recapitulation) $ 1,794.67
If more space is needed,insert additional sheets of the same size,
���^ni�u.i_.n�r�r e
� REV-1513 EX+(02-15)
� pennsylvania SCHEDULE �
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Kathryn S. Batdorf 2115-0449
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 W.Stock,417 Old Stage Rd,Lewisberry,PA Son 1,864,894.15 :
_ _.
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 DISTRIBUlI0N5 UNDER SECTION 9113 fOR WHICH AN ELECTION TO TAX IS NOT TAKEN;
1. '
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1. : _ . _ _
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.
�� ,,,,,. �� �,� ,
v zew�necx�nage Yage 1 0� 1
dAlr►lE3 W S70CK.8► '�CIOZ
NtARIQN A STOCK
417 OW STAGE ROAD. 82-15t311
LEWISBERRY;PA 1733�9329 !
di
o�u
o��a� �od v�� �.�{ �l ��v� -� r� a ,�� $ /�,5�y, �
_ ,--
� p s! r!t fs ��cl �r� vI✓�eC /� �f, `�'�� oliars � �
1"1liw�,����i.� ,s,,,�.ya�.,r. ��110
�
E� A��.
c
For "�'
�".D3i� �D0L57�: �878i953�,3►t■ iOD �
z z
o �
ro
�� '"+ �. � .
0
�� v N a
� �
G f*+ -1
-o
�� � C �
-,�� z � v
" �a_w.�a r��e� e�r�rs��+r��.A {�f+j��+r+s�ar�r+��e�.2i"�Ai'f�.r�. � �.
1.i.3L713.� ..i�J� �l..O.JLYl71� ilt}4L� I3:3i.�J.�'LYiJ.7 i�L2�1�31 �7
�
tn �
https://accountaccess.edwardjones.com/ca-accounts/all-investment-activity.action 5/23/2015
w Route 422&Lucy lAvenue
• 6611 LinaIestown Road P.�.Box 475
Harrisburg, PA 17112 � � _ � HersheS�,PA 17033
(717)652-8888 (717)533-7700
Warren R. Hoover,Jr., Scepervisor F"1°���°m"��°"9��'� Shzldon K. Hoover, Supervisor
�
- � ��- ��s� ��' "Otir Family Serving Your Farraily far Five Gensradans" ..l"� A`:-.� '.������-� z
,� - �
- ��(�^e', � ,� s �_ ""� ' �"..x � � .����{*`c'-�
:�( ,r x'S_ �� a''��5�t,}�
l�l
-,� ���" � ��v.hooverfuneralhomz:com - -
'3.�'�=� . -. _ • �r �. ,�.—�,.`.W "s. ....-..--a�'�n�_ , .x.,..,.r...-r "�4-
James W. Stack March 23,2015
417 Old Stage Road
Letivisberry,PA 17339
�at�rvn S.Batdorf
Professianal Services,Use of'Facilities,Automotive
Equipment and Necessary Documents � 4,385,00
1Vlerchandise Selected
Register Book Box$et $ 100.00
Tiger Eye- 16 gauge steet casket $ 4,325,00
12 Gauge Gatva�ized Stee1 Clark�ir Seal $ 1,43U.00
TOTAL FUNERAL HOME C�iARGES $ 1o,7ao.00
Cash Advanced Items
Cemetery Charges $ 1,350.00
Certified Copies ofthe Death Certificate $ 60.00
Harrisburg Newspaper $ Z3�.Q0
Lebanon Newspaper $ 180.00
Lowering Device,Greens&Tent $ 210.00
Ctergy $ �00.00
Monument Inscriptian $ 170.00
Flowers � 2�S.Q0
Saturday Vault Char�e $ 75.00
TOTAL CASH ADVANCED CHARGES $ 3,009.00
TOTAL FUNERAL & CASH ADVANCED C�IARGES $ 13,749.00
Payrnents and Adjustments (� 185.00)
February 27,2015 Packaoe t7iscount (� 185.04}
BALANCE DUE: $ 13,564.0�
��! �-�' E � � �� %�
��
� ���� � / �� �.___._
$ �
�r.�-�V� ���"`�'� ���`'.,�,
If III II �1■ 1
`� HARTMAN &
�y SCHEUCHENZUBER
CPAS AND BUSINSSS hDVISORS
4823 E.Trindle Road,Suite 200 Tel:(717)761-4000
Mechanicsburg,PA 17050-3642 Fa�c:(717)761-4241
06/23/2015
Estate of Kathryn S. Batdorf
c/o James W. Stock, Executor
417 Old Stage Road
Lewisberry, PA 17339
For professional services rendered re:
Meetings in our office on June 1 and June 22, 2015 to obtain and review
information pertaining to the Pennsylvania lnheritance Tax Return; preparation of
Form PA-1500,Pennsylvania lnheritance Tax Return, for the Estate of Katluyn S.
Batdorf; discussions with Jim Stock and with Paul Smith of Edward Jones
regarding the assets being transferred to James Stock and no assets to be
transferred via KathrSm's Will, gift tax rules and issues,and related matters
, Amount of this invoice $ 750.00
0-30 31-60 61-90 91-120 Over 120 Balance
750.00 0.00 0.00 0.00 0.00 750.00
A FINANCE CHARGE of one and one-half(1 1/2)percent per month(annual rate of 18%)will be added to any account
balance which remains outstanding for more than thirty(30)days from the date such balance is first invoiced.
r1vL uniuie tsantcmg rage i oz i
`�F1`C OniineBanking
Dafe DeseripUon Amourrt Account
03/03/20'IS Check 2368 $27.65 5005648239
This is an image of a check,substitute check,or deposit ticket.Refer to your posted transactions to verify
the status of the item.For more infortnation about image delivery click here or to speak with a
representative call:1-888-PNC-BANK(1-88&762-2265)Monday-Friday:7 a.m.-10 p.m.ET,Saturday
&Sunday.8 a.m.-5 p.m.ET.
I
j tcnzt$�na s�A'#n+oFtF 2368:
� �AAAES,IFlST�CEC r�r�u
4iZ.Oi.D SfAHfi.4� Qr!
L�Ydlfi$�f3T11iPA3]'�E'�219 . �..:�..ZU��
�Qrderal� �t �5 �,�P.�T6�1't !�/��/�/`bk! �C[�Uit-aS� .$� �������
a � �
�� � .. Dolfas.. �J ��;�;L7..
��' C$A�K ����
. ..�r.cc.;x� oso.
r� �1��
�;C��131273'8�; ap0�6ka�39u■ 3�,$
��
'�y � S�r�li- ..__.�.... � �_����_� �.�. . . . .. .
�. .'l ��-f' 1.;. ���' _s. � : "� .
. � _: f C edif to th¢acFour�#of w7t�ln n�m�.i pay��
� ; �-i ��a.. r.s3�� . . . � . . .. .
:j4 .�
� '�ayment aGcepted w.�out.�rejudice�
� 1 K�
(a- Lµ � .�3�,�3x i:� . ./absence of enatv'ser�et�t 9aarantee�
�� � L ; _ _. TL?Bai'rk,.N,q. " ;
: . ,� .. . .�-. �
3: ; y a ;
r n - - �. , �� -
:� t
��:=. .[ '�� z �� _ � .. __ . - }
i.= '�. . � ' .
4• . _ _ . � , i � • .
.p_ _ _ ..� _ . - .-:T � 3.
t� '{ .. " " . "' �I _ i
. �t_ �,�� � ��� ' . .
�� 1 ' • _ •
;•-,-y,•;�,.,..��.-,r.-;
_._.. ....___. _.......__.._._. _. ___..
O Copyright 2010.The PNC Finenaal Services Gioup,lnc.PJI Righb Reserved. �
https://www.onlinebanking.pnc.com/alservlet/ImageRequestServlet?accountNo=1 edd35dc... 5/23/2015
no.,u.u.ya..::... .�+. ;... : _;. ,- .;,; ".-; ,, �'- _ _ __
C���of ' Descr�pt�on. Provider Ctiarge';lnsurance " PatientPaid: �djust Insuran�e P.afi�nt , :' Tofat
Servlce ; Paitl �alance... Balan�e : Batan�e '
�3--�'=2-15 '�0�. S�ivicFs J. Hess � 2�6.�0;�- -b�n.�4 0.��': -2�9�-.sti �21�:��03 � 21.65 o.O�Q�� .
- Grarid'Tatal: 216.00:: -=Oo`.54 0.00:: _2,79 i£ -21.55 21.55 O.q_0.
_ .� -
�
�� ��
,;.
� ��
_ '� ' �'�
-�
'TOTALACCOUNT BA�ANCE: a.�0 �E
1NSURANCE PEi�DING: 21:65
PATIENT BALANCE:' 21.65 <�Amt. Due $21.65. -
Last Patient.Payment Date: 03-31-14'
Per the applicable patient s bepefits,.the patient may:6e responsible for any. _
unpaid'batances not covered by the insurance due to, but not limited to,
deductibles; coinsurances; copayments, and uncoveretl services. ' :
. .tofT� . � � �� . . � .
` s 108994969-d710957
Y1vc.; unline t3anKing Page 1 of 1
,
�FNC Online 8anking
Date Description Amount Account
03/05/2015 Check 2369 $74.59 5005648239
This is an image of a check,substitute check,or deposit ticket.Refer to your posted transactions to verify
the status of the item.For more information about image delivery click here or to speak with a
represenTative call:1-888-PNC-BANK(1-888-762-2265)Mo�day-Friday:7 a.m.-10 p.m.ET,Saturday
&Sunday:8 a.m.-5 p.m.ET.
xATtiE�9�+1 s�T��� 2369.
ar��src� —
4sf�s9
A47 QLII.$7AGE R4 �
��1'i PA t793D�9379 � � ���/�j .
�
e�y.w-�e� �. - �. 5'q
Q��t� �r�wz��� ��� �,��1�:�� ► � �7�:.:
i� �Yr.i �q/cx� � �;�i�,�
��� �
sr�¢w�.ws-. o,u.
S� _
�CJ�Qlr.
F�I]3�:312?38�: 50C356�:5'�i3�1�' ���� '"
��
__ _ �
�.
�
_-_-... � _ �:�,
. • --- – — –.
_ -... . .
_
_ _ �.
��
;,�.�
�A�3315U3GC �•�i;�
6rYs�own 8ank �rc
�'o,-.
Shippexisi�uxg PA:17257 'a:
PIlone, 717.532-6114.` :�
`�u's_6ate:i '�3,/�512o�S. `R
�
9ranahJTel7.ex 000SJa143
43/05i2u15 18;A5%i5
._...----._-____...._---------------------..._--�-------_._.
�Copyright 2010.The PNC Flnantlal Services Group,Ina PJI Righls Reserved.
https://www.onlinebanking.pnc.com/alservlet/ImageRequestServlet?accountNo=1 edd35dc... 5/23/2015
��AMILY HOME MEDTCAL
1 SPRINT DltIVE
CARLISLE, PA 17015-7696 I���'��
(866)486 5201
MiSC Customer
Print Date 2/i;7/2015 KATHRYN S BATDORF
First Print 2/17[2015 BRIDCES AT BENT CREEK- RM 227
Invoice 78906 2100 BENT CREEK BLVD
Order 22599 MECHANICSBURG, PA 17Q50
Account No.
�
Qty Date- Drestr��itiot� � �� - - - Charges/Debits Peyments/Credits_
�� � ,�, ..:
_ -1-- p�/25/2015 .:.1NC16X16 - — ---- _
- --- �1D�:00 -- __ __---.. _.
WHEELCHAIR.16 X 16
01126/2015 Write-OffAll.ov�rable $2651
�
` 02/0512015 AdjustAilowabie Ad;ust Allowabie-Manual � $1.10 � ,
Total $IO1.S0 $26.51
.� Balance $74.59
Payment Cash _ Check rha�ge _ _ _ P��f�C:IS.d°��"lfs�d�`!Z'; — $a�.59
Name ents - — � v�.� 7�' ��t,.l-�'1��=-�
CC#
Expires -- --
,`
, � ��
��
L
, s � ��
`.v
BT-INV4-I9648 � Page 1
rtv�;Unune tjanx�ng rage i or 1
,
�FNC OnLineBanking _
Date Desehptlon AmouM Account
._ . . . . . . . . . _. ..._ . . . ... .... . . ..... . . .
03/0912015 Check 7123 $96.00 5005648239
This is an image of a check,substitute check,or deposif ticket.Refer to your posted transactions to veriFy
the status of the item.For more infortnation about image delivery Gick here or to speak with a
representative pll:'1-888-PNGBANK(1-888-762-2265)Monday-Friday:7 a.m.-10 p.m.ET,Saturday
8 Sunday.8 a.m.-5 p.m.ET.
r
. A�i�lt�-#b�'F�fi� y;�.n,�viftise vosr s»(s r�u��vA��,cus�r�oNEn �.l30
� � �^� �� ���� P�oas�¢,��ec ssn,,,��e��u`�i�T �z72131a ,
�•�r�� o�t���#�P�n°t e�r���r��`�Eriter Q��!�00�`1�3 4
����S7c�4.rt�-� t`i � r�! 2594-st,ny � 2 '��'at.+��L��'sa��•'�.z .
�p� � T�p�a� g3y 9 �f�y ., #,�,d yx;� ��5� ''4�'�t�'�s+�$��43��+�^t`��a�1� ��
'� y2''.3 l�:� ��� 7���£y� ��. `Wt��.'�'yl �3� j't �#�,4�.-F �'i�z,F, ` ..:�!
'c7�P 'k�Y� �:ktS � +fz�� �csi� a��' }� .,M.#,7!s If
_ . . . D74��tkfT�OG7AS^OQGO,UCOW7ffilAA ���� {f
PayN1�1EfV SiX`AND 13ti/3�»,�»..............»•�«= — - DC)LL.ARS:, }
Q.. 4#iHYfi1(iL`.(�/�.�
_ �If�.�t��,�l;»i��B�lah1►�l1i►��,�131�l��IJ��aptllq�l�i�Il� iQ 3II yN
. �
� �. +� Vo3si AUer �80 Df1Y rt�` �•hp,� :
T4 SYF7ERGl1�t�k1cCF.RE.QF:PA �i.a.. S�gna�ur�-(�r�t�-�A'�c"�y��-3 "sa ��
•.'j}i� $.53�Ii3COLC#S�3Tc I10.�.- � � ) �.
O��RDE� CARSISLE,?fi 1701318&7 - 'ihls check has�'e�$u�J � ; t���1.
:by yovr d�atr%��.�°.��vr?' t
9
u�QflPi�3��' �:03i�1�738�: SDO���,S23'�a*
_ _ ..— ,
.�.
�`7�J_3>5�8�`:
^. � Q�.
:� _ °°
�
��'.,A .,,� . 9� .
. r- �'..t'7.
a �.:
� `� ��
p m
n���� � .g �� . � .
m o a
�6:.#z'r�� pfN,� �. ; .
�':��� �' N�q-S� ...
:�
'.o �.�� m, .
}v
� �.� ��{. w�.��� �'. ;
�� x �� ��"��.
��. � �
SP � �
��,�� g ��_�
� �a. �1
�=� :
�,R �� .. �
_.....____.....____._._.__....__._--__- ._----..._______._----
O Capyifghl2010.The PNC Fnandal Services Gmup,i�All Rights Reserved.
https://www.onlinebankiug.pnc.com/alservletlImageRequestServlet?accountNo=1 edd3 Sdc... 5/23/2015
� Syner�y HomeCare of Mid Pennsylvartia '�� ���
453 Lincaln St., Suite 110
Date invoice�
Garlisle PA 17413
717-243-547� z�23izois czs9�
Bi�l To
Tllll SIOCli
=417 Old Stase Rd
Le.ivisbeny,PA 17339
P.O..No. Terms Project
Due on receipt
Quantity Description Rate Amount
2 Seivice:02/16/201�-Sarau.I3ever 24.00 48.00
2 Serv.ice:02/17l2015-S�u-ali,Dever 24.00 48.00
�
c
� � .
�
°� � �
� � � ��
�� j�
��
�
HaE�e a�eat�veek! `r���� $96.00
Phone#
7I7-243-�473
YN c; unune�an�ng rage i or t
.
'�,PN�. Online Banking
Date DescdpUon Amourtt . Account
_.. .___ . . . . . . . . . ... . _ .
03/11/2015 Check7724 $336.00 5005648239
This is an image of a check,substitute check,or deposit ticket.Refer to your posted transactions to verify
the status of the item.For more intormation about image delivery click here or to speak with a
representative call:1-888-PNGBANK(1-888-762-2265)Monday-Friday:7 a.m.-10 p.m.ET,Saturday
8 Sunday:B a.m.-5 p.m.El'_
i A€�ounLt �S76S � �' ,, 5336.� A
Ptease Derect Any Questfana To siT'.va�3 �
t,kiii�;Bil1 Payment Arocossutp Contcu ODD�D�'�'��.�
�:IA3dE5 W ST.00K- lHUM Ta7.�?S90 ....� . . .
d57 q.A 5TaGE Rp �
cemsaesrre.rfl»�a-s3ta �l�rth D9: 2U15:_
_ Yf.G�hhK,:AA ' �
� ?3p54-=�.24?.�pl}47b413Ur�ODOOi!DUVDS►73066
FayTNit�NIJ�IDREb:'�F{iii'fY SIX AHD.u07t4o: _ ��... , --- - U9LLAR5
... : . ••— .. � (�.�tikii:F4iit7G��M +
yl.�.l'�rll�ll�l•�ll�tull���I1Hll�l nll#���il.,�td�luttil{��. .p .��Q .,�.:.
1/wd Aher 18U D6,Y5,
Tci. ��i�cin, i�.,uis .�Fi,� �•� �� S,gnati;�e Un�ilQ
THb �r3 Ita�i�_tt�t 1 1 l�t Thls'ch0r,k.haS boan a�i[huiizeti
URflER 4.AFCwI� .f'h 1 rtsi 3 ti�f.+
OE t?Y Yaw dcpos{Sor",
u'qt]:7 i�2�.ip �,031:3;i�738�: S00'56�,8`2�.9n' �
� �'���,9113
R �� pz:
� g � O
�. ��� ���� . .
� a f[I._ '-'�_ :
� �
�`' � � � � "J.
' �� �� � � °�,
o � � � _
a R. � , r�:.
�� , `
� :� ��
,�. . ,.,i�.� - . . rt-�- -.
..._..__..._...._.._'_'____......._.___..---._.._...__.__....._...._._...._......_._.._.._._.._..
O CopyrigM 2070.The PNG Flnenciel Services Group,lnc.M Righ[s Reserved.
https://www.onlinebauking.pnc.com/alservlet/�mageRequestServlet?accountNo=1 edd35dc... 5/23/2015
' Synergy HomeCare ofMid Pennsylvania �������
453 Lincoln St., Suite 110 Date r InvQice#
Carlisle PA 17413
717-243-5473 2/9/zots C2539
Bill To
Jim Stoek
�17 Olcl Stage Rd
Le��-isbe�zlt,PA 17339
P:O. No, Terms ProJect
lltte on ieceipt
Quantity Description Rate Amount
2 Service:02/02/2Q.1�-Sarah Dever 24.00 43.00
2 Seivice:02/U3/2015-Sarah Dever 24.Q9 �$.�0
? Service:02/04f2�1�-Sarah Dever 34:D0 =�8.00
2 Service:02/05/20 i 5-S�rah DeveF 24.OQ 48.4Q
2 Service:02f06/2QiS-Sara�Dev�r 24.OQ 48.00
2 Sarvice:02/fI7l2015-Kareii Kelle}; 24.00 �i$.00
2 5ervice:02/Q8/2Q15-Karen Keliey 2�#.00 4$.00
' �N � ��
•i / \�
11 �� �\
\ i
M1 A� � `
� ��
�
Have a great week! �
- Phone# ����� �336.OU
717-243-5473
Y�Vt;Unune�anxing rage i oi 1
,
(��-,FNC Onfine Banking
Dafe ' Description Amourrt Accouni
03M72015 Check 783a $13.02 5'140062185
This is an image of a check,substitute check,or deposit ticket.Refer to your posted transactions to verify
the slatus of the item.For more infortnation about image delivery click here or to speak with a
representative pll:1�88-PNC-BANK(1-888-762-2265)Monday-Friday:7 a.m.-10 p.m.ET,Saturday
8 Sunday.B a.m.-5 p.m.ET.
_ _
- ---
t.SA9R�►ass�'ni4s eAYe[EIiTF6A aUR NU�laL.cUsroMEIL� -� � �
At�a� BA7�C .7Z0T0� S1�:ti2
- � , el�se oirect.A�r Cuq�4�ts To �ai�t9)s
�nth�s�HI Payxnent Prccessl�Conte► �Q�$��1
�nMEs w sTocx ���z�,�a,
477 OLD 5?AGE RU�
�ansaE�av.Pn,�ia �Ilarch 1�, �i}1�
vHC9nrlX,nA
o��ss�+i;+siia awina000e�000i a�3rnsn
PaylH{R'iEOV AHD 02J400—•--_... . _ �1LAR8
. .E"ttrtityl��.Yi�
,p
TO ALEkT PI�Ak>4ACY SEkNlCES.It+I� V4id Ai;sf 164 PAYS.
'rt16 zi9 r�E��.iir�oRE nv�. Sfgnatura Dn Ff!$
ORDEFt MOtlNTNOLLY SPEi3NG5,Pq 17065•�2Q4: Thi5 has�ien audloriznd
qf . �Yaiu tl�ppsltor
�'0�?83�i�+ �:03 L-3 i 2:�=3_$�= 5�4��6'2�$Sa•
_ ���
N. �C �'i ht
Fi �.
r :rtrt �
� o _rn
�d. :. £'`.'�U; .
�' rt � �'
(tiJ. :y .. .(1}..
ri ..� � F'_
,-h .�o,- _r � { I .'1:} ;d�-i.i�t.-� "1;�.�5 . .�� � ��
_. . . _ . . -- —-. . ... . �. � "..3.'
C1 I"i �:Q ,
r:; cR. . �
{�4 1 �-+
Ei �C.
�
�O �
� `
_____. _____... __.. . ._.__.___ ...___... ___..
O Copyrigh[2010.The PNC Fnancial Services Group,Inc.NI Righh Reserved.
https://www.onlinebankiug.pnc.com/alservlet/TransactionInfoRequestServlet?accountNo=... 5/23/2015
219 North Baltunore Ave � FINANCE CHARGE QF 1.5 0 � PER MONTH
Ft3lsztrsr,cY S�tvtcss,m�c. Mt Holly 3pcings, PA 17065 (AN ANNUAL PERCEN'TAGE RATE QF 1.8.0%) OR A
Rzsponsive. Innovative. Reliable. �DO-266-9954 (717)486-8606 MINIMUM SERVTCE CHARGE OF $ l.00 WiLL BE CHARGED
www.AlertPharmacy.com
ON ALL AMOUNTS 30 DAYS OR MORE PAST DUE
�`�Al'� E °r �� ACCOUN7° 1 . : , -
` I� YOU R�C��`VE �:NEW 3NSUk�N�E CARD,FOR YQUR
�. PRESCRIP'PIO1�iS BS SURE:_TO SL7�PLY`LTS V1ITFi 3�._CQ�Y �
��$� 02/28/2015 — ;;
PM� �����`�'/� � 1 � BATDORF, KATHRYN � BATDK2
- i ` JAMES STOCK y GRP-58
w'-� f v ' � 417 OLD STAGE RD � �AGE T
� { -b - i � LEWISBERRY PA 17339 � AmountPaid
PL�di$E�E7'AGld AI�D RE'8'tJFtAI TOP PORTIOP{Mi{�1i°f0lJE2 @AYMIEN'F
_ _. . -_ ___ _ . --- - ._ .. . .. ..__._.__
-
AI,ERT PHARMACY SERV. INC.21.9 I30RTH BAL'FIMORE P:VE. M'I' HOLLY SPGS PA 17065
e• . �
, � e ' a s a . �
. .:. , .: . � ;, " -
.: _.� :. . , -
-
*.* AC'T'I�TI.'Z'Y` FOR BPi`I'DORF', 'I{�THI2'YN BA'FDK2 : = 12,`07t]2 ,. '
02/1�/�5 .9296�19 ��.$ V.: G�IAT�ENE52N-'-D1K SY 0� * •3.4$ _ � ` ' 00 , 3� 48
,.; .';
. .b2�12�15 `5257324 ,4. . PREDNISONE 20 MG 0�, _; 1.•27 _ O�Q ,1 27c �
02/12/,15 � 927�,.629 4 " NtETOFROLOL 25 1+�IG , Oi: .92 QO ,92C �,
,;U2F12�15 ` 919Taa5�. , � ,
4� . PRASTASTA�xN 1Q M� Ok ;- 2.9S � " � 00 � 9�c
'02�12;/.7.� ' 97.95;$-�S7 4 POTASSSITP�[. 10 ME4 E}1: .'. 1..94 �Q 1 94C �
i ' " : _ ,`; �
42/12�/�5 :; 9�95-86Q, 4 �'UFtOSEM�E 20Nl� 41 = .87 'OQ 87� `
"OZE13:��.5 ' ��95;86� 2 : ACETAMIN013HEN �325 `" Ol * 1;-59 � E �, :> OQ, 1 59
.. „ .,., _ _
";0��17-/�5 . � : ; Payment-Thank Yo� �; 54:�3 UO 5D 43-�
. r CK# 7121 '. �
02/I,'���.5 Payci►ent 'Tlxank 'You 25;i9 0� �5 �.g
� ` , , ; CK##�;'712� ' �`
,Q2/7,��7,� � 1 ; REF�7ND FII3 FE� * l.Q� 00 �.,��
i _r
.1 _ F t
)
h � h $
�� �
, �� .�, _
� -.: � -
s� � �
��
-� �-- .� -— _ - -
_ r� �` - _ _ _
- � � - -
� --
I _
� -
_ i . 00 ;
7:95 ' . 4: 07 �+ � {
- LEGENp . NON LE�END,'j , Yo�rr�` �,6 T,�c I
. �, - F'OR MON.`I'H FOR MONTH,� A �
Pcevious BaQance � Charges this month Fiasarec�Char e.= G 'Cotal PayrnenE$`Credits .
7;6"� 6 2 ' :+,. 13 :0 2.�`�. �- ; 0 0 89 6�4 '� 7 6 6 2 - 13 . 0
`F�R ALL PHAI?MACY RELATED lI�QUIR�S F�.�AS�GALL AterE Phatmacy Se_rv�ces,_Inc at 9-SDQ 26f-9954 ,;..-�
Sfatement Terminology on reverse __
YN l: Vnline t3anKing rage 1 ot 1
�PNC OnGneBanking
�ate - Descrlptlon Amourrt Account
03I1?J2015 Check 2370 $31.08 5005648239
This is an image of a check,substitute check,or deposit ticket Refer to your posted transacGons to verify
the status of the item.For more information about image delivery click here or to speak with a
representative call:1�8&PNGBANK(1-88&762-2265)Monday-Friday:7 a.m.-10 p.m.ET,Saturday
8 Sunday.8 a.m.-5 p.m.ET.
K�i'�`fi�mi.s saT�4RE 237{3
�A�t�s;w s�cK �-,�
a17 S7LD 5Tl1GE AR�� ��
tFAY3SB�FtY;PI117�f9.63iA
� ..-,:..:.�.,.,.. ..�� -���.... . : ,. . . � �. :a�,:.
�deroF . —— � -d Ci �`��
� �� f ., :.�� � - �oUin 1:� �:=. .
�F'� BA�l1C
��.� �
�aF�.�7`��aoa ).p,:1: f'U �
i,Q�13���38.�: �SD0961��239�` '�3?0
� -��
C�,..: - �
. - _ 1
.� i � 3 .
-20�5o3r� .pn5i'ofl3��2r,:.7_'r�a�.�lci`t03a�17. • - __. ' c�o � �. -
' � � n�. � �.
� _ ��4 �yF�.
i: ����2
- E ; . � ���
, . , � �:
0
- F. i-. . u�������C
� ���....A-, -�
, =• ; �� '�
, � , �.
:��i ' !� . ���
:�J ��t., . . '.4� ' .
{
. .'i`i' . i- : . �
. ..._.__.........._._..._--..._..._...._....__�...,...-----......_.......__..-----........_._.._... .
O CopyAght 2070.The PNC Ffiandal SeMces Gioup,lnc M Wgh�Reserved.
https://www.onlinebanking.pnc.com/alservlet/ImageRequestServlet?accountNo=1 edd35dc... 5/23/2015
S7aTEMENT
Account�#: p700001815
Sr.No. Serv. Date description Provider Charges Pat.Bal.
1 02/04/2015 CHARGES:11720 Debride Nails up to 5 Holtz, Peter 45.OQ
MEDICARE PA-NOVITAS SOLUTIGNS PAID:0.00
WRITEOFF: 13.92
CAPfTAL BLUE CROSS PAID: 0.00
PATIENT RESPONSIBLE:31,08 31.0$
Patient Bafance Nate: Deductible Amount
'Cotat: 31.08
Amount Due: 31.0�
Cwrrent Over 30 Ovec 60 Over 90 Open Credit
Patient: 31.U8 OAO 0.00 0.00 0.00
Kindfy remit payment by march 20,2014. Credit card payments by phone are welcome.
P[ease make check payable to Holtgate Podiatry,PLLC and send with top part of this statement. THANK YOUI
Piease call (717)731-1133 if you have any questions about this statement or amount due.
V � ' �
�
� �
��
��� �
�i
Page 1 of 1
YN L Unline t3anking Yage 1 ot 1
�PNC OnGneBanking .
Dafe Descrlption Amount Account
04/06/2075 Check2371 $535.00 SOD5648239
This is an image of a check,subs6tute check,or deposit ticket.Refer to your posted transactions to verify
the status of the item.For more information about image delivery click here or to speak with a
representative qli:1-888-PNGBANK(1-888-762-2265)Monday-Friday:7 a.m.-10 p.m.ET,Saturday
&Sunday.8 a.m.-5 p.m.ET.
� KATHRY#t$BA790R� — 2�7�
�1�1�5 W STOCx m�ann»
; si7otnsTM�fi4. : +� / m�
.��f'111�94. . ..��[� �l � ..
4 :
��.;�2.�t�M:���d � .��sv, 1�� � �����.�
�T
�y�- ��l��7��4�Y r��� ��� ���� ��s � �
� �-�a�� . . .
��� �
' � �:-r��s���
� � - -
�:(13,�3::�2`�38i; 50{]:5bti8�39�343. ,
� ��
� _ ; : : .
-- --= �
_ ._ -�,..:f_ _�:: __ v. •
� . a j; .. a
- '- � �.��i_,::� p �
_� �:.,. 3..
. +i 2 - i:i . ,. _ ._ .
� _ - r .5 �:s-�i . - ���� �... .
_ r - i . - -� �9� -
ES x ..a .'sfil.' •_ .. .,_ . _ - ... , ' �a � �
. - < � �1 _, N�".
s 0�
_ - �: - .
`� �e . .. _,. - _,- , �
- � '.i'- '� �::t�n� . '
� ::�� �,f- .., � . ., . _ . . � - ;�. -. . .
.::�?,, . �r �
.._..__'_'..__.�.__"_._�'_�____"__.—_____"_'__._..___._..
O Copyrighl7A10.The PNC FnendalSeMces Group,Inc.Ail Rigt�fteserved. �
https://www.onlinebanking.pnc.com/alservlet/TransactionInfoRec�uestS ervlet?accountNo=... 5/23/2015
�
Diana M. Reed & Associates, PC
i 1505 E Chocolate 1�ve
� Iiershey,PA 17033
717-533-5513
March 27,2015
CONFIDENTIAL
JAMES STOCK
41�OLD STAGE ROAD
LEWISBURY,PA 17339
For professional services rendered in connection with the preparation of y�ur ZOI4 individual ta�c
return:
Form 1040(Individual Income Tax Return)....................................................$ 175.00.
Sehedule A(Itemized Deductions)....................................................�............. 100.00
Sel7edule B (7 @ $ S.OQ per item).................................................................. 35.00
Schedule D(Capital�rains aud Lossesj........................................................... 20.00
Form 8949(7�a $ 10.00 per sale}................................................................... 74.Q0
Schedule E Page 2(1 @$4Q 00 perK-l)....................................................... 40.00
.
Form I 116.(Foreign Tax Credit)......................................_......_...........,....;....... . No Charge
Form4952(InvesimentInterestExpense).... ......... .....................,,.......,..:.:. 35.Q0 ;
Form 1310(Refund Due a Deceased Taxpayer)................................o............. 30.00
PA Form PA-40ES(Estimated Tax Pa}nnent Vouchers)................................. 3(}z
Amount due $ 535.00
c�.�,�, � �� I�
�
�
����
��� E
.,U��-�
v��l�� ����
�
YN(.;Unt�ne tianking Yage 1 ot 1
. '
�P1VC OnGneBanking �
Oafe Oescrtptlon Amount Aecount
04/10/2015 Check2372 $646.00 5005648239
This is an image of a check,substitute check,or deposit ticket.Refer to your pos[ed Vansactions to verify
the status of the item.For more information about image delivery click here or to speak with a
representative call:1-888-PNC-BANK(1�88-762-2265)Monday-Friday:7 a.m.-10 p.m.ET,Saturday
&Sunday:8 a.m.-5 p.m.ET.
Kl►�'t1RYt�18�A�Df,i#� 2372 �
dA4��S w ST4�K r�frr��;
4970tDSTAGEAS / .Q $ � I
LBYiSSEARY,PA1783D.g�t6 �l
_�
'�J N„ I
Ma�iu�Ix � � � �/� ,/ /�f
Oidiiof��NNS•l/riiujA YJ41o! �`j ���fCIlV�' � +� !Q "1�.
� � ��J /
1.( /�Gf�� �� !o�71F�7/1(��%S�/�`:��/�r�'"'�� q
f FJi,�lais W -
�,���1"l�� ..
�� I�C➢�ncHA 6w � . �. �rj
n�n
Far 4Lt.��:�'G����Ff.eK F'/t�.:�'V ,�. ��-',�'!�id�`7"''c...
�.03131273$�: Sa0�64�239� � ?2
�17=Y38-G3?�
,�za�Q$�1�;'1^�'�k.�.;�{�i� �} —_ _ _' —_-_ _— ' �
� �..,:f_
� ��014�900�s#�� .��56 I
_ '
�
. - ;
;
i
_._.-- ---------_._...._..._.....- -__.._-----._....
m Copyright 2070.The PNC Flnantlal Service5 Group,ina M Righls Reserved. .
https://www.onlinebanking.pnc.com/alservlet/TransactionlnfoRequestS ervlet?accountNo=... 5/23/2015
� :-,�.,ei�u i_.u rtnr +
« •
R . _ _: .
r _
�;PLEASE DETACH HERE AND RETURN TOR PORTION WITH YOUR PAYMENT �
_ . , . .
� . . _ e - . . • m � . . . .- '. - � . � - e -
For billmg inqu�ries,please contact 1-800 420-XRAY(717:-561-4940)
s t:
�02/16/15 KATHRYN T12Al�TSPORTATION 1 .:, R0070 485 PD'IXPA : = 250.00 = _ ';.5.42'
Patieu't BA�DORF,KATHItYN -260152 ,
�: Serviemg Pro�ider:,Physiciaus Ivlobile X-ray: ;
03/12/2015 MEDICARE.PENNSYLVANIA• 124 73; 88 03
Applied towards deductible ; : . ; ,
; . . - _
i � 03/20/20`l� CAPITAL BLUE CROSS SECONDARY ' 3182�
Apphed towards deductible= r
k t : .- .. = i � ,
r��T
02/16/15 KATHItYN C$EST lV; 71010 485 PNIXPA 17 00 � r I2:31
;
`' ` , Patieiit BATDORF,KATHRYN.=.260152 '
Servicmg Provider Physicians Mobile X-ray 3
` ; 'Q3l12/20151VIEDICARE PENNSYLVANIA vy 4 69 =
. : � j'"� y`"� v.F . �. �. .. . . . `:. . i � �. '�.a a
`?�ppl�ed t�wards deductible� ' - ' y
..� 0�/�01,20�5 CAPITAL BLLTE CROSS SECONDARY ' {t ;
` Appf�ed.,tdw2rds dedu�tible. 4
� � ,
h ; ; � -.
h��� . �
< � E , � . �,,
Q2/I6/15 KATHRYN SE�T*UP`FEE ' Q0092 485 .. �'1l�A : 28 00 23 60
F ' P,�.,�a�ient F$A'�DORF;KATHRYN .260152 ` e.� �
� Y
_ s �F� ���.'e�;c1I1�� T � � �1 � �:;. s < � c �. + .
P�a�nder Ph sicians Mobile X=ra ,
4; T . � : -���b3sf�.�J20L5MET�ICAR�FENNSYLVAI�IA 4z; z � {,��
� 44
` A� Iied towards�deductible:' + ' `
, t ' `�����s`03�I2`0'12015 CAPITAL�LUE CROSS S�CONDARY h` ys Y�� "y�`',
} �,,,w,.3+ r� F .^re,s- x � � � Fir ���.s i ; � r t
� �� 1iec�towards deduct�ble , r -, u"' `
t
r � ,. : , � -
���i;.�.s �+r` 1 . LL� �r t k �yk
� ; 3t. �t '��� :
- � � ', .'. '�iSL�i . .: t y
. � � f.L��k �
; �4 � £
. �ur �,k i 4 .x{ry `
�, „. ��� r'�� s� k:� a � u
` '
h .; . ,r�s-�s`�1� ��sx _
a - �'� �.4��� �.��' n.l£�':i.t n�'�5i.-. , v.v,.�, .. -.:.... ... ..:��,
..� �. . J �. �� r:..� �$.wiR . �'[40.. Syr'S .
.... ' ` u �.a: ... . .,. ..>�� ..., ... ... ....�._.
...:. ' " .. � �k .�'2�t ::ti�'t t tks°-..F- � 1 4,� 1. {.- �t ..., .." :� � . . . �.. . �
�PHILSIC'TA:IV�1V�0'BI���xZA.�,yTNC � �. ' SE�:REVERSE$tDE � .
MAKE YOUR <� �r � �- �� �
CHECKS: �45�E�iS't�PE�K�DR, S'T�lb2 ` � �' IF AM INSfJRANCE. �s �k� ��¢��,�- ,,,��t���i�
PAIFABCE T0 �y��5B�C'r,�PA ]�711�1 28,04` < -F M�SSAGE APPEARS ' �*$ p�5��z�41�33u�
, '^�Y. �/' 7iS ;r� a { 1 {t . ' . � �s '1n 4`l t F . 4.��:���F..
. .' -' ..'�; �. y+
. . . :l-. W la Y.:. a 'i l .aGJ-:.t�' � ..J � C...Y Jr
. .. . . .,w...... � ..�.rv_ . .....-.
GOMMENTS: . c
F�lease.pay vrithin 30 days.:thank you.
_
� 2 2�15 .: O
' RP 12421 41:33 `; � ; ; k
... o�• � .-• . O. Y�_�.o:' �a / �'� .
_ iiiuiiiiiiuimii�iiuiiiiuiiiiiiiiiiiiuiiiiiiiiiiiiiiiiii�iiii�iiniima�
� , �, _ � � � IItl.al II �IY9 1
t�> '
# 3 3
,� ;w. ;;' ;} �
> ;s
s `a �� s w� y
� , ` , �
� i �
k t j
k
fj��'�� �' t
`f r� �L
cx �5 kk��x �°= �..
_ x Y:�.
..i
a:..
'�P�.
1-}; ��:,+.� �
k! Q C.� ��I ' _
,�: w `�' .-+ �. `� �
,t �, +..' H .. -
=': � ��: i_ °.� �' .�
W � �
r; �'- *�_ ;.� �-�,, � �
� � �:�:: ,.
� �
�, c� - �c. _.,:
�:a �_ , � .� � � �
ca ;_° r—r `_`;�: :,C t � �- �
c� � --� � � \/ Jl �
a �r; � m
� � ~ � � � � �
o e �c.7►
c�., ,�! � � � ���
� � � �:��
't'i
O ` ,. •*�,
,�1 � � ` '��
� � . � �.. �
� ` rU .J _�� .,�
�, � � `� ` �
� � � � � �, �o
� � � � �����
�
�, ��
{�� M ��
'yJ�T
'ci coa
�� �
L
W Q.�
Q� 3
m
�
����I����� ����.. .